COYNE AND HILSENRATH RESPOND

Abstract

We are appreciative of Hyder's thoughtful response to our piece on the World Health Report 2000. Overall, we think the methodological concerns he raises are important, and that our differences are due not only to disciplinary approach but also to practical realities of methodologies employed by the World Health Organization (WHO). With regard to disability-adjusted life expectancy and health system performance, the intent of adjusting life expectancy is to account for time spent in less than perfect health; however, we lack confidence in disability-adjusted life expectancy because of (1) the lack of data on disability prevalence across regions (P. Musgrove, unpublished manuscript, 2002), and (2) the fact that disability-adjusted life expectancy provides insufficient additional information compared with unadjusted life expectancy.1 Undeniably, health outcomes are critical, but such aggregates may conceal performance, as in South Africa, where AIDS is overwhelming a medical system with many good features. The reasons for the HIV/AIDS epidemic in South Africa are complex and cannot be laid on the doorstep of the medical, or even the health, system. These reasons have deep socioeconomic roots that transcend the measures used in the World Health Report 2000.2 With respect to the issues of equity and technology, the American Heritage Dictionary of the English Language defines equity as “the state, quality, or ideal of being just, impartial, and fair.” To many, a just and fair distribution of health resources and health outcomes is not necessarily an equal one. Certainly in the United States there is no consensus that all citizens are entitled to the same health benefits, and we would submit that many finance ministries around the world, which have much to say about the allocation of health resources, do not share the egalitarian notions of equity commonly found within public health circles. Furthermore, technology should have been a dimension of efficiency and performance captured by the WHO report. The notion of dynamic efficiency is central to economic theory, and it is technology, more than any other single factor, that has raised living standards for so much of the world's population. To ignore this element, particularly at a time when health-related technologies are a driving force in economic growth, is to disregard a very important dimension of health sector efficiency and performance—a dimension that is particularly important for future generations everywhere. In terms of interventions, undoubtedly the WHO report could have gone further in discussing interventions for the benefit of developing health policies, as noted by the editor-in-chief of the report: “What it has yet to provide is a convincing demonstration that the information constitutes evidence for guiding or assessing health policy” (P. Musgrove, unpublished manuscript, 2002). We support the scholars' continuing to challenge cross-country comparative studies. Although we feel that the results of our critical analysis are correct, comments such as Hyder's provide a helpful platform for such challenges. Through such exchanges, the scholarly community can help to build more complete databases and analytic tools that in turn will help in the formulation of policies for improved global health.