Roger Cook, MSc, PhD – Brain Blogger Health and Science Blog Covering Brain Topics Wed, 30 May 2018 15:00:03 +0000 en-US hourly 1 Can You Compare Different Health Systems? Wed, 29 Jun 2011 12:00:03 +0000 The effectiveness of different approaches to funding and running health systems is often hotly debated, with every viewpoint seemingly able to marshal facts in support of their case. In effect, health statistics have become every bit as politicized as criminal justice. With the current political focus on the limited reforms introduced into the US system by the Obama administration, accurate information is critical and in short supply.

So lets start with some comparative data courtesy of the Organisation for Economic Co-operation and Development (OECD).

In 2007, US health expenditure was estimated to be $7,290 per head leading to an average life expectancy of 78.05 and an infant mortality rate of 6.7 per 1000 live births. In comparison, Sweden spent $3,323 per capita, leading to life expectancy of 80.95 and infant mortality rates of 2.5 per 1000.

Life expectancy and infant mortality are used by the OECD as outcome measures as they are held to reflect the effectiveness of the overall public health system for the complete population.

If correct, the largely privatized US system dependent on individual insurance payments is more expensive (by a factor of 2) and far less effective than a system funded by taxation with access relatively free for the actual user. If true (and the figures are correct and available) then the clear implication is that the US system is both expensive and ineffective (at least for the population as a whole).

However, a more fundamental question is to ask if the methodology and the comparative usage is correct? For example, an early attempt by the World Health Organization (WHO) in the 1990s to prepare such comparisons was withdrawn after US complaints specifically about the methodology adopted.

So, what are the underlying problems in trying to compare different approaches to public health?

In effect, there are three related to the underlying data and an overarching issue about presentation. In terms of data gathering:

1) Measuring expenditure on health is not simple. Even those systems that rely mainly on state provision also raise money directly from users (such as prescription charges) and usually have a parallel private provision (and of course individuals can take out their own health insurance). In a system such as the US, actually identifying all the various strands of health expenditure is particularly complex. Furthermore health expenditure is not just spending on primary and secondary health care it can include public health initiatives around disease prevention and wider health advice (obesity, alcohol, diet). In effect, deciding just how much a given state is spending on health care is never easy;

2) If measuring expenditure is complex, measuring outcomes is even more so. The variety of perfectly valid indicators is overwhelming and each give different information. The data above cites two, based around infant mortality and longevity as these are often used as proxies for the overall health of the population. The World Health Organization, after its initial battering by the US administration, has started to rely on the concept ‘years of healthy life’ for such comparisons. Even without looking at the indicator in any detail that immediately raises the question how something as judgmental as ‘healthy life’ can be consistently measured;

3) The final problem is that each country has a different demographic profile and, in consequence, different health needs. The simplest example is that the elderly and the very young need the most health care. However, even this is not a sufficient adjustment to allow for comparisons (i.e. to start to answer the question does this country spend enough, as well to ask questions about efficiency of expenditure). For example, the health demands of a given population aged between 60-70 will vary due to differences in diet, consumption of alcohol, use of tobacco and level of physical activity undertaken in earlier years. On the other hand, a state with a large immigrant population (typically in their 20s-30s) will appear to do well on outcome measures regardless of actual expenditure, as this group are usually the healthiest sub-section of any human population.

All this leads to one final problem in comparing health outcomes. If all these figures are aggregated to give a simple single figure, as the WHO tried to do in the late 1990s, then that process of aggregation can be flawed. How can different measures, collected on different bases be combined? On the other hand, presenting users and policy makers with a sea of unaggregated numbers will invariably lead to a focus on those that most closely support their existing beliefs.

Given the importance of the current US debate on methods of health funding, these issues are not abstract. If a debate as to the merits of individual funded healthcare in comparison to socially funded models is to be conducted properly, a key element has to be to compare both levels of expenditure and health outcomes.


Becker, Gary S, Thomas J Philpson, and Rodrigo R Soares. The Quantity and Quality of Life and the Evolution of World Inequality. Chicago, 2003.

Buckley, John E., and Robert W. Van Giezen. Federal Statistics on Healthcare Benefits and Cost Trends: An Overview. Monthly Labor Review, 2004.

Holahan, John, and Linda J. Blumberg. An Analysis of the Obama Health Care Proposal. The Urban Institute Health Policy Center, 2008.

Castelli, A., Dawson, D., Gravelle, H., & Street, A. (2007). Improving the measurement of health system output growth Health Economics, 16 (10), 1091-1107 DOI: 10.1002/hec.1211

Navarro, V. (2000). Assessment of the World Health Report 2000 The Lancet, 356 (9241), 1598-1601 DOI: 10.1016/S0140-6736(00)03139-1

OECD. Health at a Glance. 2009. OECD Publishing. 3 August 2010.

Veillard, J. (2005). A performance assessment framework for hospitals: the WHO regional office for Europe PATH project International Journal for Quality in Health Care, 17 (6), 487-496 DOI: 10.1093/intqhc/mzi072

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Is Charity Bad For Your Health? Mon, 20 Jun 2011 12:00:59 +0000 Since 2000, there has been a massive flow of funding from the West into health care in developing African countries. Some of this has come from governmental sources in response to G8 initiatives such as the 2000 Millenium Fund and a significant amount has come from charitable organizations. One of the largest of these, the Bill & Melinda Gates Foundation, in 2010 alone gave $164bn for research and treatment of tuberculosis (TB) and another $100bn for malaria. From 1994 to date, the foundation gave $14,350bn of funding on global health issues and was one of the first bodies to fund access to retro-viral HIV drugs in Africa.

