Earlier this year, the Commonwealth Fund published survey results comparing the performance of health systems in 10 developed countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Sweden, Switzerland, United Kingdom and the United States).
Information included most recent data collected from patients and medical professionals from 2021-23, so including the Covid-19 pandemic. They assessed 70 health performance measures in five defined areas (access to care, care process, administrative efficiency, equity and health outcomes). These were published as an article entitled "Mirror, Mirror 2024, Portrait of the Failing US Health System", which is available online.
All countries demonstrated strengths and weaknesses, nine of them being more alike than different. The US was the poorly performing outlier. Australia, the Netherlands and UK were the top three, with New Zealand a very creditable fourth. What strengths and weaknesses contributed to these ratings?
Countries (excluding the US) spent 4%-8% GDP on healthcare in 1980, increasing to 8%-12% by 2023. New Zealand ranked fifth, consuming 11.3% of its relatively low GDP on healthcare. The US spends 16.5%.
Performance related to spending pushed New Zealand one place up the rankings to fourth. Australia provided the best value, the US by far the poorest.
Barriers to accessing available and affordable healthcare included out-of-pocket expenses (even at low cost) and lack of timely and universal coverage. New Zealand ranked fifth. Expensive (or unavailable) after-hours care, unacceptably long waiting times for appointments, patchy availability of GPs and absence of a dental care subsidy accounted for our poor performance.
Australia, though ranking very highly in most areas, came ninth because insufficiently insured patients wait too long for care. The US was again a poor 10th.
The care delivery process was New Zealand’s only top ranking, notable for motivating GPs to conduct immunisation and preventive programmes. Positive features also included overall affordability, co-ordination, safety measures, patient management once in the system and sensitivity to patient preferences. The US also performed well here (second).
Administrative efficiency considered hurdles related to insurance rules, billing disputes and reporting requirements. New Zealand, ranking third, does well. Helpful electronic data collection and billing methods were recognised. Separation of ACC claims may help simplify our administrative load. The US did poorly (10th) with multiple variations of complex systems.
Equity and healthcare access measured differences between people with high and low incomes, urban and rural residence, pure cost-related issues, treatment considered unfair particularly related to gender, race or ethnicity, and general patient satisfaction. New Zealand fared very poorly, ranking ninth, close behind the US in 10th.
Health outcomes measured life expectancy at birth, and deaths from preventable and treatable causes. Management of Covid-19 pandemic data was included. New Zealand was well above average, ranking third. The US (10th) carried the burden of high mortality related to substance abuse and gun violence.
This survey confirms New Zealand has performed well in offering excellent and efficient care for patients in the public system.
However, as many will also attest, New Zealand rates poorly in availability, accessibility and equitability of services. Survey findings leading to that conclusion confirm the validity of both complementary and critical comments appearing regularly in New Zealand media.
Administrative efficiency is lauded, benefited by good electronic data systems and the ACC dealing with complex patient issues. Universal patient healthcare, funded in a similar manner to the ACC’s ring-fenced tax-based fund, could deliver great benefits.
The survey does not consider shortcomings in infrastructure and facilities. New Zealand has suffered from decades of underinvestment, with crippling deficits in hospital buildings and equipment. Absence of the political will to correct these problems is blamed on many years of fiscal constraints.
Poor integration with social welfare, housing and education is a common stumbling block to effective healthcare. Patients with complex needs require better integration of healthcare services.
The pitiful healthcare performance of the US is overwhelming, despite high expenditure. Clearly, money alone is not the most important factor in achieving good healthcare.
This sounds a loud warning of the dangers of reliance on markets for determination of basic public services, especially health. Both overt and covert moves to shift New Zealand healthcare towards private partnerships and care, recognised in some recent political attitudes from our present government, takes us in a false and dangerous direction.
This data strongly vindicates the efforts of our hardworking health professionals. Our problems are not based on poor staff efficiency or productivity as suggested recently by HNZ. Funding appropriately demonstrated staff numbers in properly equipped facilities readily accessible to the public is what is urgently required to correct the demonstrable deficiencies in the system.
— Gil Barbezat is an emeritus professor of medicine.
