Comparative efficiency of national health systems: cross national econometric analysis
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7308.307 (Published 11 August 2001) Cite this as: BMJ 2001;323:307
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Dear editor,
In the 11th of August issue, one more paper of the WHO appeared,
comparing efficiency of all national health care systems of the world.1
Efficiency relates to the health you get for the money you spend. The
main question is then how to quantify the health you get.
Evans use the 'healthy life expectancy' as measure of the outcome of
the health care system. Healthy life expectancy needs literally thousands
of assumptions, as extensive information about disease specific morbidity
is needed. Evans et al fail to explain why healthy life expectancy is
chosen instead of life expectancy. Evans et all correct then this measure
for the 'minimum achievable health in the absence of a health system from
observations on 25 countries before the existence of a modern health
system (average year 1908)'. In the refered paper (http://www-
nt.who.int/whosis/statistics/discussion_papers/pdf/paper29.pdf), there is
no mention whatsoever of the data and methods used in this truly heroic
enterprise.
Evans et al explain health by health care expenditure and schooling.
Evans et al state 'We did not include income per capita, because income is
highly correlated with health expenditure'. Evans et al do not adress the
wealth of literature written about wealth, health and health care
expenditure.2 3 Their 'econometric analysis' attributes all consequences
of wealth (housing, sanitation, food intake, and so on) to health care
expenditure. This is nonsense.
It takes little time to 'explain' the weird results of this
'econometric analysis'. Time which is not taken in the discussion. Oil
producing countries of the Middle East rank highly. Life expectancy is
mediocre, levels of health care funding are poor (< 4% of GDP), levels
of literacy are low (http://www-
nt.who.int/whosis/statistics/discussion_papers/pdf/paper27.pdf) and
'minimum achievable health' was probably very low (before oil brought
wealth, this was a very poor, largely undeveloped region). Because their
actual wealth is not taken into account, the life expectancy 'expected' by
poor schooling, poor funding of health care and a general history of
poverty is even more mediocre than observed, meaning a great health care
service.
All Mediterranean European countries are very efficient, regardless
the fact that they have very different health care systems, plagued with
many troubles.3 The reason is known as 'the French paradox' in
cardiovascular disease epidemiology. These countries experience a low
cardiovascular mortality, often attributed to the drinking of red wine.
As a consequence, mortality is low. Health care funding is poorer than
average, so that the expected life expectancy is lower than the observed.
Zimbabwe is poorest performer of all. Except from being a poor
Subsaharan country ravaged by AIDS, Zimbabwe funded its health care and
schooling better than average (http://www-
nt.who.int/whosis/statistics/discussion_papers/pdf/paper27.pdf). Other
Subsaharan countries spend only a few dollars to health care and
schooling. Better funding and higher litteracy rates condemns Zimbabwe as
'inefficient' because its expected life expectancy is high.
Evans' conclusions about health care efficiency ought to be
summarised as follows: keep your people ignorant, underfund your health
care service, find oil and drink red wine.
Competing interests: No competing interests
EDITOR--Evans et al. present an unproblematic image of the methods
and findings of the World Health Report 2000 (WHR 2000) and their
paper,[1] despite the controversy that has surrounded the report on
conceptual, methodological and procedural grounds. I have published with
others concerns about the report[2] and here only draw attention to some
issues relating to the paper.
'Healthy' (or 'disability adjusted') life expectancy (DALE), the
outcome measure used to estimate health system efficiency, is presented as
an unproblematic indicator, despite the lack of necessary data for many
developing countries and the consequent arcane computational manipulation
- often based on speculative assumptions - that was required to arrive at
estimates for 191 countries.[3] Uncertainty intervals were calculated for
DALEs, but for the methods used the paper refers back to the WHR 2000,
which refers back to an internal WHO discussion paper, which has not yet
been released on WHO's website.
Criticisms have also been expressed about the technical and ethical
bases of the disability weights used in calculating DALE and, more
fundamentally, about the meaning, usefulness and validity of compressing
mortality, morbidity and disability data into a single number.[4] Many
view death and non-fatal health outcomes as qualitatively different and
incommensurable. It is difficult to see how a highly composite measure
like DALE, which obscures epidemiological information, will assist in
meeting the stated objective of improving the evidence base for health
policy. To effect change, policy needs to be specific and based on
disaggregated data. Given the close correlation of DALE with standard life
expectancy, it seems difficult to justify the effort and expense involved
in constructing DALEs rather than using more transparent standard measures
of mortality and morbidity. The approach to efficiency employed and the
use of education rather than income to represent non-health-system
determinants of health have also been questioned.[5]
Evans et al. conclude from their extensive study that more money
should be spent on health systems in poor countries and most countries
would gain by using health resources more efficiently. Did we not know
this already?
