OVERVIEW day and every day, the lives of vast numbers of people lie in the hands of health systems. From the safe delivery of a healthy baby to the care with dignity of the frail elderly, health systems have a vital and continuing responsibility to people throughou the lifespan. They are crucial to the healthy development of individuals, families and socie- ties everywhere In this report, health systems are defined as comprising all the organizations, institu ns and resources that are devoted to producing health actions. a health action is defined as any effort, whetherin personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health. But while improving health is clearly the main objective of a health system, it is not the only one. The objective of good health itself is really twofold: the best attainable average level - goodness-and the smallest feasible differences among individuals and groups faimess. Goodness means a health system responding well to what people expect of it; fairness it responds equally well to everyone, without discrimination. In The world health report 2000, devoted entirely to health systems, the World Health Organization ex- pands its traditional concen for people,'s physical and mental well-being to emphasize these other elements of goodness and fairness To an unprecedented degree, it takes account of the roles people have as providers and consumers of health services, as financial contributors to health systems, as workers within them, and as citizens engaged in the responsible management, or stewardship, of them And it looks at how well or how badly systems address inequalities, how they respond people' s expectations, and how much or how little they respect people's dignity, rights and The world health report 2000 also breaks new ground in presenting for the first time an dex of national health systems performance in trying to achieve three overall goals: goo health, responsiveness to the expectations of the population, and faimess of financial contribution Progress towards them depends crucially on how well systems carry out four vital func tions. These are: service provision, resource generation, financing and stewardship. The report devotes a chapter to each function, and reaches conclusions and makes policy recommen dations on each. It places special emphasis on stewardship, which has a profound influence the other three Many questions about health system performance have no clear or simple answers because outcomes are hard to measure and it is hard to disentangle the health system's contribution from other factors. Building on valuable previous work, this report introduces WHOs framework for assessing health system performance. By
Overview xi OVERVIEW oday and every day, the lives of vast numbers of people lie in the hands of health systems. From the safe delivery of a healthy baby to the care with dignity of the frail elderly, health systems have a vital and continuing responsibility to people throughout the lifespan. They are crucial to the healthy development of individuals, families and societies everywhere. In this report, health systems are defined as comprising all the organizations, institutions and resources that are devoted to producing health actions. A health action is defined as any effort, whether in personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health. But while improving health is clearly the main objective of a health system, it is not the only one. The objective of good health itself is really twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness. Goodness means a health system responding well to what people expect of it; fairness means it responds equally well to everyone, without discrimination. In The world health report 2000, devoted entirely to health systems, the World Health Organization expands its traditional concern for people’s physical and mental well-being to emphasize these other elements of goodness and fairness. To an unprecedented degree, it takes account of the roles people have as providers and consumers of health services, as financial contributors to health systems, as workers within them, and as citizens engaged in the responsible management, or stewardship, of them. And it looks at how well or how badly systems address inequalities, how they respond to people’s expectations, and how much or how little they respect people’s dignity, rights and freedoms. The world health report 2000 also breaks new ground in presenting for the first time an index of national health systems’ performance in trying to achieve three overall goals: good health, responsiveness to the expectations of the population, and fairness of financial contribution. Progress towards them depends crucially on how well systems carry out four vital functions. These are: service provision, resource generation, financing and stewardship. The report devotes a chapter to each function, and reaches conclusions and makes policy recommendations on each. It places special emphasis on stewardship, which has a profound influence on the other three. Many questions about health system performance have no clear or simple answers – because outcomes are hard to measure and it is hard to disentangle the health system’s contribution from other factors. Building on valuable previous work, this report introduces WHO’s framework for assessing health system performance. By clarifying and quantifying
The World Health Report the goals of health systems and relating them to the essential functions, the framework is meant to help Member States measure their own performance, understand the factors that contribute to it, improve it, and respond better to the needs and expectations of the people they serve and represent The analysis and synthesis of a wealth of information is summa- rized by a measure of overall achievement and by a performance index which should lead to much new research and policy development. The index will be a regular feature of forth coming World health reports and will be improved and updated every year. The framework was the basis for round table discussions entitled"Addressing the major health system challenges"among Ministers of Health at the 53rd World Health Assembly in Geneva in May 2000. The subject of these discussions is reflected throughout the report, and the outcome of the discussions will help orient future work on the framework. Policy-makers need to know why health systems perform in certain ways and what they can do to improve the situation. All health systems carry out the functions of providing or delivering personal and non-personal health services; generating the necessary human and physical resources to make that possible; raising and pooling the revenues used to purchase services; and acting as the overall stewards of the resources, powers and expect tions entrusted to them Comparing the way these functions are actually carried out provides a basis for under- standing performance variations over time and among countries. Undoubtedly, many of the concepts and measures used in