Making a Cross-Country Comparison of Health Systems: What Are the Possible Study Design Frameworks?

Purpose:   Health care systems form the framework and context through which countries provide health care services to their populations. They are comprised of an amalgam of culturally- and often economically-driven structures (e.g., facilities, personnel, policies, processes) to attain optimal health outcomes. No single health system is precisely like another. However, when studies explore differences in population health status or outcomes across countries, often the comparison focuses solely on health outcomes, completely omitting the effects and influences of the health system. This omission is problematic, since as several health care provision models suggest, health care outcome inequities may be connected to or even originate from the health system's context and approach; but this topic has been explored by very few studies. With increasing globalization, nurses comprising the largest health professional labor force in the world must employ the most rigorous study design frameworks when conducting cross-country comparisons of health outcomes. Thus, the goal of this research project is to examine study design frameworks used to make cross-country comparisons of health care outcomes taking into account the health care system context.  

Methods: To address this goal, this study examined study design frameworks using a scoping review methodology with the following steps: the identification of the domains of the health care system that must be explored; search and selection of relevant studies; charting the studies’ findings; and summarization of the results.

Results: Study design frameworks for cross-country comparisons of health care outcomes within the health system context varied by: (1) use of country selection criteria as a basis for country selection, (2) use of a guiding theory to govern the elements for comparison, (3) the decision of the data type (i.e., quantitative, qualitative, mixed-methods), (4) ascertainment and validation of measurements, (5) synthesis of findings employed a wide versus narrow focus, (6) inclusion of countries' cultures and population composition, and (7) contribution to other countries' health systems. 

Conclusion: A grid denoting a variety of cross-country study design frameworks depicts a variety of strengths and weaknesses. Countries' health care systems are culturally-linked, but criteria exploring or explicating cultural influences within the health system context were sparse or absent. Moreover, cross-country comparison frameworks were inconsistent in their abilities to delineate and define approaches that resulted in inequitable health service outcomes for different population groups. Design frameworks failing to include the cultural context limit our ability to fully examine differences in health care outcomes. Nurses and other health professionals must choose a study design framework that is systematic, comprehensive and sufficiently robust to meet the challenge of conducting cross-country comparisons so that study results are able to assist countries' policymakers and administrators to make improvements that promote better and more equitable health outcomes for their population.