World Health Report 2000Methodological concerns and recommendations on policy consequences of the World Health Report 2000
Introduction
The authors of the WHO's World Health Report 20001 have placed on the WHO agenda a commitment to the laudable goals of assessing health systems, monitoring inequalities in health, and achieving equity in health-care financing. Their proposition that health services should be responsive to people's expectations is a welcome one. While these commitments should be sustained, we believe that the approaches taken toward these ends in the World Health Report are seriously flawed. We aim to suggest changes to the approach in the World Health Report to ensure that measurement strategies supporting public health policy throughout the world are scientifically sound, socially responsible, and practical.
Both the conceptual basis and methodological approaches to the World Health Report composite index of health system goal attainment and its individual components, and the indices of health system performance, have major problems. Data needed to calculate four of the five component measures for overall goal attainment were absent for 70–89% of countries, but this was not acknowledged in the report. Because all the measures are new, and imputed values for the 70–89% of countries without data were based on new methods involving multiple non-standard assumptions, readers deserve to know the underlying assumptions, methods, and key limitations, which were not adequately acknowledged. The measures of health inequalities and fair financing do not seem conceptually sound or useful to guide policy; of particular concern are some ethical aspects of the methodology for both these measures, whose implications for social policy are cause for concern. The use of the composite indices for guiding policy is not evident, mainly because of the opacity of the component measures.
In response to criticisms of the report from member states, the WHO Executive Board on Jan 19, 2001, recognised the need to establish a technical consultation process that would obtain input from member states and a small advisory group for the cross-country assessments of health systems (www.who.org, accessed May 15, 2001); we do not know what steps have been taken in that process. The Lancet published an article by Navarro in November, 2000,2 that analysed the World Health Report, focusing mainly on a series of important policy concerns. Little attention was given to methodological discussion. We therefore focus on the methodological and related conceptual issues of the report, in the hope of making an additional, constructive contribution to a thorough process of consultation that must now be opened up by WHO.
Section snippets
Data availability
Data were unavailable for 133 (70%) of 191 countries to construct the index of health inequality (inequality in child survival); in 161 (84%) of 191 countries to construct the two measures of responsiveness; and in 170 (89%) of 191 countries to construct the index reflecting fairness in households' financial contribution; yet this was inadequately acknowledged. We were unable to find out how many countries lacked data to calculate disability-adjusted life years (DALYs) and disability-adjusted
Conclusion
The positive contribution of the World Health Report 2000 is its stimulation of fresh thinking about a range of issues relevant to measuring health-system performance. The goals to improve average levels of health as well as distribution of health in populations, and to monitor progress toward these goals, are sound ones. Our comments are offered in the hope that they will help WHO, guided by its member states, to move ahead with an open process of conceptualisation, measurement, and
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