the report will require refinement. There is an impor tant agenda of developing more and better data on goal attainment and on health system functions. Yet much can be learned from existing information. The report presents the best available evidence to date. In doing so, it seeks to push forward national and global devel opment of the skills and information required to build a solid body of evidence on the level and determinants of performance, as a basis for improving how systems work. Improving performance"are therefore the key words and the raison d'etre of this report The overall mission of WHO is the attainment by all people of the highest possible level of ganization,'s ability to fulfil this mission depends greatly on the effectiveness of health sys- tems in Member States-and strengthening those systems is one of WHOs four strategic directions. It connects very well with the other three: reducing the excess mortality of poor and marginalized populations; dealing effectively with the leading risk factors; and placing health at the centre of the broader development agenda. pregnancy are all WHO priorities. But the Organization will have very little impact in these and other battlegrounds unless it is equally concerned to strengthen the health systems through which the ammunition of life-saving and life-enhancing interventions are deliv- This report asserts that the differing degrees of efficiency with which health system organize and finance themselves, and react to the needs of their populations, explain much of the widening gap in death rates between the rich and poor, in countries and between countries, around the world. Even among countries with similar income levels, there are unacceptably large variations in health outcomes. The report finds that inequalities in life expectancy persist, and are strongly associated with socioeconomic class, even in countries that enjoy an average of quite good health. Furthermore the gap between rich and poor widens when life expectancy is divided into years in good health and years of disability. In effect, the poor not only have shorter lives than the non-poor, a bigger part of their lifetime is surrendered to disability
xii The World Health Report 2000 the goals of health systems and relating them to the essential functions, the framework is meant to help Member States measure their own performance, understand the factors that contribute to it, improve it, and respond better to the needs and expectations of the people they serve and represent. The analysis and synthesis of a wealth of information is summarized by a measure of overall achievement and by a performance index which should lead to much new research and policy development. The index will be a regular feature of forthcoming World health reports and will be improved and updated every year. The framework was the basis for round table discussions entitled “Addressing the major health system challenges” among Ministers of Health at the 53rd World Health Assembly in Geneva in May 2000. The subject of these discussions is reflected throughout the report, and the outcome of the discussions will help orient future work on the framework. Policy-makers need to know why health systems perform in certain ways and what they can do to improve the situation. All health systems carry out the functions of providing or delivering personal and non-personal health services; generating the necessary human and physical resources to make that possible; raising and pooling the revenues used to purchase services; and acting as the overall stewards of the resources, powers and expectations entrusted to them. Comparing the way these functions are actually carried out provides a basis for understanding performance variations over time and among countries. Undoubtedly, many of the concepts and measures used in the report will require refinement. There is an important agenda of developing more and better data on goal attainment and on health system functions. Yet much can be learned from existing information. The report presents the best available evidence to date. In doing so, it seeks to push forward national and global development of the skills and information required to build a solid body of evidence on the level and determinants of performance, as a basis for improving how systems work. “Improving performance” are therefore the key words and the raison d’être of this report. The overall mission of WHO is the attainment by all people of the highest possible level of health, with special emphasis on closing the gaps within and among countries. The Organization’s ability to fulfil this mission depends greatly on the effectiveness of health systems in Member States – and strengthening those systems is one of WHO’s four strategic directions. It connects very well with the other three: reducing the excess mortality of poor and marginalized populations; dealing effectively with the leading risk factors; and placing health at the centre of the broader development agenda. Combating disease epidemics, striving to reduce infant mortality, and fighting for safer pregnancy are all WHO priorities. But the Organization will have very little impact in these and other battlegrounds unless it is equally concerned to strengthen the health systems through which the ammunition of life-saving and life-enhancing interventions are delivered to the front line. This report asserts that the differing degrees of efficiency with which health systems organize and finance themselves, and react to the needs of their populations, explain much of the widening gap in death rates between the rich and poor, in countries and between countries, around the world. Even among countries with similar income levels, there are unacceptably large variations in health outcomes. The report finds that inequalities in life expectancy persist, and are strongly associated with socioeconomic class, even in countries that enjoy an average of quite good health. Furthermore the gap between rich and poor widens when life expectancy is divided into years in good health and years of disability. In effect, the poor not only have shorter lives than the non-poor, a bigger part of their lifetime is surrendered to disability
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 popu
Overview xiii In short, how health systems – and the estimated 35 million or more people they employ 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, smallpox, 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 physician 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 maternity 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 achieving 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 population
