《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2000_Health Systems：Improving performance_2 How Well do Health Systems Perform?

CHAPTER TWO ealth ystems Perform Better health is unquestionably the primary goal of a health system. But because health care can be catastrophically costly and the need for it unpre dictable, mechanisms for sharing risk and providing financial protection are important. A second goal of health systems is therefore fairness in financial contribution. a third goal responsiveness to people's expecta tions in regard to non-health matters-reflects the importance of respecting people's dignity, autonomy and the confidentiality of information. WHO has engaged in a major exercise to obtain and analyse data in order to assess how far health systems in WHO Member States are achieving these goals for which they should be accountable, and how efficiently they are using their resources in doing so. By focusing on a few universal functions that health systems undertake, this report provides an evidence base to as sist policy-makers improve health system performance

How Well do Health Systems Perform? 21 CHAPTER TWO
ow ell do
ealth ystems erform ? Better health is unquestionably the primary goal of a health system. But because health care can be catastrophically costly and the need for it unpre￾dictable, mechanisms for sharing risk and providing financial protection are important. A second goal of health systems is therefore fairness in financial contribution. A third goal – responsiveness to people’s expecta￾tions in regard to non-health matters – reflects the importance of respecting people’s dignity, autonomy and the confidentiality of information. WHO has engaged in a major exercise to obtain and analyse data in order to assess how far health systems in WHO Member States are achieving these goals for which they should be accountable, and how efficiently they are using their resources in doing so. By focusing on a few universal functions that health systems undertake, this report provides an evidence base to as￾sist policy-makers improve health system performance. 21

HOW WELL DO HEALTH SYSTEMS PERFORM? ATTAINMENT AND PERFORMANCE ( ssessing how well a health system does its job requires dealing with two large questions. The first is how to measure the outcomes of interest-that is to determine what is achieved with respect to the three objectives of good health, respon siveness and fair financial contribution(attainment). The second is how to compare those attainments with what the system should be able to accomplish-that is, the best that could be achieved with the same resources (performance). Although progress is feasible against many of society s health problems, some of the causes lie completely outside even a broad notion of what health systems are. Health systems cannot be held responsible for influ ences such as the distribution of income and wealth, any more than for the impact of the climate But avoidable deaths and illness from childbirth, measles, malaria or tobacco con- sumption can properly be laid at their door. A fair judgement of how much health damage it should be possible to avoid requires an estimate of the best that can be expected, and of the least that can be demanded, of a system. The same is true of progress towards the other two objectives, although much less is known about them(1) GOALS AND FUNCTIONS Better health is of course the raison d'etre of a health system, and unquestionably its primary or defining goal: if health systems did nothing to protect or improve health there would be no reason for them. Other systems in society may contribute greatly to the popu lations health, but not as their primary goal. For example, the education system makes a large difference to health, but its defining goal is to educate Influence also flows the other way: better health makes children better able to learn, but that is not the defining purpose of the health system. In contrast, the goal of fair financing is common to all societal sys- tems. This is obvious when the system is paid for socially, but it holds even when everything is financed purely by individual purchases. It is only the notion of faimess that may vary. Getting what you pay for "is generally accepted as fair in market transactions, but seems much less fair where health services are concemed. Similarly, in any system, people have expectations which society regards as legitimate, as to how they should be treated, both physically and psychologically Responsiveness is therefore always a social goal.Taking the education system as an example, fair financing means the right balance of contributions from households which do and those which do not have children in school, and enough subsidy that poor children are not denied schooling for financial reasons. Responsiveness cludes respect for parents' wishes for their children, and avoiding abuse or humiliation of the students themselves

