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%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.
2. Health Distribution: 25%
3. Responsiveness: 12.5%
4. Responsiveness Distribution: 12.5%
5. Financial Fairness: 25%
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.]