The World Health Report 2000 This shift has been partly due to the profound political and economic changes of the last 20 years or so. These include the transformation from centrally planned to market-oriented economies, reduced state intervention in national economies, fewer government controls, and more decentralization deologically, this has meant greater emphasis on individual choice and responsibility Politically, it has meant limiting promises and expectations about what govemments should do. But at the same time peoples expectations of health systems are greater than ever before. Almost every day another new drug or treatment, or a further advance in medicine and health technology, is announced. This pace of progress is matched only by the rate at which the population seeks its share of the benefits The result is increasing demands and pressures on health systems, including both their public and private sectors, in all countries, rich or poor. Clearly, limits exist on what govern ments can finance and on what services they can deliver. This report means to stimulate public policies that acknowledge the constraints govemments face. If services are to be provided for all, then not all services can be provided THE POTENTIAL TO IMPROVE Within all systems there are many highly skilled, dedicated people working at all levels to improve the health of their communities. As the new century begins, health systems have the power and the potential to achieve further extraordinary improvements Unfortunately, health systems can also misuse their power and squander their poten- al. Poorly structured, badly led, inefficiently organized and inadequately funded health systems can do more harm than good This report finds that many countries are falling far short of their potential, and most are making inadequate efforts in terms of responsiveness and fairness of financial contribu- tion. There are serious shortcomings in the performance of one or more functions in virtu ally all countries These failings result in very large numbers of preventable deaths and disabilities in each country: in unnecessary suffering in injustice, inequality and denial of basic rights of indi viduals. The impact is most severe on the poor, who are driven deeper into poverty by lack of financial protection against ill-health. In trying to buy health from their own pockets, sometimes they only succeed in lining the pockets of others In this report, the poor also emerge as receiving the worst levels of responsiveness they are treated with less respect for their dignity, given less choice of service providers and offered lower-quality amenities The ultimate responsibility for the overall performance of a countrys health system lies with government, which in turn should involve all sectors of society in its stewardship. The ng of the population is the ve sence of good government. For every country it means establishing the best and fairest health system possible with available resources. The health of the people is always a na tional priority: government responsibility for it is continuous and permanent Ministries of large pa Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as ing goals that are in the compasses the tasks of defining the vision and direction of health policy, exerting influence lation and advocacy, and collecting and using information. At the intena
xiv The World Health Report 2000 This shift has been partly due to the profound political and economic changes of the last 20 years or so. These include the transformation from centrally planned to market-oriented economies, reduced state intervention in national economies, fewer government controls, and more decentralization. Ideologically, this has meant greater emphasis on individual choice and responsibility. Politically, it has meant limiting promises and expectations about what governments should do. But at the same time people’s expectations of health systems are greater than ever before. Almost every day another new drug or treatment, or a further advance in medicine and health technology, is announced. This pace of progress is matched only by the rate at which the population seeks its share of the benefits. The result is increasing demands and pressures on health systems, including both their public and private sectors, in all countries, rich or poor. Clearly, limits exist on what governments can finance and on what services they can deliver. This report means to stimulate public policies that acknowledge the constraints governments face. If services are to be provided for all, then not all services can be provided. THE POTENTIAL TO IMPROVE Within all systems there are many highly skilled, dedicated people working at all levels to improve the health of their communities. As the new century begins, health systems have the power and the potential to achieve further extraordinary improvements. Unfortunately, health systems can also misuse their power and squander their potential. Poorly structured, badly led, inefficiently organized and inadequately funded health systems can do more harm than good. This report finds that many countries are falling far short of their potential, and most are making inadequate efforts in terms of responsiveness and fairness of financial contribution. There are serious shortcomings in the performance of one or more functions in virtually all countries. These failings result in very large numbers of preventable deaths and disabilities in each country; in unnecessary suffering; in injustice, inequality and denial of basic rights of individuals. The impact is most severe on the poor, who are driven deeper into poverty by lack of financial protection against ill-health. In trying to buy health from their own pockets, sometimes they only succeed in lining the pockets of others. In this report, the poor also emerge as receiving the worst levels of responsiveness – they are treated with less respect for their dignity, given less choice of service providers and offered lower-quality amenities. The ultimate responsibility for the overall performance of a country’s health system lies with government, which in turn should involve all sectors of society in its stewardship. The careful and responsible management of the well-being of the population is the very essence of good government. For every country it means establishing the best and fairest health system possible with available resources. The health of the people is always a national priority: government responsibility for it is continuous and permanent. Ministries of health must therefore take on a large part of the stewardship of health systems. Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest. Stewardship encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and advocacy, and collecting and using information. At the interna-
