Making Sense of Health Rankings
Are Canadians healthier than residents of other countries? Introduction Have Canada's public health policies and health care systems succeeded in promoting the health of its citizens? The answers to these seemingly simple questions are important to the public and policy-makers alike, but unfortunately they are surprisingly difficult to answer. To gauge how changes in Canadian policies or practices might affect the health of the population, comparisons are sometimes made between Canada and countries whose socio-economic characteristics are similar but whose health care financing or delivery mechanisms differ. Often, countries are rank ordered according to one or a number of indicators. Depending on the purpose of the comparisons, the indicators considered and methods used, the rank order of countries may be starkly different. As shown in Box 1, Canada came in 11th out of 24 countries according to one source and 23rd out of 30 in another health-related ranking.
Canada ranked 11th among 24 countries belonging to the Organisation for Economic Co-operation and Development (OECD) in terms of overall health performance. The ranking considered life expectancy, rates of death and disease, immunization rates, selfreported health and certain risk factors (such as rates of obesity).1
Canada ranked 23rd among 30 countries according to a Euro- Canada Health Consumer Index that incorporated measures of patient rights and information, waiting times for treatment, clinical outcomes, generosity of public health care systems and provision of pharmaceuticals.2
Canada's health system was ranked 30th among 191 nations by the World Health Organization according to measures of the health status of the population, the responsiveness of the health system and national health expenditures.3
Ranking procedures are not confined to international comparisons. Recent reports have also used rankings to compare the performance of provincial health care systems within Canada1 and to assess the quality of hospitals within certain provinces.4
Reports of international and within-country rankings receive widespread media attention because rankings, while often constructed using complex concepts and underlying methods, appear straightforward. For example, virtually everyone can understand that a rank of 1 out of 10 is better than a rank of 5 out of 10.
Rankings are usually made to focus attention on the success of public health efforts, health system performance and quality of medical care. Although the media grab our attention with such rankings, how seriously can they be taken? What questions should Canadians be asking as they read news articles about the relative ranking of their hospital or their jurisdiction's health care system? This report raises four key questions to consider carefully when critically evaluating health ranking reports:
- Which aspects of health or health care are considered in the ranking?
- How meaningful and valid are the indicators chosen to quantify these aspects of health and health care?
- Are ranking indicators based on accurate, reliable and comparable information?
- Do sound methods underlie the ranking process?