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The folly of cross-country ranking exercises
... As noted by Oliver[38], with respect to international rankings of healthcare systems, ''Some countries seem to perform very well on specific aspects of healthcare, and those from other countries should attempt to learn how they do this and deduce whether policies can be transferred to and within the institutional structure of their own system without undermining other important health policy goals'' ([38], p. 17). On this issue, see also Street and Smith[39]. ...
... As noted by Oliver[38], with respect to international rankings of healthcare systems, ''Some countries seem to perform very well on specific aspects of healthcare, and those from other countries should attempt to learn how they do this and deduce whether policies can be transferred to and within the institutional structure of their own system without undermining other important health policy goals'' ([38], p. 17). On this issue, see also Street and Smith[39]. ...
... These findings are consistent with comparative health policy studies that have highlighted how new policy instruments are shaped by country-specific demands and constraints of national healthcare systems and governance traditions, as well as the interests and veto power of key actors, public preferences, and the structure of the wider political system [51][52][53]. Such factors are likely to create path dependencies in the way that quality indicators are developed and put to use in each country [8,[54][55][56]. We can go further in explaining the nationally specific character of indicator sets, however, if we differentiate between 'demandside' pressures for quality indicators, and 'supply-side' constraints on how indicators can be constructed. ...
... Our analysis helps explain why international efforts to benchmark hospital quality and identify universal measures are so difficult [26,54]. In the absence of universal agreement about the meaning of quality, countries necessarily steer by their own lights when selecting quality indicators. ...
Despite widespread faith that quality indicators are key to healthcare improvement and regulation, surprisingly little is known about what is actually measured in different countries, nor how, nor why. To address that gap, this article compares the official indicator sets--comprising some 1100 quality measures-- used by statutory hospital regulators in England, Germany, France, and the Netherlands. The findings demonstrate that those countries' regulators strike very different balances in: the dimensions of quality they assess (e.g. between safety, effectiveness, and patient-centredness); the hospital activities they target (e.g. between clinical and non-clinical activities and management); and the 'Donabedian' measurement style of their indicators (between structure, process and outcome indicators). We argue that these contrasts reflect: i) how the distinctive problems facing each country's healthcare system create different 'demand-side' pressures on what national indicator sets measure; and ii) how the configuration of national healthcare systems and governance traditions create 'supply-side' constraints on the kinds of data that regulators can use for indicator construction. Our analysis suggests fundamental differences in the meaning of quality and its measurement across countries that are likely to impede international efforts to benchmark quality and identify best practice.
... minimum and maximum sentences, threshold quantities) and the relevance of different indicators of law enforcement. These questions might be especially relevant in the construction of drug policy indexes (Oliver, 2012). ...
... Instead of the simple expected patterns between laws and their enforcement over time, we found (i) liberal drug laws on paper and in practice with increasingly strict policing of use crimes over time (the Czech Republic); (ii) moderate drug laws on paper with increasingly strict enforcement and lenient sentencing towards drug use offences (NSW, Australia); and (iii) strict drug laws with increasingly lenient enforcement of drugs crimes, and decreasing severity in sentencing of supply crimes over time (Florida, U.S.). While the choice whether "laws on the books", their enforcement or both should be used in comparative policy analysis or other related work (Ritter, Livingston et al., 2016), and eventually, drug policy indices (Oliver, 2012), will be driven by the specific research questions and the outcomes of their empirical testing, this analysis suggests that there is substantial variability in both types of indicators for them to be considered separately. ...
BACKGROUND: Variations in drug laws, as well as variations in enforcement practice, exist across jurisdictions. This study explored the feasibility of categorising drug laws “on the books” in terms of their punitiveness, and the extent of their concordance with “laws in practice” in a cross-national comparison.
METHODS: “Laws on the books”, classified with respect to both cannabis and other drug offences in the Czech Republic, NSW (AU) and Florida (USA) were analysed in order to establish an ordinal relationship between the three states. Indicators to assess the “laws in practice” covered both police (arrests) and court (sentencing) activity between 2002 and 2013. Parametric and non-parametric tests of equality of means, tests of stationarity and correlation analysis were used to examine the concordance between the ordinal categorisation of “laws on the books” and “laws in practice”, as well as trends over time.
RESULTS: The Czech Republic had the most lenient drug laws; Florida had the most punitive and NSW was in-between. Examining the indicators of “laws in practice”, we found that the population adjusted number of individuals sentenced to prison ranked across the three states was concordant with categorisation of “laws on the books”, but the average sentence length and percentage of court cases sentenced to prison were not. Also, the de jure decriminalisation of drug possession in the Czech Republic yielded a far greater share of administrative offenses than the de facto decriminalisation of cannabis use / possession in NSW. Finally, the mean value of most “laws in practice” indicators changed significantly over time although the “laws on the books” didn’t change.
