A framework for assessing health systems from the public's perspective: the ALPS approach.

There is hardly a country in the world where the health system is not undergoing major changes. Low- and middle-income countries are particularly hard hit by enforced reforms and commercialization. The overwhelming focus of assessment of these reforms has been on the supply side: effects on governments and providers. Yet the raison d'être of health services is to serve people when in need, and most systems have the equity objective of ensuring the widest possible access to essential services for the whole population, and poor people in particular. The Affordability Ladder Program (ALPS) is a tool for analyzing health systems from the public's perspective--the so-called "demand side," which the authors prefer to consider in terms of "need" for care. ALPS is concerned with how social inequities in health care are experienced by people in different sections of society. By taking a step-by-step approach to examining the many aspects of a health care system from a household/patient perspective, one can more accurately pinpoint where and why a country's health system is working and where it is breaking down, and identify the sticking points that need to be addressed by reconsidering present policies and initiating new ones to promote efficient, equitable health care systems.