the 20thC, health system reforms encouraged not only by perceived in
health but also by a search for greater efficiency, fairness and responsiveness
to the expectations of the people that systems serve. The first generation of health
reforms witnessed the founding of national health care systems, and the
extension to middle income countries of social insurance systems in 1940s and
1950s in richer countries and somewhat later in poorer countries. By 1960s,
many of the systems founded a decade or two earlier were under great stress.
Costs were rising, especially as the volume and intensity of hospital care
increased in developed and developing countries. Among systems that were
nominally universal in coverage, the better off still used health services more
heavily, and efforts to attain the poor were often incomplete.


resources devoted to health systems are unequally distributed, and not at all
in proportion to the distribution of health problems. Yet 84% of the world’s
population lives in these countries, and they bear 93% of the world’s disease
burden. Low and middle income countries face
many challenges in building robust, reliable health systems.  These challenges include insufficient
financing lack of inter agency co ordination, poorly functioning information
systems, health worker shortages and supply interruptions. 
These countries face many difficult challenges in meeting the health
needs of their populations, mobilizing sufficient financing in an equitable and
affordable manner, and securing value for scarce resources (The World Health Report, 2000).

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health systems are modeled to varying degrees on one or more of a few basic designs
that emerged and have been refined since the late 19th century. This aims to
cover all citizens through mandated employer and employee payments to insurance
or sickness funds, while providing care through both public and private
providers. In developed countries and middle income countries, governments have
become central to social policy and health care. Their involvement is acceptable
on the grounds of both equity and efficiency. In low income countries, where
total public revenues for all uses are scarce and institutional capacity in the
public sector is weak financing and delivery of health services is largely in
the depends on the private sector. In many of these countries, large segments
of the poor still have no access to basic and effective care.

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