CONCLUSIONS: While some indicators of “laws in practice” were concordant with the ordinal categorisation of drug laws, several indicators of “laws in practice” appeared to operate independently from the drug laws as stated. This has significant implications for drug policy analysis and means that research should not assume they are interchangeable and should consider each separately when designing research
... In this case, even the information provided by the score of the composite measure is flattened by the instrumentality of its use for the positioning of the units in the ranking, which is the sort of dominant "message" arising from rankings. As noted by Oliver (2012), with respect to international rankings of health care systems, "Some countries seem to perform very well on specific aspects of health care, and those from other countries should attempt to learn how they do this, and deduce whether policies can be transferred to and within the institutional structure of their own system without undermining other important health policy goals" (Oliver, 2012, p. 17) 6 . This outcome, however, can be achieved only if the information from the composite measure is complemented with other information on how the single components of the composite measure contribute to the overall performance as it happens with MDir_BoD. ...
While individual indicators in health care quality assessment provide detailed insights into specific aspects, they often fail to capture the full and relevant information. Consequently, there is a growing need to develop composite measures that comprehensively assess the overall quality or performance of health care systems, especially those not covered by official OECD measures. A novel multi-directional robust Benefit of the Doubt approach is proposed to measure overall health care quality, through a composite indicator, while, at the same time, highlighting the potential improvement directions for each single component indicator. The method is developed within a robust framework. To show its advantages, the approach is applied, first, to simulated data, and then to country-level OECD data, drawn from the Healthcare Quality and Outcomes program, relative to acute care services.
... Finally, a third strand of critique poses a more radical challenge to governance by CPI (e.g., Scott and Light 2004;Oliver 2012;Broome, Homolar, and Matthias Kranke 2018). While indicators are derived from mathematical equations, human interpretation is inescapably involved in deciding what factors to count and how to weigh them. ...
As the number of international rankings has risen dramatically since the 1990s, a large body of scholarship has emerged to examine and understand them. The aim of this article is to provide an overview of this body of work and to chart out fruitful directions for future research. In short, prior scholarship has been surprisingly quiet on the relations among multiple actors and their economic dimensions at the core of country performance indicator (CPI) activities. To foreground crucial socioeconomic relations, we develop a relational heuristic based upon a sports analogy: the actors involved in the creation and maintenance of CPIs can fruitfully be approached as a complex of players, referees, coaches, and audiences. Such an account helps us better understand how CPIs emerge and are sustained, even when they rely on dodgy data and their effects are perverse. We use nation brand rankings—overlooked in international relations research—as empirical illustration.
... Arguably a strength of an index is that it facilitates a multicomponent approach to capturing the policy under study -thus an index can include not only whether the policy exists or not (the simple categorical), but also the strength, reach and/or enforceability of the policy (Erickson et al., 2014) or weightings based on the efficacy and implementation of the policy (Naimi et al., 2014). Yet it still remains a single score, whether at a state or national level and is open to the criticism of simplification (Oliver, 2012;Ritter, 2007). An index is subject to the same problems noted elsewhere for other CPA tools: data availability challenges, comparability problems, and accounting for the difference between policy-as-stated versus policy-in-implemented. ...
Background:
A central policy research question concerns the extent to which specific policies produce certain effects - and cross-national (or between state/province) comparisons appear to be an ideal way to answer such a question. This paper explores the current state of comparative policy analysis (CPA) with respect to alcohol and drugs policies.
Methods:
We created a database of journal articles published between 2010 and 2014 as the body of CPA work for analysis. We used this database of 57 articles to clarify, extract and analyse the ways in which CPA has been defined. Quantitative and qualitative analysis of the CPA methods employed, the policy areas that have been studied, and differences between alcohol CPA and drug CPA are explored.
Results:
There is a lack of clear definition as to what counts as a CPA. The two criteria for a CPA (explicit study of a policy, and comparison across two or more geographic locations), exclude descriptive epidemiology and single state comparisons. With the strict definition, most CPAs were with reference to alcohol (42%), although the most common policy to be analysed was medical cannabis (23%). The vast majority of papers undertook quantitative data analysis, with a variety of advanced statistical methods. We identified five approaches to the policy specification: classification or categorical coding of policy as present or absent; the use of an index; implied policy differences; described policy difference and data-driven policy coding. Each of these has limitations, but perhaps the most common limitation was the inability for the method to account for the differences between policy-as-stated versus policy-as-implemented.
