WORLD HEALTH ORGANIZATION ⑦e WORLD HEALTH REPORT 200O Health Systems. Improving performance
ealth ystems: mproving erformance he W ORLD HE ALTH R EPORT 2000 WORLD HEALTH ORGANIZATION
WHO Library Cataloguing in Publication Data The World health report 2000: health systems: improving performance 1. World health 2. Health systems plans 3. Del 4. Health services administration 5. Financing, Health 6. Health services ssibility 7. Social justice 8. Health care evaluation mechanisms Title: Health systems: improving performance ISBN924156198 NLM Classification: WA 540.1) ISSN1020-3311 The World Health Organization welcomes requests for per roduce or translate its publica ons, in part or in full Applications and enquiries should be addressed to the Office of Publications, World Health Organization, 1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. o World Health Organization 2000 ights res The designations employed and the presentation of the material in this publication, including tables and do not imply the expression of any opinion whatsoever on the part of the Secretariat of the worl alth Organization concerming the legal status of any country, territory, city or area or of its authoritie or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate not yet be full ag The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distin- guished by initial capital letters Information concerning this publication can be obtained from forld Health Report World Health Organization 1211 Geneva 27, Switzerland Fax(412)714870 Email: whr(@who int Copies of this publication can be ordered from: bookorders@who int The principal writers of this report were Philip Musgrove, Andrew Creese, disease, disability-adjusted life expectancy, health inequalities, responsive- Alex Preker, Christian Baeza, Anders Anell and Thomson Prentice, with con- ness, faimess of financial contribution, health system preferences, national tributions from Andrew Cassels, Debra Lipson, Dyna Arhin Tenkorang and health accounts and profiles, performance analysis and basic economic data. Mark Wheeler. The report was directed by a steering committee formed by Members of each working group are listed in the Acknowledgements. Mar Julio Frenk(chair), Susan Holck, Christopher Murray, Orvill Adams, Andrew gerialand technical leadership for the working groups Creese, Dean Jamison, Kei Kawabata, Philip Musgrove and Thomson Prentice. Frenk, Christopher Murray, Kei Kawabata, Alan Lopez and David Evans.Ase- Valuable input was received from an internal advisory group and a regional ries of technical reports from each of the working groups provides details reference group, the members of which are listed in the Acknowledgements. on the methods, data and results, beyond the explanations included in the \dditional help and advice were gratefully received from regional directors, Statistical Annex. executive directors at WHO headquarters and senior policy advisers to the The general approach to this report was discussed at an Director-General tional consultative meeting on health systems, and the measur ement of The conceptual framework that underpins the report was formu- responsiveness was facilitated by a meeting of key informants. Both lated by Christopher Murray and Julio Frenk. The development of new ana- ings were held in Geneva in December 1999 and the participants are listed cal methods and summary indicators, new international data collection in the Acknowledgements. fforts and extensive empirical analysis that form the basis for the report The report was edited by Ang assisted by barbara was undertaken by over 50 individuals, most of them from the WHO Global Campanini. Administrative and tech the world health Re- rogramme on Evidence for Health Policy, organized in eleven working port team were provided by Shelagh nel Beusenberg amel groups. These groups covered basic demography, cause of death, burden of Chaouachi and Chrissie Chitsulo The index was prepared by Liza Weinkove. shows a photograph of a sculpture entitled"Ascending Horizon"by Rafael Barrios, in Caracas, Venezuela. The photograph by Mireille vautier is reproduced with the kind permission of ANA Agence Design by Marilyn Langfeld Layout by WHO Graphics 200012934- Sadar-30000
ii The World Health Report 2000 WHO Library Cataloguing in Publication Data The World health report 2000 : health systems : improving performance. 1. World health 2. Health systems plans 3. Delivery of health care 4. Health services administration 5. Financing, Health 6. Health services accessibility 7. Social justice 8. Health care evaluation mechanisms I. Title: Health systems : improving performance ISBN 92 4 156198 X (NLM Classification: WA 540.1) ISSN 1020-3311 The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, 1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 2000 All rights reserved. The designations employed and the presentation of the material in this publication, including tables and maps, do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland Fax: (41-22) 791 4870 Email: whr@who.int Copies of this publication can be ordered from: bookorders@who.int The principal writers of this report were Philip