by Miriam Meijer

baby crawlingRecently the World Health Organization (WHO) evaluated the world's healthcare systems in terms of bang for the buck. How effectively did governments spend their money on health? How well did the public health system prevent illness instead of just treating it? How fairly were the poor, minorities and other special populations treated? The study uncovered both the expected and the unexpected. While most of the lowest-ranking countries in provision of quality healthcare fell in Sub-Saharan Africa, countries with an abundance of wealth and technology were doing a less-than-adequate job of supplying the healthcare needs of their populations. Although Scandinavian countries and Canada have always been presented as models, Norway scored 11, Canada 30, and Britain, with its much-debated free national health service, came in 18th.

Who was first among the 191 member states of the WHO? France had the best overall healthcare system, followed by Italy, Spain, Oman, Austria and Japan. Previous analyses had examined how healthy people were and gave the impression that the wealthy countries did well because they were wealthy. The new WHO analysis praised healthcare systems that used few resources very effectively. Oman, which spends US$334 per person on healthcare, rated 8th on the WHO list. Twenty years ago, one in four children in Oman died before their fifth birthday. Today, thanks to 24-hour clinics and a new tax-funded universal care system, infant mortality in Oman has plummeted to 15 deaths per 1,000 children.

The World Health Report took into consideration who paid the cost of healthcare and the fairness of the payments. In most of the world the poor pay a disproportionate share, particularly in "out-of-pocket'" expenses that drive families into bankruptcy when someone is sick. The country that spends the most money on healthcare than any other country ranked No. 37 on the WHO list; that was the United States of America. In measuring how long people live in good health—rather than just how long they live—the Japanese beat Americans by 4 years, and the French lived 3 additional healthy years.

America annually spends $3,724 per person on health to Japan's $1,759 and France's $2,125. Americans pay more than the $2,500 spent per person in Switzerland, the world's 2nd most expensive country. Many a car in America has more insurance than its human owner; 44 million Americans are without health insurance (one out of seven Americans). Uninsured Americans do not receive care for illnesses like cancer, diabetes and hypertension until their illness has reached an advanced stage.

In a series of articles in The New England Journal of Medicine 340 (1999), John K. Iglehart concluded that the American healthcare system is "a work in progress, driven by a disparate array of interests with two goals that are often in conflict: providing healthcare to the sick, and generating income for the persons and organizations that assume the financial risk." Americans pay about $1,000 more per person than what would be expected based upon the country's per capita income for three reasons. Their physicians are paid more than those in other countries for the same amount of work, a day in the American hospital costs more, and Americans embrace new expensive technologies more rapidly.

Iglehart reported that in 1997 hospital costs consumed the largest portion of the healthcare dollar, accounting for $371 billion. The bill for physicians' services was $217.6 billion, nearly 20% of the healthcare dollar. Nonetheless, the annual growth in average net income for all physicians declined from an average of 7.2% (1986 to 1992) to 1.7% (1993 to 1996), largely as a result of managed care contracting. Although prescription drugs account for 8% of personal health expenses ($78.8 billion), the price for medicines is the fastest growing item in the healthcare bill. "There are several explanations for this acceleration in costs," the journal reported, "including broader insurance coverage of prescription drugs, growth in the number of drugs dispensed, more approvals of expensive new drugs by the Food and Drug Administration and direct advertising of pharmaceutical products to consumers." The biggest chunk of spending—38%—goes for hospital care, half of which is paid by Medicare and Medicaid, with private insurance covering about one-third. The system hits the American poor and families the hardest.

Life is certainly not fair. Of the world's 6 billion people, 4.8 billion live in low-income and middle-income countries. Within this group, almost 60% lack basic sanitation, nearly 33% have no access to clean water, 25% do not have adequate housing, and 20% have no modern healthcare. The gap between rich and poor widens when life expectancy is divided into years of good health and years of disability. In effect, the poor not only have shorter lives than the non-poor but a larger part of their lifetime is surrendered to disability. Polio, while eradicated in the western hemisphere, continues to cripple 5 to 10 children per 1,000 in the absence of an immunization program.

The fifth of the world's people who live in the high-income countries consume 58% of the world's energy, 65% of electricity, 87% of cars, 74% of telephones, 46% of meat and 84% of paper—86% of total expenditure. Yet, even inside these countries, inequalities in life expectancy persist and are strongly associated with socioeconomic class. It is not how much funding a health system has, but what it does with the funding that matters. The differing degrees of efficiency with which health systems organize, finance themselves, and react to the needs of their populations explain much of the widening gap in death rates between the rich and poor, in countries and between countries.

Can a developing nation ever set an example? Yes. Recently, an expert advised everyone to use Uganda (No. 149 on the WHO list), Senegal (No. 59), and Thailand (No. 47) as their models in the global fight against AIDS. This advice came from Dr. Roy Anderson, of the University of Oxford, at the 13th International AIDS Conference held in South Africa. Early intervention, government commitment and serious public prevention campaigns had successfully stemmed the AIDS epidemic in these three nations. There is no cure for AIDS, and, currently, one out of five people in the world is an adolescent. In 1998, the WHO, the United Nations Children's Fund (UNICEF) and the United Nations Population Fund (UNFPA) agreed jointly that the term "adolescent" refers to people ages 10–19 and that their health needs as a group are all too neglected.

