《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2000_Health Systems：Improving performance_1 Why do Health Systems Matter?

CHAPTER ONE y go Health ystems (atter Health systems consist ofall the people and actions whose primary purpose is to improve health. They may be integrated and centrally directed, but often they are not. After centuries as small-scale, largely private or charitable, mostly inef- factual entities, they have grown explosively in this century as knowledge has been gained and applied. They have contributed enormously to better health, but their contribution could be greater still, especially for the poor. Failure to achieve that potential is due more to systemic failings than to technical limita- tions. It is therefore urgent to assess current performance and to judge how health systems can reach their potential

Why do Health Systems Matter? 1 CHAPTER ONE
hy do ealth ystems atter? Health systems consist of all the people and actions whose primary purpose is to improve health. They may be integrated and centrally directed, but often they are not. After centuries as small-scale, largely private or charitable, mostly inef￾fectual entities, they have grown explosively in this century as knowledge has been gained and applied. They have contributed enormously to better health, but their contribution could be greater still, especially for the poor. Failure to achieve that potential is due more to systemic failings than to technical limita￾tions. It is therefore urgent to assess current performance and to judge how health systems can reach their potential. 1

WHY DO HEALTH SYSTEMS MATTER? THE CHANGING LANDSCAPE O n 13 October 1999, in a maternity clinic in Sarajevo, Helac Fatima gave birth to a on. This was a special occasion, because United Nations demographers had cal culated the global population would reach six billion on that day. The little Sarajevo boy was designated as the sixth billionth person on the planet Today there are four times as many people in the world as there were 100 years ago there are now about 4000 babies born every minute of every day -and among the count less, bewildering changes that have occurred since then, some of the most profound have occurred in human health. For example, few if any of Helac Fatimas ancestors around 1899 were likely to have seen a hospital, far less been born in one. The same was true for the great majority of the 1.5 billion people then alive. Throughout he world, childbirth invariably occurred at home, rarely with a physician present. Most people relied on traditional remedies and treatments, some of them thousands of years old. Most babies 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 for adults was short-even half a century ago it was a mere 48 years at birth Last year the son of Helac Fatima entered the world with a life expectancy at birth of 73 rears-the current Bosnian average. The global average is 66 years. He was born in a big city hospital staffed by well-trained midwives, nurses, doctors and technicians-who were sup- ported by modern equipment, drugs and medicines. The hospital is part of a sophisticated Ith service. It is connected in turn to a wide network of people and actions that in( way or another are concerned with maintaining and improving his health for the rest of his fe-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. c Health systems have played a part in the dramatic rise in life expectancy that occurred aring the 20th century. They have contributed enormously to better health and influenced the lives and well-being of billions of men, women and children around the world. Their role has become increasingly important. Enormous gaps remain, however, between the potential of health systems and their actual performance, and there is far too much variation in outcomes among countries which seem to have the same resources and possibilities. Why should this be so? Health systems would seem no different from other social systems in facing demands and incentives

Why do Health Systems Matter? 3 1 WHY DO HEALTH SYSTEMS MATTER? THE CHANGING LANDSCAPE  n 13 October 1999, in a maternity clinic in Sarajevo, Helac Fatima gave birth to a son. This was a special occasion, because United Nations demographers had cal￾culated the global population would reach six billion on that day. The little Sarajevo boy was designated as the sixth billionth person on the planet. Today there are four times as many people in the world as there were 100 years ago – there are now about 4000 babies born every minute of every day – and among the count￾less, bewildering changes that have occurred since then, some of the most profound have occurred in human health. For example, few if any of Helac Fatima’s ancestors around 1899 were likely to have seen a hospital, far less been born in one. The same was true for the great majority of the 1.5 billion people then alive. Throughout the world, childbirth invariably occurred at home, rarely with a physician present. Most people relied on traditional remedies and treatments, some of them thousands of years old. Most babies 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 for adults was short – even half a century ago it was a mere 48 years at birth. Last year the son of Helac Fatima entered the world with a life expectancy at birth of 73 years – the current Bosnian average. The global average is 66 years. He was born in a big city hospital staffed by well-trained midwives, nurses, doctors and technicians – who were sup￾ported by modern equipment, drugs