Comparing Health Systems

Comparison is elemental and learning inevitable in life as much as in health services research. We know what something is only by reference to what it is not, while the very process of referring and distinguishing depends on patterns of classification and categorization inherited from others and inhabited by virtue of the language we use.

Much of the rationale of comparative analysis in public policy rests on the claims it makes about learning. Ordinarily, these are of two kinds, one cast in terms of evaluation and the other as explanation. Cross-national evaluation assumes that researchers might learn from others: If they look abroad, they might examine alternative ways of doing things, alternative solutions to common problems, and new ideas that might work for them. Single-pipe financing, for example, or the flow of funds from a single source, seems to limit the growth of the cost of healthcare (simply because those standing at the pipe can turn the tap on or off).

Meanwhile, in seeking explanations of why things happen as they do, comparing two or more cases makes it possible to isolate dependent and independent variables and then to specify relationships between them. This makes for greater (and sometimes lesser) confidence in the understanding of causes and effects, inputs, outputs, and outcomes. Historians of health policy, for example, note the role of organized labor in the introduction and expansion of public coverage for the personal costs of healthcare: In some European countries, national systems were introduced by conservative regimes to meet (or at least blunt) workers' demands; in others, they were introduced by workers' parties once in power.

In both instances, evaluation and explanation, comparison constitutes a more or less elaborate appeal to scientific method to establish what works, and why. It is encouraged by demands for evidence-based policy and plays well to an assumption that good policy should be based on good science.

Yet there is a third function of comparison, one that may in fact be prior to the other two. Because it seems more ordinary, more ubiquitous, it often passes unnoticed. This is comparison as a form of exploration, of self as much as others. Researchers figure out who they are and what they do by reference to others, by association with them, and in distinction from them. As the British medical sociologist Philip Strong described in The Ceremonial Order of the Clinic, it was only when he watched clinical encounters in the United States that he understood how those in the United Kingdom really worked.

The origins of the cross-national, comparative investigation of health systems lie at least as far back as the University of Chicago's medical sociologist Odin W. Anderson's work of the early 1960s. But they came into vogue in the 1980s and 1990s for a number of contextual reasons. Some of these have to do with the increased availability of low-cost air travel and information technology. But it has also become clear that systems of all kinds had to find some way of managing increasing demand in the context of fixed or at least finite resources. At the same time, relations between countries were becoming more competitive, meaning that getting it right in health policy—ensuring universal access to high-quality healthcare without breaking the bank—was to get ahead both in domestic politics and in the international economy. Global trends were creating unprecedented opportunities for comparison and learning, as well as a pressing need to take them.

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