International league tables and medicines

Many people love a good league table; those tables that show you the best schools and universities to study at, the best companies to work for, or even the best airline to fly with. But when applied to medicines, what do they tell us?

Health care now has many league tables that explore which country has the best system, including the Commonwealth Fund and Health Consumer Powerhouse and even a recent Economist Intelligence Unit study looking at the issue with a cost and outcome index and ranking 166 countries.

The Organisation for Economic Co-operation and Development (OECD) and the World Health Organisation (WHO) both provide access to databases that allow country comparisons on a host of indicators, ranging from mortality to the number of doctors and nurses.

Note that not everyone will call efforts to make cross-country comparisons relating to health a league table, but as soon as comparable data is published which can show one country is better (or worse) than another, you can bet a league table will emerge... and this is the case even if it's not comparable data!

Medicines league tables abound

League tables that compare countries on a host of issues relating to medicines abound too. We've now got several that look at different aspects and are updated on a regular basis (see bullets below).

The many international league tables relating to medicines

• Which country gets the best medicine prices?

The database of medicine prices, availability, affordability, and price components from Health Action International and WHO enables users to generate their own league for a host of developing countries. WHO also has data relating to generics.

It is also possible to see which country from 12, mostly European but also the US and Australia, pays more or less than the UK for a basket of medicines in regular reports on the Pharmaceutical Price Regulation Scheme (PPRS). The last time this was done, in 2011, the US was in the top spot, and the UK was paying less than others in Europe. (Don't forget, though, that what is really paid is often commercial in confidence, so some of these league tables may not be accurate).

• Which country is best for access to medicines?

Germany is the best place to access medicines, followed by Italy and France in joint second place, with the UK fourth in line, according to a recent Patient View report.

• How long do patients have to wait to get access to innovative medicines?

The European Federation of Pharmaceutical Industries and Associations (EFPIA) produces the W.A.I.T indicator which looks at the time between the date of the European Union marketing authorisation and when an innovative medicine is made available; Estonia has the worst record in this league with 848 days, while Denmark is the best of the countries included, at just 116 days in 2011. Although a regular yearly run from 2008, the latest report only goes up to 2011.

• Which country's HTA agency takes the longest to reach a recommendation?

Charles River Associates (CRA) has updated its work on comparing HTA agencies, including which is the fastest in producing an HTA recommendation, with England being particularly slow.

There is also a host of academic and less academic studies that compare, contrast and debate the myriad issues for medicines and where league tables form a part (or can be generated). An example is the Karolinska Institute work that pitted countries against one another in terms of uptake of cancer drugs. The UK generally did poorly versus its European neighbours, while France did well in the 2009 update of the original 2005 work.

Plus there are indicators that explore how countries compare on competitiveness that seem to have fallen out of favour, such as the UK's Pharmaceutical Industry Competitiveness Task Force (PICTF) indicators. A refresh of these is long overdue; the last PICTF publication was in 2009 and even that was slim compared to the run from 2001 to 2005.

What do international league tables tell us?

A good league table should generate questions; what can be learned from those at the top? It might also give some clues on what to avoid from those who linger at the bottom.

They can also help provide understanding on whether things are getting better or worse if they're updated over time. The Association of the British Pharmaceutical Industry (ABPI) has just published work from the Office of Health Economics (OHE) that explores access to medicines in the UK versus other European countries. This is an update on 2010 work by Sir Mike Richards (so it's often referred to as the Richards Review).

The 2010 work put the UK in 8th place (out of 14) in 2008/9 but in 2012/13 it had fallen to 9th place. France topped the league.

It will be interesting to re-evaluate the situation in light of a host of recent efforts to address access to medicines in the UK, ranging from the Early Access to Medicines Scheme through to the Innovative Medicines and MedTech Review.

"Access depends on a host of factors, ranging from health technology assessment through to diagnosis and access to specialists"

Rarely, though, are league tables enough on their own to find out what drives the results. For that, deeper analysis is needed, such as the study Rand has produced. Perhaps predictably, they conclude that access depends on a host of factors, ranging from health technology assessment through to diagnosis and access to specialists.

Often, league tables can't say definitively how good or bad things are. When looking at measures of access to medicines, part of the problem lies in knowing exactly what the 'right' level is. It is also difficult to ascertain what benefits arise from different levels of access, and whether it's worth it.

But there is untold political capitol in league tables; Secretary of State for Health in the UK, Jeremy Hunt, has referenced the UK's position on the Commonwealth ranking of health care systems on more than one occasion. Who can blame him, since it does put the UK in the number one spot? So far, I haven't heard him acknowledging the UK's less impressive position on access to medicines... Is it time for him to take a closer look at that?

About the author:

Leela Barham is an independent health economist and policy expert who has worked with all stakeholders across the health care system, both in the UK and internationally. Leela works on a variety of issues: from the health and wellbeing of NHS staff to pricing and reimbursement of medicines and policies such as the Cancer Drugs Fund and Patient Access Schemes. Find out more here and you can contact Leela on leels@btinternet.com

Have your say: How useful a tool are league tables?