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How to speak comparative international healthcare

Updated: Jul 2

Ever have occasion to talk to partners overseas? Ever been drawn into wonky and/or political discussions comparing U.S. healthcare cost/quality to that of other countries? Ever been faced with a ‘best practice’ from elsewhere that may, or may not, make any sense in a different national environment? In today's blog post, we will share five starter principles for U.S.-context healthcare professionals in navigating the murky waters of comparative international healthcare. Granted, this is only a slice of our longer "How to speak comparative international healthcare" training. And, obviously, no single blog post can make you a true global healthcare expert. But you can level up in a hurry if you keep some of these real-talk insights in mind. So let's dive in.


1. Both more and less economically developed nations healthcare systems can be roughly categorized into five models; it is helpful to have at least a general conceptual vocabulary of all five.


Developed nations' healthcare systems were each founded on one or more organizing principles. These principles are important to understand because they shape the payment and provider landscape, influence outcomes, and are often used to make tradeoffs (seeing as no country has infinite healthcare resources). Performance shortfalls in cost, quality, access, etc., while never intentional per se, may reflect the tradeoffs that different countries have chosen to make.

 

While not the end-all-be-all in understanding any given country's system—more on that in a moment—it's still very handy to have a grip on the five basic national models. Especially when placed in the context of similar models that a U.S.-based expert will know. (Here's where it's actually helpful that we have a mish-mash of every single system right here at home!) Credit to journalist T.R. Reid's book "Healing of America," for this comparative discussion connecting familiar-to-U.S. healthcare models with the major flavors of international systems.

Informational graphic showing international healthcare models, their descriptions, a comparison to a similar part of the U.S. healthcare system, and example countries

2. Operational differences among international provider systems tend to be relatively small....


If you walk around a hospital in a developed nation abroad, daily operations may appear superficially very similar to what you are used to in the U.S.


Any given hospital you are visiting, or whose leaders you're talking with, will share the familiar goals and constraints of trying to deliver high quality, safety, access, productivity, and patient and staff satisfaction, all on some kind of budget. The workforce—and associated challenges such as shortage and burnout—will be similar. Access to clinical technology (e.g., imaging) will also feel generally familiar to U.S.-based healthcare professionals. One operational exception: The IT situation may be different; for example, hospitals in the U.S. adopted EMR before hospitals abroad did, so most inpatient settings abroad may be earlier along the curve of EMR implementations, especially across the care continuum. EMR purchases may be happening at the central government or regional level, not the hospital level. EMR vendors both from here (with Epic in the lead) are vying with EMR companies from overseas to gain and expand market share.


3. ...But strategic differences can be big


Operational similarities and nuances aside, the important contrasting point to remember is that behind-the-scenes strategy may be quite different in terms of what providers, especially, are trying to accomplish in any given country..


Here's one central strategic differentiator: Is a given provider trying to attract more patients, or not (and over what period of time)? Depending on the country, kind of patient, and service, provider executives may not be actively seeking to attract more patients or volumes because there is no incremental payment for those services (i.e., it's a capitated payment environment)—at least not in the short term. In this setting, a consultant from the U..S who comes along and says "This will help you grow" may not be well received.


If unsure what the central strategic goal is, it's critical to find this information out. Which may be easier said than done in a capitated country, where "we don't want more patients" will often not be said explicitly..


Also consider a flip-side question about timeframe and growth. While there may be no incremental budget given for attracting more patients during a given year or multiyear funding cycle, centrally funded international systems do look at volume data to determine how to allocate budgets, investments in technology, new facilities, etc. In other words, incremental volume may be painful in the short term, but beneficial in the long term. It's nuanced and only investigating this question on a case-by-case basis will do.


4. Model-centric comparisons between healthcare systems are useful—but only to a point. 


Yes, it is both possible and useful to categorize different countries by central intent and/or how the system generally works. But, don't over-rely on the explanatory or conceptual way-finding power of the models, because they are limited by various real-world factors, including:


Most models are not mutually exclusive/not pure; each has elements of the other systems also present.


Any could be called hybrid. The U.S. has the most famously mixed system, of course, but even the U.K.'s seemingly pure Beveridge model contains elements of both public and private reimbursement and care delivery. That makes the big question not, "is this a public or private system?" but more, "how big is the public versus private layer relative to each other, and how messy does it get?" 


Spending and quality comparisons across international healthcare systems have to contend with a tremendous number of "apples to oranges" differences.


These differences permeate accounting, quality metrics, terminology, and more. For example, quality alone has many different dimensions in it, and different countries have highs and lows in each. It''s easy to fall into massive over-generalizations—and counter-productive to do so—because each quality domain tends to have at least some unique drivers (and solutions) that do not apply across the quality board. We went into cost/quality comparison issues much more in the full version of the webinar; if you're a Union member, you can access the full deck here. (If you're not a Union member, but interested in more info or checking out the deck, message us at info@unionhealthcareinsight.com)


National healthcare systems frequently feature significant within-country variability AND, models also morph over time.


