Thisfactormeasuresavari-ety of health care system features, includingspeed of service, protection of privacy, choiceofdoctors,andqualityofamenities(e.g.,cleanhospital bed linens). Although those featuresmay not directly contribute to longer lifeexpectancy, people do consider them aspectsofthequalityofhealthcareservices,sothereisastrongcaseforincludingthem.Theotherthreefactors,however,areprob-lematic:
Ahealthsystem’sfinan-cialfairness(FF)ismeasuredbydetermininga household’s contribution to health expendi-ture as a percentage of household income(beyond subsistence), then looking at the dis-persionofthispercentageoverallhouseholds.The wider the dispersion in the percentage of household income spent on health care, theworse a nation will perform on the FF factorand the overall index (other things beingequal).In the aggregate, poor people spend a larg-er percentage of income on health care thando the rich.
Insofar as health care is regardedasanecessity,peoplecanbeexpectedtospendadecreasingfractionoftheirincomeonhealthcare as their income increases. The samewould be true of food, except that the richtendtobuyhigher-qualityfood.The FF factor is not an objective measureof health attainment, but rather reflects a value judgment that rich people should pay more for health care, even if they consumethe same amount. This is a value judgmentnot applied to most other goods, even thoseregarded as necessities such as food andhousing.Mostpeopleunderstandandacceptthat the poor will tend to spend a larger per-centage of their income on these items.More importantly, the FF factor, whichaccounts for one-fourth of each nation’s OAscore, necessarily makes countries that rely onmarket incentives look inferior. The FF mea-sure rewards nations that finance health careaccordingtoabilitytopay,ratherthanaccord-ing to actual consumption or willingness topay. In most countries, a household’s tax bur-den is proportional to income, or progressive(i.e., taxes consume an increasing share of income as income rises). Thus, a nation’s FFscore rises when the government shouldersmore of the health spending burden, becausemore of the nation’s medical expenditures arefinanced according to ability to pay. In theextreme, if the government pays for
healthcare,thenthedistributionofthehealth-spend-ing burden is exactly the same as the distribu-tion of the tax burden. To use the existingWHO rankings to justify more governmentinvolvement in health care—such as via a sin-gle-payer health care system—is therefore toengage in circular reasoning because the rank-ingsare
inamannerthatfavorsgreatergovernment involvement. If the WHO rank-ingsaretobeusedtodeterminewhethermoregovernment involvement in health care pro-motes better health outcomes, the FF factorshouldbeexcluded.The ostensible reason for including FF inthe health care performance index is to con-sider the possibility of people landing in direfinancial straits because of their health needs.It is debatable whether the potential for desti-tutiondeservesinclusioninastrictmeasureof health performance
. But even if it does,the FF factor does not actually measure expo-suretoriskofimpoverishment.FFiscalculat-ed by (1) finding each household’s contribu-tion to health expenditure as a percentage of household income (beyond subsistence), (2)
the difference between that percentageand the corresponding percentage for theaverage household, and (3) taking the sum of all such cubed differences.
Consequently, theFF factor penalizes a country for each house-hold that spends a larger-than-average per-centage of its income on health care. But italso penalizes a country for each householdthat spends a
-than-average percentageofitsincomeonhealthcare.Put more simply, the FF penalizes a coun-try because some households are especially likely to become impoverished from healthcosts—butitalsopenalizesacountrybecausesome households are especially
tobecome impoverished from health costs. Inshort, the FF factor can cause a country’s