Theme Papers A framework for assessing the performance of ...

1 Theme PapersA framework for assessing the performanceof health systemsChristopher Murray1& Julio Frenk2 health systems vary widely in performance , and countries with similar levels of income, education and healthexpenditure differ in their ability to attain key health goals. This paper proposes a framework to advance theunderstanding of health system performance . A first step is to define the boundaries of the health system, based on theconcept of health action. health action is defined as any set of activities whose primary intent is to improve or maintainhealth. Within these boundaries, the concept of performance is centred around three fundamental goals: improvinghealth, enhancing responsiveness to the expectations of the population, and assuring fairness of financialcontribution. Improving health means both increasing the average health status and reducing health includes two major components: (a) respect for persons (including dignity, confidentiality andautonomy of individuals and families to decide about their own health ); and (b) client orientation (including promptattention, access to social support networks during care, quality of basic amenities and choice of provider).

2 Fairness offinancial contribution means that every household pays a fair share of the total health bill for a country (which maymean that very poor households pay nothing at all). This implies that everyone is protected from financial risks due tohealth care. The measurement of performance relates goal attainment to the resources available. Variation inperformance is a function of the way in which the health system organizes four key functions: stewardship (a broaderconcept than regulation); financing (including revenue collection, fund pooling and purchasing); service provision (forpersonal and non-personal health services); and resource generation (including personnel, facilities and knowledge).By investigating these four functions and how they combine, it is possible not only to understand the proximatedeterminants of health system performance , but also to contemplate major policy :outcome and process assessment, health care; health care rationing; health services accessibility; socialjustice; health systems plans; financing, page 728 le re sume en franc ais.

3 En la pa gina 729 figura un resumen en espan is wide variation in health outcomes forcountrieswithsimilarlevelsofincomeand education(1, 2). Some of this variation is due to differences inhealth system performance . Differences in thedesign, content and management of health systemstranslateintodifferencesinarangeo fsociallyvaluedoutcomes,suchashealth,res ponsiveness, at all levels need to quantify thevariation in health system performance , identifyfactorsthatinfluenceitandarticul atepoliciesthatwillachieve better results in a variety of settings. Theperformance of system sub-components, such asregions within countries or public health services,also needs to be assessed. Meaningful, comparableinformation on health system performance , and onkey factors that explain performance variation, and operational framework for assessinghealth system performance is vital for the work ofgovernments, frameworks for measuring healthsystem performance have been proposed (3 10)and are testimony to the importance given to thisenterprise.

4 Taken together, these frameworks are arich source of ideas and approaches. Nevertheless,we believe that there is room for improvement. Forexample, approaches to health system performanceoften fall into two related traps. Some are inclusivelists of multiple, and often overlapping, ,forexample,haveincludedgoalsrelatedtohe alth,healthinequalities, coverage, equitable financing, quality,consumersatisfaction,allocativee fficiency,technicalefficiency, cost containment, political acceptability,and financial sustainability. Other approaches startfrom a consideration of which indicators are readilyavailable, and construct a performance assessmentthat replicates the conceptual and technical inade-1 Director, Global Programme on Evidence for health Policy, WorldHealth Organization, 1211 Geneva 27, Switzerland. Correspondenceshould be addressed to this Director, Evidence and Information for Policy, WorldHealth Organization, Geneva, of the World health Organization, 2000,78(6)#World health Organization 2000quacies of available measures.

5 Both approaches areunsatisfactory for a comprehensive and meaningfulassessment of health system believe that a coherent and consistentframework should begin with addressing a simplequestion: what are health systems for? Once theintrinsic goals of health systems have been clearlyarticulated, these goals must be measured, and boththeconcept ofperformanceandthekey factors both a framework and a blueprint for furtherrefinement and development work that WHO framework will be to structure the statisticalannexesoftheWorld health ,thereportwill presentinformationonhealth systemperformance for each developing the conceptual basis for healthsystem performance , this paper covers eight topics:the boundaries of the health system, the differencebetween intrinsic and instrumental goals, mappingbetween social systems and social goals, the maingoals of a health system, the instrumental goals forhealth systems, the concepts of performance andefficiency, applying the concept of performance tosubsystems or institutions, and key factors influen-cing health system performance .