How Well do Health Systems Perform? 23 2 HOW WELL DO HEALTH SYSTEMS PERFORM? ATTAINMENT AND PERFORMANCE  ssessing how well a health system does its job requires dealing with two large questions. The first is how to measure the outcomes of interest – that is, to determine what is achieved with respect to the three objectives of good health, respon￾siveness and fair financial contribution (attainment). The second is how to compare those attainments with what the system should be able to accomplish – that is, the best that could be achieved with the same resources (performance). Although progress is feasible against many of society’s health problems, some of the causes lie completely outside even a broad notion of what health systems are. Health systems cannot be held responsible for influ￾ences such as the distribution of income and wealth, any more than for the impact of the climate. But avoidable deaths and illness from childbirth, measles, malaria or tobacco con￾sumption can properly be laid at their door. A fair judgement of how much health damage it should be possible to avoid requires an estimate of the best that can be expected, and of the least that can be demanded, of a system. The same is true of progress towards the other two objectives, although much less is known about them (1). GOALS AND FUNCTIONS Better health is of course the raison d’être of a health system, and unquestionably its primary or defining goal: if health systems did nothing to protect or improve health there would be no reason for them. Other systems in society may contribute greatly to the popu￾lation’s health, but not as their primary goal. For example, the education system makes a large difference to health, but its defining goal is to educate. Influence also flows the other way: better health makes children better able to learn, but that is not the defining purpose of the health system. In contrast, the goal of fair financing is common to all societal sys￾tems. This is obvious when the system is paid for socially, but it holds even when everything is financed purely by individual purchases. It is only the notion of fairness that may vary. “Getting what you pay for” is generally accepted as fair in market transactions, but seems much less fair where health services are concerned. Similarly, in any system, people have expectations which society regards as legitimate, as to how they should be treated, both physically and psychologically. Responsiveness is therefore always a social goal. Taking the education system as an example, fair financing means the right balance of contributions from households which do and those which do not have children in school, and enough subsidy that poor children are not denied schooling for financial reasons. Responsiveness includes respect for parents’ wishes for their children, and avoiding abuse or humiliation of the students themselves

The World Health Report The health system differs from other social systems such as education, and from the markets for most consumer goods and services, in two ways which make the goals of fai health care can be cata strophically costly Much of the need for care is unpredictable, so it is vital for people to be protected from having to choose between financial ruin and loss of health. Mechanisms for sharing risk and providing financial protection are more important even than in other cases where people buy insurance, as for physical assets like homes or vehicles, or against the financial risk to the of a breadwinner dying young. The other peculiarity of health is that illness itself, and medical care as well, can threaten people's dignity and their ability to control what happens to them more than most other events to which they are exposed Among other things, responsiveness means reducing the damage to one's dignity and au tonomy, and the fear and shame that sickness often brings with it. Systems are often charged to be affordable, equitable, accessible, sustainable, of good quality, and perhaps to have many other virtues as well. However, desiderata such as acces sibility are really a means to an end; they are instrumental rather than final goals.The more accessible a system is, the more people should utilize it to improve their health. In contrast, the goals of health, fair financing, and responsiveness are each intrinsically valuable. Rais ing the achievement of any goal or combination of goals, without lowering the attainment of another, represents an improvement. So if the achievement of these goals can be meas- ured, then instrumental goals such as accessibility become unnecessary as proxy measures of overall performance; they are relevant rather as explanations of good or bad outcomes. It is certainly true that financing that is more fairly distributed may contribute to better alth, by reducing the risk that people who need care do not get it because it would cost too much, or that paying for health care leaves them impoverished and exposed to more health problems. And a system that is more responsive to what people want and expect can also make for better health, because potential patients are more likely to utilize care if they ticipate being treated well. Both goals therefore are partly instrumental, in that they pro- mote improvements in health status. But they would be valuable even if that did not hap- pen. That is, paying equitably for the system is a good thing in itself. So is assuring that people are treated promptly, with respect for their dignity and their wishes, and that pa tients receive adequate physical and affective support while undergoing treatment. The three goals are separable, as is often shown by people's unhappiness with a system even omparing how health systems perform means looking at what they achieve and at what they do-how they carry out certain functions-in order to achieve anything(2).These functions could be classified and related to system objectives in many different ways. For example, the"Public health in the Americas"initiative led by the Pan American Health Organization describes 12 different"essential functions", and proposes between three and six sub-functions for each one(3). Many of these functions correspond to the task of stew ardship which this report emphasizes, others to service provision and to resource genera tion. The four functions described in this chapter embrace these and other more specific activities. Figure 2.1 indicates how these functions-delivering personal and non-personal health services; raising, pooling and allocating the revenues to purchase those services investing in people, buildings and equipment; and acting as the overall stewards of the esources, powers and expectations entrusted to them- are related to one another and to the objectives of the system. Stewardship occupies a special place because it involves over- sight of all the other functions, and has direct or indirect effects on all the outcomes. Com paring the way these functions are actually carried out provides a basis for understanding

