Figure 2.7 Overall health system performance(all attainments)relative to health expenditure per capita, 191 Member States, 1997 Figure 3.1 The multiple roles of people in health system Figure 3.2 Questions to ask in deciding what interventions to finance and provide 55 Figure 3.3 Different ways of rationing health interventions according to cost and frequency of need Figure 3.4 Different internal incentives in three organizational structures Figure 4.1 Health system inputs: from financial resources to health interventions 75 Figure 4.2 Health systems input mix: comparison of four high income countries, around 1997 Figure 4.3 Health systems input mix comparison of four middle income countries, around 1997 Figure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity Figure 5.2 Structure of health system financing and provision in four countries 102 BOX Box 1.1 Poverty, ill-health and cost-effectiveness 5 Box 1.2 Health knowledge, not income, explains historical change in urban-rural health differences 10 Box 2.1 Summary measures of population health Box 2.2 How important are the different elements of responsiveness? Box 2.3 What does fair contribution measure and not measure? Box 2.4 Weighting the achievements that go into overall attainment Box 2.5 Estimating the best to be expected and the least to be demanded Box 4.1 Substitution among human resources 78 Box 4.2 Human resources problems in service delivery Box 4.3 A widening gap in technology use Box 4.4 The Global Alliance for Vaccines and Immunization(GAVe) Box 4.5 Investment in hospitals in countries of the former Soviet Union prior to policy reform Box 5.1 The importance of donor contributions in revenue collection and purchasing in developing countries Box 5.2 The Chilean health insurance market: when stewardship fails to imbalances between internal and external incentives Box 6.1 Trends in national health policy: from plans to frameworks Box 6.2 Ghana's medium-term health policy framework Box 6.3 SWAPs: are they good for stewardship? Box 6.4 Stewardship: the Hisba system in Islamic countries Box 6.5 South Africa: regulating the private insurance market to increase risk pooling Box 6.6 Opening up the health insurance system in the Netherlands 128 Box 6.7 Responsiveness to patients'rights Box 6.8 Towards good stewardship-the case of pharmaceuticals Box 6.9 Thailand: the role of the media in health system stewardship
vi The World Health Report 2000 Figure 2.7 Overall health system performance (all attainments) relative to health expenditure per capita, 191 Member States, 1997 44 Figure 3.1 The multiple roles of people in health systems 50 Figure 3.2 Questions to ask in deciding what interventions to finance and provide 55 Figure 3.3 Different ways of rationing health interventions according to cost and frequency of need 60 Figure 3.4 Different internal incentives in three organizational structures 66 Figure 4.1 Health system inputs: from financial resources to health interventions 75 Figure 4.2 Health systems input mix: comparison of four high income countries, around 1997 86 Figure 4.3 Health systems input mix: comparison of four middle income countries, around 1997 87 Figure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity 100 Figure 5.2 Structure of health system financing and provision in four countries 102 BOXES Box 1.1 Poverty, ill-health and cost-effectiveness 5 Box 1.2 Health knowledge, not income, explains historical change in urban–rural health differences 10 Box 2.1 Summary measures of population health 28 Box 2.2 How important are the different elements of responsiveness? 32 Box 2.3 What does fair contribution measure and not measure? 38 Box 2.4 Weighting the achievements that go into overall attainment 39 Box 2.5 Estimating the best to be expected and the least to be demanded 41 Box 4.1 Substitution among human resources 78 Box 4.2 Human resources problems in service delivery 79 Box 4.3 A widening gap in technology use? 82 Box 4.4 The Global Alliance for Vaccines and Immunization (GAVI) 83 Box 4.5 Investment in hospitals in countries of the former Soviet Union prior to policy reform 89 Box 5.1 The importance of donor contributions in revenue collection and purchasing in developing countries 96 Box 5.2 The Chilean health insurance market: when stewardship fails to compensate for pooling competition problems and for imbalances between internal and external incentives 109 Box 6.1 Trends in national health policy: from plans to frameworks 121 Box 6.2 Ghana’s medium-term health policy framework 122 Box 6.3 SWAPs: are they good for stewardship? 123 Box 6.4 Stewardship: the Hisba system in Islamic countries 124 Box 6.5 South Africa: regulating the private insurance market to increase risk pooling 126 Box 6.6 Opening up the health insurance system in the Netherlands 128 Box 6.7 Responsiveness to patients’ rights 130 Box 6.8 Towards good stewardship – the case of pharmaceuticals 131 Box 6.9 Thailand: the role of the media in health system stewardship 133
MESSAGE FROM THE DIRECTOR-GENERAL at 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. defending the budget in parliament; a minister of finance attempting to balance multiple laims on the public purse; a harassed hospital superintendent under pres- sure 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 spending. The way health systems are designed, managed and ary markedly, even in countries with very similar levels of health financed affects people's lives and livelihoods. The difference be tween a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humilia- tion and despair When i became Director-General in 1998, one of oncerns was that health systems development should become Dr Gro harlem Brundtland 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 recom- mendations 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 sys- tems development. Improving the performance of health systems around the world is the raison d'etre 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 concem 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 ctions whose primary intent is to improve health
Overview vii MESSAGE FROM THE DIRECTOR-GENERAL Dr Gro Harlem Brundtland hat 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