CHAPTER TWO ealth ystems Perform Better health is unquestionably the primary goal of a health system. But because health care can be catastrophically costly and the need for it unpre dictable, mechanisms for sharing risk and providing financial protection are important. A second goal of health systems is therefore fairness in financial contribution. a third goal responsiveness to people's expecta tions in regard to non-health matters-reflects the importance of respecting people's dignity, autonomy and the confidentiality of information. WHO has engaged in a major exercise to obtain and analyse data in order to assess how far health systems in WHO Member States are achieving these goals for which they should be accountable, and how efficiently they are using their resources in doing so. By focusing on a few universal functions that health systems undertake, this report provides an evidence base to as sist policy-makers improve health system performance
How Well do Health Systems Perform? 21 CHAPTER TWO ow ell do ealth ystems erform ? Better health is unquestionably the primary goal of a health system. But because health care can be catastrophically costly and the need for it unpredictable, mechanisms for sharing risk and providing financial protection are important. A second goal of health systems is therefore fairness in financial contribution. A third goal – responsiveness to people’s expectations in regard to non-health matters – reflects the importance of respecting people’s dignity, autonomy and the confidentiality of information. WHO has engaged in a major exercise to obtain and analyse data in order to assess how far health systems in WHO Member States are achieving these goals for which they should be accountable, and how efficiently they are using their resources in doing so. By focusing on a few universal functions that health systems undertake, this report provides an evidence base to assist policy-makers improve health system performance. 21
HOW WELL DO HEALTH SYSTEMS PERFORM? ATTAINMENT AND PERFORMANCE ( ssessing how well a health system does its job requires dealing with two large questions. The first is how to measure the outcomes of interest-that is to determine what is achieved with respect to the three objectives of good health, respon siveness and fair financial contribution(attainment). The second is how to compare those attainments with what the system should be able to accomplish-that is, the best that could be achieved with the same resources (performance). Although progress is feasible against many of society s health problems, some of the causes lie completely outside even a broad notion of what health systems are. Health systems cannot be held responsible for influ ences such as the distribution of income and wealth, any more than for the impact of the climate But avoidable deaths and illness from childbirth, measles, malaria or tobacco con- sumption can properly be laid at their door. A fair judgement of how much health damage it should be possible to avoid requires an estimate of the best that can be expected, and of the least that can be demanded, of a system. The same is true of progress towards the other two objectives, although much less is known about them(1) GOALS AND FUNCTIONS Better health is of course the raison d'etre of a health system, and unquestionably its primary or defining goal: if health systems did nothing to protect or improve health there would be no reason for them. Other systems in society may contribute greatly to the popu lations health, but not as their primary goal. For example, the education system makes a large difference to health, but its defining goal is to educate Influence also flows the other way: better health makes children better able to learn, but that is not the defining purpose of the health system. In contrast, the goal of fair financing is common to all societal sys- tems. This is obvious when the system is paid for socially, but it holds even when everything is financed purely by individual purchases. It is only the notion of faimess that may vary. Getting what you pay for "is generally accepted as fair in market transactions, but seems much less fair where health services are concemed. Similarly, in any system, people have expectations which society regards as legitimate, as to how they should be treated, both physically and psychologically Responsiveness is therefore always a social goal.Taking the education system as an example, fair financing means the right balance of contributions from households which do and those which do not have children in school, and enough subsidy that poor children are not denied schooling for financial reasons. Responsiveness cludes respect for parents' wishes for their children, and avoiding abuse or humiliation of the students themselves
How Well do Health Systems Perform? 23 2 HOW WELL DO HEALTH SYSTEMS PERFORM? ATTAINMENT AND PERFORMANCE ssessing how well a health system does its job requires dealing with two large questions. The first is how to measure the outcomes of interest – that is, to determine what is achieved with respect to the three objectives of good health, responsiveness and fair financial contribution (attainment). The second is how to compare those attainments with what the system should be able to accomplish – that is, the best that could be achieved with the same resources (performance). Although progress is feasible against many of society’s health problems, some of the causes lie completely outside even a broad notion of what health systems are. Health systems cannot be held responsible for influences such as the distribution of income and wealth, any more than for the impact of the climate. But avoidable deaths and illness from childbirth, measles, malaria or tobacco consumption can properly be laid at their door. A fair judgement of how much health damage it should be possible to avoid requires an estimate of the best that can be expected, and of the least that can be demanded, of a system. The same is true of progress towards the other two objectives, although much less is known about them (1). GOALS AND FUNCTIONS Better health is of course the raison d’être of a health system, and unquestionably its primary or defining goal: if health systems did nothing to protect or improve health there would be no reason for them. Other systems in society may contribute greatly to the population’s health, but not as their primary goal. For example, the education system makes a large difference to health, but its defining goal is to educate. Influence also flows the other way: better health makes children better able to learn, but that is not the defining purpose of the health system. In contrast, the goal of fair financing is common to all societal systems. This is obvious when the system is paid for socially, but it holds even when everything is financed purely by individual purchases. It is only the notion of fairness that may vary. “Getting what you pay for” is generally accepted as fair in market transactions, but seems much less fair where health services are concerned. Similarly, in any system, people have expectations which society regards as legitimate, as to how they should be treated, both physically and psychologically. Responsiveness is therefore always a social goal. Taking the education system as an example, fair financing means the right balance of contributions from households which do and those which do not have children in school, and enough subsidy that poor children are not denied schooling for financial reasons. Responsiveness includes respect for parents’ wishes for their children, and avoiding abuse or humiliation of the students themselves