Conclusion:
There is significant diversity in CPA methods for analysis of alcohol and drugs policy, and some substantial challenges with the currently employed methods. The absence of clear boundaries to a definition of what counts as a 'comparative policy analysis' may account for the methodological plurality but also appears to stand in the way of advancing the techniques.
... No se trata de una comparación stricto sensu, pues se entiende que la configuración actual de los sistemas de salud y de la APS en cada país está condicionada por trayectorias históricas, políticas y económicas distintas y que las comparaciones valorativas de desempeño de los sistemas de salud con producción de índices sintéticos y ordenamiento de más y menos son inapropiadas para el análisis (OLIVER, 2012). La comparación en nuestro enfoque no pretende, por lo tanto, establecer una valoración de más o menos; de mejor o peor, sino contribuir con un enfoque más analítico que permita elucidar los principales desafíos para la concreción de una atención primaria integral a la salud en nuestros países. ...
El artículo presenta un panorama de la Atención Primaria de Salud en Suramérica a
partir de mapeos realizados en los 12 países según una matriz analítica organizada en
las dimensiones: conducción, financiamiento, características de la prestación y
organización, coordinación de cuidados e integración a la red de servicios, fuerza de
trabajo, participación social, acción intersectorial e interculturalidad. Se observa
diversidad en la implementación y de abordajes de APS, condicionada por directrices
políticas, modalidades de protección social y segmentación de los sistemas de salud.
Se destacan iniciativas innovadoras de atención primaria integral y se identifican
los principales desafíos.
... Given these findings, is there any point in continuing to think about the difference between Bismarck and Beveridge systems? Even if we suppose that we are not in the game of ranking countries, with the folly that such exercises involve (Oliver, 2012), there is still the question of whether the distinction between Bismarck and Beveridge systems remains useful, a view that some have doubted on the grounds that social insurance schemes have come to rely more heavily on tax-based funding (Saltman, 2012: 12). If outcomes overlap and sources of funding are becoming more similar, does the distinction still serve any useful purpose? ...
Reflecting on ‘Are health problems systemic? Politics of access and choice under Beveridge and Bismarck systems’ - Volume 10 Issue 4 - Albert Weale
... Calculation of a country-level MTS involves consideration of several qualitative factors beyond those included in the quantitative inventory and personnel calculation. Furthermore, the results of international MTS comparison are unlikely to yield policyrelevant or useful results and might even be arbitrarily and subjectively defined, given differing levels of prioritization of, and resources dedicated to, health technology [8]. ...
This paper presents a second look at the computation of the Medical Technology Score (MTS), a metric designed to convey the relative technical competence of a health facility. Modification of the score to reflect local disease burden is discussed, as are its intended interpretations. Extensive data collection on up-to-date equipment and personnel resources must be undertaken before the MTS can become useful as a policy-relevant tool.
Over the last decade, international rankings have emerged as a critical tool used by international actors engaged in global governance. State practices and performance are now judged by a number of high-profile indices, including assessments of their levels of corruption, quality of democracy, creditworthiness, media freedom, and business environment. However, these rankings always carry value judgments, methodological choices, and implicit political agendas. This volume expertly addresses the important analytical, normative, and policy issues associated with the contemporary practice of 'grading states'. The chapters explore how rankings affect our perceptions of state performance, how states react to being ranked, why some rankings exert more global influence than others, and how states have come to strategize and respond to these public judgments. The book also critically examines how treating state rankings like popular consumer choice indices may actually lead policymakers to internalize questionable normative assumptions and lead to poorer, not improved, public policy outcomes.
Countries can learn a great deal from the experiences of others. Because the United States performs poorly in most measures of equity and efficiency, it has a great deal it can learn. Four lessons that these other countries provide are: (1) the systems are built on a bedrock of equitable access to care, (2) they have a single, publicly mandated system that promotes both fairness and efficiency, (3) governments are actively involved in planning for the supply of health care resources and constraining prices, and (4) cost-effectiveness analyses and pricing tools are used to determine benefits and prices, particularly for pharmaceuticals. The countries also offer each other a number of ways in which performance can be improved in the areas of access and equity, expenditure control, and health outcomes.
Over the last decade, international rankings have emerged as a critical tool used by international actors engaged in global governance. State practices and performance are now judged by a number of high-profile indices, including assessments of their levels of corruption, quality of democracy, creditworthiness, media freedom, and business environment. However, these rankings always carry value judgments, methodological choices, and implicit political agendas. This volume expertly addresses the important analytical, normative, and policy issues associated with the contemporary practice of 'grading states'. The chapters explore how rankings affect our perceptions of state performance, how states react to being ranked, why some rankings exert more global influence than others, and how states have come to strategize and respond to these public judgments. The book also critically examines how treating state rankings like popular consumer choice indices may actually lead policymakers to internalize questionable normative assumptions and lead to poorer, not improved, public policy outcomes.
