5 Reflections on Mirror, Mirror 2021 (Commonwealth Fund Study on Healthcare Systems)

Recently, the Commonwealth Fund reported on its regular multi-year survey of health care systems in the developed world. This survey provides excellent insight into what researchers and policy makers feel is important for a well-functioning health care system. It also provides insights into blind spots of various countries and whether their policies are actually working.

As I read the report, a few things jumped out at me that I wanted to share with colleagues, students, policy makers and interested citizens.

The Mirror, Mirror 2021 study reports its findings on 5 dimensions of care that are considered important for a well-functioning healthcare system including, Access to Care, Processes of Care, Administrative Efficiency, Equity and Healthcare Outcomes. Obviously, all of them are important for a well-functioning healthcare system. I encourage you to read more about the definitions of those terms in the report.

Here are the rankings as provided in the report for ease of reference:


Let’s get to the crux of my reflections.

First, although Healthcare Outcomes is reported in a similar way as the other elements, it is not the same as the other elements. Healthcare outcomes arise from the other elements and is not a process in of itself. This is important because we can see patterns in the data which might otherwise be lost.

So, let’s do some simple math on the numbers. Let’s start with subtracting the Health Care Outcomes rankings from each of the process rankings and calculate the absolute value (ignoring negative numbers) of the difference between the two factors. This is what we see:

What this table tells us is the distance between the rank for health care outcomes and the rank for the different processes for each country. The smaller the difference, the closer those two items are correlated. Presumably, we have all those processes because we believe that doing those processes will lead to better health outcomes. So, the greater distance there is between a process and an outcome, the less important that process is for driving that outcome in that particular country. So, the higher the number, the LESS important it is. The smaller the number, the MORE important it is. The average gives us a quick indicator of which factor may be the biggest driver for better outcomes across our sample of 11 countries.

Reflection #1. Better processes of care do not lead to better outcomes.

Take, for example, the US. It ranks #2 in care processes but ranks #11 in outcomes. We can draw the conclusion that, in the US, good care processes are not enough to drive good outcomes. They are missing one or more essential ingredients. Similarly, Canada ranks #4 in care processes, yet ranks #10 in outcomes. Other countries like Australia, Norway, and Sweden have relatively poor care processes, yet generate better outcomes. Perhaps it’s time for us to realize that making our healthcare system more efficient is not going to necessarily lead us to better health care outcomes. That’s a shocking realization but should not be surprising to keen observers of the healthcare space. Lots of well-planned and well-executed initiatives that aimed to improve care processes over the last decade have not led to better outcomes in Canada. We need to look at our system in a different way and we need to try different things. I think COVID made that lesson crystal clear to us.

Reflection #2: Equity of services is the best predictor of good outcomes.

Perhaps not surprising to keen observers of global health care systems, countries that have more equitable healthcare systems performed much better than those that have less equitable systems. Eight out of 11 countries have a difference of 0 or 1 between their ranking for Equity and their ranking for Health care outcomes, meaning that this factor contributed significantly to health care outcomes rankings. We’ve known for years that the most vulnerable people in our society are the most likely to get sick and the sickest patients are the most vulnerable. If we paid more attention to them and provided them with better services, including pharmacare, dental care, food security, rent security, and more walkable neighborhoods, we would see a big improvement in healthcare outcomes.

Reflection #3: Administrative Efficiency is the next best predictor of good outcomes

Paperwork slows doctors, nurses, and pharmacists down. When they are bogged down, patient care is delayed. Even small delays get magnified significantly when millions of patients are involved. Countries that have robust health IT infrastructures like Norway, Australia, and New Zealand have the best outcomes. However, administrative efficiency alone is not enough. The Netherlands, with relatively poor administrative performance, still did well in the outcomes rankings. The UK, with a very good administrative efficiency ranking, still managed to do poorly in health care outcomes. Administrative efficiency is necessary, but not sufficient for good health care outcomes.

Reflection #4: Healthcare access continues to be a challenge for the sickest and most vulnerable across North America.

Only a few countries with good healthcare access also do well when it comes to healthcare outcomes. Norway and the Netherlands fit this category. However, Germany and the UK which have good access to care still perform poorly on healthcare outcomes. And Switzerland which has very poor access to care broke the top 3 in healthcare outcomes. So, although health care access is poorly correlated with outcomes, it is clearly still important. Canada and the US do very poorly on access, and that's reflected in the health care outcomes they are able to achieve. Poor performance on Equity magnifies the impact of poor Access. If Canada wants to improve health care outcomes, it needs to commit to bringing pharma care, dental care and better patient engagement. It’s only when we tackle both Equity and Access that we’ll make a dent in outcomes.

Reflection #5: There’s more to the story than Access, Care, Efficiency and Equity.

Some country rankings tell a contrarian story. Take Sweden, for example. They rank worse on every process measure compared to the UK and yet manage to achieve better Health Care Outcomes. One major aspect missing from the Mirror, Mirror 2021 story is the social determinants of health that are prevalent in each country. How is wealth distributed? How prevalent is rental anxiety? How prevalent is food insecurity? How prevalent are food deserts? How prevalent are unwalkable neighborhoods? These factors can sometimes have a bigger impact on people’s health than how well the health system is functioning. If you can’t exercise and you can’t get a good diet, any excellent care you receive in the healthcare system will not achieve its optimal effect. Surgeries and medications can’t fix what poor diet and lack of exercise have undermined. Sweden's health care system may not be that great, but the health of their population is probably much better than that of most other countries. Health trumps health care.

The Mirror, Mirror 2021 report provides much for us to ponder and reflect upon. It tells a sad story for Canada and the US. However, things will not change unless we question our assumptions and challenge our ways of doing things. What the report doesn’t do is tell us what we should be doing. Where do we want to go as a society? What do we want to achieve for our citizens? These are questions that need more thought and more discussion.

Please let me know what you think of my reflections. I would appreciate having your feedback.

My next blog will present my 5 recommendations on how we can fix the problems of poor health and poor health care outcomes and also how we can improve the next iteration of Mirror, Mirror.