2009 Euro-Canada Health Consumer Index

7/30/2019 2009 Euro-Canada Health Consumer Index

1/46EURO-CANADA HEALTH CONSUMER INDEX 2009 20O9

FRONTIER CEN

FCPP POLICY SERIES NO. 61MAY 2POLICY SERIES

Euro-Canada HealthConsumer Index

2009

FCPP POLICY SERIES NO. 61 MAY 2009

FRONTIER CENTREFOR PUBLIC POLICY

Daniel Eriksson, M.Sc.and Arne Bjrnberg, Ph.D.

PRESENTED BY


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FRONTIER CENTREFCPP POLICY SERIES NO. 61 MAY 2009 20O9

EURO-CANADA HEALTH CONSUMER INDEX 2009 POLICY SERIE

The Frontier Centre for Public Policy is an independent, non-profit organization thatundertakes research and education in support of economic growth and social outcomes thatwill enhance the quality of life in our communities. Through a variety of publications andpublic forums, the Centre explores policy innovations required to make the eastern prairiesregion a winner in the open economy. It also provides new insights into solving importantissues facing our cities, towns and provinces. These include improving the performance ofpublic expenditures in important areas like local government, education, health and socialpolicy. The author of this study has worked independently and the opinions expressed aretherefore his own, and do not necessarily reflect the opinions of the board of the FrontierCentre for Public Policy.

Policy Series No. 61Copyright 2009 by the Frontier Centre for Public Policy

& Health Consumer Powerhouse.

Date of First Issue: May, 2009.Reproduced here with permission of the authors.

ISSN 1491-78

This report may be freely quoted, referring to the source.

FRONTIER CENTREFOR PUBLIC POLICY

www.fcpp.org

MB: 203-2727 Portage Avenue,

Winnipeg, Manitoba Canada R3J 0R2

Tel: 204 957-1567 Fax: 204 957-1570

SK: 2353 McIntyre Street,

Regina, Saskatchewan Canada S4P 2S3Tel: 306 352-2915 Fax: 306 352-2938

AB: Ste. 2000 444 5th Avenue SW

Calgary, Alberta Canada T2P 2T8

Tel: 403 230-2435


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EURO-CANADA HEALTH CONSUMER INDEX 2009 20O9FRONTIER CEN

FCPP POLICY SERIES NO. 61MAY 2POLICY SERIES Ideas for a better tomorro

Table of Contents1 EXECUTIVE SUMMARY 52 INTRODUCTION 6

2.1 Background 6

2.2 About the authors 7

2.3 Countries involved 7

3 RESULTS OF THE EURO-CANADA HEALTH CONSUMER INDEX 2009 8

3.1 Results summary 10

4 HOW DOES CANADA COMPARE TO EUROPE? 16

4.1 Patient rights and information 16

4.2 Waiting times for treatment 194.3 Outcomes 20

4.4 Range and reach of services provided 21

4.5 Pharmaceuticals 22

5 BANG-FOR-THE-BUCK ADJUSTED SCORES 23

5.1 BFB adjustment methodology 24

5.2 Results in the BFB score sheet 25

6 HOW TO INTERPRET THE INDEX RESULTS 26

7 SCOPE AND CONTENT OF THE EURO-CANADA HEALTH CONSUMER INDEX 27

7.1 Strategy and background 28

7.2 Indicators introduced for the ECHCI 2009 287.3 Indicator areas (sub-disciplines) 28

7.4 Scoring 29

7.5 Weight coefficients 29

7.6 Regional differences 30

8 INDICATOR DEFINITIONS AND DATA SOURCES 31

8.1 Additional data gathering survey 36

8.2 Additional data gathering feedback from National Ministries/Agencies 36

8.3 Threshold value settings 38

9 HOW THE ECHCI 2009 WAS BUILT 39

9.1 Phase 1 399.2 Phase 2 39

9.3 Phase 3 39

9.4 Phase 4 40

9.5 Phase 5 40

9.6 External expert reference panel 41

10 FAQS 42

11 REFERENCES 45

11.1 Useful links 45

FCPP Policy Series No. 61 May 2009

Euro-Canada Health Consumer Index 2009Daniel Eriksson, M.Sc. and Arne Bjrnberg, Ph.D.


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In 2008 the Health Consumer Powerhouse (HCP) and the Frontier Centre for Public Policypresented the first Euro-Canada Health Consumer Index. This marked the inductionof Canada into a comprehensive benchmarking exercise that analyzes the consumerresponsiveness among 29 national European healthcare systems.

The Euro-Canada Health Consumer Index (ECHCI) was an alarm bell, as it showed thatCanada was placed in the bottom quarter of the Index though it spent more money toachieve worse results than a large number of European competitors. In specific:

Canadians suffer from a healthcare system officially based on equity and solidarity but in reality it is a sub-standard one that denies Canadian healthcare consumers manyof the services taken for granted in Europe;

Patient rights, access to information, and choice and services without delay areunderdeveloped in Canada and deliver low value for the money spent;

The positive part of the comparison is that the qualityof treatment when delivered puts Canada on par with most European countries.

The authors believe in the power of benchmarks. The lesson from the HCPs five yearsof healthcare benchmarking is that comparisons count. Weak or excellent performancesamong the national healthcare systems are highlighted as good examples. But to servethe intended purpose, stakeholders must take action when the alarm bell rings.

The 2008 Index caused a stir within Canada. But that is far from enough. Governments,patients and consumers now have a better foundation for taking action. This years Indexwill provide additional fuel for that fire as it confirms the poor cross-Atlantic position ofCanada; 2008 evidently was no isolated poor score on Canadas part.

Canada can ill-afford another lost year without closing the gap and the question remains:why should Canadians be satisfied with a level of (poor) care that is becoming outdatedin Europe?

Brussels, Ottawa, Winnipeg

May, 2009

Johan Hjertqvist, President, Peter Holle, President,

Health Consumer Powerhouse, Frontier Centre for Public Policy,

Brussels/Stockholm, Sweden Winnipeg, MB Canada

Canadian healthcare: another lost year


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1. Executive Summary

In this second annual Euro-Canada Health Consumer Index (ECHCI), Canada ends up in23rd place. This years winner, the Netherlands, scores 824 points out of 1,000 edgingout runner-up and last years winner, Austria, by a margin of eleven points. Luxembourgand Denmark take third and fourth place with 795 and 794 points, respectively.

In terms of medical outcomes, Canada compares reasonably well with the bestperforming healthcare systems and on the generosity scale Canada collects an averagescore. With respect to patient rights, waiting times and availability of pharmaceuticalsCanada places at the absolute bottom in the rankings.

Estonia prevails in the value-for-money-adjusted Bang-for-the-Buck index, while placing11th overall in the ECHCI Index and competing very well with countries spending vastly

more per capita on healthcare. Taken together Canadas poor overall performance inthe Index along with a high expenditure on healthcare services leads to Canadas last-place ranking in the Bang-for-the-Buck index.


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The Health Consumer Powerhouse (HCP) isa centre for visionary thinking and action-promoting consumer-related healthcarein Europe. HCP declares that Tomorrowshealth consumer will not accept anytraditional borders. In order to become apowerful actor, and to build the necessaryreform pressure from below, the consumerneeds access to knowledge in order tocompare health policies, consumer servicesand quality outcomes. In the 2009 Euro-

Canada Index, Canadas Frontier Centrefor Public Policy (FCPP), together withHCP, continues its commitment to evaluatehealth policy across Canada. All theEuropean countries included in the Indexshare Canadas commitment to accessibleand effective healthcare. By comparingthe performance of Canadas healthcaresystem with the extremely varied systemsin Europe, we can gain much insight intohow Canada is succeeding and how it can

improve.

Since 2004 HCP has published a widerange of comparative publications onhealthcare in various countries. Startingwith the Swedish Health Consumer Indexin 2004, HCP now has a series of annualpublications including the Euro ConsumerHealth Index, the Euro Consumer HeartIndex and the Euro Consumer DiabetesIndex. As of 2008, HCP in collaborationwith FCPP also publishes the Euro-CanadaHealth Consumer Index and the Canada

Health Consumer Index.Though it is still a somewhat controversialposition, HCP advocates that qualitycomparisons within the field of healthcareare a win-win situation. For the consumer,better information will create a betterplatform for informed choice andaction. For governments, authoritiesand providers, the sharpened focus onconsumer satisfaction and quality outcomes

will help to support change whether asapplied to evidence of shortcomings ormethod flaws; the index also illustratesthe potential for improvement. With sucha view, the ECHCI is designed to becomean important benchmark that supportsinteractive assessment and improvement.