Overview tional level, stewardship means mobilizing the collective action of countries to generate global public goods such as research, while fostering a shared vision towards more equita le development across and within countries. It also means providing an evidence base to assist countries'efforts to improve the performance of their health systems But this report finds that some countries appear to have issued no national health policy statement in the past decade; in others, policy exists in the form of documents which gather dust and are never translated into action. Too often, health policy and strategic planning have envisaged unrealistic expansion of the publicly funded health care system, sometimes well in excess of national economic growth. Eventually, the policy and planning document seen as infeasible and is ignored. A policy framework should recognize all three health system goals and identify strate- gies to improve the attainment of each. But not all countries have explicit policies on the overall goodness and fairness of the health system. Public statements about the desired balance among health outcomes, system responsiveness and fairness in financial contribu tion are yet to be made in many countries. Policy should address the way in which the ystem's key functions are to be improve This report finds that, within governments, many health ministries are seriously short sighted, focusing on the public sector and often disregarding the - frequently much larger private provision of care. At worst, governments are capable of turning a blind eye to a black market"in health, where widespread corruption, bribery, "moonlighting"and other illegal practices have flourished for years and are difficult to tackle successfully. Their vision does not extend far enough to help construct a healthier future. Moreover, some health ministries are prone to losing sight completely of their most important target: the population at large. Patients and consumers may only come into view when rising public dissatisfaction forces them to the ministrys attention. Many health ministries condone the evasion of regulations that they themselves have created or are supposed to implement in the public interest Rules rarely enforced are invi tations to abuse. A widespread example is the condoning of public employees charging illicit fees from patients and pocketing the proceeds, a practice known euphemistically as informal charging". Such corruption deters poor people from using services they need, making health financing even more unfair, and it distorts overall health priorities. PROVIDING BETTER SERVICE Too many governments know far too little about what is happening in the provision of services to their people. In many countries, some if not most physicians work simultane ously for the govemment and in private practice. When public providers illegally use public acilities to provide special care to private patients, the public sector ends up subsidizing unofficial private practice. Health professionals are aware of practice-related laws but know that enforcement is weak or non-existent. Professional associations, nominally responsibl for self-regulation, are too often ineffective Oversight and regulation of private sector providers and insurers must be placed high on national policy agendas. At the same time it is crucial to adopt incentives that are sensi- tive to performance. Good policy needs to differentiate between providers (public or pri- vate)who are contributing to health goals, and those who are doing damage, and encourage or sanction appropriately Policies to change the balance between providers' autonomy and accountability need to be monitored closely in terms of their effect on health, responsive- ness and the distribution of the financing burden
Overview xv tional level, stewardship means mobilizing the collective action of countries to generate global public goods such as research, while fostering a shared vision towards more equitable development across and within countries. It also means providing an evidence base to assist countries’ efforts to improve the performance of their health systems. But this report finds that some countries appear to have issued no national health policy statement in the past decade; in others, policy exists in the form of documents which gather dust and are never translated into action. Too often, health policy and strategic planning have envisaged unrealistic expansion of the publicly funded health care system, sometimes well in excess of national economic growth. Eventually, the policy and planning document is seen as infeasible and is ignored. A policy framework should recognize all three health system goals and identify strategies to improve the attainment of each. But not all countries have explicit policies on the overall goodness and fairness of the health system. Public statements about the desired balance among health outcomes, system responsiveness and fairness in financial contribution are yet to be made in many countries. Policy should address the way in which the system’s key functions are to be improved. This report finds that, within governments, many health ministries are seriously shortsighted, focusing on the public sector and often disregarding the – frequently much larger – private provision of care. At worst, governments are capable of turning a blind eye to a “black market” in health, where widespread corruption, bribery, “moonlighting” and other illegal practices have flourished for years and are difficult to tackle successfully. Their vision does not extend far enough to help construct a healthier future. Moreover, some health ministries are prone to losing sight completely of their most important target: the population at large. Patients and consumers may only come into view when rising public dissatisfaction forces them to the ministry’s attention. Many health ministries condone the evasion of regulations that they themselves have created or are supposed to implement in the public interest. Rules rarely enforced are invitations to abuse. A widespread example is the condoning of public employees charging illicit fees from patients and pocketing the proceeds, a practice known euphemistically as “informal charging”. Such corruption deters poor people from using services they need, making health financing even more unfair, and it distorts overall health priorities. PROVIDING BETTER SERVICES Too many governments know far too little about what is happening in the provision of services to their people. In many countries, some if not most physicians work simultaneously for the government and in private practice. When public providers illegally use public facilities to provide special care to private patients, the public sector ends up subsidizing unofficial private practice. Health professionals are aware of practice-related laws but know that enforcement is weak or non-existent. Professional associations, nominally responsible for self-regulation, are too often ineffective. Oversight and regulation of private sector providers and insurers must be placed high on national policy agendas. At the same time it is crucial to adopt incentives that are sensitive to performance. Good policy needs to differentiate between providers (public or private) who are contributing to health goals, and those who are doing damage, and encourage or sanction appropriately. Policies to change the balance between providers’ autonomy and accountability need to be monitored closely in terms of their effect on health, responsiveness and the distribution of the financing burden