EDITORIAL

A new look at health systems

Kei Kawabata

Coordinator, Financing, Resource Allocation, Regulation and Legislation, Global Programme on Evidence for Health Policy, World Health Organization, 1211 Geneva 27, Switzerland

Most countries, faced with rising demands, rising costs and limited resources, are acutely concerned with the performance of their health systems. The need to design a health system that durably meets social goals is not new. Beveridge envisaged a comprehensive health system for the United Kingdom half a century ago, and the resulting National Health Service remains an important model today (pp. 846–856). Nor is the analysis of how to improve health system performance new, as we can see from Donabedian's visionary speech on evaluating physician competence (pp. 857–860). Yet this month's theme section breaks new ground in that it reflects new ways of looking at health systems and considering how their performance can be assessed.

Although in many countries health systems need additional resources simply to function adequately, systems in all countries — no matter how wealthy or poor — can perform better. There are no universal solutions, but the articles in this collection contain three main messages. First, in order to improve the performance of a health system it is necessary to identify the factors, both internal and external, responsible for its merits and shortcomings. Second, a real concern for equity requires that the information be disaggregated for analysis. Third, the debate on health service delivery and finance should focus not only on the public– private dichotomy but also on the political and organizational requirements and on prepayment versus out-of-pocket payment.

The first group of papers focuses on what is meant by health system performance and how that performance can be measured. Murray & Frenk (pp. 717–731) provide a clear definition of the boundaries of a health system and a framework for measuring its performance. They argue that a better understanding of health system functions such as resource generation, financing, service provision, and stewardship could improve performance. Stewardship, defined by Saltman & Ferroussier-Davis (pp. 732–739) as state leadership providing strategic guidance and promoting social responsibility, is clearly the overarching function that facilitates or inhibits all others. Stewardship extends the concept of good governance and focuses on outcomes rather than processes. Daniels et al. (pp. 740–750) take an ethical perspective to assess the fairness of health system reforms, the distribution of health services, the responsiveness to people's needs, and the financial burden imposed on a country's population.

The second group of articles suggests analytical approaches to acquiring a better understanding of the determinants of performance and more accurate and targeted policy options. Hurst (pp. 751–760) culls data from 29 OECD countries to assess performance. He shows that, as might be expected, these countries on the whole fare quite well but many of them already face the challenge of maintaining performance under budgetary constraints. Peters et al. (pp. 761–769) review health expenditure in Africa and stress the importance of analysing equity at the sub-national level. Anell & Willis (pp. 770–778) believe that health expenditure information alone could be misleading: it is equally important to look at the balance between human resources and physical capital.

The third group of papers looks at the public–private debate, especially with respect to service delivery. Preker et al. (pp. 779–790) draw on institutional economics and organizational theory to examine the appropriate roles of the state and private sector in the production of goods and services. Berman (pp. 791–802) argues that the organization of ambulatory personal health care services is a critical determinant of health systems performance. Mckee & Healy (pp. 803–810) emphasize the roles that hospitals fulfil in caring for people and in staff training. McPake & Mills (pp. 811–820) indicate the circumstances in which comparisons of reforms, notably those related to contracting, work more or less well. Palmer's review of contracting (pp. 821–829) also confirms the importance of stewardship. Finally, Sekhri (pp. 830–844) outlines the US managed-care experience and points to elements that may be adopted by other, particularly developing, countries to enhance the performance of their health systems.

All in all, the messages from this special theme section are positive ones. Yes, there are almost as many different health systems as there are countries; and yes, it is a formidable task to determine whether health system reforms introduced by one country are likely to have similar effects in different settings. Policy-makers are looking for practical guidance on how they can change their health system so that it will perform better, and this month's Bulletin tackles the task head-on: it describes new ways of looking at health systems, their complex mechanisms, and the key factors to target if performance is to be enhanced. It explores the concept of and need for a stewardship approach, which remains a challenge to governments. And it highlights basic principles to help ensure that a health system stays the course towards its ultimate objective — enabling all its citizens to attain their fullest potential for good health.