The World Health Report The health system differs from other social systems such as education, and from the markets for most consumer goods and services, in two ways which make the goals of fai health care can be cata strophically costly Much of the need for care is unpredictable, so it is vital for people to be protected from having to choose between financial ruin and loss of health. Mechanisms for sharing risk and providing financial protection are more important even than in other cases where people buy insurance, as for physical assets like homes or vehicles, or against the financial risk to the of a breadwinner dying young. The other peculiarity of health is that illness itself, and medical care as well, can threaten people's dignity and their ability to control what happens to them more than most other events to which they are exposed Among other things, responsiveness means reducing the damage to one's dignity and au tonomy, and the fear and shame that sickness often brings with it. Systems are often charged to be affordable, equitable, accessible, sustainable, of good quality, and perhaps to have many other virtues as well. However, desiderata such as acces sibility are really a means to an end; they are instrumental rather than final goals.The more accessible a system is, the more people should utilize it to improve their health. In contrast, the goals of health, fair financing, and responsiveness are each intrinsically valuable. Rais ing the achievement of any goal or combination of goals, without lowering the attainment of another, represents an improvement. So if the achievement of these goals can be meas- ured, then instrumental goals such as accessibility become unnecessary as proxy measures of overall performance; they are relevant rather as explanations of good or bad outcomes. It is certainly true that financing that is more fairly distributed may contribute to better alth, by reducing the risk that people who need care do not get it because it would cost too much, or that paying for health care leaves them impoverished and exposed to more health problems. And a system that is more responsive to what people want and expect can also make for better health, because potential patients are more likely to utilize care if they ticipate being treated well. Both goals therefore are partly instrumental, in that they pro- mote improvements in health status. But they would be valuable even if that did not hap- pen. That is, paying equitably for the system is a good thing in itself. So is assuring that people are treated promptly, with respect for their dignity and their wishes, and that pa tients receive adequate physical and affective support while undergoing treatment. The three goals are separable, as is often shown by people's unhappiness with a system even omparing how health systems perform means looking at what they achieve and at what they do-how they carry out certain functions-in order to achieve anything(2).These functions could be classified and related to system objectives in many different ways. For example, the"Public health in the Americas"initiative led by the Pan American Health Organization describes 12 different"essential functions", and proposes between three and six sub-functions for each one(3). Many of these functions correspond to the task of stew ardship which this report emphasizes, others to service provision and to resource genera tion. The four functions described in this chapter embrace these and other more specific activities. Figure 2.1 indicates how these functions-delivering personal and non-personal health services; raising, pooling and allocating the revenues to purchase those services investing in people, buildings and equipment; and acting as the overall stewards of the esources, powers and expectations entrusted to them- are related to one another and to the objectives of the system. Stewardship occupies a special place because it involves over- sight of all the other functions, and has direct or indirect effects on all the outcomes. Com paring the way these functions are actually carried out provides a basis for understanding
24 The World Health Report 2000 The health system differs from other social systems such as education, and from the markets for most consumer goods and services, in two ways which make the goals of fair financing and responsiveness particularly significant. One is that health care can be catastrophically costly. Much of the need for care is unpredictable, so it is vital for people to be protected from having to choose between financial ruin and loss of health. Mechanisms for sharing risk and providing financial protection are more important even than in other cases where people buy insurance, as for physical assets like homes or vehicles, or against the financial risk to the family of a breadwinner dying young. The other peculiarity of health is that illness itself, and medical care as well, can threaten people’s dignity and their ability to control what happens to them more than most other events to which they are exposed. Among other things, responsiveness means reducing the damage to one’s dignity and autonomy, and the fear and shame that sickness often brings with it. Systems are often charged to be affordable, equitable, accessible, sustainable, of good quality, and perhaps to have many other virtues as well. However, desiderata such as accessibility are really a means to an end; they are instrumental rather than final goals. The more accessible a system is, the more people should utilize it to improve their health. In contrast, the goals of health, fair financing, and responsiveness are each intrinsically valuable. Raising the achievement of any goal or combination of goals, without lowering the attainment of another, represents an improvement. So if the achievement of these goals can be measured, then instrumental goals such as accessibility become unnecessary as proxy measures of overall performance; they are relevant rather as explanations of good or bad outcomes. It is certainly true that financing that is more fairly distributed may contribute to better health, by reducing the risk that people who need care do not get it because it would cost too much, or that paying for health care leaves them impoverished and exposed to more health problems. And a system that is more responsive to what people want and