France's health care system

Articles about health care in other countries are uncommon in CMAJ, so I was pleased to read the interesting News article about the French system.1 Alas, Christina Lopes presents misleading conclusions from the World Health Organization's 2000 report on international health care systems2 as have other commentators, including Michael Moore in his film Sicko.

It is misleading and simplistic to state that “the World Health Organization … anointed the French health care system as the best in the world” and that it “ranked Canada 30th in the same survey.” The World Health Organization report includes 9 tables with international rankings along with an additional summary table. France is ranked first in only 1 of the tables: Table 10, which indicates health system performance. This index was calculated by relating a country's overall health achievement to its expenditure on its health system. Simply put, France ranks first in efficiency.

According to the World Health Organization, one must measure 5 things to assess a health care system: the overall level of health, the distribution of health in the population, the system's level of responsiveness, the distribution of responsiveness and the distribution of financial contribution.2 The way in which the system deals with access to specialists and wait times, which Lopes highlights as a star feature of the French system, falls into the category of the system's level of responsiveness. The World Health Organization report combines these 5 features of a health care system into 1 composite measure, overall health system attainment, in Table 9. It is a country's ranking in Table 9, one can argue, that is the most important ranking: it provides an indication of how well the system works for the user. Canada ranks seventh in this table and France ranks sixth. Japan ranks first.