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 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 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 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 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 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’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