expect can also make for better health, because potential patients are more likely to utilize care if they anticipate being treated well. Both goals therefore are partly instrumental, in that they promote improvements in health status. But they would be valuable even if that did not happen. That is, paying equitably for the system is a good thing in itself. So is assuring that people are treated promptly, with respect for their dignity and their wishes, and that patients receive adequate physical and affective support while undergoing treatment. The three goals are separable, as is often shown by people’s unhappiness with a system even when the health outcomes are satisfactory. Comparing how health systems perform means looking at what they achieve and at what they do – how they carry out certain functions – in order to achieve anything (2). These functions could be classified and related to system objectives in many different ways. For example, the “Public health in the Americas” initiative led by the Pan American Health Organization describes 12 different “essential functions”, and proposes between three and six sub-functions for each one (3). Many of these functions correspond to the task of stewardship which this report emphasizes, others to service provision and to resource generation. The four functions described in this chapter embrace these and other more specific activities. Figure 2.1 indicates how these functions – delivering personal and non-personal health services; raising, pooling and allocating the revenues to purchase those services; investing in people, buildings and equipment; and acting as the overall stewards of the resources, powers and expectations entrusted to them – are related to one another and to the objectives of the system. Stewardship occupies a special place because it involves oversight of all the other functions, and has direct or indirect effects on all the outcomes. Comparing the way these functions are actually carried out provides a basis for understanding
Howo Well do Health Systems Perform? performance variations over time and among countries. Some evidence about these func tions, and how they influence the attainment of the fundamental objectives in different health systems, is examined in the next four chapters In the view of most people, the health system is simply those providers and organ ons which deliver personal medical services. Defining the health system more broadly leans that the people and organizations which deliver medical care are not the whole system; rather, they exercise one of the principal functions of the system. They also share, sometimes appropriately and sometimes less so, in the other functions of financing, inves ment and stewardship. The question of who should undertake which functions is one of It is common to describe the struggle for good health in quasi-military terms, to talk of fighting"malaria or AIDS, to refer to a"campaign"of immunization or the"conquest"of mailbox, to“free area of some arms race"that constantly occurs between pathogens and the drugs to hold them in check, to hope for a"silver bullet"against cancer or diabetes. In those terms, the providers of direct health services-whether aimed at individuals, communities or the environment -can be considered the front-line troops defending society against illness. But just as with an army, the health system must be much more than the soldiers in the field if it is to win any battles Behind them is an entire apparatus to ensure that the fighters are adequately trained, in formed, financed, supplied, inspired and led. It is also crucial to treat decently the popula tion they are supposed to protect, to teach the "civilians"in the struggle how to defend themselves and their families, and to share equitably the burden of financing the war. Unless those functions are properly carried out, firepower will be much less effective than it might be, and casualties will be higher. The emphasis here on overall results and on the functions more distant from the front line does not mean any denigration of the impor- ance of disease control. It means rather to step back and consider what it is that the system as a whole is trying to do, and how well it is succeeding. Success means, among other things, more effective control of diseases, through better performance. Figure 2.1 Relations between functions and objectives of a health system Functions the system performs Objectives of the system Delivering services (investment and training
How Well do Health Systems Perform? 25 performance variations over time and among countries. Some evidence about these functions, and how they influence the attainment of the fundamental objectives in different health systems, is examined in the next four chapters. In the view of most people, the health system is simply those providers and organizations which deliver personal medical services. Defining the health system more broadly means that the people and organizations which deliver medical care are not the whole system; rather, they exercise one of the principal functions of the system. They also share, sometimes appropriately and sometimes less so, in the other functions of financing, investment and stewardship. The question of who should undertake which functions is one of the crucial issues treated in later chapters. It is common to describe the struggle for good health in quasi-military terms, to talk of “fighting” malaria or AIDS, to refer to a “campaign” of immunization or the “conquest” of smallpox, to “free” a population or a geographical area of some disease, to worry about the “arms race” that constantly occurs between pathogens and the drugs to hold them in check, to hope for a “silver bullet” against cancer or diabetes. In those terms, the providers of direct health services – whether aimed at individuals, communities or the environment – can be considered the front-line troops defending society against illness. But just as with an army, the health system must be much more than the soldiers in the field if it is to win any battles. Behind them is an entire apparatus to ensure that the fighters are adequately trained, informed, financed, supplied, inspired and led. It is also crucial to treat decently the population they are supposed to protect, to teach the “civilians” in the struggle how to defend themselves and their families, and to share equitably the burden of financing the war. Unless those functions are properly carried out, firepower will be much less effective than it might be, and casualties will be higher. The emphasis here on overall results and on the functions more distant from the front line does not mean any denigration of the importance of disease control. It means rather to step back and consider what it is that the system as a whole is trying to do, and how well it is succeeding. Success means, among other things, more effective control of diseases, through better performance. Figure 2.1 Relations between functions and objectives of a health system Stewardship (oversight) Health Responsiveness (to people's non-medical expectations) Fair (financial) contribution Creating resources (investment and training) Financing (collecting, pooling and purchasing) Functions the system performs Objectives of the system Delivering services (provision)
