In 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.

• measuring the health system's contribution to socially desirable goals;
• measuring the health system and non-health system resources used to achieve these outcomes;
• 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 and efficiency;
• designing and implementing policies to improve attainment and efficiency and monitoring the effect.

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.

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 goals.

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.