Overview In short, how health systems-and the estimated 35 million or more people they em ploy worldwide-perform makes a profound difference to the quality and value, as well as the length of the lives of the billions of people they serve. HOW HEALTH SYSTEMS HAVE EVOLVED This reports review of the evolution of modern health systems, and their various stages reform, leaves little doubt that in general they have already contributed enormously to better health for most of the global population during the 20th century Today, health systems in all countries, rich and poor, play a bigger and more influential role in people' s lives than ever before. Health systems of some sort have existed for as long as people have tried to protect their health and treat diseases. Traditional practices, often integrated with spiritual counselling and providing both preventive and curative care, have existed for thousands of years and often coexist today with modern medicine But 100 years ago, organized health systems in the modern sense barely existed. Few people alive then would ever visit a hospital. Most were bom into large families and faced an infancy and childhood threatened by a host of potentially fatal diseases-measles, small- pox, malaria and poliomyelitis among them. Infant and child mortality rates were very high, as were maternal mortality rates. Life expectancy was short-even half a century ago it was a mere 48 years at birth. Birth itself invariably occurred at home, rarely with a physi clan present. As a brief illustration of the contemporary role of health systems, one particular birth receives special attention in this report. Last year, United Nations experts calculated that the global population would reach six billion on 13 October 1999. On that day, in a mater- nity clinicin Sarajevo, a baby boy was designated as the sixth billionth person on the planet He entered the world with a life expectancy of 73 years, the current Bosnian average He was born in a big city hospital, staffed by well-trained midwives, nurses, doctors and technicians. They were supported by high-technology equipment, drugs and medicines The hospital is part of a sophisticated health service, connected in turn to a wide network of people and actions that in one way or another are concemed with measuring, maintaining and improving his health for the rest of his life -as for the rest of the population. Together, all these interested parties, whether they provide services, finance them or set policies to administer them, make up a health system. Health systems have undergone overlapping generations of reforms in the past 100 years, including the founding of national health care systems and the extension of social insurance schemes. Later came the promotion of primary health care as a route to achiev- affordable universal coverage-the goal of health for all. Despite its many virtues, criticism of this route has been that it gave too little attention to peoples demand for health care, and instead concentrated almost exclusively on their perceived needs. Systems have foundered when these two concepts did not match, because then the supply of services offered could not possibly align with both In the past decade or so there has been a gradual shift of vision towards what WHO calls the"new universalism" Rather than all possible care for everyone, or only the simplest and most basic care for the poor, this means delivery to all of high-quality essential care, defined mostly by criteria of effectiveness, cost and social acceptability. It implies explicit choice of priorities among interventions, respecting the ethical principle that it may be necessary and efficient to ration services, but that it is inadmissible to exclude whole groups of the popuOverview xiii In short, how health systems – and the estimated 35 million or more people they em￾ploy worldwide – perform makes a profound difference to the quality and value, as well as the length of the lives of the billions of people they serve. HOW HEALTH SYSTEMS HAVE EVOLVED This report’s review of the evolution of modern health systems, and their various stages of reform, leaves little doubt that in general they have already contributed enormously to better health for most of the global population during the 20th century. Today, health systems in all countries, rich and poor, play a bigger and more influential role in people’s lives than ever before. Health systems of some sort have existed for as long as people have tried to protect their health and treat diseases. Traditional practices, often integrated with spiritual counselling and providing both preventive and curative care, have existed for thousands of years and often coexist today with modern medicine. But 100 years ago, organized health systems in the modern sense barely existed. Few people alive then would ever visit a hospital. Most were born into large families and faced an infancy and childhood threatened by a host of potentially fatal diseases – measles, small￾pox, malaria and poliomyelitis among them. Infant and child mortality rates were very high, as were maternal mortality rates. Life expectancy was short – even half a century ago it was a mere 48 years at birth. Birth itself invariably occurred at home, rarely with a physi￾cian present. As a brief illustration of the contemporary role of health systems, one particular birth receives special attention in this report. Last year, United Nations experts calculated that the global population would reach six billion on 13 October 1999. On that day, in a mater￾nity clinic in Sarajevo, a baby boy was designated as the sixth billionth person on the planet. He entered the world with a life expectancy of 73 years, the current Bosnian average. He was born in a big city hospital, staffed by well-trained midwives, nurses, doctors and technicians. They were supported by high-technology equipment, drugs and medicines. The hospital is part of a sophisticated health service, connected in turn to a wide network of people and actions that in one way or another are concerned with measuring, maintaining and improving his health for the rest of his life – as for the rest of the population. Together, all these interested parties, whether they provide services, finance them or set policies to administer them, make up a health system. Health systems have undergone overlapping generations of reforms in the past 100 years, including the founding of national health care systems and the extension of social insurance schemes. Later came the promotion of primary health care as a route to achiev￾ing affordable universal coverage – the goal of health for all. Despite its many virtues, a criticism of this route has been that it gave too little attention to people’s demand for health care, and instead concentrated almost exclusively on their perceived needs. Systems have foundered when these two concepts did not match, because then the supply of services offered could not possibly align with both. In the past decade or so there has been a gradual shift of vision towards what WHO calls the “new universalism”. Rather than all possible care for everyone, or only the simplest and most basic care for the poor, this means delivery to all of high-quality essential care, defined mostly by criteria of effectiveness, cost and social acceptability. It implies explicit choice of priorities among interventions, respecting the ethical principle that it may be necessary and efficient to ration services, but that it is inadmissible to exclude whole groups of the popu￾lation