The World Health Report 2000 GOODNESS AND FAIRNESS BOTH LEVEL AND DISTRIBUTION MATTER A good health system, above all, contributes to good health. But it is not always satisfac- tory to protect or improve the average health of the population, if at the same time inequal ity worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce in- equalities by preferentially improving the health of the worse-off, wherever these inequa ties are caused by conditions amenable to intervention. The objective of good health really twofold: the best attainable average level-goodness -and the smallest feasible differ- ences among individuals and groups -faimess. A gain in either one of these, with no change in the other, constitutes an improvement, but the two may be in conflict. The logic is some what parallel to that concerning the distribution of income in a population. It is desirable ise the average level, to reduce inequality, or both, and sometimes to judge the relative health away from anyone -health, unlike income or nonhuman assets, cannot be direct The distinction between the overall level and how it is distributed in the population also applies to responsiveness. Goodness means the system responds well on average to what people expect of it, with respect to its non-health aspects. Fairness means that it responds equally well to everyone, without discrimination or differences in how people are treated The distribution of responsiveness matters, just as the distribution of health does Either one is valuable by itself. In contrast to the objectives of good health and responsiveness, there is no overall no- tion of goodness related to financing. There are good and bad ways to raise the resources a health system, of course, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is concerned only with distribution It is not related to the total resource bill, nor to how the funds are used. While it is unambiguously preferable to have better health or a higher level of responsive ness, it is not always better to spend more on health because at high levels of expenditure there may be little additional health gain from more resources. The objectives of the healtl system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending, the resources devoted to health have competing uses, and it is a social choice-with no correct answer-how much to allocate to the health system. Nonetheless there is probably a minimum level of expenditure required to provide a whole population with a handful of the most cost-effective services, and many poor countries are currently spending too little even to assure that(4) countries where most health financing is private, and is largely out of pocket,no one makes this choice overall: it results from millions of individual decisions as the level of prepayment rises, there are fewer and larger decisions, because spending is more and more determined by the policies and budgets of public entities and insurance funds. The public budget decision has the greatest effect in high income countries where most funding is government controlled or mandated, but in all countries it is one of the most basic public decisions. It is something that can be directly chosen, as the level of health outcome or of cannot be
26 The World Health Report 2000 GOODNESS AND FAIRNESS: BOTH LEVEL AND DISTRIBUTION MATTER A good health system, above all, contributes to good health. But it is not always satisfactory to protect or improve the average health of the population, if at the same time inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce inequalities by preferentially improving the health of the worse-off, wherever these inequalities are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness. A gain in either one of these, with no change in the other, constitutes an improvement, but the two may be in conflict. The logic is somewhat parallel to that concerning the distribution of income in a population. It is desirable to raise the average level, to reduce inequality, or both, and sometimes to judge the relative values of one and the other goal (with the difference that there is no argument for taking health away from anyone – health, unlike income or nonhuman assets, cannot be directly redistributed). The distinction between the overall level and how it is distributed in the population also applies to responsiveness. Goodness means the system responds well on average to what people expect of it, with respect to its non-health aspects. Fairness means that it responds equally well to everyone, without discrimination or differences in how people are treated. The distribution of responsiveness matters, just as the distribution of health does. Either one is valuable by itself. In contrast to the objectives of good health and responsiveness, there is no overall notion of goodness related to financing. There are good and bad ways to raise the resources for a health system, of course, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is concerned only with distribution. It is not related to the total resource bill, nor to how the funds are used. While it is unambiguously preferable to have better health or a higher level of responsiveness, it is not always better to spend more on health because at high levels of expenditure there may be little additional health gain from more resources. The objectives of the health system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending, the resources devoted to health have competing uses, and it is a social choice – with no correct answer – how much to allocate to the health system. Nonetheless there is probably a minimum level of expenditure required to provide a whole population with a handful of the most cost-effective services, and many poor countries are currently spending too little even to assure that (4). In countries where most health financing is private, and is largely out of pocket, no one makes this choice overall; it results from millions of individual decisions. As the level of prepayment rises, there are fewer and larger decisions, because spending is more and more determined by the policies and budgets of public entities and insurance funds. The public budget decision has the greatest effect in high income countries where most funding is government controlled or mandated, but in all countries it is one of the most basic public decisions. It is something that can be directly chosen, as the level of health outcome or of responsiveness cannot be