The section headed 'validity of findings' makes no reference to the
extensive literature discussing these and other problems and it is a pity
that the BMJ did not require the authors to do this. The paper lends
credence to the view that the WHR 2000 enterprise may owe more to
institutional marketing than to science.[5] Following pressure from
countries and regions, the WHO will not update the assessments of health
system performance this year but will initiate a scientific peer review of
the methods to be employed in the future.
Malcolm Segall associate (retired fellow)
Institute of Development Studies,
University of Sussex, Brighton
BN1 9RE
m.segall@ids.ac.uk
1. Evans DB, Tandon A, Murray CJL, Lauer JA. Comparative efficiency
of national health systems: cross national econometric analysis. BMJ
2001;323:307-10. (11 August.)
2. Almeida C, Braveman P, Gold MR, Szwarcwald CL, Ribeiro JM,
Miglionico A, et al. Methodological concerns and recommendations on policy
consequences of the World Health Report 2000. Lancet 2001;357:1692-7.
3. Mathers CD, Sadana R, Salomon JA, Murray CJL, Lopez AD. Estimates
of DALE for 191 countries: methods and results. Geneva: World Health
Organization, 2000 (Global programme on evidence for health policy
discussion paper No 16.)
4. Arnesen T, Nord E. The value of DALY life: problems with ethics
and validity of disability adjusted life years. BMJ 1999;319:1423-5. (27
November.)
5. Williams A. Science or marketing at WHO? A commentary on 'World
Health 2000'. Health Econ 2001;10:93-100.
Competing interests: None.
Competing interests: No competing interests
Editor,
Evans et al identified Oman as the lead country in their efficiency
(performance) score involving estimated efficiency of 191 countries from
data for 1993-7.
It may be of interest to readers that the Royal College of General
Practitioners (RCGP), has for the past three years had an ongoing
involvement with the Department of Family and Community Health, College of
Medicine, Sultan Qaboos University, Muscat Oman.
For some years in many parts of the world, there has been a wish to
develop an internationally recognised postgraduate qualification for
general practice/family medicine equivalent in status to qualifications in
hospital- based specialities.
In Oman (as was the case in UK many years ago) due to the lack of an
internationally recognised qualification many ‘graduates’ from their
excellent four year family medicine programme sought MSc or PhD degrees
overseas - excellent for some but not the way to address the primary care
needs of the population.
The RCGP Council, Examination Board and International Division have
over the past several years designed a high quality assessment package
tailored to local needs of culture, educational systems, medical practice
and epidemiology. Thus a new category of International Member to support
and develop general practice/family medicine is in an advanced stage of
development. Assessment of candidates will take place in the host country.
Successful candidates will be designated
MRCGP [INT]. This will be in addition to, rather than replace any
nationally awarded qualification.
As can be deduced from the article by Evans et al Oman has a very
progressive policy for health care. Reduction of child mortality from 310
to 18 per live births over the past 40 years is only part of the story.
There are approximately 14 doctors per 10,000 of the population. 9.5 are
general practitioners, 4.5 are hospital based.
All medical disciplines and administrations in Oman have with great
commitment and enthusiasm cooperated with the RCGP and the first pilot of
MRCGP [INT] is to be held in Oman in November of this year.
Cameron Lockie.
RCGP Omani Fellow
Visiting Professor in Family and Community Health, Sultan Qaboos
University, Muscat, Oman.
1 Evans D, Tandon A, Murray C, Lauer J. Comparative efficiency of
national health systems: cross national economic analysis.
BMJ 2001; 323:307-310
Competing interests: No competing interests
Western World responsibility for improving the health of poorer
countries.
The latest contribution .( BMJ 2001 323 307-310) (1) to the debate on
the World Health Report 2000 (2) deserves a comment on the wider issues of
the findings rather than just on their validity.
The one outstanding feature of the league table on performance is how
well most of the countries of the European Union have done and how poorly
the countries of Africa South of the Sahara have performed in comparison.
This raises the question of whether we in the western world should be
exercising an even greater responsibility than previously for the health
of the poorer nation? (3).
The key activities that must be included in the context of richer
western nations helping poorer ones are :-
* world leaders, especially of the G8, to review the globalisation of
the world economies with a view to removing unpayable debts, providing
targeted economic aid directed towards sustainable development and making
serious inroads into controlling the arms and drugs trade and resolving
conflict
* international agencies to accelerate the development of health and
social welfare plans, provide grants for education and training and
encourage research into the most efficient and effective ways of improving
health.
