seventeen industrialized nations we discussed. WHO interviewed 150 people each in only three countries (the Philippines, Tanzania, and Colombia) of the 191 whose health systems WHO rated. 1 We doubt that survey data gathered from three developing countries can be used to understand citizens' experiences in Italy, Denmark, and the United States.We are pleased that WHO is now conducting these surveys in many more countries. But we believe that it would have been more appropriate to analyze the results of such surveys before WHO released their ratings worldwide. We also applaud WHO's attempt to adjust for expectations in different countries. However, we do not believe that Italians' being seventy-one percentage points less satisfied than Danes are can be explained by higher expectations among Italians. Generally, expectations rise with income, education, and per capita health spending. Since Denmark surpasses Italy on all three measures, it is unlikely that Italians have higher expectations of their health system. 2 We continue to believe that the public's perceptions of how their health system works should be one measure of overall health system performance, but not the only one. Having this measure might have made WHO more cautious in interpreting their results. For instance, how can a system be rated highly in overall effectiveness if three-fourths of citizens, including the poor and elderly, are dissatisfied with it? Yet this is exactly the case with Italy, whose health system WHO rated as second best among 191 countries.As to whether people's experiences are a better measure than satisfaction, our own work leads us to believe that both are important.3 However, for this paper about seventeen industrialized countries, we had only satisfaction measures available, while WHO used neither measure.Murray and colleagues suggest that public opinion data about satisfaction are not reliable. They cite as an example the variation in responses over three surveys in Spain, one of WHO's highest-rated industrialized countries. However, these measures involved three different question wordings, so it is incorrect to compare the percentage responses. 4 The important point is that in each case, Spain ranked at the bottom in citizen satisfaction when compared with other industrialized countries, most of which were rated lower by WHO.Finally, Murray and colleagues raise the concern that in two countries our data show the poor to be more satisfied than the nonpoor. In fact, the difference between the poor and nonpoor in the United States is not statistically significant. The United Kingdom is the only one of seventeen countries where the poor are more satisfied than the nonpoor are. What matters most is that the poor in the industrialized countries rated highest by WHO are less satisfied than are the poor in lower-rated countries.
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