Howo Well do Health Systems Perform? MEASURING GOAL ACHIEVEMENT To assess a health system, one must measure five things: the overall level of health; the distribution of health in the population; the overall level of responsiveness; the distribution of responsiveness; and the distribution of financial contribution For each one, WHO has used existing sources or newly generated data to calculate measures of attainment for the countries where information could be obtained. These data were also used to estimate values when particular numbers were judged unreliable, and to estimate attainment and performance for all other Member States. Several of these measures are novel and are explained in detail in the Statistical Annex, where all the estimates are given, along with ntervals expressing the uncertainty or degree of confidence in the point estimate. The cor- rect value for any indicator is estimated to have an 80% probability of falling within the uncertainty interval, with chances of 10% each of falling below the low value or above the high one. This recognition of inexactness underscores the importance of getting more and better data on all the basic indicators of population health, responsiveness and faimess in financial contribution, a task which forms part of WHO's continuing programme of work. The achievements with respect to each objective are used to rank countries, as are the overall measures of achievement and performance described below. Since a given coun or health system may have very different ranks on different attainments, Annex Table shows the complete ranking for all Member States on all the measures. In several subse quent tables, countries are ranked in order of achievement or performance, and the order varies from one table to another. Since the ranking is based on estimates which include uncertainty as to the exact values, the rank assigned also includes uncertainty: a health system is not always assigned a specific position relative to all others but is estimated to lie somewhere within a narrower or broader range, depending on the uncertainties in the calculation. The ranks of different health systems therefore sometimes overlap to a greater or lesser degree, and two or more countries may have the same rank. Health is the defining objective for the health system. This means making the health status of the entire population as good as possible over people's whole life cycle, taking account of both premature mortality ar Annex Table 2 presents three conven tional and partial measures of health status, by country, without ranking: these are the probability of dying before age five years or between ages 15 and 59 years, and life expect ancy at birth. For the first time, these measures are presented with estimates of uncertainty nd these uncertainties carry over to subsequent calculations On the basis of the mortality figures, five strata are identified, ranging from low child and adult mortality to high chi mortality and very high adult death rates. Combining these strata with the six WHO Regions gives 14 subregions defined geographically and epidemiologically(see the list of Member States by WHO Region and mortality stratum) Annex Table 3 presents estimates of mortality by cause and sex in 1999 in each of these subregions(not by country), and Annex Table 4 combines these death rates with information about disability mates of one measure of overall population health: the burden of disease, that is, the num- bers of disability-adjusted life years(DALYs) lost. To assess overall population health and thus to judge how well the objective of good health is being achieved, WHO has chosen to use disability-adjusted life expectancy (ALe), which has the advantage of being directly comparable to life expectancy estimated from mortality alone and is readily compared across populations. Annex Table 5 provides esti mates for all countries of disability-adjusted life expectancy. DALE is estimated to equal or exceed 70 years in 24 countries, and 60 years in over half the Member States of WHO. At
How Well do Health Systems Perform? 27 MEASURING GOAL ACHIEVEMENT To assess a health system, one must measure five things: the overall level of health; the distribution of health in the population; the overall level of responsiveness; the distribution of responsiveness; and the distribution of financial contribution. For each one, WHO has used existing sources or newly generated data to calculate measures of attainment for the countries where information could be obtained. These data were also used to estimate values when particular numbers were judged unreliable, and to estimate attainment and performance for all other Member States. Several of these measures are novel and are explained in detail in the Statistical Annex, where all the estimates are given, along with intervals expressing the uncertainty or degree of confidence in the point estimate. The correct value for any indicator is estimated to have an 80% probability of falling within the uncertainty interval, with chances of 10% each of falling below the low value or above the high one. This recognition of inexactness underscores the importance of getting more and better data on all the basic indicators of population health, responsiveness and fairness in financial contribution, a task which forms part of WHO’s continuing programme of work. The achievements with respect to each objective are used to rank countries, as are the overall measures of achievement and performance described below. Since a given country or health system may have very different ranks on different attainments, Annex Table 1 shows the complete ranking for all Member States on all the measures. In several subsequent tables, countries are ranked in order of achievement or performance, and the order varies from one table to another. Since the ranking is based on estimates which include uncertainty as to the exact values, the rank assigned also includes uncertainty: a health system is not always assigned a specific position relative to all others but is estimated to lie somewhere within a narrower or broader range, depending on the uncertainties in the calculation. The ranks of different health systems therefore sometimes overlap to a greater or lesser degree, and two or more countries may have the same rank. Health is the defining objective for the health system. This means making the health status of the entire population as good as possible over people’s whole life cycle, taking account of both premature mortality and disability. Annex Table 2 presents three conventional and partial measures of health status, by country, without ranking: these are the probability of dying before age five years or between ages 15 and 59 years, and life expectancy at birth. For the first time, these measures are presented with estimates of uncertainty, and these uncertainties carry over to subsequent calculations. On the basis of the mortality figures, five strata are identified, ranging from low child and adult mortality to high child mortality and very high adult death rates. Combining these strata with the six WHO Regions gives 14 subregions defined geographically and epidemiologically (see the list of Member States by WHO Region and mortality stratum). Annex Table 3 presents estimates of mortality by cause and sex in 1999 in each of these subregions (not by country), and Annex Table 4 combines these death rates with information about disability to create estimates of one measure of overall population health: the burden of disease, that is, the numbers of disability-adjusted life years (DALYs) lost. To assess overall population health and thus to judge how well the objective of good health is being achieved, WHO has chosen to use disability-adjusted life expectancy (DALE), which has the advantage of being directly comparable to life expectancy estimated from mortality alone and is readily compared across populations. Annex Table 5 provides estimates for all countries of disability-adjusted life expectancy. DALE is estimated to equal or exceed 70 years in 24 countries, and 60 years in over half the Member States of WHO. At
