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France heads WHO's league table of health systems

Zosia Kmietowicz, London

If you are going to be ill, the best place to be is Francethe country ranked first in an analysis of the world's healthcare systems carried out by the World Health Organization (WHO).

Among major countries, France was followed by Italy, Spain, Oman, Austria, and Japan, with several small countries (including San Marino, Andorra, Malta, and Singapore) rated among the top 10 healthcare providers.

The analysis, which used five performance indicators to measure health systems, showed that it is not what you spend on health care but how you spend the resources available to you that is important.

Despite spending more of its gross domestic product on health than any other country (13.7%), the United States ranked only 37 out of 191 WHO member states; the United Kingdom, which spends just 6% of gross domestic product on health services, came out 18th. France spends 9.8%.

The surprise finding of the analysis, said Dr Christopher Murray, director of the WHO's global programme on evidence for health policy, was the vast underuse of resources available and the tremendous range of health systems. "Some countries are only performing 20% of what they could achieve while others are 99% efficient," he said.

Oman, which has reduced its child mortality from 230 per 1000 to 15 per 1000 in the past 20 years, and Colombia, which was judged to have the most fair financing system, have seen dramatic improvements in their healthcare systems as a result of focused investment.

Most of the lower placed countries are in sub-Saharan Africa, and performed badly because of the havoc wreaked by HIV and AIDS, which have reduced life expectancy to less than 40 years in many countries.

One of the key recommendations of the report is to fund health services through prepayment schemes, such as taxes, insurance, or social security, rather than through out of pocket expenses when people receive their health care.

"In many countries without a health insurance safety net, many families have to pay more than 100% of their income for health care when hit with sudden emergencies. In other words, illness forces them into debt," said Julio Frenk, executive director for evidence and information for policy at the WHO.

The report attributes the failings of many health systems to a variety of factors, including "black markets" and "moonlighting," the practice of doctors working simultaneously for the public and private sectors.

"We are trying to help countries improve their performance and we have devised a method which makes it possible to see how well resources are being used rather than the dismal conclusion that poor countries are doing worse than rich countries," said Dr Murray.

"Our real objective is to find out the best way of managing a health service based on sound scientific evidence. For example, we want to build up objective measurements so that we will be able to see whether the purchaser-provider split, as introduced into the United Kingdom, really helps to achieve better health."

The analysis, which took two years to complete, will be an annual event.

The World Health Report 2000 Health Systems: Improving Performance is published by the WHO (price SwFr15 (£6); SwFr10.50 in developing countries) and can also be accessed at www.who.int/

Overall level of population health

Health inequalities within the population

Overall level of health system responsiveness (a combination of patients' satisfaction and how well the system operates)

How well people of varying economic status are served by the health system

Distribution of the health system's financial burden within the population (who pays the costs)

(Credit: WORLDHEALTH ORGANIZATION ) United States, the world"s big spender on health care, trails Europe in value for money