MISUNDERSTANDING THE WORLD HEALTH REPORT 2000

Coyne and Hilsenrath's piece on the World Health Report 2000 is a welcome contribution to the US discourse on the nature and goals of the important document from the World Health Organization.1 However, the depth of analysis and some of the interpretation in that article need clarification and may be contested. Their statement that “[t]he emphasis on [disability-adjusted life expectancy] can be misleading and undermines rankings for countries with low life expectancy but otherwise good health systems” is itself misleading. Disability-adjusted life expectancy is just that—it adjusts (and does not change) the national life expectancy for the duration of time spent in states of less than perfect health. In other words, it is the duration, severity, and magnitude of disability that determine the extent of this adjustment. In addition, countries with low life expectancies have a high component of premature mortality (e.g., infant and child mortality); therefore the component of life expectancy affected by disability is quite small.2 Judgment of a health system has to be linked with performance and the achievement of health outcomes, as in the World Health Report 2000. A good health system is expected to increase the health status of the population, and an important measure of that status is overall life expectancy. Evaluations of health systems that consider systems “otherwise good” in the absence of measurable changes in health outcomes need to be carefully interpreted, because the core mission of the health system is not being achieved. The authors put forth a more disturbing claim, whose basis is unclear, that “[e]quity is not universally considered desirable and is difficult to achieve in heterogeneous societies.” The value placed on equity has been central to global health dialogue since the start of the primary health care movement at Alma-Ata in 1978.3 The focus on equity has also been considered a central mission of health systems at the country level.4 It is confusing to read a statement that reduces the operational notion of justice and fairness to a less than desirable status. Moreover, the fact that equity is difficult to achieve has no merit in terms of its value as a vision for health systems around the world. In describing the case of the United States, only 1 country of 191countries considered in the global report, the authors state that advances in health technologies have not been captured in the report. First, that was never the intent of the report and therefore was not the purpose of the methods. Second, not all of the $22 billion spent on research in the United States in 1999, or the $74 billion spent on health research in the world in 1998, is spent on the production of health technologies; rather, it funds a broad mix of basic science and operational research.5 These investments do not all result in health technologies, nor are they predictable in terms of their output. The authors seem to confuse the measurement of a system with the next step, which is the ability to intervene. These are distinct aspects of the analysis of a health system and should not be confused, since many problems can be measured and monitored even though interventions may not be currently available. That is where the role of research and development becomes critical. It is common knowledge that a wide variety of health determinants, such as education, lie outside the health sector—in addition to key determinants that are within the purview of the health sector. Assessing the best actions for specific health problems or for the health system as a whole will require consideration of a multisectoral approach. However, the health system can be held responsible only for those interventions within its mandate, and this was made clear in the definition of a health system at the beginning of the World Health Report 2000. Finally, the World Health Organization established several committees in response to valid critiques of the report, and the methodology and empirical work has progressed greatly in the past 2 years. It is critical that academia challenge such global developments in a dynamic way, and yet understanding the nature and application of methods within the global context should be part of the constructive critique.