For our final point on the limitations of generalizing about a country's healthcare system based on its official "model", let's take a look at Spain. As it turns out, Spain is a terrific example of the complexities faced by the aspiring master of comparative international healthcare. Here, I also want to introduce Daniel Dellaferrera, a former colleague and international healthcare expert who joined us live as a guest panelist on Union's Strategy Bootcamp webinar for members last week.


As Daniel pointed out in the session: T.R. Reid's overview of international healthcare models bucketed Spain as a Beveridge model healthcare system in 2010–and rightly so, because it started out that way. In fact, Spanish officials went to the NHS to study how it worked and figure out how to adapt it to the Spanish context after the end of the Franco regime in the late 1970s. "But since that time," as Daniel explained, "Spain keeps swinging back and forth between two political parties that are actually further apart from each other than Democrats and Republicans are here in the US. Every time the Partido Popular (the PP), the rightwing group, comes into power, they go after many of the NHS-like elements." (NHS= National Health System = England's Beveridge-model public health system). Daniel continued:


"They allowed privately-funded actors to enter what used to be a fully publicly funded health system. And they gave regions within Spain more leeway to try their own thing without much central control from the central government in Madrid. So now, in Spain, if you focus in Catalonia and Basque Country, you will still find an almost purely Beveridge-model health coverage system. But if you look at Valencia, you will see more and more instances of private provision and additional private payment coming into the equation."


Spinning the globe over to North America: This type of wthin-country variability can be found in many other places around the world. For example, "Canadians outside Ontario may be offended if you assume all of Canada is like Ontario." Daniel said. "The differences between Ontario and, say, British Columbia are significant, you have to take them into consideration. Interestingly, [spins globe to Australia] British Columbia actually resembles New South Wales more than it does Ontario; meanwhile Ontario is much more similar to Victoria in Australia than it is like other parts of Canada!" Got all that?


If you are thinking, "No way can I remember all this about Spain, Canada much less the whole world," just go back to these two main points about the limitatiosn of model-centric thinking.


  • WITHIN a country, a 'national healthcare model' is not always consistent. There is a regional healthcare structure that is easy for U.S.-based healthcare people to overlook, because we are used to a regulatory and market situation that, while it may be messy and variable, is TYPICALLY messy/variable in the same way across all US states.


  • OVER TIME, countries' (as well as regions') healthcare models can and do change. Healthcare is always and everywhere a political issue, and political winds shift. But knowing which systems fall into which basic model is a good place to start.


5. All developed nations’ healthcare systems are wrestling with a common set of challenges


Here in the U.S., conventional wisdom often says that healthcare here is in horrible trouble (poor quality, high cost, low access),and that in contrast, other developed nations have figured it out and created ideal, or at least far-superior systems. Without getting deeply into that discussion, and regardless of the benchmark, it's important to keep at least one major contextual insight in mind: Most developed nations share common problems—at least in the trend line. Namely:


  • Aging populations

  • Increasing prevalence of obesity and chronic conditions

  • Rising cost of technology and drugs

  • Clinical workforce challenges, such as shortages and burnout


All of these are shared issues across international systems, at least to some extent, and no healthcare system has fully figured these problems out.


Also: While less-developed countries certainly don't have the near-term challenges stemming from an aging population, they're not immune from other shared afflictions in common with the developed world. From obesity to pollution-linked asthma, the speed of economic development in less developed countries has brought many of the challenges associated with the developed world—and far faster than most observers expected. 

A graphic summarizing common trend-line challenges in international healthcare - including increases in average age, obesity, and chronic condition prevalence


Key takeaways on comparative international healthcare


In this post, we've covered the following major takeaways.

  • You can roughly categorize both more and less economically developed nations healthcare systems into five models.; it is helpful to have at least a general conceptual vocabulary of all five.

  • In developed nations, within a given clinical setting (such as a hospital) operational issues are generally similar—e.g., all hospitals everywhere are trying to deliver high quality, safety, access, productivity, patient and staff satisfaction, all on some kind of budget.

  • However, strategic goals and behavior will differ significantly depending on country and healthcare system context.

  • Model-centric comparisons between healthcare systems are only useful to a point. For various reasons, including: Shortfalls reflect tradeoffs that different countries have chosen to make. Most models are not pure (and so, not mutually exclusive/have elements of the other systems also present). And last but not least, both spending and quality comparisons across international healthcare systems have to contend with a tremendous number of "apples to oranges" differences in accounting, quality metrics, terminology, and more.

  • Within both developed and developing nations, many of the biggest challenges are similar on trend line. Absolute performance can be quite different among countries, but no country's healthcare leaders will say they have issues like "aging population", "rising prevalence of chronic conditions", or "rising cost" figured out.

Another day, another great strategy topic


If you're trying to keep your board/exec team/colleagues all educated on fundamentals, not to mention up to date on the ever-changing healthcare environment—this is what we do! Our educational modules cover a wide range of topics, from enabling productive participation in comparative international healthcare discussions, to what's happening in healthcare tech, policy, workforce, service lines, and more. We are happy to provide more info; reach out to info@unionhealthcareinsight.com to set up time to talk about how Union can help.

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