Introduction

Health systems have three goals: (i) to improve the health of the populations they serve; (ii) to respond to the reasonable expectations of those populations; and (iii) to collect the funds to do so in a way that is fair (WHO 2000). The first of these has traditionally been captured using broad measures of mortality such as total mortality, life expectancy, premature mortality or years of life lost. More recently these have been supplemented by measures of the time lived in poor health, exemplified by the use of disability-adjusted life years (DALYs).

These measures are being employed increasingly as a means of assessing health system performance in comparisons between and within countries. Their main advantage is that the data are generally available. The most important drawback is the inability to distinguish between the component of the overall burden of disease that is attributable to health systems and that which is attributable to actions initiated elsewhere. The world health report 2000 sought to overcome this problem by adopting a very broad definition of a health system as “all the activities whose primary purpose is to promote, restore or maintain health” (WHO 2000) (Box 2.1.1). A somewhat circular logic makes it possible to use this to justify the use of DALYs as a measure of performance. However, in many cases policy-makers will wish to examine a rather more narrow question – how is a particular health system performing in the delivery of health care?