and medicines. The hospital is part of a sophisticated health service. It is connected in turn to a wide network of people and actions that in one way or another are concerned with 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 played a part in the dramatic rise in life expectancy that occurred during the 20th century. They have contributed enormously to better health and influenced the lives and well-being of billions of men, women and children around the world. Their role has become increasingly important. Enormous gaps remain, however, between the potential of health systems and their actual performance, and there is far too much variation in outcomes among countries which seem to have the same resources and possibilities. Why should this be so? Health systems would seem no different from other social systems in facing demands and incentives to

The World Health Report 2000 perform as well as possible, and it might be expected that-with some degree of regulation by the state- their performance could be largely left to markets, just as with the provision of most other goods and services. But health is fundamentally different from other things that people want, and the dif ference is rooted in biology. As eloquently expressed by Jonathan Miller, "Of all the objects in the world, the human body has a peculiar status: it is not only possessed by the person who has it, it also possesses and constitutes him. Our body is quite different from all the other things we claim as our own. We can lose money, books and even houses and still remain recognisably ourselves, but it is hard to give any intelligible sense to the idea of disembodied person. Although we speak of our bodies as premises that we live in, it is a special form of tenancy: our body is where we can always be contacted"(1).The person who seeks health care is of course a consumer- as with all other products and services-and may also be a co-producer of his or her health, in following good habits of diet, hygiene and exercise, and complying with medication or other recommendations of providers. But he or she is also the physical object to which all such care is directed Health, then, is a characteristic of an inalienable asset, and in this respect resembles other forms of human capital, such as education, professional knowledge o athletic skills. But it still differs from them in crucial respects. It is subject to large and un predictable risks, which are mostly independent of one another. And it cannot be accumu- lated as knowledge and skills can. These features are enough to make health radically unlike all other assets which people insure against loss or damage, and are the reason why health insurance is more complex than any other kind of insurance. If a car worth US$ 10 000 would cost $15 000 to repair after an accident, an insurer would only pay $10 000. The apossibility of replacing the body, and the consequent absence of a market value for it, precludes any such ceiling on health costs Since the poor are condemned to live in their bodies just as the rich are, they need protection against health risks fully as much. In contrast, where other assets such as hous ing are concerned, the need for such protection either does not arise, or arises only in proportion to income. This basic biological difference between health and other assets even exaggerates forms of market failure, such as moral hazard and imperfect and asymmetric information, that occur for other goods and services Directly or indirectly, it explains much of the reason why markets work less well for health than for other things, why there is need for a more active and also more complicated role for the state, and in general why good performance cannot be taken for granted. The physical integrity and dignity of the individual are recognized in international law, yet there have been shameful instances of the perversion of medical knowledge and skills, such as involuntary or uninformed participation in experiments, forced sterilization, or vio- lent expropriation of organs. Health systems therefore have an additional responsibility to ensure that people are treated with respect, in accordance with human rights This report sets out to analyse the role of health systems and suggest how to make them more efficient and, most importantly, more accessible and responsive to the hundreds of millions of people presently excluded from benefiting fully from them. The denial of access to basic health care is fundamentally linked to poverty -the greatest blight on humanitys landscape. For all their achievements and good intentions, health systems have failed glo- bally to narrow the health divide between rich and poor in the last 100 years. In fact, the gap is actually widening. Some such worsening often accompanies economic progress, as the already better-off are the first to benefit from it. But the means exist to accelerate the sharing by the poor in these benefits, and often at relatively low cost(see Box 1.1). Finding