2. Introduction 2.1 Background


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Daniel Eriksson (M.Sc.), for the FrontierCentre for Public Policy, is the leadresearcher for the Canadian componentof the Euro-Canada Health ConsumerIndex 2009. Mr. Eriksson wrote his thesison product introduction on the healthcaremarket and received his masters degreein Industrial Engineering and Managementfrom Linkping University, Sweden. He alsoattended classes at the Asper School ofBusiness, Winnipeg.

The project management function of theEuro-Canada Health Consumer Index 2009was carried out by Arne Bjrnberg (Ph.D.).Dr. Bjrnberg has previous experience fromResearch Director positions in Swedishindustry. His experience includes havingserved as CEO of the Swedish NationalPharmacy Corporation (Apoteket AB),Director of Healthcare & Network Solutionsfor IBM Europe Middle East & Africa, and

CEO of the University Hospital of NorthernSweden (Norrlands Universitetssjukhus,Ume). Dr. Bjrnberg was also the ProjectManager for the EHCI 2005 2008projects.

2.2 About the Authors 2.3 Countries Involved

Last year the ECHCI already included all 27European Union member states as well asNorway and Switzerland. This year, Croatiaand FYR Macedonia expand the Index toinclude a total of 32 candidate countries,including Canada.

Countries included in Euro-Canada HealthConsumer Index 2009:

Austria Italy

Belgium Latvia

Bulgaria Lithuania

Canada Luxembourg

Croatia Malta

Cyprus Netherlands

Czech Republic Norway

Denmark Poland

Estonia Portugal

Finland Romania

France Slovakia

FYR Macedonia Slovenia

Germany Spain

Greece Sweden

Hungary Switzerland

Ireland United Kingdom


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3. Results of the Euro-Canada HealthConsumer Index 2009


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3.1 Results SummaryThis second attempt at creating acomparative index for the Canadian

and the European national healthcaresystems confirms that there is a groupof EU member states that all have goodhealthcare systems as seen from thecustomer/consumers point of view. Thescoring was done in such a way that thelikelihood that two states should end upsharing a position in the ranking is almostzero. It must therefore be noted that greatefforts should not be spent on in-depthanalysis of why one country is in 11th

place, and another in 14th. Very subtlechanges in single scores can modify theinternal order of countries.

In the ECHCI 2009 the Netherlands ranksfirst among the 32 participating countries,scoring 824 points out of 1,000. Lastyears winner, Austria, claims the secondspot with 813 points, ahead of Luxemburg

and Denmark with 795 and 794 points,respectively. Meanwhile, Canada maintains

its 23rd position from last years Euro-Canada Index.

The ECHCI winner, the Netherlands, hasconsistently been at the top in the totalranking of all Health Consumer Powerhouseindexes published since 2005. The Dutchhealthcare system does not seem tohave any real weak spots in the five sub-disciplines of the Index except possibly forwaiting times where some other Europeancountries excel, including runner-upsAustria and Luxembourg. Denmark, infourth place, has continually risen sinceit was first included in the EHCI in 2006.It would seem that the dedicated effortsmade by Danish politicians and publicagencies to achieve real upgrades in thehealthcare system are paying off. This isalso corroborated by the fact that Denmark


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emerged as the total winner of the 2008Euro Consumer Diabetes Index.

Consumer and patient rights are improving.In a growing number of European

countries, there is healthcare legislationexplicitly based on patient rights, andfunctional access to ones medical recordis becoming standard. Still, very fewcountries have hospital/clinic catalogueswith quality rankings. Canada ranks verypoorly in this sub-discipline in particular.

Generally, European healthcare continuesto improve but medical outcomes are stillappallingly poor in many countries. This is

particularly true regarding the number onekiller: cardiovascular diseases. Canada,on the other hand, achieves one of its fiveGreen scores for cardiac outcomes.

In some respects, progress is not onlyslow but also lacking. MRSA infectionsin hospitals seem to spread and area significant health threat in one outof two measured countries. Half ofthe governments systematically delayconsumer access to new medicines and not

just for reasons of poor national wealth.Canadas major weak spot in the Indexis still waiting times for treatment;Canada scores the lowest possible scorein this category. For years, the wait-timesituation in Canadian healthcare hasbeen on the discussion agenda for alllevels of government and has become themost important healthcare issue amonghealthcare providers. Even if waiting timesin Canada have showed improvements incertain areas over the last years, whencompared to the European competition,Canada still has a long way to go.

Some eastern EU member systems dosurprisingly well considering their muchsmaller healthcare spending in purchasingpower adjusted dollars per capita. However,readjusting from politically-planned to

consumer-driven economies does taketime.

If healthcare officials and politicians lookacross borders and steal improvement

ideas from their colleagues, there is a goodchance for a national system to come muchcloser to the possible top score of 1,000.As a prominent example, if Sweden couldachieve a German or Swiss waiting-listsituation, that alone would lift Sweden tothe top of the Index with a total score of869.

3.1.1 Country scores

No country excels across the entire rangeof indicators. The national scores seemto reflect national and organizationalcultures (including attitudes) rather than areflection of how many resources a countryspends on healthcare. In all likelihood, thecultural aspects have deep historical roots.Turning a large corporation around takes acouple of years turning a country around

can take decades.Countries with pluralistic financingsystems, i.e., those that offer a choiceof health insurance solutions and alsoprovide the citizen with a choice betweenproviders regardless of whether these arepublic, private, non-profit or for-profit,generally score high on patient rights andinformation issues. Under this sub-set ofindicators, countries like Denmark andthe Netherlands score high on openness

and patients access to their medicalinformation. Scores of countries such asCanada, Germany, France, Italy and Greecesuffer from what seem to be an expert-driven attitude to healthcare, wherepatients access healthcare information withhealthcare professionals as intermediariesrather than accessing the informationdirectly.


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In an attempt to summarize the mainfeatures of the scoring of each countryincluded in the Index, the following tablegives a somewhat subjective synopsis.

To the consumer, i.e., most of us, adescription and comparison of healthcarerequires some simplifications. (A medical

information system deals with scientificevidence such as individual diagnosis ormedication guidelines requires very strictcriteria; in contrast, the Index should

be seen as consumer information and itcannot be considered scientific research.)

Country Scoring Synopsis

Austria Very good medical results and excellent accessibility to healthcare.Austria leads the EU on overall cancer survival. Slightly autocraticattitude to patient empowerment risks affecting good therapy outcomes.

Belgium Good at accessibility; suffers on outcome quality, possibly because of aneven weaker reporting culture than the European average. Remarkably

slow at offering access to new medicines.Bulgaria Has a long way to go. Public health situation also suffers from severe life-

style related problems (obesity, smoking, alcohol) affecting cardiac diseaseand other death rates.

Canada Solid medical outcomes, moderate-to-poor provision levels, and very poorscores with regard to patients rights and accessibility. Canada is in thebottom quartile in the overall matrix; Canadas very high level ofhealthcare spending means that when adjusted for bang-for-the-buck, thecountry places last in the that ranking.

Croatia Scores well on patient rights and information, probably due to good

legislative background of patients position within the healthcare system.The ranking would likely be better if statistics on waiting times andpharmaceuticals had been available.

Cyprus Problematic to score, as no other member state has as high a proportionof healthcare being privately funded. If the patient can afford to pay out ofpocket, good healthcare can be had in any country.

Czech Solid mid-field performer with improvement record. Could reconsiderRepublic resource distribution between healthcare staff and equipment/medicines;

notoriously thrifty on prescription drugs.

Denmark Ranked number one on patient rights and information, and e-Health.Danes are very satisfied with their primary care, and medical outcomeshave improved; hence the solid top spot in the Index.Waiting times could improve.

Estonia Estonia, with its population of 1.5 million people, proves that a smallcountry can engage in dramatic change quicker than larger nations. Ittakes more than a dozen years to change a top-down planned economyto become a customer-driven one. Good on MRSA infections and efficientfinancial administration of pharmaceuticals. Sweeps the floor withcompetition on value-for-money adjusted scores.


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Finland Good medical outcomes and range and reach of services. The waitinglist situation is still the Achilles Heel in a European comparison. Not much ofconsumer empowerment to be seen yet.

France Poor on e-health and increased restrictions on access to specialist carecreate a fall in ranking from top position two years ago. Reasonably goodoutcomes quality but slightly authoritarianif you want healthcareinformation, you must ask your doctor. Waiting times for specialistappointments are rising.

FYR Scores well on patient rights and information probably due to goodMacedonia legislation; ongoing reform promises further improvement. Acceptable

levels if we consider the resources available and socio-economicbackground of the country. Problem with lack of healthcare coverage;particularly for ethnic minorities.

Germany Superb access to healthcare but surprisingly mediocre outcomes and rangeand reach of services. Germany does not actively invite pro-active care;e.g. women and access to mammography screening, and has poor coveragein spite of unlimited access.