* voluntary and philanthropic agencies to enhance their outstanding
work in disease eradication and famine, disaster and poverty relief.
* national governments to increase aid directed towards tackling
major diseases, improving education, primary health care and health
promotion and encouraging sustainable development in agriculture.
* political and religious leaders to set aside their differences and
personal interests and work together for the common good of the people
they serve.
* corporate business to engage in ethical and non monopolistic
business practices which avoid exporting unhealthy products, encourage
fair trade, pay fair wages and genuinely help to build up commercial and
economic foundations.
* health professionals and academic institutions to carry out more
basic research into the best methods to achieve health improvement in poor
environments.
None of these proposals is revolutionary and many may appear
unrealistic and idealistic. We in the western world have already made
major contributions to health improvement in developing countries.
However, if we don’t pay attention to the wider issues there are likely to
be repercussions for all of us. (4) All we shall be doing is perpetuating
the misery, suffering and gross inequalities in health that we in the
western world are partly responsible for and can do something about
REFERENCES
1. Evans DB Tandon A Murray.CJL, Lauer JA. Comparative efficiency of
national health systems: cross national econometric analysis. BMJ
2001;323;307-10
2. World Health Organisation. World Health Report 2000. Health
Systems:improving performance. Geneva: WHO, 2000
3. Martin J. AIDS as a lever for reducing inequilty and increasing
solidarity. Bull. WHO 1999 77 (4) 364
4. Sachs J. The Links of Public Health and Economic Development.
office of Health Economic. 8th Annual Lecture. London OHE 2001
Competing interests: No competing interests
More evidence to inform the health system debate is clearly welcome.
At a country level, however, the key questions remain. What are the
concrete alternatives to achieve efficiency? How can these alternatives
be systematically tested and evaluated? How can we best learn from other
countries?
Isn't it time to move on from improving a methodology to identifying
more and better options at the country level?
Competing interests: No competing interests
I was interested to see that Oman tops the league of national health
systems. Evans et al attribute this to the huge reduction in childhood
mortality. I am sure that some of the credit for this must go to those who
set up a sound system of primary care and to a British GP who ran it in
the south of Oman (Dhofar) in the late 1970s - Dr HCT (Hugh) Morris.
In 1979, you published my account of a student elective there (BMJ 24
Nov 1979; 2: 1352 - 3).
Competing interests: No competing interests
The true complexity of the WHO study about devising an information
base for improving health service (`system') performance worldwide is once
again in danger of being overlooked in favour of knee-jerk reactions to
the rankings of various countries in a preliminary league table that is
presented quite properly only as a data supplement to the recently
published report on study methods (BMJ,2001;323:307-310).
It will be necessary to dig deep through the details of the study to
discover how sensitive are the results and rankings to variations in the
specific data, methods and criteria of performance used to produce them.
Meanwhile, anyone who is discomfited by the position in the rankings of
any particular country will have plenty of scope to suggest that the study
has its limitations.
In one respect, at least, the emphasis on comparisons in responding
to the study is appropriate. The methods of study use comparative criteria
of performance rather than any absolute standard. In principle, though not
in the published list, this comparative method could produce a result in
which a health service would appear at the head of the rankings even
though it contributed nothing at all to population health, if health
services everywhere else made health worse than it would be without any
service at all. Hence, even a top ranking is not a legitimate cause for
complacency if population health is a priority.
One of the more intriguing findings available so far from the WHO
study is the extent to which variations between different health services
in the level of contribution to population health appear to be associated
with more than just expenditure levels, especially among those health
services that are shown to contribute the most to population health. A
more rigorous investigation of why some health services appear to produce
so much greater a contribution than others with similar or higher levels
of expenditure would be a more constructive response to the WHO study,
though more difficult to do, than jumping to conclusions about the league
table or individual rankings within it.
Competing interests: No competing interests
Re: Why Oman tops the league
In Oman, the health system performance is the best one in the region
given a score of ,961 and a rank of one. Health for all has been endorsed
as national policy at the highest official level. The principal thrusts of
the national health policies are that health care is the right of every
individual; improving the quality of health services in general and basic
health services in particular; integration of curative, preventive and
promotive services at local and regional levels; use of appropriate modern
technology for the diagnosis and treatment of chronic diseases; reduction
of mortality, particularly infant mortality (to reach 20 per 1000 by the
end of the fourth five-year plan; reduction of the incidence of
communicable diseases to such low levels as not to be public health
problems; improvement in the fields of environmental health and community
development; health education of the public through the mass media on
health problems and ways to deal with them; development of human resources
with a view to gradually replacing expatriates by national health
personnel.
Competing interests: No competing interests