There is wide variation in health outcomes even between countries at similar levels of economic development. Murray and Frenk wrote an evidence briefing on this topic for the World Health Organization in 2000 (1,2). That briefing discussed the several frameworks that existed then for measurement of health system performance and proposed a number of improvements to get over difficulties from multiple and overlapping attributes of health systems and a common tendency to focus on available but inadequate indicators. They expressed a belief that a consistent coherent framework should start by addressing the very simple question ”what are health systems for?” and set out their views on the conceptual basis for measuring health system performance and the operationalisation of those concepts. The discussion covered a large number of issues, including setting boundaries for a health system, the concepts of intrinsic and instrumental goals, social systems and social goals, health system goals, health, system responsiveness, fair financing, financial risk protection, instrumental goals, goal attainment, the performance of sub-systems and factors that explain health system performance. They also proposed that annual assessments of health system performance by undertaken and that global institutional assessment of performance would be a helpful development.