HEALTH PUBLIC EXPENDITURE REVIEWS: A HOW-TO GUIDE Start Here © 2025 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use HEALTH PUBLIC the information, methods, processes, or conclusions set forth. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover and Guide Design: Andres de la Roche, Adelaroche Designs, LLC 3 HEALTH PUBLIC SECTION 3 CONTENTS EXPENDITURE REVIEWS: A HOW-TO GUIDE Topic-Specific Analysis OVERVIEW Country Context Health Financing Preface Inputs How to Navigate this Guide Service Delivery List of Acronyms Outcomes 1 List of Acronyms SECTION 1 4 What Is a Health PER? SECTION 4 What Is a Health PER? Additional Guidance List of Acronyms Benchmarking 2 SECTION 2 Health Labor Market Analysis & Health Workforce Projections Cross-Cutting Efficiency Service Availability & Readiness To easily navigate and Equity Analysis within the Toolkit, Quality of Health Services you may click on each section or subsection. Assessing Spending Efficiency Crafting Impactful Recommendations in PERs Assessing Equity in Health Spending Health Expenditure Data Sources The button will always take you back to this Table of Contents. List of Acronyms List of Acronyms OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Overview 4 SECTION 4 Additional Guidance This section helps PER authors understand the context, contents, and purpose of the guide and how to best use each of its components. PREFACE HOW TO NAVITE THIS GUIDE CONTINUE OVERVIEW Preface How to Navigate this Guide 1 PREFACE List of Acronyms SECTION 1 What Is a Health PER? The 2024 Guidance Update 2 SECTION 2 Cross-Cutting Building on the earlier guidance, this latest update responds to significant shifts in global health over Analysis on Efficiency and the past 15 years. These shifts include the increasing recognition of health as a driver of inclusive Equity 3 economic growth; evolving health system objectives with a focus on universal health coverage SECTION 3 (UHC); and emerging challenges, such as aging populations, changes in the burden of disease, and Topic-Specific Analysis technological advances. 4 SECTION 4 Additional Guidance TABLE OF CONTENTS OVERVIEW Preface 5 OVERVIEW Preface How to Navigate this Guide The 2024 update also aligns with the World Bank’s renewed strategic focus on public expenditures, they also include an analysis of priorities for Health, Nutrition, and Population, including the goal to private health expenditure. As such, a health PER examines the 1 List of Acronyms support countries in delivering affordable, quality health services flow of funds within the health sector, the performance of the SECTION 1 to 1.5 billion people by 2030, as well as the World Bank’s Human health system in ensuring and financing the provision of care and What Is a Capital Project.1 improving welfare, and specific aspects of sector performance in Health PER? accordance with policy priorities. 2 This new 2024 guidance offers significant practical support for SECTION 2 PER authors and other stakeholders. It is intended as a living The primary principles of this initial guidance remain relevant Cross-Cutting Analysis on document that will continue to evolve as shifts in the health today: Efficiency and Equity sector continue and even accelerate. For example, future updates • The aggregate levels of public spending and deficit must be 3 might incorporate approaches to assessing public expenditure on consistent with the medium-term macroeconomic framework, pandemic preparedness. Additionally, it is crucial to consider how yielding a sustainable deficit and public debt. SECTION 3 Topic-Specific to strengthen country capacities to carry out public expenditure • The aggregate spending should be allocated within and Analysis reviews in health. across sectors to maximize social welfare, including the 4 impact on the poor. Public expenditure reviews (PERs) are among the World Bank’s core SECTION 4 diagnostic tools, with a long tradition in the institution. In 1996, the • The role of the government versus the private sector ought to Additional Guidance World Bank produced the first guidance and framework for public be a principal criterion governing the choice of programs for expenditure analyses (Pradhan 1996). public financing and provision. A PER is an evaluation of the effectiveness of government-wide These principles formed the basis for the development of health- expenditures in a country, their consistency with policy priorities, specific public expenditure guidance notes first in 2004 and then and their contributions to health outcomes. Although PERs generally an update in 2009 (World Bank 2009). 1 For example, the guidance draws on the Human Capital Project’s work Investing in Human Capital for a Resilient Recovery: The Role of Public Finance. TABLE OF CONTENTS OVERVIEW Preface 6 OVERVIEW Preface How to Navigate this Guide Acknowledgments 1 List of Acronyms Health Public Expenditure Reviews: A How-to Guide was developed Sven Neelsen, Moritz Piatti-Fünfkirchen, Lubina Fatima Qureshy, Priyanka SECTION 1 under the overall guidance of HNP Directors Muhammed Pate and Saksena, Martin Schmidt, Andreas Seiter, Jigyasa Sharma, Pia Schneider, What Is a Health PER? Juan Pablo Uribe. Christoph Kurowski spearheaded the project, with Zara Shubber, Denise Silfverberg, Sakshi Thorat, and Thomas Wilkinson. 2 Catalina Gutiérrez and Denise Silfverberg leading and coordinating SECTION 2 efforts at different stages. Special thanks to staff who reviewed drafts, providing thoughtful Cross-Cutting feedback that immensely strengthened chapters, including Miriam Analysis on Efficiency and The initiative has been a truly collective effort of HNP GP staff. A Ally, Christophe Lemiere, Mickey Chopra, Olena Doroshenko, Patrick Equity 3 dedicated working group, including Sarah Alkenbrack, Marion Cross, Hoang-Vu Eozenou, David Evans, Jacopo Gabani, Catalina Gutiérrez, Laura Di Giorgio, Denizhan Duran, Patricia Geli, Eko Setyo Pambudi, Reem Hafez, Christopher Herbst, Anurag Kumar, Mathew Neilson, Ha SECTION 3 Fedja Pivodic, Moritz Piatti, Marvin Ploetz, Nicolas Rosemberg, Owen Thi Hong Nguyen, Kyoko Shibata Okamura, Anne Marie Provo, Jumana Topic-Specific Smith, Yemdaogo Tougma, Huihui Wang, and Soazic Elise Wang Sonne, Qamruddin, Priyanka Saksena, Martin Schmidt, Pia Schneider, Gil Analysis developed the concept, conceptual framework, and structure. Catalina Shapira, Mirja Sjoblom, Owen Smith, Jeremy Veillard, Manuela Villar, 4 Gutiérrez, Jacopo Gabani, and Priyanka Saksena made significant Luka Voncina, and Huihui Wang. Additional thanks to Jennifer Anderson, SECTION 4 contributions to the conceptualization and structuring of the guide who led the logistical and administrative support during the first years Additional during the later stages of the project. Agnès Couffinhal led the final of the project; Carmen del Rio, who provided communication and Guidance review process. project management support; as well as editor Cathy Lips and designer Andres de la Roche. The development of individual chapters was led by topic experts, including Kathryn Gilman Andrews, Edson Araujo, Alexandra Beith, Finally, sincere appreciation to the peer reviewers, who provided Nejma Cheikh, Bernardo Coelho, Agnès Couffinhal, Olena Doroshenko, excellent feedback at the concept stage and final progress reviews: Denizhan Duran, Riku Elovainio, Patrick Hoang-Vu Eozenou, David Evans, Samer Al-Samarrai, Nick Carroll, David Coady, Yohana Dukhan, Driss M. Ian Forde, Jacopo Gabani, Laura Di Giorgio, Catalina Gutiérrez, Dominic Zine-Eddine El-Idrissi, Maureen Lewis, Magnus Lindelow, and Christel Haazen, Xiaohui Hou, Christoph Kurowski, Ana Mercado, Somil Nagpal, Vermeersch. TABLE OF CONTENTS OVERVIEW Preface 7 OVERVIEW Preface How to Navigate this Guide References 1 List of Acronyms SECTION 1 Hafez, R., ed. 2020. Measuring Health System Efficiency in Low- and Middle-Income Countries: A Resource Guide. Joint Learning Network for What Is a Health PER? Universal Health Coverage. https://jointlearningnetwork.org/resources/resource-guide-for-measuring-health-system-efficiency-in-low-and- 2 middle-inc/. SECTION 2 Musgrove, Philip. 1999. “Public spending on health care: how are different criteria related?” Health Policy 47 (3): 207–23. https://www. Cross-Cutting sciencedirect.com/science/article/abs/pii/S016885109900024X?via%3Dihubare. Analysis on Efficiency and Equity Pradhan, Sanjay. 1996. “Evaluating Public Spending: A Framework for Public Expenditure Reviews.” World Bank Discussion Paper. World Bank, 3 Washington, DC. https://documents1.worldbank.org/curated/en/509221468740209997/pdf/multi-page.pdf. SECTION 3 World Bank. 2009. Core Guidance: Preparing PERs for Human Development. Washington, DC: World Bank. http://siteresources.worldbank.org/ Topic-Specific Analysis EXTPERGUIDE/Resources/PER-Core.pdf. 4 World Bank. 2017. Education Public Expenditure Review Guidelines. Washington, DC: World Bank. https://documents1.worldbank.org/curated/ en/155861497609568842/pdf/Education-public-expenditure-review-guidelines.pdf. SECTION 4 Additional World Bank. 2021. Investing in Human Capital for a Resilient Recovery: The Role of Public Finance. Washington, DC: World Bank. http://hdl. Guidance handle.net/10986/35840. TABLE OF CONTENTS OVERVIEW Preface 8 OVERVIEW Preface How to Navigate this Guide 1 List of Acronyms SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis 4 SECTION 4 HOW TO NAVIGATE THIS GUIDE Additional Guidance Health Public Expenditure Reviews: A How-to Guide is a collection of standalone modular tools and notes. PER authors can select, combine, and tailor these resources to meet their specific needs, depending on the timeframe, the analysis requirements, and the scope of the health public expenditure review (for simplicity referred to as “PER” throughout the How-to Guide. It is not intended to be read cover to cover but to be used as a flexible guide for targeted support. TABLE OF CONTENTS OVERVIEW How to Navigate this Guide 9 OVERVIEW Preface Structure and Contents of the Guide How to Navigate this Guide 1 List of Acronyms SECTION 1 The How-to Guide is organized into four sections, each addressing different stages and needs of the PER process. What Is a Health PER? If you... If you... If you... If you... 2 SECTION 2 Cross-Cutting • Want to investigate efficiency • Are focusing the analysis on a Analysis on • Are starting a PER... and/or equity with a cross- few topics • Need more additional guidance... Efficiency and • New to PERs... cutting view of the health • Complementing the analysis of Equity system Section 2 3 SECTION 3 Topic-Specific Analysis GO TO GO TO GO TO GO TO 4 SECTION 1 SECTION 2 SECTION 3 SECTION 4 SECTION 4 Cross-Cutting Efficiencey What Is a Health PER? Topic-Specific Analysis Additional Guidance Additional and Equity Analysis Guidance • Health system context (1 • Benchmarking results module) • The purpose of a PER • Health labor market analysis • Assessing Efficiency of Health • Resource mobilization, pooling, • Framework for analysis and allocation (5 modules) • Service availability and readiness Spending • Conducting a PER: Procedural • Inputs (3 modules) • Quality of health services • Assessing Equity in Health considerations Spending • Service delivery (2 modules) • Providing policy • Generic outline for a PER report recommendations • Final and intermediate outcomes (4 modules) • Measuring heath spending TABLE OF CONTENTS OVERVIEW How to Navigate this Guide 10 OVERVIEW Preface How to Navigate this Guide productivity. The note also includes indicators to evaluate SECTION 1 What Is a Health PER? 1 List of Acronyms allocative efficiency, examining whether the country is This section provides a framework for the analysis and step-by- producing the right mix of health services. SECTION 1 step guidance on conducting a PER. What Is a • Assessing Equity in Health Spending (forthcoming): This note Health PER? will offer guidance for PER authors to determine whether 2 health services are reaching all segments of the population SECTION 2 proportional to their health needs, regardless of geographic Cross-Cutting SECTION 2 Cross-Cutting Analysis on location, income, or socioeconomic group. Analysis on Efficiency and Efficiency and Equity Equity 3 This section, rather than targeting specific health spending SECTION 3 components like medicines or hospitals, provides an overall view, Topic-Specific offering a high-level understanding of these critical areas: SECTION 3 Topic-Specific Analysis Analysis 4 • Assessing Efficiency of Health Spending: This note offers This section is designed to support authors focusing their analysis guidance for PER authors to understand a country’s overall on specific topics or looking to build on the insights from Section SECTION 4 Additional efficiency. The first section focuses on macro efficiency. It 2. Section 3 offers in-depth modules on various components of Guidance helps PER authors assess how the country’s health outcomes an analytical framework that views the health system as a results compare with those of other countries with similar spending chain, where resources are mobilized and pooled to purchase levels and development. The second section discusses inputs and are then transformed into health services to improve efficiency using micro-data and offers a set of tracer health outcomes. indicators that provide a cross-cutting view of efficiency issues. These indicators help determine whether the country is using an appropriate mix of inputs, procuring inputs at the lowest cost, and combining them effectively to optimize TABLE OF CONTENTS OVERVIEW How to Navigate this Guide 11 OVERVIEW Preface Each module addresses questions related to the efficiency and • Modules 10–11 investigate spending on hospitals and primary How to Navigate this Guide equity of spending, as well as sustainability and the processes and care and essential public health functions. 1 List of Acronyms rules governing expenditure: • Modules 12–15 focus on health system outcomes, providing SECTION 1 • Module 1 provides guidance on understanding the country tools to evaluate the results of health spending. What Is a context. Health PER? 2 • Modules 2–6 offer insights into resource mobilization, This section allows PER authors to delve into specific areas of SECTION 2 allocation, and pooling. interest, enabling a targeted and comprehensive analysis of Cross-Cutting specific components of health spending. Analysis on • Modules 7–9 provide guidance to analyze the distribution and Efficiency and Equity efficiency of spending on health inputs. 3 SECTION 3 Topic-Specific Analysis HEALTH SYSTEM CONTEXT RESOURCE MOBILIZATION, POOLING AND ALLOCATION INPUTS OUTPUTS: SERVICE DELIVERY INTERMEDIATE OUTCOMES OUTCOMES 4 MODULE 2 SECTION 4 Resource Mobilization MODULE 7 MODULE 13 Human Resources Financial Risk Additional MODULE 10 for Health Protection Guidance MODULE 3 Hospitals Pooling MODULE 12 MODULE 1 Service Coverage MODULE 8 Health MODULE 4 MODULE 14 Medicines and System Benefits Specification Health Status Medical Devices Context and Risk MODULE 5 MODULE 11 Purchasing Health Services Primary Care and MODULE 9 Essential Public Infrastructure and Health Services MODULE 15 MODULE 6 Equipment Universal Health Coverage Public Financial Management TABLE OF CONTENTS OVERVIEW How to Navigate this Guide 12 OVERVIEW Preface How to Navigate this Guide SECTION 4 Additional 1 List of Acronyms SECTION 1 Guidance What Is a Health PER? This section offers more detailed 2 information through six technical SECTION 2 notes covering health labor market Cross-Cutting analysis, measuring quality of health Analysis on Efficiency and services, measuring service readiness Equity 3 and availability, benchmarking and cross-country comparisons, SECTION 3 how to best communicate policy Topic-Specific Analysis recommendations, and on concepts 4 and data sources for measuring health expenditure. SECTION 4 Additional Guidance TABLE OF CONTENTS OVERVIEW How to Navigate this Guide 13 OVERVIEW Preface How to Navigate this Guide Navigation, and Downloading Health Public Expenditure Reviews: A How-to Guide is an interactive PDF file, which allows for easy navigation across sections and their content 1 List of Acronyms and provides easy-to-follow guidance. The figure below shows the navigation tools and the structure of the Topic-Specific Modules. PER authors SECTION 1 have the flexibility to download the entire How-to Guide or select individual sections, notes, or modules. However, if only individual components What Is a are downloaded, the embedded links to other parts of the guide will not function offline. When authors are online, these links will direct them Health PER? to the PER webpage, where they can manually download any additional components they need. 2 SECTION 2 In Section 3, each section provides indicators to help answer the key question, with sources where Cross-Cutting OVERVIEW 1 the indicator can be obtained or data from which it Analysis on In Section 3, each section starts with key questions Clicking on the link symbol can be constructed. Whenever possible, the table Efficiency and followed by guidance on how to answer them. will take PER authors to other also indicates sources of data for international Equity 3 SECTION 1 EFFICIENCY content in the How-to Guide. comparisons or benchmarking. What is a Health PER 2 OVERVIEW 1 Aggregate EFFICIENCY Spending 1 SECTION 3 SECTION 2 SECTION 1 Topic-Specific VOLUME 1 What is a Introduction Health PER & Navigation Analysis Cross-cutting 2 2 4 SECTION 2 When comparing pharmaceutical spending between countries, Key Sources for Data for and Equity Cross-cutting Aggregate Spending VOLUME 2 Cross-cutting it’s important to differentiate between outpatient and inpatient Indicators Local Data Benchmarking information and determine whether the data include over-the- Analysis Technical 3 and Equity Notes Analysis counter (OTC) medicines, prescription drugs, or both. GHED data • What is the level of spending on medicines in the country? 3 KEY QUESTIONS • What percent 3 of the budget is absorbed by pharmaceutical spending? The share of total • GHED • What is the level of spending on medicines in the country? follow the National Health Accounts methodology and capture pharmaceutical • National Health SECTION 3 KEY QUESTIONS • What percent of the budget is absorbed by pharmaceutical spending? expenditure on prescription medicines purchased in outpatient SECTION 4 VOLUME 3 expenditure in total Accounts Topic-specific Toolkit Modules and retail (OTC) settings.4 Spending in hospital (inpatient) settings health expenditure SECTION 3 Analysis • How has pharmaceutical spending increased relative to total health spending? is aggregated with hospital spending and can add another 20 • OECD Statistics on Additional Topic-specific percent or more to pharmaceutical spending. Domestic government health have data • How has pharmaceutical spending increased relative to total health spending? Country Context Country Context spending on for a few middle- Guidance Analysis Health Financing Health of The share of the budget spent and the level a conclusion might per Financing also entail looking at coverage Teams should also analyze the growth in pharmaceutical spending pharmaceuticals as a income countries. Inputs capita spending on pharmaceuticals can reveal Inputs (readers may want relative togrowth to the refer of the health tototal Health Service spending to identify whether percentage of general • MoH budgets MODULE 7: government health Human Resources for Health Human Resources for Health module). Coverage the share of pharmaceuticals is increasing. A rising share of or expenditure • GHED expenditure, level and Country Context Infrastructure & Equipment than countries with a similar level of income, this MODULE 8: pharmaceutical spending in a country with a low baseline of trends reports Physical Infrastructure & Equipment spending on medicines (relative to similar countries) might be If possible, PER authors should focus on might also entailexpenditure looking at coverage • National a asconclusion Medicines & Medical Supplies of per spent and the level government higher might indicate that the country is paying MODULE Health Financing theItbudget The share of prices. Service Delivery can also indicate unnecessary prescription 9: pharmaceutical spending Medicines & Medical Supplies a a sign of improved access. A rising share of pharmaceuticals in a country that is already spending more than similar countries might Outcomes tracking signalgovernment share of total Service Delivery spending on health. Total pharmaceutical (readers maygrowth. want to per capita, to the Health Service refer an inefficient procurement process that leads to higher prices on pharmaceuticals can reveal and should raise concerns about the or larger consumption of high-cost medicines. Inputs capita spending information 4 List of Acronyms Outcomes sustainability of such spending However, higher share and level of spending can systems level and trends 4 List of Acronyms Paying high prices for medicines can be a major source of Coverage module). SECTION 4 also indicate better access to medicines, so drawing • For population Human The left menu allows for Resources Health navigation Additional data, WDI Guidance VOLUME 3 between sections and within 4 Account HC.5 corresponds to Domestic General Government Expenditure on Medical Goods not differ- Technical Notes entiated by function; it aggregates medical devices and medicines. Some countries further disaggre- Note: GHED = Global Health Expenditure Database; MoH = Ministry of Health; OECD = Organisation for Economic Infrastructure & Equipment than countries with a similar level of income, this gate between medicines and medical devices. Co-operation and Development; WDI = World Development Indicators. components of each section, and shows which section Medicines and & Medical module Supplies TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies might indicate that the country is paying higher If possible, PER authors should focus on 248 or guidance/additional guidance government pharmaceutical spending as a FRONT MATTER MODULE 9 Medicines & Medical Supplies 245 Service Delivery are displayed. prices. It can also indicate unnecessary prescription Outcomes or larger consumption The arrows of will move authors high-cost between medicines. pages and share the home button will take them to the of total government spending on health. front matter. List of Acronyms However, higher share and level of spending can TABLE OF CONTENTS OVERVIEW How to SECTION 4 Navigate this alsoGuide indicate better access to medicines, so drawing 14 Additional OVERVIEW Preface How to Navigate this Guide ACRONYMS 1 List of Acronyms HNP Health Nutrition and Population SECTION 1 What Is a HNP Health PER? GP Health Nutrition and Population Global 2 Practice SECTION 2 PER Cross-Cutting Analysis on Public Expenditure Review Efficiency and Equity UHC 3 Universal Health Coverage SECTION 3 Topic-Specific Analysis 4 SECTION 4 Additional Guidance TABLE OF CONTENTS OVERVIEW User Guide 15 OVERVIEW 1 SECTION 1 What Is a Health PER? SECTION 1 2 SECTION 2 Cross-Cutting Analysis on Efficiency and What is a Health PER? Equity 3 AUTHORS Agnès Couffinhal, Catalina Gutiérrez, Denise Silfverberg, and Pia Schneider SECTION 3 Topic-Specific Analysis This introduction to the updated “Health Public Expenditure Reviews: A How-to Guide” defines the purpose 4 of health Public Expenditure Reviews (PERs) and introduces an analytical framework to guide the review. It SECTION 4 highlights the key steps for conducting a PER and offers an example of an outline for a PER report. Additional Guidance CONTINUE OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? THE PURPOSE OF A PER A Public Expenditure Review aims CORE HEALTH PER QUESTIONS 2 List of Acronyms to evaluate the effectiveness of SECTION 2 Cross-Cutting government expenditures in a country. A HEALTH PER SHOULD ADDRESS THE FOLLOWING: Analysis on Efficiency and 1. Sustainability and sufficiency: How does revenue capacity compare Equity The objective of a health-specific PER is to assess 3 with the expected level of health spending necessary to achieve the effectiveness of public spending in supporting national health goals in the medium term? Is the level and growth of SECTION 3 the achievement of health system goals and policy spending in line with fiscal sustainability? Topic-Specific priorities by examining performance in one or more Analysis 2. Efficiency: Can health outcomes be improved with the same level of of four core domains: sustainability and sufficiency, 4 efficiency, equity, and governance. PERs typically spending? Is the country spending on those things that improve most examine the flow of funds within the health sector the outcomes and welfare? SECTION 4 Additional and analyze public spending over several years. 3. Equity: Who benefits from health spending? Is health spending Guidance improving health outcomes and financial protection for all, regardless Health PERs also assess the articulation and the role of private and public entities operating in the of geographic location and socioeconomic status? Is health spending sector. A successful health PER identifies, assesses, adequately targeting the poorest and most vulnerable segments of and prioritizes areas to strengthen the use of the population? public financial resources and thus improve health 4. Governance: Are the rules, processes, and institutional arrangements outcomes. 1 that govern health spending aligned to achieve health system goals? Do public financial management systems improve predictability, transparency, and accountability of health spending? 1 In the remainder of this document, for ease of reference, health systems goals are referred to as “health outcomes.” TABLE OF CONTENTS SECTION 1 What Is a Health PER? 17 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? A health PER may be prepared specifically for the health sector as a standalone document (for example, Namibia). It may cover the health sector in a social sector or macroeconomic PER (for example, Armenia, Georgia, Egypt), in a human capital PER (for example, Pacific Islands), or in a government-wide PER (for example, Belize PER, Comoros PER health chapter). Authors should ensure 2 List of Acronyms government ownership of the health PER throughout the policy dialogue, using SECTION 2 workshops and regular meetings. Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 FRAMEWORK FOR ANALYSIS Topic-Specific Analysis 4 The guidance adopts a single overarching analytical framework that conceptualizes the health system as a results chain—from mobilizing, pooling, SECTION 4 and allocating resources to health outcomes (Figure 1).2 Financial resources are Additional Guidance used to pay for inputs: human resources for health, infrastructure, equipment, and medical supplies. Different processes convert these inputs into outputs (health services delivered via hospitals, primary health care, and public health functions), which subsequently translate into intermediate and final health outcomes (service coverage, financial protection, and health status and risks). Efficiency, equity, governance, and financial sustainability are the main lenses used when looking at the different parts in the results chain. Section 3 provides guidance to analyze expenditure on each component of the results chain 2 The framework refines earlier concepts to assess the efficiency of health systems (Hafez 2019; Smith, O. 2017; Smith, P. 2012). TABLE OF CONTENTS SECTION 1 What Is a Health PER? 18 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? FIGURE 1: ANALYTICAL FRAMEWORK Resource mobilization, pooling, and allocation Inputs Outputs: Service delivery Intermediate outcomes Final outcomes 2 List of Acronyms E ciency • Resource mobilization • Human resources • Hospitals • Service cover- • Financial pro- • Pooling • Medicines and • Primary care and age tection Sustainability SECTION 2 • Resource allocation medical supplies essential public • Health status Cross-Cutting Equity • Infrastructure and health functions and health Analysis on equipment risks Governance Efficiency and Equity 3 Are resources su cient, Is there an undersupply Are services su cient Are people able Is the population sustainable, and or oversupply of inputs? and of good quality? to access the facing financial e ciently mobilized? services they hardship to access SECTION 3 Are they being Is there an Pooled e ectively to need and getting health services? or purchased at the lowest underutilization or Topic-Specific spread health risks, avoid adequate forgoing care due price? overutilization of Analysis fragmentation, inequity, treatment? to financiaI barriers? services? 4 and high administrative Is there evidence of Is access to How healthy is the costs? waste in input use? Are they being services equitably Are inputs of su cient produced at the lowest population and how Purchasing the right distributed across SECTION 4 quality? cost? health services? geographic e ectively are Additional Is the mix of inputs Are services locations and health risks Are providers' incentive Guidance e cient? integrated? socioeconomic controlled? aligned with health system status? Are inputs equitably Is the mix of services Are health status goals? distributed across e cient? and risks and Are fund transfers geographic and financial protection Are services equitably predictable, and reliable, socioeconomic equitably distributed across and is budget execution dimensions? distributed across geographic and transparent and socioeconomic and socioeconomic accountable? geographic dimensions? dimensions? Source: World Bank staff. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 19 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? CONDUCTING A PER: PROCEDURAL CONSIDERATIONS 2 List of Acronyms SECTION 2 Cross-Cutting Analysis on The World Bank follows a standard operational process to prepare a PER Efficiency and Equity 3 In line with Bank procedures, PER authors first prepare a concept partners. The final PER report will be peer reviewed by Bank staff SECTION 3 note (CN) to describe the activity and demonstrate how the and will have to be approved at the decision review meeting Topic-Specific Analysis proposed analysis will help the country solve the problem to be before it is published. Authors should prioritize strengthening 4 addressed. The CN acknowledges the scope and key policy issues the government’s analytical capacity and fostering ownership to be addressed in the study. It will lay out the proposed scope of the health PER. This can be achieved by having government SECTION 4 and depth of analysis to be covered, data and resources needed, leaders assign staff to collaborate and work with the Bank team Additional Guidance reasons for possible limitations, and the outline for the report. and by organizing regular stakeholder meetings to discuss The Bank’s quality assurance process will have to approve the CN preliminary findings. Finally, dissemination events are organized during a review meeting, which is usually chaired by the Bank’s with policymakers and relevant stakeholders to present the PER country director. results and discuss recommendations and their implementation. Second, authors collect data from government and stakeholders, The process for conducting a PER can be structured into a five- conduct the analysis for the PER, and write the report. Findings step approach, as outlined in this section. Figure 2 provides an are shared and discussed with government and development overview. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 20 OVERVIEW 1 SECTION 1 FIGURE 2. Five steps to prepare a health PER What Is a Health PER? STEP 1: Define the Scope STEP 4: Conduct the Analysis • Understand the context in which the PER is being conducted: new or renewed • Referring to the chapter “How to Navigate this What Is a Health PER? engagement, government-driven request, informing a World Bank project. Guide” in Section 1, define which cross-cutting notes 2 List of Acronyms • Consider whether the document is a standalone PER or section/chapter of a (Section 2), modules (Section 3), or technical notes broader PER. (Section 4) will be used for the analysis. SECTION 2 • Identify budget and time frame. • Identify other tools that will be needed to Cross-Cutting complement the analysis. Analysis on • Follow the guidance and construct the indicators. Efficiency and Equity STEP 2: Define the Objectives and Key Questions Analyze the indicators using the guidance provided. 