In the opening chapter we argue that the goals of any performance measurement instrument are twofold: to promote accountability and to improve the performance of the health system. The modern health system is immensely complex, comprising of diverse agents such as insurers, provider organizations, health-care professionals and central and local governments. Measurement of the actions and outcomes of these agents is a necessary condition if the health system is to be held properly to account by citizens and patients. That accountability may be considered a good thing in its own right as it enhances transparency and promotes informed debate about the health system. Furthermore, by providing reassurance that finances are being used effectively, performance measurement can increase government and citizens' willingness to invest additional resources in the health system. In this book the prime focus is how performance measurement and the increased accountability it offers directly promotes the achievement of health system objectives – higher quality and more cost-effective health care and improved population health.

Measurement alone is not sufficient to achieve these objectives. In this book we cite numerous instances of technically satisfactory performance measurement initiatives that have failed to make material impacts on health systems (or indeed have had perversely adverse impacts). For example, there are examples of public performance reporting schemes being ignored; professional improvement efforts becoming moribund; and the use of centrally mandated targets inducing perverse results. To have maximum effect, performance measurement needs to be aligned with other aspects of system design such as financing, market structure, governance arrangements and regulation.