Greece Doctors in charge. Some improved medical outcomes, but still too manyout-of-pocket (and under-the-table) payments. E-health seems to not havebeen heard of in Greece.

Hungary Recent improvement of patient rights and information services is payingoff. Promising attempt to start an information revolution in healthcare.60 years of publicly financed healthcare has resulted in good coverage butmedical outcomes are still disappointing.

Ireland The Health Service Executive reform seems to have started improving ahistorically dismal performance. The severe waiting list problems seem tobe improving, and so are medical outcomes. However, patient organizationsdo not seem to have discovered this.

Italy Technically excellent in many places, but poor geographical equity.Autocratic attitude from doctors prevents Italy from scoring high in aconsumer index. A power shift to patients necessary.

Latvia At this point, Latvia lacks in resources and organizational culture to beconsidered a consumer-adapted system. The country does consist of morethan downtown Riga; poor geographical equity. Acute need for a systemoverhaul by external auditors.

Lithuania Noticeable improvement on patient rights and information, and access tohealthcare service. Still a long way from good outcomes but seems to haverisen from the absolute bottom level which it formerly occupied.

Luxembourg Winners of the 2008 Heart Index and rising in the EHCI - have had thegood sense (not self-evident in the public sector) to allow its citizens to visitcentres of excellence in other countries instead of insisting every procedureperformed at home. It is unclear what has withheld e-Health implement-ation, perhaps complacency?


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Malta The opening of the first state-of-the-art hospital in Malta (Mater Dei,November 2007) should provide the opportunity to obtain better care.High diabetes prevalence, possibly due to highest obesity rates in Europe.

Netherlands During the past four years the HCP has been unable to design an Indexwhere the Dutch are not in the top five countries. Holland may in factpossess the best healthcare system in Europe. Full marks on range andreach of services. Holland should eliminate general practitioner

gatekeeping and do away with waiting times to become superb.

Norway Still some access problems in spite of having poured significant money intohealthcare. Slow on new medicines deployment, and lots of prescriptionmedicines outside subsidy system. E-Health proficient in the top four.

Poland It takes more than a dozen years to change a top-down planned economyto a customer-driven one. Healthcare management reform necessary in

order to make decently paid professionals actually stay and work inhospitals, Poor access to new medicines and to low-cost prevention such asmammography and blood sugar control.

Portugal Severe access problems. Low infant mortality one of the few bright spots.It takes consistent action to change the long-term downturn. Bettertransparency could be a first step.

Romania Shares the problem of unofficial payments to doctors with several of itsneighbours. Good healthcare obtained this way unfortunately does notscore in the EHCI, apart from possibly improving waiting times scores.

Slovakia Not as financially stable as their Czech neighbours, and not significantly

consumer-oriented. Informal payment problems. Weak on medicaloutcomes. Some improvement on patient rights and involvement indecision-making.

Slovenia Noticeable improvement on patients rights and information. Decentoutcomes, but range and reach of services and waiting times have scopefor improvement. Still poor access to new medicines.

Spain It still seems that private healthcare is needed if patients want realexcellence. Informal payments in the public system are a small problem forin southern Europe. Fairly good access to medicines.

Sweden Excels at medical outcomes and good healthcare coverage. Poor (and

worsening) accessibility; oddly, the system has found no cure for waiting.Switzerland Running outside of EU competition. In a consumer Index, a system based

on individual responsibility does score high. Good but expensive.

United The NHS shares some fundamental problems with other centrally-Kingdom planned healthcare systems such as Sweden. Would require top class

management for that giant system. Superbug problems improving butstill poor.


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3.1.2 Results in Pentathlon

The Index is made up of five sub-disciplin-es. As no country excels across all aspectsof measuring a healthcare system, it istherefore of interest to study how the 32

countries rank in each of the five parts ofthe pentathlon. The scores within eachsub-discipline are summarized in the tableabove.

As the table indicates, the total score forthe Dutch healthcare system is to a greatextent a product of an even performanceacross the sub-disciplines, very good

Sub-

discipline Cana

da

Austr

ia

Belgium

Bulga

ria

Croat

ia

Cypru

s

CzechRepublic

Denm

ark

Eston

ia

Finland

Franc

e

FYRM

acedonia

Germ

any

Greec

e

Hung

ary

Irelan

d

Italy

Latvia

Lithuania

Luxembourg

Malta

Nethe

rlands

Norway

Polan

d

Portu

gal

Roma

nia

Slova

kia

Slove

nia

Spain

Swed

en

Switz

erland

UnitedKingdom

1. Patient rights and

information 75 95 100 85 85 90 80 145 115 125 110 85 95 90 115 85 95 55 115 100 90 125 110 85 65 75 90 115 75 100 100 105

2. Waiting times for

treatment 83 217 217 167 117 150 183 150 183 100 167 117 233 167 200 133 150 83 150 233 133 167 133 133 100 200 167 100 117 100 233 117 1

3. Outcomes 229 243 157 129 143 171 214 257 171 257 229 129 229 214 157 229 229 171 143 229 143 257 243 157 157 86 114 200 214 286 214 186 1

4. Range and reach

of services provided 100 108 133 58 75 75 92 117 92 133 108 75 100 67 92 92 100 100 67 133 92 150 117 83 92 67 92 92 117 125 83 117

5. Pharmaceuticals 63 150 75 50 50 88 100 125 113 88 100 50 113 88 88 125 88 50 50 100 88 125 100 63 100 75 100 75 125 125 125 100

medical quality and the only full score onrange and reach of services. Runner-upDenmark is still in top position for patientrights and information.

The Swedish healthcare system would bea top contender were it not for an accessi-bility situation, which by Austrian, Belgian,German or Swiss standards only can bedescribed as abysmal. Canadas healthcaresystem has much room for improvementand scores below the Index average inthree out of the five sub-disciplines.


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4.1 Patient rightsand information

The patient rights and information sub-discipline tests the ability of a healthcaresystem to provide the patient with a status

strong enough to diminish the gap betweenprofessional and patient. Even the poorestcountries can grant the patient knowledgeand a firm position within the healthcaresystem.

At their root, poor results in the othercategories often have a culture that isdisdainful of the rights of healthcareconsumers and which lack in transparency.Transparency allows consumers to holdtheir healthcare providers accountable,and it is the only real mechanism forempowering consumers.

In the patient rights and information sub-discipline, Canada places ahead of onlyLatvia and Portugal; there is much roomfor improvement. Scoring of this sub-discipline is presented based on the tenfollowing indicators.

4.1.1 Healthcare lawbased on patientsrights

At the national level, Canadian healthcareis largely governed by the Canada

Health Act, CHA (1984). As healthcare isconstitutionally a provincial responsibility,the CHA lays out the terms under whichit will transfer money to the provincesfor health spending. The Act determinestreatments that are provided at publicexpense, imposes restrictions onadditional fees and mandates portabilityand accessibility. Accessibility, though,is expressed solely in terms of the rightof all patients to uniform treatment

without regard to age, lifestyle or othercircumstances. The right to timely,appropriate or effective treatment is notmandated.

Individual provinces have been consideringvarious bills of rights for patients, but todate no province has a clearly enshrinedright to timely and effective treatment thatprovides practical remedies, without which

4. How does Canada compare to Europe?

The Euro-Canada Health Consumer Index2009 is the second annual report in

which the Canadian healthcare system iscompared to the healthcare systems ofEurope. The European countries, againstwhich Canada is compared, span a widerange of systems with respect to wealth,population size and history. While all statesprovide public healthcare, the degree towhich private care is available varies.

The Index research team has collecteddata on 32 healthcare performanceindicators structured to a framework whichconsists of five sub-disciplines: Patientrights and information, Waiting times fortreatment, Outcomes, Range and reach of

services provided, and Pharmaceuticals.Each of these sub-disciplines reflects

a certain logical entity, e.g. medicaloutcomes or waiting times.

Since the Index does not take the source offunding into consideration when measuringoutcomes, this tool is especially suited toa discussion of how Canadian healthcaremight be improved and brought up to thestandard enjoyed in most of Europe. TheIndex thus avoids the overdone conflictabout combining public and private careproviders. It is worth stressing thatthe Index does reward outcomes andconsumer-friendliness, not private or publicsolutions per se.


