Now let's look at the health system performance assessment issues. First, we reviewed the financing flow in global health in the first lecture. Since the 1990, 28% of all development assistance for health was allocated for maternal health, and newborn and child health. 23.2% for HIV/AIDS. But very limited allocation on money on health system strengthening. Doctor Brundtland, then WHO Director-General, set an agenda for health systems in her acceptance speech in May 1998. She said, what is our key mission? I see WHO's role as being the moral voice and the technical leader in improving health of the people of the world. Ready and able to give advice on the key issues that can unleash development and alleviate suffering. And finally she said, I see our purpose to be combating disease and ill-health, promoting sustainable and equitable health systems in all countries. There are many definition in the literature on health systems, including WHO's World Health Report 2000. A publication by the group of Harvard experts in 2004, WHO annual publication Everybody's Business in 2007, OECD framework, and World Bank's 2007 report on healthy development. But more or less, they are consistent in the sense that key functions are similar. According to WHO's definition, health system include all actors, institutions, and resources that undertake health actions. And health actions are all actions whose primary intent is to improve a health. A wide range of actions targeting individuals and communities would meet this definitions. From immunization campaign to raising of taxes to random based testing for drunk drinking. WHO's World Health Report 2000, subtitle Health System: Improving Performance was a landmark report that set the agenda for health system. The report primarily focused on metrics for health system performance assessment, but there was limited description of causes and cures for inadequate performance. And above all, the ranking of national health systems caused a huge debate and controversies. And there are five key questions as shown here to understand health system performance. First, how much of the variation in health outcomes is due to differences in health system performance? Second, how much can the improvement of health system performance improve health outcomes in the future? Third, which health system is doing a better job of improving health outcomes? Fourth, which health system is getting value for money? And finally, what are the determinants of health system performance? So these are very essential five questions. Here, I will briefly discuss the WHO 2000 health system performance framework. It is a simplified input-output framework. And inputs to the system include the following four functions. First, financing, health system financing is the process by which revenues are collected from primary and secondary sources. Accumulated in fund pools and allocated to specific activities of particular providers. And it is useful to subdivide health system financing into two sub-functions, namely, revenue collection, pooling, and purchasing. The second component of health system inputs is resource generation. Health systems are not limited to the set of institution that finance or provide services. But include a diverse group of organizations that produce inputs to those services, particularly human resources, physical resources such as facilities and equipment and even knowledge. The third component is stewardship. Stewardship goes beyond the conventional notion of regulation. Stewardship includes three key aspects, setting, implementing, and monitoring the rules of the game for the health systems, assuring a level playing field among all actors in the system, and defining strategic directions for the health system as a whole. Finally, service provision is a combination of inputs into a production process. That takes place in a particular organizational setting, and that leads to the delivery of a series of interventions. A leading service provision includes both personal and non-personal health services. WHO define three main goals for the health system, health itself, responsiveness, and fairness in financing. First, the defining goal for any health system is to improve the health of the population. If health system didn't contribute to improving health, we would choose not to have them. Health of the population should reflect the health of the individual, throughout the life goals, and include both premature mortality and non-fatal health outcome as key component. We are concerned both with the average level, at the population level, and with the distribution health within the population. So we are concerning both average level of population and also distribution of health equalities. The second intrinsic goal is to enhance the responsiveness of the health system to the legitimate expectation of the population for the non-health improving dimensions of their interaction with the health system. So responsiveness has two key subcomponents, respect for persons and client orientation. So this our extension of the consumer satisfaction and includes various components in it. The third goal of the health system is fairness in financing and financial risk protection for households. In order to be fair, financing of the health system should address two key challenges. First, hospitals should not become impoverished or paid an excessive share of their income in obtaining needed health care. In other words, fairness in financing requires important degree of finance risk pruning. Second, poor households should pay less toward the health system than rich household. So contribution to the health system should reflect the difference between rich and poor in disposable income. This figure is the geometric presentation of the four function in blue and three goals in red. To understand the health system in Japan, we will employ this assessment framework in the later sections. And this is a summary of health system goals. So simply, two goals on average reflect the quality of the health system, while the three metrics of distribution measure equity consolidation. And health system performance can be assessed for each of the five components of three goals. To summarize on health system performance, there is a growing interest in health systems strengthening but limited investment. And still in global health, disease control dominates major activities. Monitoring and evaluation, based on a clear conceptual framework, is the key to understanding the complexities of health system strengthening.
