Commonwealth Fund fourth place ranking has merit, but not when it’s behind Australia

As the old joke goes, “God said to Moses, come forth! He came fifth and won a toaster.”

Unlike Moses, New Zealand teams and athletes have been very proficient at coming fourth in international competitions. This proficiency now extends to the health sector, as last year the Commonwealth Fund – a US-based health systems think tank not to be confused with the group of countries paying homage to the Queen – rated us the fourth best health system out of 11 high-income countries.

Depending on whether your disposition is closer to Tigger or to Eeyore, you can feel proud about being a plucky small country punching above its weight, or ruminate about another lost opportunity to be even better – in this case, than the UK, Australia and the Netherlands that ranked above us.

But what does such a judgement tell us, and how was it constructed in the first place? There is no objective way of comparing the performance of health systems. All approaches require criteria, which must be defined in terms of values. So, all comparative judgements are fundamentally shaped by the specific values chosen and how they are weighted against each other.

The Commonwealth Fund uses five, equally weighted criteria: care process; access; administrative efficiency; equity; and health outcomes (you can check out its website to find out how these are defined – commonwealthfund.org). These five criteria generally match those that are used by comparative health policy scholars. Others – such as patient choice – could have been used but were not.

Nevertheless, none of these criteria are that simple to pin down empirically, or to measure comparatively. The Commonwealth Fund uses patient and citizen surveys to compare countries in terms of care process and access, and while one can easily poke holes in this method, it is probably the least-worst option. There is no obvious reason to weight the five criteria equally either. You could argue there is not much point having equitable or efficient health systems if care processes are abysmal, and access is lousy in the first place.

It is also questionable as to whether it is possible to compare health systems in terms of health outcomes. The Commonwealth Fund used amenable mortality, because this indicator can, in theory, be influenced by health services. But when we look at the Commonwealth Fund rankings, the UK ranks highly on every criterion except health outcomes, where it ranks second worst to the US. Even amenable mortality appears to be driven predominantly by factors beyond a health system’s control. That’s why Australia – which ranked first on health outcomes – was lucky to beat us. So now we can pick arguments with Australians about that instead of about Phar Lap and pavlovas.

New Zealand’s fourth place is a result of us ranking highly on administrative efficiency (second) and care processes (third). This contrasts to below average ratings for access (seventh), equity (eighth) and health outcomes (seventh). This provides support for these criteria having a high profile in New Zealand health policy. We could conclude from New Zealand’s performance that there is an inevitable trade-off between equity and efficiency. But this is doubtful because other countries manage to rank highly (the UK), or lowly (the US and France) on both.

Some readers might raise eyebrows at our high rankings on efficiency and care processes. How can a system with 20 DHBs for 4.8 million people be efficient? And how can a system starved of resources for nearly a decade be ranked highly on care processes, when we see a cascade of news stories pointing out gaps in services and quality? Can we take these rankings seriously?

I think we can, and we should. The best way to have a (relatively) efficient health system is to have one based on tax funding rather than insurance. Tax-based systems are better at controlling costs and they waste less money. Put simply, the fewer people and processes involved in deciding whether or not patients are eligible to have their health costs paid for by a third party (an insurer or government), the more efficient the health system.

We ranked highly on care processes because – believe it or not – New Zealand does coordinated care very well, and neither are we shabby (comparatively) at engaging patients.

Basically, the architecture of health systems matters a lot. The US system’s heavy reliance on private insurance keeps it pinned to the bottom of the Commonwealth Fund rankings. Canadians have been rather proud of their health system compared with their southern neighbour. However, Canada ranks ninth overall, and below New Zealand on every criterion. Their Canada Health Act only guarantees universal access to “medically necessary” services, but anything outside that magic circle (eg, pharmaceuticals, home care, physiotherapy) is much harder to get access to if you are poor, and waiting times for health services are comparatively long.

New Zealand has some design advantages. We have one predominant funder (the Government), and one reason we rank ahead of the other comparable countries is that we have PHOs which can, and often do, facilitate care process improvements.

New Zealand’s health system certainly has its weaknesses, but we have also much to be proud of. If we can make headway on tackling our poor record on access and equity, we might just become world-beaters.

Tim Tenbensel is associate professor of health policy at the University of Auckland’s School of Population Health