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patient guarantees are meaningless. Inthis regard, Canada falls well behind thegreat majority of European countries inthe Index. Canada scores the lowest mark,

Red. h

4.1.2 Patient organi-zations involved indecision making

There is no statutory requirement toinvolve patient advocacy (or otherstakeholder) groups in the policy-makingprocess. Nonetheless, in practice, broad,

national groups (such as the CanadianCancer Society and the Canadian DiabetesAssociation) as well as more disease-specific patient groups are invited to shareinformation with policy-making bodiesand they commonly endorse or criticizedecisions made by regional, provincial andfederal bodies regarding healthcare andtheir area of interest. While a full score isawarded to countries in which patient andconsumer groups are formally included

in the formation of health policy, Canadagets partial marks, Amber, for doing this incommon practice. l

4.1.3 No-faultmalpracticeinsurance

Canada does not have no-fault medicalmalpractice insurance. Patients seeking

compensation after an adverse event onlyhave the option of suing their healthcareprovider. There is a growing awarenessthat this system only focuses on findingfaults instead of cultivating efficiency orpatient safety. Recommendations have alsobeen made at the federal level to improvethis situation. As long as medical staffis discouraged from admitting errors forfear of lawsuits or until patients can get

compensation without the assistance of thejudicial system, Canada retains a score ofRed on this indicator.h

4.1.4 Right to asecond opinion

Canada provides no guaranteed right toa second opinion. While many patientadvocacy groups speak of a right to asecond opinion, this right is not guar-anteed in law. Many provinces and reg-ional health authorities encourage consu-mers to request a second opinion if theyare not confident in the diagnosis or recom-mendations of their physician but theyprovide no recourse for patients if such arequest is denied.

Further, since a second opinion from aspecialist requires a referral and often alengthy wait, even those regions that seekto provide second opinions have greatdifficulty in translating this into reality.The literature indicates that the access-ibility of second opinions remains much

worse than that of specialist referralsin general. Canada accordingly gets thelowest mark on this indicator, Red. h

4.1.5 Access to ownmedical record

Canadian law considers medical recordsthe property of the practitioner, with thepatient retaining the right to access the

contents. In practice, this means thatunless a physician can demonstrate thatallowing the patient or his proxy access toa record will harm the patient or a thirdparty, the contents of the record must bemade available to patients. Practitionerscan require that records be examinedonly in their presence, or charge a feefor the transfer of information, makingthe exercise of this right occasionally


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problematic. Because Canadians havethe nominal right to access their recordsbut the exercise of this right is subject tovarious conditions, Canada scores Amber

on this indicator. l

4.1.6 Register of legitdoctors

All provincial medical associations providea directory of physicians within theirprovince. Medical associations will alsoprovide disciplinary action information,although often the nature of suchcomplaints and the disciplinary actiontaken is not available to the public. Theaccessibility and content of physiciandirectories vary greatly between provinces.Verified physician profiles and informationon family physicians accepting new patientsare not always readily available through aweb- or telephone-based service. Further,because many registries depend upon self-reporting from physicians and accurateinformation about specialties is harder toobtain, Canada scores Amber. l

4.1.7 Web or 24/7telephone health-care information

Almost all provinces and territories provide24/7 telephone access to registerednurses through call centres. The PublicHealth Agency of Canada provides some

basic health information online and at theprovincial level many health ministries alsoprovide access to healthcare informationonline. However, there is a great rangein the quality and accessibility of theinformation offered. Based on the largeproportion of the population having accessto 24/7 healthcare hotlines Canada gets thehighest mark on this indicator, Green. i

4.1.8 Provider cataloguewith qualityranking

The federal Canadian Institute for HealthInformation collects comprehensive statis-tical information on hospital performancebut this information is not available to thepublic. Further, Canadian hospitals arenot compelled to publicly report statistics.As a result there are no provider (orhospital) listings available where patientscan actually see which hospitals have goodresults in term of actual success rates orsurvival percentages. Canada scores Red

on this indicator. h

4.1.9 e-Healthproficiency

Canada Health Infoway, an organizationfunded by the federal government, has setas its goal that 50 per cent of Canadiansshould have electronic patient recordsby 2010. An article published in HealthAffairs, 2007, states that only 23% ofprimary care practices in Canada useselectronic medical records. Since the Indexcut-off for the lowest criteria is a 50%use of electronic medical records amonggeneral practitioners, Canada is clearly inthe bottom category for this indicator andscores Red. h

4.1.10Cross-border careinformation

This indicator is meant to measure thewillingness of national governments toperform PR for cross-border healthcare.Since Canadas healthcare system doesnot encourage healthcare delivery outsideof each respective provincial healthauthority, cross-border care informationis lacking. Patients might, under specialcircumstances, be sent out of province for


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treatment or obtain healthcare out of thecountry, but this generally only happensin cases where medical treatment is notavailable or waiting lines are too long.

Canada scores Red on this indicator. h

4.2 Waiting times fortreatment

Health consumers with a complicatedcondition can be subject to up to fourlengthy waits: first, to see their familydoctor, or to find a general practitioner;second, to see the appropriate specialistfor their ailment; third, for diagnostic

procedures to determine appropriatetreatment; and fourth, for treatment.Relative to the other indicator areas, thewaiting times for treatment sub-disciplineand the outcomes sub-discipline are givenhigher weights to reflect of the importancethey have to patients.

Waiting times is Canadas weak spot in theIndex: Canada shares last place with Latviain the waiting times sub-discipline. This

sub-discipline is made up of five indicators,which are discussed below.

4.2.1 Family doctor sameday access

This indicator tests a very reasonabledemand: Can I count on seeing myprimary care doctor today? The 2007Commonwealth Fund International HealthPolicy Survey interviewed adults in seven

countries. Twenty-two per cent of Canadianrespondents stated they received anappointment the same day the last timethey needed care, while 30% waited morethan six days to get an appointment. As acomparison, the same results for the UKwere 41 and 12%, respectively. Canadareceives the lowest mark on this indicator,Red. h

4.2.2 Direct access tospecialist

While a referral to see a specialist is not

required in Canada, incentives makesself-referral a rarity in practice. Without areferral, specialists may see patients, butsince the fee is reduced most practicesoperate by referral only. On this indicatorCanada scores Red. h

4.2.3 Major non-acuteoperations


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4.2.5 MRI examinations


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4.3.5 MRSA infectionsPublic disclosure of nosocomial infectionrates, such as MRSA infection, is notmandatory in Canada. Starting as late as

2008, participating healthcare institutionsare now asked by Accreditation Canada toreport infection rates for either C. difficileor MRSA. The most recent available dataon MRSA rates in Canada is from 2003and states a 10.4% incidence rate ofMRSA in Canadian hospitals (percentageof S. aureus isolates which are resistant).More recent studies indicate that MRSAinfections are a growing problem in theCanadian healthcare setting, and this mostlikely means that the actual incidence rateis higher than what was reported in 2003.On this indicator Canada scores Amber. l

4.3.6 Rate of declineof suicide

This is a new indicator for the 2009 Indexand measures the relative decline ofsuicide rate. By using logarithmic values,

effects from countries having very differentabsolute suicide rates are eliminated. Thus,a country lowering its suicide rate fromfour to three receive the same trend line asa country lowering its rate from 40 to 30.Since the mid-1990s Canada shows a stabledeclining trend in the number of suicides,matched only by a handful of countries inthe Index. On this indicator Canada scoresGreen. i

4.3.7 Percentage ofpatients with highHbA1c levels (>7)

This is another new indicator for theECHCI. The HbA1c test is an importantassessment tool of how well diabetes hasbeen managed for individual patients.

While there is no official and nationalreport on this indicator in Canada, a 2005national cross-sectional study reported that49% of diabetes patients had an HbA1c

higher than 7. This puts Canada among thetop countries in the Index with a score ofGreen. i

4.4 Range and reach ofservices provided

This sub-discipline measures the breadthof services provided and the rate at whichinsured services are offered. Canadashealthcare system performs close to theIndex average when it comes to rangeand reach of services provided. However,Canada does underperform in two of thefive indicators in this sub-discipline: infantvaccination and dental care affordability.A closer look at the six indicators thatmake up the range and reach of servicesprovided sub-discipline is given here.