3 • Draft preliminary findings. • Identify country key informants who understand the way the health system operates and the government’s main concerns about efficiency, SECTION 3 sustainability, governance, and/or equity. Topic-Specific • Engage informants in a discussion about key concerns and their causes. STEP 5: Present the Results to Analysis Inquire about other possible issues using the list of core questions (Box Key Policymakers and Define Policy Actions 4 1), the results chain framework, and previous analytical work. • Develop a list of the main concerns of stakeholders—MoF, MoH, • Present the preliminary findings to key policymakers providers, etc.—and agree on the scope, objectives, and areas/ to confirm they agree with the results. SECTION 4 questions the PER will seek to address. • Adjust the analysis based on discussions about the Additional • Agree on the final scope, objectives, and questions with key results. Go back to step 4 if needed. Guidance policymakers. • Prioritize which sources of inefficiency, inequities, unsustainability, or governance issues warrant action. STEP 3: Seek Data to Answer the Key Questions • Start the discussion about possible policy levers to improve prioritized inefficiencies, inequities, • Identify primary and/or secondary government data (from MoF, MoH, unsustainability, or governance issues; feasibility; insurance agency/purchaser, statistics office), including raw data, and possible obstacles. government reports, and laws and regulations. • Identify where further analysis and technical • Identify data available in international data repositories (WHO Global assistance are needed to define the policy actions Health Expenditure Database, WHO Global Health Observatory, World and work with the appropriate part of government to Bank, etc.). develop a detailed strategy. • Identify key informants for qualitative information. • Collect the data. Source: World Bank staff. Note: MoF = Ministry of Finance; MoH = Ministry of Health; WHO = World Health Organization. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 21 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? STEP 1 Defining the Scope The first step involves defining and refining the scope of a specific When responding to government requests, the Ministry of Finance health PER and elaborating a list of prioritized policy issues (MoF) often has specific questions about whether government 2 List of Acronyms important to the country. The scope and depth of a health PER is spending on health is in line with the country’s financing ability and SECTION 2 defined by the policy issues important to the country. In addition, goal to achieve health objectives in an efficient way. Additionally, Cross-Cutting Analysis on authors need to determine which of the questions in Box 1 their a PER may be needed to help inform the policy dialogue and Bank Efficiency and Equity PER will address and whether it will examine all or just a few lending operations. Overarching health system reform requires a 3 components of the results chain. wider analysis, covering in depth each or several components of the results chain, if the relevant data are available. SECTION 3 Topic-Specific Defining the scope is an iterative process that begins with Analysis understanding the context and motivation for undertaking the The scope of the analysis should also be informed by whether the 4 analysis. A PER might be initiated to engage or renew the World PER is a standalone health PER or a health chapter in a broader PER Bank’s involvement in the country’s health system. In such cases, covering multiple sectors. A health chapter should have a narrower SECTION 4 a thorough diagnostic may be necessary if there are no up-to- scope. The chapter might focus on one to two key questions, or Additional Guidance date analyses of the health system. Alternatively, the government the PER authors could review relevant documents and conduct might request the review to assess specific policy issues, such stakeholder interviews to identify two to three main sources of as health spending in a context of tight fiscal constraints, the inefficiency or inequity in the results chain. Equity analyses in a need to improve spending efficiency, identify possible savings, health chapter should pinpoint the primary challenges (for example, or sustainable financing in a country with an aging population which groups lack access to care or financial protection) and and a costlier disease profile. Here, a narrower scope might be determine whether the distribution of inputs or funding schemes appropriate, focusing on reforms in infrastructure investments, contributes to these inequalities. The scope must be informed by pharmaceutical procurement, rightsizing the health workforce, or and aligned with the overall objective of the multisectoral PER. hospital spending efficiency. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 22 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? A standalone health PER can investigate all four core PER areas of analysis: financial sustainability and sufficiency, efficiency, equity, and good governance. While all PERs share these high- level objectives, the specific scope and questions of individual PERs scope and a more focused approach, especially in countries with limited data. Once the preliminary scope is defined, it is important to discuss it with the key stakeholders (typically, the Ministry of Health (MoH) and the the Ministry of Finance (MoF)) and agree on 2 List of Acronyms may vary depending on the country context. A PER analysis is data the final scope, objectives, and policy questions—with modification driven. For instance, if the data show high spending on medicines as needed. This early engagement is important for ensuring client SECTION 2 Cross-Cutting and medical supplies, identifying and addressing the underlying ownership of the PER process and the resulting report. Continued Analysis on reasons may become a policy priority. stakeholder engagement throughout the process increases the Efficiency and Equity chance that the findings and policy recommendations will be 3 It is crucial that the scope reflects the available budget, time relevant, accepted, and implemented. SECTION 3 frame, and data. A shorter time frame will necessitate a narrower Topic-Specific Analysis 4 SECTION 4 Additional Guidance STEP 2 Defining the Objectives and Questions To define the objectives and questions, PER authors need to obtain in all four PER core areas can be addressed (otherwise, authors should relevant data from the government. They also should identify key focus on the one or two most important areas). After developing a informants familiar with the health system to interview about their preliminary list of the issues and priority topics revealed in key main concerns and issues and whether these pertain to efficiency, informant interviews, authors can consider whether any unraised sustainability, equity, or governance. Once the main policy issues, issues merit analysis. To do so, they can use the framework in Figure scope, and objectives have been acknowledged, authors can list the 1 and the list of modules in Section 3. The questions listed for each questions the PER will aim to address. If the data are available for component of the results chain can guide author discussions, analysis and it is within the time frame and framework, the questions complemented by existing analytical work from the World Bank TABLE OF CONTENTS SECTION 1 What Is a Health PER? 23 OVERVIEW 1 SECTION 1 and country development partners. Before proceeding to the next • Government Staff: Including HMIS PER authors, health and What Is a step, the final list of questions and well-defined, clearly stated finance ministries, and relevant department heads (for Health PER? objectives should be agreed on by key stakeholders. PER analysts will example,, pharmaceuticals for related PER topics). Analysts collaborate with country counterparts to define the scope, objectives, may also interview health facility managers and health What Is a Health PER? and policy questions of the PER, engaging the following groups: insurance leaders to identify challenges. 2 List of Acronyms • Development Partners: To coordinate efforts, identify SECTION 2 • Policymakers: To align on the PER approach, secure approval synergies, address additional relevant questions, and Cross-Cutting to meet with government staff, and access essential data (for Analysis on facilitate data sharing. Efficiency and example,, budgets, expenditures, health services, policies, Equity 3 and surveys). SECTION 3 Topic-Specific STEP 3 Gathering Data and Information Analysis 4 SECTION 4 Additional Guidance PERs use a mix of quantitative and qualitative data, evidence from the literature, and stakeholders’ tacit knowledge. Once the objectives and questions are defined, PER authors can identify all existing data sets and resources within the country, including those Regardless of the type of PER, the analysis should build on earlier sector advisory services and analytics from the World Bank and development partners. These may include the most recent PERs for the country (if available), other Bank documents (poverty from national statistics offices and the MoH and MoF. In countries assessments, systematic country diagnostic, Public Expenditure with insurance systems or a payer-provider split, data from the and Financial Accountability (PEFA) assessments. The International insurance agency might also provide relevant information. Authors Monetary Fund (IMF) provides its Article 4 Reports, which contain are advised to consult with government and development partners macroeconomic assessments. Key government documents, such in a country to identify the relevant datasets and reports that can as national sectoral development plans, laws, and regulations as be used for analysis. well as academic literature and country research reports, can also be important information sources. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 24 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? An effort was made to ensure that the indicators in this guidance can be constructed with data likely available in low- and middle-income countries. The indicators rely primarily on five types of data sources: unaudited), budget execution reports, and other expenditure- related documents. The BOOST database, where available, is a key tool to analyze detailed budget data across sectors, while national websites often provide public finance information. International Repositories of Guidance on accessing these data is detailed in the Public 1 2 List of Acronyms Health and Economic Information Financial Management (PFM) module. SECTION 2 Cross-Cutting • Health insurance reports: If the country has health insurance Analysis on • Global repositories with data for multiple countries: The World programs (public and/or private), authors should also meet Efficiency and Health Organization (WHO) Global Health Expenditure Database, Equity with insurance management to receive annual reports on 3 Organisation for Economic Co-operation and Development membership, revenue and expenditures, and health service use. (OECD) Health at a Glance, the European Health Interview SECTION 3 Private health insurance performance indicators are usually Survey, Global Health Workforce Statistics database, the Topic-Specific published by the country’s insurance oversight body in the Analysis World Health Survey, and Global Burden of Disease (GBD) data annual insurance market report. 4 provide standardized data for comparing health expenditures, outcomes, and workforce statistics across countries. Relevant • National Health Accounts (NHAs): When available, NHAs offer SECTION 4 macroeconomic and fiscal data, such as GDP, general insights into health expenditures from multiple sources, Additional including government, private, and development partners. They Guidance government revenues, and expenditures, can be found on the World Bank’s World Development Indicators (WDI) website, which show the flow of funds through intermediary agencies and their also provides information on health outcomes and expenditures. use by different types of health care providers. This is covered in more depth in the Resource Mobilization Module 2. 2 Country Revenue and Expenditure Data 3 Health Sector-Specific Data • Government budget and expenditure data: A crucial source for PERs is government administrative data provided by the MoF and • Health sector data: Detailed data on health infrastructure, MoH. Access to these data can be facilitated by the Bank’s country workforce composition, service use, and health status are economist. These include budget reports (both audited and critical for analyzing the efficiency and performance of health TABLE OF CONTENTS SECTION 1 What Is a Health PER? 25 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? expenditures. Sources include MOH annual reports, Health insurance agency reports, health management information systems (HMIS), and strategic documents such as health policies, laws, and regulations. The private health sector can Equity-focused PERs especially benefit from this data. • Service readiness and delivery surveys: These include tools such as the Service Readiness Assessment (SARA) and Service Delivery Indicators (SDI), which provide insights into the provide additional data through associations or regulatory 2 List of Acronyms readiness and capacity of health facilities to deliver services, bodies. SECTION 2 as well as overall service performance. Cross-Cutting • Population and demographic profiles: Data on population Analysis on structure, gender, educational attainment, and future Efficiency and 5 Key Informant Interviews Equity 3 demographic trends are necessary for projecting health needs and expenditures. National statistics offices and sources like the • PER authors will conduct interviews with key informants in SECTION 3 Wittgenstein Center’s Data on Multidimensional Demographics the health sector, mainly to gather additional information, Topic-Specific provide detailed insights into population trends and their impact Analysis interpret findings, and validate results and recommendations. on health service demand. United Nations, Population Division 4 Data Portal provides population projections. SECTION 4 PER authors should rely on readily available data on government Additional 4 Special-Purpose Surveys budgets and expenditures, health service utilization, the composition Guidance of the health workforce, and household surveys whenever possible. • Household surveys: Household surveys provide critical For PERs with a broader scope and longer time frame, authors may information for analyzing household health expenditures, consider conducting primary data collection and analysis to enhance access to care, health service usage, and equity in health existing data collection efforts. Qualitative data collected from key financing. The World Bank central data catalog provides a informant interviews can provide crucial insights to help interpret list of Demographic and Health Surveys (DHS), income and findings. expenditure surveys, and the Multiple Indicator Cluster Survey (MICS), all of which provide valuable data for understanding The PER guidance in Section 2 and Section 3 offers potential sources how health financing impacts different population groups. of information for each suggested indicator. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 26 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? Next, it is crucial to ensure that the government shares the data needed for the PER analysis. It is beneficial to include among the PER authors at least one person who is very familiar with the offices efforts occurring in the country and aim to optimize output from these exercises, such as existing NHA exercises or Resource Mapping and Expenditure Tracking (RMET). It is also useful for PER authors to that hold the data. This person ideally should be country based to discuss opportunities for coordinating such efforts between sectors 2 List of Acronyms travel easily and affordably to gather data. and development partners. SECTION 2 Cross-Cutting Analysis on During the concept stage of a health chapter or standalone health After the data sources are secured, the next step is to conduct the Efficiency and Equity PER, authors should consider synergies in health data collection analysis using the guidance provided. 3 SECTION 3 Topic-Specific Analysis 4 SECTION 4 Additional Guidance STEP 4 Analyzing the Data and Validating the Results The How-to Guide offers alternative approaches to the analysis. The cross-cutting notes in Section 2 provide an overall view of health The modules in Section 3, however, cover each component of the results chain in more depth, addressing several or all four core system efficiency and health equity. These notes are useful for PER health PER areas and questions. These modules complement authors with a broader scope. The notes may also be preferred the analysis from the cross-cutting notes—and are ideal for PER by authors aiming to reengage or develop new engagements with authors with specific government requests or those using PER country governments. analysis to inform targeted health projects, such as improving the availability, procurement, and efficiency of spending on medicines, TABLE OF CONTENTS SECTION 1 What Is a Health PER? 27 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? or redesigning the health service delivery model. Authors informing a large reform might use the macro-efficiency section of the Efficiency Cross-Cutting Notefffffto set the stage for discussion, benchmarks for comparing country results. In cases where no agreed-on benchmarks exist or data for similar countries are unavailable, the results should guide discussions with stakeholders alongside several modules from Section 3. and experts. In some instances, it may be possible to compare 2 List of Acronyms performance across geographical areas or providers. SECTION 2 The modules and cross-cutting notes are structured around key Cross-Cutting Analysis on questions and provide a comprehensive set of indicators for each PER authors should identify the most pertinent issues they want Efficiency and Equity component of the results chain. For each indicator, data sources to validate with key stakeholders and policymakers. If many issues 3 are indicated. The indicators can illuminate a range of performance are identified, to ensure clarity and succinctness in the PER, authors issues by using simple analytical approaches like benchmarking can work with the stakeholders and policymakers to narrow the list, SECTION 3 Topic-Specific and trend analysis (see Additional Guidance 1 for more on as discussed in the next step. Analysis benchmarking). The guidance also provides, when possible, 4 SECTION 4 Additional Guidance STEP 5 Presenting the Results to Key Policymakers and Defining Policy Actions 1 Prioritize Issues for Action feasible and politically viable. This step may be unnecessary for PERs with narrow scopes of two or three issues. It can also be After the preliminary performance issues have been validated with unnecessary when the PER is informing a sector-wide reform, stakeholders, the next step is to agree on priority issues that warrant and multiple domains will be tackled. In these cases, authors can action and are amenable to policy interventions that are technically proceed directly to developing policy recommendations. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 28 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? There are several ways to prioritize issues for policy action. During an unstructured discussion with policymakers and key stakeholders, for example, PER authors can (1) present FIGURE 3. MULTICRITERIA ANALYSIS Relevance How important Technical Feasibility Political Feasibility Strength of the Evidence the results from the previous step; (2) pose open questions is the issue to Are there Are the issues What is the 2 List of Acronyms about which issues merit more attention and prioritized improving overall effective policies aligned with the strength of SECTION 2 action; and (3) seek to build consensus on the three to performance that can address current national the supporting Cross-Cutting five most important issues. Or authors can take a more (sustainability the issues? health plans evidence? Analysis on Efficiency and structured approach, such as multicriteria analysis. and sufficiency, If so, are the and the political Have identified Equity efficiency, equity, human, financial, priorities? challenges 3 governance)? and technical been confirmed Multicriteria analysis is often used to prioritize intervention resources Score from 1 through data, SECTION 3 areas or policy options. It helps analysts and decision Score from 1 to 4 available to to 4 (1 = low evidence in the Topic-Specific makers visualize how a list of options compares with a set of Analysis (1 = low relevance undertake the alignment/ literature, and evaluation criteria. The first step in multicriteria analysis is 4 and 4 = high policy actions? political support tacit knowledge to select the criteria or goals on which the areas or policies relevance). and 4 = very of policymakers? will be evaluated. For a PER, authors should compare actions Score from 1 to 4 high alignment/ SECTION 4 (1 = low technical political Score from 1 to 4 Additional in at least four domains: relevance, technical feasibility, Guidance feasibility and 4 = support). (1 = weak evidence political viability, and strength of the evidence. Figure 3 high feasibility). and 4 = very shows an example of multicriteria analysis. strong evidence). Issue 1 In discussions with policymakers and key stakeholders, each issue should be graded, for example, on a scale of 1 to Issue 2 4, and the total score for each issue calculated. The highest- Issue 3 scoring issues can then be prioritized for policy actions. Grades can be tallied by consensus or, if no consensus is Issue 4 reached, averaged among participants. Source: World Bank staff. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 29 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? Relevance is a criterion used to assess the importance of an issue or challenge in improving overall system efficiency, equity, institutional performance, or financial sustainability, and its role review the available budget to ensure the proposed solutions are financially viable. within the results chain. It evaluates whether the issue constitutes Political feasibility examines whether the identified issues are 2 List of Acronyms the weakest link or root cause in a chain of causes and effects. likely to be prioritized by decision makers, budget authorities, SECTION 2 Relevance can pertain to the questions in one or more of the core and lawmakers. It also considers whether powerful stakeholders Cross-Cutting Analysis on areas of a health PER (sustainability and sufficiency, efficiency, benefit from maintaining the status quo. Alignment with national Efficiency and Equity equity, and governance). health goals or plans is a clear indication that the government is 3 likely to support action on an issue. Participants in the prioritization If issues are evaluated against all four sets of questions, it may exercise may choose to drop issues with very low political feasibility SECTION 3 Topic-Specific be better to have separate relevance criteria for each question. or, if an issue scores very high on other criteria, they may decide Analysis Alternatively, a single relevance criterion can be used, with a graded to add technical support to justify addressing the issue and raise 4 scale reflecting the breadth of performance issues addressed. For awareness of its importance to garner political support. example, a score of 1 would be assigned if the issue addressed only SECTION 4 one core performance question, while a score of 4 would be given Strength of the evidence is crucial because significant time and Additional Guidance if it addressed all four. resources are likely to be devoted to addressing a particular issue. It is important to ensure that the evidence is robust to avoid Technical feasibility examines the likelihood of overcoming the erroneous diagnostics and wasted efforts. For instance, have the challenge. This includes evaluating whether effective policies exist identified challenges been confirmed through data, literature to address the issues and whether the necessary human, financial, evidence, and the tacit knowledge of policymakers? Or was the and technical resources are available to implement these policies. issue identified through a few informal interviews and without PER authors should be prepared with information on potential data to triangulate or confirm the results? When evidence is weak, policies that can address the issue, evidence of their effectiveness, authors should consider delaying any decision on the topic until and a rough estimate of the costs involved. Ideally, authors should stronger evidence is collected. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 30 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? When prioritizing efficiency and sustainability issues for policy action, PER authors should be aware that efficiency gains do not automatically translate into more fiscal space for health. Barroy 2 Identify Policies to Address the Prioritized Issues et al. (2021) suggest that three preconditions need to be met for 2 List of Acronyms The purpose of Health Public Expenditure Reviews: A How-to Guide efficiency gains to be converted into additional budget: (1) countries SECTION 2 is to provide the methodology to analyze data for a PER, develop must develop well-defined and -targeted interventions that change Cross-Cutting recommendations based on findings, engage policymakers, and Analysis on the prices or the mix of inputs; (2) the interventions must generate Efficiency and disseminate results to stakeholders. Authors should avoid generic Equity sizable and quantifiable financial gains; and (3) public financial 3 recommendations that do not include specific actionable strategies management (PFM) systems must allow those gains to be kept and policies to achieve the intended goal. within the health sector and repurposed toward prioritized health SECTION 3 Topic-Specific needs, in particular, flexible PFM systems that allow the central The following actions can help PER authors develop and Analysis or local levels as well as purchasers and providers to keep and communicate policy options. Authors should: 4 repurpose the savings that need to be in place. Moreover, most reforms do not generate cash on hand but rather allow providers SECTION 4 • Search the literature for information on policies used to and purchasers to do more with the same resources, except when Additional tackle similar issues in comparable country contexts and Guidance prices of inputs, such as medicines, are reduced. Reforms that the resulting impacts. The topic-specific modules provide improve quality and processes might take several years or more to references that can aid in identifying potential policies. reduce expenditure and often require large upfront investments. For example, quality improvements in promotion and prevention of • Identify World Bank expertise that can help develop noncommunicable diseases might only yield savings from improved actionable policy options. health decades later. • Initiate with policymakers a discussion about possible policy levers to improve prioritized inefficiencies, inequities, sustainability or governance issues, and potential obstacles. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 31 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? • Identify where further analysis and technical assistance are needed to define the policy actions and work with the appropriate part of government to develop a detailed strategy. • When making recommendations, avoid generic suggestions that do 2 List of Acronyms not include specific actionable strategies and policies to achieve the SECTION 2 intended goal. Recommendations such as “increase expenditure in Cross-Cutting Analysis on infrastructure,” for example, “reduce waste in the use of medicines,” Efficiency and Equity or “improve primary health care” are not useful, because they are 3 not actionable. Before presenting recommendations, consult with and receive validation from policymakers and key stakeholders. SECTION 3 Topic-Specific Recommendations should be justified and well documented to ensure Analysis credibility and buy-in. When a recommendation could lead to a 4 potential “tradeoff” of results (for example, a policy measure to improve efficiency may come at the expense of equity), that should be clearly SECTION 4 stated and, if possible, a reconciliation discussed. Additional Guidance Once finalized, authors should present the PER to government and various stakeholders during an in-country workshop. The goal of the workshop could also be to help the government identify possible support for the implementation of recommendations from Bank projects and development partners and other stakeholders. Additional Guidance 5 offers further guidance on providing recommendations. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 32 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? Pulling It All Together: A Generic Outline 2 Socioeconomic and Health Context Findings from the analysis are presented in 2 List of Acronyms the health PER report. The structure for the SECTION 2 Set the stage for the health analysis by offering an overview of macrofiscal challenges Cross-Cutting report will depend on the scope and context and socioeconomic and poverty issues relevant to the health PER. This section Analysis on of the PER. Therefore, this outline is primarily includes: Efficiency and Equity 3 illustrative, offering (1) high-level guidance on • A description of the current and projected population profile, the burden of SECTION 3 key issues typically covered in a PER report, disease (current and future), and emerging health threats. Topic-Specific and (2) links to relevant content in Public • A review of the health system’s structure, including governance, service Analysis 4 Expenditure Reviews: A How-to Guide. PER delivery, and financing arrangements, such as the role of public and private authors should take the actions set out below sectors. SECTION 4 Additional • Key health system indicators, such as life expectancy, under-five mortality, Guidance 1 Introduction and Objectives immunization rates, and access to health care. • An assessment of government health priorities and reform plans, based on Provide a brief description of the key health policy concerns the most recent policy and strategy documents, highlighting their alignment facing the government, acknowledging recent reforms and with emerging health concerns. any challenges in their implementation. Clearly outline the objectives of the PER along with the key questions guiding See: Country Context Module , Service Coverage Module , Health Status the analysis and the overall scope of the review. and Risk Module , Universal Health Coverage Module , and Additional Guidance 1 on Benchmarking TABLE OF CONTENTS SECTION 1 What Is a Health PER? 33 OVERVIEW 1 SECTION 1 3 Overview of Health Financing • A discussion on whether the PFM system effectively supports What Is a (Resource Mobilization, Pooling, Allocation, health policy implementation and the achievement of health Health PER? and Budgetary Performance) objectives. What Is a Health PER? • If there is health insurance, a description of the methods of This section assesses the adequacy and sufficiency of health government budget allocation to public health insurance, as 2 List of Acronyms spending in relation to national health goals, the sustainability and well as a list of the issues that need policy attention, such as SECTION 2 predictability of resources, the allocation of health expenditure sustainability. Cross-Cutting among different categories, and the performance of PFM. It is likely Analysis on Efficiency and to include: PER authors should conclude with a summary of the fiscal and Equity 3 • An analysis of the composition levels and trends in total and economic implications of health financing, assessing whether funding public expenditure on health (with some benchmarking). sources, spending priorities, and allocation methods align with SECTION 3 government objectives and health priorities. Authors should highlight Topic-Specific • An analysis of the fiscal impact of government health critical issues, including financial accountability, adequacy, efficiency, Analysis expenditures and issues of sustainability and sufficiency. equity, and sustainability, to provide a clear and actionable conclusion. 