4 The World Health Report 2000 perform as well as possible, and it might be expected that – with some degree of regulation by the state – their performance could be largely left to markets, just as with the provision of most other goods and services. But health is fundamentally different from other things that people want, and the dif￾ference is rooted in biology. As eloquently expressed by Jonathan Miller, “Of all the objects in the world, the human body has a peculiar status: it is not only possessed by the person who has it, it also possesses and constitutes him. Our body is quite different from all the other things we claim as our own. We can lose money, books and even houses and still remain recognisably ourselves, but it is hard to give any intelligible sense to the idea of a disembodied person. Although we speak of our bodies as premises that we live in, it is a special form of tenancy: our body is where we can always be contacted”(1). The person who seeks health care is of course a consumer – as with all other products and services – and may also be a co-producer of his or her health, in following good habits of diet, hygiene and exercise, and complying with medication or other recommendations of providers. But he or she is also the physical object to which all such care is directed. Health, then, is a characteristic of an inalienable asset, and in this respect it somewhat resembles other forms of human capital, such as education, professional knowledge or athletic skills. But it still differs from them in crucial respects. It is subject to large and un￾predictable risks, which are mostly independent of one another. And it cannot be accumu￾lated as knowledge and skills can. These features are enough to make health radically unlike all other assets which people insure against loss or damage, and are the reason why health insurance is more complex than any other kind of insurance. If a car worth US$ 10 000 would cost $15 000 to repair after an accident, an insurer would only pay $10 000. The impossibility of replacing the body, and the consequent absence of a market value for it, precludes any such ceiling on health costs. Since the poor are condemned to live in their bodies just as the rich are, they need protection against health risks fully as much. In contrast, where other assets such as hous￾ing are concerned, the need for such protection either does not arise, or arises only in proportion to income. This basic biological difference between health and other assets even exaggerates forms of market failure, such as moral hazard and imperfect and asymmetric information, that occur for other goods and services. Directly or indirectly, it explains much of the reason why markets work less well for health than for other things, why there is need for a more active and also more complicated role for the state, and in general why good performance cannot be taken for granted. The physical integrity and dignity of the individual are recognized in international law, yet there have been shameful instances of the perversion of medical knowledge and skills, such as involuntary or uninformed participation in experiments, forced sterilization, or vio￾lent expropriation of organs. Health systems therefore have an additional responsibility to ensure that people are treated with respect, in accordance with human rights. This report sets out to analyse the role of health systems and suggest how to make them more efficient and, most importantly, more accessible and responsive to the hundreds of millions of people presently excluded from benefiting fully from them. The denial of access to basic health care is fundamentally linked to poverty – the greatest blight on humanity’s landscape. For all their achievements and good intentions, health systems have failed glo￾bally to narrow the health divide between rich and poor in the last 100 years. In fact, the gap is actually widening. Some such worsening often accompanies economic progress, as the already better-off are the first to benefit from it. But the means exist to accelerate the sharing by the poor in these benefits, and often at relatively low cost (see Box 1.1). Finding

Why do Health Systems Matter? a successful new direction for health systems is therefore a powerful weapon in the fight against poverty to which WHO is dedicated. Not least for the children of the new century countries need systems that protect all their citizens against both the health risks and the financial risks of illnes WHAT IS A HEALTH SYSTEM? In today's complex world, it can be difficult to say exactly what a health system is, what it consists of, and where it begins and ends. This report defines a health system to inchude all the activities whose primary purpose is to promote, restore or maintain health Formal health services, including the professional delivery of personal medical atten tion, are clearly within these boundaries. So are actions by traditional healers, and all use of medication, whether prescribed by a provider or not. So is home care of the sick, which is how somewhere between 70% and 90% of all sickness is managed (2). Such traditional public health activities as health promotion and disease prevention, and other health nhancing interventions like road and environmental safety improvement, are also part of the system. Beyond the boundaries of this definition are those activities whose primary purpose is something other than health-education, for example -even if these activities have a secondary, health-enhancing benefit. Hence, the general education system is out side the boundaries, but specifically health-related education is included. So are actions intended chiefly to improve health indirectly by influencing how non-health systems fur tion-for example, actions to increase girls school enrolment or change the curriculum to make students better future caregivers and consumers of health care Box 1.1 Poverty, ill-health and cost-effectiveness The series of global estimates of years(DALYs) were similar, with a country, where deaths at early ages communicable and