Why do Health Systems Matter? bers or religious caregivers, or sometimes paid a professional healer to treat him or her has expanded over the past two centuries into the complex network of activities that now comprise a health system More than simple growth, the creation of modern health systems has involved increas- ing differentiation and specialization of skills and activities. It has also involved an im mense shift in the economic burden of ill-health. Until recently, most of that burden took the form of lost productivity, as people died young or became and remained too sick to work at full strength. The cost of health care accounted for only a small part of the economic loss, because such care was relatively cheap and largely ineffective. Productivity losses are still substantial, especially in the poorest countries, but success in prolonging life and re- ducing disability has meant that more and more of the burden is borne by health systems This includes the cost of drugs- for controlling diabetes, hypertension, and heart disease, for example that allow people to stay active and productive. Part of the growth in re- sources used by health systems is a transfer from other ways of paying for the economic damage due to illness and early death. The resources devoted to health systems are very unequally distributed, and not at all in proportion to the distribution of health problems. Low and middle income countries ac count for only 18% of world income and 11% of global health spending($250 billion or 4% of GDP in those countries). Yet 84% of the worlds population live in these countries, and they bear 93% of the worlds disease burden. These countries face many difficult challenges in meeting the health needs of their populations, mobilizing sufficient financing in an equitable and affordable manner, and securing value for scarce resources Today in most developed countries- and many middle income countries- govern ments have become central to social policy and health care. Their involvement is justified on the grounds of both equity and efficiency. However, in low income countries-where total public revenues for all uses are scarce(often less than 20% of GDP)and institutional capacity in the public sector is weak-the financing and delivery of health services is largely he hands of the private sector. In many of these countries, large segments of the poor still have no access to basic and effective care WHAT DO HEALTH SYSTEMS DO? For rich and poor alike, health needs today are very different from those of 100 or even 50 years ago. There are growing expectations of access to health care in some form, and growing demands for measures to protect the sick, and their families, against the financial costs of ill-health. The circle in which health systems are required to function has been pushed yet wider by raised awareness of the impact on health of developments such as industrialization, road transport, environmental damage and the globalization of trade People also now turn to health systems for help with a much wider variety of problems than before -not just for the relief of pain and treatment of physical limitations and emo- tional disorders but for advice on diet, child-rearing and sexual behaviour that they used to seek from other sources People typically come into direct contact with a health system as patients, attended by providers, only once or twice a year. More often their contact is as consumers of non- prescription medications and as recipients of health-related information and advice.They meet the system as contributors to paying for it, knowingly every time they buy care out of pocket or pay insurance premiums or social security contributions, and unknowingly when ever they pay taxes that are used in part to finance health. It matters very much how the
Why do Health Systems Matter? 7 bers or religious caregivers, or sometimes paid a professional healer to treat him or her – has expanded over the past two centuries into the complex network of activities that now comprise a health system. More than simple growth, the creation of modern health systems has involved increasing differentiation and specialization of skills and activities. It has also involved an immense shift in the economic burden of ill-health. Until recently, most of that burden took the form of lost productivity, as people died young or became and remained too sick to work at full strength. The cost of health care accounted for only a small part of the economic loss, because such care was relatively cheap and largely ineffective. Productivity losses are still substantial, especially in the poorest countries, but success in prolonging life and reducing disability has meant that more and more of the burden is borne by health systems. This includes the cost of drugs – for controlling diabetes, hypertension, and heart disease, for example – that allow people to stay active and productive. Part of the growth in resources used by health systems is a transfer from other ways of paying for the economic damage due to illness and early death. The resources devoted to health systems are very unequally distributed, and not at all in proportion to the distribution of health problems. Low and middle income countries account for only 18% of world income and 11% of global health spending ($250 billion or 4% of GDP in those countries). Yet 84% of the world’s population live in these countries, and they bear 93% of the world’s disease burden. These countries face many difficult challenges in meeting the health needs of their populations, mobilizing sufficient financing in an equitable and affordable manner, and securing value for scarce resources. Today in most developed countries – and many middle income countries – governments have become central to social policy and health care. Their involvement is justified on the grounds of both equity and efficiency. However, in low income countries – where total public revenues for all uses are scarce (often less than 20% of GDP) and institutional capacity in the public sector is weak – the financing and delivery of health services is largely in the hands of the private sector. In many of these countries, large segments of the poor still have no access to basic and effective care. WHAT DO HEALTH SYSTEMS DO? For rich and poor alike, health needs today are very different from those of 100 or even 50 years ago. There are growing expectations of access to health care in some form, and growing demands for measures to protect the sick, and their families, against the financial costs of ill-health. The circle in which health systems are required to function has been pushed yet wider by raised awareness of the impact on health of developments such as industrialization, road transport, environmental damage and the globalization of trade. People also now turn to health systems for help with a much wider variety of problems than before – not just for the relief of pain and treatment of physical limitations and emotional disorders but for advice on diet, child-rearing and sexual behaviour that they used to seek from other sources. People typically come into direct contact with a health system as patients, attended by providers, only once or twice a year. More often their contact is as consumers of nonprescription medications and as recipients of health-related information and advice. They meet the system as contributors to paying for it, knowingly every time they buy care out of pocket or pay insurance premiums or social security contributions, and unknowingly whenever they pay taxes that are used in part to finance health. It matters very much how the
