Researchers and policy-makers have long compared health system performance. International comparisons raise awareness of health systems’ relative strengths and shortcomings, prompting policy debates and informing policy decisions. Yet determining how these international comparisons can be used to improve health system performance is challenging. Health systems can differ in many ways, including how they are governed, how they are funded, how they generate and deploy resources, and how they deliver services. While the international health community widely agrees that these functions influence health system performance, understanding of how much they matter, which ones matter most, and how they are affected by the context in which they operate remains limited. To gain relevant and meaningful insights from health systems comparisons that offer lessons for policy, we must agree on how to compare health systems. In this article, we argue that doing so requires collecting better, more granular data on a broad range of health system characteristics and using those data to choose the most appropriate health system comparators.

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

In their Letter to the Editor, Olivença and colleagues question the benefit of adopting health technology assessment (HTA) in the US, and suggest it could result in fewer drugs being available to patients. They raise 3 main critiques of our study.1

First, Olivença et al note that patients in countries with HTA have voiced concerns about inadequate access to new therapies, citing 5 media reports from negative coverage decisions in England. The extent to which these reports represent the broader views of society is unclear. Recent decades have seen global consensus that universal health coverage is desirable for health care systems. Achieving universal coverage requires decisions about which services should be made available to maximize population health. As many new drugs offer little or no added therapeutic value,2 no coverage may be acceptable unless pharmaceutical companies offer reasonable prices (otherwise, funds would not be available to pay for other health services). In our study, we observed good coverage in all countries of high-value drugs following HTA review.

Total hip arthroplasty (THA) is among the most commonly performed elective surgeries in high-income countries, and wait times for THA have frequently been cited by US commentators as evidence that countries with universal insurance programs or national health systems “ration” care. This novel qualitative study explores processes of care for hip replacement in the United States and 6 high-income countries with a focus on eligibility, wait times, decision-making, postoperative care, and payment policies. We found no evidence of rationing or government interference in decision-making across high-income countries. Compared with the 6 other high-income countries in our study, the United States has developed efficient care processes that often allow for a same-day discharge. In contrast, THA patients in Germany stay in the hospital 7–9 days and receive 2–3 weeks of inpatient rehabilitation. However, the payment per THA in the United States remains far above other countries, despite far fewer inpatient days.

Brown’s new Center for Health System Sustainability (CHeSS), led by Professor Irene Papanicolas, aims to standardize data from across global health systems, then compare them in order to inform policy choices and improve health care value and patient care.

Multisite observational research reusing sensitive data requires a federated approach. Building on the lessons learned in several international research projects, we will discuss key issues in the deployment of federated research including how to achieve the data-visiting principle, the orchestration of the nodes in a federation, and the need for semantic and technical interoperability. Some tools for the deployment of federated research projects will be proposed.

Ageism is the discrimination of older adults based on their age and the negative portrayals of older adults as derived from age-based stereotypes centered on illness, irrelevance, and incompetence. The insidious consequences of ageism on health prompted 194 member countries to collectively work through the World Health Organization on a global campaign to combat ageism. Join us as Dr. Ng discusses innovative methods in analyzing the historical narratives of aging over 200 years, contemporary media portrayals of older adults, and strategies to reframe aging.

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Sara Machado Ph.D. uses the HSPA framework to examine the health policy propositions being debated by parties in the 2024 Portuguese legislative elections.

Medical crowdfunding is a key source of finance for individuals facing high out of pocket costs, including organ transplant candidates. However, little is known about racial disparities in campaigning activity and outcomes, or how these relate to access to care. In this exploratory nationwide cross-sectional study, we examined racial disparities in campaigning activity across states and the association between U.S. campaigners’ race and ethnicity and crowdfunding outcomes using a novel database of organ-transplant related campaigns, and an algorithm to identify race and ethnicity based on name and geographic location. This analysis suggests that there are racial disparities in individuals’ ability to successfully raise requested funds, with Black and Hispanic campaigners fundraising lower amounts and less likely to achieve their monetary goals. We also find that crowdfunding among White, Black, and Hispanic populations exhibit different patterns of activity at the state level, and in relation to race specific uninsurance and wait list additions, highlighting potential differences in fundraising need across the three groups. Policy efforts should consider not only how inequalities in fundraising ability for associated costs influences accessibility to care, but also how to identify clinical need among minorities.

Most high-income countries except the US rely on health technology assessment (HTA) to ensure that prices paid for new medicines reflect the value they provide.1,2 Health technology assessment bodies assess the relative clinical or economic impact of new drugs to guide pricing and coverage decisions. These assessments usually occur after marketing authorization by a medicines regulatory body (eg, European Medicines Agency), and patients may have little or no access to therapies not assessed favorably by HTA bodies. As Medicare considers using comparative effectiveness data to negotiate drug prices, examining HTA decisions abroad can inform US policymakers about how HTA affects the availability and coverage of new medicines.3 We analyzed HTA outcomes and review times in 6 countries (Australia, Canada, England, France, Germany, and Switzerland) for novel therapeutic agents approved by the US Food and Drug Administration (FDA).

