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A strategy for evaluating the performance of Health Systems, the method developed and used by who, was published in the World Health Report 2000 (who 2001; Valentine et al. 2000). The World Health Report 2000 set out a set of performance indicators that serve to assess whether health system targets have been achieved. The report brings together important health issues and is methodologically innovative, with an impressive database, using advanced statistical techniques and providing interesting comments to researchers and health policy makers (Nord 2002). The aim is to provide information to governments for health policy development and to establish a solid structure in revealing the relationship between organization and outcomes of Health Systems (who 2001).

The WHO’s strategy for assessing health system performance begins with answering a simple question ‘ ‘ What are health systems for?’. A clear answer to this question is that health systems exist for the development and maintenance of Public Health. Thus Health will be a defined purpose of Health Systems. But another similar answer to this question is that health systems meet the needs of the people they serve. In meeting these needs, the concept of what the WHO calls competence has become important (Darby et al. 2000).

World Health Report 2000, as mentioned earlier, defines the health system as consisting of all organizations, institutions and resources that have the main goal of improving health (IHSD, 2000, Murray et al. 2001). The WHO’s new strategy for evaluating health system performance has three important goals: improving health, competence, and fairness in finance (Silva 2000; Murray et al. 2000; Gakidou et al. 2000; Murray, Frank 2001; Evans et al. 2001; WHO 2001). These basic objectives should be routinely monitored by all countries and should be the basis for assessing the performance of the health system in programmes supported by who. For this reason, in evaluating achieving goals, it is necessary to focus on measuring these three goals (Murray, Frank 2000; Murray, Frank 2000a). The strategy developed to measure achievement of goals is to make an assessment by weighing the main goals of the health system within itself. This means helping countries measure their own health system performance, understanding the factors that affect it, improving it, drawing attention to areas of needed reform, and better responding to the needs and expectations of the people served. The most important goal is to hold governments accountable for the performance of their own health systems. The report says that if the system wants to successfully achieve the three above objectives, there are four general functions that a health system must perform. These:

* Provision of services

* Creation of resources

• Financing

* Administration (stewardship) (IHSD 2000; Daniels et al. 2000; IHSD 2000a; WHO 2001).

For a country, not only is the level of these goals important, but also their distribution (Silva 2000). When it is necessary to measure health promotion and competence, it is important to measure the level of success (the average over the entire society) as well as the distribution (the equal distribution of this success to all segments of the public) (Darby et al. 2000). Disparities in distribution may be due to social, economic, demographic, and other forms of inequality (Silva 2000).

The three main objectives of the health system laid out by the WHO in the World Health Report 2000 can be explained briefly as follows:

1. Raising Health

The first goal defined for the health system is to improve the health of the community. Better health is the raison d’être of a health system, and undoubtedly its fundamental and defining purpose. If health systems had done nothing to protect or improve health, there would have been no reason for them to exist. (Murray, Frank 2000; who 2000; Murray, Frank 2000a; Gakidou et al. 2000).

It is difficult to assess the contribution that health systems make to improve health. Even without progress in the basic sciences, changes in existing medical interventions organized and presented can reverse the spread of epidemics, as well as significantly reduce the cost of saving a life. Looking at diseases with effective treatment from a narrower perspective, many studies show that preventable deaths thought to be responsible for medical treatment in the early 1970s fell rapidly compared to other deaths. At the same time, some other indicators show that health systems have created little or no changes in health. Furthermore, there is significant evidence that health systems are expensive and that fatal errors are often made in the health system (WHO 2000).

2. Financial Contributor Fairness

Another main purpose of the health care system is fairness in finance and financial risk protection for households (Gakidou et al. 2000; WHO 2001). Justice is a broader and more versatile concept than equality. Justice covers equality in finance, access to care, and health outcomes, as well as effectiveness and responsibility in management and distribution (Daniels et al. 2000). The World Health Report 2000 defines fair funding as the ratio of the total health contribution to total non-food expenditures being similar in all households regardless of income, health status or use of health care (IHSD 2000; who 2000a). To be fair, the funding of the health care system must pay attention to two important points. First, households should not be impoverished or spend a large portion of their income on getting the health care they need. Second, poor households should pay less to the health care system than wealthy households. This is not only because poor households have low incomes, but also because they have a wide range of these incomes.

Better health is, of course, the raison d’être of a health system, and undoubtedly its fundamental and defining purpose. Other systems in society can also contribute broadly to the health of the public. But that is not their main goal. For example, the education system creates big changes in health, but its defined purpose is education. The effect occurs in another way: better health can make children learn better, but this is not a fundamental goal of the health system. Conversely, the purpose of fair funding is general for all social systems. Only the notion of justice can change. ’ Take what you pay ‘ is generally considered fair in market transactions, but when health care is the issue, it seems less fair. Similarly, in each system, people have legally accepted expectations about how they should be treated, both physically and psychologically. Competence is always a social goal for this reason. Take the education system as an example; fair funding includes subsidizing poor children who cannot attend school for financial reasons, ensuring the right balance of participation of households with and without children in school. Qualification includes respect for parents ‘ preferences regarding their children and avoiding abuse and embarrassment of students (WHO 2000).