noncom- the burden of disease do not dis- larger contribution from noncom- have almost been eliminated municable diseases among the tinguish between rich and poor, municable diseases. The large differ- among the wealthy oor. If the projected rate of de- but an approximate breakdown ence between the effects of There are relatively cost-effective cline of communicable disease can be derived by ranking coun- communicable and noncommunic. interventions available against the damage could be doubled, the t incomes to form groups communicable diseases among the particularly to combat deaths and yea f s ould gain only 04 ies by per capita income, aggi ple diseases reflects the concentra- diseases that account for most of global rich gating from the lowest and tion of deaths and DALYs lost to these rich-poor differences, and obal poor would gain an addi constituting 20% of the bal poor: about 60% of all ill- health losses among young chil- tional 4. 1 years, narrowing the dif population, and studying health for the poor versus 8-11% dren. Interventions costing an es- ference between the two groups stribution of deaths in each among the richest quintile. This is timated S100 or less per DALY saved from 18. 4 to 13. 7 years. Doubling group, by age, cause and sex 2 strongly associated with differences could deal with 8 or 9 of the 10 lead- the pace of reduction of non- These estimates show that in in the age distribution of deaths: just ing causes of ill-health under the communicable disease damage, 1990, 70% of all deaths and fully over half of all deaths among the age of 5 years, and 6 to 8 of the 10 in contrast, would preferentially 92%of deaths from communica- poor occur before 15 years of age, main causes between the ages of 5 benefit the well-off as well as ble diseases in the poorest quintile compared to only 49% among the and 14 years. All of these are either costing considerably more. The as- were"excess"compared to the rich. The difference between the communicable diseases or forms of sociation betweer mortality that would have oc- poor and the rich is large even in a malnutrition. Death and disability cost-effectiveness is only part curred at the death rates of the typical high-mortality African coun- from these causes is projected to and probably transi tinto- ichest quintile. The figures for to- try, and much greater in a typical decline rapidly by 2020, roughly day epidemiological andeconomic tal losses of disability-adjusted life lower-mortality Latin American equalizing the health damage from conditions it is quite strong DR Thee of knowledge about how well govemment health services reach the poor implications for sector-wide approaches. Washington, DC, The World Bank, Guillot M The burden of disease among the world's poor: current situation, future trends, and implications for policy. Washington, DC, Human Development Network of The world Bank. 2000 3 World development report 1993-lnvesting in health. New York, Oxford University Press for The World Bank, 1993: Tables B6 and B7

Why do Health Systems Matter? 5 a successful new direction for health systems is therefore a powerful weapon in the fight against poverty to which WHO is dedicated. Not least for the children of the new century, countries need systems that protect all their citizens against both the health risks and the financial risks of illness. WHAT IS A HEALTH SYSTEM? In today’s complex world, it can be difficult to say exactly what a health system is, what it consists of, and where it begins and ends. This report defines a health system to include all the activities whose primary purpose is to promote, restore or maintain health. Formal health services, including the professional delivery of personal medical atten￾tion, are clearly within these boundaries. So are actions by traditional healers, and all use of medication, whether prescribed by a provider or not. So is home care of the sick, which is how somewhere between 70% and 90% of all sickness is managed (2). Such traditional public health activities as health promotion and disease prevention, and other health￾enhancing interventions like road and environmental safety improvement, are also part of the system. Beyond the boundaries of this definition are those activities whose primary purpose is something other than health – education, for example – even if these activities have a secondary, health-enhancing benefit. Hence, the general education system is out￾side the boundaries, but specifically health-related education is included. So are actions intended chiefly to improve health indirectly by influencing how non-health systems func￾tion – for example, actions to increase girls’ school enrolment or change the curriculum to make students better future caregivers and consumers of health care. Box 1.1 Poverty, ill-health and cost-effectiveness The series of global estimates of the burden of disease do not dis￾tinguish between rich and poor, but an approximate breakdown can be derived by ranking coun￾tries by per capita income, aggre￾gating from the lowest and highest incomes to form groups each constituting 20% of the world’s population, and studying the distribution of deaths in each group, by age,1 cause and sex.2 These estimates show that in 1990, 70% of all deaths and fully 92% of deaths from communica￾ble diseases in the poorest quintile were “excess” compared to the mortality that would have oc￾curred at the death rates of the richest quintile. The figures for to￾tal losses of disability-adjusted life years (DALYs) were similar, with a larger