The editors of this volume identify four critical roles that ranking and rating organizations (RROs) perform. They act as judges, global monitors and regulators, advocates, and as branding exercises to claim ownership over issues. In the case of credit rating agencies (CRAs), we see the first three as primary and the fourth as inapplicable in the rating of sovereign debt and in the performance of CRAs in the 2008 financial crisis that originated in repo and mortgage markets. The first role identified by the editors is what US-based rating agencies do by their own admission. They judge the creditworthiness of bond issuers, but with a twist. Protected by the first amendment to the US constitution, CRAs (the big three CRAs are all private American corporations) offer “opinions” that are taken by market and government actors to be “expert judgments.” As Fitch puts it, “ratings are not themselves facts and therefore cannot be described as ‘accurate’ or ‘inaccurate.’” Whether the opinions offered are, or are not, such a thing is a question we shall investigate below, but they are, oddly, both protected speech and a product for sale. Their second role, as monitors and regulators, is again central to what they are and do. The threat of being put on CreditWatch by Standard and Poor's (S&P), for example, is a particular monitoring category that most sovereign bond issuers would like to avoid. Yet the extent to which this monitoring and signaling actually works as advertised is again something to be investigated rather than something to be assumed. Third, CRAs are also advocates, but not in the hands of the raters themselves. We usually think of ratings as advocacy tools in the hands of social entrepreneurs and NGOs against governments and firms, as, for example, in the case of corruption indices used by pro-democracy NGOs to promote reform. In the case of the relationship between sovereigns and CRAs, however, a different dynamic unfolds.
Over the last decade, international rankings have emerged as a critical tool used by international actors engaged in global governance. State practices and performance are now judged by a number of high-profile indices, including assessments of their levels of corruption, quality of democracy, creditworthiness, media freedom, and business environment. However, these rankings always carry value judgments, methodological choices, and implicit political agendas. This volume expertly addresses the important analytical, normative, and policy issues associated with the contemporary practice of 'grading states'. The chapters explore how rankings affect our perceptions of state performance, how states react to being ranked, why some rankings exert more global influence than others, and how states have come to strategize and respond to these public judgments. The book also critically examines how treating state rankings like popular consumer choice indices may actually lead policymakers to internalize questionable normative assumptions and lead to poorer, not improved, public policy outcomes.
Over the last decade, international rankings have emerged as a critical tool used by international actors engaged in global governance. State practices and performance are now judged by a number of high-profile indices, including assessments of their levels of corruption, quality of democracy, creditworthiness, media freedom, and business environment. However, these rankings always carry value judgments, methodological choices, and implicit political agendas. This volume expertly addresses the important analytical, normative, and policy issues associated with the contemporary practice of 'grading states'. The chapters explore how rankings affect our perceptions of state performance, how states react to being ranked, why some rankings exert more global influence than others, and how states have come to strategize and respond to these public judgments. The book also critically examines how treating state rankings like popular consumer choice indices may actually lead policymakers to internalize questionable normative assumptions and lead to poorer, not improved, public policy outcomes.
Ranking of countries with respect to some welfare measure is highly popular and takes places with high frequency. Ranking of a country can change over time given the same welfare measure is applied. Rankings can also change depending on which welfare measure is applied in a given year. To what extent do we see ranking changes and which existing welfare measures best captures an unobserved, yet existing, notion of welfare in society? To investigate this we apply seven welfare indicators for fifteen EU countries covering the years from 2005 until 2011. The results indicate that rankings are particularly volatile for countries in the middle of the ranking distribution, while countries with either high or low welfare generally have lower volatility. A multidimensional poverty index has the highest correlation with the latent welfare measure. It is concluded that the observed rankings do not tell a coherent story, but often point in very different directions, although welfare indicators are often highly correlated. The change in indicator ranks is much less correlated.
The paper analyzes trends in contemporary health sector reforms in three European countries with Bismarckian and Beveridgean models of national health systems within the context of strong financial pressure resulting from the economic crisis (2008-date), and proceeds to discuss the implications for universal care. The authors examine recent health system reforms in Spain, Germany, and the United Kingdom. Health systems are described using a matrix to compare state intervention in financing, regulation, organization, and services delivery. The reforms' impacts on universal care are examined in three dimensions: breadth of population coverage, depth of the services package, and height of coverage by public financing. Models of health protection, institutionality, stakeholder constellations, and differing positions in the European economy are factors that condition the repercussions of restrictive policies that have undermined universality to different degrees in the three dimensions specified above and have extended policies for regulated competition as well as commercialization in health care systems.
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