Improving health systems’ performance

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Last year the World Health Organization dedicated its World Health Report 2000 to improving the performance of health systems. We did so because we recognised that the good health of nations is key to human development and economic growth and we felt it was important to analyse health systems’ performance and to share what we knew with governments and the international community.

The challenge is to develop health systems that equitably improve health outcomes, respond to people’s legitimate demands and are financially fair. Recent research indicates that the way health systems are designed, managed and financed seriously affects people’s lives. We know that equitable health outcomes are essential for global prosperity and the well-being of societies. We also know that better health is key to reducing poverty, particularly among the nearly three billion people who live on less than US$2 per day.

Our research has shown that virtually all countries are not obtaining as much as they could from available health resources available to them. In response to many requests, the WHO has been working closely with member states in an initiative to enhance the performance of health systems.

The effectiveness of health systems is the subject of intense public debate all over the world. The World Health Report 2000 plugged into this debate and helped to shift the focus from opinion and ideology toward evidence and knowledge. For the first time it contained a composite index of health systems’ performance. Using five different measures it analysed the extent to which health systems produce better health and the extent to which these benefits are distributed equitably. It examined the degree to which health systems respond to people’s legitimate needs, and the fairness with which they are financed. It also related the composite performance to the resources available, to create an efficiency index. These indicators are used to compare performance in 191 countries and to identify the types of policies that work and those that do not. They also help countries monitor their own performance over time.

The report showed that significant improvements in performance are possible. The question we are now asking is: which factors are critical in making a difference? Four appear to stand out: social inequality; total health spending below a critical threshold of about US$60 per capita; the magnitude of the HIV/AIDS epidemic; and the overall effectiveness of governments. We have also identified three areas where we think that further work may be rewarding. First, we need to look at what could happen if all countries raised their performance to the maximum possible – without increasing resources. Preliminary research suggests that disability-adjusted life expectancy could increase from less than 57 to approximately 70 years. In Sub-Saharan Africa, the potential for change could be even more dramatic – from 37.5 to 64 years of disability-free life – just by making better use of existing resources.

Second, the overall effectiveness of government seems to have a particularly strong influence on health systems’ performance. On the basis of initial work it seems possible that the health systems performance index of the least-well-governed countries could increase by up to 50% through better governance alone.

Third, the data in the World Health Report 2000 suggested that good performance is very difficult to achieve if total health spending in a country is less than about US$60 per capita. This finding is very significant in making the case for additional development assistance. In 2000, the WHO estimated that 41 countries had expenditure below this threshold in 1997. Bringing health spending up to US$60 per capita would cost about US$6 billion a year, or less than one quarter of 1% of total global spending on health. The potential pay-off is an increase of about eight years in disability-adjusted life expectancy in those 41 countries.

In moving forward, the WHO initiated a consultative process on the framework, methods and data sources for health system performance assessment. We have established a scientific peer review process to guide further development. We have hosted technical consultations on important topics involving the world’s best scientists on the relevant technical area. And, we have established an Advisory Group on Health System Performance Assessment with members from the WHO’s Executive Board and the Advisory Council on Health Research.

The WHO can help governments define priorities for action, and not only in terms of better and more equitably distributed health outcomes. The choice of how to finance services is critical. The costs of healthcare can tip the balance from bare subsistence to real poverty. However, providing services is not enough. Unless people are treated with dignity and protected from financial exploitation, they will not use the services – and precious resources will be wasted as a result.

©OECD Observer No 229, November 2001 

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