One-third of all women of reproductive age in low- and middle- income countries do not have access to modern family planning. Of the estimated 960 million people worldwide who are illiterate, nearly two-thirds are female. Of all those living in poverty worldwide, 60% are female. Of the 200 million annual pregnancies in the world, 75 million are unplanned. The equivalent of 4 jumbo jets full of women die daily from pregnancy-related causes, 99% of them in low-income countries. The human tragedy is that these annual 600,000 maternal deaths and 50 million cases of disability are largely preventable.

Most of the world's women do not enjoy "reproductive autonomy." The Center for Reproductive Law and Policy (CRLP) in New York City defines reproductive autonomy as every act of sex is consensual, every pregnancy/child is wanted, and every delivery is safe. How true is this for the world's richest country? Not. The United States suffers the highest rates of teen pregnancy and births in the developed world. The American rate is six times higher than France and twice as high as Great Britain. According to health economist Uwe Reinhardt at Princeton University, Americans are good at expensive, heroic care, but very poor at the low-cost preventive care that is enjoyed in western Europe.

Susheela Singh, lead author on a study by The Alan Guttmacher Institute in New York, reported that the United States in terms of teen pregnancy—despite a 17% decline the last decade—was still behind other developed nations. In 45 countries between 1970 and 1995, the American rate was nearly as high as the one for the Russian Federation (101.7 pregnancies per 1,000 women); on par with the rates in Bulgaria and several other eastern European countries. Her study also found that the United States was at the high end of the range of teen birth rates worldwide. In 1996, for every 1,000 women between the ages of 15 and 19, America had 54.4. Only Armenia's rates were higher, with 56.2 births.

Adolescent pregnancy costs America at least US$7 billion annually. Four in 10 young women become pregnant at least once before they reach the age of 20—nearly one million a year. Eight in ten of these pregnancies were unintended and 79% were to unmarried teens. Only one-third of teen mothers complete high school and nearly 80% of unmarried teen mothers end up on welfare (the dole). The children of teenage mothers have lower birth weights, are more likely to perform poorly in school, and are at greater risk of abuse and neglect. The sons of teen mothers are 13% more likely to end up in prison while teen daughters are 22% more likely to become teen mothers themselves.

American teenagers do not have sex more frequently than their foreign counterparts; their sex tends to be unprotected because they feel embarrassed or afraid to plan for sex. They just "let it happen." Americans on the whole have more unintended pregnancies than Europeans. Researchers on the President's Council on Sustainable Development (PCSD) concluded that most Americans rather deny the need for family planning and reproductive health services, particularly for young people, and allow the punishing consequences, than address the need for prevention forthrightly. Media images in America are laden with sex but it is almost always sex without consequences.

Michael McGee, vice president for education at the Planned Parenthood Federation of America, believes that "in western Europe the approach is more concerned with the health and well-being of youngsters. That translates into comprehensive services that give young people access to medical care at much better levels than in the United States." In her forthcoming book, Sex and Sensibility (a play on words of Jane Austen's classic Sense and Sensibility), Deborah Roffman criticizes American sex education for being limited to the mechanical—how to prevent disease and pregnancy—and the moralistic—which only preaches abstinence—while ignoring age-appropriate emotional education about relationships, boundaries, and self-respect.

Europeans view sexuality pragmatically as a natural part of a human being's development, but Americans carry a Scarlet Letter from their Puritan Pilgrim Fathers. Instead of facing a potentially hostile environment outside an abortion clinic, American women will finally be able to abort unwanted pregnancies more discreetly, earlier, and with what many women describe as a greater sense of control. The United States Food and Drug Administration (FDA), after a decade's delay, has just approved RU-486 (chemical name: mifepristone), the abortion pill that debuted in France in 1988 and has been used by millions of women in 13 countries.

In our earthly unfair world, money certainly matters a great deal but money is not everything. The most expensive heathcare system in the world did not earn the highest grade from the WHO. More holistic or integrative approaches could upgrade the world's healthcare systems that rely too much on expensive heroics. France, also recognized as the world's premier model in prenatal care, makes l'amour with attitude sound très bon!


Emery, Gene. "Journal Calls U.S. Health Care Expensive, Inadequate," Reuters Limited (January 6, 1999).

"France Tops Global Health Care," The Christian Science Monitor (June 20, 2000).

Henshaw, Stanley K. "Unintended Pregnancy in the United States," Family Planning Perspectives 30 (Jan./Feb. 1998): 24-29, 46.

Iglehart, John K. The New England Journal of Medicine 340 (1999).

Kim, Hae Lee. "Foreign Teens More Successful At Preventing Pregnancy,", a web site for teens by teens (Spring 1997).

Maynard, R. A., ed. Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy (Washington, DC: The Urban Institute Press, 1997).

Mongan, James J. "The Forgotten Uninsured," The Washington Post (October 10, 2000): A25.

The National Campaign to Prevent Teen Pregnancy

Ponton, Lynn E. The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls (New York: Dutton, 2000).

Reaney, Patricia. "Uganda an AIDS Success Story" Reuters Limited (July 10, 2000).

Trafford, Abigail. "Don't Blame Kids For Failing Sex Ed," The Washington Post (September 26, 2000) Health, p. 5.

"U.S. health system most expensive in world," Reuters Health (January 6, 2000).

Ventura, S. J., Mathews, T. J., and Curtin, S. C. "Declines in teenage birthrates, 1991-98: Update of national and state trends," National Vital Statistics Reports 47 (1999).

Vogel, Shawna. "The United States has one of the highest teen pregnancy rates in the developed world, according to a new study," (February 24, 2000).

The WHO Report (June 26, 2000).

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