The authors of the WHO's World Health Report 2000 1 have placed on the WHO agenda a commitment to the laudable goals of assessing health systems, monitoring inequalities in health, and achieving equity in health-care financing. Their proposition that health services should be responsive to people's expectations is a welcome one. While these commitments should be sustained, we believe that the approaches taken toward these ends in the World Health Report are seriously flawed. We aim to suggest changes to the approach in the World Health Report to ensure that measurement strategies supporting public health policy throughout the world are scientifically sound, socially responsible, and practical.Both the conceptual basis and methodological approaches to the World Health Report composite index of health system goal attainment and its individual components, and the indices of health system performance, have major problems. Data needed to calculate four of the five component measures for overall goal attainment were absent for 70-89% of countries, but this was not acknowledged in the report. Because all the measures are new, and imputed values for the 70-89% of countries without data were based on new methods involving multiple non-standard assumptions, readers deserve to know the underlying assumptions, methods, and key limitations, which were not adequately acknowledged. The measures of health inequalities and fair financing do not seem conceptually sound or useful to guide policy; of particular concern are some ethical aspects of the methodology for both these measures, whose implications for social policy

SUMMARYDistrict health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity.The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform-to be superseded by third generation reforms with a market orientationflows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim.Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery.District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization.Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency).Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation.Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass compaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above al...

Study objectives: To assess the affordability of health care to poor rural households in Vietnam under conditions of transition from a planned to a market economy and, in light of other transitional experience, inform policy on increasing access of the poor to affordable care of acceptable quality. Design: Observational study by cross sectional socioeconomic survey, longitudinal healthcare seeking survey, and qualitative semi-structured interviews and focus group discussions; qualitative follow up over six years. Setting: Four rural communes in north of Vietnam between 1992 and 1998. Survey participants: 656 households (2995 people) selected by systematic random sampling. Main results: Compared with non-poor households, poor households had significantly lower average per capita rates of healthcare consultation and expenditure (p<0.01 in both cases). Poor households delayed and minimised healthcare seeking, especially of expensive hospital services. Two thirds of average healthcare spending by poor households was on relatively inexpensive but frequent acts of local ambulatory care. The poor restrained their healthcare seeking but not in proportion to income: for households reporting illness, the average proportion of income devoted to health care was 21.9% for the poor compared with 8.2% for the non-poor (p<0.01). To meet healthcare costs, many poor households reduced essential consumption, sold assets and incurred debt, threatening their future livelihood. Conclusions: In the short-term the poor need exemption from public sector user fees in both primary and hospital care. In the longer run the government budget and prepayment schemes should replace direct user charges in healthcare finance. Transitional economies like Vietnam should preserve the public health services built up under the planned economy. Market reforms that stimulate growth in the economy appear inappropriate to reform of social sectors. ECONOMIC TRANSITION AND HEALTHIn the past 20 years a number of countries have been undergoing a transition from a socialist planned economy to a market economy. These countries are spread across the globe and vary enormously in their levels of development, from the relatively advanced industrialised countries of central Europe, through the former Soviet Union to the mainly rural countries of east and south east Asia. The economic transition in Europe and the former Soviet Union has been associated with political change, while political continuity has been mostly the case in east Asia.In socialist countries under the planned economy, health services were financed and provided mainly by the public sector. The services were not well resourced and quality and efficiency were often low. But coverage of the population with essential services was effectively universal at little or no direct cost to households. Preventive care was relatively well developed, at least for the control of communicable diseases. The health systems of developing socialist countries like China and Cuba came to influence the formulation of the ...

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