The World Health Report 2000 the other extreme are 32 countries where disability-adjusted life expectancy is estimated to be less than 40 years. Many of these are countries with major epidemics of HiviAIds among other causes Box 2.1 describes how these summary measures of population health are constructed and how they are related Figure 2.2 summarizes the relation between DALE and life expectancy without adjust- ment, for each of the 14 subregions, for both men and women. The adjustment is nearly uniform, at about seven years of healthy life equivalent lost to disability. Both absolute and relatively this loss is slightly less for richer, low-mortality subregions, despite the fact that people live longer there and so have more opportunity to acquire non-fatal disabilities Disability makes a substantial difference in poorer countries because some limitations injury, blindness, paralysis and the debilitating effects of several tropical diseases such as malaria and shistosomiasis-strike children and young adults. Separating life expectancy into years in good health and years lived with disability therefore widens rather than nar- rows the difference in health status between richer and poorer populations. This is most evident in the share of life expectancy which is lost to disability: it ranges from less than 9% in the healthiest subregions to more than 14% in the least healthy. Annex Table 5 shows these shares for individual countries, where the range is even wider. Annex Table 5 also provides estimates of health inequality. The distributional measure of health ranges from 1 for the case of perfect equality to zero for extreme inequality, which corresponds to a fraction of the population having an expectancy of 100 years and the rest Box 2. 1 Summary measures of population health population; each way of estimating it violates ono ming up the health of a vival plus part of that for disability No measure is perfect for the purpose of sumI or another desirable cri- DALE is estimated from three kinds of information the fraction of the ion. The two principal approaches are the burden of disease, which meas- population surviving to each age, calculated from birth and death rates ures losses of good health compared to a long life free of disability, and the prevalence of each type of disability at each age; and the weight as- some measure of life expectancy, adjusted to take account of time lived signed to each type of disability, which may or may not vary with age. with a disability. Both ways of summarizing health use the same informa- Survival at each age is adjusted downward by the sum of all the disabi tion about mortality and disability, and Summarizing population health from mortality ffects, each of which is the product of a and disabil ight and the complement of a preva- curve, such as the bold line between 1 lence(the share of the population not suf- the areas labelled Disability and Mor- fering that disability). These adjusted survival shares are then divided by the The area labelled Mortality repre- initial population, before any mortality sents losses due to death, compared ccurred, to give the average number of to a high standard of life expectancy uivalent healthy life years that a new- the burden of disease corresponds to born member of the population could ex all of that area plus a fraction of the a ect to live. One important difference between the disability. Ihe fraction depends on the 8 burden of disease estimation using dis- disability weights assigned to various rs(DALYs)and that states between death and perfect of dale is that the former do but the lat- health. Life expectancy without any ter do not, distinguish the contribution of adjustment corresponds to the areas each diseaseto the overall result dale has I free of disability an Survival free of disabil Disability together, the whole area many choices of parameters for the cal- under the survivorship curve Disabil- culation, and it is directly comparable to ity-adjusted life expectancy(DALE) the more familiar notion of life expectancy then corresponds to the area for sur- 0 Source: Murray CJL, Salomon JA, Mathers CA critical examination of summary measures of population health. Geneva, World Health Organization, 1999(GPE Disaussion paper No. 1
28 The World Health Report 2000 the other extreme are 32 countries where disability-adjusted life expectancy is estimated to be less than 40 years. Many of these are countries with major epidemics of HIV/AIDS, among other causes. Box 2.1 describes how these summary measures of population health are constructed and how they are related. Figure 2.2 summarizes the relation between DALE and life expectancy without adjustment, for each of the 14 subregions, for both men and women. The adjustment is nearly uniform, at about seven years of healthy life equivalent lost to disability. Both absolutely and relatively this loss is slightly less for richer, low-mortality subregions, despite the fact that people live longer there and so have more opportunity to acquire non-fatal disabilities. Disability makes a substantial difference in poorer countries because some limitations – injury, blindness, paralysis and the debilitating effects of several tropical diseases such as malaria and shistosomiasis – strike children and young adults. Separating life expectancy into years in good health and years lived with disability therefore widens rather than narrows the difference in health status between richer and poorer populations. This is most evident in the share of life expectancy which is lost to disability: it ranges from less than 9% in the healthiest subregions to more than 14% in the least healthy. Annex Table 5 shows these shares for individual countries, where the range is even wider. Annex Table 5 also provides estimates of health inequality. The distributional measure of health ranges from 1 for the case of perfect equality to zero for extreme inequality, which corresponds to a fraction of the population having an expectancy of 100 years and the rest Box 2.1 Summary measures of population health No measure is perfect for the purpose of summing up the health of a population; each way of estimating it