contribution from noncom￾municable diseases. The large differ￾ence between the effects of communicable and noncommunic￾able diseases reflects the concentra￾tion of deaths and DALYs lost to communicable diseases among the global poor: about 60% of all ill￾health for the poor versus 8–11 % among the richest quintile. This is strongly associated with differences in the age distribution of deaths: just over half of all deaths among the poor occur before 15 years of age, compared to only 4% among the rich. The difference between the poor and the rich is large even in a typical high-mortality African coun￾try, and much greater in a typical lower-mortality Latin American country, where deaths at early ages have almost been eliminated among the wealthy. There are relatively cost-effective interventions available against the diseases that account for most of these rich–poor differences, and particularly to combat deaths and health losses among young chil￾dren.3 Interventions costing an es￾timated $100 or less per DALY saved could deal with 8 or 9 of the 10 lead￾ing causes of ill-health under the age of 5 years, and 6 to 8 of the 10 main causes between the ages of 5 and 14 years. All of these are either communicable diseases or forms of malnutrition. Death and disability from these causes is projected to decline rapidly by 2020, roughly equalizing the health damage from communicable and noncom￾municable diseases among the poor. If the projected rate of de￾cline of communicable disease damage could be doubled, the global rich would gain only 0.4 years of life expectancy, but the global poor would gain an addi￾tional 4.1 years, narrowing the dif￾ference between the two groups from 18.4 to 13.7 years. Doubling the pace of reduction of non￾communicable disease damage, in contrast, would preferentially benefit the well-off as well as costing considerably more. The as￾sociation between poverty and cost-effectiveness is only partial, and probably transitory, but in to￾day’s epidemiological and economic conditions it is quite strong. 1 Gwatkin DR. The current state of knowledge about how well government health services reach the poor: implications for sector-wide approaches. Washington, DC, The World Bank, 5 February 1998 (discussion draft). 2 Gwatkin DR, Guillot M. The burden of disease among the world’s poor: current situation, future trends, and implications for policy. Washington, DC, Human Development Network of The World Bank, 2000. 3 World development report 1993 – Investing in health. New York, Oxford University Press for The World Bank, 1993: Tables B.6 and B.7

The World Health Report 2000 This way of defining a system does not imply any particular degree of integration, nor that anyone is in overall charge of the activities that compose it. In this sense, every country has a health system, however fragmented it may be among different organizations or how ever unsystematically it may seem to operate. Integration and oversight do not determine the system, but they may greatly influence how well it performs Unfortunately, nearly all the information available about health systems refers only to the provision of, and investment in, health services: that is, the health care system, includ ing preventive, curative and palliative interventions, whether directed to individuals or to populations. In most countries, these services account for the great bulk of employment, expenditure and activity that would be included in a broader notion of the health system, so it might seem that little is lost in concentrating on a narrower definition that fits the existing data. Those data have required great efforts to collect-and this report furtheroffers several kinds of information and analysis, such as estimates of life expectancy adjusted for time lived with disability, assessments of how well health systems treat patients, national health accounts, and estimates of household contribution to financing Nonetheless, efforts are needed to quantify and assess those activities implied by the wider definition, so as to begin to gauge their relative cost and effectiveness in contributing the goals of the system To take one example, in the United States between 1966 and 1979 the introduction of a variety of safety features in automobile design (laminated windshields, collapsible steering columns, interior padding, lap and shoulder belts, side marker lights, head restraints, leak resistant fuel systems, stronger bumpers, increased side door strength and better brakes) helped reduce the vehicle accident fatality rate per mile travelled by 40% Only three of these innovations added more than $10 to the price of a car, and in total they accounted for only 2% of the average price increase during 1975-1979(3) From 1975 to 1998. seat belts saved an estimated 112 000 lives in the United States, and tal traffic fatalities continued to fall. The potential health gains were even greater: in 1998 alone, 9000 people died because they did not use their belts(4) The potential savings in other countries are very large. Road traffic accidents are increas ing rapidly in poor countries and are projected to move from the ninth to third place in the worldwide ranking of burden of ill-health by the year 2020. Even in many middle income countries, the fatality rates per head or per vehicle mile are much higher than in the United States (5). Sub-Saharan Africa has the world's highest rate of fatalities per vehicle. The cost of improving vehicles may be high, relative to expenditure on health care, in low and dle income