WORLD HEALTH ORGANIZATION he WOR L D HE A LT H R E P ORT 2000 ealth ystems: mproving erformance ii The World Health Report 2000 WHO Library Cataloguing in Publication Data The World health report 2000 : health systems : improving performance World health Health systems plans Delivery of health care Health services administration Financing, Health Health services accessibility Social justice Health care evaluation mechanisms I Title: Health systems : improving performance ISBN 92 156198 X ISSN 1020-3311 (NLM Classification: WA 540.1) The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full Applications and enquiries should be addressed to the Office of Publications, World Health Organization, 1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available © World Health Organization 2000 All rights reserved The designations employed and the presentation of the material in this publication, including tables and maps, not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland Fax: (41-22) 791 4870 Email: whr@who.int Copies of this publication can be ordered from: bookorders@who.int The principal writers of this report were Philip Musgrove, Andrew Creese, Alex Preker, Christian Baeza, Anders Anell and Thomson Prentice, with contributions from Andrew Cassels, Debra Lipson, Dyna Arhin Tenkorang and Mark Wheeler The report was directed by a steering committee formed by Julio Frenk (chair), Susan Holck, Christopher Murray, Orvill Adams, Andrew Creese, Dean Jamison, Kei Kawabata, Philip Musgrove and Thomson Prentice Valuable input was received from an internal advisory group and a regional reference group, the members of which are listed in the Acknowledgements Additional help and advice were gratefully received from regional directors, executive directors at WHO headquarters and senior policy advisers to the Director-General The conceptual framework that underpins the report was formulated by Christopher Murray and Julio Frenk The development of new analytical methods and summary indicators, new international data collection efforts and extensive empirical analysis that form the basis for the report was undertaken by over 50 individuals, most of them from the WHO Global Programme on Evidence for Health Policy, organized in eleven working groups These groups covered basic demography, cause of death, burden of disease, disability-adjusted life expectancy, health inequalities, responsiveness, fairness of financial contribution, health system preferences, national health accounts and profiles, performance analysis and basic economic data Members of each working group are listed in the Acknowledgements Managerial and technical leadership for the working groups was provided by Julio Frenk, Christopher Murray, Kei Kawabata, Alan Lopez and David Evans A series of technical reports from each of the working groups provides details on the methods, data and results, beyond the explanations included in the Statistical Annex The general approach to this report was discussed at an international consultative meeting on health systems, and the measurement of responsiveness was facilitated by a meeting of key informants Both meetings were held in Geneva in December 1999 and the participants are listed in the Acknowledgements The report was edited by Angela Haden, assisted by Barbara Campanini Administrative and technical support for the World Health Report team were provided by Shelagh Probst, Michel Beusenberg, Amel Chaouachi and Chrissie Chitsulo The index was prepared by Liza Weinkove The cover shows a photograph of a sculpture entitled “Ascending Horizon” by Rafael Barrios, in Caracas, Venezuela The photograph by Mireille Vautier is reproduced with the kind permission of ANA Agence photographique de presse, Paris, France Design by Marilyn Langfeld Layout by WHO Graphics Printed in France 2000/12934 – Sadag – 30 000 iii Overview CONTENTS MESSAGE FROM THE DIRECTOR-GENERAL OVERVIEW How health systems have evolved The potential to improve Providing better services Finding a better balance Protecting the poor VII XI xiii xiv xv xvi xviii CHAPTER WHY DO HEALTH SYSTEMS MATTER? The changing landscape What is a health system? What health systems do? Why health systems matter How modern health systems evolved Three generations of health system reform Focusing on performance 11 13 17 CHAPTER HOW WELL DO HEALTH SYSTEMS PERFORM? Attainment and performance Goals and functions Goodness and fairness: both level and distribution matter Measuring goal achievement Overall attainment: goodness and fairness combined Performance: getting results from resources Improving performance: four key functions 21 23 23 26 27 40 40 44 CHAPTER HEALTH SERVICES: WELL CHOSEN, WELL ORGANIZED? 47 Organizational failings People at the centre of health services Choosing interventions: getting the most health from resources Choosing interventions: what else matters? Choosing interventions: what must be known? Enforcing priorities by rationing care After choosing priorities: service organization and provider incentives Organizational forms 49 50 52 55 57 58 61 62 iv The World Health Report 2000 Service delivery configurations Aligning incentives Integration of provision 63 64 68 CHAPTER WHAT RESOURCES ARE NEEDED? Balancing the mix of resources Human resources are vital Adjusting to advances in knowledge and technology Public and private production of resources The legacy of past investments Health care resource profiles Changing investment patterns The way forward 73 75 77 81 82 84 85 88 90 CHAPTER WHO PAYS FOR HEALTH SYSTEMS? How financing works Prepayment and collection Spreading risk and subsidizing the poor: pooling of resources Strategic purchasing Organizational forms Incentives How financing affects equity and efficiency 93 95 97 99 104 108 110 113 CHAPTER HOW IS THE PUBLIC INTEREST PROTECTED? 117 Governments as stewards of health resources What is wrong with stewardship today? Health policy – vision for the future Setting the rules, ensuring compliance Exercising intelligence, sharing knowledge Strategies, roles and resources: who should what? What are the challenges? How to improve performance 119 120 122 124 129 132 135 137 STATISTICAL ANNEX 143 Explanatory notes Annex Table Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997 Annex Table Basic indicators for all Member States Annex Table Deaths by cause, sex and mortality stratum in WHO Regions, estimates for 1999 144 152 156 164 v Overview Annex Table Burden of disease in disability-adjusted life years (DALYs) by cause, sex and mortality stratum in WHO Regions, estimates for 1999 Annex Table Health attainment, level and distribution in all Member States, estimates for 1997 and 1999 Annex Table Responsiveness of health systems, level and distribution in all Member States, WHO indexes, estimates for 1999 Annex Table Fairness of financial contribution to health systems in all Member States, WHO index, estimates for 1997 Annex Table Selected national health accounts indicators for all Member States, estimates for 1997 Annex Table Overall health system attainment in all Member States, WHO index, estimates for 1997 Annex Table 10 Health system performance in all Member States, WHO indexes, estimates for 1997 170 176 184 188 192 196 200 LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM 204 ACKNOWLEDGEMENTS 206 INDEX 207 TABLES Table 3.1 Table 3.2 