United Press International - Friday, 10 August 2001
Al Webb, UPI Science News

The WHO's league table, compiled by its Global Program on Evidence for Health Policy, contained a number of surprises. France was ranked No. 4, but Britain came in 24th and the United States was well down the list, in the 72nd spot.

The study, published in the latest edition of the British Medical Journal, said researchers took into consideration the level of education in populations, and adjusted for the different number of years of healthy life that people can expect in rich and poor countries.

The researchers said they looked at trends in the years between 1993 and 1997.

Basically, one analyst said, what the WHO research did was to measure the life expectancy in the 191 countries surveyed against the amount of resources spent per head of population -- in effect, measuring efficiency by turning expenditure into healthy life expectancy.

On this basis, Oman came tops, followed by Malta, Italy, France and San Marino. Rounding out the top 10 were, in order, Spain, Andorra, Jamaica, Japan and Saudi Arabia.

The bottom 10 countries in the league table were all African. South Africa was No. 182, followed by Sierra Leone, Swaziland, the Democratic Republic of Congo, Lesotho, Malawi, Botswana, Namibia, Zambia and, in last place, Zimbabwe.

According to the researchers, performance increased sharply with health expenditure per capita. The least efficient countries by the WHO standards had a history of civil conflict and/or a high prevalence of HIV and Aids.

"Performance increased greatly with expenditure up to about $80 per capita a year, suggesting it is difficult for systems to be efficient at low expenditure," the researchers wrote in their report.

Dr. David Evans, who led the research team explained why the United States finished so low. "The responsiveness indicator produced a good result for the U.S. last time (in 2000, when it finished 37th), but the average level of health in the U.S. is not very high."

Oman, on the other hand, scored high because of what was described as a "spectacular performance" in reducing infant mortality, from 310 per 1,000 births to just 18 per thousand over the past four decades.

The WHO researcher did not go unchallenged. Professor Martin McKee of the London School of Hygiene and Tropical Medicine suggested in an editorial accompanying the research report in the BMJ that the study was flawed, although it was still right to put the countries in some sort of league.

"It has invoked the concept of stewardship, which implies a more active involvement in promoting health than most governments have previously assumed," McKee said.

"It has not, however, provided a valid answer to the question of whether one system is better than another," he added.

Tony Harrison, of the independent Kings Fund, a study institute specializing in analyzing health systems, described the study as "interesting" but warned against putting too much reliance in it.

"Health systems are not simply measured in terms of prolonging life," Harrison said. "There are many treatments -- such as cataract removal, for instance -- which greatly improve quality of life without necessarily extending it."

"There are, in addition, many other factors which determine good health and longevity, not just the state of the health system," he said.

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