Friday, January 9, 2009

WHO's Fooling Who?

Excerpts from a CATO Report-- with the same title-- by Glen Whitman...

Whitman analyzes the 2000 World Health Report of the World Health Organization (WHO).

It is always difficult to compare methods and outcomes in various countries. In the on-going debates between statism and markets, both sides probably embrace international evidence selectively. But it would seem to be especially prevalent among statists-- whether they favor statism philosophically or because they genuinely think more govt intervention will work because of the international evidences. In any case, the comparisons between small, relatively homogeneous countries does not extend well to a far larger, far less homogeneous country like the U.S.

As such, Whitman brings some important considerations to the proverbial table.

From his Executive Summary:

The World Health Report 2000, prepared by the World Health Organization, presented performance rankings of 191 nations’ health care systems. These rankings have been widely cited in public debates about health care, particularly by those interested in reforming the U.S. health care system to resemble more closely those of other countries....Those who cite the WHO rankings typically present them as an objective measure of the relative performance of national health care systems. They are not. The WHO rankings depend crucially on a number of underlying assumptions— some of them logically incoherent, some characterized by substantial uncertainty, and some rooted in ideological beliefs and values that not everyone shares.

Now, some details of the analysis:

The first thing to realize about the WHO health care ranking system is that there is more than one. One ranking claims to measure “overall attainment” (OA) while another claims to measure “overall performance” (OP)....the OP index is adjusted to reflect a country’s performance relative to how well it theoretically could have performed...

WHO’s index is based on five factors, weighted as follows:
1. Health Level: 25 percent
2. Health Distribution: 25 percent
3. Responsiveness: 12.5 percent
4. Responsiveness Distribution: 12.5 percent
5. Financial Fairness: 25 percent

The first and third factors have reasonably good justifications for inclusion in the index....The other three factors, however, are problematic....

Building on the technical problems, Hartman has a section on the "underlying paternalistic assumptions" of the WHO approach...

The WHO rankings, by purporting to measure the efficacy of health care systems, implicitly take all differences in health outcomes not explained by spending or literacy and attribute them entirely to health care 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....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.

That 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 [e.g., culture]....Second, the WHO approach fails to consider people’s willingness to trade off health against other values.


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