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Interventions with a large potential impact on health outcomes Examples of organizational incentives for ambulatory care Estimated out-of-pocket share in health spending by income level, 1997 Approaches to spreading risk and subsidizing the poor: country cases Provider payment mechanisms and provider behaviour Exposure of different organizational forms to internal incentives Exposure of different organizational forms to external incentives 53 67 96 101 106 111 112 FIGURES Figure 1.1 Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Figure 2.5 Figure 2.6 Coverage of population and of interventions under different notions of primary health care Relations between functions and objectives of a health system Life expectancy and disability-adjusted life expectancy for males and females, by WHO Region and stratum defined by child mortality and adult mortality, 1999 Inequality in life expectancy at birth, by sex, in six countries Relative scores of health system responsiveness elements, in 13 countries, 1999 Household contributions to financing health, as percentage of capacity to pay, in eight countries Performance on level of health (disability-adjusted life expectancy) relative to health expenditure per capita, 191 Member States, 1999 15 25 29 30 34 37 43 vi The World Health Report 2000 Figure 2.7 Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 4.1 Figure 4.2 Figure 4.3 Figure 5.1 Figure 5.2 Overall health system performance (all attainments) relative to health expenditure per capita, 191 Member States, 1997 The multiple roles of people in health systems Questions to ask in deciding what interventions to finance and provide Different ways of rationing health interventions according to cost and frequency of need Different internal incentives in three organizational structures Health system inputs: from financial resources to health interventions Health systems input mix: comparison of four high income countries, around 1997 Health systems input mix: comparison of four middle income countries, around 1997 Pooling to redistribute risk, and cross-subsidy for greater equity Structure of health system financing and provision in four countries 44 50 55 60 66 75 86 87 100 102 BOXES Box 1.1 Box 1.2 Box 2.1 Box 2.2 Box 2.3 Box 2.4 Box 2.5 Box 4.1 Box 4.2 Box 4.3 Box 4.4 Box 4.5 Box 5.1 Box 5.2 Box 6.1 Box 6.2 Box 6.3 Box 6.4 Box 6.5 Box 6.6 Box 6.7 Box 6.8 Box 6.9 Poverty, ill-health and cost-effectiveness Health knowledge, not income, explains historical change in urban–rural health differences Summary measures of population health How important are the different elements of responsiveness? What does fair contribution measure and not measure? Weighting the achievements that go into overall attainment Estimating the best to be expected and the least to be demanded Substitution among human resources Human resources problems in service delivery A widening gap in technology use? The Global Alliance for Vaccines and Immunization (GAVI) Investment in hospitals in countries of the former Soviet Union prior to policy reform The importance of donor contributions in revenue collection and purchasing in developing countries The Chilean health insurance market: when stewardship fails to compensate for pooling competition problems and for imbalances between internal and external incentives Trends in national health policy: from plans to frameworks Ghana’s medium-term health policy framework SWAPs: are they good for stewardship? Stewardship: the Hisba system in Islamic countries South Africa: regulating the private insurance market to increase risk pooling Opening up the health insurance system in the Netherlands Responsiveness to patients’ rights Towards good stewardship – the case of pharmaceuticals Thailand: the role of the media in health system stewardship 10 28 32 38 39 41 78 79 82 83 89 96 109 121 122 123 124 126 128 130 131 133 vii Overview MESSAGE THE FROM DIRECTOR-GENERAL hat makes for a good health system? What makes a health system fair? And how 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 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 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 viii The World Health Report 2000 The report breaks new ground in the way that it helps us understand the goals of health systems Clearly, their defining purpose is to improve and protect health – but they have other intrinsic goals These are concerned with fairness in the way people pay for health care, and with how systems respond to people’s expectations with regard to how they are treated Where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities, in ways that improve the situation of the worst-off In this report attainment in relation to these goals provides the basis for measuring the performance of health systems If policy-makers are to act on measures of performance, they need a clear understanding of the key functions that health systems have to undertake The report defines four key functions: providing services; generating the human and physical resources that make service delivery possible; raising and pooling the resources used to pay for health care; and, most critically, the function of stewardship – setting and enforcing the rules of the game and providing strategic direction for all the different actors involved Undoubtedly, many of the concepts and measures used in the report require further refinement and development To date, our knowledge about health systems has been hampered by the weakness of routine information systems and insufficient attention to research.This report has thus required a major effort to assemble data, collect new information, and carry out the required analysis and synthesis It has also drawn on the views of a large number of respondents, within and outside WHO, concerning the interpretation of data and the relative importance of different goals The material in this report cannot provide definitive answers to every question about health systems performance It does though bring together the best available evidence to date It demonstrates that, despite the complexity of the topic and the limitations of the data, it is possible to get a reasonable approximation of the current situation, in a way that provides an exciting agenda for future work I hope that the report will contribute to work on how to assess and improve health systems Performance assessment allows policy-makers, health providers and the population at large to see themselves in terms of the social arrangements they have constructed to improve health It invites reflection on the forces that shape performance and the actions that can improve it For WHO, The world health report 2000 is a milestone in a long-term process The measurement of health systems performance will be a regular feature of all World health reports from now on – using improved and updated information and methods as they are developed Even though we are at an early stage in understanding a complex set of interactions, some important conclusions are clear • Ultimate responsibility for the performance of a country’s health system lies with government.The careful and responsible management of the well-being of the population – stewardship – is the very essence of good government The health of people is always a national priority: government responsibility for it is