24 The World Health Report 2000 The health system differs from other social systems such as education, and from the markets for most consumer goods and services, in two ways which make the goals of fair financing and responsiveness particularly significant. One is that health care can be cata￾strophically costly. Much of the need for care is unpredictable, so it is vital for people to be protected from having to choose between financial ruin and loss of health. Mechanisms for sharing risk and providing financial protection are more important even than in other cases where people buy insurance, as for physical assets like homes or vehicles, or against the financial risk to the family of a breadwinner dying young. The other peculiarity of health is that illness itself, and medical care as well, can threaten people’s dignity and their ability to control what happens to them more than most other events to which they are exposed. Among other things, responsiveness means reducing the damage to one’s dignity and au￾tonomy, and the fear and shame that sickness often brings with it. Systems are often charged to be affordable, equitable, accessible, sustainable, of good quality, and perhaps to have many other virtues as well. However, desiderata such as acces￾sibility are really a means to an end; they are instrumental rather than final goals. The more accessible a system is, the more people should utilize it to improve their health. In contrast, the goals of health, fair financing, and responsiveness are each intrinsically valuable. Rais￾ing the achievement of any goal or combination of goals, without lowering the attainment of another, represents an improvement. So if the achievement of these goals can be meas￾ured, then instrumental goals such as accessibility become unnecessary as proxy measures of overall performance; they are relevant rather as explanations of good or bad outcomes. It is certainly true that financing that is more fairly distributed may contribute to better health, by reducing the risk that people who need care do not get it because it would cost too much, or that paying for health care leaves them impoverished and exposed to more health problems. And a system that is more responsive to what people want and expect can also make for better health, because potential patients are more likely to utilize care if they anticipate being treated well. Both goals therefore are partly instrumental, in that they pro￾mote improvements in health status. But they would be valuable even if that did not hap￾pen. That is, paying equitably for the system is a good thing in itself. So is assuring that people are treated promptly, with respect for their dignity and their wishes, and that pa￾tients receive adequate physical and affective support while undergoing treatment. The three goals are separable, as is often shown by people’s unhappiness with a system even when the health outcomes are satisfactory. Comparing how health systems perform means looking at what they achieve and at what they do – how they carry out certain functions – in order to achieve anything (2). These functions could be classified and related to system objectives in many different ways. For example, the “Public health in the Americas” initiative led by the Pan American Health Organization describes 12 different “essential functions”, and proposes between three and six sub-functions for each one (3). Many of these functions correspond to the task of stew￾ardship which this report emphasizes, others to service provision and to resource genera￾tion. The four functions described in this chapter embrace these and other more specific activities. Figure 2.1 indicates how these functions – delivering personal and non-personal health services; raising, pooling and allocating the revenues to purchase those services; investing in people, buildings and equipment; and acting as the overall stewards of the resources, powers and expectations entrusted to them – are related to one another and to the objectives of the system. Stewardship occupies a special place because it involves over￾sight of all the other functions, and has direct or indirect effects on all the outcomes. Com￾paring the way these functions are actually carried out provides a basis for understanding

