Health Care Outcomes

National health care expenditures, usually expressed per capita, do not correlate in a linear fashion with health care outcomes; if they did, the United States would be at the top. We are first in per capita expenditures but rank 37th in health care outcomes among the 191 countries the World Health Organization tracks in its surveys. I got curious about these rankings. How are they calculated?

I discovered that the rankings everywhere quoted derive from WHO’s World Health Report for 2000, which is based on 1997 data. Many of the basic statistics of which that ranking was built have been updated in subsequent WHO annual reports—but have not been combined to yield an updated world ranking. What we are looking at, therefore are ranks obtained fifteen years ago.

These rankings were built up by measuring five basic indicators. These were (1) life expectancy, usually rendered as DALE for “disability-adjusted life expectancy”; (2) the distribution of DALE across age groups, which was measured by looking child survival; (3) responsiveness of the health care system to the needs of the population and (4) the distribution of this response, measuring the degree to which it reached the whole population equally; and (5) fairness of financial contribution. WHO’s definition of fairness is that all households’ out-of pocket expenditures will be roughly the same, measured as a percentage of income exceeding what is needed for subsistence. This implies a subsidized health system.

The five categories shown were labeled the “goals” of the health system: high life expectancy and low infant mortality, a responsive system that reaches all inhabitants in equal measure, and a fair apportionment of total costs based on ability to pay. Data on health expenditures per capita were finally added. Then, with uniform weights applied to each category to indicate relative importance, an Overall Health System Performance rank was calculated.

In 1997 the United States ranked first in responsiveness and in per capita expenditures on health care. It was 24th in life expectancy, 32nd in “distribution” of life expectancy, thus infant mortality, third in the “distribution” of responsiveness, 55th in fairness of financial contribution, and 37th overall. A tabulation of the best and worst follows. The original WHO data may be viewed here. Annex Table 1 contains a summation.

Health Care System Performance in 1997 - Best and Worse
Best
France	1
Italy	2
San Marino	3
Andorra	4
Malta	5
Singapore	6
Spain	7
Oman	8
Austria	9
Japan	10
Worst
Angola	181
Zambia	182
Lesotho	183
Mozambique	184
Malawi	185
Liberia	186
Nigeria	187
Democratic Republic of the Congo	188
Central African Republic	189
Myanmar	190
Sierra Leone	191