Twila Brase, R.N., is president of the Citizens’ Council on Health Care in St. Paul, Minnesota (www.cchc-mn.org).
The World Health Organization (WHO) didn’t blink twice before shooting down the United States’ world-class health-care system. In a recently released report, “The World Health Report 2000—Health Systems: Improving Performance,” the WHO ranked the overall performance of the U.S. health system at 37th out of 191 countries surveyed.
In fact, for a study purported to be a “balanced judgment” of the world’s health systems, the WHO waited only until the third paragraph of a six-page press release to herald its conclusion that the United States’ system did poorly in the evaluation. Published in June, the WHO’s “first ever analysis of the world’s health systems” listed America well behind first-ranked France, second-ranked Italy, and various other European, Middle Eastern, and Asian countries.
At gut level, this assertion rings false. When was the last time someone chose France or Italy over America for health care? How about the third-place little island of San Marino? Since the U.S. ranking fails to correspond with the documented practice of foreign patients’ flocking to the United States for care, a brief description of the report’s terms is required.
A health system, according to the WHO, is quite inclusive. Not only does it include the doctors, clinics, and hospitals that deliver patient care, but also “all the organizations, institutions and resources that are devoted to producing health actions.” Government oversight functions, public health activities, personal health dollars, and health-care financing schemes are all part of the system.
In addition, the WHO adds goodness and fairness to the traditional service objectives of a health system. High-performing health systems should not only deliver health-care services, but also be responsive to patient expectations and provide equal treatment to all patients irrespective of finances or social status. With these goals in mind, the WHO’s critical measure of a health system’s performance was its “achievement relative to resources.”
The World Health Organization primarily faults the United States for not requiring mandatory insurance or offering social welfare programs to all citizens—in other words, for being a free country with independent citizens. Given America’s high level of health-care spending, the U.S. system does not achieve the organization’s fairness and distribution goals relative to total health-care resources. In addition, the report criticizes the move toward medical savings accounts and the fact that 56 percent of America’s health-care expenses are privately funded.
Interestingly, the WHO completely failed to broadcast that America’s health system ranked first in responsiveness to patients’ needs for choice of provider, dignity, autonomy, timely care, and confidentiality. In other words, where it matters most to patients, the U.S. system excels.
Since health-care systems are created solely to meet the needs of patients, it seems only natural to assume that responsiveness would receive top consideration when judging performance. Yet, first-ranked France ranked only 16th or 17th in responsiveness, while second-ranked Italy ranked 22nd or 23rd. Oman was given a ranking of eighth in performance, but only 83rd in responsiveness to patients. And Morocco, ranked 29th in performance, was ranked at 151-153 in responsiveness—near the bottom of the list.
According to the WHO, America did not even outperform Canada, which received a performance ranking of 30th despite the regular visits of Canadians to American hospitals and doctors. Surprisingly, the Netherlands, known for involuntary euthanasia—a less than patient-friendly policy—was rated 17th best, 20 countries higher than the United States.
WHO’s Global Agenda
Because the World Health Organization took great pains not to announce publicly that the United States took grand prize in patient care, there is reason to believe its public chastisement has little to do with America’s quality and delivery of health-care services.
Indeed, the criticism appears to be aimed at furthering redistribution of American dollars around the globe. The WHO claims governments are responsible for “mobilizing the collective action of countries to generate global public goods such as research, while fostering a shared vision towards more equitable development across and within countries.” In addition, the WHO’s overall mission is “the attainment by all people of the highest possible level of health, with special emphasis on closing the gaps within and among countries.”
The WHO writes that its vision includes “placing health at the centre of the broader development agenda,” most likely through financial transfers from countries with greater resources. It is not surprising then to find the WHO report promoting centralized collection, pooling, and redistribution of health-care funds—and chastising countries that fail to march in step with collectivist thinking.
That this centralized approach requires health-care rationing to vulnerable, sick, disabled, elderly, and politically disenfranchised citizens does not bother the WHO, an unabashed supporter of explicit rationing. WHO officials describe rationing as central to their emerging vision of “new universalism”: “Rather than all possible care for everyone, or only the simplest and most basic care for the poor, this means delivery to all of high-quality essential care, defined mostly by criteria of effectiveness, cost and social acceptability. It implies explicit choice of priorities among interventions, respecting the ethical principle that it may be necessary and efficient to ration services, but that it is inadmissible to exclude whole groups of the population.”
To enforce the necessary limits on health-care services, the report suggests that physicians and other practitioners be monitored through data collection, and if necessary sanctioned for providing patients with care classified as unnecessary or impermissible. Noting that practitioners are difficult to control, the WHO advocates the creation of a national benefit package with lists of available health-care treatments. The lists, coupled with practitioner-control mechanisms such as clinical protocols, registration, training, and licensing and accreditation processes, can then be used to enforce health-care rationing.