Irene Papanicolas: Every health care model involves people doing their best to balance competing priorities in the face of limited resources. In other words, every system involves tradeoffs.

Davos, Switzerland — Findings from an ongoing research collaboration between FOUR, LinkedIn, CHeSS, and the VA on the AI workforce in health were featured in a session at the World Economic Forum on January 18, 2024.

In low- and middle-income countries, many believe that telehealth services could significantly expand access to doctors by offering remote access at low cost. Yet, despite its convenience, telehealth care is limited by the absence of physical examination, point-of-care testing, or immediate treatment. Hence it is unclear how individuals value such options compared to standard face-to-face care. We study this issue in South Africa with general practitioners who today mostly practice in the private sector and are geographically located in wealthier areas with higher health insurance coverage. We use an incentive-compatible method to elicit robust measures of willingness-to-pay (WTP) for telehealth and face-to-face consultations with general practitioners in a sample of uninsured individuals. We find that only 36% of respondents are willing to pay the prevailing market price for a telehealth consultation. We find average WTP for in-person consultations is only 10% higher than that of telehealth. Additionally, individuals with higher health needs are willing to pay a premium for face-to-face consultations, while others are indifferent. Our findings suggest that private telehealth services are better suited for more minor health needs, but are unlikely to expand access to a majority unless cheaper models are introduced.

Americans pay more for brand-name prescription medications than do residents of most other countries, with per capita spending on pharmaceuticals nearly three times the average of other member nations of the Organisation for Economic Co-operation and Development (OECD). In 2022, high costs forced one of five U.S. adults age 65 and older to skip or delay filling a prescription, miss or reduce doses, or use someone else’s medication. More than half of patients resort to cost-coping strategies like coupons or free samples so they can get the medications they need but cannot afford. Such stopgap measures can have particularly serious consequences for older people who rely on medications to control chronic health conditions.

The key messages of this policy brief published by the European Observatory on Health Systems and Policies are as follows:
- Health systems performance assessment (HSPA) is about helping decision-makers to work through performance challenges in context, that is, in light of what drives their own health system and its outcomes, to make better informed choices about change.
- Health systems have porous boundaries but act on wider societal goals through a complex iteration of functions, intermediate objectives and goals.
- The global HSPA Framework is based on the consensus reached by a coalition of countries, key stakeholders and civil society coordinated by WHO (UHC2030). It reflects a rigorous review of existing tools by the UHC2030 Technical Working Group on Health System Assessments, which included Member States, global health organizations, key players like the European Commission, the OECD and the World Bank, donors and academia, and agreed a harmonized approach to assessment.
- The new elements of the framework are about learning from the pandemic and bringing to the fore those existing elements that proved particularly policy- relevant. These include the following.
- The health system plays a significant role in contributing to larger societal objectives and to well-being, for example by fostering cohesion and supporting economic development.

The COVID-19 pandemic was associated with increased mental health visits for parents of young children. This raises concerns about mental health impacts and highlights the need to address these concerns.

Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns.

Report identifies striking lack of progress relative to peer countries.

“You get what you pay for” most aptly summarises the UK’s position in recent international comparisons published by the King’s Fund.1 Compared with the health systems of 19 high income countries, the UK spends just below average per capita on health and is “neither a leader nor a laggard” in overall performance, but “more of a laggard than a leader on health outcomes.” As the authors note, these findings are not so different from a series of comparisons published around the time of the 70th birthday of the NHS, five years ago.23 This indicates a lack of progress at best, but given that international data often come with a lag, the full effects of the pandemic on the health system are also not fully reflected.

COVID-19 has demonstrated the serious threat pandemics pose to both health and health systems. Pandemic preparedness plans are key strategic tools that enable policymakers to limit the severity of a disease outbreak but plans also need to build resilience into the health system to withstand pandemic shocks.

Health system performance assessment can be applied to pandemic preparedness planning to identify those strategies that improve health system resilience.

Which pandemic preparedness strategies strengthen health system resilience? Can health system strengthening and pandemic preparedness align? How can we use health system performance assessment to support pandemic preparedness? Join us to find out!

Jonathan Cylus and colleagues argue that inflationary pressures mean the NHS may have reached the limit on its ability to contain costs for goods and staff without affecting care.

The need for cardiac transplantation (CT) in eligible patients with advanced heart failure has continued to grow, with a substantial mismatch between organ availability and demand. As the demand for transplantable organs has risen in the United States,1 so has the prevalence of major cardiometabolic risk factors, including diabetes mellitus (DM), among the current and emerging pool of potential donors.2 Although the cardiovascular complications of DM are well recognized, donor DM status has not been shown to adversely impact post-CT outcomes in older analyses.3 However, this has not been evaluated in the contemporary era or over longer-term follow-up.