Musgrove, Andrew Creese, Alex Preker, Christian Baeza, Anders Anell and Thomson Prentice, with contributions from Andrew Cassels, Debra Lipson, Dyna Arhin Tenkorang and Mark Wheeler. The report was directed by a steering committee formed by Julio Frenk (chair), Susan Holck, Christopher Murray, Orvill Adams, Andrew Creese, Dean Jamison, Kei Kawabata, Philip Musgrove and Thomson Prentice. Valuable input was received from an internal advisory group and a regional reference group, the members of which are listed in the Acknowledgements. Additional help and advice were gratefully received from regional directors, executive directors at WHO headquarters and senior policy advisers to the Director-General. The conceptual framework that underpins the report was formulated by Christopher Murray and Julio Frenk. The development of new analytical methods and summary indicators, new international data collection efforts and extensive empirical analysis that form the basis for the report was undertaken by over 50 individuals, most of them from the WHO Global Programme on Evidence for Health Policy, organized in eleven working groups. These groups covered basic demography, cause of death, burden of The cover shows a photograph of a sculpture entitled “Ascending Horizon” by Rafael Barrios, in Caracas, Venezuela. The photograph by Mireille Vautier is reproduced with the kind permission of ANA Agence photographique de presse, Paris, France. Design by Marilyn Langfeld. Layout by WHO Graphics Printed in France 2000/12934 – Sadag – 30 000 disease, disability-adjusted life expectancy, health inequalities, responsiveness, fairness of financial contribution, health system preferences, national health accounts and profiles, performance analysis and basic economic data. Members of each working group are listed in the Acknowledgements. Managerial and technical leadership for the working groups was provided by Julio Frenk, Christopher Murray, Kei Kawabata, Alan Lopez and David Evans. A series of technical reports from each of the working groups provides details on the methods, data and results, beyond the explanations included in the Statistical Annex. The general approach to this report was discussed at an international consultative meeting on health systems, and the measurement of responsiveness was facilitated by a meeting of key informants. Both meetings were held in Geneva in December 1999 and the participants are listed in the Acknowledgements. The report was edited by Angela Haden, assisted by Barbara Campanini. Administrative and technical support for the World Health Report team were provided by Shelagh Probst, Michel Beusenberg, Amel Chaouachi and Chrissie Chitsulo. The index was prepared by Liza Weinkove
CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL OVERVIEW How health systems have evolved The potential to improve roviding better services inding a better balance rotecting the poor CHAPTER 1 WHY DO HEALTH SYSTEMS MATTER The changing landscape What is a health system? What do health systems do? Why health systems matter How modern health systems evolved 357813 Three generations of health system reform Focusing on performance CHAPTER 2 HOW WELL DO HEALTH SYSTEMS PERFORM? Attainment and performance Goals and functions Goodness and fairness: both level and distribution matter measuring goal achievement Overall attainment: goodness and fairness combined Performance: getting results from resources Improving performance: four key functions ChAPTER 3 HEALTH SERVICES: WELL CHOSEN, WELL ORGANIZED? tional failin ngs People at the centre of health services Choosing interventions: getting the most health from resources Choosing interventions: what else matters? Choosing interventions: what must be known? Enforcing priorities by rationing care After choosing priorities: service organization and provider incentives
Overview iii CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL VII OVERVIEW XI How health systems have evolved xiii The potential to improve xiv Providing better services xv Finding a better balance xvi Protecting the poor xviii CHAPTER 1 WHY DO HEALTH SYSTEMS MATTER? 1 The changing landscape 3 What is a health system? 5 What do health systems do? 7 Why health systems matter 8 How modern health systems evolved 11 Three generations of health system reform 13 Focusing on performance 17 CHAPTER 2 HOW WELL DO HEALTH SYSTEMS PERFORM? 21 Attainment and performance 23 Goals and functions 23 Goodness and fairness: both level and distribution matter 26 Measuring goal achievement 27 Overall attainment: goodness and fairness combined 40 Performance: getting results from resources 40 Improving performance: four key functions 44 CHAPTER 3 HEALTH SERVICES: WELL CHOSEN, WELL ORGANIZED? 47 Organizational failings 49 People at the centre of health services 50 Choosing interventions: getting the most health from resources 52 Choosing interventions: what else matters? 55 Choosing interventions: what must be known? 57 Enforcing priorities by rationing care 58 After choosing priorities: service organization and provider incentives 61 Organizational forms 62