continuous and permanent • Dollar for dollar spent on health, many countries are falling short of their performance potential The result is a large number of preventable deaths and lives stunted by disability The impact of this failure is born disproportionately by the poor ix Overview Message fron the Director-General • Health systems are not just concerned with improving people’s health but with protecting them against the financial costs of illness The challenge facing governments in low income countries is to reduce the regressive burden of out-of-pocket payment for health by expanding prepayment schemes, which spread financial risk and reduce the spectre of catastrophic health care expenditures • Within governments, many health ministries focus on the public sector often disregarding the – frequently much larger – private finance and provision of care A growing challenge is for governments to harness the energies of the private and voluntary sectors in achieving better levels of health systems performance, while offsetting the failures of private markets • Stewardship is ultimately concerned with oversight of the entire system, avoiding myopia, tunnel vision and the turning of a blind eye to a system’s failings This report is meant to make that task easier by bringing new evidence into sharp focus In conclusion, I hope this report will help policy-makers to make wise choices If they so, substantial gains will be possible for all countries, and the poor will be the principal beneficiaries Gro Harlem Brundtland Geneva June 2000 203 Statistical Annex PERFORMANCE ON HEALTH LEVEL (DALE) Rank Uncertainty Member State interval OVERALL PERFORMANCE Index Uncertainty interval Rank Uncertainty Member State interval Index Uncertainty interval 163 164 165 158 – 167 160 – 166 159 – 167 Djibouti Central African Republic Angola 0.457 0.454 0.453 0.434 – 0.479 0.436 – 0.470 0.433 – 0.473 163 164 165 156 – 176 150 – 181 157 – 178 Mali Cameroon Lao People’s Democratic Republic 0.361 0.357 0.356 0.284 – 0.429 0.246 – 0.458 0.298 – 0.410 166 167 162 – 168 164 – 170 Nauru Congo 0.444 0.433 0.424 – 0.464 0.411 – 0.454 166 167 160 – 176 157 – 180 0.354 0.302 – 0.401 168 169 170 164 – 172 167 – 171 168 – 172 Mozambique Ethiopia Mali 0.424 0.418 0.410 0.399 – 0.450 0.400 – 0.435 0.393 – 0.426 168 169 170 158 – 180 164 – 179 158 – 180 Congo Democratic People’s Republic of Korea Namibia Botswana Niger 0.353 0.340 0.338 0.337 0.278 – 0.414 0.268 – 0.413 0.288 – 0.373 0.266 – 0.416 171 172 173 174 175 168 – 174 169 – 174 170 – 174 172 – 175 174 – 176 Burundi Cameroon Madagascar Equatorial Guinea Nigeria 0.403 0.399 0.394 0.377 0.353 0.374 – 0.435 0.375 – 0.421 0.378 – 0.410 0.355 – 0.400 0.331 – 0.375 171 172 173 174 175 163 – 180 161 – 182 164 – 181 161 – 184 164 – 182 Equatorial Guinea Rwanda Afghanistan Cambodia South Africa 0.337 0.327 0.325 0.322 0.319 0.277 – 0.384 0.268 – 0.389 0.262 – 0.376 0.234 – 0.392 0.251 – 0.374 176 177 178 179 180 175 – 178 176 – 178 176 – 178 179 – 180 179 – 180 Liberia Niger Kenya Uganda United Republic of Tanzania 0.337 0.323 0.320 0.280 0.279 0.318 – 0.355 0.306 – 0.340 0.298 – 0.343 0.264 – 0.295 0.260 – 0.298 176 177 178 179 180 164 – 183 166 – 184 167 – 183 167 – 186 173 – 185 Guinea-Bissau Swaziland Chad Somalia Ethiopia 0.314 0.305 0.303 0.286 0.276 0.239 – 0.375 0.234 – 0.369 0.231 – 0.363 0.199 – 0.369 0.215 – 0.326 181 182 183 184 185 181 – 185 181 – 185 181 – 185 181 – 186 182 – 187 Rwanda South Africa Sierra Leone Swaziland Democratic Republic of the Congo 0.240 0.232 0.230 0.229 0.217 0.214 – 0.265 0.209 – 0.251 0.213 – 0.247 0.205 – 0.255 0.198 – 0.235 181 182 183 184 185 172 – 186 170 – 186 174 – 186 170 – 187 171 – 188 Angola Zambia Lesotho Mozambique Malawi 0.275 0.269 0.266 0.260 0.251 0.198 – 0.343 0.204 – 0.339 0.205 – 0.319 0.186 – 0.339 0.174 – 0.332 186 187 188 189 190 183 – 188 186 – 188 187 – 189 185 – 189 190 Lesotho Malawi Botswana Namibia Zambia 0.211 0.196 0.183 0.183 0.112 0.187 – 0.236 0.181 – 0.211 0.172 – 0.194 0.152 – 0.214 0.095 – 0.129 186 187 188 189 190 180 – 189 183 – 189 185 – 189 179 – 190 175 – 191 Liberia Nigeria Democratic Republic of the Congo Central African Republic Myanmar 0.200 0.176 0.171 0.156 0.138 0.117 – 0.282 0.094 – 0.251 0.100 – 0.232 0.000 – 0.306 0.000 – 0.311 191 191 Zimbabwe 0.080 0.057 – 0.103 191 190 – 191 Sierra Leone 0.000 0.000 – 0.079 204 The World Health Report 2000 LIST OF WHO REGION African Region (AFR) Algeria – High child, high adult Angola – High child, high adult Benin – High child, high adult Botswana – High child,very high adult Burkina Faso – High child, high adult Burundi – High child,very high adult Cameroon – High child, high adult Cape Verde – High child, high adult Central African Republic – High child,very high adult Chad – High child, high adult Comoros – High child, high adult Congo – High child,very high adult Côte d’Ivoire – High child,very high adult Democratic Republic of the Congo – High child,very high adult Equatorial Guinea – High child, high adult Eritrea – High child,very high adult Ethiopia – High child,very high adult Gabon – High child, high adult Gambia – High child, high adult Ghana – High child, high adult Guinea – High child, high adult Guinea-Bissau – High child, high adult Kenya – High child,very high adult Lesotho – High child,very high adult Liberia – High child, high adult Madagascar – High child, high adult Malawi – High child,very high adult Mali – High child, high adult Mauritania – High child, high adult Mauritius – High child, high adult Mozambique – High child,very high adult Namibia – High child,very high adult Niger – High child, high adult MEMBER STATES AND BY MORTALITY STRATUM Nigeria – High child, high adult Rwanda – High child,very high adult Sao Tome and Principe – High child, high adult Senegal – High child, high adult Seychelles – High child, high adult Sierra Leone – High child, high adult South Africa – High child,very high adult Swaziland – High child,very high adult Togo – High child, high adult Uganda – High child,very high adult United Republic of Tanzania – High child,very high adult Zambia – High child,very high adult Zimbabwe – High child,very high adult Region of the Americas (AMR) Antigua and Barbuda – Low child, low adult Argentina – Low child, low adult Bahamas – Low child, low adult Barbados – Low child, low adult Belize – Low child, low adult Bolivia – High child, high adult Brazil – Low child, low adult Canada – Very low child, very low adult Chile – Low child, low adult Colombia – Low child, low adult Costa Rica – Low child, low adult Cuba – Very low child, very low adult Dominica – Low child, low adult Dominican Republic – Low child, low adult Ecuador – High child, high adult El Salvador – Low child, low adult Grenada – Low child, low adult Guatemala – High child, high adult Guyana – Low child, low adult Haiti – High child, high adult Honduras – Low child, low adult Jamaica – Low child, low adult Mexico – Low child, low adult Nicaragua – High child, high adult Panama – Low child, low adult Paraguay – Low child, low adult Peru – High child, high adult Saint Kitts and Nevis – Low child, low adult Saint Lucia – Low child, low adult Saint Vincent and the Grenadines – Low child, low adult Suriname – Low child, low adult Trinidad and Tobago – Low child, low adult United States of America – Very low child, very low adult Uruguay – Low