4 • A breakdown of health financing sources, including domestic SECTION 4 government spending, external donors, and household out-of- See: Resource Mobilization Module and Public Financial Additional pocket payments. Management Module Guidance • A description of the organization and governance of public financial flows in the system. 4 Efficiency of Health Expenditures • An assessment of the adequacy, sustainability, and equity of the health financing system. This section assesses whether the country is utilizing its health resources efficiently, minimizing waste, and focusing spending on areas • An evaluation of budget execution in the health sector, that most improve population health and welfare. It can begin with an including delays, any discrepancies between planned and introduction describing expenditure disaggregated by function (for actual spending, and an analysis of fund allocation across example,” [“for example,,” in tables and figures], inpatient, outpatient, national and subnational levels, if relevant. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 34 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? medical goods) and provider type, and continue by covering selected topics, tailored based on the country’s context and government priorities. The most relevant policy issues and concerns should be selected in the health sector. Not all topics may be applicable or See: Primary Health Care and Essential Public Health Functions Module Module Readiness , Hospitals Module , Purchasing of Health Services , Additional Guidance 3 on Service Availability and , and Additional Guidance 4 on Quality of Health necessary. Below are potential areas for PER authors to assess: Services 2 List of Acronyms SECTION 2 Cross-Cutting • Analysis of expenditures on key inputs: Assess spending on • Efficiency in pooling, benefit specification, and purchasing of Analysis on critical resources such as infrastructure, human resources health services: In countries with health insurance or multiple Efficiency and Equity for health (HRH), and pharmaceuticals. This could include financing pools, PER authors should assess how well resources 3 issues like workforce management, health payroll concerns, are pooled and whether purchasing, and procurement SECTION 3 pharmaceutical procurement, and facility maintenance. mechanisms lead to duplication, high prices or inefficiency. Topic-Specific This also includes examining the efficiency implicit in benefit Analysis See: Human Resources in Health Module , Medicines and package(s) provided by insurance schemes or government 4 Medical Devices Module , Infrastructure and Equipment programs. Module , Additional Guidance 1 on Benchmarking , and SECTION 4 Additional Guidance 2 on Health Labor Market Analysis See: Pooling Module , Benefits Specification Module , Additional Purchasing Health Services Module Guidance • Evaluation of health service delivery performance: PER authors should review efficiency in hospitals, primary care, • Specific policy issues: Depending on national priorities, this and essential public health functions. This includes access to section can delve into specific health concerns such as HIV/ care, quality of services, availability of essential medicines, AIDS, noncommunicable diseases (NCDs), or maternal and child and health facility readiness. Metrics like bed occupancy health. rates, length of stay, cesarean section rates, and service use are crucial for understanding service delivery efficiency. Further, authors should evaluate whether purchasing mechanisms are aligned with efficiency objectives. TABLE OF CONTENTS SECTION 1 What Is a Health PER? 35 OVERVIEW 1 5 Equity of Health Expenditures 6 Conclusions, Recommendations, and Policy Options 7 Annexes SECTION 1 What Is a Health PER? This section analyzes how health spending is Authors should summarize key findings, highlighting inefficiencies, • Detailed data distributed across different population groups equity gaps, and opportunities for improving health sector tables on health What Is a Health PER? (urban vs. rural, rich vs. poor, gender) and geographic performance. Recommendations should be in groups of short- or expenditures, 2 List of Acronyms regions, with an emphasis on the most vulnerable medium-term actions that are most relevant for improving population service delivery population groups. It assesses: health. Authors should consider the fiscal and resource implications of performance, and SECTION 2 Cross-Cutting recommendations and identify eventual barriers to implementation. health outcomes. Analysis on • The equity of service use and spending based on Actionable policy recommendations should be provided. These can Efficiency and household survey data, with particular attention • Technical Equity be grouped by topic: 3 to disparities in service coverage between appendixes • Resource mobilization strategies: Proposals to increase fiscal socioeconomic groups, insured vs. uninsured that provide SECTION 3 space for health, including raising domestic resources (for populations, and geographic locations. methodological Topic-Specific example,, health taxes) and improving the sustainability of Analysis notes, including • Financial protection, analyzing how external financing, as well as improvements in PFM. 4 approaches to out-of-pocket expenditures differ across • Efficiency improvements: Recommendations for optimizing data collection, socioeconomic groups and the insured/ SECTION 4 health spending through upgrading resource allocation, reducing analysis, and Additional uninsured divide. inefficiencies, and improving governance in health system interpretation. Guidance • Any inequities in benefit packages provided functions (for example, procurement, HRH management). by various insurance schemes or government • Equity-focused strategies: Proposals to reduce disparities in programs, identifying reforms needed to access to care, particularly for vulnerable populations, and improve equity in health financing and service reduce out-of-pocket payments. PER authors should discuss delivery. the next steps for implementing reforms, monitoring progress, See: Benefits Specification Module , and evaluating the government’s capacity to address these Service Coverage Module , Financial Protection challenges, based on projected economic growth and fiscal space. Module , UHC Module , and, Cross-Cutting See: Additional Guidance 5 on Recommendations Note on Equity TABLE OF CONTENTS SECTION 1 What Is a Health PER? 36 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? References Barroy, Hélène, Jonathan Cylus, Walaiporn Patcharanarumol, Jacob Novignon, Tamás Evetovits, and Sanjeev Gupta. 2021. “Do efficiency gains 2 List of Acronyms really translate into more budget for health? An assessment framework and country applications.” Health Policy and Planning, Volume 36, SECTION 2 Issue 8: 1307–15. https://doi.org/10.1093/heapol/czab040. Cross-Cutting Analysis on Hafez, R., ed. 2020. Measuring Health System Efficiency in Low- and Middle-Income Countries: A Resource Guide. Joint Learning Network for Efficiency and Universal Health Coverage. https://jointlearningnetwork.org/wp-content/uploads/2020/02/Resource-Guide-Measuring-Health-System- Equity 3 Efficiency-200807.pdf. SECTION 3 Smith, Owen. 2017. Note on Efficiency of Health Spending. Preliminary version of unpublished document. Topic-Specific Analysis Smith, Peter C., and Andrew Street. 2006. “Concepts and Challenges in Measuring the Performance of Health Care Organisations.” Centre 4 for Health Economics, University of York. https://pure.york.ac.uk/portal/en/publications/concepts-and-challenges-in-measuring-the- performance-of-health-ca. SECTION 4 Additional Guidance TABLE OF CONTENTS SECTION 1 What Is a Health PER? 37 OVERVIEW 1 SECTION 1 What Is a Health PER? What Is a Health PER? ACRONYMS CN Concept Note NHA National Health Accounts DHS OECD 2 List of Acronyms Demographic and Health Survey Organisation for Economic Co-operation and Development SECTION 2 GBD PEFA Cross-Cutting Analysis on Global Burden of Disease Public Expenditure and Financial Accountability Efficiency and Equity GDP PER 3 Gross Domestic Product Public Expenditure Report SECTION 3 HMIS PFM Topic-Specific Health Management Information System Public Financial Management Analysis HRH RMET 4 Human Resources for Health Resource Mapping and Expenditure Tracking SECTION 4 IMF SARA Additional International Monetary Fund Service Readiness Assessment Guidance MICS SDI Multiple Indicator Cluster Survey Service Delivery Indicators MoF UHC Ministry of Finance Universal Health Care MoH WDI Ministry of Health World Development Indicators NCD WHO Noncommunicable Disease World Health Organization TABLE OF CONTENTS SECTION 1 List of Acronyms 38 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on SECTION 2 Efficiency and Cross-Cutting Analysis Equity 3 SECTION 3 Topic-Specific Analysis on Efficiency and Equity 4 SECTION 4 Additional Guidance Rather than targeting specific health spending components like medicines or hospitals—which CROSS-CUTTING NOTE 1 ASSESSING SPENDING EFFICIENCY are covered in Section 3—this section provides tools for a high-level understanding of the efficiency and equity of spending. CROSS-CUTTING NOTE 2 CONTINUE ASSESSING EQUITY IN SPENDING (FORTHCOMING) OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and CROSS-CUTTING 1 Equity Assessing Assessing Spending Efficiency Assessing Equity in Spending List of Acronyms Spending 3 SECTION 3 Topic-Specific Analysis Efficiency 4 SECTION 4 Additional Guidance AUTHORS David B. Evans, Christoph Kurowski, and Denise V. Silfverberg CONTINUE TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 40 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Raising additional funds for health to move closer of health spending has the potential to facilitate substantial Cross-Cutting increases in coverage with health services and financial protection Analysis on Efficiency and to universal coverage with quality health services for the available resources.3 Efficiency improvements can also Equity and financial protection is important to countries help generate additional resources. Demonstrated improvements Assessing Spending Efficiency at all income levels. However, the absolute need in the efficiency of health spending gives ministries of finance the confidence that additional resources will be well used, so they can Assessing Equity in Spending for additional funds is particularly high in low- then allocate more to health. List of Acronyms and lower-middle-income countries that lack 3 the resources necessary to reach the Sustainable Despite inefficiencies, health systems still produce important SECTION 3 Development Goals (SDGs) for health by 2030 benefits for the population, hence the recognition that inefficiency Topic-Specific Analysis (World Bank 2017; Kurowski et al. 2021). and waste exist does not warrant a blanket approach such as across- 4 the-board cuts of the health budget. While such an approach can At the same time, studies suggest that somewhere between reduce spending on some unproductive activities, it also risks SECTION 4 20 percent and 50 percent of current health spending is used cutting back on activities that produce critical health benefits. Additional Guidance inefficiently, or even totally wasted, even in countries with very little The challenge for policymakers is, therefore, to search for ways to spend (Cutler 2007; WHO 2010; OECD 2017).1,2 While inefficiency is to improve efficiency without doing harm, a “surgical approach,” not unique to the health sector, any improvement in the efficiency using a scalpel rather than a cleaver (Cutler 2007). This requires 1 WHO. 2010. The World Health Report 2010. Health Systems Financing: the Path to Universal Coverage. Geneva: World Health Organization. 2 OECD. 2017. Tackling Wasteful Spending on Health. Paris: OECD Publishing. Organisation for Economic Co-operation and Development. http://dx.doi.org/10.1787/9789264266414-en. 3 One study found that inefficiency in health spending is similar to the inefficiency in education spending but less than in infrastructure spending (Herrera and Ouedraogo 2018), while another found that the potential for output gains from increases in efficiency was higher in education than health spending (Dutu and Sicari 2016; 2020). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 41 OVERVIEW 1 SECTION 1 What Is a Health PER? understanding the main causes of inefficiency in the health system cutting as a first step, one of the critical issues explored in this capita will yield benefits equivalent to only $1 per capita. While important, the effect is small in terms of the estimated annual 2 document. government spending requirement of $115 per capita necessary SECTION 2 to reach the health SDGs by 2030 in low-income countries (LICs) Cross-Cutting Three considerations. When examining the efficiency of health (Stenberg et al. 2017).4 Analysis on Efficiency and spending, public expenditure review (PER) authors need to keep Equity three considerations in mind. First, on average, countries with lower Third, efficiency improvements in the health sector typically result levels of health spending tend to be more inefficient than those in greater productivity, that is, achieving more with the available Assessing Spending Efficiency with higher per capita spending (Herrera and Ouedraogo 2018). resources. Only sometimes do they save and free up funds that Assessing Equity in Spending Efficient production of even a limited set of health services requires can be reallocated to other uses. One of the few exceptions is in minimum quantities of a range of inputs, including sufficient health procurement—for example, of medicines—where negotiating lower List of Acronyms 3 workers of different types, adequate medicines and other health prices results in financial savings. Moreover, efficiency improvements products, medical equipment for tests, and buildings for outpatient often require an upfront or even sustained investment before they SECTION 3 and inpatient care. The lower the level of available funds, the more have any impact. For example, the introduction of gatekeeping rules Topic-Specific Analysis difficult it is to ensure that all of them are available at sufficient to reduce the number of patients who seek care at secondary or 4 levels, in the right place and at the right time, to enable the health tertiary health facilities without a referral will require staff training, system to operate efficiently. communication strategies, and information systems, costing money SECTION 4 and taking time to produce results. Additional Guidance Second, in countries with very low levels of spending, any efficiency improvement can have only a relatively low impact on health service coverage and other outcomes compared to population needs. For example, a 10 percent increase in the efficiency of resource use in a country with an annual government health spending of $10 per 4 The Stenberg et al. estimates for government spending are updated to 2023 constant dollars using the US gross domestic product (GDP) deflator. The necessary level of government spending per capita in 2030 is estimated as 81 percent of the total in LICs based on the assumptions in Stenberg et al. (2017). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 42 OVERVIEW 1 SECTION 1 What Is a Health PER? OBJECTIVES AND STRUCTURE OF THE DOCUMENT 2 SECTION 2 Cross-Cutting The purpose of this cross-cutting note is to outline including a simple approach and more formal frontier models. Analysis on Section 6 turns to identifying sources of inefficiency using micro Efficiency and the ways in which PER authors can assess the Equity data and information on inputs, outputs, and the relationship efficiency of health spending. It draws on the other between them. It draws on the framework described in Section 1 Assessing Spending Efficiency modules in the Health PER How-to Guide that focus of the Health PER How-to Guide to illustrate how different upstream components in the financing results chain can influence the Assessing Equity in Spending on specific components of health spending. inefficiencies linked to inputs and outputs purchased or produced List of Acronyms 3 with health spending. Section 7 then provides guidance on how Following a brief description of the main focus of the document to prioritize multiple sources of inefficiencies for policy action. (on spending efficiency) in section 3, section 4 covers definitions SECTION 3 The note continues in section 8 with a short section on identifying Topic-Specific and concepts. Section 5 then provides guidance on how to assess Analysis inefficiencies that, when addressed, can result in financial savings the macro efficiency of health systems. It introduces the concept 4 before the conclusions of section 9. of macro efficiency and different methodologies for assessing it, SECTION 4 Additional Guidance TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 43 OVERVIEW 1 SECTION 1 What Is a Health PER? A FOCUS ON THE EFFICIENCY OF GOVERNMENT SPENDING 2 SECTION 2 For the purposes of this PER guidance note, public Nevertheless, some insights on how to improve private spending may Cross-Cutting well emerge during a PER focusing on government spending, and Analysis on expenditure on health is defined as spending from this is considered further toward the end of this note. Inefficiency Efficiency and Equity general government funds or from social health in spending relates to purchasing inputs to make health services or Assessing Spending Efficiency insurance contributions, including any expenditure to purchasing the services themselves. Inefficiency can also exist in resource mobilization, pooling, and in the way revenues, once from development assistance for health (DAH) Assessing Equity in Spending collected, are channeled to financing schemes and agencies, and channeled through government systems. then to public health and health system functions—that is, resource List of Acronyms 3 allocation. These “upstream” activities can also have an impact on In contrast, spending from private sources comprises expenditure spending efficiency further downstream. Both issues are considered SECTION 3 from forms of voluntary private health insurance (excluding any briefly before focusing on the question of spending efficiency. Topic-Specific transfers from government revenues), payments for health by Analysis corporations (profit, not-for-profit, and civil society), and out-of- 4 Finally, a selection of indicators is provided in the various sections pocket (OOP) spending by households. Expenditure from DAH that can help PER authors identify the extent and nature of SECTION 4 commingled with any of these sources is also classified as private inefficiency and possible causes. Wherever possible, the selection Additional (OECD, Eurostat, WHO 2016). Guidance prioritizes indicators that are suggested in the modules in Section 3 of the How-to Guide, and indicators that are available in the World By definition, the PER focuses on the efficiency of public spending. Bank’s Health Financing Data Visualization Tool (DVT)—although PER However, inefficiencies also exist in the different forms of private authors will invariably need to search for other sources of data as spending, including OOP spending—for example, the purchase of well. The DVT is available on Resources (mcas.ms), under Data Tools.5 inappropriate medicines, or suboptimal doses sold over the counter. 5 Contact person is Kat Andrews: kandrews@worldbank.org. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 44 OVERVIEW 1 SECTION 1 What Is a Health PER? SPENDING EFFICIENCY: SOME ECONOMIC CONCEPTS AND DEFINITIONS 2 SECTION 2 Cross-Cutting Health economics typically defines two types of efficiency—allocative Analysis on and technical (World Bank 2017)—see Box 1. A system is allocatively BOX 1. WHAT IS EFFICIENCY? Efficiency and Equity efficient if it produces the mix of goods and services that maximizes ALLOCATIVE EFFICIENCY Assessing Spending Efficiency Allocative efficiency is achieved when society’s objectives for the sector (PER authors should think of this the mix of health goods and services that Assessing Equity in Spending as “doing the right things”). Traditionally, this has been assessed maximizes social objectives is produced List of Acronyms in terms of whether the available mix of health services maximizes for the available resources. 3 population health status for the expenditure. TECHNICAL EFFICIENCY SECTION 3 Topic-Specific Technical efficiency requires that the mix Analysis A system is technically efficient when it produces the maximum outputs with the available of inputs used produces the maximum 4 inputs (authors should think of it as “doing things right”). Inputs include, for example, possible output. different types of health workers, medicines, other medical supplies, equipment, and SECTION 4 infrastructure, and outputs are usually measured in terms of service coverage. The PRODUCTION EFFICIENCY Additional health economics literature often subsumes the concept of production efficiency from The concept of production efficiency— Guidance microeconomics under technical efficiency. Production efficiency means that a system the lowest cost mix of inputs is used to produces the chosen set of goods and services at the lowest cost. achieve the desired output—is usually subsumed under technical efficiency in Analysis of both allocative and technical efficiency requires specifying the desired health economics. outcome, the numerator, with costs as the denominator. For allocative efficiency, the literature has traditionally specified benefits in terms of population health indicators such TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 45 OVERVIEW 1 SECTION 1 What Is a Health PER? as disability adjusted life years avoided (DALYs), years of life or healthy years of life gained (HLEs), “healthy life expectancy”, 2 or quality adjusted life years gained (QALYs). For technical SECTION 2 efficiency, outputs such as coverage levels achieved for specific Cross-Cutting health services are usually used rather than outcomes such as Analysis on Efficiency and DALYs. Equity In the universal health coverage (UHC) era, however, improving Assessing Spending Efficiency coverage with health services, and through that, health status, Assessing Equity in Spending is only one of the two objectives of health financing policy. The second is to ensure that people do not suffer undue financial List of Acronyms 3 hardship associated with paying out of pocket for the health services they receive (WHO 2010). While health financing policy SECTION 3 is increasingly considering the impact of different strategies Topic-Specific Analysis on both pillars of UHC (for example, Verguet, Kim, and Jamison 4 2016; Fraser et al. 2024), the analysis of both allocative and technical efficiency still focuses essentially on how well SECTION 4 resources increase coverage with quality health services or Additional Guidance improve population health. Two main ways of assessing inefficiency in health spending exist—macro-efficiency and micro-efficiency analysis. They are now discussed in turn. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 46 OVERVIEW 1 SECTION 1 What Is a Health PER? MACRO-EFFICIENCY ANALYSIS 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity For a PER, the primary objective of a macro- In federal systems, PER authors might find it useful to undertake a macro-efficiency analysis comparing the efficiency of subnational Assessing Spending Efficiency efficiency study is to gain insights into whether units, or health facilities such as hospitals,6 to identify which ones Assessing Equity in Spending a country obtains less (or more) from its health achieve relatively less than others for their health expenditures. spending than comparable countries. Assessing The techniques are the same as for the cross-country macro- List of Acronyms 3 efficiency analyses described here. the relative macro efficiency of health systems SECTION 3 can be helpful in initiating discussions on the Two ways of assessing macro efficiency are possible. First, a quick Topic-Specific Analysis importance of reducing inefficiency with country and simple approach that is not data intensive can help raise 4 counterparts and stakeholders. It will not, however, the importance of efficiency improvements with policymakers. The alternative is to use formal methods, most commonly data SECTION 4 reveal the causes of inefficiency. For this, more envelopment analysis (DEA) and stochastic frontier analysis (SFA), to Additional granular assessments are required. obtain a numerical estimate of the relative efficiency of a country’s Guidance health system in cross-country comparisons. This approach is data intensive and time consuming. The first approach is described in the next subsection, followed by more formal methods. 6 The Hospitals module in Section 3 of the How-to Guide goes deeper into how the comparative efficiency of hospitals in a country can be assessed, including through macro-efficiency analysis. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 47 OVERVIEW 1 SECTION 1 What Is a Health PER? Quick and Simple 2 SECTION 2 A quick and simple way of gauging how efficiently a health system variants that include both mortality and morbidity components Cross-Cutting translates inputs into outcomes is to compare a specific health such as healthy life expectance, or mortality rates (Table 1). The Analysis on Efficiency and outcome with per capita spending levels across a set of similar Universal Health Coverage Index may also be used: a weighted Equity countries—usually chosen because they have similar levels of average score of service coverage targeting a range of health Assessing Spending Efficiency health spending per capita. The goal is to see if the PER country conditions (WHO and World Bank 2021). achieves more or less from its spending than comparator countries. Assessing Equity in Spending When selecting outcome indicators, it is important to choose those List of Acronyms For this type of analysis, current per capita health expenditure is that are affected mainly by factors within the health system. For 3 commonly used as a proxy for all the inputs that go into producing example, childhood stunting may not be the best choice, because it the particular outcome. Current health spending is preferred to is affected by many factors outside the control of the health system, SECTION 3 Topic-Specific total country health spending (total is current plus capital) on the including poverty rates and the availability of food. Analysis grounds that capital spending is “lumpy”, often with large variations 4 across years—for example, in countries prone to natural disasters If of interest to a government, the same approach can be used to where buildings need to be rapidly repaired or rebuilt. All health assess the efficiency of a specific health program compared to SECTION 4 spending, public and private, is included because it is impossible to those in other countries or across health facilities for a particular Additional Guidance determine which part of the outcome is attributable to each source condition. Recent examples cover noncommunicable disease of spending. It is therefore critical not to interpret the results of a and malaria control (for example, Bala, Singh, and Gautam 2022; macro-efficiency analysis as implying efficiency or inefficiency in Novignon et al. 2023). government health spending alone. To illustrate the approach, a recent Zambia health PER (World Outcomes are typically measured in terms of some indicator of Bank 2019b) visually explores the relationship between country population health status such as life expectancy, some of its health expenditure and three separate outcome indicators: a TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 48 OVERVIEW 1 SECTION 1 What Is a Health PER? Healthcare Access and Quality (HAQ) Index that had been calculated for multiple countries, the maternal mortality rate, and the under-5 Table 1. Possible Indicators for Assessing Macro Efficiency Outcomes Indicators 2 mortality rate. The analysis suggests that Zambia was less efficient SECTION 2 in translating its health expenditure into improved access and Life expectancy • Life expectancy at birth Cross-Cutting quality, and in reducing under-5 mortality, than comparator • Healthy life expectancy at birth Analysis on Efficiency and countries. Interestingly, it performed better than the comparator Mortality • Neonatal mortality Equity countries with similar levels of per capita health spending in terms • Infant mortality rate of reducing maternal mortality. This led to discussions about the Assessing Spending Efficiency • Under-5 mortality rate implications for the allocation of the available funds to the different • Maternal mortality rate Assessing Equity in Spending programs as well as for ways to improve efficiency.77 Morbidity • New cases of vaccine preventable diseases List of Acronyms 3 Where the analysis shows that a country achieves low levels of Coverage • UHC Health Coverage Index7 health outcomes or service coverage compared to countries with SECTION 3 Note: UHC = universal health coverage. See WHO (2018a) for a range of indicators that might be useful similar levels of health spending, it is suggestive that it is less depending on data availability in the country. Topic-Specific Analysis efficient in transforming inputs (spending) into health outcomes 4 or coverage. This is, of course, not strictly correct. First, there how effectively inputs can be translated into outputs, including are many other determinants of health outcomes that might population density and topography: urbanization, for example, SECTION 4 vary across countries in addition to the current year’s health reduces while mountainous terrains increase the costs of health Additional Guidance spending. For example, investments in water and sanitation, service provision to populations. differences in female education levels, and poverty rates vary across countries and can result in differences in health outcomes In the case that the analysis shows that a country attains relatively independent of differences in current health spending. Second, high health outcomes or service coverage levels in comparison there can be variation across countries in factors that mediate with countries of similar spending levels, the results are still 7 WHO and World Bank 2021, 2023. The estimates of the HAQ Index used in the Zambia PER are available only for 2016. