This is how the WHO describes its evaluation factors. No bias, just a statement of how they did the rankings.
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Information in the WHO report also rates countries according to the different components of the performance index.
Responsiveness: The nations with the most responsive health systems are the United States, Switzerland, Luxembourg, Denmark, Germany, Japan, Canada, Norway, Netherlands and Sweden. The reason these are all advanced industrial nations is that a number of the elements of responsiveness depend strongly on the availability of resources. In addition, many of these countries were the first to begin addressing the responsiveness of their health systems to people’s needs.
Fairness of financial contribution: When WHO measured the fairness of financial contribution to health systems, countries lined up differently. The measurement is based on the fraction of a household’s capacity to spend (income minus food expenditure) that goes on health care (including tax payments, social insurance, private insurance and out of pocket payments). Colombia was the top-rated country in this category, followed by Luxembourg, Belgium, Djibouti, Denmark, Ireland, Germany, Norway, Japan and Finland.
Colombia achieved top rank because someone with a low income might pay the equivalent of one dollar per year for health care, while a high- income individual pays 7.6 dollars.
Countries judged to have the least fair financing of health systems include Sierra Leone, Myanmar, Brazil, China, Viet Nam, Nepal, Russian Federation, Peru and Cambodia.
Brazil, a middle-income nation, ranks low in this table because its people make high out-of-pocket payments for health care. This means a substantial number of households pay a large fraction of their income (after paying for food) on health care. The same explanation applies to the fairness of financing Peru’s health system. The reason why the Russian Federation ranks low is most likely related to the impact of the economic crisis in the 1990s. This has severely reduced government spending on health and led to increased out-of-pocket payment.
In North America, Canada rates as the country with the fairest mechanism for health system finance – ranked at 17-19, while the United States is at 54-55. Cuba is the highest among Latin American and Caribbean nations at 23-25.
The report indicates – clearly – the attributes of a good health system in relation to the elements of the performance measure, given below.
Overall Level of Health: A good health system, above all, contributes to good health. To assess overall population health and thus to judge how well the objective of good health is being achieved, WHO has chosen to use the measure of disability- adjusted life expectancy (DALE). This has the advantage of being directly comparable to life expectancy and is readily compared across populations. The report provides estimates for all countries of disability- adjusted life expectancy. DALE is estimated to equal or exceed 70 years in 24 countries, and 60 years in over half the Member States of WHO. At the other extreme are 32 countries where disability- adjusted life expectancy is estimated to be less than 40 years. Many of these are countries characterised by major epidemics of HIV/AIDS, among other causes.
Distribution of Health in the Populations: It is not sufficient to protect or improve the average health of the population, if - at the same time - inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce inequalities by prioritizing actions to improve the health of the worse-off, wherever these inequalities are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness. A gain in either one of these, with no change in the other, constitutes an improvement.
Responsiveness: Responsiveness includes two major components. These are (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider).
Distribution of Financing: There are good and bad ways to raise the resources for a health system, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is only concerned with distribution. It is not related to the total resource bill, nor to how the funds are used. The objectives of the health system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending there are other possible uses for the resources devoted to health. The level of funding to allocate to the health system is a social choice – with no correct answer. Nonetheless, the report suggests that countries spending less than around 60 dollars per person per year on health find that their populations are unable to access health services from an adequately performing health system.
In order to reflect these attributes, health systems have to carry out certain functions. They build human resources through investment and training, they deliver services, they finance all these activities. They act as the overall stewards of the resources and powers entrusted to them. In focusing on these few universal functions of health systems, the report provides evidence to assist policy-makers as they make choices to improve health system performance.
