International Health Care Systems

Are WHO rankings entirely worthless?

According to the World Health Organization’s (WHO) 2000 report, the U.S. ranked 37th in the world in terms of the quality of its health care system.  The placed the U.S. health system behind Saudi Arabia, Costa Rica and Morocco.  Do we need to fire all U.S. doctors?  Should everyone stop reading this blog post and immediately go for a run or eat a tofu salad?

Maybe not.

In a letter to the New England Journal of Medicine, Dr. Philip Musgrove, the former editor of the WHO report recounts the unreliable data used to rank country health systems.   In the case of the United States, the only data available were for life expectancy and child survival, which together only account for about half of the the attainment measure.  Thus, the rest of the figures in the U.S. figures had to be imputed.  In fact, the values of for many variables for many countries had to be imputed.  With such an indictment for the editor of this report, putting much value in these rankings seems dubious.  According to Dr. Musgrove:

The number 37 is meaningless, but it continues to be cited, for four reasons. First, people would like to trust the WHO and presume that the organization must know what it is talking about. Second, very few people are aware of the reason why in this case that trust is misplaced, partly because the explanation was published 3 years after the report containing the ranking. Third, numbers confer a spurious precision, appealing even to people who have no idea where the numbers came from. Finally, those persons responsible for the number continue to peddle it anyway…Analyzing the failings of health systems can be valuable; making up rankings among them is not. It is long past time for this zombie number to disappear from circulation.


  1. Great info – Thanks, Jason!

    I get so weary of folks using these #’s as an indictment of our health care system, and this is one more nail in that particular coffin (so to speak).


  2. The WHO health statistics are biased, not just meaningless. The WHO itself ranks the US #1 in health care delivery that is important to patients. It issues another ranking of 37th because this quality of care costs more and is not delivered by government! Critics of US health care always refer to the 37th ranking. That is a pure political judgement by the WHO.

    The offered arguments against the quality of US health care are based on flawed infant mortality and life expectancy comparisons. Much of the early death in the US is from auto accidents and drug violence, which is not an indictment of the the health care system.

    I have collected some of the detals and further links at the page below.

    USA Healthcare is First – Infant Mortality is Low

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  4. This is a fraught debate.
    My take on the performance metrics used for the 2000 World Health Report (WHR) is that they represented a big step forward, and there is no doubt that efforts to measure health system performance increased dramatically as a result. Many of these efforts were motivated by a desire to show how bad the measures and rankings were – but I think they wouldn’t have happened otherwise.
    Before the 2000 shake up, most cross-country comparisons used some indicator of health levels (e.g. DALYs or DALEs) and spending. Some rankings just used the health measures, others, how much health you were getting relative to spending.
    The 2000 WHR rankings added to health, responsiveness and financial fairness. Andrew Garland’s comment that the 2000 metric was biased toward systems with much gov’t delivery of services is incorrect for this reason. Systems with pluralistic delivery (the social health insurance systems and our own private insurance system) do BETTER on responsiveness (responsiveness is a measure of how well the health systems responds to peoples preferences about healthcare delivery that aren’t about health…stuff like: choice; confidentiality; being involved in the care decisionmaking process; privacy).
    It was considered radical by many to even give a health system credit for doing well on this by the way.

    The measures the WHR team used for responsiveness were indeed poor quality. Why you ask? Because countries don’t bother to monitor how their system performs on this indicator. Because as I noted, few thought it was a meaningful measure. So, yes, let us rightly criticize the poor reliability of the indicators they used. But let us give credit to the WHR team, and the then WHO leadership, for getting this radical concept into the mainstream: that it is right and proper to judge a health system not just for the health it delivers but for how it treats people (and not in the curative sense).

  5. I have lived in the US, Germany, Australia, Switzerland and Norway, and been treated by the different Health Care Systems. I agree that the other countries have better systems that the US. That does not mean that the health system in the US is bad. However, I feel it is a bit strange that you defend your system and criticize the WHO instead of discussing how to improve it. Life expectancy in the US ranks 72. in the world. Furthermore, more money per person is spent on health care in the USA than in any other nation in the world. One reason European countries get more out of their health care money is that they focus on preventing diseases before they develop. That is difficult to achieve in a system where people have to pay, as few would want to take time off work and pay for a consultation, only to hear that you have to lose weight.

    What makes you believe that “stuff like choice, confidentiality, being involved in the care decision making process, privacy”?? is any better in the US? Because it is not . Confidentiality is the corner stone in medicine throughout the world.

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