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 49 OVERVIEW 1 Using the Health Financing no reason for complacency. The risk is that policymakers may SECTION 1  conclude that there is no need to address inefficiency, but the What Is a Health PER? GSG Data Visualization Tool truth is that even relatively high-performing countries suffer 2 from inefficiencies that are worth addressing—the inefficiencies The World Bank Global Solutions Group data visualization tool SECTION 2 might be equivalent to 20 percent of all health spending—the Cross-Cutting (DVT) can be helpful for this type of efficiency analysis. It allows PER Analysis on lower rather than the higher end of the estimated 20–50 percent authors to chart per capita health spending against an outcome or Efficiency and of health resources wasted—but even a 20 percent loss due to Equity coverage indicator, and benchmark against comparator countries. inefficiency needs action. The tool also allows easy groupings of countries. Assessing Spending Efficiency Whatever the result, the quick and simple macroanalysis of Assessing Equity in Spending An example is shown in Figure 1 where life expectancy at birth spending efficiency can be misleading, and care needs to be taken is used as the outcome variable, mapped against current health List of Acronyms in the interpretation of the results. It can, nevertheless, be a 3 expenditure per capita (in natural logarithms) for 2020. Each dot useful starting point for conversations with policymakers about is a low- or middle-income country, and blue dots are countries SECTION 3 inefficiency in sector spending and how to reduce it. And it may in Sub-Saharan Africa. Topic-Specific prompt interest and show whether a more formal macroanalysis Analysis of spending efficiency is worth it. 4 As a general trend, life expectancy increases with increasing expenditure. Focusing now on the Sub-Saharan African countries SECTION 4 with spending ranging from $50 to $100 per capita, the life Additional Guidance expectancy at birth in Côte d’Ivoire is below 60 years, and in Nigeria below 55 years. In contrast, Senegal has the highest life expectancy, nearly 70 years, at similar expenditure levels. This type of analysis can be used to start a conversation with the governments of Nigeria and Côte d’Ivoire about why they might perform relatively poorly and the role that inefficiency in health spending might play. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 50 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 1 EXAMPLE USING HEALTH FINANCING DATA VISUALIZATION TOOL 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity Assessing Spending Efficiency Assessing Equity in Spending List of Acronyms 3 SECTION 3 Topic-Specific Analysis 4 SECTION 4 Additional Guidance Sources: CHE (current health expenditure) per capita (constant 2020 US$). WHO-GHED-cchepc_usd: World Bank staff calculations using data from WHO Global Health Expenditure Database Life expectancy at birth, total (years): World Development Indicators TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 51 OVERVIEW 1 SECTION 1 What Is a Health PER? Formal Methods for Macro-Efficiency Analysis 2 SECTION 2 Simple and quick analysis is only FIGURE 2 Cross-Cutting suggestive of spending inefficiency EXAMPLE OF A FRONTIER FOR LIFE EXPECTANCY Analysis on Efficiency and because it does not control for the Equity myriad other possible determinants of health outcomes or service coverage. Assessing Spending Efficiency 75 Formal methods have been developed Assessing Equity in Spending to do this, though they are also less than perfect. Two of these methods are Life expectancy at birth, total (years) List of Acronyms Senegal 3 70 data envelopment analysis (DEA) and stochastic frontier production function SECTION 3 Topic-Specific analysis (SFA), and more recently, the 65 Analysis methods are sometimes combined. 4 Both essentially estimate a frontier SECTION 4 from the set of country data points: 60 Additional Guidance the maximum attainment (for example, Cote d’Ivoire life expectancy at birth in Figure 1) possible for any level of per capita 55 Nigeria health spending. The frontier, or upper 50 100 500 envelope line, is illustrated in Figure 2 using the data in Figure 1. CHE per capita (constant 2020 US$), WHO-GHED - cchepc_usd Sources: CHE per capita (constant 2020 US$). WHO-GHED-cchepc_usd: World Bank staff calculations using data from WHO Global Health Expenditure Database. Life expectancy at birth, total (years): World Development Indicators TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 52 OVERVIEW 1 SECTION 1 What Is a Health PER? Inefficiency for a given country is estimated as the gap between its level of attainment and the frontier, after adjusting for the In contrast to the simplified approach described in the previous section, these formal methods seek to control for potential sources 2 contributions of the other possible determinants of attainment of variation in the outcome that are not attributed to inefficiency SECTION 2 (health status or service coverage). (See the modules on Health by including other explanatory variables in addition to health Cross-Cutting Status and Health Risks and Service Coverage. ) expenditure (for example, Hollingsworth 2003, 2008; Herrera and Analysis on Efficiency and Pang 2005; Jourmard, André, and Nicq 2010; Liu, Wu, and Yao 2022). In Equity Explanations of the theoretical basis of the two approaches are the past 15 years, they have also become increasingly sophisticated, widely available, as is STATA code and alternative packages for and PER authors with good econometric skills might want to consult Assessing Spending Efficiency estimating them (for example, Cylus, Papanicolas, and Smith 2016; the work of Berenguer et al. (2016); Olesen and Petersen (2016); Assessing Equity in Spending chapter 3 in Thanassoulis, Portela, and Despic 2008; Greene 2008). Hamidi and Akinci (2016); Herrera and Ouedraogo (2018); and Briefly, DEA is a nonparametric method that uses mathematical Izadikhah (2022) for some of the latest developments. List of Acronyms 3 programming to estimate a frontier from the observed data points.8 SFA is a parametric approach that specifies a functional form for the Although formal methods seek to account for a range of possible SECTION 3 relationship between health spending, other possible inputs, and determinants of outcome other than health spending, they also Topic-Specific Analysis the chosen output or outcome. SFA employs regression analysis to have limitations. In essence, they treat unexplained deviations 4 estimate a frontier equation—a production or cost function—with from the frontier—deviations from the maximum possible level an error term showing the departure from the frontier that cannot of attainment given the level of health expenditure and levels SECTION 4 be explained by the different explanators that have been included of other determinants — as inefficiency. This is only true if it Additional Guidance in the model. The error term is then subdivided into random noise is possible to measure and control for all the other possible (random variation due to chance) and the component of inefficiency. determinants, which is rare. 8 Parametric methods derive statistical implications using assumptions about the population distribution being studied—for example, it might be assumed to be a normal distribution. Nonparametric methods make no such assumptions but simply observe what is happening. For an easy-to-understand explanation, see Difference between Parametric and Non-Parametric Methods—GeeksforGeeks (https://www.geeksforgeeks.org/difference-be- tween-parametric-and-non-parametric-methods/). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 53 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors should also be aware of a range of other issues, including: • As the quick and simple approach, the formal methods use current health expenditure per capita as an explanator 2 of outcome. As such, they do not show inefficiency in SECTION 2 • The models assume that countries on the frontier are government spending, the usual focus of a PER, but in total Cross-Cutting efficient, when more micro-level work suggests forms of health spending. As explained earlier, it would not be Analysis on inefficiency exist in all countries. correct, however, to use GHE per capita as the explanatory Efficiency and Equity variable, because health outcomes are determined by the mix • The efficiency scores and rankings are sensitive to the of both private and government spending and the techniques Assessing Spending Efficiency model specification and the data used for inputs, outputs/ do not allow the assessment of the efficiency of government outcomes, and determinants: sometimes a country (or health Assessing Equity in Spending spending alone. facility) will appear relatively inefficient in one specification List of Acronyms and relatively efficient in another (Gearhart 2016). • Finally, the models have not yet integrated the two goals of 3 UHC—coverage with health services (or health outcomes) • The existing models, even those using panel data (where SECTION 3 and coverage with financial protection—as joint objectives many years of data points are included), assume a Topic-Specific of efficiency. They focus on some indicator of coverage with Analysis relationship between expenditure and outcomes only in the health services or health status. 4 year of the expenditure. They do not capture the lags that are important in translating inputs into outputs and outcomes. SECTION 4 For example, health spending today on prevention produces Additional Guidance health benefits for many years rather than simply in the year the expenditure is made. • The models allow for assessing a country’s efficiency in producing health relative to other countries but, like the quick and simple method, do not unpack the reasons for its performance being better or worse than others or the causes of any apparent inefficiency. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 54 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 When to Carry Out a Macro-Efficiency Assessment and What Approach to Use SECTION 2 Cross-Cutting Analysis on Efficiency and On balance, if policymakers are convinced of the need to reduce In general, a formal macro-efficiency study is likely to be the Equity inefficiency in health spending, there is no need to undertake a exception, not the rule, for a health PER. Sometimes a formal Assessing Spending Efficiency macro-efficiency analysis (see Table 2). However, if this is not the analysis can be found in the literature for a range of countries, case, the quick and simple approach (the data visualization tool can including the PER country. If so, the earlier discussion of the Assessing Equity in Spending help with this) allows checking if health spending looks inefficient approach should be helpful in interpreting the results. List of Acronyms compared to comparator countries (with similar current health 3 spending per capita, similar regional grouping). If a country is concerned with the relative efficiency of production SECTION 3 units such as hospitals, or subnational health units, it might be If “yes,” the analysis can be used as an entry point useful to undertake a formal analysis, though data requirements will Topic-Specific A Analysis to discussions with policymakers about the need be substantial. An example is the health chapter of the Chile PER 4 to pay attention to inefficiency; or (World Bank 2016) that assessed the relative efficiency of regional public integrated service delivery networks and its determinants SECTION 4 If “no,” it may be better to turn directly to the using formal techniques. Other useful examples include Kirigia et Additional B Guidance micro-efficiency approach and combine the al. (2004), Osei et al. (2005), Kohl et al. (2019), Cinaroglu (2020), Jiang identification of sources of inefficiencies with and Andrews (2020), Nwakobi (2020), and Cordero et al. (2023). an attempt to quantify their impact on overall spending efficiency. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 55 OVERVIEW 1 SECTION 1 What Is a Health PER? Table 2. Pros and Cons of a Macro-Efficiency Analysis Approach Value Possible Problems 2 SECTION 2 Quick and Can help to convince decision A. Can have the opposite effect if a country turns out to be relatively efficient—this Cross-Cutting simple makers that it is important to does not mean there are no major causes of inefficiency, so the exercise could be Analysis on improve the efficiency of sector counterproductive. Efficiency and Equity spending. B. Does not control for other determinants of outcome, so only a possible indication of Assessing Spending Efficiency relative efficiency. Assessing Equity in Spending C. Gives no idea of the sources of inefficiency, or possible ways to address them—micro- efficiency analysis is still required. List of Acronyms 3 Macro A. Can help convince decision A. Data availability restrictions mean that the methods cannot control for all SECTION 3 efficiency— makers that it is important to determinants of outcome. Hence, while it is more accurate than the quick and simple improve the efficiency of sector approach, it gives only an indication of relative efficiency. Topic-Specific formal Analysis spending. modeling (e.g., 4 B. Gives no idea of the sources of inefficiency, or possible ways to address them—micro- stochastic B. Controls for some of the other efficiency analysis is still required. SECTION 4 production possible determinants of Additional functions, data output or outcome, hence, may C. Different model specifications give different efficiency rankings for the same data and Guidance be perceived as having more country, so it is difficult to be sure unless a country is consistently ranked high or low. envelopment) validity. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 56 OVERVIEW 1 SECTION 1 What Is a Health PER? MICRO APPROACHES TO IDENTIFYING 2 SECTION 2 Cross-Cutting Analysis on Efficiency and SOURCES OF INEFFICIENCY Equity Assessing Spending Efficiency For a health PER, the prime objective of a micro- Secondary objectives of a micro-efficiency analysis are to: Assessing Equity in Spending efficiency analysis is to identify the main sources of • Identify the sources of inefficiency that are likely or unlikely to inefficiency in the health system, which can then be generate cost savings. List of Acronyms 3 addressed by policy action. • Identify policy levers to address all sources. SECTION 3 A PER micro-efficiency analysis would consider how inputs interact • Prioritize the areas for immediate policy action considering Topic-Specific Analysis and translate into the production of outputs and outcomes, based the associated costs, possible benefits, and likely political and 4 on the definitions of efficiency described earlier. It would consider other constraints to action. the range of possible sources of inefficiency separately and some of SECTION 4 their linkages but could not estimate the implications of all these Additional Guidance sources together for overall health system efficiency.9 9 Another common use of microanalysis asks whether a proposed use of health funds represents value for money compared to alternative uses (Leelahavarong et al. 2019; Bloem et al. 2021). This form of micro-efficiency analysis is most commonly used in deciding whether new medicines or health technologies should be publicly financed. It would not usually come into a health PER and is not considered further. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 57 OVERVIEW 1 SECTION 1 What Is a Health PER? The Health Financing Framework as an Entry Point 2 SECTION 2 The introduction to the Health PER How-to Guide describes the of inefficiency and their interlinkages. Many possible sources Cross-Cutting health financing framework used to organize the discussion in of inefficiency could emerge from the analysis, and PER authors Analysis on Efficiency and the various modules. A simplified version for the purposes of the will need to focus on a subset that is most important to them. Equity micro-efficiency analysis is reproduced in Figure 3. It is then used Accordingly, the micro-efficiency discussion concludes by describing Assessing Spending Efficiency to organize the subsequent discussion. It can also help PER authors an approach for putting all the available information together and understand the various factors that influence inefficiency, as well focusing on areas that are priorities for the PER country. Assessing Equity in Spending as providing a structure for thinking about the various sources List of Acronyms 3 FIGURE 3 SECTION 3 HEALTH FINANCING FRAMEWORK AND EFFICIENCY Topic-Specific Analysis 4 OUTPUTS: INTERMEDIATE ENABLERS INPUTS OUTCOMES SERVICE DELIVERY OUTCOMES SECTION 4 Additional Resource Mobilization • Allocative Efficiency: Guidance • Input Quantity The mix of health goods • Input Productivity and services produced or • Efficiency in Producing and Quality purchased Outcomes Considered DIMENSION Pooling • Service Coverage Part of Macro-Efficiency • Input Prices • Technical Efficiency of Analysis Production • Input Mix Resource Allocation • Service Quality Sources: World Bank staff. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 58 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 The Framework and Efficiency Cross-Cutting Analysis on Efficiency and Reiterating the earlier definitions of efficiency, technical efficiency Allocative efficiency requires that the “right” set of outputs or health Equity requires that the inputs that are used produce the maximum services are produced. This requires identifying the range of services Assessing Spending Efficiency possible benefit, which in micro-efficiency analysis is usually available, their quality, and their coverage levels achieved compared measured in terms of the outputs achieved—for example, coverage to an ideal set—the range, quality, and coverage levels that would Assessing Equity in Spending with a specified health service or the number of bed days occupied maximize the desired outcome (assuming each is produced in a List of Acronyms annually in a hospital. This cuts across the columns in the framework technically efficient manner). 3 of Figure 3 marked at outputs and intermediate outcomes. SECTION 3 While spending efficiency analysis focuses on the relationship Topic-Specific Technical efficiency also requires that the output is achieved at between inputs and outputs, enablers in the framework—the Analysis the lowest cost. There are two implications of this requirement: health financing functions—can be important to a micro-efficiency 4 the prices paid for each input (of a specified quality) should be analysis in two ways. First, there can be technical inefficiencies in the lowest possible, and inputs should not be wasted—that is, the the “upstream” activities of resource mobilization, pooling, and SECTION 4 Additional minimum possible quantity of an input should be used to achieve resource allocation. Second, the way these activities are organized Guidance the desired output (of a specified quality). Technical efficiency, can influence the efficiency of subsequent spending. Understanding therefore, requires consideration of the inputs used to make health these links can help identify the possible causes of any inefficiencies services as well as the relationship between those inputs and the in health spending. The next subsection considers these aspects for outputs achieved. resource mobilization, pooling, and resource allocation. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 59 OVERVIEW 1 SECTION 1 What Is a Health PER? Resource Mobilization, Pooling, and Resource Allocation 2 SECTION 2 Cross-Cutting This section considers the inefficiencies found in the upstream or a health PER. The International financial institutions such as Analysis on Efficiency and activities of resource mobilization, pooling, and resource allocation, the World Bank and IMF, however, work with countries to improve Equity as well as the way their organization can influence spending revenue collection and undertake country- and region-specific Assessing Spending Efficiency efficiency. This understanding enables PER authors to think through reports (Dom et al. 2022; IMF 2023a). For the broader objectives of what types of inefficiencies to look for. It also helps them consider a PER, it is often important to explore whether this type of work has Assessing Equity in Spending possible reasons that various types of spending efficiency exist. been or is being undertaken in the PER country to gauge the extent List of Acronyms that overall revenue mobilization is likely to improve as a share of 3 gross domestic product (GDP) over time. SECTION 3 Topic-Specific  Resource Mobilization If this information is not available, government revenue (or tax Analysis revenue) as a share of GDP compared to countries with similar 4 Inefficiencies in resource mobilization. Government revenue levels of GDP per capita is useful to PER authors as a rough indicator collection systems, including tax administration, particularly in of the efficiency of government revenue generation efforts: this SECTION 4 LICs and LMICs, are often inefficient in that they do not collect is suggested in the Resource Mobilization module of the Health Additional Guidance anywhere near the full amount that would be expected from the How-to Guide. These indicators do not, of course, reflect only taxes and charges (including social contributions such as obligatory inefficiency in collecting currently defined taxes and charges, but health insurance) that are specified in law. The ministry of finance can also be associated with differences across countries in the or a tax authority is usually responsible for collecting most tax range of taxes and charges that are levied, their rates, and the range revenues, so questions about the efficiency of this type of revenue of people and firms required to pay—the so-called tax base—and collection are not generally the responsibility of the health sector need to be interpreted cautiously. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 60 OVERVIEW 1 SECTION 1 What Is a Health PER? The collection of obligatory health insurance contributions is sometimes the responsibility of a ministry of finance and sometimes health expenditure compared to comparable countries might give an idea of the extent of this type of inefficiency. 2 a health insurance or social insurance agency. As with tax payments, SECTION 2 evasion and other forms of inefficiency in the collection of social Where countries rely heavily on external funding, donors sometimes Cross-Cutting insurance contributions abound (McGillivray 2001; Minerva and choose to create their own systems rather than using existing Analysis on Efficiency and Sefanov 2018; Yazbeck et al. 2021). Where social health insurance country systems (for example, for channeling funds, audit, reporting, Equity (SHI) contributions are collected separately to tax contributions, laboratory testing, even service delivery). Duplication of costs leads PER authors may be interested in understanding the extent that the to system-wide inefficiency. This occurs mostly where DAH is not Assessing Spending Efficiency revenues expected from the mandated contributions are collected channeled through the government so would not be picked up by Assessing Equity in Spending along the lines of Jowett and Hsiao (2007) and Alkenbrack, Hanson, a health PER focusing only on government spending. PER authors and Lindelow (2015). could usefully consider the proportion of country health expenditure List of Acronyms 3 provided by donor funding and the share of donor spending that The impact of resource mobilization on spending efficiency. In is on-budget. If, for example, the share of DAH passing through SECTION 3 many countries, OOP spending remains an important source of government channels is low relative to comparable countries, it Topic-Specific Analysis revenues for the health system. When charged by for-profit service would be useful to evaluate the extent of duplication of different 4 providers, OOP spending can be associated with different forms of components of the health system linked to off-budget DAH. spending inefficiency, including overservicing for people who can SECTION 4 afford it. Where fees are charged for government health services, Additional Guidance or copayments for obligatory health insurance, the largest impact is likely to be on deterring the people who cannot afford them  Pooling from seeking services. This can result in subsequent spending inefficiency in that people delay seeking care until their case is Pooling inefficiencies. Technically, inefficiency can arise in pooling more severe, sometimes requiring higher treatment costs than when the administration and operation of the pool(s) cost more than would have resulted from more timely treatment. This is difficult to necessary. For obligatory health insurance, this can occur particularly measure and track, although the share of OOP spending in country where there are multiple pools, each with its own administration, but TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 61 OVERVIEW 1 SECTION 1 What Is a Health PER? it also happens in single pools where administration absorbs a high share of the revenue in salaries and other benefits for staff (Mathauer administrative costs relating to health (including health insurance)— under the category of governance and health-system and financing 2 and Nicole 2011; Mathauer et al. 2020). administration (OECD 2013). The share of country health expenditure SECTION 2 allocated to governance and administration tends to fall as income Cross-Cutting The most common way of looking at this is in terms of administrative per capita rises (Dieleman et al. 2017). This cannot be construed as Analysis on Efficiency and costs as a share of total spending. The Pooling module suggests being inefficiency—part may, for example, be due to economies of Equity that anything above the benchmark of 1–3 percent implies that scale in administration. A health system requires a minimum level administration and operation costs are higher than necessary. The of spending on administration to operate, but once that is achieved, Assessing Spending Efficiency 3 percent figure is the average across Organisation for Economic the incremental administrative costs of expanding the system might Assessing Equity in Spending Co-operation and Development (OECD) countries for all administrative be relatively low. On the other hand, differences across countries costs associated with health, including health insurance (obligatory at similar income levels in the share of country health expenditure List of Acronyms 3 and voluntary) (OECD 2013; Mueller, Hagenaars, and Morgan 2017). allocated to governance and administration could be an indicator of Indeed, in most LICs and LMICs, pooled funds for health derive possible inefficiency. PER authors could check this if their country SECTION 3 predominantly from general government revenues, so the share has undertaken a recent health account study. Topic-Specific Analysis of general government health spending, including SHI, taken by 4 administration is more relevant than the share of administration in The impact of pooling on spending efficiency. Large pools allow the spending of SHI agencies alone. for increased bargaining power in purchasing negotiations with SECTION 4 the suppliers of inputs or health service providers. This has the Additional Guidance The OECD data suggest that countries’ administrative costs absorb potential to reduce prices. PER authors could explore the nature of greater shares of spending for private than for obligatory insurance pooling and the resulting purchasing arrangements—for example, and absorb more in countries with SHI than for health funded do hospitals, health centers, subnational levels of government, or solely from general government funds (Mueller, Hagenaars, and different social health insurance schemes hold funds allowing them Morgan 2017). Data on administrative spending by health insurance to purchase independently, each with lower bargaining power, or agencies should be available in their annual accounts. is there some form of central purchasing? This may well happen More broadly, country health account studies report all more in decentralized systems. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 62 OVERVIEW 1 SECTION 1 What Is a Health PER? This is useful background information for exploring, in subsequent stages of the efficiency analysis, whether and why prices paid are (Artificial Fiscal Intelligence 2023; Laing 2023). Using a “follow the money” approach in the budget cycle—budgeting, commitment, 2 “too high.” procurement, contract management, verification and payment, SECTION 2 audit—Artificial Fiscal Intelligence (2023) recently illustrated how Cross-Cutting corrupt officials can receive payment to divert budget flows from Analysis on Efficiency and their intended use and reduce the available funds to spend on Equity  Resource Allocation budget priorities. Interestingly, a higher proportion of total losses were estimated to occur in the budgeting step than in the other Assessing Spending Efficiency Resource allocation refers to the distribution of government funds, steps of the budget cycle—for example, interested parties pay so Assessing Equity in Spending once collected, to financing schemes and agencies including that public funds are budgeted for activities that directly benefit ministries, social health insurance agencies, and subnational levels political allies or entities that are controlled by them (Artificial List of Acronyms 3 of government. This also includes any financial transfers between Fiscal Intelligence 2023). agencies—for example, risk equalization mechanisms when there SECTION 3 are multiple insurance agencies. The next stage of resource Other types of leakages involve pilfering of medicines, equipment, Topic-Specific Analysis allocation involves transfers from these agencies to different or cash reserves. There are no simple indicators of the extent of 4 types of departments, agencies, and health programs (for example, leakages in health by itself, but the Artificial Fiscal Intelligence hospitals versus primary health care (PHC) centers; malaria versus (2023) study estimates losses for 2012–18 for many countries, SECTION 4 including most LICs and LMICs. PER authors can also search for control of noncommunicable diseases) and to secure public health Additional Guidance and health system functions. The final step involves the flow of similar studies undertaken for their PER country. funds from purchasers to the providers of inputs or services. The impact of resource allocation on spending efficiency. Drawing Inefficiency in resource allocation. Corruption and leakages of on work from the Public Financial Management (PFM) Performance various types are major sources of inefficiency in resource allocation Framework (PEFA 2019), the OECD’s Good Budgeting Practices (OECD in many countries, though they are apparently higher in lower- 2023), the Artificial Fiscal Intelligence approach (2023) described income settings due to relatively weak public financial management above, and a recent application to Kenya (Musiega et al. 2023), TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 63 OVERVIEW 1 SECTION 1 What Is a Health PER? all stages of the budget cycle can impact the level and nature of the flows of government resources from collecting agencies which can lead to paying higher than necessary prices. Delays also result in arrears—bills being unpaid—meaning suppliers 2 to purchasers, with implications for spending efficiency. This is are less willing to provide inputs or services in the future or SECTION 2 illustrated using the budget cycle described earlier from Artificial demand higher prices, believing there will be payment delays. Cross-Cutting Fiscal Intelligence (2023) with the components budgeting, Delayed release of funds can also result in underspending on Analysis on Efficiency and commitment, procurement, contract management, verification some budget lines, meaning funds are returned to the treasury Equity and payment, and audit. at the end of the fiscal year. Although not an inefficiency per se, it means that the available funds could not be used to improve Assessing Spending Efficiency • Budgeting. Input-based line-item budgets often have limited health and financial wellbeing (Fritz, Sweet, and Verhoeven 2014; Assessing Equity in Spending in-year budget flexibility because of tight limits on transfers Barroy, Sparkes, and Dale 2016; WHO 2016; Cashin et al. 2017). between budget lines (virements). This can lead to shortages List of Acronyms • Procurement. A lack of accountability across purchasers for 3 of the inputs where a budget line is exhausted—even if the how they follow PFM rules such as competitive bidding can lead original intention was to ensure there was sufficient funding for SECTION 3 to paying too much for inputs or services. Similarly, a lack of each input. Forms of program budgeting with overly detailed Topic-Specific accountability or capacity across purchasers for specifying clear Analysis budgeting can limit the flexibility of purchasers to reallocate contract deliverables and timelines leads to higher costs or lower 4 funds within their budgets when needed. Where budget outputs. Payroll management is a case in point where ineffective execution is routinely monitored, over- or underspends can be SECTION 4 management can lead to overpayments to existing workers or identified early and corrected. Additional payments for workers who do not exist—ghost workers (WHO Guidance • Commitment. Delays in releases from a ministry of finance or 2020). Complex procurement rules, often introduced to restrict from a ministry of health to purchasing units (for example, corruption, can also lead to delays in obtaining the necessary health centers, subnational levels of government) can mean inputs or services. Contingency frameworks setting rules for that medicines, equipment, and personnel cannot be purchased how procurement can be undertaken during any sudden shocks in a timely manner, possibly resulting in shortages of inputs. (for example, pandemics, natural disasters) sometimes relax When the funds become available, they need to be purchased these complexities to allow rapid and efficient responses to rapidly, before the cutoff date for spending in the financial year, emergencies. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 64 OVERVIEW 1 SECTION 1 What Is a Health PER? • Contract management, verification, and payment. Irregular monitoring of contract deliverables or lax 2 enforcement of timelines reduce productivity and SECTION 2 can lead to corruption—for example, payment for Cross-Cutting services that were not delivered with kickbacks to Analysis on Efficiency and the payer. Inadequate verification of deliverables Equity before payment has the same effect, while on the other hand, late payment by purchasers can Assessing Spending Efficiency lead to delayed delivery of inputs or services, or Assessing Equity in Spending reduced quality. List of Acronyms • Audit. Low capacity to conduct internal audits can 3 mean that expenditures are not used as intended SECTION 3 following the country’s PFM rules, or are used Topic-Specific corruptly—for example, channeled to other uses Analysis that benefit the payer. 4 SECTION 4 Additional Guidance Table 3 on the following page draws on this discussion to summarize indicators that might suggest inefficiency in resource mobilization, pooling, and resource allocation as well as how they might affect spending efficiency. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 65 OVERVIEW 1 SECTION 1 Table 3. Inefficiency in Resource Mobilization, Pooling, and Resource Allocation What Is a Health PER? Key Indicators Sources 2  Resource Mobilization SECTION 2 Inefficiency in RM Cross-Cutting Analysis on • Tax revenues as % of GDP IMF World Economic Outlook (IMF 2023b) Efficiency and • General government revenue as % of GDP Equity Impact on spending efficiency • OOP spending as a share of country health spending Country health accounts and WHO (2024) Assessing Spending Efficiency • DAH as a share of country health spending Assessing Equity in Spending • On-budget DAH as a share of DAH  Pooling Country health accounts List of Acronyms 3 Inefficiency in pooling • Administrative costs in health, including SHI, as a share of total spending Country health accounts; annual report(s) or financial SECTION 3 • Administrative costs as a percentage of total SHI spending statement(s) of SHI scheme(s) Topic-Specific • Administrative costs per member per year* Analysis • Impact on spending efficiency 4 • Number of obligatory prepaid financing schemes in the country including subnational levels of government Policy documents, reports, key informants SECTION 4 Additional  Resource Allocation Artificial Fiscal Intelligence (2023) study or recent Guidance Inefficiency in resource allocation country-specific reports • Leakages as a share of general government health expenditure Impact on spending efficiency PEFA country report where available (PEFA 2019) • Country study of PEFA indicators (31) of PFM system relating to the budget cycle * Only useful where there are multiple schemes to compare. Note: DAH = development assistance for health; GDP = gross domestic product; IMF = International Monetary Fund; OOP = out-of-pocket; PEFA = Public Expenditure and Financial Accountability; PFM = public financial management; RM = resource mobilization; SHI = social health insurance; WHO = World Health Organization. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 66 OVERVIEW 1 SECTION 1 What Is a Health PER? Inputs 2 SECTION 2 Earlier it was shown that technical and allocative inefficiency in  Input Quantity Cross-Cutting health spending requires considering both inputs and outputs, as Analysis on Efficiency and well as their relationship. In the next two sections, we run through The quantity of an input used is not, by itself, an indicator of Equity inputs and outputs showing how PER authors can think about the inefficiency. For technical efficiency, the quantity of an input that Assessing Spending Efficiency way they relate to the different forms of inefficiency, linking back to should be used depends on its price and how much each additional the discussion on the enablers where appropriate. A set of indicators unit of the input will produce of the desired output. This is not easy Assessing Equity in Spending that PER authors can draw on to explore inefficiency in their context is to assess in the health sector, given the difficulty of measuring the List of Acronyms also suggested. Subsequently, an approach that PER authors can use 3 impact of each additional unit of an input in terms of increasing to tie all this information together to explore sources of inefficiency coverage with needed services or financial protection. It also means SECTION 3 in public spending on health is described. that simply looking at the quantity of an input (in total or per Topic-Specific population) without an understanding of its price and productivity Analysis To reiterate, technical efficiency requires that any output is says little about its under- or overuse. 4 produced at the lowest possible cost. This means ensuring there is no waste in the use of inputs, each input is of sufficient quality A rapid assessment of the relative availability of different types of SECTION 4 Additional and as productive as possible, prices paid for each input are the key inputs, however, can be useful in suggesting where to look for Guidance lowest possible, and the mix of inputs minimizes cost for the level possible inefficiencies, particularly in terms of oversupply and likely of output. These ideas are now explored in turn. Inputs include underuse. This can be done by running through the availability of the different types of human resources, physical infrastructure, each of the major inputs—health workers, equipment, inpatient equipment, and medicines and medical supplies (see the modules beds, medicines—and comparing the findings to comparator on Human Resources for Health, Physical Infrastructure and countries. Equipment, and Medicines and Medical Supplies). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 67 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 For example, if there are relatively more hospital beds per On the other hand, a yardstick has been developed for a country SECTION 2 population in a country (or part of a country) compared to others, having too few health workers to enable the health system to Cross-Cutting there is more likely to be “underutilization” in terms of low bed function—an extreme of inefficiency. The World Health Organization Analysis on Efficiency and occupancy rates. The different sources of data that might be used (WHO) estimated that 44.5 health workers per 10,000 population Equity to rapidly benchmark the PER country against similar countries are is the minimum necessary to achieve at least a 25 percent score on Assessing Spending Efficiency found for each indicator described in Table 4.10 12 SDG health targets (WHO 2016).11 Assessing Equity in Spending Findings of relative oversupply, however, need to be interpreted The other aspect of input quantity relating to efficiency is waste. List of Acronyms carefully. There are no valid indicators of need for the different Examples are medicines expiring before they can be used, pilfering 3 inputs for a population with a given disease burden and pattern, and of medicines, and equipment that is not functional (Table 4). SECTION 3 it is likely that many LICs and LMICs, even those with higher levels Topic-Specific of each input, do not have enough to meet the real health needs Analysis of the population. So, where the PER country has higher levels of 4 different inputs compared to other countries, for example, health workers per 10,000 population, there may still not be sufficient SECTION 4 Additional inputs to meet population health needs. However, PER authors Guidance could use this information to look deeper into the productivity and appropriate mix of the relatively abundant inputs, for example, outpatient visits per full-time-equivalent doctor. 10 The Health PER How-to Guide module on Physical Infrastructure and Equipment suggests using a combination of utilization and availability in this way to make judgments about under- and overuse. 11 See the Human Resources for Health module in Section 3 of the How-to Guide for more information. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 68 OVERVIEW 1 SECTION 1 What Is a Health PER? Table 4. Possible Indicators for Input Quantities Linked to Efficiency 2 SECTION 2 INPUT QUANTITY Cross-Cutting Analysis on Input Types and Indicators Sources Efficiency and Equity Health workers • MoH human resource information system Assessing Spending Efficiency • Number of health workers of all types (doctors, nurses and midwives, other types) per • Professional councils and associations 10,000 population • WHO Global Health Workforce Statistics Assessing Equity in Spending • Number of particular types of health workers per 10,000 population • OECD Health Statistics • World Bank Open Data List of Acronyms 3 Physical infrastructure • MoH • Number of acute care hospitals beds per 1,000 population • World Development Indicators SECTION 3 • Number of PHC facilities per 100,000 population (could be disaggregated by level, e.g., • WHO—regional observatories Topic-Specific Analysis community versus health center/dispensary 4 Equipment • MoH • Number of different types of equipment per 10,000 population • Specific studies SECTION 4 • Proportion of different types of equipment that are nonfunctional • Hospital performance assessment framework data Additional Guidance Medicines and medical supplies • Specific studies • Value of expired medicines annually • MoH • Value of estimated leakage of medicines from public system • Hospital performance assessment framework data % of facilities with acceptable storage facilities meeting minimal standards of • • Audit reports protection from theft, ventilation, temperature, and humidity Note: MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Development; PHC = primary health care; WHO = World Health Organization.  TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 69 OVERVIEW 1 SECTION 1 What Is a Health PER?  Input Productivity and Quality High utilization rates, however, do not always suggest the efficient use of these capital items. Where hospitals are paid on a daily 2 Technical efficiency requires that each chosen input produces as rate, for example, they sometimes compensate for relatively low SECTION 2 much output as possible, sometimes called “input productivity.” admission rates by keeping patients in the hospital longer, so it is Cross-Cutting Human resources, infrastructure, and equipment can face also useful to check average length of stay for particular conditions Analysis on Efficiency and inefficiency in the form of low production per unit of use. For against clinical guidelines. WHO, for example, suggests that the Equity human resources, a low number of patient contacts per full-time- clinically necessary length of hospital stay after a normal delivery equivalent health worker per day suggests that health workers are is 24–48 hours, though in practice, the duration varies considerably Assessing Spending Efficiency not being fully utilized, although the reasons for this would need across settings (WHO 2022; Campbell et al. 2016). Assessing Equity in Spending to be explored by PER authors. High absenteeism rates mean that health workers are being paid for this time but are not producing any Overutilization also occurs with equipment—more diagnostic tests List of Acronyms 3 benefit in terms of coverage with needed health services. Ideally, are ordered than needed, for example. Mostly, this occurs in the PER authors would work through all inputs to explore whether private sector when providers are paid fee-for-service either by SECTION 3 evidence of low productivity can be found. patients directly or by forms of insurance, including SHI. PER authors Topic-Specific Analysis should check the extent that government health spending is used 4 At the other extreme, where health workers are in short supply, to purchase services on a fee-for-service basis before exploring in some countries there is evidence of “overuse,” which can also this avenue of overuse of inputs. SECTION 4 be inefficient. An example is clinical health workers having to Additional Guidance see many patients each hour, leading to possible medical errors Inappropriate use and overuse are well-known problems with because they can spend little time with each patient. medicines as well, particularly of antibiotics. Overuse of antibiotics creates resistance, reducing the effectiveness of treatment in the Low productivity of infrastructure and equipment such as X-ray future, while inappropriate use means that health spending is machines can be proxied by inpatient bed occupancy rates higher than it needs to be to achieve the same result. and number of pictures per week, respectively. Relatively low utilization means that the investments costs incurred were not needed, or the services are unaffordable. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 70 OVERVIEW 1 SECTION 1 What Is a Health PER? There are no scientific cut points for the indicators that unequivocally show what level of productivity is too little. Technical efficiency would normally seek to minimize the costs of producing an output of a given quality, but in health, it has proven 2 Benchmarking against similar countries using the data visualization difficult to combine the quantity and quality of the outputs that are SECTION 2 tool, or across subnational units or health facilities in a country if produced—for example, the quality of the average outpatient visit in Cross-Cutting data are available, can be useful for PER authors to consider if there one health facility compared to another, or one country compared Analysis on Efficiency and are signs of low productivity. to another, is difficult to assess in a single indicator. Accordingly, Equity the assessment of efficiency in health tends to consider indicators A complication of this discussion is that the quality and costs of of quality separately from the productivity indicators described Assessing Spending Efficiency different inputs can vary. One X-ray machine might produce a above. This requires PER authors to assess average productivity Assessing Equity in Spending picture more rapidly, or require servicing less frequently, than indicators and average quality indicators concomitantly to make another. It is also likely to be more expensive. Comparing X-ray an assessment of how each input is performing. List of Acronyms 3 machines in terms of the number of pictures per week will give a misleading picture of their relative efficiency. This requires To facilitate this work, Table 5 includes some indicators of quality SECTION 3 information on their relative costs as well. for the various inputs to the production of health services along Topic-Specific Analysis with productivity indicators that might be available. Output quality 4 Another problem is that the output produced by any given input is discussed subsequently. For example, readiness metrics have might not be comparable. So, a health center with a high number been developed to capture quality (and sometimes quantity and SECTION 4 of outpatient visits per full-time-equivalent health workers might productivity) for various inputs, including basic amenities available Additional Guidance not be more efficient than others, because the quality of each visit at health facilities, diagnostic capacity, and essential medicine is lower. This can occur if some health providers understand or availability. These are available for some countries and years from follow clinical guidelines less than others or spend an inadequate the WHO Service Availability and Readiness Assessments (SARA) amount of time with patients to properly diagnose the problem and (WHO 2024a) and the World Bank’s Service Delivery Indicators inform the patient of the prescribed treatment. (SDI) (World Bank 2024) while the Demographic and Health Survey (DHS) of USAID has revised its service provision assessment (SPA) TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 71 OVERVIEW 1 SECTION 1 What Is a Health PER? with indicators of quality and productivity (USAID 2024).12 They are, however, not efficiency indicators 2 by themselves and need to be interpreted carefully. SECTION 2 Cross-Cutting Take a primary level health facility, for example. Analysis on Efficiency and Its domain score on essential medicines might be Equity lower than its score on diagnostic capacity and basic amenities. Does this indicate inefficiency in Assessing Spending Efficiency the use of the current budget? If so, funds should Assessing Equity in Spending be transferred from ensuring diagnostic capacity or from basic amenities to ensuring that more essential List of Acronyms 3 medicines are available. Simply examining relative domain scores, or other indicators of quality by SECTION 3 themselves, cannot answer this question, although Topic-Specific Analysis they give PER authors an entry point for a dialogue 4 with policymakers about how efficiency could be improved at primary-level facilities if budgets remain SECTION 4 constant or if they increase. At the extreme, there Additional Guidance might be domain score levels below which safe care is no longer possible. 12 Service Delivery Indicators (SDI) reports are currently available for selected coun- tries in Sub-Saharan Africa, the most recent from 2019. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 72 OVERVIEW 1 Table 5. Possible Indicators for Input Productivity and Quality SECTION 1 What Is a INPUT PRODUCTIVITY AND QUALITY Health PER? Input Type Indicators Possible Sources 2 HRH Productivity SECTION 2 • Number of consultations per day per full-time equivalent (fte) doctor (by type of facility) • Facility surveys Cross-Cutting • Number of consultations per day per full-time nurse (by type of facility) • Administrative data from MoH, health insurance fund Analysis on • % days absent during a given period for different types of HRH at different types of health facilities • Specific studies Efficiency and Equity Quality • Diagnostic accuracy • Specific studies Assessing Spending Efficiency • Adherence to clinical guidelines Physical Productivity Assessing Equity in Spending infrastructure • Hospital admission rate per 10,000 population • MoH • Inpatient bed occupancy rate • Health insurance data List of Acronyms 3 • Average length of stay for specific conditions compared to clinical guidelines • Specific studies Quality SECTION 3 • Domain score for basic amenities • SDI (World Bank 2024), SARA (WHO 2024a), or revised Topic-Specific SPA (USAID 2024) where available* Analysis Equipment Productivity 4 • Number of investigations (e.g., scans, X-rays) per machine per week • MoH • Health insurance records SECTION 4 Quality Additional • Proportion of different types of equipment not in working order • MoH Guidance • Domain score for readiness of basic equipment • Specific studies • SARA or SDI Medicines Productivity and medical • Relative consumption of first-line vs. second-line medicines for a particular condition such as • Special studies supplies malaria, childhood pneumonia, etc. Quality • Value of counterfeit drugs seized in the country • Special studies *As of April 12, 2024, the WHO SARA website was no longer functioning, with a note that an updated archive is under development. PER authors should check whether recent surveys have been undertaken in their country. Note: MoH = Ministry of Health; SARA = Service Availability and Readiness Assessment; SDI = Service Delivery Indicators; SPA = Service Provision Assessment; USAID = United States Agency for International Development. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 73 OVERVIEW 1 SECTION 1 What Is a Health PER?  Input Prices: Paying Too Much Deciding how much is too much is not really feasible, therefore, and even if it were possible, public service salaries are not within 2 Comparing price levels of key inputs can point to inefficiencies in the control of a minister of health but are usually set by a civil SECTION 2 the form of paying too much for the inputs purchased. PER authors service commission or equivalent. Cross-Cutting may want to search for the price paid for critical inputs and make Analysis on Efficiency and decisions about whether prices are “too high.” Paying “too little” for HRH can result in low levels of motivation Equity and low productivity. That being said, when resources of health Frequently, however, the availability of data is limited to are scarce, there is a clear tradeoff between employing more Assessing Spending Efficiency medicines, medical supplies, and equipment. Some PERs have health workers at lower wages or paying higher wages, which Assessing Equity in Spending also undertaken work on health worker salaries, either across means hiring fewer workers. List of Acronyms countries or across different types of health workers. Health 3 worker salaries have sometimes been compared to those of It is simpler to decide whether a country pays too much for teachers as well, partly to understand why vacancy rates of health medicines or different types of equipment and medical supplies. SECTION 3 workers might be high. The United Nations Children’s Fund (UNICEF) acts as a purchaser Topic-Specific Analysis for many inputs that countries might need to import, and its 4 As for salaries of human resources for health (HRH), the cross- website provides details of the prices that countries would be country variation can be substantial. For example, within the able to obtain currently for these items (UNICEF 2024). They can SECTION 4 be compared with the prices the country recently paid. The Pan OECD, the most generous countries pay doctors two to five times Additional Guidance more than the least generous as a share of the average wage American Health Organization (PAHO) publishes reference prices (Fujisawa and Lafortune 2008). However, even if a country pays for some medicines (PAHO 2024). more than comparable countries at similar income levels, there might be other explanations: for example, there is a relatively The use of brand-name medicines rather than generics, which high migration of health workers to richer countries and the are usually cheaper with the same therapeutic effect, is another salary scales reflect an attempt to retain as many as possible. source of overpaying for medicines. There is no easy international source of data on which countries have purchased brand-name TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 74 OVERVIEW 1 medicines when generics are available. One way for PER SECTION 1 authors is to take a selection of medicines purchased by a Table 6. Paying Too Much for Inputs What Is a Health PER? central purchasing agency (or purchasing agencies) where INPUT PRICES 2 generics are available, preferably those responsible for SECTION 2 relatively high expenditures. The purchases of the brand- Prices Indicators Possible Sources Cross-Cutting name and generic versions can be collated, though this Analysis on Human resources • Physician/nurse salary ratio • MoH Efficiency and requires good recordkeeping in the purchasing agency, for health (HRH) • Physician/teacher salary ratio • MoH and Ministry Equity and it can take time. Other sources might be studies • Different types of HRH salaries of Education Assessing Spending Efficiency already undertaken in a country including Master’s and as a ratio of the average wage • Ministry of Labor PhD theses. Medicines, other • Prices of medicines and • UNICEF (2024) Assessing Equity in Spending medical products medical supplies and • PAHO (2024) List of Acronyms Another option for medicines suggested in the Health and equipment equipment compared to the specific studies 3 PER How-to Guide is to check the share of generics in lowest international prices • Expenditure on a brand-name SECTION 3 total medicine expenditure or in government medicine medicine minus the estimated Topic-Specific expenditure. This is sometimes available from health Analysis expenditure if a generic had account studies or other more specific studies. The 4 been used for particular Medicines and Medical Supplies module advises that conditions even though there is no magic number, comparing this • Share of total medicine SECTION 4 against comparator countries might give an idea of the expenditure on generics Additional Guidance relative use of generics. Note: MoH = Ministry of Health; PAHO = Pan American Health Organization; UNICEF = United Nations Children’s Fund. Table 6 provides some of the possible indicators that might be available to explore the idea of paying more than necessary for particular inputs, but PER authors would need to supplement this by adding any other data they can find on other inputs. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 75 OVERVIEW 1 SECTION 1 What Is a Health PER?  The Mix of Inputs government spending on HRH might indicate there are insufficient inputs of other types—medicines, for example—to allow health 2 The COVID-19 pandemic, which started toward the end of 2019, workers to do their jobs appropriately. SECTION 2 highlighted the problems with service delivery caused by imbalances Cross-Cutting in the mix of inputs—for example, insufficient health workers in Another type of indicator compares the absolute numbers of inputs Analysis on Efficiency and some countries to deliver the available vaccines. Extreme cases of most appropriate to HRH. For example, operating with a high ratio Equity imbalance can also be documented in terms of health centers with of doctors to nurses or to all other types of health workers (who no skilled health workers to provide clinical care, or infrastructure typically are paid at lower rates) might suggest that the available Assessing Spending Efficiency that is purchased or donated but cannot then be serviced because funds could be used better by increasing the relative proportion of Assessing Equity in Spending of a shortage of operational funds. other types of health workers. The same idea applies to the ratio of specialist to generalist doctors. List of Acronyms 3 However, once extreme cases are accounted for, it is more difficult to identify inappropriate mixes of inputs. Technical efficiency In terms of medicines, the question of whether the PER country’s SECTION 3 requires that the least cost mix is used to produce the desired formulary or benefit package for medicine is based on the WHO Topic-Specific Analysis output. Identifying the lowest cost mix of inputs is complicated, medicine list is a first step in assessing whether the mix of medicines 4 requiring an understanding of unit prices and the benefit from using is appropriate. The proportion of health facilities with a core set of each additional unit—for example, would the last unit of nursing essential medicines is another option, although this might reflect SECTION 4 the availability of funds more than the appropriate mix of medicines time have achieved more than additional units of medicines, or Additional Guidance equipment, in extending coverage with tuberculosis treatment? in many cases. This type of calculation is beyond the scope of a health PER. Table 7 suggests indicators on the mix of inputs, largely drawn from Instead, it is sometimes possible to start to ask questions about the other health PER modules. inefficiency by considering the share of health spending on particular inputs. For example, high and increasing shares of TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 76 OVERVIEW 1 SECTION 1 What Is a Health PER? Table 7. Indicators for the Mix of Inputs Input Indicators Possible Sources 2 SECTION 2 HRH vs. other • Spending on HRH as a % of government health expenditure • Health accounts Cross-Cutting inputs • Consolidated government spending Analysis on Efficiency and HRH—mix of • Ratio of nurses to physicians (full-time equivalents) • MoH Equity health workers • Ratio of practicing specialist medical doctors to generalist medical doctors Assessing Spending Efficiency Medicines—mix • Spending on medicines as a % of government health expenditure • Health accounts of medicines • Is the country’s formulary or guaranteed benefit package for medicines based on • Key informants Assessing Equity in Spending the WHO essential medicines list? • Surveys or studies List of Acronyms • Proportion of facilities with availability of a core set of essential medicines 3 Infrastructure • Capital expenditure as a % of total health expenditure • Government expenditure records SECTION 3 and equipment • Health accounts Topic-Specific • WHO GHED Analysis 4 Note: HRH = Human Resources for Health; MoH = Ministry of Health; WHO GHED = World Health Organization Global Health Expenditure Database. SECTION 4 Additional However, care needs to be taken when interpreting this type of Does an increased share reflect the fact that overall health spending Guidance indicator. For example, a change in the share of HRH in total is being constrained, and employment is being protected by reducing government spending is not easy to interpret, and the policies to expenditure on other items? If so, it might be true that health workers address any apparent inefficiency are not straightforward. 