Who Health Rankings Methodology

The WHO 2000 World Health Report rankings of the world's health systems has three objectives: 1) to monitor and evaluate attainment of critical outcomes and the efficiency of the health system in a way that allows comparison over time and across systems, 2) to build an evidence-base on the relationship between the design of the health system and Performance, 3) to empower the public with information relevant to their well-being (The World Health Report, 2000). These objectives illustrate that the WHO report is research rather than a QI initiative. It is intended to create knowledge about the relative strengths and weaknesses of health systems. The WHO report does not use a defined process, such as Plan-Do-Check-Act, nor call on continuous efforts from stakeholders to improve population health (Batalden & Davidoff, 2007).

The WHO employed a new and contentious methodology for evaluating health systems. The rankings are based on an index of five factors: 1) overall or average health (25%), 2) distribution or equality of health (25%), 3) overall or average (12.5%) responsiveness, 4) distribution or equality of responsiveness (12.5%), 5) fair financial contribution (25%). The five factors are weighted and summed to generate a single indicator of performance for a country.

Overall health and health equality measurements are based on disability-adjusted life expectancy (DALE), which is a computation developed by the WHO. It aims to express health quality of life in addition to length of life. The WHO conducted worldwide surveys to determine how disabling specified conditions are considered to be. These severity weightings are combined with standard measures of years of ill health due to particular ailments and deducted from total life expectancy to calculate the DALE. An issue with DALE involves the difficulty in gathering estimations of illness severity and mortality statistics in some poor countries ("Life expectancy: Quality counts," 2000).

Responsiveness is a measure of how the system performs relative to non-health aspects. It aims to evaluate whether the system meets a populations' expectations of how it should be treated by health care providers (The World Health Report, 2000). More specifically, responsiveness measures the ability to protect the patient's dignity, to provide confidentiality and autonomy, to provide care promptly with high-quality amenities, to provide access to social support, and to ensure a choice of provider.

Data for measuring responsiveness was derived from a key informant survey that is weighted by an internet-based survey. The key informant survey consisted of 1791 interviews in 35 countries. This survey did not interview citizens; rather, it surveyed public health experts. This method exposed the methodology to criticism for bias (Blendon, Kim, & Benson, 2001). The internet-based survey of 1006 participants (half from within WHO) generated opinions about