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WHO ranking of national health systems reveals some surprises

13-Aug-2001

Some of the world's poorest and least developed countries have more efficient health systems than many western countries, according to a report by the World Health Organisation.

A comparison of 191 country's health systems, published in the British Medical Journal on Friday, shows significant variations across the world. Oman has the most effective health system in the world in terms of outcome, while countries in sub-Saharan Africa had the worst performance records, according the WHO analysis.

In the report, David B. Evans of the Global Programme on Evidence for Health Policy at the WHO and colleagues suggest that countries like Malta, Jamaica and Morocco provide more efficient healthcare than the UK, Canada and the US. The report ranks the UK as 24th, Canada as 35th and the US at 72nd.

Three intrinsic goals of health systems were considered in the analysis. These included "improving health, increasing responsiveness to the legitimate demands of the population, and ensuring that financial burdens are distributed fairly," Evan's group explains. The researchers then assessed the effectiveness of health systems by comparing the amount of money spent with the extent of health improvement of the population.

The authors suggest that Oman's top ranking could be attributed to the fact that it has drastically reduced child mortality over the past 40 years, cutting rates from 310 to 18 per 1000 live births.

Similarly, poor health records in countries like Zimbabwe (ranked 191st), Zambia and the Democratic Republic of Congo could be attributed to a record of civil unrest and high rates of HIV infection and AIDS.

The WHO report notes that improvements in the health of a population can be achieved in a number of different ways, not just by spending more on healthcare. It suggests that the healthy diet of Mediterranean countries is responsible for giving them a high ranking. Mediterranean countries, including Italy and Spain, occupy six of the seven top places.

However, the authors add that government spending is an important factor. "We found that efficiency is positively related to health expenditure per capita. Performance increased greatly with expenditure up to about $80 per capita a year, suggesting it is difficult for systems to be efficient at low expenditure."

Evans and colleagues added that some countries, in particular the US and sub-Saharan African states, could improve the effectiveness of their systems by reallocating money for schemes that are not cost-effective to schemes that provide a good return in terms of improving people's health.

In an editorial in the BMJ, Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, welcomed the study but warned that it was difficult to make comparisons between individual countries.

"I think the idea of trying to assess the performance of healthcare systems in different countries is a good one and the work done in this paper is a good start," McKee told Reuters Health.

"We should be careful reading into individual rankings and I would warn against any comparisons," he added. "But certainly this report is a very good start in terms of enabling us to determine which countries have the most efficient health systems."

McKee said it was important that countries were given an opportunity to compare their health policies, but more work needed to be done. "It will enable countries and governments to learn from those that are better. There is a quest for comparison, in the same way as we compare the economic performance or literacy levels of countries."

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