The World Health Organisation (WHO)'s World Health Report for the year 2000 faces health ministries head on, and refuses to take their data for granted. Instead, it makes its own statistical analysis of how well 191 different national health systems are functioning. Tables cover a wide range of indicators, but summing up performance into a single measure, the report ranks the massively costly US system way down the list.
WHO's Chris Murray - who with Julio Frenk created the conceptual framework that underpins the report - says the objective was to see "how well" each health system spent the money it had.
And judging by WHO Director-General Gro Harlem Brundtland's introductory message, and the overview to the report, fairness and responsiveness to consumer demand were the key issues addressed by the measures. To do our own statistics, the words "fair" or "unfair", "fairness" or "unfairness" occur 14 times in these first 12 pages of the report.
Brundtland says this report " breaks new ground in the way that it helps us understand the goals of health systems. Clearly, their defining purpose is to improve and protect health - but they have other intrinsic goals. These are concerned with fairness in the way people pay for healthcare, and with how systems respond to peoples' expectations with regard to how they are treated. Where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities, in ways that improve the situation of the worst-off. In this report attainment in relation to these goals provides the basis for measuring the performance of health systems".
To create the data, eleven working groups studied basic demography, cause of death, burden of disease, disability-adjusted life expectancy, health inequalities, responsiveness, fairness of financial contribution, health system preferences, national health accounts and profiles, performance analysis and basic economic data.
The key factor in pushing the US down low in the overall rankings was African Americans in the Mississippi delta, the poor in Appalachia for example have healthy life expectancies around 55 years. "Those are African levels", said Murray.
Britain came out well in its relative equality in child health - ranking second on that list taken alone - but was pushed down in the overall rank to 18th by poor customer satisfaction with the national health service.
Senegal at 59th came highest among Sub-Saharan African countries, way ahead of the next (Benin at 97th), undoubtedly a result of decades of stability and relatively benign government. Unsurprisingly Sierra Leone - the country where rebels hack arms of children in a fight for control of the diamond trade - came 191st.
France came top of the list, which will please the pharmaceutical companies, who do well out of French GPs' generosity with drugs: what treatment you want, you can get, with most of it refunded by the state.
The full report is available for downloading from the WHO web site.