6 Some of the health systemMany boundaries have been proposed for separatingthehealthsystemfromelementsout sideofit(11 16).Some components, such as individual health servicesdelivered at clinics, are included by all boundarydefinitions. But there is more controversy with ,areseatbeltregulationsandtheir enforcement part of the health system? Clearly,allboundarydefinitionsarearbitra ry,buttoundertakean assessment of health system performance anoperational boundary must be with the concept of a health action . Ahealth action is defined to be any set of activitieswhose primary intent is to improve or maintainhealth. And a health system includes the resources,actors and institutions related to the financing,regulation and provision of health actions. ,itincludeseffortstoimprove road and vehicle safety where the primaryintent is to reduce road traffic accidents, and it alsoincludes personal health services whether theycontribute to health or not.

7 One major advantageoftheprimaryintentcriterionisth atitincludesintheassessment of health system performance all actorsand institutions who see their primary purpose ascontributing to ,such as educating young girls, are not part of thehealth system according to this definition, as these actions from the definition of ahealth system does not, in any way, question theimportanceofdeterminantsofhealththata reoutsidethe health system. In addition, it is critical torecognize that efforts to influence other sectors areclearly part of the health system when they improvedeterminantsofhealth,suchaseducat ingyounggirlsor reducing social inequalities. These efforts atintersectoral action are intended to improve healthand therefore fulfil the primary intent with a clearly articulated definition of ahealth action, questions remain about a range ofactions. For example, what is the primary intent offood supplementation programmes: to improvehealth by preventing malnutrition, or to redressincomeinequality?

8 Forambiguouscases,particularlyin the area of water and nutrition, some arbitrarydecisions must be made so that health systems areconsistently defined. Such codification of theboundaries of health systems is essential to thisexerciseandtorelatedefforts,suchasna tionalhealthaccounts. While important for practical measure-ment, resolution of this limited number of ambig-uous cases is not relevant to the rest of this and instrumental goalsMany laudable goals have been articulated for socialsystems, including the health system. To have aninformed debate about goals, however, we need todistinguishbetweenintrinsicgoals goalsvaluedinthemselves andinstrumentalgoals,whosepursuitis really a means toanother goals fulfilthe following two criteria:.Itispossibletoraisethelevelofa ttainmentofthegoal, while holding the level of all other ,agivenintrinsicgoalisatleast partially independent of all the level of attainment of an intrinsicgoal is desirable.

9 If it is not, it is probably aninstrumental goal and not an intrinsic likely to be instrumental goals. We will use thedistinction between intrinsic and instrumental goalsto keep the list of goals for the health systemparsimonious and to simplify measurement of systems and social goalsAs shown in Fig. 1, the organized activity of societycan be divided into various systems such aseducation, health , economic, political, etc. For eachof these systems there is a defining goal, the ,forexample,istoeducateindividuals;andfo rthehealthsystem the defining goal, there are two other goalsSpecial Theme health Systems718 Bulletin of the World health Organization, 2000,78(6) the system to the legitimate expectations of thepopulation;andfairnessinthefinancialc ontributionrequired to make the system work. For all systemsanddefininggoals,thepopulationwil lhaveexpecta-tions about how institutions and actors shouldinteract with them as they attempt to achieve a example, are human rights respected?

10 To whatextent are individuals autonomous and involved indecisions? Are people treated with dignity?Similarly,thereisthegoaloffairne ssinfinancialcontribution for every system. The definition youpayforwhatyou get is appropriate for most consumptiongoods. But for health , education, security and someother systems, the concept of fairness in financialcontribution may be very health , education or security systems mayand probably do affect (positively or negatively)attainment of the defining goals of other , and goals emphasizes the recognizes the primacy of the defining goal system goalsBased on the matrix in Fig. 1, we can more explicitlyformulate the three main goals for the health system: health , responsiveness and fairness in financial con-tribution. These intrinsic goals should be routinelymonitored by all countries and should form the mainbasis for assessing health system performance inprogrammes facilitated by WHO.