Besides the organization’s draconian promotion of global health-care rationing, the drive to cultivate collectivist health care can be seen through a subtle deviation from typical terminology. The WHO premises its report and assessment on comprehensive “health systems” organized by government bureaucracies rather than “health-care systems” comprised of individual providers treating individual patients. Private funding by individuals and the private practice of medicine are assiduously discouraged throughout the report.
In these health systems, governments are to assume the crucial role of “stewardship” to enforce “rational” use of health-care services. Governments are thus called on to collect health-care funds from citizens, set and direct health policy, define allowable health-care services for citizens, and provide oversight.
Because system-wide control of health-care resources is desired, WHO officials express particular distaste for America’s abundance of private financing for health care (56 percent) and Congress’s advancement of medical savings accounts (MSAs) for individual provision and payment of health care. Although they acknowledge that MSAs are a form of prepayment—the pooling mechanism they aggressively support—they assert that MSAs and private funding prevent centralized pooling of dollars without which certain public health initiatives may never be funded.
In addition, they argue that individual financing fosters fee-for-service payments—as if paying for the care you need at the time you need it is ill-advised—and makes it difficult to regulate and control the treatment practices of providers—a blessing to patients who value unrationed care.
Ironically, the report attempts to discredit MSAs for performing the insurance function insurance is meant to perform. WHO officials are displeased that “the healthy and the young, whose risk is usually low, might prepay for a long time without needing the services for which they had saved.”
WHO’s System of Control
According to the report, the control of health-care spending should be placed in the hands of bureaucrats through mandatory and pooled prepayments for health-care services. Each household’s prepayment could be based on a defined percentage of the income that remains after anticipated food expenses are subtracted from total household income. These prepayments would then be collected using employment-based insurance schemes, direct taxation, or social security programs.
Prepayment is key because it facilitates decisions about spending limits. As prepayment rises, “spending is more and more determined by the policies and budgets of public entities and insurance funds.” But when health care is financed privately, WHO officials note with dissatisfaction, the level of financing is decentralized as a result of “millions of individual decisions”—a situation the WHO apparently wants to avoid to keep its agenda intact.
Not only does the WHO desire prepayment, it wants fairness throughout the system. But its definition of fairness emphasizes equitable distribution of services, not necessarily related to individual needs for services. As the report clarifies, “If services are to be provided for all, then not all services can be provided.” According to the report, the level of annual health-care funding available to patients is to be determined once funds are pooled and priorities are set.
Fairness is also strongly advised for financing strategies. As noted in the report: “the risks each household faces due to the costs of the health system are [to be] distributed according to ability to pay rather than to the risk of illness.” Therefore, those with higher incomes are to contribute more than those with lower incomes, regardless of lifestyle choices or behaviors. Indeed, the WHO declares, “Fairness of financial risk protection requires the highest possible degree of separation between contributions and utilization.”
The organization’s skewed view of equity is seen most clearly in its contention that wealthy citizens must prepay more for health care than poor citizens because left to their own resources, a greater percentage of the poor family’s income goes to health care than that of the wealthy family. Lest we forget, this is the case for any purchase made by one person who earns less than another person. If one man earns $100,000 and another earns $10,000 and both want to buy a $1,000 used car, the cost is ten percent of the lower income but only one percent of the higher income. Following the organization’s line of reasoning, why stop with health care? If such “fairness” can be required in one type of purchase—health care—it can be mandated across all purchases of social value.
WHO officials have become present-day Robin Hoods, declaring that individuals have no right to keep what they earn. To rationalize their position, they dismiss real fairness—the ethic inherent in earning, keeping, and controlling the fruits of one’s own labors—in exchange for a perverted description of fairness that fits their own need for control.
Banking on America
Although never stated directly, the WHO’s baseless criticism of the U.S. health-care system appears to be an attempt to pressure America’s policymakers into commandeering a larger share of Americans’ health-care dollars for contribution toward global and public health initiatives around the world.
It is also entirely possible that improved health care is not the primary goal of countries seeking the American dollar. The other 190 member countries of the World Health Organization may view dollars designated for health care as a meal ticket for purchases not directly related to medical services. After all, it can be reasonably argued that improved roads, schools, environment, transportation, and agriculture all positively affect health.
Clearly, WHO officials have an agenda that is neither patient-friendly nor protective of individual freedoms cherished by American citizens. Given the opportunity, they would readily place control of every person’s earnings and every patient’s care into a few powerful hands.
American taxpayers pay over $96 million per year to the World Health Organization—roughly 25 percent of its general budget. Rather than dignifying the WHO report with further self-evaluation, Americans should question congressional support of this organization, which insufficiently understands and respects the constitutional freedoms that have made the U.S. health-care system number one with patients around the world. 
- World Health Organization, “The World Health Report 2000,” “Overview,” June 21, 2000.
- Ibid., “Who Pays for Health Systems?” p. 99.
- Ibid., “Overview.”
- Ibid., “How Well Do Health Systems Perform?” p. 35.
- Ibid., “Who Pays for Health Systems?” p. 97.
- Telephone interview with Nelle Temple Brown, external relations officer, World Health Organization Liaison Office, Washington, D.C., July 26, 2000.