Service delivery configurations Incentives CHAPTER 4 WHAT RESOURCES ARE NEEDED? Balancing the mix of resources 75 Human resources are vital 81 Public and private production of resources The legacy of past Health care resource profiles 85 The way forward CHAPTER S WHO PAYS FOR HEALTH SYSTEMS? How financing work Prepayment and collection preading risk and subsidizing the poor: pooling of resources rategic purchasing anizational forms Incentives 110 How financing affects equity and efficiency 113 CHAPTER 6 HOW IS THE PUBLIC INTEREST PROTECTED? 117 Governments as stewards of health resources What is ewa Health policy-vision for the future Setting the rules, ensuring compliance Exercising intelligence, sharing knowledge Strategies, roles and resources: who should do what? What are the challenges? STATISTICAL ANNEX 143 144 Annex Table 1 Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997 Annex Table 2 basic indicators for all Member States Annex Table 3 Deaths by cause, sex and mortality stratum in WHO Region estimates for 1999
iv The World Health Report 2000 Service delivery configurations 63 Aligning incentives 64 Integration of provision 68 CHAPTER 4 WHAT RESOURCES ARE NEEDED? 73 Balancing the mix of resources 75 Human resources are vital 77 Adjusting to advances in knowledge and technology 81 Public and private production of resources 82 The legacy of past investments 84 Health care resource profiles 85 Changing investment patterns 88 The way forward 90 CHAPTER 5 WHO PAYS FOR HEALTH SYSTEMS? 93 How financing works 95 Prepayment and collection 97 Spreading risk and subsidizing the poor: pooling of resources 99 Strategic purchasing 104 Organizational forms 108 Incentives 110 How financing affects equity and efficiency 113 CHAPTER 6 HOW IS THE PUBLIC INTEREST PROTECTED? 117 Governments as stewards of health resources 119 What is wrong with stewardship today? 120 Health policy – vision for the future 122 Setting the rules, ensuring compliance 124 Exercising intelligence, sharing knowledge 129 Strategies, roles and resources: who should do what? 132 What are the challenges? 135 How to improve performance 137 STATISTICAL ANNEX 143 Explanatory notes 144 Annex Table 1 Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997 152 Annex Table 2 Basic indicators for all Member States 156 Annex Table 3 Deaths by cause, sex and mortality stratum in WHO Regions, estimates for 1999 164
Annex Table 4 Burden of disease in disability-adjusted life years (DALYs) by cause, sex and mortality stratum in WHO Regions, estimates for 1999 170 Annex Table 5 Health attainment, level and distribution in all Member States stomates for 1997 and 1999 Annex Table 6 Responsiveness of health systems, level and distribution in all Member States, WHO indexes, estimates for 1999 Annex Table 7 Faimess of financial contribution to health systems in al Member States, WHO index, estimates for 1997 Annex Table8 Selected national health accounts indicators for all member States estimates for 1997 192 Annex Table 9 Overall health system attainment in all Member States, WHO index estimates for 1997 196 Annex Table 10 Health system performance in all Member States, WHO indexes, estimates for 1997 200 LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM ACKNOWLEDGEMENTS 206 INDEX 207 TABLES Table 3.1 Interventions with a large potential impact on health outcomes Table 3. 2 Examples of organizational incentives for ambulatory care Table 5.1 Estimated out-of-pocket share in health spending by income level, 1997 96 Table 5.2 Approaches to spreading risk and subsidizing the poor: country cases Table 5.3 Provider payment mechanisms and provider behaviour Table 5.4 Exposure of different organizational forms to internal incentives 111 Table 5.5 Exposure of different organizational forms to extermal incentives 112 FIGURES Figure 1.1 Coverage of population and of interventions under different notions of primary health care Figure 2.2 Life expectancy and disability-adjusted life expectancy for males and females, by WHO Region and stratum defined by child Figure 2.3 Inequality in life expectancy at birth, by sex, in six countries Figure 2.4 Relative scores of health system responsiveness elements, in 13 Figure 2.5 Household contributions to financing health, as percentage of Figure 2.6 Performance on level of health(disability-adjusted life expectancy) relative to health expenditure per capita, 191 Member States, 1999
Overview v Annex Table 4 Burden of disease in disability-adjusted life years (DALYs) by cause, sex and mortality stratum in WHO Regions, estimates for 1999 170 Annex Table 5 Health attainment, level and distribution in all Member States, estimates for 1997 and 1999 176 Annex Table 6 Responsiveness of health systems, level and distribution in all Member States, WHO indexes, estimates for 1999 184 Annex Table 7 Fairness of financial contribution to health systems in all Member States, WHO index, estimates for 1997 188 Annex Table 8 Selected national health accounts indicators for all Member States, estimates for 1997 192 Annex Table 9 Overall health system attainment in all Member States, WHO index, estimates for 1997 196 Annex Table 10 Health system performance in all Member States, WHO indexes, estimates for 1997 