Assessing how well a health system does its job requires dealing with two
large questions. The first is how to measure the outcomes of interest – that is,
to determine what is achieved with respect to the three objectives of good health, responsiveness
and fair financial contribution (attainment). The second is how to compare those
attainments with what the system should be able to accomplish – that is, the best that could
be achieved with the same resources (performance). Although progress is feasible against
many of society’s health problems, some of the causes lie completely outside even a broad
notion of what health systems are. Health systems cannot be held responsible for influences
such as the distribution of income and wealth, any more than for the impact of the
climate. But avoidable deaths and illness from childbirth, measles, malaria or tobacco consumption
can properly be laid at their door. A fair judgement of how much health damage
it should be possible to avoid requires an estimate of the best that can be expected, and of
the least that can be demanded, of a system. The same is true of progress towards the other
two objectives, although much less is known about them (1).