child, low adult Venezuela, Bolivarian Republic of – Low child, low adult Eastern Mediterranean Region (EMR) Afghanistan – High child, high adult Bahrain – Low child, low adult Cyprus – Low child, low adult Djibouti – High child, high adult Egypt – High child, high adult Iran, Islamic Republic of – Low child, low adult Iraq – High child, high adult Jordan – Low child, low adult Kuwait – Low child, low adult Lebanon – Low child, low adult Libyan Arab Jamahiriya – Low child, low adult Morocco – High child, high adult Oman – Low child, low adult 205 Statistical Annex Pakistan – High child, high adult Qatar – Low child, low adult Saudi Arabia – Low child, low adult Somalia – High child, high adult Sudan – High child, high adult Syrian Arab Republic – Low child, low adult Tunisia – Low child, low adult United Arab Emirates – Low child, low adult Yemen – High child, high adult European Region (EUR) Albania – Low child, low adult Andorra – Very low child, very low adult Armenia – Low child, low adult Austria – Very low child, very low adult Azerbaijan – Low child, low adult Belarus – Low child, high adult Belgium – Very low child, very low adult Bosnia and Herzegovina – Low child, low adult Bulgaria – Low child, low adult Croatia – Very low child, very low adult Czech Republic – Very low child, very low adult Denmark – Very low child, very low adult Estonia – Low child, high adult Finland – Very low child, very low adult France – Very low child, very low adult Georgia – Low child, low adult Germany – Very low child, very low adult Greece – Very low child, very low adult Hungary – Low child, high adult Iceland – Very low child, very low adult Ireland – Very low child, very low adult Israel – Very low child, very low adult Italy – Very low child, very low adult Kazakhstan – Low child, high adult Kyrgyzstan – Low child, low adult Latvia – Low child, high adult Lithuania – Low child, high adult Luxembourg – Very low child, very low adult Malta – Very low child, very low adult Monaco – Very low child, very low adult Netherlands – Very low child, very low adult Norway – Very low child, very low adult Poland – Low child, low adult Portugal – Very low child, very low adult Republic of Moldova – Low child, high adult Romania – Low child, low adult Russian Federation – Low child, high adult San Marino – Very low child, very low adult Slovakia – Low child, low adult Slovenia – Very low child, very low adult Spain – Very low child, very low adult Sweden – Very low child, very low adult Switzerland – Very low child, very low adult Tajikistan – Low child, low adult The former Yugoslav Republic of Macedonia – Low child, low adult Turkey – Low child, low adult Turkmenistan – Low child, low adult Ukraine – Low child, high adult United Kingdom – Very low child, very low adult Uzbekistan – Low child, low adult Yugoslavia – Low child, low adult South-East Asia Region (SEAR) Bangladesh – High child, high adult Bhutan – High child, high adult Democratic People’s Republic of Korea – High child, high adult India – High child, high adult Indonesia – Low child, low adult Maldives – High child, high adult Myanmar – High child, high adult Nepal – High child, high adult Sri Lanka – Low child, low adult Thailand – Low child, low adult Western Pacific Region (WPR) Australia – Very low child, very low adult Brunei Darussalam – Very low child, very low adult Cambodia – Low child, low adult China – Low child, low adult Cook Islands – Low child, low adult Fiji – Low child, low adult Japan – Very low child, very low adult Kiribati – Low child, low adult Lao People’s Democratic Republic – Low child, low adult Malaysia – Low child, low adult Marshall Islands – Low child, low adult Micronesia, Federated States of – Low child, low adult Mongolia – Low child, low adult Nauru – Low child, low adult New Zealand – Very low child, very low adult Niue – Low child, low adult Palau – Low child, low adult Papua New Guinea – Low child, low adult Philippines – Low child, low adult Republic of Korea – Low child, low adult Samoa – Low child, low adult Singapore – Very low child, very low adult Solomon Islands – Low child, low adult Tonga – Low child, low adult Tuvalu – Low child, low adult Vanuatu – Low child, low adult Viet Nam – Low child, low adult 206 The World Health Report 2000 ACKNOWLEDGEMENTS Headquarters Advisory Group Anarfi Asamoa-Baah James Banda Jamie Bartram Rafael Bengoa Andrew Cassels David Evans Pamela Hartigan Hans Hogerzeil Katja Janovsky Sergio Spinaci Jim Tulloch Eva Wallstam Hilary Wild Derek Yach Regional Reference Group Daniel López Acuña, AMRO Alastair Dingwall, WPRO Josep Figueras, EURO Martin Mckee, EURO Abdel Aziz Saleh, EURO U Than Sein, SEARO Leonard Tapsoba, AFRO Working Groups Basic demography Omar Ahmad Alan Lopez Doris Ma Fat Christopher Murray Joshua Salomon Causes of death Christina Biller Cynthia Boschi Pinto Mie Inoue Alan Lopez Rafael Lozano Christopher Murray Eduardo Sabate Joshua Salomon Toshihiko Satoh Lana Tomaskovic Burden of disease Cynthia Boschi Pinto Somnath Chatterji Brodie Ferguson Mie Inoue Alan Lopez Rafael Lozano Colin Mathers Christopher Murray Anthony Rodgers Eduardo Sabate Toshihiko Satoh Lana Tomaskovic Bedirhan Üstün Voranuch Wangsuphachart Disability-adjusted life expectancy Brodie Ferguson Alan Lopez Colin Mathers Christopher Murray Ritu Sadana Joshua Salomon Health inequalities Brodie Ferguson Julio Frenk Emmanuela Gakidou Gary King Christopher Murray Lana Tomaskovic Responsiveness Charles Darby Amala de Silva Kei Kawabata Christopher Murray Nicole Valentine Fairness of financial contribution Carmen Elisa Florez Jürgen John Kei Kawabata Felicia Knaul Patrick Lydon Christopher Murray Philip Musgrove Juan Pablo Ortiz de Iturbide Wibulpolprasert Suwit Aysit Tansel Hugh Waters Ke Xu Health system preferences Julio Frenk Emmanuela Gakidou Christopher Murray National health accounts and profiles Dominique Freire Patricia Hernández Catharina Hjortsberg Chandika Indikadahena Jack Langenbrunner Jean-Pierre Poullier Phyllida Travis Naoko Watanabe Performance analysis Lydia Bendib David Evans Jeremy Lauer Christopher Murray Ajay Tandon Basic economic data Yukiko Asada Lydia Bendib Steeve Ebener David Evans Raymond Hutubessy Jeremy Lauer Christopher Murray Tessa Tan-Torres Edejer Ajay Tandon Other contributors Gabriella Covino Dan Wikler Marie Windsor-Leutke Participants at Consultative Meeting of Health System Experts (Geneva, December 1999) Walid Ammar (Ministry of Health, Lebanon) Anders Anell (The Swedish Institute for Health Economics, Sweden) Peter Berman (Harvard School of Public Health, United States) Jonathan Broomberg (Praxis Capital, South Africa) Richard Feachem (Editor-in-Chief, Bulletin of WHO) Toshihiko Hasegawa (Institute of Health Services Management, Japan) William Hsiao (Harvard School of Public Health, United States) Jeremy Hurst (Organization for Economic Cooperation and Development, France) Barbara McPake (London School of Hygiene and Tropical Medicine, United Kingdom) Abdelhay Mechbal (WHO Regional Office for the Eastern Mediterranean) Ingrid Petersson (Swedish National Insurance Board, Sweden) Alexander Preker (The World Bank, United States) Neelam Sekhri Feachem (Healthcare Redesign Group of Companies, United States) Suwit Wibulpolprasert (Ministry of Public Health, Thailand) Beatriz Zurita (Mexican Health Foundation, Mexico) Participants at Meeting of