200 LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM 204 ACKNOWLEDGEMENTS 206 INDEX 207 TABLES Table 3.1 Interventions with a large potential impact on health outcomes 53 Table 3.2 Examples of organizational incentives for ambulatory care 67 Table 5.1 Estimated out-of-pocket share in health spending by income level, 1997 96 Table 5.2 Approaches to spreading risk and subsidizing the poor: country cases 101 Table 5.3 Provider payment mechanisms and provider behaviour 106 Table 5.4 Exposure of different organizational forms to internal incentives 111 Table 5.5 Exposure of different organizational forms to external incentives 112 FIGURES Figure 1.1 Coverage of population and of interventions under different notions of primary health care 15 Figure 2.1 Relations between functions and objectives of a health system 25 Figure 2.2 Life expectancy and disability-adjusted life expectancy for males and females, by WHO Region and stratum defined by child mortality and adult mortality, 1999 29 Figure 2.3 Inequality in life expectancy at birth, by sex, in six countries 30 Figure 2.4 Relative scores of health system responsiveness elements, in 13 countries, 1999 34 Figure 2.5 Household contributions to financing health, as percentage of capacity to pay, in eight countries 37 Figure 2.6 Performance on level of health (disability-adjusted life expectancy) relative to health expenditure per capita, 191 Member States, 1999 43
Figure 2.7 Overall health system performance(all attainments)relative to health expenditure per capita, 191 Member States, 1997 Figure 3.1 The multiple roles of people in health system Figure 3.2 Questions to ask in deciding what interventions to finance and provide 55 Figure 3.3 Different ways of rationing health interventions according to cost and frequency of need Figure 3.4 Different internal incentives in three organizational structures Figure 4.1 Health system inputs: from financial resources to health interventions 75 Figure 4.2 Health systems input mix: comparison of four high income countries, around 1997 Figure 4.3 Health systems input mix comparison of four middle income countries, around 1997 Figure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity Figure 5.2 Structure of health system financing and provision in four countries 102 BOX Box 1.1 Poverty, ill-health and cost-effectiveness 5 Box 1.2 Health knowledge, not income, explains historical change in urban-rural health differences 10 Box 2.1 Summary measures of population health Box 2.2 How important are the different elements of responsiveness? Box 2.3 What does fair contribution measure and not measure? Box 2.4 Weighting the achievements that go into overall attainment Box 2.5 Estimating the best to be expected and the least to be demanded Box 4.1 Substitution among human resources 78 Box 4.2 Human resources problems in service delivery Box 4.3 A widening gap in technology use Box 4.4 The Global Alliance for Vaccines and Immunization(GAVe) Box 4.5 Investment in hospitals in countries of the former Soviet Union prior to policy reform Box 5.1 The importance of donor contributions in revenue collection and purchasing in developing countries Box 5.2 The Chilean health insurance market: when stewardship fails to imbalances between internal and external incentives Box 6.1 Trends in national health policy: from plans to frameworks Box 6.2 Ghana's medium-term health policy framework Box 6.3 SWAPs: are they good for stewardship? Box 6.4 Stewardship: the Hisba system in Islamic countries Box 6.5 South Africa: regulating the private insurance market to increase risk pooling Box 6.6 Opening up the health insurance system in the Netherlands 128 Box 6.7 Responsiveness to patients'rights Box 6.8 Towards good stewardship-the case of pharmaceuticals Box 6.9 Thailand: the role of the media in health system stewardship
vi The World Health Report 2000 Figure 2.7 Overall health system performance (all attainments) relative to health expenditure per capita, 191 Member States, 1997 44 Figure 3.1 The multiple roles of people in health systems 50 Figure 3.2 Questions to ask in deciding what interventions to finance and provide 55 Figure 3.3 Different ways of rationing health interventions according to cost and frequency of need 60 Figure 3.4 Different internal incentives in three organizational structures 66 Figure 4.1 Health system inputs: from financial resources to health interventions 75 Figure 4.2 Health systems input mix: comparison of four high income countries, around 1997 86 Figure 4.3 Health systems input mix: comparison of four middle income countries, around 1997 87 Figure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity 100 Figure 5.2 Structure of health system financing and provision in four countries 102 BOXES Box 1.1 Poverty, ill-health and cost-effectiveness 5 Box 1.2 Health knowledge, not income, explains historical change in urban–rural health differences 10 Box 2.1 Summary measures of population health 28 Box 2.2 How important are the different elements of responsiveness? 32 Box 2.3 What does fair contribution measure and not measure? 