Financial Times - June 20, 2000
France tops world health league By Nicholas Timmins, Public Policy Editor
France has the world's best performing health system according to a radical new analysis by the World Health Organisation.
It is followed by Italy, Singapore, Spain, Oman, Austria and Japan among major countries, with the UK ranked 18th out of 191 countries and the US - which has by far the world's largest health expenditure - ranked only 37, just above Cuba.
Sierra Leone, Burma, the Central African Republic and the Congo prop up the table.
The rankings come from a new index, compiled by the WHO, which attempts to measure how much health each country's system delivers, health inequalities, how responsive systems are, how fairly funding is raised and distributed and how well governments regulate public and private health care.
The rankings show "wide variation in performance, even among countries with similar levels of income and health expenditure", said Dr Gro Harlem Brundtland, WHO director-general.
Middle income countries such as Chile and Lebanon, for example, are ranked 60 paces apart, in part because of the impact of Lebanon's largely unregulated private sector.
The report also shows that "virtually all countries are under-utilising the resources that are available to them", according to Dr Christopher Murray, director of WHO's global programme on evidence for health policy. "This leads to large numbers of preventable deaths and disabilities."
Oman rates highly, not because of high expenditure but because it has developed a network of highly responsive, easily available health centres which over 20 years have sharply reduced high child mortality, said Dr Julio Frenk, executive director of the WHO.
But countries can move in the other direction. Dr Murray said China would have been high in the tables in the 1970s, delivering good health at low cost. But having dismantled its social insurance system, "a lot of people have been left unprotected from catastrophic health expenditures, so they are down at 144th".
Dr Frenk said a key aim of the index was that "by providing a comparative guide to what works and what doesn't work, we can help countries to learn from each other and improve the performance of their health systems".
The WHO finds that health ministries must look at the overall impact of the private as well as public sector.
Pre-payment systems, which avoid large out-of-pocket spending at the time of treatment, are crucial. Given that most poorer and even some middle income countries cannot achieve that through taxation, work-based and community-based social insurance systems should be encouraged. Setting priorities is also important, and rationing should limit the procedures covered, rather than the people covered.