Key Informants (Geneva, December 1999) Jeannette Aguirre de Abruzzese (Bolivia) Robert Basaza (Uganda) Aleksandra Banaszewska (Poland) Edgar Barillas (Guatemala) Gilbert Buckle (Ghana) Vung Nguyen Dang (Viet Nam) Charles Darby (United States) Jose de Noronha (Brazil) Damani de Silva (Sri Lanka) Orkhon Dontor (Mongolia) Andras Fogarsi (Hungary) Samy Gadalla (Egypt) Zora Gerova (Slovak Republic) David Gzirishvili (Georgia) Jorge Hermida (Ecuador) Gilbert Hiawalyer (Papua New Guinea) Pimonpan Isarabhakdi (Thailand) Saroj Jayasinghe (Sri Lanka) Mohd Ab Kadar bin Marikar (Malaysia) Shereen Khan (Bangladesh) Shixue Li (China) Marilyn Lorenzo (Philippines) Gillian Moalosi (Botswana) Ok Ryun Moon (Republic of Korea) Grace Murindwa (Uganda) Lipika Nanda (India) Kai Hong Phua (Singapore) Bhojraj Pokharel (Nepal) Andreas Polynikis (Cyprus) Farba Sall (Senegal) Dragomira Shuleva (Bulgaria) Agus Suwandono (Indonesia) Karl Theodore (Trinidad and Tobago) Martin Valdivia (Peru) Marcos Vergara (Chile) Gohar Wajid (United Arab Emirates) David Whittaker (South Africa) Yazoume Ye (Burkino Faso) Thomas Zigora (Zimbabwe) Beatriz Zurita (Mexico) INDEX Page numbers in bold type indicate main discussions Accessibility 24 Accountability health financing organizations 110, 111 service providers 65, 66, 68 Adult mortality 27, 145 inequalities 29 30, 31 statistics 156 163 strata 27, 145, 204 205 Advocacy 134 Afghanistan 31 Africa 6, 14, 51, 123 health financing 96 health system performance 40, 43 human resources 79 inequalities in health 31 service provision 57, 58 Age distribution, health care staff 78 AIDS, see HIV/AIDS Alma-Ata conference (1978) 14 Ambulatory services investment in 83 organizational incentives 67 68 regulation 126 Angola 79, 96 Antibiotics 9, 54, 81 Argentina 17, 65 health financing 100, 101, 103, 107, 108, 111 public stewardship 130, 138 Armenia 68 Asia health systems 14, 17 service provision 58, 69 Attainment, health system 23 assessing 17, 23 46 individual measures 27 29, 144, 152 155 overall score (index) 40, 149, 152 155 country rankings 196 199 resources available and 41, 43 44 weighting individual elements 39 Australia 30, 31 Austria 130 Autonomy health financing organizations 110, 111 patient 32 country ratings 33, 34 urban rural differences 33 35 providers 65, 66, 67 68, 122 purchasers 122 Bahrain 78 Bangladesh health financing 38, 78, 96, 102 service provision 51, 59, 67, 68 stewardship function 121, 123, 128 Beds, hospital changing investment patterns 88 89 resource profiles 85, 86, 87 Belarus 67, 130 Belgium 12 Bill and Melinda Gates Children's Vaccine Program 83 Birth attendants 51 of sixth billionth person xiii, Bolivia 96 Bosnia and Herzegovina 3, 62 Botswana 78 Brain drain, trained staff 78, 81, 136 Brazil 57, 100, 138 fair financing 36, 37, 38 health system responsiveness 34 malaria control service provision 65 British Medical Association 133 Budgets 58 59 global 106 investment planning and 89 line item 106, 107 operating, resources for 84 85 in primary care 17 in purchaser provider interactions 106 Buildings 76 Bulgaria 36, 37, 38 Burkina Faso 67, 76, 123 Cambodia 76, 79, 80, 123 Canada 65 66, 80, 130, 134 Cancer 145, 166 167, 172 173 Capital xvii, 75, 76, 138 economic lifetime 76 human, see Human resources investment ratios 76 77 public and private production 83 84 Capitation 106 107 risk adjusted 104 Capture financial decision-making 112 113 "personality", of specific policies 124 "regulatory" 128 Cardiovascular disease 145, 166 167, 172 173 Cataract 62 Charters, patients' 130 Childhood illness, integrated management 53, 64 Child mortality, under-5 27, 145 cost-effective prevention 10 distribution (index of equality) 29 31, 147, 176 183 service provision and 57 statistics 156 163 strata 27, 145, 204 205 Chile health financing 97, 102, 108, 109 health system development 12, 13, 17 health system performance 40, 45 health system responsiveness 34 inequality in life expectancy 30, 31 public stewardship 125 126 China 36 38, 79 health system reform 14, 16, 17 public stewardship 125, 138 Chinese medicine, traditional 11 Choice of providers 32, 33, 34, 106 Citizens 50, 51 Client orientation country ratings 33, 34 elements 32 Colombia 17, 59, 138 fair financing 38 health financing 100, 101, 104, 109 110 health system performance 40, 45 Colonies, former 14 Communicable diseases 5, 51, 56, 64 disease burden 170 171 mortality statistics 164 165 Communication in regulation 128 for stewardship 132, 133, 134 Communist states 13, 16, 17 Community pooling organizations 103, 104, 108 incentives 111, 112 Community health workers 14 15 Competition between providers 137 138 pooling 103 104, 109 Compliance, ensuring 124 129 Computerized tomography (CT) scanners 85, 86 Confidentiality 32, 130 country ratings 33, 34 urban rural differences 33 35 Consultation 132, 133 Consumables 75 production 82, 83 in resource profiles 85 Consumers 50 51, 134 135, 136 Continuing education 76, 80 81 Contracts provider 62, 63, 67, 68, 105 106, 107 staff 81 Contributors (to financing) 50, 51 Control mechanisms, in health financing 111 112 Coordination 132 Co-payments 98 99 Corruption xv, 121 122 Costa Rica 12, 14, 68 health financing 100, 108, 113 Cost-effectiveness additional criteria 55 57 misuse 54 55 poverty and prevention of child mortality 10 in priority-setting 52 55 Costs (see also Expenditure) capital investment 76 77 containment provider incentives 106, 107 techniques 58 59 health interventions 54 labour 77 recurrent 75, 76 77, 84 85, 138 Croatia 63, 67 Cross-subsidies 99 100 Cuba 14, 40, 125 Cyprus 34 Czech Republic 63, 68 DALE, see Disability-adjusted life expectancy DALYs, see Disability-adjusted life years Death, see Mortality Decentralization 65, 69, 91, 138 revenue pooling and 100 Decision rights health financing organizations 110, 111 provider organizations 65, 66 Demand, responding to 15, 16 Denmark 12, 130 health care resource profile 85, 86 service provision 63 Dependency ratio 156 163 Developed countries evolution of health systems 11 12, 17 health care resource profiles 85 86 health financing 139 140 primary care 15 Developing countries health financing 96, 98, 107 primary health care 14 15 priority setting 53 private sector regulation 128 Diagnostic activities 52 Diagnostic related payments 106 Dignity, respect for 24, 32, 34 urban rural differences 33 35 Disability 28 survival free of 28 Disability-adjusted life expectancy (DALE) 27 28, 146 derivation 28 in overall attainment index 39, 40 in overall performance index 42 43, 150, 200 203 relation to life expectancy 28, 29 resources available and 41, 42 43 statistics 176 183 Disability-adjusted life years (DALYs) 27, 28, 146, 170 175 Disasters 58 Disease burden by cause, sex and mortality stratum 146, 170 175 patterns 51 poverty and setting priorities and 53, 56 summary measures 28 Doctors, see Physicians Donors decentralization and 91 financial contributions 96 sector-wide approaches 84 85, 123, 135 stewardship role 135 Drugs, see Medications Economies of scale 101, 103, 105 Ecuador 34, 96 Education (see also Training) continuing 76, 80 81 health system investment 77 health system performance and 41 42 of human resources 76 system 5, 23, 134 Efficiency conflict with equity 56 57 health financing and 113 Egypt 34, 64 health care resource profile 86 88 health financing 102 human resources 78, 79, 81 public stewardship 127, 138 