World health system performance revisited: the impact of varying the relative importance of health system goals

We investigate the feasibility and desirability of using mathematical programming techniques that allow weights to vary across countries to reflect their varying circumstances and objectives.By global distributional measures, scores and ranks are found to be not very sensitive to changes in weights, although differences can be large for individual countries.Building the flexibility of variable weights into calculation of the performance index is a useful way to respond to the debates and criticisms appearing since publication of the ranking.The World Health Organization recently published a performance ranking of the health systems of its 191 member countries, and intends to update it at regular intervals [1-4]. It was based on a framework outlining a set of social goals to which health systems should contribute [5]. It was argued that systems should contribute to improving population health, be responsive to the people they serve and be financed fairly. Five outcome indicators were defined – the level of population health, inequalities in health, the level of responsiveness, inequalities in responsiveness and fairness in financial contributions. Estimates of attainment on these five indicators were made for the 191 countries that were members of WHO at that time, and a composite (overall) attainment indicator was constructed for each country as a weighted average of attainment on the five individual outcome indicators.Publication of the analytical framework and the resulting ranking provoked considerable comment, and a variety of issues concerning the methodology and country positions in the ranking have been raised. A central component of the methodology for measuring overall attainment was the use of fixed weights, common to all countries, to aggregate the five indicators. This feature has been controversial, with some arguing that people in different cultural and social settings value individual health system goals in different ways [6-13]. The fixed weights had