Howo Well do Health Systems Perform? performance variations over time and among countries. Some evidence about these func tions, and how they influence the attainment of the fundamental objectives in different health systems, is examined in the next four chapters In the view of most people, the health system is simply those providers and organ ons which deliver personal medical services. Defining the health system more broadly leans that the people and organizations which deliver medical care are not the whole system; rather, they exercise one of the principal functions of the system. They also share, sometimes appropriately and sometimes less so, in the other functions of financing, inves ment and stewardship. The question of who should undertake which functions is one of It is common to describe the struggle for good health in quasi-military terms, to talk of fighting"malaria or AIDS, to refer to a"campaign"of immunization or the"conquest"of mailbox, to“free area of some arms race"that constantly occurs between pathogens and the drugs to hold them in check, to hope for a"silver bullet"against cancer or diabetes. In those terms, the providers of direct health services-whether aimed at individuals, communities or the environment -can be considered the front-line troops defending society against illness. But just as with an army, the health system must be much more than the soldiers in the field if it is to win any battles Behind them is an entire apparatus to ensure that the fighters are adequately trained, in formed, financed, supplied, inspired and led. It is also crucial to treat decently the popula tion they are supposed to protect, to teach the "civilians"in the struggle how to defend themselves and their families, and to share equitably the burden of financing the war. Unless those functions are properly carried out, firepower will be much less effective than it might be, and casualties will be higher. The emphasis here on overall results and on the functions more distant from the front line does not mean any denigration of the impor- ance of disease control. It means rather to step back and consider what it is that the system as a whole is trying to do, and how well it is succeeding. Success means, among other things, more effective control of diseases, through better performance. Figure 2.1 Relations between functions and objectives of a health system Functions the system performs Objectives of the system Delivering services (investment and training

How Well do Health Systems Perform? 25 performance variations over time and among countries. Some evidence about these func￾tions, and how they influence the attainment of the fundamental objectives in different health systems, is examined in the next four chapters. In the view of most people, the health system is simply those providers and organiza￾tions which deliver personal medical services. Defining the health system more broadly means that the people and organizations which deliver medical care are not the whole system; rather, they exercise one of the principal functions of the system. They also share, sometimes appropriately and sometimes less so, in the other functions of financing, invest￾ment and stewardship. The question of who should undertake which functions is one of the crucial issues treated in later chapters. It is common to describe the struggle for good health in quasi-military terms, to talk of “fighting” malaria or AIDS, to refer to a “campaign” of immunization or the “conquest” of smallpox, to “free” a population or a geographical area of some disease, to worry about the “arms race” that constantly occurs between pathogens and the drugs to hold them in check, to hope for a “silver bullet” against cancer or diabetes. In those terms, the providers of direct health services – whether aimed at individuals, communities or the environment – can be considered the front-line troops defending society against illness. But just as with an army, the health system must be much more than the soldiers in the field if it is to win any battles. Behind them is an entire apparatus to ensure that the fighters are adequately trained, in￾formed, financed, supplied, inspired and led. It is also crucial to treat decently the popula￾tion they are supposed to protect, to teach the “civilians” in the struggle how to defend themselves and their families, and to share equitably the burden of financing the war. Unless those functions are properly carried out, firepower will be much less effective than it might be, and casualties will be higher. The emphasis here on overall results and on the functions more distant from the front line does not mean any denigration of the impor￾tance of disease control. It means rather to step back and consider what it is that the system as a whole is trying to do, and how well it is succeeding. Success means, among other things, more effective control of diseases, through better performance. Figure 2.1 Relations between functions and objectives of a health system Stewardship (oversight) Health Responsiveness (to people's non-medical expectations) Fair (financial) contribution Creating resources (investment and training) Financing (collecting, pooling and purchasing) Functions the system performs Objectives of the system Delivering services (provision)