Emergency care 110 Environmental safety Epidemics 58 Epidemiological data 57 58 Equatorial Guinea 51 Equipment 76 extent of use 79 public and private production 82 83 purchasing xvii xviii, 82 stewardship 139 Equity (see also Inequalities) in conflict with efficiency 56 57 cross-subsidies to increase 99 100 health financing and 113 in overall attainment index 39 Eritrea 96 Errors, medical 10 Essential drugs 128, 131 Ethiopia 51, 64, 123, 125 Ethnic differences, distribution of resources 88 Europe 51, 57 central and eastern 9, 16, 64, 67 health equality 30 western Expanded Programme on Immunization (EPI) 83 Expectations, responding to people's, see Responsiveness Expenditure (see also Costs) food 36 health, see Health expenditure non-food 36, 38 out-of-pocket, see Out-of-pocket payments Fair financing 8, 23 24, 26, 97 country rankings 188 191 measuring 27, 35 39 summary measure (index) 36 38, 148 weighting 39 Fairness xi, 23, 26 in overall attainment index 39, 40 revenue collection methods 97 98, 113 Family planning 53 Family practice 15 Fee-for-service payments 106 Fertility rate, total 156 163 Fiji 80 Financial responsibility health financing organizations 110, 111 service providers 65 Financing, health system xi, xviii xix, 44 45, 95 113 contributors 50, 51 effect on equity and efficiency 113 fairness of distribution, see Fair financing functions 95 97 organizations 98 forms 108 110 incentives 110 113 stewardship of 124 prepayment and collection 97 99 protection from risk 8, 24, 35 purpose 95 reforms 16 17 regulation 103, 104, 111 112, 125 126, 138 setting priorities 55, 56 spreading risk and subsidizing poor 99 104 stewardship 105, 111, 112, 136, 139 140 strategic purchasing 104 107 Finland 67, 90, 130, 133 Food spending 36 Fragmentation health service 68 revenue pool 101 103 France 10, 121, 130, 138 Free-of-charge services 99 Frontiers 41 42 Functions, health system xi, 8, 23 25 improving performance and 44 46 relations to objectives 25 Gabon 51 Gambia 96 General practice 15 General practitioners 65, 67, 78 fundholding 17, 107 Georgia 34, 130 Germany 12, 109, 139 Ghana health financing 96, 107 health policy framework 121, 122, 123 resources 78, 84 service provision 57, 68, 69 Global Alliance for Vaccines and Immunization (GAVI) 83 Global Programme on Evidence for Health Policy 144 Goals, health system xi, 8, 23—25 attainment, see Attainment, health system measuring achievement 27 39 relation to functions 25 Goodness xi, 26 in overall attainment index 39, 40 Governance 111, 112 Governments (see also Ministry of health) health system performance and 135 136 partnerships with donors 84 service organization 62 stewardship role xiv xv, 45, 119 120, 132 Greece 32, 125, 130 Guatemala 14 Guinea 54, 130 Guinea-Bissau 80 Guyana 38 Haemophilus influenzae type b (Hib) vaccine 83 Health actions defined xiii indirectly affecting health actors, in non-health sectors 120, 122 average level (status) 26 health expenditure and 42 43, 150, 200 203 measuring 27 28, 146 147 resources available and 41, 42 43 summary measures 28 tables 152 183 weighting 39 distribution in population (equality) 26 measuring 27, 28 31, 146 147 tables 152 155, 176 183 weighting 39 impact of health systems on 11 measuring goal achievement 27 31 in overall attainment index 39, 40 as primary goal 8, 23, 24 unique characteristics "Health for All" strategy 14 Health assistants 78 Health care workers (see also Nurses; Physicians) brain drain 78, 81, 136 complaints about 31 distribution 79, 80 generation 77 information collection 130 motivation 78, 79 numerical balance 79, 80 pay and benefits 78, 80 problems facing 78 self-regulation 128, 134 skill mix 77 78, 79, 80 substitution among 77, 78 training, see Training Health education 63 64 Health expenditure global 6, 95 health system performance and 40 44, 150, 200 203 household, assessing fairness 36 39, 148 impact on health national statistics 39, 149, 192 195 per capita 86, 87, 192 195 resource profiles 86, 87 Health insurance 95 evolution 12 13, 17 organizational problems 109 private, see Private health insurance work-related xviii, 12, 13, 98 Health Maintenance Organizations 17, 62, 68 69, 107 Health policy, national xv, 122 124 frameworks 121, 123 124 in health financing 111, 112 resource use 79, 91 trends 121 Health promotion Health services 5, choosing interventions 52 58 additional criteria 55 57 cost-effectiveness criteria 52 55 information needed 57 58 delivery configurations 63 64 concentrated 63 64 dispersed 63 hybrid 64 integration 68 69 organization 61 69 failings 49 50 forms 62 63 people involved 50 52 providers, see Providers provision xi, xv xvi, 44, 49 69 improving 137 138 provider incentives 106 rationing, see Rationing, health care Health systems attainment, see Attainment, health system definition xiii, evolution xiii xiv, 11 13 functions, see Functions, health system goals (objectives), see Goals, health system importance 11 performance, see Performance, health system reform 13 17 Hepatitis B vaccine 83 Hierarchical bureaucracies 62 63, 65 66, 68 changing investment patterns 89 90, 91 control of health financing 112 shortcomings 120 High income countries, see Developed countries Hisba system, Islamic countries 123 124 HIV/AIDS availability of treatment 82, 126 control programmes 64 epidemic 28, 43, 58, 145 prevention 53 Home care Hong Kong 130 Hospitals 63 64 capital investment in 76 changing investment patterns 88 89 historical evolution 11, 12 in low income countries 14 medical errors 10 operating costs 85 organizational incentives 66 67 private, regulation 126 public and private investment 83 84 semi-autonomous 65 Household, burden of health financing 36 39, 148 Human resources (capital) (see also Health care workers) 76, 77 81 health system performance and 41 42 imbalances xvi xvii, 77 79 investment in 76, 77, 84 prices for 82 recurrent costs 77, 84 in resource profiles 85, 86 87, 88 stewardship 138 substitution among 77, 78 successful strategies 80 81 Hungary 80, 97 health system responsiveness 34 service provision 63, 65, 68, 69 Hygiene 10, 11 Iceland 130 Ill-health economic burden poverty and Immunization 9, 32, 53, 83 Incentives definition 61 health care workers 80 health financing organizations 110 113 internal vs external 109, 110 111 to join pools 104 physician 78, 79 provider 61 68, 106 107 aligning 64 68 coherence 66, 121 organizational forms and 65 66 regulatory approaches 125 Income growth, impact on health 10 11 out-of-pocket financing and 96 pooling of risk and 99 100 Independent Practice Associations 17, 107 India fair financing 37, 38 health financing 96, 107 health system evolution 13, 14 human resources 81 public stewardship 12, 120, 121, 127 service provision 62, 67 Indigenous populations, exclusion 14 Indonesia 14, 34, 65, 96 Industrialized countries, see Developed countries Industrial revolution 11 12 Inequalities in health, see Health, distribution in population in life expectancy 29 31 reducing 26, 55 Infectious diseases, see Communicable diseases Influenza epidemic 88 89 "Informal charging" xv, 78, 121 Information xvi, 6, 137 for priority setting 57 58 on resource use 90 91 for stewardship 129 132 collection 129 130 dissemination 130 131 resources required 130 131 strategies to improve 133 134 Injuries 53, 145, 168 169, 174 175 Inputs, health system (see also Resources, health care) 75 77 Institutional factors, in health