Against this background is it not rather churlish to suggest that such charitable giving has had the effect of harming the overall health of the population in the recipient countries? And, even less fair to suggest that the bulk of funding provided by western governments since 2000 has not just been wasteful but has distorted the health systems in many parts of Africa and Asia?

Well it may sound churlish but the reality is that how this largesse has been allocated and distributed has created major problems in the recipient states. First, it has followed the priorities set by the donor and these are often focussed on specific issues (HIV, TB, malaria) with specified outcomes in terms of the type of treatment to be delivered rather than building up the overall health infrastructure. In effect, large sums have been allocated to small specific portions of the overall public health leaving those states struggling with poor basic health infrastructures.

HIV has often been a specific focus for additional funding and this has brought very specific problems. The first is that even if the availability of HIV retro-viral drugs is improved, basic flaws elsewhere in the primary health infrastructure may undermine any gains. President Clinton in 2006 argued that what should happen is what he described as a “HIV-out” model. In effect the infrastructure constructed around a HIV program would underpin and build up the rest of the health system. In reality, in country after country this has failed to happen. In Botswana a program from 2002-06 aimed to provide retro-viral drugs to 55,000 out of 280,000 individuals with HIV.The program foundered due to a lack of locally trained medical and nursing staff (and this was worsened by the practice of OECD countries of recruiting locally trained staff to work in their countries). The net result was some improvement but at the cost of undermining other areas of public health provision. The few available doctors and nurses took up relatively well paid positions with the new programs rather than in the poorly funded and resourced state health sector. The outcome was not one where the HIV health programme became the basis for a wider health system, instead it effectively crowded out other areas of primary health.

More generally, this funding has not been aligned to the overall plans and needs of the recipient state, leading to a distortion of local priorities. In effect, such aid is spent as the donor (whether a private charity or a state) wishes and this often ignores the  needs of the recipient country. Very little of this funding is allocated to non-specific primary health provision as the donors wish to see direct results linked to their investments. Also particularly with US funding on HIV in the Bush years, the funding came with a very specific ideology around issues such as sexual health and this in turn biased how the programmes were developed.

The net effect has been that most of the HIV programmes have developed in isolation to any wider population health concerns. This has undermined the effectiveness of the HIV efforts (as other illnesses connected to poverty, lack of clean drinking water, lack of basic primary health provision) have offset any gains. Equally once the specific funding is withdrawn, the programmes tend to collapse as they are not part of an integrated (even if poorly resourced) health system.

On this basis, there is a strong case to suggest all the billions of dollars allocated since 2000, no matter how well intended, have been largely wasted. If this is the case, is there a better method to make use of the substantial investment in public health in the poorest countries?

The answer can be a cautious yes. But to make any difference, there has to be a major shift of attitudes among the donors. Two changes would be critical:

  • One is to fund generic public health provision so the recipient state can decide on local usage. This carries the risk of corruption but that already affects all too many of the current targetted programmes. If this was linked to a moratorium on recruiting expensively trained health professionals the result would be an under-funded but robust basic public health infrastructure . With that framework in place, there is then a greater chance of effective use being made of more targetted provision.
  • Second, all health programmes should be evaluated against two basic indices of public health. These are maternal survival rates and overall life expectancy.

The advantage of such broad measures is that they are effective measures of the impact not of just a particular programme but the overall gains in population health. Maternal survival rates are a good proxy for the overall level of health care (including the numbers of trained professionals) and the presence of sufficient sterile equipment and antibiotics. If these are present, maternal death rates fall, if they are absent they increase. Life expectancy in turn picks up the adequacy of all the factors that lead to wider population health. This can include reducing the incidence and impact of diseases such as Malaria, but alsothe provision of clean drinking water, access to sufficient nutrition, and immunisation programmes using sterile needles. In the OECD countries the recent growth in life expectancy has been led by a reduction in the rates of infant mortality (in effect more people are surviving to old age in the first place).

This is not to say there is no scope for specific programmes and special funding. However, if they were evaluated against these two fundamental measures then both donors and recipients can be assured that any funding is actually having a positive impact. In particular for state provided funding, this should be made available with less constraints so it can be spent on the overall public health infrastructure. Such changes, will help ensure that the current global investment in health outside the OECD is well spent. At the moment too much well intentioned funding is effectively being wasted.


Alvarado, C. H., Martínez, M. E., Vivas-Martínez, S., Gutiérrez, N. J., & Metzger, W. (2008). Social Change and Health Policy in Venezuela. Social Medicine, 3(2), 95-109.

Garrett, L. (2007). The Challenge of Global Health. Foreign Affairs, 86(1), 14-40.

Melinda & Gates Foundation

Kickbusch, I. (2004). From charity to rights: proposal for five action areas of global health Journal of Epidemiology & Community Health, 58 (8), 630-631 DOI: 10.1136/jech.2004.021121

Muntaner C, Sridharan S, Solar O, & Benach J (2009). Against unjust global distribution of power and money: the report of the WHO commission on the social determinants of health: global inequality and the future of public health policy. Journal of public health policy, 30 (2), 163-75 PMID: 19597448

Whitehead, M., Dahlgren, G., & Gilson, L. (2001). Developing the policy response to inequities in Health: a global perspective. In T. Evans, M. Whitehead, F. Diderichsen, A. Bhuiya & M. Wirth (Eds.), Challenging inequities in health care: From ethics to action (pp. 309-322). Oxford: Oxford University Press.

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