The World Health Organization has carried out the
first ever analysis of the world’s health systems. Using five
performance indicators to measure health systems in 191 member states,
it finds that France provides the best overall health care followed
among major countries by Italy, Spain, Oman, Austria and Japan.
The findings are published today, 21 June, in The
World Health Report 2000 – Health systems: Improving performance.
The U. S. health system spends a higher portion of
its gross domestic product than any other country but ranks 37 out of
191 countries according to its performance, the report finds. The
United Kingdom, which spends just six percent of gross domestic
product (GDP) on health services, ranks 18th . Several small countries
– San Marino, Andorra, Malta and Singapore are rated close behind
second- placed Italy.
WHO Director-General Dr Gro Harlem Brundtland says:
"The main message from this report is that the health and
well-being of people around the world depend critically on the
performance of the health systems that serve them. Yet there is wide
variation in performance, even among countries with similar levels of
income and health expenditure. It is essential for decision- makers to
understand the underlying reasons so that system performance, and
hence the health of populations, can be improved."
Dr Christopher Murray, Director of WHO’s Global
Programme on Evidence for Health Policy. says: "Although
significant progress has been achieved in past decades, virtually all
countries are underutilizing the resources that are available to them.
This leads to large numbers of preventable deaths and disabilities;
unnecessary suffering, injustice, inequality and denial of an
individual’s basic rights to health."
The impact of failures in health systems is most
severe on the poor everywhere, who are driven deeper into poverty by
lack of financial protection against ill- health, the report says.
"The poor are treated with less respect, given
less choice of service providers and offered lower- quality
amenities," says Dr Brundtland. "In trying to buy health
from their own pockets, they pay and become poorer."
The World Health Report says the
main failings of many health systems are:
Many health ministries focus on the public
sector and often disregard the frequently much larger private
sector health care.
In many countries, some if not most physicians
work simultaneously for the public sector and in private practice.
This means the public sector ends up subsidizing unofficial
Many governments fail to prevent a "black
market" in health, where widespread corruption, bribery,
"moonlighting" and other illegal practices flourish. The
black markets, which themselves are caused by malfunctioning
health systems, and low income of health workers, further
undermine those systems.
Many health ministries fail to enforce
regulations that they themselves have created or are supposed to
implement in the public interest.
Dr Julio Frenk, Executive Director for Evidence and
Information for Policy at WHO, says: "By providing a comparative
guide to what works and what doesn’t work, we can help countries to
learn from each other and thereby improve the performance of their
Dr Philip Musgrove, editor-in-chief of the report,
says: "The WHO study finds that it isn’t just how much you
invest in total, or where you put facilities geographically, that
matters. It’s the balance among inputs that counts – for example,
you have to have the right number of nurses per doctor."
Most of the lowest placed countries are in
sub-Saharan Africa where life expectancies are low. HIV and AIDS are
major causes of ill-health. Because of the AIDS epidemic, healthy life
expectancy for babies born in 2000 in many of these nations has
dropped to 40 years or less.
One key recommendation from the report is for
countries to extend health insurance to as large a percentage of the
population as possible. WHO says that it is better to make
"pre-payments" on health care as much as possible, whether
in the form of insurance, taxes or social security.
While private health expenses in industrial
countries now average only some 25 percent because of universal health
coverage (except in the United States, where it is 56%), in India,
families typically pay 80 percent of their health care costs as
"out-of- pocket" expenses when they receive health care.
"It is especially beneficial to make sure that
as large a percentage as possible of the poorest people in each
country can get insurance," says Dr Frenk. "Insurance
protects people against the catastrophic effects of poor health. What
we are seeing is that in many countries, the poor pay a higher
percentage of their income on health care than the rich."
"In many countries without a health insurance
safety net, many families have to pay more than 100 percent of their
income for health care when hit with sudden emergencies. In other
words, illness forces them into debt."
In designing the framework for health system
performance, WHO broke new methodological ground, employing a
technique not previously used for health systems. It compares each
country’s system to what the experts estimate to be the upper limit
of what can be done with the level of resources available in that
country. It also measures what each country’s system has
accomplished in comparison with those of other countries.
WHO’s assessment system was based on five
indicators: overall level of population health; health inequalities
(or disparities) within the population; overall level of health system
responsiveness (a combination of patient satisfaction and how well the
system acts); distribution of responsiveness within the population
(how well people of varying economic status find that they are served
by the health system); and the distribution of the health system’s
financial burden within the population (who pays the costs).
"We have created a new tool to help us measure
performance," says Dr Murray. "As we develop it further and
strengthen the raw data used for these measures in the years to come,
we believe this will be an increasingly useful tool for governments in
improving their own health systems."
Other findings in the annual WHO report include:
In Europe, health systems in Mediterranean
countries such as France, Italy and Spain are rated higher than
others in the continent. Norway is the highest Scandinavian
nation, at 11th .
Colombia, Chile, Costa Rica and Cuba are rated
highest among the Latin American nations – 22nd, 33rd, 36th and
39th in the world, respectively.
Singapore is ranked 6th , the only Asian
country apart from Japan in the top 50 countries.