financing 98, 108 110 Institutions 61 Insurance (see also Health insurance; Social insurance) xviii, 62 evolution 12 13, 16 17 failures 38, 56 function, health system 96 regulation 61 Integration health service 6, 45, 68 69 vertical 68 69 virtual 68 69, 132 Intelligence, see Information International Federation of Pharmaceutical Manufacturers Associations (IFPMA) 83 International Labour Organisation Interventions 51 52 choosing 52 58, 105 additional criteria 55 57 cost-effectiveness criteria 52 55 information needed 57 58 clinical 52 combinations 54 definition 61 essential, basic, core 59 public health 52 range 52 Investment 45, 76 central policy and guidance 91 changing patterns 88 90 expenditure ratios 76 77 joint ventures 83 84, 132 legacies of past 84 85 public and private 83 84 Iran, Islamic Republic of 14 Ireland 130 Islamic countries, Hisba system 123 124 Israel 130 Jamaica 36, 38, 80, 81 Japan 79, 138, 139 health system attainment 40 health system evolution 12, 13 inequality in life expectancy 30, 31 Joint investment ventures 83 84, 132 Kazakhstan 78 Kenya 76, 96, 121, 133 Knowledge advances in 9, 10, 11, 81 82 investment in 83, 84 Kyrgyzstan 36, 38 Laboratories central public health 63 64 extent of use 79 investment in 83 Labour costs 77 Lao People's Democratic Republic 96 Latin America health equality 30 31 health systems 13, 14, 45 service provision 65 Life expectancy health expenditure and 43 inequalities in 29 31 measures 28 relation to DALE 28, 29 rise during 20th century statistics 156 163 Lithuania 130 Lobbying 88 Low income countries health financing xviii, 98, 103, 139 health system development 14 imbalance in health care inputs 76 77 service provision 58 59 Magnetic resonance imaging (MRI) scanners 85, 86 Maintenance 76, 84 Malaria 64, 82 control 9, 12, 53, 54 vaccine 82 Malaysia 17, 68 Mali 67, 76, 96, 123 Malnutrition 5, 57 Managed care 15 Mandates, unfunded, see Unfunded mandates Market economies, transition to 16 17 Market exposure health financing organizations 110, 111 service providers 65, 66, 68 Markets internal 110 in service provision 62, 63 Maternal health interventions 53 Mauritania 51 Media, mass 133 Medical associations 128 Medical savings accounts 99 Medications (drugs) allocating resources to 81 82 branded vs generic 79, 87 errors in use 10 excessive use 79 public and private production 82 83 public stewardship 128, 131, 139 in resource profiles 85, 86 87 Mexico 13, 17, 59 fair financing 36, 37, 38 health care resource profile 86 88 health financing 107 inequality in life expectancy 30, 31 Micro-purchasing 106 Middle income countries health care resource profiles 86 88 health financing xviii, 98, 103, 139 improving health systems 137 138 Minister of health 124 Ministry of finance 96, 109 incentives 110, 111, 112, 113 Ministry of health financing function 96, 108, 109 incentives 110, 111, 112, 113 role xvii, 119 140 short-sightedness 120 121 tunnel vision 121 turning a blind eye 121 122 Mongolia 121 Monopsony power 105 Morocco 64 Mortality (see also Adult mortality; Child mortality, under-5) 28 by cause and sex 27, 145, 164 169 preventable rates, declining 10 11 strata 27, 145, 204 205 Mosquito control 9, 12 Motherhood, safe 53 Motivation, health care workers 78, 79 Motor vehicles accidents 6, 120, 133 exhaust fumes 10 maintenance 84 Mozambique 76, 96, 123, 125 Myanmar 120 National health accounts (NHAs) xvii, 90 91, 149 Member States 192 195 as tools for stewardship 136, 138 National health policy, see Health policy, national National Health Service (UK) 12, 45, 58, 62, 107, 133 Needs, responding to 15 Nepal 51, 78, 79 fair financing 36 38 health system responsiveness 34 Netherlands 12, 59 health financing 100, 101, 109 public stewardship 128, 130 New Zealand 12, 129, 134 health financing 17, 97, 107 service provision 59, 66, 68, 69 Nicaragua 57, 96, 108 fair financing 36, 38 Niger 14 Nigeria 120 Noncommunicable diseases 53, 166 169, 172 175 Norway 45, 130 health system evolution 12, 13 inequality in life expectancy 30, 31 service provision 59, 63 Nurse practitioners 15 Nurses 78, 80, 81, 87 Nutritional deficiencies 164 165, 170 171 Objectives, health system, see Goals, health system Oman 80 Oregon, United States 59, 131 Organizations 61 health financing, see Financing, health system, organizations health services, see Health services, organization Out-of-pocket payments (see also User fees) xviii, 95 96, 139 income level and 96 unfairness 35 39, 97 98 Outsourcing 67 Ownership 111 Pakistan 31, 57, 96 fair financing 37, 38 health system performance 40 Pan American Health Organization 24 Papua New Guinea 96, 107 Paraguay 36, 38 Patients 50 51 expectations, responsiveness to, see Responsiveness rights 4, 130, 131, 136 Performance, health system (see also Attainment, health system) xi xii, 17, 23 46 government responsibility 135 136 improving 44 46, 137 140 lower limits 41, 42 overall indicators xi xii, 40 44, 150, 152 155, 200 203 potential for improvement xiv xv, 10 upper bounds (frontiers) 41 42 Peru 36, 38, 57 Pharmaceutical industry 136 Pharmaceuticals, see Medications Pharmacists 78 Philippines 57, 67, 81 Physician assistants 15 Physicians 77 78 health financing and 113 incentives to 78, 79 incompetent/unsafe 121 numerical balance 79, 80, 89 private charging 78, 121 regulation 127, 128 in resource profiles 85, 86 87, 88 retention in public sector 78, 81 in rural areas 79, 80, 81, 88 specialist 78, 79 Poland 68, 121 Political parties 124 Pooling xviii, 96 97, 99 104, 136 competition 103 104, 109 efficiency and equity 113 mandatory participation 103 104, 126 within providers 107, 108 Pools exclusion from 104 fragmentation 101 103 large 101, 103 Poor xiv, burden of disease 5, 51 health system responsiveness 33 impact of co-payments 99 improving access for 16 incentives to protect 110 responsibilities to subsidizing xviii xix, 66, 99 104 Populations 50 growth rates 156 163 percentage aged 60+ years 156 163 statistics 156 163 Portugal 121, 130 Poverty ill-health, cost-effectiveness and unexpressed needs 15 Prepayment xviii xix, 97 99, 136 collection mechanisms 97 99 fairness 35 36, 37, 38 39, 97 98 health care rationing and 59 public stewardship 139 140 related to risk 35 36, 109 Prevention, disease 5, 52 provider incentives 106 107 Prices, input 81 Primary health care xiii, 14 16 budget holding in 17 equality of access 16 groups 107 interventions and population covered 15 16 Priorities enforcing 58 60, 61 62 setting xvi, 52 58, 61, 131, 137 Privacy, right to 130 Private health insurance internal and external incentives 110, 111, 112 regulation 125 126, 128, 136 voluntary 95, 96, 98, 108 109 Private sector xv xvi, 62 financing 97 investment ratios 76 77 loss of trained staff to 78, 81 production of resources 82 84 regulation 61, 125 129 stewardship of 120, 134, 136 stewardship within 45, 134 Professional organizations 128, 134 Profiles, health care resource 85 88 Progressive payments 35 36 Project approach 96, 135 Promptness of attention 32 country ratings 33, 34 urban rural differences 33 Providers 50, 51, 61 68 choice of 32, 33, 34, 106 competition between 137 138 identifying best 105 incentives, see Incentives, provider information collection 130 instruments for paying 97 investment decisions 91 micro-management 106 nongovernmental, importance 120 organization 62 64 payment mechanisms 106 107 as pooling organizations 107, 108 purchasing