38 Box 2.4 Weighting the achievements that go into overall attainment 39 Box 2.5 Estimating the best to be expected and the least to be demanded 41 Box 4.1 Substitution among human resources 78 Box 4.2 Human resources problems in service delivery 79 Box 4.3 A widening gap in technology use? 82 Box 4.4 The Global Alliance for Vaccines and Immunization (GAVI) 83 Box 4.5 Investment in hospitals in countries of the former Soviet Union prior to policy reform 89 Box 5.1 The importance of donor contributions in revenue collection and purchasing in developing countries 96 Box 5.2 The Chilean health insurance market: when stewardship fails to compensate for pooling competition problems and for imbalances between internal and external incentives 109 Box 6.1 Trends in national health policy: from plans to frameworks 121 Box 6.2 Ghana’s medium-term health policy framework 122 Box 6.3 SWAPs: are they good for stewardship? 123 Box 6.4 Stewardship: the Hisba system in Islamic countries 124 Box 6.5 South Africa: regulating the private insurance market to increase risk pooling 126 Box 6.6 Opening up the health insurance system in the Netherlands 128 Box 6.7 Responsiveness to patients’ rights 130 Box 6.8 Towards good stewardship – the case of pharmaceuticals 131 Box 6.9 Thailand: the role of the media in health system stewardship 133
MESSAGE FROM THE DIRECTOR-GENERAL at makes for a good health system? What makes a health system fair? And how do we know whether a health system is performing as well as it could? These questions are the subject of public debate in most countries around the world. defending the budget in parliament; a minister of finance attempting to balance multiple laims on the public purse; a harassed hospital superintendent under pres- sure to find more beds; a health centre doctor or nurse who has just run out of antibiotics; a news editor looking for a story; a mother seeking treatment for her sick two-year old child; a pressure group lobbying for better services-all will have their views We in the world health Organization need to help all involved to reach a balanced judgement. Whatever standard we apply, it is evident that health systems in some countries perform well, while others perform poorly. This is not due just to differences in income or expenditure: we know that performance can spending. The way health systems are designed, managed and ary markedly, even in countries with very similar levels of health financed affects people's lives and livelihoods. The difference be tween a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humilia- tion and despair When i became Director-General in 1998, one of oncerns was that health systems development should become Dr Gro harlem Brundtland increasingly central to the work of WHO. I also took the view that while our work in this area must be consistent with the values of health for all, our recom- mendations should be based on evidence rather than ideology. This report is a product of those concerns. I hope it will be seen as a landmark publication in the field of health sys- tems development. Improving the performance of health systems around the world is the raison d'etre of this report Our challenge is to gain a better understanding of the factors that make a difference. It has not been an easy task. We have debated how a health system should be defined in order to extend our field of concem beyond the provision of public and personal health services, and encompass other key areas of public policy that have an impact on people's health. This report suggests that the boundaries of health systems should encompass all ctions whose primary intent is to improve health
Overview vii MESSAGE FROM THE DIRECTOR-GENERAL Dr Gro Harlem Brundtland hat makes for a good health system? What makes a health system fair? And how do we know whether a health system is performing as well as it could? These questions are the subject of public debate in most countries around the world. Naturally, answers will depend on the perspective of the respondent. A minister of health defending the budget in parliament; a minister of finance attempting to balance multiple claims on the public purse; a harassed hospital superintendent under pressure to find more beds; a health centre doctor or nurse who has just run out of antibiotics; a news editor looking for a story; a mother seeking treatment for her sick two-year old child; a pressure group lobbying for better services – all will have their views. We in the World Health Organization need to help all involved to reach a balanced judgement. Whatever standard we apply, it is evident that health systems in some countries perform well, while others perform poorly. This is not due just to differences in income or expenditure: we know that performance can vary markedly, even in countries with very similar levels of health spending. The way health systems are designed, managed and financed affects people’s lives and livelihoods. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair. When I became Director-General in 1998, one of my prime concerns was that health systems development should become increasingly central to the work of WHO. I also took the view that while our work in this area must be consistent with the values of health for all, our recommendations should be based on evidence rather than ideology. This report is a product of those concerns. I hope it will be seen as a landmark publication in the field of health systems development. Improving the performance of health systems around the world is the raison d’être of this report. Our challenge is to gain a better understanding of the factors that make a difference. It has not been an easy task. We have debated how a health system should be defined in order to extend our field of concern beyond the provision of public and personal health services, and encompass other key areas of public policy that have an impact on people’s health. This report suggests that the boundaries of health systems should encompass all actions whose primary intent is to improve health
The World Health Report 2000 The report breaks new ground in the way that it helps us understand the goals of health systems. Clearly, their defining purpose is to improve and protect health- but they have other intrinsic goals. These are concerned with fairness in the way people pay for health care, and with how systems respond to people's expectations with regard to how they are treated. Where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities, in ways that improve the situation of the worst-off. In this report attainment in relation to nete policy-makers are to act on measures of performance, they need a clear understand these goals provides the basis for measuring the performance of health systems ing of the key functions that health systems have to undertake The report defines four key functions: providing services; generating the human and physical resources that make service delivery possible; raising and pooling the resources used to pay for health care; and,most critically, the function of stewardship setting and enforcing the rules of the game and providing strategic direction for all the different actors involved Undoubtedly, many of the concepts and measures used in the report require further refinement and development. To date, our knowledge about health systems has been ham pered by the weakness of routine information systems and insufficient attention to arch. This report has thus required a major effort to assemble data, collect new information, and carry out the required analysis and synthesis. It has also drawn on the views of a large number of respondents, within and outside WHO, conceming the interpretation of data and the relative importance of different goal The material in this report cannot provide definitive answers to every question about health systems performance. It does though bring together the best available evidence to date. It demonstrates that, despite the complexity of the topic and the limitations of th data, it is possible to get a reasonable approximation of the current situation, in a way that I hope that the report will contribute to work on how to assess and improve health systems Performance assessment allows policy-makers, health providers and the popula improve health. It invites reflection on the forces that shape performance and the actions For WHO, The world health report 2000 is a milestone in a long-term process. The meas- irement of health systems performance will be a regular feature of all Word health reports from now on- using improved and updated information and methods as they are devel Even though we are at an early stage in understanding a complex set of interactions, some important conclusions are clear. Ultimate responsibility for the performance of a countrys health system lies with government. The careful and responsible management of the well-being of the popu lation-stewardship -is the very essence of good government. The health of people is always a national priority: government responsibility for it is continuous and per- Dollar for dollar spent on health, many countries are falling short of their pe ance potential. The result is a large number of preventable deaths and lives stunted by disability. The impact of this failure is bom disproportionately by the poor
viii The World Health Report 2000 The report breaks new ground in the way that it helps us understand the goals of health systems. Clearly, their defining purpose is to improve and protect health – but they have other intrinsic goals. These are concerned with fairness in the way people pay for health care, and with how systems respond to people’s expectations with regard to how they are treated. Where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities, in ways that improve the situation of the worst-off. In this report attainment in relation to these goals provides the basis for measuring the performance of health systems. If policy-makers are to act on measures of performance, they need a clear understanding of the key functions that health systems have to undertake. The report defines four key functions: providing services; generating the human and physical resources that make service delivery possible; raising and pooling the resources used to pay for health care; and, most critically, the function of stewardship – setting and enforcing the rules of the game