4.4.1 Cataract operationsThis indicator measures the number ofcataract operations performed on seniorsaged 65 years and older. Compared withother more costly procedures for non-life-threatening conditions, cataract operationsseem to be a good and less GDP-correlatedindicator on the generosity of publichealthcare systems. Canada reports acompetitive number of 821 proceduresper 100,000 population aged 65 years and

older and scores Green on this indicator. i

4.4.2 Infant 4-diseasevaccination

The most recent national data on infant4-disease vaccination (diphteria, tetanus,pertussis and polio) dates back from 2004and states an immunization coverage


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rate of 78.5%. A 2009 report fromthe Ontario Ministry of Health statedimmunization coverage rate estimates of75% for Toronto and 66-70% for all Ontario

children (children who had received allrecommended vaccines by the age of two).On the infant vaccinations indicator Canadascores Red. h

4.4.3 Kidney transplantsThere is a common notion that the numberof kidney transplants is greatly influencedby factors outside the control of healthcaresystems, such as the number of traffic

victims in a country. However, the levelof kidney donations reflects a complexrange of factors internal to the healthcaresystem. A high level of donation requireseverything from appropriate training foranaesthesiologists, dedicated donationteams that involve doctors, nurses andcounselors, and a high number of ICUbeds. This means that the level of kidneydonations is an excellent indicator onhow healthcare services perform, not an

indicator on the volume of traffic victims.With 37 transplants per million people,Canada scores Amber on this indicator.l

4.4.4 Dental careaffordability

Dental care is generally not included inCanadian Medicare, leaving patients torely on private dental insurance. While, in

2003, 61% of all Canadians reported havingdental insurance, 18% cited cost a reasonfor not seeking dental care and only 29%of seniors had insurance. Canada scoresRed on this indicator. h

4.4.5 Mammographyreach

This indicator was introduced as a proxy

of practical ability to organize and followa simple screening on a well-definedand easily reachable target population.Statistics Canada reports that 70.4% offemales aged 50-69 were screened withinthe last two years. This gives Canada ascore of Amber for the mammographyreach indicator. l

4.4.6 Informal payments

to doctorsThis is also a new indicator for the ECHCI.An informal payment is considered anypayment made by the patient in additionto official co-payment. As reported inthis years ECHCI and in the Euro HealthConsumer Index 2008, under-the-tablepayments are more common in someWestern European countries than perhapspreviously believed. However, in Canadathere are no indications of unofficial pay-ments and Canada scores Green on thisindicator. i

4.5 PharmaceuticalsEffective use of pharmaceuticals has thepotential to significantly reduce the needfor more drastic interventions and toimprove the quality of life for consumers.The availability of pharmaceuticals is a

crucial measure of how well a healthcaresystem serves its consumers. Whethermost people can afford drugs is oneaspect of this. Others are the speed withwhich new drugs are made availableto consumers and the degree to whichinformation about new drugs is accessibleto the public. Canadas score in thepharmaceutical sub-discipline is very low,placing above only a handful of countries.


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A look at the four indicators that make upthis sub-discipline follows below.

4.5.1 Rx subsidyCanada does not have a national pharma-ceutical program. Each province sets itsown policy for access, coverage and costsharing and as a result copayments varygreatly between provinces. Overall, publicexpenditure on prescription medicinestotals 48%, earning Canada a score of Redon this indicator. h

4.5.2 Layman-adaptedpharmacopeiaCanada does not have a consumer-friendlyservice equivalent to US-based RxList, amedical resource website, which offersdetailed pharmaceutical information onboth brand and generic drugs. The DrugProduct Database, DPD, offered by HealthCanada is a listing of drugs approved foruse in Canada. The database covers 23,000

drugs but information on each drug issparse and the data provided is of a verytechnical nature. While the DPD serveshealthcare professionals, it is not adaptedto the needs of consumers. Canada scoresRed on this indicator. h

4.5.3 New cancer drugsdeployment speed

The Cancer Advocacy Coalition of Canadareports that the time difference betweenCanada and the US to approve new cancerdrugs decreased since their last review ofapproval times. Their report from 2007stated that the new cancer drugs that metHealth Canadas regulatory requirementshad a median delay of seven months forapproval compared with the US.

Since the level of funding and access tocancer drugs varies between provinces inCanada, additional waiting times such asprovincial funding approval and guideline

writing are also added to the total waitingtime before a drug can be used by patients.Looking at major new cancer drugs andthe delay between their approval and firstuse, Canada is close to the EU average andscores Amber on this indicator. l

4.5.4 Access to newdrugs (time to

subsidy)This indicator measures the average timefrom date of approval for marketing tothe date of formulary listing. According toan OECD report from 2006, the speed ofaccess to new drugs across Canada wasaround one year or longer, well abovethe Index cut-off for a top score. Canadascores Red on this indicator.

5. Bang-for-the-BuckAdjusted Scores

After assessing 32 national healthcaresystems, it is apparent the Index triedto compare states with a significantdifference in financial resources. Theannual healthcare spending, in PPP-adjusted (Purchasing Power Parity) U.S.dollars, varies from less than $500 in FYRMacedonia to more than $4,000 in Norway,Switzerland, and Luxembourg. ContinentalWestern Europe and the Nordic countriesgenerally fall between $2,700 and $3,500,while Canada spends close to $3,700. As anattempt to account for these differences,the ECHCI Index includes a value-for-money adjusted score: the Bang-For-the-Buck adjusted score (BFB score).


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5.1 BFB adjustment methodology

*For Bulgaria and Romania,

the WHO HfA database (July

2008) contains old values

for the healthcare spend;

latest avai lable is $214 and

$314, respectively, which are

unreasonably low numbers.

The European Observatory HiT

report (http://www.euro.who.

int/Document/E90023brief.

pdf) on Bulgaria quotes the

WHO, giving the number $648,

also confirming the fact that

this is slightly higher than the

Romanian figure. The number

for Romania was taken from

a report from the Romanian

MoH (http://www.euro.who.int/

document/MPS/ROM_MPSEURO_

countryprofiles.pdf), also quoting

the WHO. Both these are a year

old, and have therefore been

raised by the same percentage

as GDP growth for the purpose of

this analysis.

The square root of this number was calcu-lated for each country. The reason for this

is that domestically produced healthcareservices are cheaper roughly in proportionto the healthcare expenditure. The basicECHCI scores were divided by this squareroot. For this exercise, the basic scoringpoints of 3, 2 and 1 were replaced by 2, 1and 0. In the basic ECHCI, the minimumscore is 333 and the maximum 1,000. With2, 1 and 0, this does not (or only verymarginally) change the relative positionsof the 32 countries, but is necessary for a

value-for-money adjustment otherwise,the 333 free bottom points have theeffect of just catapulting the less affluentcountries to the top of the list.

The score thus obtained was then multipl-ied by the arithmetic means of all 32square roots (creating the effect thatscores are normalized back to the samenumerical value range as the originalscores).

At the outset, it was not immediatelyapparent on how to perform such an

adjustment. If scores were adjusted inproportion to healthcare spending percapita, all less affluent states would beelevated to the top of the scoring sheet.

This, however, would be decidedly unfairto the financially stronger states. Even ifhealthcare spending is PPP adjusted, itis obvious that also PPP dollars go a lotfurther to purchase healthcare services inmember states where the monthly salaryof a nurse is 200, than in states wherenurses salaries exceed 3,500. For thisreason, the PPP adjusted scores werecalculated as follows:

Healthcare spending per capita in PPPdollars was taken from the WHO HfAdatabase (July 2008; latest availablenumbers, most frequently 2006) and fromthe OECD Health Database (December,2008) as illustrated in the graph below*:


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5.2 Results in the BFB score sheet

The outcome of the BFB exercise is shownin the graphic below. Even with the square

root exercise described in the previous

section, many less affluent nations aredramatically elevated in the scoring sheet.

The BFB scores, naturally, should beregarded as somewhat of an academicexercise. Not least, the method of

adjusting to the square root of healthcarespending certainly lacks scientific support.After the research work, however, it doesseem that the supreme winner in the 2008and 2009 BFB scores, Estonia, continuesto do well within its financial capacity. Tosome extent, the same could be said aboutHungary and the Czech Republic.

Of particular interest to the authors is

to compare how countries that top thelist in the BFB scores also do well in theoriginal scores. Examples of such countries

are primarily the Netherlands, Denmarkand Austria; with Germany, Finland andSweden doing reasonably well. The U.K.has a less prominent position in the 2009BFB exercise than in previous years itwould seem that the increased healthcarespending in the U.K. has not yet led toimproved healthcare servicesat least notthat which can yet be seen in the results.


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Canada, which spends more on healthcarethan any country in the Index exceptLuxembourg, Switzerland and Norway,performs very poorly in four of the five

matrix disciplines. As a consequence,when the quality of care delivered iscompared with the cost of providing thatcare, Canada, just as it did last year, sitsat the very bottom in the BFB ranking.

Obviously, high healthcare expendituresdo not automatically transfer into betterhealthcare. Instead of pouring money intothe healthcare system, improvement can

come about in other ways, e.g. by holdinghealthcare providers more accountablefor results and changing provisions forhealthcare funding.

6. How to interpret the Index ResultsThe first and most important considerationon how to treat the results is to not leap

to dramatic conclusions. The Euro-CanadaHealth Consumer Index 2009 is an attemptto measure and rank the performances ofhealthcare systems from the viewpoint of aconsumer. The results contain informationwhich on occasion possess qualityproblems; for example, there is a shortageof multi-country uniform procedures fordata gathering.