The World Health Report 2000 GOODNESS AND FAIRNESS BOTH LEVEL AND DISTRIBUTION MATTER A good health system, above all, contributes to good health. But it is not always satisfac- tory to protect or improve the average health of the population, if at the same time inequal ity worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce in- equalities by preferentially improving the health of the worse-off, wherever these inequa ties are caused by conditions amenable to intervention. The objective of good health really twofold: the best attainable average level-goodness -and the smallest feasible differ- ences among individuals and groups -faimess. A gain in either one of these, with no change in the other, constitutes an improvement, but the two may be in conflict. The logic is some what parallel to that concerning the distribution of income in a population. It is desirable ise the average level, to reduce inequality, or both, and sometimes to judge the relative health away from anyone -health, unlike income or nonhuman assets, cannot be direct The distinction between the overall level and how it is distributed in the population also applies to responsiveness. Goodness means the system responds well on average to what people expect of it, with respect to its non-health aspects. Fairness means that it responds equally well to everyone, without discrimination or differences in how people are treated The distribution of responsiveness matters, just as the distribution of health does Either one is valuable by itself. In contrast to the objectives of good health and responsiveness, there is no overall no- tion of goodness related to financing. There are good and bad ways to raise the resources a health system, of course, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is concerned only with distribution It is not related to the total resource bill, nor to how the funds are used. While it is unambiguously preferable to have better health or a higher level of responsive ness, it is not always better to spend more on health because at high levels of expenditure there may be little additional health gain from more resources. The objectives of the healtl system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending, the resources devoted to health have competing uses, and it is a social choice-with no correct answer-how much to allocate to the health system. Nonetheless there is probably a minimum level of expenditure required to provide a whole population with a handful of the most cost-effective services, and many poor countries are currently spending too little even to assure that(4) countries where most health financing is private, and is largely out of pocket,no one makes this choice overall: it results from millions of individual decisions as the level of prepayment rises, there are fewer and larger decisions, because spending is more and more determined by the policies and budgets of public entities and insurance funds. The public budget decision has the greatest effect in high income countries where most funding is government controlled or mandated, but in all countries it is one of the most basic public decisions. It is something that can be directly chosen, as the level of health outcome or of cannot be

26 The World Health Report 2000 GOODNESS AND FAIRNESS: BOTH LEVEL AND DISTRIBUTION MATTER A good health system, above all, contributes to good health. But it is not always satisfac￾tory to protect or improve the average health of the population, if at the same time inequal￾ity worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce in￾equalities by preferentially improving the health of the worse-off, wherever these inequali￾ties are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level – goodness – and the smallest feasible differ￾ences among individuals and groups – fairness. A gain in either one of these, with no change in the other, constitutes an improvement, but the two may be in conflict. The logic is some￾what parallel to that concerning the distribution of income in a population. It is desirable to raise the average level, to reduce inequality, or both, and sometimes to judge the relative values of one and the other goal (with the difference that there is no argument for taking health away from anyone – health, unlike income or nonhuman assets, cannot be directly redistributed). The distinction between the overall level and how it is distributed in the population also applies to responsiveness. Goodness means the system responds well on average to what people expect of it, with respect to its non-health aspects. Fairness means that it responds equally well to everyone, without discrimination or differences in how people are treated. The distribution of responsiveness matters, just as the distribution of health does. Either one is valuable by itself. In contrast to the objectives of good health and responsiveness, there is no overall no￾tion of goodness related to financing. There are good and bad ways to raise the resources for a health system, of course, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is concerned only with distribution. It is not related to the total resource bill, nor to how the funds are used. While it is unambiguously preferable to have better health or a higher level of responsive￾ness, it is not always better to spend more on health because at high levels of expenditure there may be little additional health gain from more resources. The objectives of the health system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending, the resources devoted to health have competing uses, and it is a social choice – with no correct answer – how much to allocate to the health system. Nonetheless there is probably a minimum level of expenditure required to provide a whole population with a handful of the most cost-effective services, and many poor countries are currently spending too little even to assure that (4). In countries where most health financing is private, and is largely out of pocket, no one makes this choice overall; it results from millions of individual decisions. As the level of prepayment rises, there are fewer and larger decisions, because spending is more and more determined by the policies and budgets of public entities and insurance funds. The public budget decision has the greatest effect in high income countries where most funding is government controlled or mandated, but in all countries it is one of the most basic public decisions. It is something that can be directly chosen, as the level of health outcome or of responsiveness cannot be