This article examines the development of health system metrics by international organizations, exploring their relationship to the politics of world health. Current historiography treats measurement either as progressive illumination or adopts a critical stance, viewing indicators as instruments of global governance by powerful nations. We draw on diverse statistical publications to provide an empirical overview of change and continuity, beginning with the League of Nations Health Organization, which initiated health system statistics, and concluding with the World health report 2000, with its controversial comparative rankings. We then develop analysis and explanation of these trends. Population indicators appeared consistently owing to their protective function and compatibility with development thinking. Others, related to provision, financing, and coverage, appeared more sporadically, owing to changing trends and assumptions in international health. While partly affirming the critical literature, metrics were also used by peripheral or resistant actors to challenge or influence policy at the centre.
Earlier versions of this article were presented at the European Social Science History Conference, University of Valencia, March 2016, the International Health Organizations Network Conference, University of Shanghai, April 2016, and the Society for the Social History of Medicine Conference, University of Kent, June 2016. We thank participants and discussants for their helpful suggestions, and also thank Anne-Emmanuelle Birn, David Reubi, and George Weisz for their advice. Our research is funded by a Wellcome Trust Medical Humanities Investigator Award (grant no. 106720/Z/15/Z) and we are most grateful for this generous support.
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30 See the contributions to Adams, Metrics.
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37 Ibid., pp. 34–7, 47–54, 76, 118–20, 163–9.
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44 Rusnock, Vital accounts, p. 217; Starr, ‘Sociology of official statistics’, pp. 18–20, 56–7; Prewitt, Kenneth, ‘Public statistics and democratic politics’, in Alonso and Starr, Politics of numbers, pp. 261–274 .
45 Fioramonti, How numbers rule, pp. 210–13; Morse, Indicators and indices, pp. 180–3.
46 Cooley, ‘Emerging politics’, pp. 9, 21–3.
47 Davis, Kevin, Kingsbury, Benedict, and Merry, Sally Engle, ‘Introduction: global governance by indicators’, in Davis et al., Governance by indicators, p. 8 .
48 Ibid., pp. 8–9; Starr, ‘Sociology of official statistics’, p. 40; Morse, Indicators and indices, p. 179.
49 Davis, Kingsbury, and Merry, ‘Indicators as a technology’, p. 87; Starr, ‘Sociology of official statistics’, pp. 40–52.
50 Starr, ‘Sociology of official statistics’, pp. 41, 53.
51 Fioramonti, How numbers rule, pp. 19–27.
52 Davis, Kingsbury, and Merry, ‘Introduction’, pp. 8, 15; Cooley, ‘Emerging politics’, pp. 20–1.
53 Davis, Kingsbury, and Merry, ‘Indicators as a technology’, pp. 93–4; Davis, Kingsbury, and Merry, ‘Introduction’, pp. 19–20.
54 Davis, Kingsbury, and Merry, ‘Indicators as a technology’, p. 30; Starr, ‘Sociology of official statistics’, p. 54.
55 Büthe, Tim, ‘Beyond supply and demand: a political–economic conceptual model’, in Davis et al., Governance by indicators, pp. 32–34 ; Fisher, ‘From diagnosing under-immunization’, pp. 244–6.
56 Dubin, Martin, ‘The League of Nations Health Organization’, in Paul Weindling, ed., International health organisations and movements, 1918–1939, Cambridge: Cambridge University Press, 1995 .
57 Weindling, International health organisations, p. 135; Weindling, Paul, ‘The League of Nations Health Organization and the rise of Latin American participation, 1920–40’, História, Ciências, Saúde-Manguinhos, 13, 3, 2006, pp. 555–570 ; Borowy, Coming to terms, p. 84.
58 Kott, Sandrine and Droux, Joelle, eds., Globalizing social rights: the International Labour Organization and beyond, Basingstoke: Palgrave Macmillan, 2013 ; Weindling, International health organisations, p. 138.
