Despite Big Spending, U.S. Ranks 37th in Study of Global Health Care

The United States spends more than any other country on health care--yet its health system ranks only 37th in the world, according to a report on the quality of health systems released today by the World Health Organization.

The French health system ranks No. 1 worldwide in the study. Italy, Spain, Oman, Austria and Japan are also in the top 10, as well as the smaller nations of San Marino, Andorra, Malta and Singapore.

Most of the lowest-ranking countries are in impoverished sub-Saharan Africa, where diseases such as AIDS contribute to very low life expectancies. Sierra Leone scored worst among the organization’s 191 member nations.

The United States, sandwiched between Costa Rica and Slovenia, got top score on the amount it spends on care and also on a multifaceted measure known as “responsiveness,” which tries to tally how well people are treated by their health systems.

But it slips elsewhere. It scores poorly (ranked at position 54/55, tied with the nation of Fiji) on whether payment for health care is fair and equitable, based on people’s ability to pay. General health of the U.S. population, and the extent to which all citizens share that level of health, also lag behind scores of comparable industrialized countries.

These shortcomings, considered in the light of the money the United States spends, drag its final score down in the overall ranking. And while that ranking doesn’t come as a surprise to public health experts, they say it should be yet another warning that changes are needed in the U.S. health care system.

“I think it’s remarkably important work,” said Dr. John Eisenberg, director of the Agency for Health Care Research and Quality in the Department of Health and Human Services.

“It lines countries up and it tells us that--as self-assured and confident as many Americans are that we have the best health care system in the world--the statistics don’t show that. Statistics tell us we could be getting a lot more value for the money we’re spending.”

Other public health experts also applauded the World Health Organization for the report, which is the first to compare countries’ health systems so comprehensively.

“The report is terrific in a lot of ways--it’s a very bold step by the WHO,” said Dr. John Peabody, health services researcher at the San Francisco Veterans Affairs Medical Center, and deputy director of the Institute for Global Health at UC San Francisco. Countries may find it uncomfortable to be thus compared, he said. “But I think it promotes useful debate.”

But some experts also cautioned that a lot of the data are crude, that not too much should be made of the absolute ranking of each country--and that there is likely to be fierce debate about the methods used to rank countries.

“There are things in this report that don’t make sense,” said Dr. Robert Brook, professor of medicine at UCLA and vice president of the Rand Corp., a nonprofit think tank based in Santa Monica whose mission is to improve the health and welfare of Americans.

“It’s the first time around. It’s a step in the right direction. But it needs a lot more work if it is to do more good than harm.”

Brook notes, for instance, that Australia, which is second in the world for life expectancy, and Canada, which is 12th, are ranked considerably lower than might be justified. The final ranking for Australia is 32, and that of Canada is 30.

Brook also points out that the United States spends a lot of money on care for the elderly. This expenditure might not have a huge effect on life expectancy and infant mortality--the measures used to assess a population’s health. “But we may want to spend that money, even though it has marginal impact,” he said.

Public health researchers cite several reasons the United States did not perform better in the study. But lack of high-tech medicine and equipment is not one of them: Relatively speaking, this country is awash with MRIs, CT scanners and pricey drugs, they say. The United States spends $3,700 per person per year on health care.

And yet the United States ranks in the lowest 25% of industrialized countries when it comes to infant mortality and life expectancy, said Gerard Anderson, professor of public health at Johns Hopkins University in Baltimore. Its position has been sliding since the 1960s.

One reason is the country’s overemphasis on state-of-the-art cures instead of prevention, he says. That drives up costs and makes for a less healthy nation.

“If you had an illness and you had enough money or health insurance to pay for it, where would you want to go in the world? I think almost everybody would say the U.S.,” he said. “Once you get sick, we’ll do a good job for you. But we’re not very good at keeping you healthy.”

Another well-aired deficiency of this country’s health care system is its failure to provide good health care for all. Forty-four million U.S. residents lack health insurance. In Los Angeles County, one in three residents is uninsured.

“The very poorest have programs for them, but that doesn’t cover all poor people by any means,” said E. Richard Brown, director of the UCLA Center for Health Policy Research. This leads to tremendous disparities in health care services and their cost to the consumer.

In fact, in the least healthy 5% of the U.S. population, the numbers of years people live free of serious sickness or disability are similar to those in sub-Saharan Africa, said Dr. Christopher Murray, director of the organization’s Global Programme on Evidence for Health Policy, the department that produced the health systems report.

Two years in the making, the report was conducted so that the World Health Organization could better guide its member nations about ways that they can improve the health of their citizens, Murray said. The world spends $2.7 trillion annually on health, yet there is very little scientific evidence brought to bear on which health policies work and which don’t, he said.

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World Rankings

In a World Health Organization comparison of the quality of health systems in 191 countries, the United States ranks 37th. Index numbers show more precisely the relative peformance of different countries’ systems. This list shows the 25 best, the five worst and selected other major countries.

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RANK COUNTRY INDEX 1. France 0.994 2. Italy 0.991 3. San Marino 0.988 4. Andorra 0.982 5. Malta 0.978 6. Singapore 0.973 7. Spain 0.972 8. Oman 0.961 9. Austria 0.959 10. Japan 0.957 11. Norway 0.955 12. Portugal 0.945 13. Monaco 0.943 14. Greece 0.933 15. Iceland 0.932 16. Luxembourg 0.928 17. Netherlands 0.928 18. Britain 0.925 19. Ireland 0.924 20. Switzerland 0.916 21. Belgium 0.915 22. Colombia 0.910 23. Sweden 0.908 24. Cyprus 0.906 25. Germany 0.902 30. Canada 0.881 37. United States 0.838 39. Cuba 0.834 61. Mexico 0.755 112. India 0.617 130. Russia 0.544 144. China 0.485 175. South Africa 0.319 187. Nigeria 0.176 188. Congo 0.171 189. Cen. African Repub. 0.156 190. Myanmar 0.138 191. Sierra Leone 0.000

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Source: World Health Organization