That caveat noted, the authors we find

it far better to present our results tothe public and to promote constructivediscussion rather than to stay with the verycommon opinion that as long as healthcareinformation is not 100 per cent completeone had better keep it in the closet.Again, we stress that the Index displaysconsumer information, not medically orindividually sensitive data.

It is clear, though, that Canada hassignificant room for improvement. The

first change, and the one which will enableimprovements in all other indicators, isin the area of patients rights. Withouta culture that encourages healthcareconsumers to demand and receivethe best, outcomes, accessibility, andgenerosity are unlikely to improve. Acrucial first step will be the provision ofmeaningful guarantees. Patients bills of

rights can be a useful approach to this,but only if the bills include remedies for

situations wherein consumers cannotaccess appropriate care. There have beensome attempts in Canada to create suchlegislation, but so far nothing but reportsand reviews has come of this. Progress inthis area will be tracked in future editionsof the Euro-Canada Index, as well as in theupcoming interprovincial index.

A consumer-sensitive culture would also bemore transparent, with better information

widely available on how the healthcaresystem performs. Today, hospitals andother health institutions do not publiclyreport patient care information, thusleaving patients without a chance tocompare or assess the quality of care.Canadians must also have the right toaccess their own medical records (whichshould be in electronic format), and theyshould have ready access to specialists,diagnostics and treatment.

Given Canadas abysmal rating in the Bang-for-the-Buck ranking, a simple increasein health budgets is not the answer.Much more can be done with the moneyalready budgeted on healthcare in Canada.Accessibility and generosity, especially asit pertains to the preventative measureof vaccination, are two areas that areparticularly ripe for reform.


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7. Scope and content of the Euro-Canada

Health Consumer Index

The aim of the EHCI and the ECHCI is toselect a limited number of indicators withina definite number of evaluation areas,which in combination can present a tellingtale of how the healthcare consumer isserved by the respective systems.

Canadians will benefit from betterunderstanding the range of possibilitiesfor healthcare that exist in Europe. TheIndex will make it possible for consumersto approach healthcare as critically as they

do other vital services, and this can onlybenefit everyone. Responsive, consumerfriendly healthcare with excellent outcomesis possible it is achieved in the top-performing countries in Europe and canalso be achieved in Canada.

7.1 Strategy andbackground

In April 2004, HCP launched the Swedish

Health Consumer Index. By ranking the 21county councils (the regional parliamentsresponsible for funding, purchasing andproviding healthcare) by 12 indicatorsconcerning the design of systems policy,consumer choice, service level andaccess to information, we introducedbenchmarking as an element in consumerempowerment. The presentation of thethird annual update of the Swedish indexon May 16, 2006, again confirmed for

Swedes the low average ranking of mostcouncils, revealing the still weak consumerposition.

There is a pronounced need forimprovement. The very strong mediaimpact of the index throughout Swedenconfirmed that the image of healthcareis rapidly moving from rationed publicgoods to consumer-related services

that are measurable by common qualityperspectives.

For the Euro Health Consumer Index, theHealth Consumer Powerhouse aimed tofollow the same approach, i.e., selecting anumber of indicators that described to whatextent the national healthcare systems areuser-friendly, thus providing a basis forcomparing different national systems. Theindex does not take into account whethera national healthcare system is publicly

or privately funded and/or operated. Thepurpose of the EHCI is health consumerempowerment, not the promotion ofpolitical ideology. Aiming for dialogue andco-operation, the ambition of HCP is to beseen as a partner in developing healthcarearound Europe.

In the initial years of index building,opinion brokers and policy-makers aswith journalists, experts and politicians are the key audience for the index.Gradually, the health consumer couldbecome the main reader along withservice providers, payers and authorities.Such a development will require user-friendly services and a deep knowledge ofconsumer values. Interactivity with usersand other parts of the European healthcaresociety will be another key characteristic.

The Euro-Canada Health Consumer Index isa step toward in bringing consumer-friendly

healthcare to Canada; the very existenceof the Index will produce an atmosphere inwhich Canadians can see how their systemsucceeds and fails. To date, Canada lacksa culture in which consumers have highexpectations of healthcare services andsignificant reform is unlikely without this.


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7.2 Indicators intro-duced for theECHCI 2009

As in every year, the internationalexpert panel presented a long list of newindicators to be included in this yearsIndex; there was a true brainstormingabout new, useful ideas. Unfortunately, theresearch team was unable to turn all ofthem into a green-yellow-red score in thematrix.

Nevertheless, the research team was ableto present data for five new indicators

spread out over three sub-disciplines:Sub-discipline 1 (Patient rights and

information)

1.10 Cross border care information

Sub-discipline 3 (Outcomes)

3.6 Rate of decline of suicide; 3.7.Percentage of patients with high HbA1clevels

Sub-discipline 4 (Range and reach of

services provided)4.5. Mammography reach; 4.6. Informalpayments to doctors

Intentionally de-selected were indicatorsmeasuring public health status, such as lifeexpectancy, lung cancer mortality, totalheart disease mortality, diabetes incidence,etc. Such indicators tend to be primarilydependent on lifestyle or environmentalfactors rather than healthcare system

performance. They generally offer verylittle information to the consumer whowants to choose among therapies orcare providers, who is waiting in line forplanned surgery or worries about the riskof having a post-treatment complication, orthe consumer who is dissatisfied with therestricted information.

7.3 Indicator areas(sub-disciplines)

The project work on the Index is a

compromise between which indicators werejudged to be most significant for providinginformation about the different nationalhealthcare systems from a user/consumersviewpoint, and the availability of data forthese indicators. This is a version of theclassic problem: Should we be looking forthe 100-dollar bill in the dark alley, or forthe dime under the lamppost?

The 2009 Index is, as with its 2008version, built with indicators grouped insub-disciplines. After surrendering to the

lack of statistics syndrome, and afterscrutiny by the expert panel, 32 indicatorsmade it into the ECHCI 2009. Of the 27indicators from last years Index, nonewas discontinued from the set in the 2009Index.

The indicator areas for the ECHCI 2009thus became:

Number ofSub-discipline indicators

1. Patient rights and information 10

2. Waiting times for treatment 5

3. Outcomes 7

4. Range and reach ofservices provided 6

5. Pharmaceuticals 4


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7.4 ScoringThe performance of the respective nationalhealthcare systems were graded on athree-grade scale for each indicator,

where the grades have the rather obviousmeaning of Green = good (i), Amber =so-so (l) and Red = not-so-good (h).A green score earns 3 points, an amberscore 2 points and a red score (or a notavailable) earns 1 point. For each of thefive sub disciplines, the country score was

calculated as a percentage of the maximumpossible (e.g. for Waiting times, the scorefor a state has been calculated as a

percentage of the maximum 3 x 5 = 15).Thereafter, the sub-discipline scores weremultiplied by the weight coefficients givenin the following section and added up tomake the final country score (rounded tonearest integer).

7.5 Weight coefficientsThe possibility of introducing weight

coefficients was discussed already for theEHCI 2005, i.e. selecting certain indicatorareas as being more important than othersand multiplying their scores by numbersother than 1.

For the EHCI 2006 explicit weightcoefficients for the five sub-disciplines wereintroduced after a careful considerationof which indicators should be consideredfor higher weight. The accessibility and

outcomes sub-disciplines were decided

as the main candidates for higher weightcoefficients based mainly on discussionswith expert panels and experience from anumber of patient survey studies. Here,as for the whole of the Index, we welcomeinput on how to improve the Indexmethodology.

In the ECHCI 2009, the scores for the fivesub-disciplines were given the followingweights:

Sub-discipline

1. Patient rights and information 150 15.00

2. Waiting times for treatment 250 50.00

3. Outcomes 300 42.86

4. Range and reach of services provided 150 25.00

5. Pharmaceuticals 150 37.50

(All Green scorecontribution to total

maximum scoreof 1000)

Points for aGreen score

Relative weight

Consequently, as the percentages of fullscores were multiplied by their respectiverelative weights and added, the maximumtheoretical score attainable for a nationalhealthcare system in the Index is 1,000 andthe lowest possible score is 333.

It should be noted that, as there arenot many examples of countries thatexcel in one sub-discipline but do verypoorly in others. The final ranking ofcountries presented by the ECHCI 2009 isremarkably stable if the weight coefficientsare varied within rather wide limits.


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The project has been experimenting withother sets of scores for Green, Amber andRed; such as 2, 1 and 0 which would reallypunish low performers; and also 4, 2 and

1 which would reward real excellence. Thefinal ranking is remarkably stable alsoduring these experiments.

