This issue of the Longwoods Review provides contrasting, yet essential perspectives on our healthcare system. The first paper is a macro analysis by Deber examining why the World Health Organization (WHO) ranked Canada's healthcare system poorly relative to other countries in the world. In contrast, the second paper reports on a survey conducted by Lacaria et al. of professional pharmacy services in one Canadian teaching hospital.

Deber describes the methodology used by the World Health Organization in Report 2000 to compare 191 countries in terms of their ability to meet specific criteria for excellence in performance. The publication of this report, and Canada's low ranking at 30 - behind many less industrialized and less wealthy countries - received considerable attention in both the popular and the professional press. The issues raised by Deber about the analysis in the Report are essentially problems of measurement. As she points out, measuring health system performance is complex especially if the main goal of the measurement is to be able to compare 191 countries across common criteria. WHO based its measures of performance on five population health indicators - level of health, distribution of health, level of and distribution of responsiveness, and equity of financial contribution. The weights of these criteria appeared arbitrary and somewhat inconsistent. Deber's criticism includes a debate of the type of criteria that were underlying the analysis - she indicates that the rankings did not take into consideration the most important issues of access, utilization, quality and cost-effectiveness.

At the more micro analysis level, Lacaria and her colleagues assessed stakeholders' opinions about the professional pharmacy services - an assessment of one hospital and one type of service performance. Close to 500 patients, nurses, physicians and pharmacists gave their opinions on the type and quality of services being provided. A written survey was distributed to participants and their impressions obtained anonymously. The specific goal was to elicit views on awareness of the different types of services already available, the quality and priority of patient care, education and research services currently offered. The overall goal was quality improvement. Results showed that of the four types of respondents, perhaps not surprisingly, patients were the least aware of the range of services being available. However, most of the ratings of services by all groups were very good. In the end, the survey did point out ways in which services could be improved in the future.

As these papers demonstrate, both macro and micro analyses of health system performance are critical in raising issues of service quality and improvement. We thank the authors for their contributions to our understanding of the issues.

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