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Former Surgeon General Joycelyn Elders on the World Health Organization 2000 Report

Dr. Jocelyn Elders commented on the World Health Organization (WHO)'s ranking of the healthcare systems of member nations. The United States is only ranked 37th, despite the fact it spends the largest percentage of its GNP on healthcare.


Dr. Elders is not associated with the WHO and was not involved with the writing of this report. She has been asked simply to respond to it and talk about American healthcare overall.


The WHO assessment system was based on five indicators:


  1. Overall level of population health (how healthy is population)


  2. Distribution of health within the population (health inequalities with the population)


  3. Overall level of system responsiveness (combination of patient satisfaction and how well the system acts.


  4. Distribution of responsiveness within the population (how well people of varying economic status find they are served by the health system)


  5. Distribution of the health system's financial burden (who's paying)



There are four main reasons that health systems fail:


  1. Health ministries focus on the public sector and ignore the private sector


  2. In many countries, physicians work for both the public and private sectors.


  3. There is a "black market" in health.


  4. Regulations are not enforced.


A key recommendation of the report is to extend health insurance to as large a percentage of the population as possible and to make provisions for prepayment to ease the financial burden on the poor.


Colombia, Chile, and Costa Rica are all ranked higher than the United States. Cuba is only two rankings below us.


When you look at the various components of the overall ranking, the U.S. ranked 1st in responsiveness, 3rd in responsiveness distribution (tied with 38 other countries), 24th in health attainment, 32nd in health distribution, and 54th in fairness of financial distribution.


The World Health Organization's report is a very ambitious project that ranks member countries' health systems for the first time. Writers acknowledge that many of the methodologies will need refinement over the years, but believe the report is a good first effort to promote both "goodness" and "fairness" in healthcare.


"Goodness" means the health system is responding to what people expect. "Fairness" means the health system responds to all people equally, without discrimination.


The WHO set three achievement goals: good health, responsiveness to the expectations of the population, and fairness of financial contribution. To achieve these goals, the WHO asserts that health systems must carry out four functions: service provision, resource generation, financing, and stewardship.


The WHO clearly believes the government holds primary responsibility for the performance of a country's healthcare system. It asserts that health systems should be concerned with improving people's health as well as protecting them from financial burdens. It acknowledges, thoug, that limits exist on what the government can finance, writing, "If services are to be provided for all, then not all services can be provided."


It also believes that many countries are falling short of their performance potential (almost all countries had a serious shortcoming in at least one category). These shortcomings result in large numbers of preventable deaths and disabilities, in unnecessary suffering, injustice and denial of basic rights.


Health system efficiency in finance and organization varies. The WHO believes the differences explain much of the widening gap in death rates between the rich and the poor. Even among countries with similar income levels, there are still large variations in results. The world's poor are a major concern of the World health Organization. It notes that the gap between how the rich and the poor are treated is growing wider and that poor people live shorter lives. Not only do they live shorter lives, a larger portion of those live are surrendered to disability. The WHO recommends prepayment as the best way to distribute financial burdens more equitably and take the larger burden off of the poor.


Q&A with DR. Elders:


Q: Were you surprised by the report?


A: No, I was not surprised by the report because I think there is such a wide disparity in healthcare. We have absolutely the best and the worst healthcare. We have the most opulent healthcare- we're the leaders in research. But it is not available for a large percentage of the population.


Q: Do you agree the poor suffer the most?


A: We all agree with that. It's fact. We know that the poor healthcare poor people get is directly related to economics. The poor are less likely to get the same responsiveness.


Q: What do you think is the best way to fix this country's healthcare?


A: There is no one thing. First, we have to educate our people on how to be healthy. You can't keep people healthy that are ignorant. We have to make care accessible and available to all our people. There are multiple interventions. They are interventions that we can make and we know how to make. It would be cheaper . . . there is nothing more expensive than intensive healthcare.


Q: Agree with the statement "If services are to be provided for all you?


A: Yes, I agree. But not all services are needed by everybody. Right now we should provide sick care to everywhere. The sicker you are, the better service you should get. We shouldn't wait for people to be close to death to get healthcare. There's no reason our infant mortality to be so high. We should educate women about their reproductive health. We should provide prenatal care for all women. Only about 35-40% of black women get any prenatal care.


Q: Did you think it was surprising that Colombia had a better ranking than we did?


A: No, because they had universal access. Iisn't as opulent as what we provide, but they give it to everyone.


Q: Is this a reality check?


A: I think the US knew this, but didn't want it to be so public.


Q: Do you think now that it is more public, people will demand more fairness?


A: I think we need to talk more. There isn't enough talk about these issues. There's talk about prescription drug help for seniors, but they are a tiny part of the population. We have so many dying kids, we need to concentrate on all people. Politicians will do anything we say we want-- there have to be enough of us yelling for it.


According to Elders: The US ranked 16 in infant mortality among white babies. It ranked LAST in infant mortality among black babies. Fairness is the problem in the US.
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