WHO's Watching Over You

I recently finished writing a draft of an article bringing together my previous criticisms of the WHO healthcare rankings. I’m not sure how soon the article will see the light of day, so I want to share a piece that doesn’t appear in previous blog posts:

The WHO rankings, by purporting to measure the efficacy of healthcare systems, implicitly takes all differences in health outcomes not explained by spending or literacy and attributes them entirely to healthcare system performance. Nothing else, from tobacco use to nutrition to sheer luck, is taken into account.

To some extent, the exclusion of other variables is simply the result of inadequacies in the data. It is difficult to get information on all relevant factors, and even more difficult to account for their expected effects on health. But some factors are deliberately excluded by the WHO analysis, on the basis of paternalistic assumptions about the proper role of health systems. An earlier paper laying out the WHO methodological framework asserts, “Problems such as tobacco consumption, diet, and unsafe sexual activity must be included in an assessment of health system performance.”

In other words, the WHO approach holds health systems responsible not just for treating lung cancer, but for preventing smoking in the first place; not just for treating heart disease, but for getting people to exercise and lay off the fatty foods.

This approach is problematic for two primary reasons. First, it does not adequately account for factors that are simply beyond the control of a health system. If the culture has a predilection for unhealthy foods, there may be little healthcare providers can do about it; and if the culture has a pre-existing preference for healthy foods, the healthcare system hardly deserves the credit. (Notice the strong ranking of Japan, known for its healthy national diet.) And it hardly makes sense to hold the health system accountable for the homicide rate. Is it reasonable to consider the police force a branch of the health system?

Second, the WHO approach fails to consider people’s willingness to trade off health against other values. Some people are happy to give up a few potential months or even years of life in exchange for the pleasures of smoking, eating, having sex, playing sports, and so on. The WHO approach, rather than taking the public’s preferences as given, deems some preferences better than others (and then praises or blames the health system for them). By doing so, it abandons its claim to objectivity.