WHO Report 2000

Comments of experts panel

The four functions

WHR 2000 described four functions of the health system – financing, resource generation, service provision, and stewardship – and summarized the available evidence about their links to outcomes and health-systemperformance.

6 Domains of Stewardship

• Generation of intelligence• Formulating strategic policy direction• Ensuring tools for implementation: powers,

incentives and sanctions• Coalition building / Building partnerships• Ensuring a fit between policy objectives and

organizational structure and culture• Ensuring accountability

Fair financingThe main criticisms relating to the chapter on the financing function werethat the analysis was ideologically driven and not based on evidence. Somecommentators viewed the framework as inherently biased towards increasingprivate sector involvement in insurance and health financing (Almeida et al.2001; Oswaldo Cruz Foundation 2000; Navarro 2000; Navarro 2001a;Navarro 2001b; Häkkinen and Ollila 2000; Van der Stuyft and Unger 2000).Such critiques noted the attention given to the analytical separation offinancing and purchasing, the high fairness-in-financing ranking of certaincountries (such as Colombia) that have engaged in market-oriented reforms,as well as discussions of a role for private provision. These papers arguedthat the Report ignored evidence regarding problems with managedcompetition, private insurance, and other kinds of market-oriented reforms.

Murray and Frenk reply to critics of fair financing

The response to these arguments of ideological […]. They argue that the WHR was not advocating any particular policy stance, but rather calling for more systematic evidence in how health systems affect the final goals. According to them, WHR 2000 states “… there is no evidence that systems relying a great deal on public funding will necessarily be more efficient than systems with a greater degree of private sector involvement, or vice versa. Whether this is seen as a Marxist or capitalist conclusion depends entirely on the ideology of the commentator and the motivations for their commentaries. We see it simply as a summary of theBest available evidence at present.”

Criticism of summary measures of health

Much of the discussion about the indicator of the level of health used in WHR 2000 was a continuation of the long-standing debate about the value of summary measures of population health (SMPH). For example, it was arguedthat SMPH do not describe health in sufficient detail to be useful for policy makers. Reporting the components separately is of more value, e.g. mortality, and prevalence, incidence duration and severity of various non fatal health outcomes (Navarro 2001a; Rosén 2001; WHO Regional Office for Africa 2001).

Health inequality as inter-individual variation

Total or partial health variationA concern with the concept of total health inequality is that it includes allvariation in health in a population, without making any judgements as towhich part of the variation is unfair. For example, during the technicalconsultation on health inequalities it was debated whether voluntary orgenetic risks should be excluded from the assessment of total variation,indicating a discomfort with the notion that all inter-individual variation isunfair.Inter-individual and/or social group approaches to inequalityThe inter-individual approach to inequality in WHR 2000 has generatedimpassioned debate about the appropriateness and relevance of inter-individualversus social-group inequality measurement. A number of analyses(Braveman et al. 2001; Houweling et al. 2001; Ugá et al. 2001; Szwarcwald2002) have shown the relative independence of the social-group measures ofinequality from the index reported in WHR 2000, and have argued for bothsocial group and inter-individual assessments of inequality.