59 Kott, Sandrine, ‘Constructing a European social model: the fight for social insurance in the interwar period’, in Jasmin van Daele et al, eds., ILO histories: essays on the International Labour Organization and its impact on the world during the twentieth century, Bern: Peter Lang, 2010, pp. 173–195 .
60 Dubin, ‘League of Nations Health Organization’; Chorev, Nitsan, The World Health Organization between North and South, Ithaca, NY: Cornell University Press, 2012 .
61 ‘Constitution of the World Health Organization’, American Journal of Public Health, 36, 11, 1946, p. 1315, paras. c, f, p.
62 Buse, Kent, ‘Spotlight on international organizations: the World Bank’, Health Policy and Planning 9, 1, 1994, pp. 95–99 ; Preker, Alexander and Feachem, Richard, ‘The role of the World Bank in facilitating health sector reform’, in Zuzana Feachem, Martin Hensher, and Laura Rose, eds., Implementing health sector reform in central Asia: papers from an EDI health policy seminar held in Ashgabat, Turkmenistan, June 1996, EDI Learning Resources Series, Washington, DC: The International Bank for Reconstruction, 1999, p. 144 .
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75 Borowy, ‘World health’, p. 126.
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78 League of Nations Health Committee, Sessions 17–18, 1931, ‘Fourth Meeting May 7th 1931. 10. Budget estimates for 1932’, pp. 42–3.
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81 Although statutory health insurance was relatively recent, returns variously included data on membership numbers or rates, claims incidence and duration, and revenue and expenditure. League of Nations Archive, Geneva (henceforth LONA), 8A/22711/19793, ‘1929 Health Year Book (Volume 6) Model statistical tables and various correspondence’, ‘Tableaux statistiques’; LONA, 8A/19793/19793, ‘1929 Health Year Book (Volume 6)’, ‘Suggestions to authors of reports for the International Health Year Book’.
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83 See e.g. LONA, R 972/12B/57467/46868, anon. [Frank Boudreau(?)], ‘Proposals in regard to the further study of health insurance in relation to public health services from the point of view of preventive medicine’, February 1927.
84 LONA, R 968/12B/46868/46868, ‘Proposal of the Czechoslovak government for an enquiry into the health conditions of various countries’; ‘Notes on the health insurance inquiry’, March 1927.
85 Key officials in collaborative efforts were Rajchman’s assistant Frank Boudreau (LNHO) and Ferdinand Maurette (ILO). See, e.g., LONA, R 968/12B/46871/46848, letter from Albert Thomas, Director of the ILO, to Sir Eric Drummond, Secretary General of the League of Nations, October 1925. See also LONA, R 992, letter, Frank Boudreau, Health Section, LNHO to Dr J. Kuhn, Secretary of the Medical Association of Denmark, 30 March 1927.
86 LONA, R 992/12B/58852/57687, ‘Joint Commission of Experts for the study of the relationship between public health services and health insurance organisations: report of the first session’, 1927; LONA, R 992/12B/58852/57687, Sir George Newman, untitled draft speech, March 1927.
87 ILO, SI 21/5/2, ‘Mixed Commission of Public Health and Social Insurance. Sub-Commission of Social Medicine. General instructions for co-operation between social insurance organizations and social hygiene institutions in Czechoslovakia’, December 1929; LONA, R 970/12B/46868/48705, letter, Rajchman to Foramitti, 4 May 1925.
88 Borowy, Coming to terms; Borowy, ‘World health’.
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92 Stouman, K. and Falk, I. S., ‘Health indices: a study of objective indices of health in relation to environment and sanitation, Milbank Memorial Fund Quarterly, 15, 1, 1937, pp. 5–36 ; Stouman, K. and Falk, I. S., ‘An international system of health indices: a preliminary report’, American Journal of Public Health, 27, 1937, pp. 363–370 .
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96 Brown, Cueto, and Fee, ‘World Health Organization’.
97 Packard, Randall, The making of a tropical disease: a short history of malaria, Baltimore, MD: Johns Hopkins University Press, 2007 .
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107 Ibid., p. 156.
108 Ibid., pp. 2, 156.
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112 Ibid., pp. 88, 96.