countries, so the effect of including such activities in the definition of the he system may be greater. Unsafe roads also contribute greatly to the vehicular toll in po countries, and the cost of improving roads could be much larger than the cost of making cars safer. But behavioural changes such as using seat belts once installed, and respecting d limits, are nearly costless and could save many lives; they are very likely to be more cost-effective than treatment of crash victims Where information corresponding to a broader definition of health systems is not avail able, this report necessarily uses the available data that match the notion of the health care system. Even by this more limited definition, health systems today represent one of the largest sectors in the world economy. Global spending on health care was about $2985 billion(thousand million)in 1997, or almost 8% of world gross domestic product (GDP), and the International Labour Organisation estimates that there were about 35 million health orkers worldwide a decade ago, while employment in health services now is likely to be substantially higher. These figures reflect how what was for thousands of years a basic private relationship-in which one person with an illness was looked after by family mem-

6 The World Health Report 2000 This way of defining a system does not imply any particular degree of integration, nor that anyone is in overall charge of the activities that compose it. In this sense, every country has a health system, however fragmented it may be among different organizations or how￾ever unsystematically it may seem to operate. Integration and oversight do not determine the system, but they may greatly influence how well it performs. Unfortunately, nearly all the information available about health systems refers only to the provision of, and investment in, health services: that is, the health care system, includ￾ing preventive, curative and palliative interventions, whether directed to individuals or to populations. In most countries, these services account for the great bulk of employment, expenditure and activity that would be included in a broader notion of the health system, so it might seem that little is lost in concentrating on a narrower definition that fits the existing data. Those data have required great efforts to collect – and this report further offers several kinds of information and analysis, such as estimates of life expectancy adjusted for time lived with disability, assessments of how well health systems treat patients, national health accounts, and estimates of household contribution to financing. Nonetheless, efforts are needed to quantify and assess those activities implied by the wider definition, so as to begin to gauge their relative cost and effectiveness in contributing to the goals of the system. To take one example, in the United States between 1966 and 1979 the introduction of a variety of safety features in automobile design (laminated windshields, collapsible steering columns, interior padding, lap and shoulder belts, side marker lights, head restraints, leak resistant fuel systems, stronger bumpers, increased side door strength and better brakes) helped reduce the vehicle accident fatality rate per mile travelled by 40%. Only three of these innovations added more than $10 to the price of a car, and in total they accounted for only 2% of the average price increase during 1975–1979 (3). From 1975 to 1998, seat belts saved an estimated 112 000 lives in the United States, and total traffic fatalities continued to fall. The potential health gains were even greater: in 1998 alone, 9000 people died because they did not use their belts (4). The potential savings in other countries are very large. Road traffic accidents are increas￾ing rapidly in poor countries and are projected to move from the ninth to third place in the worldwide ranking of burden of ill-health by the year 2020. Even in many middle income countries, the fatality rates per head or per vehicle mile are much higher than in the United States (5). Sub-Saharan Africa has the world’s highest rate of fatalities per vehicle. The cost of improving vehicles may be high, relative to expenditure on health care, in low and mid￾dle income countries, so the effect of including such activities in the definition of the health system may be greater. Unsafe roads also contribute greatly to the vehicular toll in poorer countries, and the cost of improving roads could be much larger than the cost of making cars safer. But behavioural changes such as using seat belts once installed, and respecting speed limits, are nearly costless and could save many lives; they are very likely to be more cost-effective than treatment of crash victims. Where information corresponding to a broader definition of health systems is not avail￾able, this report necessarily uses the available data that match the notion of the health care system. Even by this more limited definition, health systems today represent one of the largest sectors in the world economy. Global spending on health care was about $2985 billion (thousand million) in 1997, or almost 8% of world gross domestic product (GDP), and the International Labour Organisation estimates that there were about 35 million health workers worldwide a decade ago, while employment in health services now is likely to be substantially higher. These figures reflect how what was for thousands of years a basic, private relationship – in which one person with an illness was looked after by family mem-