and providing strategic direction for all the different actors involved. Undoubtedly, many of the concepts and measures used in the report require further refinement and development. To date, our knowledge about health systems has been hampered by the weakness of routine information systems and insufficient attention to research. This report has thus required a major effort to assemble data, collect new information, and carry out the required analysis and synthesis. It has also drawn on the views of a large number of respondents, within and outside WHO, concerning the interpretation of data and the relative importance of different goals. The material in this report cannot provide definitive answers to every question about health systems performance. It does though bring together the best available evidence to date. It demonstrates that, despite the complexity of the topic and the limitations of the data, it is possible to get a reasonable approximation of the current situation, in a way that provides an exciting agenda for future work. I hope that the report will contribute to work on how to assess and improve health systems. Performance assessment allows policy-makers, health providers and the population at large to see themselves in terms of the social arrangements they have constructed to improve health. It invites reflection on the forces that shape performance and the actions that can improve it. For WHO, The world health report 2000 is a milestone in a long-term process. The measurement of health systems performance will be a regular feature of all World health reports from now on – using improved and updated information and methods as they are developed. Even though we are at an early stage in understanding a complex set of interactions, some important conclusions are clear. • Ultimate responsibility for the performance of a country’s health system lies with government. The careful and responsible management of the well-being of the population – stewardship – is the very essence of good government. The health of people is always a national priority: government responsibility for it is continuous and permanent. • Dollar for dollar spent on health, many countries are falling short of their performance potential. The result is a large number of preventable deaths and lives stunted by disability. The impact of this failure is born disproportionately by the poor
ssage fron the Director-General Health systems are not just concerned with improving people's health but with tecting them against the financial costs of illness. The challenge facing governments in low income countries is to reduce the regressive burden of out-of-pocket payment for health by expanding prepayment schemes, which spread financial risk and re- duce the spectre of catastrophic health care expenditures Within governments, many health ministries focus on the public sector often disre- garding the - frequently much larger-private finance and provision of care. A grow ing challenge is for governments to harness the energies of the private and voluntary sectors in achieving better levels of health systems performance, while offsetting the failures of private markets Stewardship is ultimately concerned with oversight of the entire system, avoiding myopia, tunnel vision and the turning of a blind eye to a systems failings. This report is meant to make that task easier by bringing new evidence into sharp focus In conclusion, Ihope this report will help policy-makers to make wise choices. If they do sO, substantial gains will be possible for all countries, and the poor will be the principal beneficiaries ∥ Gro Harlem Brundtland ne2000
Overview ix • Health systems are not just concerned with improving people’s health but with protecting them against the financial costs of illness. The challenge facing governments in low income countries is to reduce the regressive burden of out-of-pocket payment for health by expanding prepayment schemes, which spread financial risk and reduce the spectre of catastrophic health care expenditures. • Within governments, many health ministries focus on the public sector often disregarding the – frequently much larger – private finance and provision of care. A growing challenge is for governments to harness the energies of the private and voluntary sectors in achieving better levels of health systems performance, while offsetting the failures of private markets. • Stewardship is ultimately concerned with oversight of the entire system, avoiding myopia, tunnel vision and the turning of a blind eye to a system’s failings. This report is meant to make that task easier by bringing new evidence into sharp focus. In conclusion, I hope this report will help policy-makers to make wise choices. If they do so, substantial gains will be possible for all countries, and the poor will be the principal beneficiaries. Gro Harlem Brundtland Geneva June 2000 Message fron the Director-General
