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BMJ. Jan 26, 2002; 324(7331): 190.
PMCID: PMC1172006

WHO to revise its method for ranking health systems

The World Health Organization has postponed until 2003 a high profile report, originally due out this year, that compares the performance of health systems around the world.

The delay, announced last week in Geneva at the WHO's executive board meeting, amounts to an admission that the UN agency needs to improve its methods for comparing countries. Its first attempt to rank health systems, in 2000 (BMJ 2000;320:1687), provoked an outcry.

The original ranking, in the World Health Report 2000 , was based on indicators of each nation's "healthy life expectancy," the "responsiveness" of the health system to patients' expectations, and the fairness of the system for financing healthcare. France came first, Britain was ranked 18th, behind Greece and Portugal, and the United States trailed in at 37th.

But critics of the 2000 report said the data on which the rankings were based were scant. Where data were missing altogether, they were extrapolated from other countries' data. Some measures relied on value judgments and were taken from small, unrepresentative samples, the critics argued. Some nations, such as Brazil, protested furiously, and one academic dismissed the WHO approach in a commentary in the journal Health Economics as mere "marketing" (2001;10:93-100).

"The first report was important in that it brought the issue of health system performance to public attention," says Peter Smith, professor of economics at the Centre for Health Economics in the University of York. "But it is very important that the scientific standard of the next one is much improved."

Last January the WHO's executive board told the director general, Dr Gro Harlem Brundtland, to consult more widely around the world on how to measure performance. More than a dozen regional and technical consultations have now been held.

"Some of the criticisms make sense," said Dr Chris Murray, executive director of the WHO's programme on evidence and information for policy, and who led the team responsible for the 2000 report. Dr Murray said the methods for the new report had been improved and the team would use new data from countries. Responding to criticisms that its process in 2000 was secretive, the WHO is also posting all relevant documents and debates on its website (http://www.who.int/health-systems-performance/www.who.int/health-systems-performance/).

Dr Brundtland also set up a WHO advisory group and a scientific peer review group to assess the methods to be used in the new report. The scientific group, chaired by Professor Sudhir Anand of the University of Oxford, met for the first time in December and has produced a preliminary report (report No EB109/6, available at http://www.who.int/gb/www.who.int/gb/). Professor Anand told the BMJ he will welcome comments from "all constituencies."

Some commentators have said privately that they believe the decision to delay the potentially controversial next ranking is convenient for Dr Brundtland, whose five year term of office ends in 2003. Although it is not known whether she intends to stand for re-election, the key nomination process takes place next January, well before the delayed report is due to appear.


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