from 105 107 split from purchasers 69, 109 110 stewardship 119, 124 Public health financing 97 laboratories, central 63 64 schools 80 81 Public sector brain drain of trained staff 78, 81 control of health financing 111 112 financing 13, 56, 97 99 inequality of access 16 production of resources 82 84 strong, as regulatory tool 127 128 Purchasers 104 107 investment decisions 91 large 105 split from providers 69, 109 110 stewardship role 119 Purchasing 97 allocation of funds to 104 corruption and 122 equity and efficiency 113 micro- 106 passive 97 strategic xvii, 97, 104 107, 138 units 105 Quality of amenities 32 country ratings 33, 34 rural urban differences 33 Quasi-contractual arrangements 107 Rationing, health care 58 60, 89, 137 approaches to 58 60 co-payments for 98 99 explicit 59, 60 Recurrent costs 75, 76 77, 84 85, 138 Referral systems 15 Reform, health system 13 17 Regressive payments 35 Regulations (and rules) 45, 61, 124 129 communication requirements 128 effective public services and 127 128 ensuring compliance 124 129 health financing 103, 104, 111 112, 125 126, 138 lack of enforcement xv, 121 122 lessons for development 128 129 patients' rights 130, 131 private sector 61, 125 129 promotive and restrictive 125 126 resources required 126 127 Religious groups 128 Republic of Korea 17, 34, 101, 139 Research and development 76, 83, 84, 136, 139 Resources, health care 7, 75 91 advances in knowledge/technology and 81 82 balancing the mix xvi xviii, 75 77 changing investment patterns 88 90 future challenges/solutions 90 91 generation xi, 45, 138 139 human, see Human resources for information collection/use 130 131 legacies of past investments 84 85 performance in relation to 40 44 profiles 85 88 public and private production 82 84 rationing 58 60, 89, 137 for regulation 126 127 Respect for persons 32, 34 urban rural differences 33 35 Responsiveness (to people's expectations) 8, 23 24, 51 components 31 32 distribution 26 country rankings 184 187 measuring 27, 33 35, 147 148 weighting 39 measuring goal achievement 31 35, 147 148 in overall attainment index 39, 40 overall level 26 country rankings 184 187 measuring 27, 31 33, 147 weighting 39 provider incentives 106 rating of individual elements 32 33, 34 stewardship role 130, 131 Revenue collection 95 96, 97 99 equity and efficiency 113 pooling, see Pooling Rights, patients' 4, 130, 131, 136 Risk factors 57, 58 prepayments related to 35 36, 109 protection, financial 8, 24, 35 redistribution 99 100 selection 104, 112 sharing xviii, 24, 96 98, 99 104 payment mechanisms 105 107 Road safety 5, Road traffic accidents 6, 120, 133 Rockefeller Foundation 83 Romania 38 Rules, see Regulations (and rules) Rural areas (see also Urban rural differences) human resources 79, 80, 81, 88 Russia 12 Russian Federation fair financing 36, 38 health care resources 82, 89 Sanitation 10, 11 San Marino 130 Saudi Arabia 80 School health 53 Seat belts Sector-wide approaches (SWAP) 84 85, 96, 123, 135 Segmentation, health system 45 Selection adverse 104 behaviour 103 104 risk 104, 112 Self-regulation 128, 130, 134 Senegal 67, 123 Service provision, see Health services, provision Sexually transmitted diseases 53 Sick, incentives to protect 110 Singapore 17, 66, 99 Sixth billionth person xiii, Social insurance 108 109 collection 98 employment-based xviii, 12, 13, 98 evolution 12 13 mandated 95, 96 Social security organizations 108 109 incentives 111, 112, 113 involvement in stewardship 134 Social support networks, access to 32, 33, 34 South Africa 67, 107 health care resource profile 86 88 health system development 13, 14 health system responsiveness 34 regulation of insurance system 82, 125, 126 Soviet Union, former 68 health care resources 82, 89 health system evolution 12, 13, 16 health system responsiveness 31 Specialist physicians 78, 79 Sri Lanka 14, 85 private sector regulation 127 service provision 65, 68, 69 Stakeholders 134 Stewards 51 Stewardship xi, xiv xv, 24, 45, 119 140 basic tasks 122 132 collecting and using intelligence 129 132 formulating health policy 122 124 implementation 132 135 regulations and rules 124 129 challenges to 135 136 current problems 120 122 definition 119 health financing 105, 111, 112, 136, 139 140 improving health system performance 137 140 international 82, 84, 131 investment decisions 91 tunnel vision in 121 Strategic purchasing xvii, 97, 104 107, 138 Subsidies xviii xix, 66, 99 104 Substitution, among human resources 77, 78 Sweden 10, 13 health care resource profile 85 86 health system performance 40 public stewardship 131, 134 service provision 59, 68 Switzerland 121 Taxation, general 95 96, 98 Tax incentives 125 Technology, medical xvii xviii, 76 advances in 9, 81 82, 91 health care resource profiles 85 86, 87 in rural areas 88 stewardship 139 widening gap in use 82 Tertiary centres 15 Thailand 67, 79, 107 health care resource profile 86 88 public stewardship 125, 133 Tobacco control 53, 133 -induced disease 41 Traditional healers Traditional medicine 11 Training xvii, 76, 80 81 imbalances 79 investment in 77, 84 stewardship 138 Tuberculosis 53, 64, 82 Tunisia 121 Turkey 62, 64 Uganda 69, 80, 96, 123 health system performance 40 health system responsiveness 34 Uncertainty intervals 27, 145, 149 Unfunded mandates health financing organizations 110, 111 service providers 65, 66 UNICEF 83 United Kingdom (UK) 10, 12, 89 health care resource profile 85 86 health financing 17, 97, 100, 102, 107 health system responsiveness 32, 130 National Health Service, see National Health Service public stewardship 121, 126, 138 service provision 58, 63, 66, 68 United Republic of Tanzania 14, 81 fair financing 37, 38 health financing 96, 107 public stewardship 123, 125, 133 United States (USA) 6, 10, 81 health care resource profile 85 86 health financing 99, 104, 110, 139 140 Health Maintenance Organizations 17, 62, 68 69, 107 health system attainment 40 inequality in life expectancy 30, 31 provider incentives 66 public stewardship 121 122, 125, 130, 138 Universalism classic 13 new xiii, 15 Urban rural differences (see also Rural areas) distribution of resources 87 88 health system development 10, 11 health system responsiveness 33 Uruguay 130 User fees (see also Out-of-pocket payments) 69, 98 99, 133 illicit xv, 78, 121 Vaccines 81, 83, 139 Vested interests 88 Viet Nam 34, 57 fair financing 36 38 public stewardship 120, 123 "Virtual" health systems 68 69, 132 Waiting times 31 Wars 12 13 Water, safe 10 Work-related health insurance xviii, 12, 13, 98 World Bank 53, 82, 83 World development report 53 World Health Assembly, 53rd (May 2000) xii World Health Organization (WHO) 82, 83 Yellow fever 12, 83 Yugoslavia, former 14 Zambia 59, 67 fair financing 36, 37, 38 health financing 101 public stewardship 123, 133 Zimbabwe 96, 107 .. .WORLD HEALTH ORGANIZATION he WOR L D HE A LT H R E P ORT 2000 ealth ystems: mproving erformance ii The World Health Report 2000 WHO Library Cataloguing in Publication Data The World health report. .. people’s health This report suggests that the boundaries of health systems should encompass all actions whose primary intent is to improve health viii The World Health Report 2000 The report breaks... World health report 2000 : health systems : improving performance World health Health systems plans Delivery of health care Health services administration Financing, Health Health services accessibility