a health system?
|The system includes all actors,
institutions and resources that undertake health actions – where a
health action is one where the primary intent is to improve health.
Although the defining goal of a health system is to improve population
health, other intrinsic goals are to be responsive to the population they
serve, determined by the way and the environment in which people are
treated, and to ensure that the financial burden of paying for health is
fairly distributed across households. Four key functions determine the way
inputs are transformed into outcomes that people value – resource
generation, financing, service provision and stewardship.
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What is health systems performance?
|The health of people is always a national priority:
government responsibility for it is continuous and permanent. How well a health system performs depends on how well it achieves the goals for
which it should be held accountable. The World Health Report
2000 defined three goals for health systems: good health, responsiveness
to the expectations of the population, and fair financial contribution. Health systems are not just concerned with improving
people's health but with protecting them against the financial costs of illness. The
challenge for 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 expenditure. Within governments,
many health ministries focus on the public sector, 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
These goals, however, do not explain the reasons for good or poor performance, or suggest
what to do. 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. To explain the reasons
behind good or poor performance, one needs to look at how well a health system is carrying
out its different tasks. The WHR 2000 presents four vital functions: service
provision, resource generation, financing, and stewardship. Ultimate responsibility for performance of the 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. Stewardship
is ultimately concerned with oversight of the entire system, avoiding myopia, tunnel
vision and turning a blind eye to a system's failings. The WHR 2000 is meant to
make that task easier by bringing new evidence into sharp focus.
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Why assess health systems performance?
|The purpose of health system performance
assessment is to empower decision makers by providing them with reliable information for
policy and system development, and to empower the public with information relevant to
their well-being. WHO's work aims to support the development of systematic ways to
monitor performance in countries, in a way that allows comparison across time within
individual systems, across different levels of a system, and between health systems.
most countries, policy-makers and the general public are vitally concerned about their
health systems whether they are performing as well as they could, and how they
could do better. Many different types of reforms and policies aimed at improving
performance have been introduced over the last decades in countries in all regions of the
world, at all levels of development. Yet the evidence about what works and what does not
is limited and mixed, and the debate about appropriate health system development is often
led more by ideology than by evidence. One of the most important roles of WHO is to assist
its Member States, as requested, to develop strategies and policies to improve the
performance of their health systems. To do this, it is critical to build the scientific
basis to ensure that its technical advice is based on the best available evidence.
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What is health systems performance assessment?
|The term health system performance
assessment describes a series of activities including
- measuring the health system's contribution to socially desirable goals;
- measuring the health system and non-health system resources used to achieve these
- estimating the efficiency with which the resources are used to attain these outcomes;
- evaluating the way the functions of the system influence observed levels of attainment
- designing and implementing policies to improve attainment and efficiency and monitoring
To enable countries to monitor their own performance and to modify their policies as
necessary it is important to be able to measure and compare performance over time. To
enable countries to learn from the experience of others, it is necessary to be able to
compare performance across settings thereby identifying what types of policies have been
associated with high performance.
Performance assessment and comparison is not new. Countries and international agencies
routinely report estimates of life expectancy, GDP and health expenditures, for example.
The World Health Report 2000 presented a new framework for assessing health
system performance, but the approach builds on the work of many other people and agencies,
and existing reporting exercises.
With the framework, WHO is trying to set out a more comprehensive, explicit and
systematic basis for making comparisons over time within a country and across settings.
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What is the WHO
Health System Performance Assessment framework?
|The essential concepts underpinning the
health system performance assessment framework are set out below. For each concept, a
short definition and the main points of debate are identified. This link will take you to a list of debates by topic.
Health system boundaries
A first step in assessing performance is to define the boundaries of the health
system. There are a number of competing concepts of a health system, which range from very
narrow (activities under the control of the Ministry of Health) to very inclusive (all
actions that contribute to improving health). The WHO framework defines a health system by
using the concept of a health action. A health system includes all actions whose
primary purpose is to promote, restore or maintain health.
Goals Health systems should contribute to a number of socially desirable
goals, which they achieve to a greater or lesser extent. Three goals are defined in the
WHO framework: improving health, enhancing responsiveness to the legitimate non-health
expectations of the population, and assuring fairness in financial contribution. Within
health and responsiveness, people are concerned with the level attained and with
inequalities. Considerable debate has focused on the appropriateness of these three goals,
on how to measure them, and on the question of causal attribution. Follow this link for
further reading on the debates surrounding health system
Health system efficiency Health systems with the same level of resources
are observed to have very different levels of attainment. The WHO framework proposes a way
to examine how well a health system is doing, given the resources available to it. This is
the concept of health system efficiency. Efficiency can be measured in terms of the
system's contribution to health alone, or to a composite index of goal attainment. In
each case outcomes are related to the resources used to achieve them. Follow this link for
further reading on the debates surrounding efficiency
and overall performance.
Health system functions Variation in efficiency is related to the way a
health system carries out four core functions: provision; financing; resource generation
and stewardship. To understand this relationship, greater understanding is required about
a range of mediating factors and the context in which the system operates. There has been
considerable debate about what these mediating factors are and how they can be measured.
The effective coverage of a set of critical health interventions is an important one. A
major effort to monitor coverage of critical interventions is now beginning, as well as to
define indicators of the organization and performance of functions and how they effect
outcomes. Follow these links for further reading on the debates surrounding health system functions or intermediate goals.
Enhancing the policy relevance of health system performance assessment
Since the publication of the WHR2000, the regional consultations have argued that the
links between the measurement of performance and the development of policy requires
strengthening. In addition, a substantial number of countries expressed interest in active
collaboration with WHO to assess the performance of their own systems and to use the
evidence to formulate policies to improve performance. To meet the country requests, the
Director-General decided to group these efforts under the rubric of the Enhancing Health Systems Performance Initiative (EHSPI) which we also
propose to use to meet the suggestions of the regional consultations.
For more on the concepts, methods and debates regarding
health systems performance, click here. For more information on
WHO's current work on HSP, click
here. To learn more about the extensive peer review and
consultation process, click here.
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What is the purpose of this website?
|This web site aims to inform and facilitate
debate about how to assess and improve the performance of health systems. It provides
access to the wide range of information, debate and new work that has been generated since
the release of the World Health Report 2000, as well as providing links to other relevant
websites and tools. Back to