25 years ago, the World Health Report 2000 presented the WHO's conceptual framework for assessing the performance of health systems.[1] This framework had three key innovations, the first of which defined the boundaries of the health system based on primary intent – encompassing all institutions and actors whose primary goal is to improve health.[1] Such an approach excluded important factors such as educational attainment, which may be major determinants of health but are not part of the health system itself.[1] Since then, methodological advances have been made in key components of health systems performance evaluation, such as responsiveness, catastrophic spending, equity, and efficiency.[1] However, less progress has been made on summary outcome measures.[1] For example, the United States of America has selected 37 indicators to assess performance in the areas of long, healthy and productive lives, quality, accessibility, efficiency and equity.[1] Countries as diverse as Indonesia, South Africa, Afghanistan, and Mexico have implemented their own health systems performance assessment systems tailored to their needs.[1]