The World Health Report 2000, Health systems: improving performance1
has received much media attention, especially the suggested ranking of health systems. However, some of the report's key conclusions are ill understood by the general public. We aim to clarify key assumptions and concepts.
Important assumptions underlying WHO's refined analysis relate to the ethical theory, the economic outcome measure, and the perspective of assessment. First, for assessment of activities, such as the services of a health system, various ethical standpoints are possible. The World Health Report 2000 calculates utilities for the comparison of health systems, with weightings derived from the rating of a selected panel of multinational key informants. Domains of these utilities are health, responsiveness, and fair financial contribution, receiving 50%, 25%, and 25% of the total weight, respectively. Health and responsiveness are further separated into an overall or average rating and distribution or equality. The underlying ethical theory is best described as “utilitarian”, and is aimed at the greatest good for the highest number of people.2
Performance is chosen as an economic outcome measure. The focus is the efficiency of health systems—their output relative to the money put in, not the effectiveness of systems (their absolute capacity to deliver services or achieve health gains). A health system with high quality services may, therefore, score badly because of poor financial management compared with a system with lower service standards but efficient management.
The societal or public interest viewpoint is taken in accordance with economic theory4
as the perspective of assessment. This viewpoint by necessity is systematically different from viewpoints such as individual sick citizens.
This ranking of health systems depends critically on the presented premises. The choosing of different assumptions results in a different ranking and can add to a balanced understanding of health systems. In an ethical discussion, a utilitarian view favours the delivery of cost-effective services, with benefit for everybody's quality of life, such as dental care. The approach of egalitarian ethics, in contrast, focuses on the worst-off in society and their rights, and disproportionate allocation of resources to these individuals such the provision of dialysis, is seen as fair.5
Some systems may, therefore, score low under one ethical theory, but high under another.
The WHO report has chosen performance to judge outcome and looks at a system's output relative to spent resources, not a system's absolute achievement. This outcome measure is important from an economist's perspective, but it may be secondary for politicians and patients. For example, a perspective based on health rights might well accept some wasteful consumption of resources, such as for research and development or as a function of decreasing marginal effectiveness, as long as the overall effectiveness meets standards. Healthsystem administration, health politics, and individual citizens might have confronting interests in this perspective. Public administration could be inclined to allocate funds technocratically, based on league tables of decreasing cost-effectiveness, to achieve maximum overall utility.
Health politics and especially sick individuals may value the appropriateness of funds allocated to health care and the improvement of their quality of life differently. The ethical yardstick used in the comparison of health systems must be chosen carefully. Moreover, the ranking of health systems will change according to who is reading the yardstick.