OVERVIEW day and every day, the lives of vast numbers of people lie in the hands of health systems. From the safe delivery of a healthy baby to the care with dignity of the frail elderly, health systems have a vital and continuing responsibility to people throughou the lifespan. They are crucial to the healthy development of individuals, families and socie- ties everywhere In this report, health systems are defined as comprising all the organizations, institu ns and resources that are devoted to producing health actions. a health action is defined as any effort, whetherin personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health. But while improving health is clearly the main objective of a health system, it is not the only one. The objective of good health itself is really twofold: the best attainable average level - goodness-and the smallest feasible differences among individuals and groups faimess. Goodness means a health system responding well to what people expect of it; fairness it responds equally well to everyone, without discrimination. In The world health report 2000, devoted entirely to health systems, the World Health Organization ex- pands its traditional concen for people,'s physical and mental well-being to emphasize these other elements of goodness and fairness To an unprecedented degree, it takes account of the roles people have as providers and consumers of health services, as financial contributors to health systems, as workers within them, and as citizens engaged in the responsible management, or stewardship, of them And it looks at how well or how badly systems address inequalities, how they respond people' s expectations, and how much or how little they respect people's dignity, rights and The world health report 2000 also breaks new ground in presenting for the first time an dex of national health systems performance in trying to achieve three overall goals: goo health, responsiveness to the expectations of the population, and faimess of financial contribution Progress towards them depends crucially on how well systems carry out four vital func tions. These are: service provision, resource generation, financing and stewardship. The report devotes a chapter to each function, and reaches conclusions and makes policy recommen dations on each. It places special emphasis on stewardship, which has a profound influence the other three Many questions about health system performance have no clear or simple answers because outcomes are hard to measure and it is hard to disentangle the health system's contribution from other factors. Building on valuable previous work, this report introduces WHOs framework for assessing health system performance. By
Overview xi OVERVIEW oday and every day, the lives of vast numbers of people lie in the hands of health systems. From the safe delivery of a healthy baby to the care with dignity of the frail elderly, health systems have a vital and continuing responsibility to people throughout the lifespan. They are crucial to the healthy development of individuals, families and societies everywhere. In this report, health systems are defined as comprising all the organizations, institutions and resources that are devoted to producing health actions. A health action is defined as any effort, whether in personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health. But while improving health is clearly the main objective of a health system, it is not the only one. The objective of good health itself is really twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness. Goodness means a health system responding well to what people expect of it; fairness means it responds equally well to everyone, without discrimination. In The world health report 2000, devoted entirely to health systems, the World Health Organization expands its traditional concern for people’s physical and mental well-being to emphasize these other elements of goodness and fairness. To an unprecedented degree, it takes account of the roles people have as providers and consumers of health services, as financial contributors to health systems, as workers within them, and as citizens engaged in the responsible management, or stewardship, of them. And it looks at how well or how badly systems address inequalities, how they respond to people’s expectations, and how much or how little they respect people’s dignity, rights and freedoms. The world health report 2000 also breaks new ground in presenting for the first time an index of national health systems’ performance in trying to achieve three overall goals: good health, responsiveness to the expectations of the population, and fairness of financial contribution. Progress towards them depends crucially on how well systems carry out four vital functions. These are: service provision, resource generation, financing and stewardship. The report devotes a chapter to each function, and reaches conclusions and makes policy recommendations on each. It places special emphasis on stewardship, which has a profound influence on the other three. Many questions about health system performance have no clear or simple answers – because outcomes are hard to measure and it is hard to disentangle the health system’s contribution from other factors. Building on valuable previous work, this report introduces WHO’s framework for assessing health system performance. By clarifying and quantifying
