Introduction

This book has been about comparing health systems, and this chapter is structured around two final comparisons. The first takes factors which were important in terms of causality from the social determinants, funding and expenditure chapters, and sees how they combine for 10 countries (the inclusion of long-term care expenditure means that New Zealand must be omitted). The combinations of these factors are then explored in terms of their necessary and sufficient conditions in relation to health outcomes. The health outcomes measure has been chosen as the best overall benchmark against which health systems should be judged – if they are generating good health outcomes for their populations, then they are probably doing a good job. Other outcome measures can make a strong case for their importance as well, but as the UK demonstrates, strong health equity can also lead to poor health outcomes, and as the US demonstrates, strong care process measures do not necessarily lead to measures in other outcome measures.

Utilising the health outcomes measure also allows a final comparison, in which the sample of countries is expanded to 31 to see how the causal patterns in that wider sample compare to those in the original 10. Including an outcome measure for the 31 countries means finding a replacement for the Commonwealth Fund health outcomes measure, but a key composite of that measure is the OECD ‘preventative life years lost’ (PYLL) measure, which provides data for a wider range of countries and so allows a wider comparison to be made.

The chapter first outlines and justifies again which causal factors it will include in its analysis. It then performs QCA using those factors and the Commonwealth Fund health outcomes measure for 10 countries to generate necessary and sufficient solutions. Next, the dataset is expanded to 31 countries, with the same causal factors included, but the OECD's preventable years of life lost (PYLL) measure used as the outcome instead, and QCA is carried out again. Finally, the two sets of results are compared to see which causal outcomes seem to most reliably link to strong health outcomes.