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
The findings are published today, 21 June, in
The World Health Report 2000 � Health systems: Improving
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
"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
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
"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
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
Information in the WHO report also rates countries
according to the different components of the performance
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 Finland.
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 out-of-pocket payment.
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
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
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 performance.
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