13 are operating with fewer inputs than in the past—inputs such as medicines, diagnostics, and other health products—and efficiency 13 The indicator is more meaningful where governments make services—for example, they employ health workers to provide health services. Where governments purchase health services on behalf of the population, data on HRH spending are very difficult to obtain and are probably misleading—for example, how much of the cost of an outpatient visit to a general practitioner can be attributed to the cost of the doctor (and any other staff involved)? TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 77 OVERVIEW 1 SECTION 1 What Is a Health PER? is falling. However, the policy implications are not obvious—for example, does this mean the government should have fired health Moving to the ratio of doctors to nurses (or skilled to unskilled health workers),14 a high ratio might imply inefficiency and that 2 workers during the downturn, which might have been impossible more highly paid doctors are undertaking tasks that nurses could SECTION 2 with existing employment contracts? It would also make it more do. Benchmarking across countries might be useful to identify Cross-Cutting costly to rehire when government spending expands, meaning that whether the country under discussion is an outlier with relatively Analysis on Efficiency and the short-term response might be more efficient in the longer term. more doctors in comparison to nurses, although differences in Equity the relative wages of health workers across countries could also Assessing Spending Efficiency Does an increasing share reflect an attempt to expand the workforce contribute. Deriving policy implications is, however, again tricky. because of historical shortages, in an expansionary budget? If so, If there are shortages of health workers of all types, it probably Assessing Equity in Spending coverage with health services should increase and the increasing means that training should focus more heavily on nurses (often the List of Acronyms share might reflect reduced efficiency if the supply of medicines domain of the education rather than health department). Firing 3 or medical products does not increase at the same rate as the doctors to reduce the ratio of doctors to nurses in current health increased number of health workers, meaning they cannot do spending, though, would only lead to reductions in health service SECTION 3 Topic-Specific their jobs effectively. coverage—unless the required number of nurses and other staff Analysis could be hired immediately. If shortages of health workers do not 4 Does an increasing share imply that health worker wages are rising exist, then firing doctors (or skilled workers) to reduce the ratio is rapidly rather than new workers being employed? If so, this might still politically complicated, especially given the strength of unions SECTION 4 also constrain spending on other essential inputs, although this in many countries. Again, the implications for policy are more long Additional Guidance could be counterbalanced if the motivation and productivity of term: increasing the training of nurses compared to doctors. health workers increase. 14 Some data sources include nurses, midwives, and nurse assistants rather than simply nurses. In any benchmarking, it is important to check the definitions used for a particular country. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 78 OVERVIEW 1 SECTION 1 What Is a Health PER? Outputs 2 SECTION 2 Allocative efficiency first requires that the mix of goods and services It is complex to determine whether the existing mix of services Cross-Cutting produced in the health system maximizes the objective function produced by public spending on health maximizes the health and Analysis on Efficiency and of UHC, although as discussed earlier, only health outcomes have financial protection outcomes required for UHC for a specific level Equity typically been considered. Allocative efficiency requires technical of expenditure. Cost-effectiveness analysis (CEA) has been used Assessing Spending Efficiency efficiency in the production of each output or service. Quality extensively to determine the relative efficiency of personal health is a component, although its relationship with efficiency is not services (though almost always in terms of health outcomes alone), Assessing Equity in Spending straightforward because, as described earlier, higher quality of particularly in richer countries. It has generally been used, however, List of Acronyms inputs is often associated with higher productivity, but also higher in an incremental fashion: to help decisions about whether new 3 cost. So, higher quality of an output will often be associated with technologies or medicines should be publicly funded. CEA is used SECTION 3 higher cost. Initially the mix of goods and services produced is less frequently to determine the allocative efficiency of the current Topic-Specific considered in the next subsection, then questions relating to the mix of health services and whether resources should be transferred Analysis production of each health service, including quality, are discussed. to allow some services to be scaled up by scaling others down—the 4 work of the WHO-CHOICE project is the only source of comparative information of this nature, but not necessarily available by country SECTION 4 Additional  Mix of Goods and Services except in a few cases (WHO 2021b). Guidance Health systems produce a large number of goods and services, There are important tradeoffs to consider, however. One is whether including personal health services (promotive, preventive, more should be spent on public health functions such as pandemic curative, rehabilitative, and palliative), population-based health preparedness, with the implication that a country should spend services, and goods and services required for cross-cutting less of the current budget somewhere else. However, it is simpler essential public health functions, from surveillance to system to measure the impact of personal health interventions, and some governance (WHO 2021a). population-based interventions such as health education, on TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 79 OVERVIEW 1 SECTION 1 What Is a Health PER? health outcomes than for most of the public health functions, so any assessment by PER authors and country policymakers of this the various Disease Control Priority (DCP) publications (WHO 2023b; University of Bergen 2023), and individual studies. There 2 nature will be inherently subjective. are also “rules of thumb” for deciding if a particular intervention SECTION 2 is cost-effective compared to other ways of using resources, with Cross-Cutting Other tradeoffs to consider are the balance between promotive/ the dollar value of the thresholds for cost-effectiveness varying Analysis on Efficiency and preventive versus curative services and between primary health according to country incomes per capita. For example, some time Equity care and higher levels. Again, there are no simple ways of ago, a WHO Commission suggested that interventions costing determining scientifically if too much of one (and not enough of less than the value of GDP per capita to achieve a unit of health Assessing Spending Efficiency something else) is being produced for a given level of expenditure. improvement (measured in terms of disability adjusted life years Assessing Equity in Spending (DALYs) averted) was very cost-effective (WHO Commission on Although there is no foolproof way of assessing whether the Macroeconomics and Health 2001). More recently, it has been List of Acronyms 3 current mix of government health spending should be changed argued that the threshold should be lower, at around 0.5 percent to improve allocative efficiency, some hints can be obtained in of GDP per capita in most low- and lower-middle-income countries SECTION 3 the following ways. (Pichon-Riviere et al. 2023). Topic-Specific Analysis 4 Where there is an explicit set of guaranteed services, one role Some of the interventions generally shown to be cost-effective in for a health PER might be to consider whether any of these items low- and lower-middle-income settings, and for which coverage SECTION 4 is not cost-effective compared to any that are not included.15 A data are often available, are reported in Table 8. Many LICs and Additional Guidance variant is to consider coverage of key interventions to see if those LMICs do not report coverage for noncommunicable disease considered to be more cost-effective have low coverage compared (NCD) interventions partly because denominators, the number to some that are less cost-effective. of people who need treatment, are often not available. Some of these interventions have also been shown to be very cost-effective A general idea of the cost-effectiveness of multiple interventions (WHO 2021b), so the full evaluation of coverage rates along the is provided in the WHO-CHOICE project’s database (WHO 2021b), lines suggested above may be more difficult in these countries. 15 The term “cost-effectiveness” is used here to capture all variations of cost-effectiveness analysis, including cost-utility analysis. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 80 OVERVIEW 1 Table 8. Allocative Efficiency: Interventions Considered Cost-Effective in Low- and Lower-Middle-Income Countries SECTION 1 What Is a Health PER? Interventions and Coverage Indicators Possible Sources 2 UHC • UHC service coverage index • WHO and World Bank (2023) SECTION 2 Pregnancy and • Antenatal care: % women 15–49 years with a live birth in a given time period who • All these indicators are part Cross-Cutting delivery received antenatal care, four times or more times from any provider16 of the Global Monitoring Analysis on Efficiency and Report, UHC service coverage Childhood diseases • Treatment of acute respiratory infection (ARI): % children under 5 years with Equity index. The definitions and suspected ARI taken to an appropriate health facility or provider sources of data are provided Assessing Spending Efficiency Tuberculosis • Treatment coverage with all forms of tuberculosis in WHO and World Bank Assessing Equity in Spending HIV/AIDS • Antiretroviral therapy coverage of people living with HIV (2023). Malaria prevention • Insecticide treated net (ITN) use—% population in endemic areas who slept under List of Acronyms 3 an ITN the previous night Family planning • % married women 15–49 years who have their need for family planning satisfied SECTION 3 with modern methods Topic-Specific Analysis Noncommunicable • Prevalence of treatment for hypertension, adults 30–79 years 4 diseases • Mean fasting plasma glucose adults 30+ years (diabetes) • Tobacco use among people aged 15+ years SECTION 4 Note: HRH = Human Resources for Health; MoH = Ministry of Health; UHC = universal health coverage GHED = World Health Organization Global Health Expenditure Database. Additional Guidance Other disease-specific interventions that are usually deemed cost- share of government health spending that is on PHC as a proxy for effective can also be considered depending on the country context spending on the set of highly cost-effective interventions. There and data availability (refer to the module on Service Coverage for a have been many questions about what types of spending should be discussion on additional interventions, including for malnutrition denoted as being part of PHC, and different country studies have and other NCDs). More recently, attention has been focused on the used different methods.16However, WHO is now producing estimates 16 Formal definitions for this and subsequent variables are found in WHO (2018). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 81 OVERVIEW 1 SECTION 1 What Is a Health PER? of expenditure on PHC annually, and as a share of current health expenditure, as part of its Global Health Expenditure Database high-priority interventions, where data are available. Although there is no gold-standard share, the indicator could be compared 2 (GHED) (WHO 2024b).It shows that PHC expenditure varies from 30 to across comparator countries, so it is also included in Table 9. SECTION 2 80 percent of current health spending: PER authors can determine if Cross-Cutting the share in their country is relatively low compared with comparator Along the same lines, the relative share of critical inputs at the Analysis on Efficiency and countries (Table 9). PER authors could also compare the share of PHC level can be compared across countries or subnational units. Equity government health spending on PHC using this source. Most relevant is the share of different types of health workers at the primary level (Table 9). Assessing Spending Efficiency A similar argument can be made for examining the share of Assessing Equity in Spending government health expenditure (GHE) spent on high-benefit or List of Acronyms 3 Table 9. Shares of Spending and Health Workers as Indicators of the Appropriate Mix of Services SECTION 3 Areas Indicators Possible Sources Topic-Specific Analysis Relative spending on • Share of current health spending on PHC • Health accounts 4 a set of cost-effective • Share of government health spending on PHC • WHO GHED (WHO 2024b) interventions Share of government health spending on high benefit/priority programs • SECTION 4 Preventive and promotive • Expenditure on preventive care as a share of current health spending • Health accounts Additional versus curative services • WHO GHED (WHO 2024b) Guidance • National budget documents Capacity in PHC versus • Share of primary care health workers as a percent of total health workers, • MoH other services by cadre • Human resource information system • Professional councils and associations • Reports on HRH (will typically have the latest available numbers) Note: HRH = Human Resources for Health; MoH = Ministry of Health; PHC = primary health care; WHO GHED = World Health Organization Global Health Expenditure Database. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 82 OVERVIEW 1 SECTION 1 What Is a Health PER?  Technical Efficiency of Individual Health Services a single country. For hospitals and health centers, the comparison of cost per unit of output is usually across multiple units in a single 2 country, sometimes using more formal forms of efficiency analysis, SECTION 2 This subsection addresses the question of whether each individual discussed in the macro-efficiency section earlier (for example, Cross-Cutting service output is produced in a technically efficient way, that is, Kirigia et al. 2004; Cinaroglu 2020; Cordero et al. 2023). Analysis on Efficiency and the combination of inputs produce the maximum output possible. Equity While indicators of the volume of services produced are available, Another approach is to search for indicators of unnecessary use of it is difficult to relate each service volume to a specific set of particular services, which means higher than necessary spending Assessing Spending Efficiency inputs that have been used to produce them. Where specific with a possibility of doing harm to the patient (Brownlee et al. 2017). Assessing Equity in Spending health programs are managed separately from others, or there This was discussed for medicines, diagnostic tests, and inpatient are program budgets and the associated expenditure of each days in the earlier section on inputs of this cross-cutting note. For List of Acronyms 3 program can be identified, the cost per unit of outcome for that a health PER, it is worth discussing with Ministry of Health officials program can be used to capture its technical efficiency. The most if there might be other examples for which data are available. One SECTION 3 common examples relate to disease programs—for example, the possible source relates to caesarean section rates. WHO suggests Topic-Specific Analysis cost per child fully immunized with the basic childhood vaccines that 10 Caesarean sections per 100 live births might be medically 4 (for example, Vaughan et al. 2019)—or to health facilities (costs per justified, so higher rates represent not only the likelihood of harm outpatient visit for health centers or costs per inpatient day for to the patient, but also unnecessary use of resources (WHO 2021c). SECTION 4 Additional hospitals) (for example, Chatterjee, Levin, and Laxminarayan 2013; Guidance Prinja et al. 2016; Hicks et al. 2019). Presumptive treatment for malaria when rapid, low-cost blood tests are readily available is another example of a technically inefficient In these cases, to get an indication of efficiency, the costs per unit delivery mode. In the same vein, inpatient care when outpatient or of output need to be benchmarked somehow. For disease programs day surgery would achieve the same results at a lower cost also such as vaccination, this is usually done by comparing countries with uses resources unnecessarily. Table 10 summarizes two indicators higher costs per unit of outcome, suggesting less efficient programs: of inappropriate or unnecessary care relevant to LICs and LMICs, this type of comparison can also be done across subnational units in which might be available in many countries. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 83 OVERVIEW 1 SECTION 1 Table 10. Ineffective and Inappropriate Care What Is a Health PER? Areas Indicators Possible Sources 2 Maternal and child health • Caesarean sections per 100 live births • MoH, health insurance, hospitals SECTION 2 • Specific studies Cross-Cutting Analysis on Tertiary care • Avoidable hospital admissions • Hospital performance assessment studies Efficiency and Equity Note: MoH = Ministry of Health. Assessing Spending Efficiency  Outputs: Quality of Services set of indicators that PER authors can use to explore service quality Assessing Equity in Spending alongside the other components of efficiency described earlier are The quality of inputs was considered earlier. The quality of health found in Table 11. List of Acronyms 3 services is generally understood as “[the] … degree to which health services for individuals and populations increase the likelihood of The indicators are organized around five dimensions: SECTION 3 desired health outcomes. …” (WHO, World Bank, and OECD 2018). Topic-Specific 1. Effectiveness: care is offered based on scientific knowledge Analysis Many dimensions of the quality of health care have been proposed and evidence-based guidelines. 4 over the years, starting with the influential work of Donabedian 2. Safety: care minimizes harm, including preventable injuries (1966).17 This body of work has recently been used as the basis of SECTION 4 and medical errors. a framework for assessing the quality of health systems (Kruk et Additional 3. Timeliness: delays in providing and receiving services are kept Guidance al. 2018; Peabody et al. 2018). Drawing on this extensive literature to a minimum. as well as the indicators suggested in the Additional Guidance on 4. Integration: care received across facilities and providers is Quality of Health Services (Section 4 of the Health PER How-to coordinated. Guide), and in the Primary Health Care and Essential Public Health 5. Patient-centeredness: care respects and responds to the Functions and the Hospitals modules of Section 3 of the guide, a 17 See also Berwick and Fox (2016). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 84 OVERVIEW 1 Table 11. Output Quality SECTION 1 What Is a Health PER? Dimensions Indicators Sources 2 Effectiveness • Diagnostic accuracy • MoH SECTION 2 • Adherence to clinical guidelines or standard care protocols • National health insurance fund Cross-Cutting • Hospital readmission rates • Hospital performance assessment framework data Analysis on • Hospital mortality rate • Surveys such as SARA, SDI Efficiency and Equity Timeliness • Proportion of adults with up-to-date NCD screening • MoH • Proportion of cancer cases treated in early stages • Health insurance data Assessing Spending Efficiency • Cancer five-year net survival rate (for different types of cancer) • Specific studies Assessing Equity in Spending Safety • Hospital acquired infection rates • MoH • Domain score for standard precautions for infection prevention • National health insurance fund List of Acronyms 3 • Overall volume of opioids prescribed • Hospital performance assessment framework data • Total volume of antibiotics for systemic use • Surveys such as SARA, SDI SECTION 3 Patient- • Community engagement efforts • Hospital performance assessment framework data Topic-Specific centeredness • Information on responsiveness and patient experience by • Surveys such as SARA, SDI Analysis socioeconomic status • Specific studies 4 Integration • Rates of emergency admissions • MoH • Avoidable hospital admissions for acute conditions, vaccine • Surveys such as SARA, SDI SECTION 4 preventable conditions, and chronic conditions Additional Guidance Note: MoH = Ministry of Health; NCD = noncommunicable disease; SARA = Service Availability and Readiness Assessment; SDI = Service Delivery Indicators. patient’s preferences, needs, and values.18 lower-middle-income countries. PER authors should feel free to use Many other indicators have been proposed (see Dudley et al. 2022), others that are available in the countries being assessed, mapping but the ones listed here are more likely to be available in low- and them to the dimensions that are described in more detail below. 18 Efficiency and equity are sometimes included as dimensions of quality, but here they are considered separate cross-cutting issues for a PER—indeed, the focus of this cross-cutting note is on efficiency. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 85 OVERVIEW 1 SECTION 1 What Is a Health PER? When care is not effective, safe, or timely, it can result in the deterioration of health. This, in turn, requires more (for example, efficiency in nonhealth areas considers whether a producer minimizes the cost of producing a product of a given quality. Costs 2 more outpatient visits, hospital admissions) and eventually of production can be lower simply because the choice was made to SECTION 2 more costly interventions, and can result in avoidable morbidity, produce a lower-quality product, rather than because of efficiency. Cross-Cutting disability, and mortality. Along these lines, the costs of malaria treatment in one country Analysis on Efficiency and Patient-centeredness means that patients are well informed and might be higher than in another because treatment is of a higher Equity actively participate in the management of their diseases and quality (treating patients in a more timely manner, for example) Assessing Spending Efficiency conditions. Failure to ensure patient information and activation rather than because the country is relatively less efficient. So, can result in low compliance and discontinuity of care processes comparing the costs per patient treated for malaria across Assessing Equity in Spending and regimes. The consequences are the same as for poor countries, or subnational units, can give a misleading picture of List of Acronyms effectiveness, safety, and timeliness, that is, possibly more, and efficiency. 3 more costly, care and avoidable mortality, disability, and mortality. SECTION 3 As argued earlier, in health, it is more difficult to assess the Topic-Specific Shortcomings in care integration can also result in gaps in the relative quality of each service that is produced to allow a full Analysis continuation of care, but also waste in the form of duplication of assessment of technical efficiency. For that reason, the indicators 4 services and avoidable care episodes. Resources are wasted that suggested above need to be used alongside information on the could have been put to good use elsewhere. costs of producing each service to make an overall assessment SECTION 4 of efficiency. Additional Guidance The indicators listed in Table 11 are not always readily available, particularly in LICs and LMICs, and PER authors working on such This also has implications for policy decisions about how to improve countries may have to draw on studies that are indicative but not efficiency. A decision to improve any dimension of quality of a service necessarily representative of the entire health system. Even in with the existing budget means taking resources from something these cases, any data need to be interpreted carefully. else, so the net impact on outcomes would need to be calculated. And if new resources become available, even if it is clear which Referring to the earlier discussion on quality of inputs, technical dimension of quality needs to be improved first, the improvement TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 86 OVERVIEW 1 SECTION 1 What Is a Health PER? in outcomes would need to be compared to the improvements that could be obtained by spending the funds in another way—perhaps discussion. For example, if there is evidence that some forms of care are not delivered in a timely manner, or that medical 2 increasing coverage of needed health services. errors occur, the possible consequences for efficiency could be SECTION 2 raised. The policymakers would then need to consider how best Cross-Cutting The best way for PER authors to use this information is to enable to address them, the funds that would be required, and whether Analysis on Efficiency and them to raise questions with country policymakers in an efficiency the funds would achieve more results if used in a different way. Equity Assessing Spending Efficiency Assessing Equity in Spending Micro-Efficiency Analysis: Tying It All Together List of Acronyms 3 The framework of Section 1 of the PER How-to Guide helps PER A complementary step can help narrow the search, making the SECTION 3 authors understand where to look for the different types of task less daunting. It draws on evidence of the most common Topic-Specific Analysis inefficiency in a system, with the focus on inputs, outputs, and causes of inefficiency that have been identified in health systems 4 the relationship between them. It also provides the basis for across many countries. This approach begins from the assumption considering what might cause the observed inefficiencies. that inefficiency affects all health systems and while all countries SECTION 4 are different, there are likely to be some similarities (WHO 2010; Additional Each of the tables in the micro-efficiency section includes a range of Chisholm and Evans 2010; World Bank 2017; OECD 2017; Hafez 2020). Guidance indicators, and their possible sources, that could be used to explore Table 12 below lists common causes that have been identified in the different forms of inefficiency. Not all will be readily available in the literature, organized according to the financing and service every country, and PER authors will need to explore other possible delivery results chains. sources in the countries they are assessing, particularly specific studies that have been undertaken by government agencies, external partners, universities, or civil society organizations. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 87 OVERVIEW 1 Table 12. Common Causes of Inefficiency in the Health System SECTION 1 What Is a Types of Inefficiency Sources of Inefficiency Health PER? Allocative efficiency 2 Outputs: Mix Spending on the wrong things: services vs. financial protection; prevention/promotion vs. treatment; SECTION 2 essential public health functions vs. personal services Cross-Cutting Technical efficiency Analysis on Resource mobilization and pooling Fragmentation in revenue generation or pooling leading to higher administration costs than necessary Efficiency and Equity Inputs: HRH HRH located in the “wrong places” Inefficient mix of HRH: e.g., ratio of doctors to nurses; nurses to nurse assistants Assessing Spending Efficiency Low productivity of HRH Assessing Equity in Spending Inputs: Infrastructure Over- or underutilization of infrastructure: e.g., excess capacity in hospitals Inputs: Equipment Underutilization of equipment: excess capacity List of Acronyms 3 Unnecessary use of equipment: too many tests ordered Inputs: Medicine Overpaying for medicines SECTION 3 Overuse of medicines Topic-Specific Use of ineffective medicines Analysis Use of brand name when generics available 4 Allowing medicines to expire or deteriorate Using medicines at the wrong time SECTION 4 Inputs: Cross-Cutting Inefficient mix of inputs to produce particular services Additional Leakages or waste of funds, medicines, equipment Guidance Higher management costs and prices for negotiated inputs or services higher than necessary because of fragmentation of procurement Outputs: Mode of delivery or level of care Services are delivered at a higher level of care than is clinically necessary, or services are delivered in an inefficient mode—inpatient vs. outpatient surgery Outputs: Mix of goods and services Ineffective or inappropriate use of services: e.g., too many caesarean sections Outputs: Quality of services Medical errors Resource mobilization Proportion of adults with up-to-date NCD screening Sources: Adapted from WHO 2010; World Bank 2017. Note: HRH = Human Resources for Health. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 88 OVERVIEW 1 SECTION 1 What Is a Health PER? The list in Table 12 can be used in discussions with country stakeholders who might understand the nature of inefficiencies in the PER country because of their 2 involvement in the governance, administration, and use of the health system. This SECTION 2 could be done through informal discussions or a more formal set of consultations Cross-Cutting or working groups to gather this tacit knowledge. Analysis on Efficiency and Equity Many different stakeholders could offer valuable perspectives on inefficiencies. These include: Assessing Spending Efficiency 1. MoH staff and staff from obligatory health insurance agencies, including health Assessing Equity in Spending administrators at different levels of seniority and the system, as well as those involved in support services linked to health—for example, procurement, List of Acronyms 3 distribution, health insurance claims, and MoH lawyers. 2. Health workers of different types and at different locations. SECTION 3 Topic-Specific 3. Ministry of Finance staff responsible for interactions with line ministries dealing Analysis with health. 4 4. Academics. SECTION 4 5. Patients or organizations representing them. Additional Guidance In the course of this conversation, PER authors would also be seeking the data needed to assess inefficiency, building on the financing framework presented earlier, as well as to verify the tacit knowledge of stakeholders. For example, if people claim that the country pays higher prices than necessary for medicines, this claim could be checked by comparing prices paid by a purchasing agency(ies) with those that UNICEF would charge if they were purchased via UNICEF. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 89 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity Assessing Spending Efficiency Assessing Equity in Spending Micro-Efficiency Analysis: When to Use It List of Acronyms 3 Unlike macro-efficiency analysis, PER authors exploring across health systems complements the use of indicators in three inefficiency would always undertake some form of micro-efficiency ways. First, PER authors can use the list to ensure that they do not SECTION 3 analysis. This requires examining the different aspects of the miss any inefficiencies that are common internationally, or that local Topic-Specific Analysis inputs used in the health system, the outputs produced, and stakeholders think are important. Second, if data are not readily 4 the relationship between them. There are many types of inputs, available to confirm that these inefficiencies exist, PER authors can and the health system produces myriad different types of health do focused deep dives searching for other sources of data in these SECTION 4 services, as well as undertakes various governance functions. areas—such as research written for PhD or Master’s theses at local Additional Guidance The data requirements to run through the inputs and outputs universities. Third, the approach requires early engagement with components of the results chain are enormous, but the earlier policymakers about their perceptions of inefficiency in the health sections outlined a range of indicators that would help PER system, rather than trying to engage with them seriously only after authors explore the various sources of inefficiency. the PER results are available. This is more likely to result in strong political support for addressing the forms of inefficiency that are The use of tacit knowledge of stakeholders combined with an identified. understanding of the main causes of inefficiency commonly found TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 90 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 POLICY RESPONSES Cross-Cutting Analysis on Efficiency and Equity The macro-efficiency approach helps PER authors  Prioritization Assessing Spending Efficiency and policymakers understand if the health system Priorities for policy response, and suggested responses, require Assessing Equity in Spending under review (or components of it, such as a consideration of causes of the inefficiencies that are identified malaria program) appears inefficient compared (causes), the costs and likely payoff to each possible policy response List of Acronyms 3 to comparator countries (or components). Micro- (costs and impact), and the likelihood of success based on technical and political feasibility (feasibility). SECTION 3 efficiency analysis is required to identify the Topic-Specific Analysis main sources of inefficiency in the health system. 