system treats people's health needs and how it raises revenues from them, including how much protection it offers them from financial risk. But it also matters how it responds to eir expectations. In particular, people have a right to expect that the health system will treat them with individual dignity. So far as possible, their needs should be promptly at long delays in waiting for diagnosis and treatme health outcomes but also to respect the value of peoples time and to reduce their anxiety Patients also often expect confidentiality, and to be involved in choices about their own alth, including where and from whom they receive care. They should not always be ex- pected passively to receive services determined by the provider alone In summary, health systems have a responsibility not just to improve peoples health but rotect them against the financial cost of illness- and to treat them with dignity. As is discussed in more detail in Chapter 2, health systems thus have three fundamental objec- improving the health of the population they serve; responding to peoples expectations the costs of ill-health Because these objectives are not always met, public dissatisfaction with the way health services are run or financed is widespread, with accounts of errors, delays, rudeness, hostil tous financial risks by insurers and governments, on a grand scale orexposure to calam ty and indifference on the part of health workers, and denial of care or exposure to calam Because better health is the most important objective of a health system, and becaus health status is worse in poor populations, one might assume that for a low income coun- try, improving health is all that matters. Concern for the non-health outcomes of the sys- tem, for fairly sharing the burden of paying for health so that no one is exposed to great financial risk, and attending to people's wishes and expectations about how they are to be nted, would then be considered luxuries, gaining in importance only as income rises and health improves. But this view is mistaken, for several reasons. Poor people, as indicated earlier, need financial protection as much as or more than the well-off, since even small absolute risks may have catastrophic consequences for them. And the poor are just as enti tled to respectful treatment as the rich, even if less can be done for them materially. More ver, pursuing the objectives of responsiveness and financial protection does not necessarily take substantial resources away from activities to improve health Much improvement in how a health system performs with respect to these responsibilities may often be had little or no cost. So all three objectives matter in every country, independently of how rich poor it is or how its health system is organized. Better ways of achieving these objectives, treated in later chapters, are similarly relevant for all countries and health systems, although the specific implications for policy will vary according to income level and the cultural and organizational features of the system. WHY HEALTH SYSTEMS MATTER The contribution that health systems make to improving health has been examined much more closely than how well they satisfy the other two objectives mentioned above, which there is little comparable information and analysis. This report therefore develops measures corresponding to all three objectives, for assessing how systems perform. Even the contribution that health systems make to improved health is difficult to judge, because different kinds of evidence seem to give conflicting answers. At the level of interventions
8 The World Health Report 2000 system treats people’s health needs and how it raises revenues from them, including how much protection it offers them from financial risk. But it also matters how it responds to their expectations. In particular, people have a right to expect that the health system will treat them with individual dignity. So far as possible, their needs should be promptly attended to, without long delays in waiting for diagnosis and treatment – not only for better health outcomes but also to respect the value of people’s time and to reduce their anxiety. Patients also often expect confidentiality, and to be involved in choices about their own health, including where and from whom they receive care. They should not always be expected passively to receive services determined by the provider alone. In summary, health systems have a responsibility not just to improve people’s health but to protect them against the financial cost of illness – and to treat them with dignity. As is discussed in more detail in Chapter 2, health systems thus have three fundamental objectives. These are: • improving the health of the population they serve; • responding to people’s expectations; • providing financial protection against the costs of ill-health. Because these objectives are not always met, public dissatisfaction with the way health services are run or financed is widespread, with accounts of errors, delays, rudeness, hostility and indifference on the part of health workers, and denial of care or exposure to calamitous financial risks by insurers and governments, on a grand scale. Because better health is the most important objective of a health system, and because health status is worse in poor populations, one might assume that for a low income country, improving health is all that matters. Concern for the non-health outcomes of the system, for fairly sharing the burden of paying for health so that no one is exposed to great financial risk, and attending to people’s wishes and expectations about how they are to be treated, would then be considered luxuries, gaining in importance only as income rises and health improves. But this view is mistaken, for several reasons. Poor people, as indicated earlier, need financial protection as much as or more than the well-off, since even small absolute risks may have catastrophic consequences for them. And the poor are just as entitled to respectful treatment as the rich, even if less can be done for them materially. Moreover, pursuing the objectives of responsiveness and financial protection does not necessarily take substantial resources away from activities to improve health. Much improvement in how a health system performs with respect to these responsibilities may often be had at little or no cost. So all three objectives matter in every country, independently of how rich or poor it is or how its health system is organized. Better ways of achieving these objectives, treated in later chapters, are similarly relevant for all countries and health systems, although the specific implications for policy will vary according to income level and the cultural and organizational features of the system. WHY HEALTH SYSTEMS MATTER The contribution that health systems make to improving health has been examined much more closely than how well they satisfy the other two objectives mentioned above, for which there is little comparable information and analysis. This report therefore develops measures corresponding to all three objectives, for assessing how systems perform. Even the contribution that health systems make to improved health is difficult to judge, because different kinds of evidence seem to give conflicting answers. At the level of interventions