violates one or another desirable criterion. The two principal approaches are the burden of disease, which measures losses of good health compared to a long life free of disability, and some measure of life expectancy, adjusted to take account of time lived with a disability. Both ways of summarizing health use the same information about mortality and disability, and both are related to a survivorship curve, such as the bold line between the areas labelled Disability and Mortality in the figure. The area labelled Mortality represents losses due to death, compared to a high standard of life expectancy: the burden of disease corresponds to all of that area plus a fraction of the area corresponding to time lived with disability. The fraction depends on the disability weights assigned to various states between death and perfect health. Life expectancy without any adjustment corresponds to the areas labelled Survival free of disability and Disability together, the whole area under the survivorship curve. Disability-adjusted life expectancy (DALE) then corresponds to the area for survival plus part of that for disability. DALE is estimated from three kinds of information: the fraction of the population surviving to each age, calculated from birth and death rates; the prevalence of each type of disability at each age; and the weight assigned to each type of disability, which may or may not vary with age. Survival at each age is adjusted downward by the sum of all the disability effects, each of which is the product of a weight and the complement of a prevalence (the share of the population not suffering that disability). These adjusted survival shares are then divided by the initial population, before any mortality occurred, to give the average number of equivalent healthy life years that a newborn member of the population could expect to live. One important difference between the burden of disease estimation using disability-adjusted life years (DALYs) and that of DALE is that the former do, but the latter do not, distinguish the contribution of each disease to the overall result. DALE has the advantage that it does not require as many choices of parameters for the calculation, and it is directly comparable to the more familiar notion of life expectancy without adjustment. Source: Murray CJL, Salomon JA, Mathers C. A critical examination of summary measures of population health. Geneva, World Health Organization, 1999 (GPE Discussion paper No. 12). Summarizing population health from mortality and disability Age Percentage surviving Mortality Disability Survival free of disability 0 100
Howo Well do Health Systems Perform? If everyone had the same life for disability, the system would be perfectly fair with respect to health, even though people would actually die at different ages. For a small number of countries it has been possible to estimate the distribution of life expectancy within the population using information on both child 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 75 Male life expectancy The dotted line represents a situation of no time lived with disability, so that life expectancy and disability-adjusted life expectancy coincide. 55 WHo Mortality stratum Males Females Region Child Life expectancy Disability adjusted Life expectancy Disability adjusted 446 470 ry low 74 610 70.7 633 62.3 EUR Very low Very low SEA WPR ry low Very low 680
How Well do Health Systems Perform? 29 having no expectation of surviving infancy. If everyone had the same life expectancy, adjusted for disability, the system would be perfectly fair with respect to health, even though people would actually die at different ages. For a small number of countries it has been possible to estimate the distribution of life expectancy within the population using information on both child Mortality stratum Males Females Region Child Adult Life expectancy Disability adjusted Life expectancy Disability adjusted AFR High High 52.0 44.6 54.9 47.0 High Very high 45.6 38.0 48.0 40.0 AMR Very low Very low 73.9 67.5 80.4 73.2 Low Low 67.3 60.6 74.1 66.8 High High 63.6 56.7 68.6 61.1 EMR Low Low 67.7 61.0 70.7 63.3 High High 60.0 53.0 62.3 54.7 EUR Very low Very low 74.5 68.1 80.8 73.7 Low Low 67.3 60.6 73.9 66.6 Low High 62.3 55.4 73.4 66.1 SEAR Low Low 67.2 60.5 73.1 65.7 High High 62.6 55.7 64.0 56.4 WPR Very low Very low 76.7 70.3 82.7 75.6 Low Low 68.0 61.3 72.3 65.0 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 35 40 45 50 55 60 65 70 75 80 40 45 50 55 60 65 70 75 80 85 Disability-adjusted life expectancy at birth (years) Life expectancy at birth (years) Male life expectancy Female life expectancy WHO The dotted line represents a situation of no time lived with disability, so that life expectancy and disability-adjusted life expectancy coincide
The World Health Report 2000 and adult mortality; these results are presented below. For most countries, however, it has so far been possible to use only child mortality data. Because high-income countries have largely eliminated child mortality, the highest ranking countries in Annex Table 5 nearly all have relatively high incomes; most are European. A few Latin American countries which Figure 2.3 Inequality in life expectancy at birth, by sex, in six countries Australia 1992 Chile 1993 出 0 Life expectancy at birth(years) Japan 1990 Mexico 1993 40 Females Females Life expectancy at birth(years) Norway 1996 USA 1990 Males 20 Life expectancy at birth (years) Life expectancy at birth(years)
30 The World Health Report 2000 and adult mortality; these results are presented below. For most countries, however, it has so far been possible to use only child mortality data. Because high-income countries have largely eliminated child mortality, the highest ranking countries in Annex Table 5 nearly all have relatively high incomes; most are European. A few Latin American countries which 54 60 66 72 78 84 90 0 10 20 30 40 50 Percentage of population Life expectancy at birth (years) Mexico 1993 54 60 66 72 78 84 90 0 10 20 30 40 50 Percentage of population Life expectancy at birth (years) Males Females Australia 1992 54 60 66 72 78 84 90 0 10 20 30 40 50 Percentage of population Life expectancy at birth (years) USA 1990 54 60 66 72 78 84 90 0 10 20 30 40 50 Percentage of population Life expectancy at birth (years) Japan 1990 54 60 66 72 78 84 90 0 10 20 30 40 50 Percentage of population Life expectancy at birth (years) Chile 1993 54 60 66 72 78 84 90 0 10 20 30 40 50 Percentage of population Life expectancy at birth (years) Norway 1996 Figure 2.3 Inequality in life expectancy at birth, by sex, in six countries Males Females Males Females Males Females Males Females Males Females