7.6 Regional differencesThe Health Consumer Powerhouse is wellaware that many European states andCanada have decentralized healthcaresystems. This is the case as well in theU.K. It is often argued that Scotland andWales have separate health services andshould be ranked separately, while Canadahas ten provincial systems that overlap in

many ways but are not identical. From acomparison standpoint, systems devolutionmight raise new challenges, but publicly-funded and publicly-governed systemshave many more features in common thanthose that are isolated or hard to compare.

Grading healthcare systems does presenta certain risk of encountering the problemwhereby one foot in an ice bucket and theother on a hot plate would result in anaverage temperature. This problem wouldbe quite pronounced if there were a desireto include the United States as one countryin a health consumer index. As equity inhealthcare has traditionally been high onthe agenda in both Canada and Europe, itwas judged that regional differences aresmall enough to make statements aboutthe national levels of healthcare servicesrelevant and meaningful.

Many Canadian indicators are readilyavailable at the national level. For thoseindicators present only at the provinciallevel, a national value was obtained byweighting each provinces performanceaccording to its share of the totalpopulation. It should be noted that evenwith the large spread in values from

province to province for some indicators,the overall score was easy to evaluate.For example, looking at pharmaceuticalcoverage even the more generousprovincial plans requires a level ofindividual spending that qualifies for thelowest score in the Index.

These differences and their impact onhealthcare performance are looked atcloser in the separate Canadian province-to-province index. It became clear whileevaluating Canada that much roomexists for provinces to learn from eachothers best practices. The Canada HealthConsumer Index, first launched in 2008,highlights these potential areas forimprovements, as well as indicates wherethe provincial systems consistently fail tomeet the needs of healthcare consumers.


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8. Indicator definitions and data sources

1. Patient 1.1. Healthcare Is national Yes Various kinds No Patients Rights Law; rights and law based on healthcare of patient http://www.healthline.com/ information patients rights. legislation charters or galecontent/patient-rights-1;

explicitly similar bylaws http://www.adviceguide.org.expressed in uk/index/family_parent/terms of health/nhs_patients_rights.patients htm; Colleen M. Flood &rights? Tracey D. Epps. Waiting for

Health Care: What Role for aPatients Bill of Rights? McGillLaw Review. Vol. 49, No. 3, 2004

1.2. Patient Yes, Yes, by common No, not Patients Perspectives oforganizations statutory practice in compul- Healthcare Systems in Europe,involved in advisory sory or survey commissioned by HCPdecision making capacity generally 2006; Personal interviews;

done in Survey of major patient

practice advocacy groups within Canada. 1.3. No-fault Can patients Yes Fair, > 25% No Swedish National Patient Insur-

malpractice get compens- invalidity ance Co. (All Nordic countriesinsurance ation without covered have no-fault insurance);

the assistance by the state www.hse.ie; www.hiqa.ie;of the judicial Rekindling Reform: Healthsystem in Care Renewal In Canada,proving that 2003-2008. Health Council ofmedical staf f Canada. 2008.made mistakes?

1.4. Right to Yes Yes, but difficult No Patients Perspectives of Health-second opinion to access due to care Systems in Europe, survey

bad information, commissioned by HCP 2006;bureaucracy or Health and Social Campaignersor doctor News International: Users per-negativism spectives on healthcare systems

globally. Patient View 2005;Personal interviews; Review ofCanadian legislation and healthministry mandates on a provinceby province basis.

1.5. Access to Can patients Yes Yes, restr icted No Patients Perspectives of Surveyown medical read their own or with Healthcare Systems in Europe,record medical intermediary survey commissioned by HCP 2008

records? Health and Social CampaignersNews International: Usersperspectives on healthcaresystems globally. Patient View2005; Personal interviews;

www.dohc.ie; McInerney v.MacDonald, [1992] 2 S.C.R. 138.

1.6. Register of Can the public Yes, easily Yes, in easily Difficult, Patients Perspectives of Health-legit doctors readily access on the accessible costly, care Waiting times in Europe,

the info: Internet publications or not survey commissioned by HCP 2007;Is doctor X a at all National physician registries;a bona fide http://www.sst.dk/T ilsyn/specialist? Individuelt_tilsyn/Tilsyn_med_

faglighed/Skaerpet_tilsyn_med_videre/Skaerpet_tilsyn/Liste.aspx;Provincial Colleges of Physiciansand Surgeons in Canada.

Sub-discipline Indicator Comment Score 3 Score 2 Score 1 Main Information Sources


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1. Patient 1.7. Web or Information Yes Yes, but No Patients Perspectives of Health- rights and 24/7 telephone which can help generally not care Systems in Europe; survey information healthcare a patient take available commissioned by HCP 2008.

information decisions of Personal interviews;the nature: http://www.nhsdirect.nhs.uk;

After consult- www.hse.ie; www.ntpf.ie;ing the service, Survey of information provided byI will take a provincial health ministries.paracetamoland wait andsee or I willhurry tothe A&Edepartment ofthe nearesthospital.

1.8. Provider Dr. Foster Yes Not really, but No http://www.drfoster.co.uk;catalogue with in the U.K. nice attempts http://www.sundhedskvalitet.dk;quality ranking remains the under way http://www.sykehusvalg.no;

standard http://www.hiqa.ie;

European http://212.80.128.9/gestion/qualification for ges161000com.html;a Green score. Survey of provincial healthThe 750 best ministries and regional healthclinics pub- authorities web sites.lished byLaPointe inFrance wouldwarrant aYellow.

1.9. e-Health What percent- > 90% 50 - 90% < 50% Commonwealth Fund Internationalproficiency age of GP Health Policy Survey of Primary

practices uses Care Physicians; Benchmarkingelectronic ICT use among GP:s in Europe.patient European Commission, 2008.

records? Study by Empirica. Bonn, Germany(p.60). Gartner Group; CEEC-IST-NET. EFPConsulting. 2006.Project co-funded by the EuropeanCommission; Toward Higher-Performance Health Systems:Adults Health Care Experiencesin Seven Countries, 2007. HealthAffairs. 2007.

1.10. Cross- Percentage Less than Close to EU More than Cross-border health servicesborder care stating lack of average average EU average in the EU. Eurobarometer.information information June 2007.

stated as areason for notseeking medicaltreatmentabroad


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2. Waiting 2.1. Family Can I count on Yes Yes, but not No Patients Perspectives of Health- times for doctor same seeing my quite fulfilled care Waiting times in Europe, treatment day access primary care survey commissioned by

doctor today? HCP 2008; Health and SocialYes Campaigners News International:

Users perspectives on healthcaresystems globally. Patient View2005; Personal interviews;http://www.nhs.uk; Toward Higher-Performance Health Systems:Adults Health Care Experiencesin Seven Countries, 2007. HealthAffairs. 2007.

2.2. Direct Without referral Yes Not really, but No Patients Perspectives of Health-access to from family quite often care Waiting times in Europe,specialist doctor (GP) in reality survey commissioned by HCP 2008;

Personal interviews with healthcare officials; http://www.im.dk/publikationer/healthcare_in_dk/healthcare.pdf; http://www.ic.nhs.

uk/; http://www.oecd.org/datao;Toward Higher-Performance HealthSystems: Adults Health CareExperiences in Seven Countries,2007. Health Affairs. 2007.

2.3. Major Coronary 90% 50 - 90% >50% OECD data: Siciliani & Hurst, 2003/non-acute bypass/PTCA


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3. Outcomes 3.1. Heart Heart infarct 25% Compilation from OECD Health at ainfarct case mortality less Glance. December 2007; MONICA;fatality than 28 days National heart registr ies; Variation

after getting in Heart Attack Mortality into hospital Canada (CIHI Survey). Healthcare

Quarterly. Vol. 9 No. 4, 2006.

3.2. Infant Per 1,000 60% EUCID; Interviews with national

of patients with total diabetic diabetes experts and health carehigh HbA1c population with officials; National Registries; S.B.levels (>7) high HbA1c Harris et al. Glycemic control and

levels (> 7) morbidity in the Canadian primarycare setting (results of thediabetes in Canada evaluationstudy). Diabetes Research andClinical Practice 70. 2005.


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4. Range and 4.1. Cataract Cataract >5,000 3,000 - 5,000 65 years Within and Beyond Wait TimePriority Areas. Canadian Institutefor Health Information. 2008.

4.2. Infant Diphtheria, 97% 92 - 97%


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5. 5.1. Rx subsidy Percentage of > 90% 60 - 90% < 60% WHO European HFA-DB; OECDPharmaceuticals Rx sales paid Health Database 2008.

for by publicsubsidy

5.2. Layman- Is there a Yes Yes, but not No Patients Perspectives of Healthcare

adapted layman-adapted really easily Systems in Europe; surveypharmacopeia pharmacopeia accessible commissioned by HCP 2006.

readily acces- Personal interviews. LIF Sweden.sible by the http://www.doctissimo.fr;public Norwegian Medicines Agency;(www or widely Drug Product Database (DPD).available)? Health Canada.