4 The dialogue with policymakers then moves to developing policies to redress them. The discussion  Causes SECTION 4 Additional on the upstream parts of the health financing Guidance The framework used to organize the discussion of micro efficiency results chain is valuable in this respect by helping can help identify some of the potential causes of each inefficiency PER authors should identify possible causes of the that are linked to health financing, thereby suggesting possible policy responses. For example, if it is verified that purchasing identified inefficiencies. agencies pay too much for medicines, one of the causes could TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 91 OVERVIEW 1 SECTION 1 What Is a Health PER? be fragmentation in purchasing. Another could be corruption, where the question would be whether strengthening PFM might be health workers to areas where they are most needed, for example, increases intervention coverage and population health for the 2 a response. If purchasing staff do not have experience negotiating same number of staff. This needs to be compared with the impact SECTION 2 prices with the private sector or are not aware of the prices paid by on population health of improving patient safety during operations Cross-Cutting other countries, this might also contribute. There might be others, in hospitals. Analysis on Efficiency and but understanding the reasons for each of the major causes of Equity inefficiency is required before policy responses can be developed. Assessing Spending Efficiency  Feasibility of Change Assessing Equity in Spending List of Acronyms  Impact and Costs of Intervention The final step is to anticipate possible obstacles to implementing 3 each policy to improve efficiency. Some barriers might be The aim is to gauge the costs of each possible policy to reduce technical—for example, scanning equipment might be sitting idle SECTION 3 Topic-Specific inefficiency, and their possible impact. The next question is to because there are no trained technicians to repair it. This will not Analysis determine the costs of taking action. The first part is understanding be resolved in the short run but will require hiring and training of 4 whether redressing the inefficiency would save money, but appropriate staff. Other barriers can be political, and these will vary mostly that will not happen. Improving timeliness of care avoids by country. Closing hospitals where there is overcapacity has often SECTION 4 downstream costs but requires an upfront investment. It is not proven to be politically complicated, for example. Task shifting Additional Guidance suggested that a full costing study be undertaken for the PER, but from higher paid to lower paid staff has also met with resistance the options could be graded as high, medium, and low cost (using from unions. Together with consideration of the impact and costs net costs—costs of implementing minus any possible subsequent of the range of possible intervention, the feasibility will enable a savings in present value terms). final list of priority policies to reduce inefficiency to be decided. Similarly, the relative impact of all possible interventions needs to be assessed and graded high, medium, or low impact. Reassigning TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 92 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity Assessing Spending Efficiency Assessing Equity in Spending List of Acronyms INEFFICIENCY IN PRIVATE SECTOR SPENDING 3 SECTION 3 Topic-Specific Analysis While the focus of a PER is predominantly on government spending, in the process of For policy purposes, PER authors and counterpart policymakers would first need to consider the extent to which the government is concerned 4 about the identified inefficiency. Some countries, for example, are not the efficiency evaluation for a PER, sources concerned if people with private health insurance pay more for medicines SECTION 4 of inefficiency that affect private spending or stay in the hospital longer than is clinically necessary. However, some Additional inefficiencies might be of concern to the government—for example, Guidance might be identified as well. An example overprescription of antibiotics, which does not just waste resources but might be the prescription of unnecessary also leads to increasing drug resistance. In such cases, PER authors would medicines for people who can afford to pay, explore with policymakers’ actions that governments could take to reduce or longer length of stays for people covered “unacceptable” private spending inefficiencies using the same process as described above for public spending—causes, costs and impact, and by private health insurance. feasibility of change. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 93 OVERVIEW 1 SECTION 1 What Is a Health PER? LOOKING FOR SAVINGS 2 SECTION 2 Governments constantly seek savings options. A PER efficiency analysis is not, however, designed to search for savings. Cross-Cutting As stated earlier, only a few interventions to improve efficiency result in Analysis on The rationale and objectives may vary, usually Efficiency and net savings: most require upfront and sometimes continuing investment Equity one or a combination of the following: to derive the intended benefits. Accordingly, a PER authors would be Assessing Spending Efficiency ill-advised to imply to the government that the authors will find areas • The economy is contracting as are where it can make net savings. The main purpose is to facilitate the Assessing Equity in Spending government revenues. achievement of higher levels of coverage with needed health services and List of Acronyms • Reprioritize expenditures to improve the financial protection with the available funds. 3 alignment of spending with government SECTION 3 However, PER authors might find themselves in a situation where spending Topic-Specific priorities and increase value for money. cuts are considered in a country because the economy is contracting or Analysis • Create fiscal space to accommodate because of the other reasons outlined above. Accordingly, described here 4 emerging fiscal pressures or new policy are the principles that apply to spending reviews, which can also be useful to PER authors in this process. SECTION 4 priorities. Additional Guidance • Reduce the growth or level of spending Spending reviews are processes specifically designed to develop and (fiscal consolidation). adopt savings measures based on the systematic assessment of baseline For a detailed discussion on policy options resulting in savings, see “From Double Shock to Double Recovery—Implications and Options for Health Financing in the Time of COVID-19” (Kurowski, Evans, Tandon, Hoang-Vu Eozenou, Schmidt, Irwin, Salcedo Cain, Pambudi, and Postolovska 2021). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 94 OVERVIEW 1 SECTION 1 What Is a Health PER? expenditures (Robinson 2013). The scope of spending reviews may be comprehensive, government-wide, or targeted to individual countries are expected to go through a prolonged period of fiscal adjustment. And after significant investment in response to the 2 sectors, programs, or agencies. pandemic, moreover, growing spending needs in the sector (for SECTION 2 example, vaccination), governments may target the search for Cross-Cutting Spending reviews include, as a first step, a systematic assessment savings options to health. Analysis on Efficiency and of baseline expenditures which aims to generate a set of promising Equity savings options. Savings options fall into the two broad categories of: The proposed approach to identify opportunities for efficiency improvement as part of World Bank PERs cannot substitute for Assessing Spending Efficiency 1. Efficiency/operational savings: Expenditure reductions that a full-fledged spending review. Most importantly, decisions on are achieved through changes in the production of services Assessing Equity in Spending strategic savings are inherently political. Moreover, the process is that generate the same quantity and quality of outputs at typically driven by savings targets, including the expected type and List of Acronyms lower costs. 3 timing of savings. 2. Strategic/output savings: Expenditure reductions achieved SECTION 3 through cutting back on services or transfers. Topic-Specific Analysis In a second step, each savings option is assessed in terms of its 4 feasibility and likely results, including the medium-term fiscal  What to cut … SECTION 4 impact; sectoral, distributional, and economic implications; When setting priorities on what to cut, it is important for Additional consequences for stakeholders and citizens; legislative and Guidance policymakers to fully appreciate the intended and unintended operational requirements; and administrative and compliance costs. effects of spending cuts on health system performance. In the COVID-19 pandemic and post-pandemic era, governments Spending categories that tolerate cuts without major harm to health may increasingly seek advice from the World Bank on possible system performance tend to be context specific and spending savings options, especially options to reduce the growth or level reviews critical to identify them. Decisions need to weigh both short- of spending in the short term. Almost all low- and middle-income TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 95 OVERVIEW 1 SECTION 1 What Is a Health PER? and longer-term effects. In past crises, administrative budgets have been considered spending categories where cuts would do little and nutrition programs, and primary health care. The COVID-19 crisis has also highlighted the need to protect spending on essential 2 damage to the system, at least in the short term. Indeed, in times of public-health functions. SECTION 2 crisis, health-sector agencies often demonstrate their commitment Cross-Cutting to reduce inefficiencies by cutting administrative costs. Analysis on Efficiency and Equity In some instances, targeted cuts in spending and entitlements  … and what to watch out for can result in lasting, positive effects on equity and efficiency. Assessing Spending Efficiency For example, where entitlements were initially broadly defined In times of declining health budgets, policymakers must also Assessing Equity in Spending and systems relied on implicit rationing, some countries seized apprehend and adjust for so-called “automatic cuts.” This term past emergencies as opportunities to introduce explicit benefits refers to the pattern whereby, as budgets shrink, expenditures List of Acronyms 3 packages that prioritized the most cost-effective interventions. on salaries crowd out spending on nonsalary items, due to difficulties in downsizing the payroll. The effect on nonsalary SECTION 3 Topic-Specific expenditures, for example, medicines and other medical supplies, Analysis is compounded when currency devaluations drive up the prices 4  … what to protect … of imported goods. The shift in the composition of spending and resulting change in the balance of medical inputs can quickly SECTION 4 The challenge for policymakers is not only to cut where it does the erode the quality of health services. Additional Guidance least harm, but also to protect spending critical for the performance of the health system. Spending categories to protect in times of crisis include, first and foremost, programs and policies that ensure access to care for vulnerable populations, such as the poor, mothers, and children, and the goods and services that benefit these groups most, in particular, essential medicines, immunization TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 96 OVERVIEW 1 SECTION 1 What Is a Health PER? CONCLUSIONS 2 SECTION 2 Cross-Cutting Analysis on Efficiency and This cross-cutting note is designed to help PER 2. Discussing with a variety of stakeholders their perceptions of Equity major causes of inefficiency, using the global experience as a authors develop a plan for how they will assess Assessing Spending Efficiency guide. efficiency in the health sector. Clearly, the first step 3. Digging deeper for data on indicators for inefficiencies Assessing Equity in Spending is to discuss with government counterparts their identified in step b. for which indicators were not readily available from step 1. List of Acronyms expectations. 3 SECTION 3 Together, these steps provide the basis not only for identifying A rapid check of the rapid macro-efficiency approach will show if it Topic-Specific key inefficiencies, but also for the subsequent discussion with is worth undertaking a more in-depth macro-efficiency analysis— Analysis policymakers about which ones to address first, and what policies for example, if the quick approach suggests the country is relatively 4 would be the most effective. Again, the discussion in the results efficient compared to others, a more detailed macroanalysis is not chain section is a useful guide to possible causes, suggesting where SECTION 4 warranted. PER authors can then move immediately to the micro- solutions might be found. Additional efficiency approach. Guidance It is, of course, hoped that the consideration of inefficiency and how Some form will always be necessary, but the process of identifying to reduce it will not stop after the PER is completed. PER authors major inefficiencies would involve some combination of: should seek to encourage local counterparts to institutionalize 1. Checking the availability of data on inputs, outputs, and their regular assessments of progress in reducing inefficiency in health relationship as described in the discussion on the results chain. if that is not already the case. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 97 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Alkenbrack, S., K. Hanson, and M. Lindelow. 2015. “Evasion of ‘mandatory’ social health insurance for the formal sector: evidence from Lao Cross-Cutting PDR.” BMC Health Services Research 15: 473. 10.1186/s12913-015-1132-5.  Analysis on Efficiency and Equity Anti-Corruption Knowledge Hub (online), Transparency International. 2023. https://knowledgehub.transparency.org/ Assessing Spending Efficiency Intelligence. 2023. “Estimating the Costs of Corruption and Efficiency Losses from Weak National and Sector Systems.” Development Policy Paper Discussion Draft (Revised). May 9. Costs-Corruption-and-Efficiency-Losses-Draft.pdf (artificialfiscalintelligence.com). Assessing Equity in Spending Bala, M.M., S. Singh, and D.K. Gautam. 2022. “Stochastic frontier approach to efficiency analysis of health facilities in providing services for List of Acronyms 3 non-communicable diseases in eight LMICs.” International Health, p.ihac080. Barroy, H., S. Sparkes, and E. Dale. 2016. “Assessing fiscal space for health expansion in low-and-middle income countries: a review of the SECTION 3 evidence.” Health Financing Working Paper 3. World Health Organization, Geneva. WHO-HIS-HGF-HFWorkingPaper-16.3-eng.pdf. Topic-Specific Analysis Berenguer, G., A.V. Iyer, and P. Yadav. 2016. “Disentangling the efficiency drivers in country-level global health programs: An empirical study.” 4 Journal of Operations Management 45: 30–43. SECTION 4 Berwick, D., and D.M. Fox. 2016. “Evaluating the Quality of Medical Care: Donabedian's Classic Article 50 Years Later.” The Milbank Quarterly 94 Additional Guidance (2): 237–41. Published online June 6. doi: 10.1111/1468-0009.12189. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4911723/. Bloem, L.T., R.A. Vreman, N.W. Peeters, J. Hoekman, M.E. van Der Elst, H.G. Leufkens, O.H. Klungel, W.G. Goettsch, and A.K. Mantel‐Teeuwisse. 2021. “Associations between uncertainties identified by the European Medicines Agency and national decision making on reimbursement by HTA agencies.” Clinical and Translational Science 14 (4): 1566–77. Brownlee, S., K. Chalkidou, J. Doust, A.G. Elshaug, P. Glasziou, I. Heath, S. Nagpal, V. Saini, D. Srivastava, K. Chalmers, and D. Korenstein. 2017. “Evidence for overuse of medical services around the world.” The Lancet 390 (10090): 156–68. July 8, 2017. doi: 10.1016/S0140-6736(16)32585-5. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 98 OVERVIEW 1 Epub July 9, 2017. Erratum in: The Lancet 399 (10328): 908. March 5, 2022. SECTION 1 What Is a Campbell, O.M.R., L. Cegolon, D. Macleod, and L. Benova. 2016. “Length of Stay After Childbirth in 92 Countries and Associated Factors in 30 Health PER? Low- and Middle-Income Countries: Compilation of Reported Data and a Cross-Sectional Analysis from Nationally Representative Surveys.” 2 PLOS Medicine 13 (3): e1001972. SECTION 2 Cross-Cutting Cashin, C., D. Bloom, S. Sparkes, H. Barroy, J. Kutzin, and S. O’Dougherty. 2017. “Aligning public financial management and health financing: Analysis on Efficiency and sustaining progress toward universal health coverage.” Health Financing Working Paper 4. World Health Organization, Geneva. 9789241512039- Equity eng.pdf (who.int). Assessing Spending Efficiency Chatterjee, S., C. Levin, and R. Laxminarayan. 2013. “Unit cost of medical services at different hospitals in India.” PLOS One 8 (7): e69728. Assessing Equity in Spending Chisholm, D., and D.B. Evans. 2010. “Improving health system efficiency as a means of moving towards universal coverage.” Background paper 28, The World Health Report 2010. World Health Organization, Geneva. http://www.who.int/healthsystems/topics/financing/healthreport/whr_ List of Acronyms 3 background/en/index1.html. SECTION 3 Cinaroglu, S. 2020. “Integrated k-means clustering with data envelopment analysis of public hospital efficiency.” Health Care Management Topic-Specific Science 23 (3): 325–38. Analysis 4 Cordero, J.M., A. García‐García, E. Lau‐Cortés, and C. Polo. 2023. “Assessing Panamanian hospitals’ performance with alternative frontier methods.” International Transactions in Operational Research 30 (1): 394–420. SECTION 4 Additional Cutler, D.M. 2007. “Use a Scalpel, Not a Meat Cleaver.” Cato Unbound. September 12. Use a Scalpel, Not a Meat Cleaver | Cato Unbound (cato- Guidance unbound.org). Cylus, J., I. Papanicolas, P.C. Smith, and World Health Organization. 2016. Health system efficiency: How to make measurement matter for policy and management. European Observatory Health Policy Series. Copenhagen: World Health Organization Regional Office for Europe. Dieleman, J., M. Campbell, A. Chapin, E. Eldrenkamp, V.Y. Fan, A. Haakenstad, J. Kates, Y. Liu, T. Matyasz, A. Micah, and A. Reynolds. 2017. “Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of- pocket health spending in 184 countries.” The Lancet 389 (10083): 1981–2004. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 99 OVERVIEW 1 Dom, R., A. Custers, S. Davenport, and W. Prichard. 2022. Innovations in Tax Compliance: Building Trust, Navigating Politics, and Tailoring SECTION 1 Reform. Washington, DC: World Bank. doi:10.1596/978-1-4648-1755-7. License: Creative Commons Attribution CC BY 3.0 IGO. What Is a Health PER? 2 Donabedian, A. 1966. “Evaluating the Quality of Medical Care.” The Milbank Memorial Fund Quarterly 44 (3) (suppl): 166–206. Reprinted in The Milbank Quarterly (2005) 83 (4): 691–729. SECTION 2 Cross-Cutting Dudley, L., P. Mamdoo, S. Naidoo, and M. Muzigaba. 2022. “Towards a harmonised framework for developing quality of care indicators for global Analysis on Efficiency and health: a scoping review of existing conceptual and methodological practices.” BMJ Health & Care Informatics 29 (1). Equity Dutu, R., and P. Sicari. 2016. “Public spending efficiency in the OECD: benchmarking health care, education and general administration.” Assessing Spending Efficiency Economics Department Working Papers 1278. Organisation for Economic Co-operation and Development, Paris. Reprinted (2020) in Review of Assessing Equity in Spending Economic Perspectives 20 (3): 253–80. List of Acronyms Fraser, H.L., I. Feldhaus, I.P. Edoka, A.N. Wade, C.N. Kohli-Lynch, K. Hofman, and S. Verguet. 2024. “Extended cost-effectiveness analysis of 3 interventions to improve uptake of diabetes services in South Africa.” Health Policy and Planning: p.czae001. SECTION 3 Fritz, V., S. Sweet, and M. Verhoeven. 2014. “Strengthening Public Financial Management: exploring drivers and effects.” World Bank Policy Topic-Specific Analysis Research Working Paper 7084. World Bank, Washington, DC. 4 Fujisawa, R., and G. Lafortune. 2008. “The remuneration of general practitioners and specialists in 14 OECD countries: what are the factors influencing variations across countries?” OECD Health Working Papers 41. Organisation for Economic Co-operation and Development, SECTION 4 Paris. https://doi.org/10.1787/228632341330. Additional Guidance Gearhart, R. 2016. “No theory: an explanation of the lack of consistency in cross-country health care comparisons using non-parametric estimators.” Health Economics Review 6 (1): 40. Greene, W., 2004. “Distinguishing between heterogeneity and inefficiency: stochastic frontier analysis of the World Health Organization’s panel data on national health care systems.” Health Economics 13 (10): 959–80. Greene, W. 2008. “The Econometric Approach to Efficiency Analysis,” in Fried, H.O., C.K. Lovell, and S.S. Schmidt, eds. 2008. The measurement of productive efficiency and productivity growth, 92–250. Oxford: Oxford University Press. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 100 OVERVIEW 1 Hafez, R., ed. 2020. Measuring Health System Efficiency in Low- and Middle-Income Countries: A Resource Guide. Joint Learning Network for SECTION 1 Universal Health Coverage. What Is a Health PER? Hamidi, S., and F. Akinci. 2016. “Measuring Efficiency of Health Systems of the Middle East and North Africa (MENA) Region Using Stochastic 2 Frontier Analysis.” Applied Health Economics and Health Policy: 1–11. SECTION 2 Cross-Cutting Herrera, S., and G. Pang. 2005. “Efficiency of public spending in developing countries: an efficiency frontier approach.” World Bank Policy Analysis on Efficiency and Research Working Paper 3645. World Bank, Washington, DC. Equity Herrera, S., and A. Ouedraogo. 2018. “Efficiency of public spending in education, health, and infrastructure: an international benchmarking Assessing Spending Efficiency exercise.” World Bank Policy Research Working Paper 8586. World Bank, Washington, DC. Assessing Equity in Spending Hicks, P., S. Huckson, E. Fenney, I. Leggett, D. Pilcher, and E. Litton. 2019. “The financial cost of intensive care in Australia: a multicentre registry List of Acronyms study.” Medical Journal of Australia 211 (7): 324–25. 3 Hollingsworth, B. 2003. “Non-parametric and parametric applications measuring efficiency in health care.”  Health Care Management Science 6 SECTION 3 (4): 203–18. Topic-Specific Analysis Hollingsworth, B., 2008. “The measurement of efficiency and productivity of health care delivery.” Health Economics 17 (10): 1107–28. 4 IMF. 2023a. Tax and Customs Administration web page. International Monetary Fund, Washington, DC. Tax-and-Customs-Administration (imf.org). SECTION 4 IMF. 2023b. World Economic Outlook Databases. International Monetary Fund, Washington, DC. World Economic Outlook Databases (imf.org). Additional Guidance Izadikhah, M., 2022. “A fuzzy stochastic slacks-based data envelopment analysis model with application to healthcare efficiency.” Healthcare Analytics 2: 100038. Jiang, N., and A. Andrews. 2020. “Efficiency of New Zealand’s District Health Boards at providing hospital services: a stochastic frontier analysis.” Journal of Productivity Analysis 53: 53–68. Jowett, M., and W. Hsiao. 2007. “The Philippines: Extending Coverage Beyond the Formal Sector”: xi, 172. In W. Hsiao and R. Shaw, eds. Social Health Insurance for Developing Nations. Washington, DC: World Bank. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 101 OVERVIEW 1 Kirigia, J.M., A. Emrouznejad, L.G. Sambo, N. Munguti, and W. Liambila. 2004. “Using data envelopment analysis to measure the technical SECTION 1 efficiency of public health centers in Kenya.” Journal of Medical Systems 28: 155–66. What Is a Health PER? Kohl, S., J. Schoenfelder, A. Fügener, and J.O. Brunner. 2019. “The use of Data Envelopment Analysis (DEA) in healthcare with a focus on 2 hospitals.” Health Care Management Science 22: 245–86. SECTION 2 Cross-Cutting Kurowski, C., D.B. Evans, A. Tandon, P. Hoang-Vu Eozenou, M. Schmidt, A. Irwin, J. Salcedo Cain, E.S. Pambudi, and I. Postolovska. 2021. “From Analysis on Double Shock to Double Recovery: Implications and Options for Health Financing in the Time of COVID-19.” Health, Nutrition and Population Efficiency and Equity (HNP) Discussion Paper. World Bank Group, Washington, DC. From-Double-Shock-to-Double-Recovery-Implications-and-Options-for-Health- Financing-in-The-Time-of-COVID-19.pdf (worldbank.org). Assessing Spending Efficiency Kruk, M.E., A.D. Gage, C. Arsenault, K. Jordan, H.H. Leslie, S. Roder-DeWan, O. Adeyi, et al. 2018. “High-Quality Health Systems in the Sustainable Assessing Equity in Spending Development Goals Era: Time for a Revolution.” The Lancet 6 (11): 1196–1252. https://doi.org/10.1016/S2214-109X(18)30386-3. List of Acronyms 3 Laing, A. 2023. “Costing corruption and efficiency losses from weak PFM systems.” International Monetary Fund Blog, April 3. Costing Corruption and Efficiency Losses from Weak PFM Systems (imf.org). SECTION 3 Topic-Specific Leelahavarong, P., S. Doungthipsirikul, S. Kumluang, A. Poonchai, N. Kittiratchakool, D. Chinnacom, N. Suchonwanich, and S. Tantivess. Analysis 2019. “Health technology assessment in Thailand: institutionalization and contribution to healthcare decision making: review of 4 literature.” International Journal of Technology Assessment in Health Care 35 (6): 467–73. SECTION 4 Liu, H., W. Wu, and P. Yao. 2022. “A study on the efficiency of pediatric healthcare services and its influencing factors in China—estimation of a Additional three-stage DEA model based on provincial-level data.” Socio-Economic Planning Sciences 84: 101315. Guidance Mathauer, I., and E. Nicolle. 2011. “A global overview of health insurance administrative costs: what are the reasons for variations found? Health Policy 102 (23): 235–46. Mathauer, I., L.V. Torres, J. Kutzin, M. Jakab, and K. Hanson. 2020. “Pooling financial resources for universal health coverage: options for reform.” Bulletin of the World Health Organization 98 (2): 132. McGillivray, W. 2001. “Contribution Evasion: Implications for Social Security Pension Schemes.” International Social Security Review, Vol. 54, 4. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 102 OVERVIEW 1 Minerva, D., and R. Stefanov. 2018. Evasion of Taxes and Social Security Contributions. European Platform on Undeclared Work, European SECTION 1 Commission. What Is a Health PER? Musiega, A., B. Tsofa, L. Nyawira, R.G. Njuguna, J. Munywoki, K. Hanson, A. Mulwa, S. Molyneux, I. Maina, C. Normand, and J. Jemutai. 2023. 2 “Examining the influence of budget execution processes on the efficiency of county health systems in Kenya.” Health Policy and Planning 38 SECTION 2 (3): 351–62. Cross-Cutting Analysis on Efficiency and Novignon, J., G. Aryeetey, J. Nonvignon, K. Malm, N.Y. Peprah, S.A. Agyemang, S. Amon, and M. Aikins. 2023. “Efficiency of malaria service delivery Equity in selected district-level hospitals in Ghana.” Health Systems 12 (2): 198–207. Assessing Spending Efficiency Nwakobi, M.N. 2020. “On the Efficiency of Health Systems in West Africa: A Data Envelopment Analysis Approach.” Communication in Physical Sciences 6 (2). Assessing Equity in Spending Olesen, O.B., and N.C. Petersen. 2016. “Stochastic Data Envelopment Analysis—A review.” European Journal of Operational Research 251 (1): 2–21. List of Acronyms 3 OECD. 2013. Guidelines to improve estimates of spending on health administration and health insurance. Paris: OECD Publishing. Organisation SECTION 3 for Economic Co-operation and Development. Improving-Estimates-of-Spending-on-Administration.pdf (oecd.org). Topic-Specific Analysis OECD. 2017. Tackling Wasteful Spending on Health. Paris: OECD Publishing. Organisation for Economic Co-operation and Development. http:// 4 dx.doi.org/10.1787/9789264266414-en. OECD, Eurostat, and WHO. 2016. A System of Health Accounts 2011 (Revised Edition). Paris: OECD Publishing. Organisation for Economic Co- SECTION 4 Additional operation and Development. http://dx.doi.org/10.1787. Guidance OECD. 2023. Applying good budgeting practices to health. OECD Joint Network of Senior Budget and Health Officials. Paris: Organisation for Economic Co-operation and Development Osei, D., S. d’Almeida, M.O. George, J.M. Kirigia, A.O. Mensah, and L.H. Kainyu. 2005. “Technical efficiency of public district hospitals and health centres in Ghana: a pilot study.” Cost Effectiveness and Resource Allocation 3 (1): 1–13. PAHO. 2024. PAHO Strategic Fund. Washington, DC: Pan American Health Organization. https://www.paho.org/en/paho-strategic-fund#q2. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 103 OVERVIEW 1 Peabody, J., R. Shimkhada, O. Adeyi, H. Wang, E. Broughton, et al. 2018. “Quality of Care,” chapter 10. In D.T. Jamison, H. Gelband, S. Horton, SECTION 1 P. Jha, R. Laxminarayan, C.N. Mock, and R. Nugent, eds. Disease Control Priorities (Third Edition), Volume 9: Improving Health and Reducing What Is a Health PER? Poverty. Washington, DC: World Bank. 2 Public Expenditure and Financial Accountability (PEFA). 2019. Framework for Assessing Public Financial Management, (Second Edition). SECTION 2 Washington, DC: PEFA Secretariat. PEFA-Framework_English.pdf. Cross-Cutting Analysis on Pichon-Riviere, A., M. Drummond, A. Palacios, S. Garcia-Marti, and F. Augustovski. 2023. “Determining the efficiency path to universal health Efficiency and Equity coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures.” The Lancet Global Health 11 (6): e833–42. Assessing Spending Efficiency Prinja, S., A. Gupta, R. Verma, P. Bahuguna, D. Kumar, M. Kaur, and R. Kumar. 2016. “Cost of delivering health care services in public sector Assessing Equity in Spending primary and community health centres in North India. PLOS ONE 11 (8): e0160986. List of Acronyms 3 Stenberg, K., O. Hanssen, T.T.T. Edejer, M. Bertram, C. Brindley, A. Meshreky, J.E. Rosen, J. Stover, P. Verboom, R. Sanders, and A. Soucat. 2017. “Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource SECTION 3 needs in 67 low-income and middle-income countries.” The Lancet Global Health 5 (9): e875–87. Topic-Specific Analysis Thanassoulis, E., M.C. Portela, and O. Despic. 2008. “Data envelopment analysis: the mathematical programming approach to efficiency 4 analysis.” In H.O. Fried, C.K. Lovell, and S.S. Schmidt, eds. 2008. The Measurement of Productive Efficiency and Productivity Growth: 251–420. Oxford: Oxford University Press. SECTION 4 Additional UNICEF. 2024. Price catalogue. New York: United Nations Children’s Fund. Home page (unicef.org). Guidance University of Bergen. 