Howo Well do Health Systems Perform? have made great progress in controlling child deaths also show considerable equality of health. Except for Afghanistan and Pakistan, all the countries ranked lowest on child health equality are in sub-Saharan Africa, where child mortality is still relatively high. When more complete data are available on inequalities in adult mortality they will be used in future WHO estimates, and these rankings will change, because high income countries differ more in adult than in child death rates Inequalities in life expectancy persist, and are strongly associated with socioeconomic class, even in countries with quite good health status on average(5). Figure 2.3 illustrates these inequalities for six countries, showing the distribution of life expectancy at birth for both men and women, using data on adult as well as child mortality, estimated from large numbers of small-area studies which cover the entire country. Among these six countries, health is most equally distributed in Japan. Both distributions of life expectancy are sharply peaked, concentrating the whole population of either men or women in a range of only about six years. There is far more inequality in Mexico and in the United States, and in both cases that arises because part of the population has a much lower expectation than the rest, after age five years. The inequality is particularly marked for men. An opposite pattern characterizes Chile, which shows very high equality in child health: the degree of adult inequality is about the same as for Mexico and the United States, but it arises because part of the population has an unusually high life expectancy. Australia and Norway both show more symmetric distributions. These results emphasize the value of judging health syste achievement not only by averages or overall levels but by seeing whether everyone has about the same expectation of life Responsiveness is not a measure of how the system responds to health needs, which shows up in health outcomes, but of how the system performs relative to non-health as- pects, meeting or not meeting a populations expectations of how it should be treated by providers of prevention, care or non-personal services. (The last category is least important, owever even r people and their wishes. Assessing the responsiveness of providers of personal services is a particular challenge. Some systems are highly unresponsive. The Soviet health system prior to 1990 had become highly impersonal and inhuman in the way it processed people. A common com- plaint in many countries about public sector health workers focuses on their rudeness and arrogance in relations with patients(6, 7). Waiting times for non-emergency surgery vary considerably among industrialized countries (8)and are the subject of much criticism of ministries of health(9). Recognizing responsiveness as an intrinsic goal of health systems establishes that these systems are there to serve people, and involves more than an assess ment of people' s satisfaction with the purely medical care they receive The general notion of responsiveness can be decomposed in many ways. One basic distinction is between elements related to respect for human beings as persons-which are largely subjective and judged primarily by the patient -and more objective elements re- lated to how a system meets certain commonly expressed concerns of patients and their families as clients of health systems, some of which can be directly observed at health facilities. Subdividing these two categories leads to seven distinct elements or aspects of
How Well do Health Systems Perform? 31 have made great progress in controlling child deaths also show considerable equality of health. Except for Afghanistan and Pakistan, all the countries ranked lowest on child health equality are in sub-Saharan Africa, where child mortality is still relatively high. When more complete data are available on inequalities in adult mortality they will be used in future WHO estimates, and these rankings will change, because high income countries differ more in adult than in child death rates. Inequalities in life expectancy persist, and are strongly associated with socioeconomic class, even in countries with quite good health status on average (5). Figure 2.3 illustrates these inequalities for six countries, showing the distribution of life expectancy at birth for both men and women, using data on adult as well as child mortality, estimated from large numbers of small-area studies which cover the entire country. Among these six countries, health is most equally distributed in Japan. Both distributions of life expectancy are sharply peaked, concentrating the whole population of either men or women in a range of only about six years. There is far more inequality in Mexico and in the United States, and in both cases that arises because part of the population has a much lower expectation than the rest, after age five years. The inequality is particularly marked for men. An opposite pattern characterizes Chile, which shows very high equality in child health: the degree of adult inequality is about the same as for Mexico and the United States, but it arises because part of the population has an unusually high life expectancy. Australia and Norway both show more symmetric distributions. These results emphasize the value of judging health system achievement not only by averages or overall levels but by seeing whether everyone has about the same expectation of life. Responsiveness is not a measure of how the system responds to health needs, which shows up in health outcomes, but of how the system performs relative to non-health aspects, meeting or not meeting a population’s expectations of how it should be treated by providers of prevention, care or non-personal services. (The last category is least important, since individuals normally do not come into personal contact with such interventions. However, even public health measures such as vector control can be conducted with more or less respect for people and their wishes. Assessing the responsiveness of providers of non-personal services is a particular challenge.) Some systems are highly unresponsive. The Soviet health system prior to 1990 had become highly impersonal and inhuman in the way it processed people. A common complaint in many countries about public sector health workers focuses on their rudeness and arrogance in relations with patients (6, 7). Waiting times for non-emergency surgery vary considerably among industrialized countries (8) and are the subject of much criticism of ministries of health (9). Recognizing responsiveness as an intrinsic goal of health systems establishes that these systems are there to serve people, and involves more than an assessment of people’s satisfaction with the purely medical care they receive. The general notion of responsiveness can be decomposed in many ways. One basic distinction is between elements related to respect for human beings as persons – which are largely subjective and judged primarily by the patient – and more objective elements related to how a system meets certain commonly expressed concerns of patients and their families as clients of health systems, some of which can be directly observed at health facilities. Subdividing these two categories leads to seven distinct elements or aspects of responsiveness
