Monday, July 02, 2007

WHO's Healthcare Rankings, Part 2

[NOTE TO NEW READERS: This series of blog posts culminated in a Cato Institute Briefing Paper, which discusses all of my criticisms of the WHO healthcare rankings.]

As I noted in the last post, WHO’s ranking of healthcare systems relies on a measure of performance that includes “financial fairness,” which has nothing to do with the quality of healthcare. At best –and even this is highly questionable – it says something about how many people face financial hardship as a result of the healthcare they receive.

But this is not the only problematic factor in the WHO rankings. The rankings result from an index based on five factors, weighted as follows:
1. Health Level: 25%
2. Health Distribution: 25%
3. Responsiveness: 12.5%
4. Responsiveness Distribution: 12.5%
5. Financial Fairness: 25%
Only two of these – health level and responsiveness – are direct indicators of health outcomes. Even these are subject to some objections (such as that health level is affected by things like crime and nutrition), but they’re at least relevant. But neither health distribution nor responsiveness distribution properly belongs in an index of healthcare performance.

Why not? Because inequality (that’s what “distribution” is all about) is distinct from quality of care. You could have a system characterized by both extensive inequality and good care for everyone. Suppose, for instance, that Country A has responsiveness ranging from “good” to “excellent,” while Country B has responsiveness that is uniformly “poor.” Then Country B does better than Country A in terms of responsiveness distribution, despite Country A having better responsiveness than Country B for even the worst-off citizens. The same point applies to the distribution of health level.

To put it another way, suppose that a country currently provides everyone the same quality of healthcare. And then suppose the quality of healthcare improves for half of the population, while remaining the same (not getting any worse) for the other half. This is obviously an improvement – some people get better off, and no one gets worse off. But this change would cause the country to fall in the WHO rankings, other things equal.

[UPDATE: Clarification of the above example. As a result of the change, average health quality would rise, but inequality would rise as well. The former effect would tend to increase the country's WHO ranking, while the latter effect would tend to decrease it. The overall effect is ambiguous, even though common sense says the effect should be unambiguously positive.]

Now, it’s not silly to consider the quality of care received by the worst-off or poorest citizens. But distribution statistics emphatically don’t do that! They measure relative differences in quality, without regard to the absolute level of quality. A better approach would include in the index a factor for the health quality of the worst-off individuals. Or you could construct a separate health performance index for (say) the bottom 20% of the income distribution. These approaches would surely have problems of their own, but they would at least be focusing on the real concern. WHO’s current approach, sadly, doesn’t even do that much.

[UPDATE: See also Part 1 and Part 3.]

7 comments:

Daniel said...

I realize I appear to be trolling, so I'll post this comment here and then get off the blog, but there are a number of scholars who would most assuredly contest your claim that health distribution is not a measure of population health.

While no one would argue that measuring distribution is equivalent to measuring quality, the entire field of social epidemiology, including a great deal of evidence from Marmot, and Daniels, Kawachi, and Kennedy show a robust correlation between income inequality and health. Moreover, this gradient is relative across social class, which means not just that the rich enjoy better health than the poor, but that the extremely rich enjoy better health than the slightly-less-well-off.

Of course, this is "just" a correlation, and does not prove causation, but the correlation is extremely strong; so strong, in fact, that it has given rise to an entire subdiscipline of epidemiology. Moreover, health reformers as far back as Rammazzini (173), and later Chadwick and Shattuck all charted just such a correlation.

All this is just to say that a plausible, if not compelling case can be made for the notion that distribution has everything to do with health.

Glen Whitman said...

"[T]here are a number of scholars who would most assuredly contest your claim that health distribution is not a measure of population health."

Given the WHO study, some scholars must think that. But it simply does not make sense, for the reasons given.

Maybe there is a correlation between overall health and health distribution, or between overall health and income distribution. But in order to establish any such correlation, you need a measure of overall health that does not already include distribution! Otherwise, the correlation will exist simply by construction.

Brandon Berg said...

Daniel:
...Marmot, and Daniels, Kawachi, and Kennedy show a robust correlation between income inequality and health. Moreover, this gradient is relative across social class, which means not just that the rich enjoy better health than the poor, but that the extremely rich enjoy better health than the slightly-less-well-off.

Daniel:
You say that the research shows a correlation between inequality and health, but what you describe is simply a correlation between income and health, which is not surprising. For a number of reasons, I'd be surprised if this relationship didn't hold even in countries with national health care.

This doesn't mean that inequality is a problem in and of itself.

Tim Worstall said...

The correlation between income and health most certainly does exist with national health care. Still there in the UK.
The only argument here is whether it is in fact income or social status which is the defining measure.

sochealth said...

The Black Report produced in 1980 after 30 years of the NHS demonstrated that health outcomes correlate to income. The authors argue for policies designed to achieve an egalitarian outcome, but I take from it the fact that the NHS did not have any effect on the distribution of health. It's almost as if the poor health resulting from the freedom to take bad decisions such as smoking, eating badly and failing to brush ones teeth could be laid at the feet of those people.

The solution is obviously to benevolently restrict freedom so that people cannot take unwise health decisions. It's for their own good.

Anonymous said...

i am late in the discussiona but i think that when money are involved in doctors decisions....it's not a good thing.
Americans should learn to be more critic about themselves and things that don't work...health care in this country is not fair, it doesn't work.

Admin said...

The WHO health statistics are biased, not just meaningless. The WHO itself ranks the US #1 in health care delivery that is important to patients. It issues another ranking of 37th because this quality of care costs more and is not delivered by government! Critics of US health care always refer to the 37th ranking. That is a pure political judgement by the WHO.

The Herbs and Supplement offered arguments against the quality of US health care are based on flawed infant mortality and life expectancy comparisons. Much of the early death in the US is from auto accidents and drug violence, which is not an indictment of the the holistic health care system.