The health care system differs from other social systems, such as education, and from markets for goods and services, many of which are consumed. This, in turn, makes the objective of Fair Funding important. Because health care can be devastatingly costly. Most care needs are unpredictable, so it’s important to protect people from choosing between financial ruin and loss of Health. For this reason, the Risk sharing mechanism and Financial Protection are important (who 2000).

It is absolutely true that fairer funding can contribute to better health by reducing the risk that people who need care but cannot get it because its cost is high, or by reducing the risk that paying for Health will impoverish them and cause more health problems. A system that is more sensitive to people’s wishes and expectations can also contribute to better health. If potential patients have the expectation that they will be treated well, they are more likely to use care (WHO 2000).

3. Qualification

The World Health Report 2000 introduced a new concept that covers the characteristics of health care that are not directly related to health. This concept is focused on how the health system should meet their expectations, caring about how the public should be treated. Meeting people’s expectations can be seen as a secondary goal besides the goal of improving health; but the World Health Report 2000 emphasizes that competence should be seen as a basic Independent goal of the health system, as well as the other two goals of the health system. For this reason, qualification can be partially increased without being affected by the other two purposes (Darby et al. 2000; Murray, Frank 2000; Murray, Frank 2000a).

Sub-elements of competence: every health system should aim to adequately and fairly meet the justified, non-health-related needs of the society it serves (who 2001). Competence within the thought of a system can be defined as the output of organizing institutions and corporate relations in accordance with the general justified expectations of individuals. Competence can be viewed from two points of view: first, the health care system user is often identified as a customer, while a better qualification is also seen as a way to attract customers. Secondly, competence concerns the protection of patients ‘ rights for timely and adequate care (Silva 2000).

What you want to be told with competence can be revealed in many ways. A basic distinction, people as individuals, with respect to the respective elements (this is very subjective, and primarily evaluated by the patient) and the general health of patients and their families as clients of the system are expressed in the specific problems of the health care system meets directly related to how elements of other elements that can be observed in health facilities with the distinction between objective. Dividing these two categories into lower branches makes it necessary to study the seven separate elements or properties of competence (WHO 2000; Gakidou et al. 2000; Murray, Frank 2000). According to this distinction, consumers say that the health system should treat themselves while maintaining their reputation, have a role in decisions about their own care, establish clear communication with health care providers, and protect the confidentiality of their medical records. Such health system activities constitute a group within the competence known as respect for persons. Consumers, the system at the same time urgent attention, social support they also expect that access to their network will be sufficient in terms of service server selection and quality of basic materials/tools/accessories. These, in turn, constitute a group called customer orientation (Darby et al. 2000; Silva, Valentine 2000; McKee 2001; Ugá et al. 2001).

In addition to being important on their own, the seven elements identified in competence are important sources of interest for consumers (McCallum 2000). These seven elements of competence can be briefly defined as:

Dignity: dignity, patient and physical disability due to asymmetric information, more than just a sick, is defined as the protection of the rights as an individual with certain rights (Silva, 2000; who, 2000A).

Autonomy: autonomy refers to an individual’s participation in decisions about their own health (Gakidou et al. 2000; WHO 2000). When making decisions about one’s own health, one should be able to act autonomously (Murray, Frank 2000). Autonomy is a freedom that includes deciding between alternative treatment, testing, and care options, and the right to refuse treatment if the patient is conscious (Valentina et al. 2000; Silva, Valentina 2000; WHO 2000a).

Privacy: privacy is an individual’s right to determine access to personal health information (WHO 2000). When individuals interact with the health system, they have the right to maintain the confidentiality of their personal health information (Murray, Frank 2000). Information about the patient and his or her illness should not be disclosed during service delivery, except in certain cases and without the patient’s permission (Silva 2000).

Urgent interest: urgent interest refers to immediate care in emergency situations and reasonable waiting times for non-emergency situations (WHO 2000; Valentina et al. 2000). Urgent interest has two views: the first refers to rapid transportation in health care units suitable for the care needed. The latter focuses on improving patient well-being by minimizing waiting times for diagnosis and treatment (Silva, Valentine 2000; who 2000a).

Quality of basic materials/tools/equipment: the quality of basic materials/tools / equipment, such as cleaning of all kinds of things, the suitability of furniture and the quality of food, is not directly related to the health of health care units he focuses on his qualities. (Valentina et al. 2000; Silva, Valentina 2000; Murray, Franken 2000; WHO 2000a).

Access to social support networks during Maintenance: Maintenance access to social support networks during care and recovery refers to the right to have access to social support through family and friends (Gakidou et al. 2000). When care is ready, if individuals are offered away from their families, then there is a problem with access to social support networks (Murray, Frank 2000).

