Critique of the World Health Organization WORLD HEALTH REPORT 2000 “FINANCIAL FAIRNESS INDICATOR”: USEFUL COMPASS OR CRYSTAL BALL?

The World Health Report 2000 generated a huge amount of controversy when it set out to rank the performance of national health systems using data, statistical measures, and an explanatory rationale that were neither well understood nor broadly accepted. This article demystifies the conceptual and empirical underpinnings of the report’s “financial fairness index, ” which resulted in country rankings that often seem counterintuitive. The author concludes that the index is seriously flawed, that rankings produced by the index should not be used, and that future WHO reports should avoid imputing financial fairness scores for countries that do not have real data. In a controversial move, the World Health Organization’s World Health Report 2000 (WHR2000) has attempted to show the world how 191 countries stack up against each other in terms of the performance of their national health systems. Speaking of this ambitious task, Gro Harlem Brundtland, director general of the WHO, comments that “despite the complexity of the topic and the limitations of the data, it is possible to get a reasonable approximation of the current situation” (1, p. viii). Moreover, the WHR2000 claims that “All the main results are reported with uncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure ” (1, p. 144). Thus, the WHR2000 not only proposes new ways of measuring the performance of national health systems but also provides a “full Monty ” of statistical rankings that promise to be rigorous. Clearing the fog of controversy to determine whether the WHR2000 provides a useful conceptual and empirical compass is a daunting task, however. Complex theoretical constructs must be unbundled, the reliability of survey data must be ascertained, and results of statistical estimates must be scrutinized before accepting the results. To contribute to this process, I focus my comments on