What makes for a good health system? What makes a health system fair? How do we know if a health system is performing as well as it could? The World Health Assembly today considered the results of four roundtables here earlier this week in which ministers identified and discussed ways in which they are designing and strengthening their health systems to respond to the major challenges they face.

While health indicators have improved in most countries, the distribution of good health, both between countries and between population groups within countries, was noted to be far from equal; and in some cases the inequality is growing. The advantages of primary health care were re-emphasized as a fundamental way of building the networks needed to deliver care to the most vulnerable—often the most remote—population groups and offering an effective approach to addressing disparities between population groups.

As the major determinants of health, such as adequate housing, food supply and social security, usually lie beyond the jurisdiction of the health ministry, Ministers repeatedly noted that reforms of their health systems involve many "partner" ministries and agencies, including donor agencies.

While all agreed that health systems must be assessed in relation to the specific context of each country, the Ministers welcomed a new WHO framework for improving health system performance as a critical tool to help identify and shape changes required to improve their health systems.

"Whatever standard we apply, it is evident that health systems in some countries perform well, while other perform poorly. This is not just due to differences in income or expenditure: performance can vary markedly even in countries with similar levels of spending," noted Dr Gro Harlem Brundtland , WHO Director-General, in her message to the WHA. "The way health systems are designed, managed and financed affects people's lives and livelihoods. This new framework brings together the best evidence available to date. It demonstrates that despite the complexity of the topic and the limitations of the data, it is possible to obtain a reasonable approximation of the current situation, in a way that provides an exciting agenda for future work. This new framework will help policy-makers to make wise choices. Substantial gains are possible for all countries and the poor will be the principal beneficiaries."

The new WHO framework focuses on three key goals of health systems.

• Achieving good health in a population both by raising its overall level and by improving its distribution among the population
• Enhancing the responsiveness of a health system to a population's needs and expectations
• Assuring fairness of financial contributions so that every household pays a share of the country's health bill based on their capacity to pay

The World Health Report 2000, to be launched 21 June 2000, analyzes the key functions that health systems need to fulfil in attaining these goals. Four key functions are identified: 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.

Ministers, in the roundtable discussions, defined their central stewardship (leadership and co-ordination) role to include:

• assessing the health situation and health system performance in order to set national health targets and priority health strategies;
• ensuring universal coverage of the population with a minimum package of services, offering, among other things, a balance between personal and public health services;
• allocating resources needed for such universal coverage;
• regulating the health sector (both public and private);
• re-orienting training and education of human resources for health;
• organizing the structure and functions of the health system and health service provision ;
• promoting collaboration with relevant ministries and health related agencies; and,
• ensuring public accountability.

Many difficulties in fulfilling the stewardship role were identified; including,

• Ministry of health legitimacy being questioned both by their own populations and by external agencies;
• external interference in policy formulation and health planning;
• conditions imposed by donors that conflict with national priorities;
• failure of external partners to comply with national policies;
• preference of aid to projects and programmes rather than to health sector policies;
• lack of agreement between the government and its partners on a minimum set of indicators for measuring health system performance;
• lack of reliable health information systems; and,
• lack of accountability of each component of the health system for performing to. consistently high standards, including standards of clinical care, and for continually striving to improve performance.

Financing was identified as a major issue in all countries; especially for developing countries where the national budget is small and there is little or no flexibility in allocating the proportion to be spent on health. Ministers agreed that a fair system can only be developed in relation to a country's specific circumstances and will vary according to such factors as a country's level of poverty, unemployment rate and ability to pay.

While many countries recognised the advantages of cost-sharing, the Ministers noted that introduction of a pre-payment schemes could face a number of obstacles; including: lack of the required experience or managerial capacity, lack of political will, potential conflict with government policies being implemented in other sectors, opposition by health providers and the public, as a result of lack of awareness of its benefits.

A major discussion centred on the desirability of competition among health care providers. Many Ministers noted that competition has lead to fragmentation and duplication of services, poor sharing of information and friction in competing for scarce resources. Concerns were raised that competition might block improved health system performance, which requires collaboration among all providers, both public and private, based on clearly defined priorities.

Acknowledging the vital importance of developing human resources if the quality of health service delivery is to be improved, the Ministers noted that hurdles include difficulties in recruitment and retention of staff, suboptimal distribution of staff functions, and inadequate staff training and education.

Decentralization of service provision, including overall authority, budgetary control and personnel management, was identified as a key factor in increasing access of the population to health care, particularly at district level. All agreed that evidence-based measures of performance should be used to decide on and to monitor clinical interventions.

The Ministers identified ways in which WHO could support the development of health systems both globally and at a national level.

• Support poverty reduction initiatives
• Promote the exchange of experiences in health system development within the proposed new comprehensive framework
• Advise countries on the best models of health care financing
• Develop models for managing health systems after decentralisation
• Reaffirm the benefit of health as an investment in development
• Continue dialogue with other international agencies.

• Strengthen the stewardship role of ministries of health, including the formulation of health policies and plans
• Support ministries of health in co-ordinating the actions of external partners.

For further information, journalists can contact Mr Gregory Hartl or Dr Franklin Apfel at WHO, Geneva. Telephone (+41 22) 917 6821; mobile (+41 79) 203 6715; Fax (+41 22) 791 4858. Email: hartlg@who.int or fap@who.dk All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can be obtained on Internet on the WHO home page http://www.who.int/