In the Pacific, Australia ranks 32nd overall,
while New Zealand is 41st.
In the Middle East and North Africa, many
countries rank highly: Oman is in 8th place overall, Saudi Arabia
is ranked 26th , United Arab Emirates 27th and Morocco, 29th.
In 1970, Oman’s health care system was not
performing well. The child mortality rate was high. But major
government investments have proved to be successful in improving
system performance. "Oman’s success shows that tremendous
strides can be accomplished in a relatively short period of
time," says Dr Murray.
Information in the WHO report also rates countries
according to the different components of the performance index.
Responsiveness: The nations with the most
responsive health systems are the United States, Switzerland,
Luxembourg, Denmark, Germany, Japan, Canada, Norway, Netherlands and
Sweden. The reason these are all advanced industrial nations is that a
number of the elements of responsiveness depend strongly on the
availability of resources. In addition, many of these countries were
the first to begin addressing the responsiveness of their health
systems to people’s needs.
Fairness of financial contribution: When
WHO measured the fairness of financial contribution to health systems,
countries lined up differently. The measurement is based on the
fraction of a household’s capacity to spend (income minus food
expenditure) that goes on health care (including tax payments, social
insurance, private insurance and out of pocket payments). Colombia was
the top-rated country in this category, followed by Luxembourg,
Belgium, Djibouti, Denmark, Ireland, Germany, Norway, Japan and
Colombia achieved top rank because someone with a
low income might pay the equivalent of one dollar per year for health
care, while a high- income individual pays 7.6 dollars.
Countries judged to have the least fair financing
of health systems include Sierra Leone, Myanmar, Brazil, China, Viet
Nam, Nepal, Russian Federation, Peru and Cambodia.
Brazil, a middle-income nation, ranks low in this
table because its people make high out-of-pocket payments for health
care. This means a substantial number of households pay a large
fraction of their income (after paying for food) on health care. The
same explanation applies to the fairness of financing Peru’s health
system. The reason why the Russian Federation ranks low is most likely
related to the impact of the economic crisis in the 1990s. This has
severely reduced government spending on health and led to increased
In North America, Canada rates as the country with
the fairest mechanism for health system finance – ranked at 17-19,
while the United States is at 54-55. Cuba is the highest among Latin
American and Caribbean nations at 23-25.
The report indicates – clearly – the attributes
of a good health system in relation to the elements of the performance
measure, given below.
Overall Level of Health: A good health
system, above all, contributes to good health. To assess overall
population health and thus to judge how well the objective of good
health is being achieved, WHO has chosen to use the measure of
disability- adjusted life expectancy (DALE). This has the advantage of
being directly comparable to life expectancy and is readily compared
across populations. The report provides estimates for all countries of
disability- adjusted life expectancy. DALE is estimated to equal or
exceed 70 years in 24 countries, and 60 years in over half the Member
States of WHO. At the other extreme are 32 countries where disability-
adjusted life expectancy is estimated to be less than 40 years. Many
of these are countries characterised by major epidemics of HIV/AIDS,
among other causes.
Distribution of Health in the Populations:
It is not sufficient to protect or improve the average health of the
population, if - at the same time - inequality worsens or remains high
because the gain accrues disproportionately to those already enjoying
better health. The health system also has the responsibility to try to
reduce inequalities by prioritizing actions to improve the health of
the worse-off, wherever these inequalities are caused by conditions
amenable to intervention. The objective of good health is really
twofold: the best attainable average level – goodness – and the
smallest feasible differences among individuals and groups –
fairness. A gain in either one of these, with no change in the other,
constitutes an improvement.
Responsiveness: Responsiveness includes
two major components. These are (a) respect for persons (including
dignity, confidentiality and autonomy of individuals and families to
decide about their own health); and (b) client orientation (including
prompt attention, access to social support networks during care,
quality of basic amenities and choice of provider).
Distribution of Financing: There are good
and bad ways to raise the resources for a health system, but they are
more or less good primarily as they affect how fairly the financial
burden is shared. Fair financing, as the name suggests, is only
concerned with distribution. It is not related to the total resource
bill, nor to how the funds are used. The objectives of the health
system do not include any particular level of total spending, either
absolutely or relative to income. This is because, at all levels of
spending there are other possible uses for the resources devoted to
health. The level of funding to allocate to the health system is a
social choice – with no correct answer. Nonetheless, the report
suggests that countries spending less than around 60 dollars per
person per year on health find that their populations are unable to
access health services from an adequately performing health system.
In order to reflect these attributes, health
systems have to carry out certain functions. They build human
resources through investment and training, they deliver services, they
finance all these activities. They act as the overall stewards of the
resources and powers entrusted to them. In focusing on these few
universal functions of health systems, the report provides evidence to
assist policy-makers as they make choices to improve health system
The World Health Report 2000 (1) consists
of a message from the WHO’s Director-General, an overview, six
chapters and statistical annexes. The chapter headings are "Why
do health systems matter?", "How well do health systems
perform?", Health services: well chosen, well organized?",
"What resources are needed?", "Who pays for health
systems?", and "How is the public interest protected?"