The World Health Report 2000: Can Health Care Systems Be Compared Using a Single Measure of Performance?

ON JUNE 24, 2000, THE World Health Organization published its World Health Report 2000, Health Systems: Improving Performance, which ranked countries according to an overall single indicator of the performance of their health care systems.1 This indicator was an aggregate of 3 other indicators that supposedly measured (1) effectiveness of health care (basically, medical care and public health services), (2) responsiveness of the health care system to users of its health services, and (3) fairness in the system of financing of health care.

Publication of the report created a worldwide debate, most of it published outside the United States.2–6 Recently, the debate has also started in the United States.

THE MEDICALIZATION OF HEALTH

The major criticisms that can be made of the WHO report are conceptual and methodological in nature and can be made for each of the components (effectiveness, responsiveness, and fairness) of the single indicator of performance used in the report. Regarding effectiveness of health care, for example, the WHO report assumes erroneously that health care is the primary force responsible for the decline of mortality and morbidity in both developed and developing countries. That assumption is evident in statements such as “[If] Sweden enjoys better health than Uganda—life expectancy is almost exactly twice as long—it is in large part because it spends exactly 35 times as much in its health systems.” Not surprisingly, the report concludes that what is needed to eradicate disease in less-developed countries is a greater investment in health care: “with investment in health care of $12 per person, one third of the disease burden in the world in 1990 would have been averted.” Such statements reveal a medicalization of the concept of health that is worrisome and surprising, coming as it does from the major international health agency of the United Nations.

Coyne and Hilsenrath seem to concur with this criticism, although somewhat moderately. They write that for some diseases, such as the dramatic and heartbreaking problem of AIDS in Africa, many other types of intervention, apart from the right medicines, are needed. Actually, the same could be said for most causes of mortality and morbidity in any country. Medical and, far more important, public health interventions are indeed crucial to improving the health and quality of life of populations. But far more important for the improvement of health and quality of life are political, economic, and social interventions—and these interventions condition also the effectiveness of the medical and public health interventions.

"The report shows a bias toward the conventional wisdom, in the US and increasingly in European health care establishments, which promotes managed competition and privatization."

For example, the very successful experience of the “barefoot doctors” in the People's Republic of China in the 1960s could not be reproduced in, for example, Iran, because Iran has a very different political context. As Navarro and Shi have shown, political forces that are committed to the redistribution of resources (not only health care resources) in a society are more successful in improving the health of their populations than are political forces that are less committed to such redistribution.7

THE SELLING OF MANAGED COMPETITION AND PRIVATIZATION

Another area that Coyne and Hilsenrath do not touch on is the bias of the WHO report in choosing the “experts” or “informants” who ranked the countries according to the responsiveness of their health care systems. In general, the WHO report shows a well-documented bias toward what may be called the conventional wisdom in US and, increasingly, European health care establishments, which promotes managed competition and privatization in the management and delivery of health services as a way of improving the efficiency and responsiveness of medical care.

Not surprisingly, therefore, the report lists the US health care system as the most responsive in the world, even though the US population is the least satisfied (among the populations of Organization for Economic Cooperation and Development countries) with the organization and funding of its health care. According to a nationwide poll on Americans' perception of their health care system prepared for the American Hospital Association,the majority of the people in the U.S. see in the health care services they receive neither a planned system nor a consumer-oriented organization, except one devoted to optimizing profit by blocking access, reducing quality, and limiting spending. They blame most of it on the pursuit of profits by health insurance companies. Americans believe that their health insurance companies have too much influence and hold too much control over their care.8Similarly, Colombia—a country that has introduced managed competition at the cost of dismantling its national health system—is ranked in the WHO report as having the most responsive health system in Latin America.

The bias of the WHO report reaches vulgar proportions when it even refers to the collapse of the Soviet Union as an indicator of the unresponsiveness of health care systems that are publicly funded and deliver health care through public institutions (i.e., national health services). This condemnation by proxy is unworthy of a document that aspires to scientific credibility. And, in another section, the report is critical of the well-known WHO Alma-Ata Report of 1978 (which established the primary care movement, from a public health perspective) for not being sufficiently sensitive to the market and to the needs of the private sector in medicine. Actually, in many of its positions and values the WHO report reproduces some heavily ideological assumptions, using a technocratic and statistical discourse that gives it an appearance of rigor that it actually lacks.

THE REPRODUCTION OF IDEOLOGY UNDER TECHNOCRATIC DISCOURSE

Another major problem with the World Health Report 2000 is the methodology chosen to develop the single performance indicator. As Coyne and Hilsenrath indicate, the report gives different weights to the different components of the single performance indicator. This weighting is highly subjective and plays a key role in determining the placement of a country's health care system in the health care performance league.

We saw recently how Spain was demoted from 7th in the world in quality of life, as defined by the United Nations Development Program (another UN agency given to producing compound single indicators), to 21st, simply because of a change in the weights given to the different components of the single quality-of-life indicator. That change created alarm in Spain's political establishment, which assumed that the country's quality of life was deteriorating very rapidly. It forced the government to change its public policies to improve those components that were given more weight in the new quality-of-life indicator to make sure that Spain's international standing would be improved.

Thus the technocrats of the United Nations Development Program or the WHO determine, by the way they weight the components of the indicators, the priorities of public policies, and the biases of international technocrats have an enormous influence in shaping the health and social policies of individual countries. This is profoundly wrong. It is one of the major problems that Coyne and Hilsenrath ignore.

THE WHO AS A POLITICAL ORGANIZATION

The history of international agencies, including the WHO, is crowded with examples of how they have reproduced the conventional wisdom of the major developed countries in other contexts, damaging other countries by introducing policies that are foreign to their interests. Banerji has documented many examples of how the WHO, as well as UNICEF, the World Bank, and other agencies, have damaged India.9

It is important to realize that the WHO is not a scientific institution but rather an agency of the United Nations, and, as such, is subject to the influence of governments of the G-7 countries—particularly those, like the United States, that fund large proportions of the WHO budget. Thus it is not uncommon for the agency to act as a transmitter of the conventional wisdom prevalent in the developed countries.

Of course, the WHO has done very good work in many areas. But there is an urgent need to analyze, more critically than has yet been done, its work and modus operandi. At a time when the World Trade Organization, the World Bank, the International Monetary Fund, and other international agencies are coming under increasing scrutiny, we should be directing an equally critical look at other agencies, including the WHO.