The WORLD HEALTH REPORT 2000

• Overview iii

• MESSAGE FROM THE DIRECTOR-GENERAL VII

• OVERVIEW XI

  • How health systems have evolved xiii

  • The potential to improve xiv

  • Providing better services xv

  • Finding a better balance xvi

  • Protecting the poor xviii

World Health Report 2000-2

• CHAPTER 1
  WHY DO HEALTH SYSTEMS MATTER? 1

  • The changing landscape 3

  • What is a health system? 5

  • What do health systems do? 7

  • Why health systems matter 8

  • How modern health systems evolved 11

  • Three generations of health system reform 13

  • Focusing on performance 17

• CHAPTER 2
  HOW WELL DO HEALTH SYSTEMS PERFORM? 21

  • Attainment and performance 23

  • Goals and functions 23

  • Goodness and fairness: both level and distribution matter 26

  • Measuring goal achievement 27

  • Overall attainment: goodness and fairness combined 40

  • Performance: getting results from resources 40

  • Improving performance: four key functions 44

• CHAPTER 3
  HEALTH SERVICES: WELL CHOSEN, WELL ORGANIZED? 47

  • Organizational failings 49

  • People at the centre of health services 50

  • Choosing interventions: getting the most health from resources 52

  • Choosing interventions: what else matters? 55

  • Choosing interventions: what must be known? 57

  • Enforcing priorities by rationing care 58

  • After choosing priorities: service organization and provider incentives 61

  • Organizational forms 62

  • Service delivery configurations 63

  • Aligning incentives 64

  • Integration of provision 68

• CHAPTER 4
  WHAT RESOURCES ARE NEEDED? 73

  • Balancing the mix of resources 75

  • Human resources are vital 77

  • Adjusting to advances in knowledge and technology 81

  • Public and private production of resources 82

  • The legacy of past investments 84

  • Health care resource profiles 85

  • Changing investment patterns 88

  • The way forward 90

• CHAPTER 5
  WHO PAYS FOR HEALTH SYSTEMS? 93

  • How financing works 95

  • Prepayment and collection 97

  • Spreading risk and subsidizing the poor: pooling of resources 99

  • Strategic purchasing 104

  • Organizational forms 108

  • Incentives 110

  • How financing affects equity and efficiency 113

• CHAPTER 6
  HOW IS THE PUBLIC INTEREST PROTECTED? 117

  • Governments as stewards of health resources 119

  • What is wrong with stewardship today? 120

  • Health policy – vision for the future 122

  • Setting the rules, ensuring compliance 124

  • Exercising intelligence, sharing knowledge 129

  • Strategies, roles and resources: who should do what? 132

  • What are the challenges? 135

  • How to improve performance 137

World Health Report 2000 -3

• STATISTICAL ANNEX 143

  • Explanatory notes 144

  • Annex Table 1 Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997 152

  • Annex Table 2 Basic indicators for all Member States 156

  • Annex Table 3 Deaths by cause, sex and mortality stratum in WHO Regions, estimates for 1999 164

  • Annex Table 4 Burden of disease in disability-adjusted life years (DALYs) by cause, sex and mortality stratum in WHO Regions, estimates for 1999 170

  • Annex Table 5 Health attainment, level and distribution in all Member States, estimates for 1997 and 1999 176

  • Annex Table 6 Responsiveness of health systems, level and distribution in all Member States, WHO indexes, estimates for 1999 184

  • Annex Table 7 Fairness of financial contribution to health systems in all Member States, WHO index, estimates for 1997 188

  • Annex Table 8 Selected national health accounts indicators for all Member States, estimates for 1997 192

  • Annex Table 9 Overall health system attainment in all Member States,

  • WHO index, estimates for 1997 196

  • Annex Table 10 Health system performance in all Member States, WHO indexes, estimates for 1997 200