113 WHO archive, WHO/OMC/1-27, Hernan Romero, ‘An approach to the problem of costs and financing of medical care services’, 8 August 1956.
114 Ibid., p. 40.
115 APHA Task Force on Chile, ‘History of the health care system in Chile’, American Journal of Public Health, 67, 1, 1977, pp. 31–36 ; Viveros-Long, Anamaria, ‘Changes in health financing: the Chilean experience’, Social Science and Medicine, 22, 3, 1986, pp. 379–385 .
116 APHA Task Force, ‘Health care system in Chile’, pp. 32–3.
117 OECD Health Policy Unit, ‘The state of implementation of the OECD manual: a system of health accounts (SHA) in OECD member countries’, 10 June 2001; UN, ‘Measurement of national income and the construction of social accounts: report of the Sub-Committee on National Income Statistics of the League of Nations Committee of Statistical Experts’, Studies and reports on statistical methods, Geneva: United Nations, 1947.
118 United Nations, A system of national accounts and supporting tables, Studies in methods no. 2, New York: United Nations, 1953. From 1982 the yearbook was renamed National accounts statistics: main aggregates and detailed tables.
119 Berman, ‘What can the U.S. learn?’; OECD Health Policy Unit, ‘State of implementation’; Pommier, Philippe, ‘Social expenditure: socialization of expenditure? The French experiment with satellite accounts’, Review of Income and Wealth, 27, 4, 1981, pp. 373–386 ; Gillion, Colin et al., Measuring health care 1960–1983, Social policy studies no. 2, Paris: OECD, 1985 .
120 Berman, ‘What can the U.S. learn?’
121 OECD, Public expenditure on health.
122 Ibid.; Kaasch, Shaping global health policy.
123 Abel-Smith, B., ‘Foreword’, in Robert Maxwell, Health and wealth: an international study of health-care spending, Lexington, MA: Lexington Books, 1980, pp. xi–xii .
124 OECD, Public expenditure on health.
125 Gillion et al., Measuring health care.
126 OECD, ‘State of implementation’; OECD, Eurostat, and WHO, A system of health accounts 2011 edition, Paris: OECD Publishing, 2011 .
127 George Schieber and OECD, Financing and delivering health care: a comparative analysis of OECD countries, Social policy studies no. 4, Paris: OECD, 1987, p. 9 .
128 Cueto, Marcos, ‘The origins of primary health care and selective primary health care’, American Journal of Public Health 94, 11, 2004, pp. 1864–1874 ; Newell, K., ed., Health by the people, Geneva: WHO, 1975 .
129 Chorev, World Health Organisation.
130 Cueto, ‘Origins of primary health care’.
131 World Bank, World development report 1993: investing in health, Oxford: Oxford University Press, 1993 .
132 Murray, C. J. and Acharya, A., ‘Understanding DALYs’, Journal of Health Economics, 16, 1997, p. 707 .
133 World Bank, World development report 1993, p. iii.
134 de Ferranti, David, Paying for health services in developing countries: an overview, Washington, DC: World Bank, 1985 ; World Bank, Financing health services in developing countries: an agenda for reform, Washington, DC: IBRD, 1987 .
135 World Bank, Financing health services, p. 2.
136 Murray, C. J. and Lopez, A., ‘Progress and directions in refining the global burden of disease approach: a response to Williams’, Health Economics, 9, 1, 2000, p. 72 ; life tables from Japan provide the healthful norms on which calculation is based.
137 Adams, ‘Metrics of the global sovereign’, pp. 21–6.
138 Stouman and Falk, ‘Health indices’, pp. 9–10.
139 Swaroop and Uemura, ‘Proportional mortality’; Hilleboe, Barkhuus, and Thomas, Approaches to national health planning, pp. 54–6; Sanders, B., ‘Measuring community health levels’, American Journal of Public Health and the Nation’s Health, 54, 7, 1964, pp. 1063–1070 ; Sullivan, D. F., ‘A single index of mortality and morbidity’, HSMHA Health Reports, 86, 4, 1971, pp. 347–354 ; Rosser, R. M. and Watt, V. C., ‘The measurement of hospital output’, International Journal of Epidemiology, 1, 4, 1972, pp. 361–368 ; Zeckhauser, R. and Shepard, D., ‘Where now for saving lives?’, Law and Contemporary Problems, 40, 4, 1976, pp. 5–45 .