Choosing a service provider: choosing a service provider includes the ability to choose between health care units and refers to the freedom to choose individuals or organizations that offer care (Valentina et al. 2000; Silva, Valentina 2000; WHO 2000; WHO 2000a). Patients may want to choose services that will offer them health care. This choice will be most relevant to individual service servers and corporate service servers (Murray, Frank 2000).
Some systems are quite weak in terms of competence. In many countries, the general complaint about public sector health workers focuses on their rudeness and arrogance in their relationship with patients. Waiting times for non-emergency surgeries vary widely among industrialized countries, and health ministries are the focus of much criticism. Defining competence as a fundamental goal of health systems reveals that these systems are set up to provide services to people and shows that it involves more than an assessment of people’s satisfaction with the medical care they receive (WHO 2000).

Competence differs from patient satisfaction and quality of care due to many interrelated characteristics (Silva 2000). Competence is more meaningful, measurable and comparable than satisfaction with the functioning of health care. Satisfaction metrics are significantly influenced by expectations. Performance evaluation reflects people’s actual experiences-related to their health, their relationship with the health care system, and their financial limitations – rather than simply their expectations (Murray et al. 2001). World Health Report 2000 challenges health systems to go beyond patient satisfaction measurements and measure people’s actual experience with health systems. Through the use of this strategy, individuals health systems are asked to evaluate the services they receive, thus eliminating the expectation filter seen in satisfaction research (McCallum 2000).

In addition to being a fundamental goal for health systems, competence is also important for many reasons (Darby et al. 2000).

Briefly these;

a. The importance of the administration function for health systems lies in meeting people’s justified expectations. Consumers, in their relationships with health care providers, are often at a disadvantage and need the health care system to help them by providing and maintaining information. Facilitating the efficient flow of information between the health system and society is an important element of competence. This flow of information is a very important tool for the administration of the system (Darby et al. 2000).

b. Competence is also important as it relates to basic human rights. Health Systems share sufficiency as a goal along with education, economic, political and cultural systems. Each system has to be successful in meeting the necessary needs of its own audience. At the heart of the common goal of competence lies the protection and enhancement of the basic human rights of the people. Within the health care system, behavior that does not address competence means a denial of responsibility that is common (Darby et al. 2000).

c. A health care system can develop some of the elements of competence without the need for broad investment. In particular, improving respect for people in the system requires significant changes in the behavior of medical personnel within the system towards the audience targeted by the system. For example, the work of health care personnel may be more sensitive to basic human rights of individuals, with respect during treatment and a minimal expense. Making significant advances in competence also does not require significant investment in technology or personnel who can make progress in health. Improving competence does not require new legislation, as does fair funding. However, the costs of all changes to qualification are not so low. Changes that address customer-oriented trends of competence, such as Doctor selection or urgent attention, may require the use of additional resources. But, usually, a health care system can make noticeable advances in competence without making significant monetary investments (Darby et al. 2000).

d. Improvements in competence may precede performance changes in the other two objectives. Because these advances do not require significant investment, and the results of interventions to improve competence can quickly turn into outputs. Competence can improve health much faster than improving it (Darby et al. 2000).


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President of Organ Transplant Center at MedicalPark Hospital Antalya

Turkey's world-renowned organ transplant specialist. Dr. Demirbaş has 104 international publications and 102 national publications.

Physician's Resume:

Born on August 7, 1963 in Çorum, Prof. Dr. Alper Demirbaş has been continuing his work as the President of MedicalPark Antalya Hospital Organ Transplantation Center since 2008.

Prof. who performed the first tissue incompatible kidney transplant in Turkey, the first blood type incompatible kidney transplant, the first kidney-pancreas transplant program and the first cadaveric donor and live donor liver transplant in Antalya. Dr. As of August 2016, Alper Demirbaş has performed 4900 kidney transplants, 500 liver transplants and 95 pancreas transplants.

In addition to being the chairman of 6 national congresses, he has also been an invited speaker at 12 international and 65 national scientific congresses. Dr. Alper Demirbaş was married and the father of 1 girl and 1 boy.


Eczacibasi Medical Award of 2002, Akdeniz University Service Award of 2005, Izder Medical Man of the Year Award of 2006, BÖHAK Medical Man of the Year Award of 2007, Sabah Mediterranean Newspaper Scientist of the Year Award of 2007, ANTIKAD Scientist of the Year Award of 2009, Social Ethics Association Award of 2010, Işık University Medical Man of the Year Award of 2015, VTV Antalya's Brand Value Award of 2015.


Doctor of Medicine Degree Hacettepe University Faculty of Medicine Ankara, General Surgeon Ministry of Health Turkey EKFMG (0-477-343-8), University of Miami School of Medicine Member of Multiple Organ Transplant, ASTS Multiorgan Transplant Scholarship. Lecturer at Kyoto University. Lecturer at University of Essen, Research assistant at the University of Cambridge .

Professional Members:

American Society of Transplant Surgeons, American Transplantation Society Nominated, Middle East and Southern Africa Council Transplantation Society 2007, International Liver Transplantation Association, Turkish Transplantation Association, Turkish Society of Surgery, Turkish Hepatobiliary Surgery Association.


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Medically Reviewed by Professor Doctor Alper Demirbaş
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