• LIST OF MEMBER STATES BY WHO REGION AND MORTALITY STRATUM 204

• ACKNOWLEDGEMENTS 206

• INDEX 207

• TABLES

  • Table 3.1 Interventions with a large potential impact on health outcomes 53

  • Table 3.2 Examples of organizational incentives for ambulatory care 67

  • Table 5.1 Estimated out-of-pocket share in health spending by income level, 1997 96

  • Table 5.2 Approaches to spreading risk and subsidizing the poor: country cases 101

  • Table 5.3 Provider payment mechanisms and provider behaviour 106

  • Table 5.4 Exposure of different organizational forms to internal incentives 111

  • Table 5.5 Exposure of different organizational forms to external incentives 112

• FIGURES

  • Figure 1.1 Coverage of population and of interventions under different notions of primary health care 15

  • Figure 2.1 Relations between functions and objectives of a health system 25

  • Figure 2.2 Life expectancy and disability-adjusted life expectancy for males and females, by WHO Region and stratum defined by child mortality and adult mortality, 1999 29

  • Figure 2.3 Inequality in life expectancy at birth, by sex, in six countries 30

  • Figure 2.4 Relative scores of health system responsiveness elements, in 13 countries, 1999 34

  • Figure 2.5 Household contributions to financing health, as percentage of capacity to pay, in eight countries 37

  • Figure 2.6 Performance on level of health (disability-adjusted life expectancy) relative to health expenditure per capita, 191 Member States, 1999 43

  • Figure 2.7 Overall health system performance (all attainments) relative to health expenditure per capita, 191 Member States, 1997 44

  • Figure 3.1 The multiple roles of people in health systems 50

  • Figure 3.2 Questions to ask in deciding what interventions to finance and provide 55

  • Figure 3.3 Different ways of rationing health interventions according to cost and frequency of need 60

  • Figure 3.4 Different internal incentives in three organizational structures 66

  • Figure 4.1 Health system inputs: from financial resources to health interventions 75

  • Figure 4.2 Health systems input mix: comparison of four high income countries, around 1997 86

  • Figure 4.3 Health systems input mix: comparison of four middle income countries, around 1997 87

  • Figure 5.1 Pooling to redistribute risk, and cross-subsidy for greater equity 100

  • Figure 5.2 Structure of health system financing and provision in four countries 102

• BOXES

  • Box 1.1 Poverty, ill-health and cost-effectiveness 5

  • Box 1.2 Health knowledge, not income, explains historical change in urban–rural health differences 10

  • Box 2.1 Summary measures of population health 28

  • Box 2.2 How important are the different elements of responsiveness? 32

  • Box 2.3 What does fair contribution measure and not measure? 38

  • Box 2.4 Weighting the achievements that go into overall attainment 39

  • Box 2.5 Estimating the best to be expected and the least to be demanded 41

  • Box 4.1 Substitution among human resources 78

  • Box 4.2 Human resources problems in service delivery 79

  • Box 4.3 A widening gap in technology use? 82

  • Box 4.4 The Global Alliance for Vaccines and Immunization (GAVI) 83

  • Box 4.5 Investment in hospitals in countries of the former Soviet Union prior to policy reform 89

  • Box 5.1 The importance of donor contributions in revenue collection and purchasing in developing countries 96

  • Box 5.2 The Chilean health insurance market: when stewardship fails to compensate for pooling competition problems and for imbalances between internal and external incentives 109

  • Box 6.1 Trends in national health policy: from plans to frameworks 121

  • Box 6.2 Ghana’s medium-term health policy framework 122

  • Box 6.3 SWAPs: are they good for stewardship? 123

  • Box 6.4 Stewardship: the Hisba system in Islamic countries 124

  • Box 6.5 South Africa: regulating the private insurance market to increase risk pooling 126

  • Box 6.6 Opening up the health insurance system in the Netherlands 128

  • Box 6.7 Responsiveness to patients’ rights 130

  • Box 6.8 Towards good stewardship – the case of pharmaceuticals 131

  • Box 6.9 Thailand: the role of the media in health system stewardship 133