Message from the Director-General
What 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 pressure 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 between a well- performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation 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 recommendations 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 systems 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.
The report breaks new ground in the way that it helps us understand the goals of health systems. Clearly, their defining purpose is to improve and protect health - but they have other intrinsic goals. These are concerned with fairness in the way people pay for health care, and with how systems respond to people's expectations with regard to how they are treated. Where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities, in ways that improve the situation of the worst-off. In this report attainment in relation to these goals provides the basis for measuring the performance of health systems.
If policy-makers are to act on measures of performance, they need a clear understanding of the key functions that health systems have to undertake. The report defines four key functions: providing services; generating the human and physical resources that make service delivery possible; raising and pooling the resources used to pay for health care; and, most critically, the function of stewardship - setting and enforcing the rules of the game and providing strategic direction for all the different actors involved.
Undoubtedly, many of the concepts and measures used in the report require further refinement and development. To date, our knowledge about health systems has been hampered by the weakness of routine information systems and insufficient attention to research. This report has thus required a major effort to assemble data, collect new information, and carry out the required analysis and synthesis. It has also drawn on the views of a large number of respondents, within and outside WHO, concerning the interpretation of data and the relative importance of different goals.
The material in this report cannot provide definitive answers to every question about health systems performance. It does though bring together the best available evidence to date. It demonstrates that, despite the complexity of the topic and the limitations of the data, it is possible to get a reasonable approximation of the current situation, in a way that provides an exciting agenda for future work.
I hope that the report will contribute to work on how to assess and improve health systems. Performance assessment allows policy- makers, health providers and the population at large to see themselves in terms of the social arrangements they have constructed to improve health. It invites reflection on the forces that shape performance and the actions that can improve it.
For WHO, The world health report 2000 is a milestone in a long- term process. The measurement of health systems performance will be a regular feature of all World health reports from now on -using improved and updated information and methods as they are developed.
Even though we are at an early stage in understanding a complex set of interactions, some important conclusions are clear.
- Ultimate responsibility for the performance of a 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. The health of people is always a national priority: government responsibility for it is continuous and permanent.
- 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.
- Health systems are not just concerned with improving people's health but with protecting them against the financial costs of illness. The challenge facing 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 expenditures.
- Within governments, many health ministries focus on the public sector often 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 markets.
- Stewardship is ultimately concerned with oversight of the entire system, avoiding myopia, tunnel vision and the turning of a blind eye to a system's failings. This report is meant to make that task easier by bringing new evidence into sharp focus.
In conclusion, I hope this report will help policy-makers to make wise choices. If they do so, substantial gains will be possible for all countries, and the poor will be the principal beneficiaries.