140 Murray and Acharya, ‘Understanding DALYs’, pp. 711–19.
141 Smith, Jeremy, Epic measures: one doctor, seven billion patients, New York: HarperCollins, 2015 .
142 Williams, Alan, ‘Calculating the global burden of disease: time for a strategic reappraisal?’, Health Economics, 8, 1, 1999, pp. 1–8 ; Sayers, B. and Fliedner, T., ‘The critique of DALYs: a counter-reply’, Bulletin of the World Health Organization, 75, 4, 1997, pp. 383–384 .
143 Anand, S. and Hanson, K., ‘Disability-adjusted life years: a critical review’, Journal of Health Economics, 16, 6, 1997, pp. 685–702 ; Arensen, T. and Nord, E., ‘The value of DALY life: problems with ethics and validity of disability adjusted life years’, British Medical Journal, 319, 1999, pp. 1423–1425 .
144 Adams, ‘Metrics of the global sovereign’, 26–7.
145 Murray and Lopez, ‘Progress and directions’; Murray and Acharya, ‘Understanding DALYs’.
146 Murray and Acharya, ‘Understanding DALYs’, p. 717.
147 Knaul, F. M. and Frenk, J., ‘Health insurance in Mexico: achieving universal coverage through structural reform’, Health Affairs, 24, 6, 2005, pp. 1467–1476 .
148 Navarro, V., ‘Assessment of the World health report 2000 ’, Lancet, 356, 2000, pp. 1598–1601 ; Almeida, Celia et al., ‘Methodological concerns and recommendations on policy consequences of the World health report 2000 ’, Lancet, 357, 2001, pp. 1692–1697 .
149 Robert Helms, ‘Sick list: health care à la Karl Marx’, Wall Street Journal Europe, 29 June 2000.
150 McKee, Martin, ‘Measuring the efficiency of health systems’, British Medical Journal, 323, 2001, pp. 295–296 ; Blendon, R. J., Kim, M. and Benson, J. M., ‘The public versus the World Health Organization on health system performance’, Health Affairs, 20, 3, 2001, pp. 10–20 ; Robbins, A., ‘Book review’, Public Health Reports, 119, 2001, pp. 268–269 ; Pedersen, Kjeld Møller, ‘The World health report 2000: dialogue of the deaf?’, Health Economics, 11, 2002, p. 94 .
151 Williams, Alan, ‘Science or marketing at WHO? A commentary on “World health 2000”’, Health Economics, 10, 2001, pp. 93–100 .
152 Knaul and Frenk, ‘Health insurance in Mexico’.
153 Zhang, Xiulan et al., ‘Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts’, Health Research Policy and Systems, 12, 44, 2014, p. 5 .
154 Barack Obama, ‘Remarks by the President to a Joint Session of Congress on Health Care September 9, 2009’, https://web.archive.org/web/20100308000433/https://www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care (consulted 22 June 2017).
155 McKee, ‘World health report 2000’.
156 Saltman, R. B. and Ferroussier-Davis, O., ‘The concept of stewardship in health policy’, Bulletin of the World Health Organization, 78, 6, 2000, pp. 732–739 .
* Earlier versions of this article were presented at the European Social Science History Conference, University of Valencia, March 2016, the International Health Organizations Network Conference, University of Shanghai, April 2016, and the Society for the Social History of Medicine Conference, University of Kent, June 2016. We thank participants and discussants for their helpful suggestions, and also thank Anne-Emmanuelle Birn, David Reubi, and George Weisz for their advice. Our research is funded by a Wellcome Trust Medical Humanities Investigator Award (grant no. 106720/Z/15/Z) and we are most grateful for this generous support.
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