International Comparisons of Health Systems: Tools of Learning or Tools of Power?

International comparisons have become unavoidable for anyone who wants to govern health systems, including health organizations and professions. Because medicine can be evidence-based, health policies would logically also be evidence-based. In parallel, since the early sociologists it is believed that comparing is the better way to produce “evidence-based social science”. As a consequence, comparing is believed to be the better way to conduct efficient policies to face health systems challenges. But the many and recurrent flaws of these comparisons cast doubt on their actual role and effects. Among the most common deficiencies are the comparability of data, the lack of clear definitions of terms (like “shortage” or "nurses”) and the state-centrism of comparisons (while issues are more and more either decentralized or global).

Why thus such a success of international comparisons among health policy-makers? The argument developed in this paper is that behind their technical substrate and their apparent neutrality, international comparisons carry values, interests and power relations. Under the guise of rationalizing and depoliticizing decisions, international comparisons are less a tool of learning than a tool of power. That is probably the fundamental reason for their success. First, comparisons hide that health policies choices are always value-laden. Indeed, comparisons are in themselves “scientific” and thus deliver the “truth”. Furthermore, the language through which comparisons are presented (tables, histogram, etc.) create effects of truth. As a consequence comparisons rule out any debate. Moreover, international comparisons create political pressure, not least because this language is easily understandable and particularly well-suited for the mass media.

This gap between the official and unofficial role of international health comparisons can contribute to explain the tension between the apparent convergence and persistence of country-specific arrangements.

My paper will develop all these points on the basis of case studies from Europe, the USA and Asia.