5.3. New cancer Quicker Close to Slower Wilking, N. & Jnsson, B. A pan- drugs deployment than EU EU average than EU European comparison regarding

speed average average patient access to cancer drugs.Karolinska Institute. Stockholm2007; Report Card on Cancer inCanada 2007. Cancer AdvocacyCoalition of Canada.

5.4. Access to Between


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Country Responded in 2006 Responded in 2007 Responded in 2008

Austria

Belgium

Bulgaria not applicable

Croatia not applicable not applicable

Cyprus

Czech Republic

Denmark

Estonia

Finland

France

FYR Macedonia not applicable not applicable

Germany

Greece

Hungary

Ireland

Italy

Latvia

Lithuania

Luxembourg

Malta

Netherlands

Norway not applicable

Poland

Portugal

Romania not applicable

Slovakia

Slovenia Spain

Sweden

Switzerland

United Kingdom


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Responding countries are those whoactually returned a single countryscore sheet with comments. With fewexceptions, simpler forms of feedback on a

limited number of indicators were receivedfrom all but a handful of countries severalof those returning a full score sheet in2007 sent simpler responses for this yearssurvey.

Score sheets sent out to nationalagencies contained only the scores forthat respective country. Corrections wereaccepted only in the form of actual data,not by national agencies just changing ascore (frequently from Red to something

better, but surprisingly often honestyprevailed and scores were reviseddownwards).

The majority of the data concerning

Canada was checked against secondarysources. Where this was not possible,experts in the public and private sectorswere consulted to verify that values andfacts corresponded to their observationsof the reality of healthcare in Canada. Infuture iterations of the Euro-Canada Index,authorities at the federal and provinciallevels will be invited to correct their scores,subject to the same scrutiny.

8.3 Threshold value settingsIt was not our ambition to establish aglobal, scientifically based principle forthreshold values to score Green, Amber orRed on the different indicators. Thresholdlevels were set after studying the actualparameter value spreads in order to avoidhaving indicators showing all Green orcompletely Red.

The HCP believes that the involvementof patients organizations in healthcaredecision-making is a good idea. Thisindicator was included in 2006, with nocountry scoring Green. In this yearsIndex, Green score is attained by Belgium,Estonia, Germany, Hungary, Ireland,Lithuania, the Netherlands, Poland andSlovakia. (Incidentally, patient organizationinvolvement was made law in Germany in

November of 2004, but not until 2008 didthis reflect in the responses to the PatientView survey.)

Setting threshold values is typically doneby studying a bar graph of country datavalues on an indicator sorted in ascending

order. The usually S-shaped curve yieldedby that is studied for notches in the curve,which can distinguish clusters of states,and such notches are often taken asstarting values for scores.

A slight preference is also given tothreshold values with even numbers.

An example of this is the cancer 5-yearsurvival indicator, where the cut-offs forGreen and Amber were set at 60% and50% respectively, with the result that onlyfour states scores Green.

Finally, the HCP is a value-drivenorganization. We believe in patient/consumer empowerment, an approach thatplaces highest importance on quantitativeand qualitative healthcare services. Asillustrated by the provider catalogue withquality ranking indicator, this sometimesleads to the inclusion of indicators whereonly few countries, theoretically none,score green (in this case, only Denmarkand the UK do).


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9. How the ECHCI 2009 was built

The work on the Euro-Canada HeathConsumer Index 2009 began with the

2008 index and a desire to retain themain structure so that the possibility ofmaking comparisons over time would notbe destroyed. The Index was developed inharmony with the EHCI 2008, using parallelmethods and data gathering. The ECHCI2009 was constructed under the followingproject plan.

9.1 Phase 1Start-up meeting with the Expert Reference

Panel Mapping of existing data

The composition of the Expert panel canbe found in section 9.6. The major areaof activity was to evaluate to what extentrelevant information is available andaccessible for the selected countries.The basic methods were:

Web search, journal search

a) Relevant bylaws and policy documents

b) Actual outcome data in relation topolicies

Telephone and e-mail interviews with keyindividuals

a) National and regional Health Authorities

b) Institutions (EHMA, Cochrane Institute,Picker Institute, University of YorkHealth Economics, Legal-ethical papersof Catholic University in Leuwen, others)

c) Private enterprise (IMS Health,pharmaceutical industry, others)

Personal visits and interviews whenrequired (to evaluate findings from earliersources, particularly to verify the realoutcomes of policy decisions)

a) Phone and e-mail

b) Personal visits to key informationproviders

9.2 Phase 2

Data collection to assemble presentlyavailable information to be included in theEHCI 2008

Identification of vital areas whereadditional information needed to beassembled

Collection of raw data for these areas

A round of personal visits by theresearchers to Health Ministries and/orState Agencies for supervision and/or

Quality Assurance of Healthcare Services We kept regular contact with the Expert

Reference Panel (see section 9.6)mainly to discuss the indicators, thecriteria to define them, and the dataacquisition problems. Finally, we hada second meeting on October 8th, inwhich we talked in detail about each ofthe indicators, including the ones thatcould not be included in the Index dueto lack of data. Also, the discrepanciesbetween data from different sources wereanalyzed.

9.3 Phase 3Consulting European patient advocates and

citizens through HCP survey performed by

external research facility (Patient View,

U.K.)

The EHCI survey contained the questionsfound in Appendix 1 of the EHCI 2008

report. The survey was committed inpartnership with The Patient View (seealso section 8.1 for more information).The closing date was October 31st; 833responses were submitted.

Score update sheet send-out

On October 8, 2008, all 31 states receivedtheir respective preliminary score sheets


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Canadian data were collected from publiclyavailable sources, including governmentdata from all three levels of government,public and private institutions for the study

of healthcare and health policy and existingliterature and research. The results of thisdata collection were further examined inthe context of existing literature, as well asthe experience of practitioners, consumersand administrators, to verify that theycorrespond reasonably well with thereality of healthcare facts on the ground.Data were obtained from publicationsonline, published periodicals, governmentdocuments and correspondence with

sources.

(with no reference to other states scores)as an e-mail send-out asking for updates/corrections by October 31. The send-outwas made to contacts at ministries/state

agencies as advised by states during thecontact efforts prior to October 2008. Tworeminders were also sent out. Correctivefeedback from states was accepted up untilNovember 4th, by which time replies hadbeen received from countries denoted insection 8.2.

9.4 Phase 4Project presentation and reports

A report describing the principles of howthe EHCI 2008 was constructed

Presentation of the EHCI 2008 at a pressconference and seminar in Brussels,November 13, 2008

On-line launch,www.healthpowerhouse.com

9.5 Phase 5

The inclusion of Canada A partnership between HCP and FCPP was

created in order to integrate Canada intothe EHCI 2008

FCPP staff studied HCPs methodologyand prior indexes

A list was compiled of equivalent or comp-arable metrics to allow Canada to be eval-uated in parallel with the 31 countries inthe EHCI 2008

Data collection and verification

Much information about the EU memberstates were already harmonized andprepared in a consistent format. Everyeffort was made to ensure that thecomparison between Canada and the 31European countries was fair.


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9.6 External expert reference panel

the panel members met for two six-hoursittings during the course of the project.

The following people took part in theExpert Reference Panel work:

As is the standard working mode for allHCP indexes, an external Expert Reference

Panel was recruited. Having been sentthe index working material in advance,

Name Affiliation

Juan Acosta, Chief Medical Officer Best Doctors, Inc. (Europe). Madrid, Spain

Martin R. Cowie, Professor National Heart and Lung Institute.Imperial College. London, U.K.

Wilfried von Eiff, Professor Dr. Dr. Centrum fr Krankenhaus-Management.Universitt Mnster. Mnster, Germany

Iva Holmerova, Asst. prof. MUDr. Gerontologicke Centrum, and CharlesUniversity. Prague, Czech Republic

Danguole Jankauskiene, Asst. prof., Mykolas Romeris University. Vilnius,Vice-Dean of the Strategic management Lithuaniaand policy department

Meni Malliori, Ass. Prof of Psychiatry Athens, Greece

Leonardo la Pietra, Chief Medical Officer Eur Institute of Oncology. Milan, Italy

The Expert Reference Panel for an HCPIndex has two core tasks:

1. To assist in the design and selectionof sub-disciplines and indicators. This isobviously of vital importance for the Index,if the ambition is to be able to say that astate scoring well can truly be consideredto have good, consumer-friendly healthcares

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2009 Euro-Canada Health Consumer Index

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