France heads WHO's health systems league table.

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If you are going to be ill, the best place to be is France—the country ranked first in an analysis of the world's health care systems carried out by the World Health Organization (WHO). Among major countries, France was followed by Italy, Spain, Oman, Austria, and Japan, with several small countries (including San Marino, Andorra, Malta, and Singapore) rated among the top 10 health care providers. The analysis, which used 5 performance indicators to measure health systems, showed that it is not what you spend on health care but how you spend the resources available to you that is important. Despite spending more of its gross domestic product on health than any other country, the United States ranked only 37 out of 191 WHO member states; the United Kingdom, which spends just 6% of gross domestic product on health services, was 18th. The surprise finding of the analysis, said Christopher Murray, director of the WHO's global program on evidence for health policy, was the vast underuse of resources available and the tremendous range of health systems. “Some countries are only performing 20% of what they could achieve while others are 99% efficient,” he said. Oman, which has reduced its child mortality from 230 per 1,000 to 15 per 1,000 in the past 20 years, and Colombia, which was judged the fairest financing system, have seen dramatic improvements in their health care systems as a result of focused investment. Most of the countries that placed lower—in sub-Sahara Africa—performed badly because of the havoc wreaked by HIV and AIDS, which have reduced life expectancy to less than 40 years in many countries. One of the key recommendations of the report is to fund health service through prepayment schemes, such as taxes, insurance, or social security, rather than out-of-pocket expenses when people receive their health care. “In many countries without a health insurance safety net, many families have to pay more than 100% of their income for health care when hit with sudden emergencies. In other words, illness forces them into debt,” said Julio Frenk, executive director for evidence and information for policy at the WHO. The report attributes the failings of many health systems to a variety of factors, including “black markets” and “moonlighting,” the practice of doctors working simultaneously for the public and private sectors. “We are trying to help countries improve their performance and we have devised a method that makes it possible to see how well resources are being used rather than the dismal conclusion that poor countries are doing worse than rich countries,” said Murray. “Our real objective is to find out the best way of managing a health service based on sound scientific evidence. For example, we want to build up objective measurements so that we will be able to see whether the purchaser-provider split, as introduced into the United Kingdom, really helps to achieve better health.” The analysis, which took 2 years to complete, will be an annual event.