2023. Disease Control Priorities 4. Bergen Centre for Ethics and Priority Setting in Health. Bergen, Norway: University of Bergen. Fourth Edition of Disease Control Priorities (DCP-4) | Bergen Centre for Ethics and Priority Setting in Health (BCEPS) | UiB. USAID. 2024. Introducing the Revised Service Provision Assessment. Demographic and Health Surveys Program, USAID. Washington, DC: United States Agency for International Development. DHSM22.pdf (dhsprogram.com). TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 104 OVERVIEW 1 Vaughan, K., A. Ozaltin, M. Mallow, F. Moi, C. Wilkason, J. Stone, and L. Brenzel 2019. “The costs of delivering vaccines in low- and middle-income SECTION 1 countries: findings from a systematic review. Vaccine: X, Vol. 2: 100034. What Is a Health PER? Verguet, S., J.J. Kim, and D.T. Jamison. 2016. “Extended cost-effectiveness analysis for health policy assessment: a tutorial.” Pharmacoeconomics 34 2 (9): 913–23. SECTION 2 Cross-Cutting WHO. 2010. The World Health Report 2010. Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization. Analysis on Efficiency and Equity WHO. 2016. “Health Workforce Requirements for Universal Health Coverage and the Sustainable Development Goals.” Human Resources of Health Observer Series 17. World Health Organization, Geneva. https://scholar.google.com/scholar_ookup?author=World+Health+Orga- Assessing Spending Efficiency nization&title=Health+workforce+requirements+for+universal+health+coverage+and+the+Sustainable+Development+Goals.%28Human+Re- Assessing Equity in Spending sources+for+Health+Observer%2C+17%29&publication_year=2016&journal=Human+Resources+for+Health+Observer+Series+No+17&volume=17. List of Acronyms WHO. 2020. “Findings from a rapid review of literature on ghost workers in the health sector: towards improving detection and prevention.” 3 Policy Brief. World Health Organization, Geneva. Findings from a rapid review of literature on ghost workers in the health sector: towards improving detection and prevention (who.int). SECTION 3 Topic-Specific WHO. 2021a. 21st Century Health Challenges: Can the Essential Public Health Functions Make a Difference? Geneva: World Health Organization. Analysis 21st century health challenges: can the essential public health functions make a difference?: discussion paper (who.int). 4 WHO. 2021b. “New Cost-Effectiveness Updates from WHO-CHOICE.” World Health Organization, Geneva. New cost-effectiveness updates from SECTION 4 WHO-CHOICE. Additional Guidance WHO. 2021c. “WHO Statement on Caesarean Section Rates.” World Health Organization, Geneva. WHO Statement on Caesarean Section Rates. World Health Organization. 2022. WHO Recommendations on Maternal and Newborn Care for a Positive Postnatal Experience. Geneva: World Health Organization. https://www.who.int/publications/i/item/9789240045989. WHO. 2023. “New Cost-Effectiveness Updates from WHO-CHOICE.” World Health Organization, Geneva. New cost-effectiveness updates from WHO-CHOICE. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 105 OVERVIEW 1 SECTION 1 What Is a Health PER? WHO. 2024a. “Service availability and readiness assessment” reports. Geneva: World Health Organization. Service availability and readiness assessment (SARA) (who.int). 2 WHO. 2024b. Global Health Expenditure Database. Online version. Geneva: World Health Organization. Global Health Expenditure Database SECTION 2 (who.int) Cross-Cutting Analysis on WHO and World Bank. 2021. Tracking Universal Health Coverage: 2021 Global Monitoring Report. Geneva: World Health Organization and Efficiency and Equity Washington, DC: International Bank for Reconstruction and Development/The World Bank. Tracking Universal Health Coverage: 2021 Global monitoring report (who.int). Assessing Spending Efficiency WHO, World Bank, and OECD. 2018. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. Geneva: World Health Assessing Equity in Spending Organization; Washington, DC: World Bank; and Paris: Organisation for Economic Co-operation and Development. World Bank Document. List of Acronyms 3 World Bank. 2016. The Republic of Chile Public Expenditure Review. Washington, DC: World Bank. The Republic of Chile Public Expenditure Review | Public Expenditure Review (worldbank.org). SECTION 3 Topic-Specific World Bank. 2017. “Greater efficiency for better health and financial protection.” Background paper, Second Annual UHC Health Financing Analysis Forum. World Bank, Washington, DC. Second Annual Universal Health Coverage Financing Forum (worldbank.org). 4 World Bank. 2019a. High-Performance Health Financing for Universal Health Coverage: Driving Sustainable, Inclusive Growth in the 21st Century. SECTION 4 Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/31930 License: Creative Commons Attribution CC BY 3.0 IGO. Additional Guidance World Bank. 2019b. Zambia Health Sector Public Expenditure Review: 2006-2016. Washington, DC: World Bank. World Bank. 2024. Service Delivery Indicators. World Bank, Washington, DC. Service Delivery Indicators (SDI) (worldbank.org). Yazbeck, A.S., W.D. Savedoff, W.C. Hsiao, J. Kutzin, A. Soucat, A. Tandon, A. Wagstaff, and W. Chi-Man Yip. 2020. “The Case Against Labor-Tax- Financed Social Health Insurance For Low- And Low-Middle-Income Countries: A summary of recent research into labor-tax financing of social health insurance in low-and low-middle-income countries.” Health Affairs 39 (5): 892–97. TABLE OF CONTENTS CROSS-CUTTING 1 Assessing Spending Efficiency 106 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and CROSS-CUTTING 2 Equity Assessing Assessing Spending Efficiency Assessing Equity in Spending List of Acronyms Equity in 3 SECTION 3 Topic-Specific Analysis Spending 4 SECTION 4 Additional Guidance This cross-cutting note is forthcoming. TABLE OF CONTENTS CROSS-CUTTING 2 Assessing Equity in Spending 107 OVERVIEW 1 SECTION 1 ACRONYMS What Is a Health PER? 2 ARI GDP MoH SECTION 2 Acute Respiratory Infections Gross Domestic Product Ministry of Health Cross-Cutting Analysis on Efficiency and CEA GHE NCD Equity Cost-Effectiveness Analysis Global Health Expenditure Noncommunicable Disease Assessing Spending Efficiency CHE GHED OECD Current Health Expenditure Global Health Expenditure Database Organisation for Economic Co-operation Assessing Equity in Spending and Development DAH HAQ List of Acronyms 3 Development Assistance for Health Healthcare Access and Quality OOP Out-of-Pocket SECTION 3 DALY HLE Topic-Specific Disability Adjusted Life Years Healthy Life Expectancy PAHO Analysis Pan American Health Organization 4 DEA HRH Data Envelopment Analysis Human Resources for Health PEFA SECTION 4 Public Expenditure and Financial Additional DHS IMF Accountability Guidance Demographic and Health Survey International Monetary Fund PER DVT LIC Public Expenditure Review Data Visualization Tool Low-Income Country PFM FTE LMIC Public Financial Management Full-Time Equivalent Lower-Middle-Income Country TABLE OF CONTENTS CROSS-CUTTING 2 List of Acronyms 108 OVERVIEW 1 SECTION 1 ACRONYMS What Is a Health PER? PHC UHC 2 Primary Health Care Universal Health Coverage SECTION 2 Cross-Cutting QALY UNICEF Analysis on Efficiency and Quality Adjusted Life Years United Nations Children’s Fund Equity RM USAID Assessing Spending Efficiency Resource Mobilization United States Agency for International Development Assessing Equity in Spending SARA Service Availability and Readiness WDI List of Acronyms 3 Assessments World Development Indicators SECTION 3 SDG WHO Topic-Specific Sustainable Development Goal World Health Organization Analysis 4 SDI Service Delivery Indicators SECTION 4 Additional SFA Guidance Stochastic Frontier Analysis SHI Social Health Insurance SPA Service Provision Assessment TABLE OF CONTENTS CROSS-CUTTING 2 List of Acronyms 109 OVERVIEW 1 HEALTH SYSTEM CONTEXT MODULE 1 HEALTH SYSTEM CONTEXT SECTION 1 What Is a Health PER? HEALTH FINANCING 2 SECTION 3 MODULE 2 RESOURCE MOBILIZATION Topic- SECTION 2 MODULE 3 POOLING Cross-Cutting Analysis on Efficiency and MODULE 4 BENEFITS SPECIFICATION Equity 3 Specific MODULE 5 PURCHASING HEALTH SERVICES SECTION 3 MODULE 6 PUBLIC FINANCIAL MANAGEMENT Topic-Specific Analysis INPUTS Analysis 4 MODULE 7 HUMAN RESOURCES FOR HEALTH SECTION 4 MODULE 8 PHYSICAL INFRASTRUCTURE AND EQUIPMENT Additional Guidance MODULE 9 MEDICINES AND MEDICAL SUPPLIES Section 3 offers guidance SERVICE DELIVERY to analyze each of the MODULE 10 HOSPITALS components of the analytical MODULE 11 PRIMARY CARE AND ESSENTIAL PUBLIC HEALTH FUNCTIONS framework described in the previous section. OUTCOMES MODULE 12 SERVICE COVERAGE MODULE 13 FINANCIAL RISK PROTECTION CONTINUE MODULE 14 HEALTH STATUS AND HEALTH RISKS MODULE 15 UNIVERSAL HEALTH COVERAGE LIST OF ACRONYMS OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific SECTION 3 The module in this section sets the context for Health Analysis health PER assessments. It provides information to Health System Context understand how the health system is organized and System M-1: Health System Context Health Financing funded, and explores the country’s epidemiological and Inputs socioeconomic profile. Context Service Delivery Outcomes MODULE 1 HEALTH SYSTEM CONTEXT 4 List of Acronyms SECTION 4 Additional CONTINUE Guidance TABLE OF CONTENTS MODULE 1 Health System Context 111 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific MODULE 1 Health System Analysis Health System Context Context M-1: Health System Context Health Financing Inputs Service Delivery Outcomes AUTHORS 4 List of Acronyms Christoph Kurowski, David B. Evans, Sakshi Thorat, Jacopo Gabani, Denise SECTION 4 Additional Silfverberg, and Catalina Gutiérrez Guidance START TABLE OF CONTENTS MODULE 1 Health System Context 112 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Cross-Cutting Analysis on • What are the country’s macro-fiscal trends and constraints? Efficiency and Equity • What is the state of poverty and inequality? 3 KEY QUESTIONS • What are the key demographic trends and their impact on population health? SECTION 3 Topic-Specific • How is the health system organized and governed? Analysis • How is the health system financed, and what are its key challenges? Health System Context M-1: Health System Context Health Financing A country’s socioeconomic, demographic, and Of note, authors must select the most relevant indicators for their country from the list of indicators below. Usually, a good Inputs health context influences the extent to which introductory context section should be brief: good examples Service Delivery a government mobilizes resources, manages are found in the Kenya health PER (DiGiorgio et al. 2022) and in Outcomes them, and uses them to deliver health care and the Zambia health PER (Chansa et al. 2019). Last, while the aim is 4 List of Acronyms to provide indicators that are relevant for most countries, each should ideally set the context for any health PER country has a different context, which might require assessing assessment. The questions in this module aim to indicators or breakdowns of indicators (subnational level SECTION 4 Additional help PER authors understand the context of their breakdowns) that are not necessarily listed here (for example, Guidance country to set the stage for a health PER. indicators broken down by region, by population group, or specific health indicators). TABLE OF CONTENTS MODULE 1 Health System Context 113 OVERVIEW 1 SECTION 1 What Is a Health PER? Finally, PER authors can choose which of the questions below to include a in 2 the analysis. For example, PERs that are SECTION 2 chapters in broader Public Expenditure Cross-Cutting Analysis on Review may not need to include a macro- Efficiency and fiscal context, as this will most likely be Equity 3 covered in other sections of the broader PER. PER authors who choose to use the SECTION 3 module on Resource Mobilization to dive Topic-Specific Analysis deeper into this topic may not need to include the section on overall health Health System Context spending, and so forth. M-1: Health System Context Health Financing In general, the country context chapter Inputs should remain short and concise and Service Delivery avoid duplicating information that will Outcomes be covered later in the analysis. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 1 Health System Context 114 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on MACRO-FISCAL CONTEXT, POVERTY, SHARED PROSPERITY, AND POPULATION HEALTH Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Knowledge of a country’s macro-fiscal context is important. The macro-fiscal context has direct implications for the general government budget and shared prosperity are also crucial for better informing health financing policies, due to their effects on population health. Poverty and shared prosperity (that is, income inequality) have an impact on population health (Smith 1999; Pickett and Wilkinson M-1: Health System Context and in turn affects the government budget for 2015), as poorer populations might not have access to good health care. Equal health outcomes across income groups is a widely Health Financing health and ultimately service coverage and Inputs accepted goal in many countries. population health. Service Delivery This section provides guidance on the introductory chapter of a Outcomes For example, the size of the economy (that is, GDP) will likely affect PER. It is organized into three subsections. The first covers the 4 List of Acronyms the amount of revenues the government can raise (via taxes or macroeconomic and fiscal context, while the second subsection other sources), and these will determine government expenditures discusses poverty and shared prosperity. Finally, demographic SECTION 4 and ultimately government health expenditures. Similarly, poverty and population trends are reviewed in the last section. Additional Guidance TABLE OF CONTENTS MODULE 1 Health System Context 115 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Macro-Fiscal Context Cross-Cutting Analysis on Efficiency and Equity KEY QUESTION • What is the macro-fiscal context? 3 SECTION 3 Topic-Specific Analysis Health System Context The size and outlook of the economy constrain a government’s capacity to fund public investments. Gross domestic product per capita and its growth rate, inflation, government revenues, external funding is a big source of funding for health expenditures, and therefore an overview of external funding is important (see the Module on Resource Mobilization). M-1: Health System Context the fiscal context, and the degree of indebtedness all affect government health expenditures. The subsequent key indicators General government gross debt as a percentage of GDP and the Health Financing can be shown to describe trends (for example,, across the three fiscal deficit in percent of GDP are important as well and can be Inputs past years to the near future). Comparison with other countries found in the World Bank World Development Indicators (WDI) and Service Delivery (for example, countries in the same region and/or income group) World Bank Prosperity data, respectively. Outcomes can be included. 4 List of Acronyms Finally, as medical goods are often imported in LMICs, currency The first indicators refer to the level of GDP and its growth and (de)evaluation might often impact health care costs. When a SECTION 4 consumer prices. General government revenues and expenditures currency loses value against the US dollar (or any other relevant Additional will ultimately impact the amount of government spending for currency used to import medical goods), this will affect the import Guidance health. In many low- and middle-income countries (LMICs), of goods by the government. TABLE OF CONTENTS MODULE 1 Health System Context 116 OVERVIEW 1 SECTION 1 What Is a Health PER? These indicators can be sourced from databases such as the WDI and the IMF World Economic Outlook Key Indicators Sources 2 (WEO). However, PER authors should triangulate GDP per capita (real local currency • IMF WEO SECTION 2 the data obtained from databases with official or constant US$, PPP) • MoF documents Cross-Cutting Analysis on government documents, such as the medium-term Efficiency and Rate of real GDP per capita growth • IMF WEO expenditure framework and/or budget documents. Equity 3 • MoF documents Authors should also select the most important measures based on their local context. Inflation, average consumer prices • World Bank WDI SECTION 3 • IMF WEO Topic-Specific Analysis • MoF documents Health System Context General government expenditures • IMF WEO as % of GDP • MoF documents M-1: Health System Context Health Financing Tax revenues as % of GDP* • World Bank WDI Inputs • IMF WEO Service Delivery • MoF documents Outcomes General government gross debt as • IMF WEO 4 List of Acronyms % of GDP • MoF documents Currency exchange rate with US$ • Central bank or MoF SECTION 4 Additional Guidance *For most countries, tax revenues as a percent of GDP would be enough. However, for some countries, other government non-tax revenues (for example, revenues related to natural resources) and/or social security contributions (for example, to social health insurance schemes) should be considered. Note: GDP = gross domestic product; IMF = International Monetary Fund; MoF = Ministry of Finance; PPP = purchasing power parity; WDI = World Development Indicators; WEO = World Economic Outlook. TABLE OF CONTENTS MODULE 1 Health System Context 117 OVERVIEW 1 SECTION 1 What Is a Health PER? Poverty and Shared Prosperity 2 • What is the overall level and distribution of poverty, informality, SECTION 2 KEY QUESTION Cross-Cutting and education in the country? Analysis on Efficiency and Equity 3 Understanding a country’s overall level and distribution of poverty Key Indicators Sources and level of education is crucial for providing a full assessment SECTION 3 Poverty headcount ratio at $2.15 a day (2017 • World Bank WDI of health inequalities and equity of health care spending. This Topic-Specific PPP), % of population • MoF Analysis is because people with a higher income and those with better Poverty headcount ratio at national poverty • National education usually report better health outcomes (Raghupathi and line,* % of population** institute or Health System Context Raghupathi 2020; Currie 2009). In addition, as the informal sector Gini index agency of M-1: Health System Context is difficult to tax, high levels of informality will limit income tax Primary school completion rate total (% of statistics, Health Financing revenues and access to care in countries with large contributory relevant age group)*** especially for Inputs schemes, ultimately affecting health outcomes (Yazbeck et al. Proportion of informal employment in total subnational data Service Delivery 2023; Gabani et al. 2024). A country’s gender equality rating is also employment • ILO or World important, as it provides information on the extent to which a Outcomes Labor force participation rate (% of total Bank Informal country has enacted policies to promote equal access to health care population) Economy 4 List of Acronyms across gender. PER authors can use the ILO definition of informality Unemployment, total (% of total labor force) Database or the national definition of informality (see section 7 of the ILO SECTION 4 CPIA gender equality rating (1=low to 6=high) (for informal database description). 1 employment) Additional (labor force) Guidance It is important for PER authors to analyze these indicators using *National poverty lines can be used, as they are typically used by country governments. However, for comparison across countries, international poverty lines are required. **Analysis by region or rural/urban areas. *** Analysis by female and male. comparator countries and trends over time. Note: CPIA = Country Policy and Institutional Agreement; ILO = International Labor Organization; MoF = Ministry of Finance; PPP = purchasing power parity; WDI = World Development Indicators. The World Bank Informal Economy Database data are until 2020. However, it might cover more countries than ILO data. 1 https://ilostat.ilo.org/methods/concepts-and-definitions/description-labour-force-statistics/. TABLE OF CONTENTS MODULE 1 Health System Context 118 OVERVIEW 1 SECTION 1 What Is a Health PER? Population Health and Overall Health Spending 2 SECTION 2 KEY QUESTION • What are the main demographics and health outcomes trends? Cross-Cutting Analysis on Efficiency and Equity Analyzing a country’s demographic profile for a public expenditure 3 Key Indicators Sources review helps PER authors understand the population health care needs; for example, older populations would have different needs Population size, aging distribution, and growth rate • World Bank WDI SECTION 3 • Demographic (for example, noncommunicable–diseases-related services) Fertility rate, total (births per woman) Topic-Specific Analysis Age dependency ratio (% of working age population) and health than younger populations (for example, reproductive, maternal, Life expectancy at birth, total (years) surveys neonatal, child, and adolescent health services). In addition, Health System Context Mortality rate, under 5 (per 1,000 live births) • National the demographic profile of a country has implications for the M-1: Health System Context institutes of government’s ability to raise revenues and is needed to guide Maternal mortality ratio (per 100,000 live births)* Health Financing statistics resource allocation (for example, a large young population would Overall disease burden distribution by category • WHO GHO Inputs require more government spending on education). Authors should of condition (communicable diseases, NCDs, and • Institute of Service Delivery assess fertility rates, age distribution, and age dependency ratios injuries) Health Metrics Outcomes to determine the extent to which aging is an issue in their country. and Evaluation, 4 List of Acronyms most recent Measuring a country’s progress in key health outcomes, such as GBD study** life expectancy, mortality, and morbidity patterns (using disease SECTION 4 Net migration, refugee population by country or • World Bank WDI Additional burden distributions), is also important for assessing the extent territory of asylum Guidance to which expenditure translated to outcomes. For some countries, *Maternal mortality ratio exists in both “modeled estimates” and “national estimates” formats. National estimates are usually net migration and/or the size of the refugee population would preferred to modeled estimates, if the quality and frequency of the national estimates are judged to be sufficient. The decision might be different in each country depending on the context. **At the time of writing, the most recent GBD study was for 2021. also be of interest; data on these two indicators can be found in Note: GBD = Global Burden of Disease; GHO = Global Health Observatory; NCD = noncommunicable disease; WDI = World Development Indicators; WHO = World Health Organization. the World Bank WDI. TABLE OF CONTENTS MODULE 1 Health System Context 119 OVERVIEW 1 SECTION 1 BOX 1. KENYA’S LEADING CAUSES OF DEATH What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 Both sexes, SECTION 3 Topic-Specific Age-standardized, Analysis Deaths per 100,000 Health System Context As shown in the figure, forecasted deaths M-1: Health System Context from noncommunicable diseases in Kenya Health Financing are expected to rise between 2020 and 2040, Inputs while deaths from some communicable Service Delivery diseases continue to decline. As Kenya Outcomes advances in its epidemiological transition, noncommunicable diseases are anticipated 4 List of Acronyms to become the leading causes of death. SECTION 4 These evolving trends will have significant Additional implications for health system financing and Guidance service delivery. Source: GBD Foresight Visualization Tool. Calculations based on GBD 2021 Causes of Death Collaborators. “Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: A systematic analysis for the Global Burden of Disease Study 2021.” The Lancet 403 (10440) 2024: 2100–32. https://www.sciencedirect.com/science/article/pii/S0140673624003672. TABLE OF CONTENTS MODULE 1 Health System Context 120 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Overall Level of Health Spending Cross-Cutting Analysis on Efficiency and Equity KEY QUESTION • What does the overall spending on health look like? 3 SECTION 3 Topic-Specific Analysis Health System Context Finally, it should be emphasized that in this section, PER authors could also include a brief introduction on the overall level of spending on health, as well as the sources of spending (out-of- pocket household expenditures, government sources, and/ Key Indicators Current health expenditure per capita, local currency,* real Sources • World Bank WDI or external sources). The following table includes four high- External financing as % of current health M-1: Health System Context expenditure Health Financing level aggregate spending indicators that authors could use in an introductory section. Authors should review the module Domestic general government health expenditure Inputs as % of current health expenditure on Resource Mobilizationttftt for guidance on how to assess Service Delivery aggregate health financing sources and schemes in more detail. Out-of-pocket health expenditure as % of current Outcomes health expenditure They should also be aware that current health expenditures do 4 List of Acronyms not include capital health expenditures. Therefore, in case capital *PER authors can also use US$ PPP for comparisons across countries. Note: WDI = World Development Indicators. health expenditures are important, PER authors should report SECTION 4 them using the “Capital health expenditure” indicator from the Additional Guidance World Health Organization (WHO) Global Health Expenditure Database. The indicator is available for both domestic financing and external financing. TABLE OF CONTENTS MODULE 1 Health System Context 121 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis HEALTH SYSTEMS ORGANIZATION AND FINANCING Health System Context M-1: Health System Context Health Financing Inputs Public Expenditure Reviews (PERs) typically begin PER readers, such as government officials and Service Delivery with a brief description of the health system’s other stakeholders, are already familiar with the Outcomes organization and financing to provide context health system’s functioning. 4 List of Acronyms for the analysis. While a thorough understanding Health PERs that are part of a broader public SECTION 4 of the health system is crucial for analyzing expenditure review selectively describe Additional Guidance expenditure and identifying opportunities to components of the health system usually in two improve efficiency and equity, the report itself to three paragraphs. only needs a brief introductory description. TABLE OF CONTENTS MODULE 1 Health System Context 122 OVERVIEW 1 SECTION 1 What Is a Health PER? Organization 2 SECTION 2 Cross-Cutting • How is the health system organized, and how are the responsibilities distributed Analysis on Efficiency and KEY QUESTION Equity among institutions? 3 SECTION 3 The following indicators capture the governance structure of PER authors should discuss the mix of public/private authorities Topic-Specific the health care system in a country to set the context for the and the extent to which the public system is decentralized and to Analysis main actors and their roles, the relationships between different what level. The PER can include an overview of major reforms— actors and stakeholders involved in health care, and the level of recently undertaken, ongoing, or planned—that will be important Health System Context decentralization. for the analysis. M-1: Health System Context Health Financing Inputs Key Indicators Sources Service Delivery How is the health system organized? Describe the levels at which the health systems (e.g., national, • KIIs Outcomes state, district/county) function and their respective roles and responsibilities for financing, planning, • Country reports administration, regulation, and provision of health care. 4 List of Acronyms • MoH documents Who are the main actors/institutions responsible for financing, planning, administration, regulation, and SECTION 4 provision of health care? Refer to the roles at different levels of governments. Additional Guidance Who are the main providers operating in the health financing system? Note: KII = key informant interview; MoH = Ministry of Health. TABLE OF CONTENTS MODULE 1 Health System Context 123 OVERVIEW 1 SECTION 1 What Is a Health PER? Provision 2 SECTION 2 KEY QUESTION • How is the provision of health care organized? Cross-Cutting Analysis on Efficiency and Equity 3 This section summarizes the levels at which health care is provided, the country context if they will use the modules in Service Delivery, along with the number of facilities aggregated by level, geographic as this information will be covered in those modules. However, SECTION 3 Topic-Specific area, and ownership. It also summarizes how the facilities are PERs that will rely on the cross-cutting notes for the analysis might Analysis funded (as an example, refer to Kenya’s health care provision in the benefit from including a description of how services are organized, annex). Again, PER authors can choose not to include this analysis in as this information is not described in the cross-cutting notes. Health System Context M-1: Health System Context Health Financing Key Indicators Sources Inputs What are the levels at which health care services are provided (e.g., national, state, subnational)? Describe • KIIs Service Delivery the types of services provided at each level. • Country reports Outcomes • MoH documents What is the distribution of health facilities at each level? 4 List of Acronyms What is the distribution of health facilities across geographical regions? SECTION 4 Additional What is the mix (public/private) of health facilities (if available)?2 Guidance 22 Note: KII = key informant interview; MoH = Ministry of Health. 2 If there are no data on the distribution of facilities between public and private, PER authors can ask for other types of information on the relative weight of public and private services in the country, for example, the distribu- tion of beds among public and private facilities, among others. TABLE OF CONTENTS MODULE 1 Health System Context 124 OVERVIEW 1 SECTION 1 What Is a Health PER? Financing 2 SECTION 2 KEY QUESTION • How is the health system financed? Cross-Cutting Analysis on Efficiency and Equity 3 This section overviews the sources of revenue that finance the Authors can refer to “Classification of Revenues of Financing health system, coverage, and how funds are collected. PER authors Schemes” (chapter 8 of SHA 2011) for information on financing SECTION 3 Topic-Specific can review the modules on Resource Mobilizationfffff, Poolingfffff, sources (central or local government revenue, user premiums, Analysis and Purchasingfffff for more detail. For a detailed example, refer employee/employer contributions, social contributions, external to Kenya’s “Intergovernmental Fiscal Transfers and Fund Flows” in donors, and so on). They should analyze the fund flows within Health System Context Annex 1. different levels of the health system, if helpful. PER authors should M-1: Health System Context also summarize any financing reforms—past, current, or planned— Health Financing that have impacted or will impact these fund flows. Inputs Service Delivery Key Indicators Sources Outcomes What are the different health financing schemes? Describe the type of schemes (national health system, with • Health accounts 4 List of Acronyms input-based financing; contributory or noncontributory insurance schemes; and population covered). • KIIs SECTION 4 • Country reports How is each scheme financed (that is,, revenue source) and at what administrative level are funds pooled? Additional Guidance Note: KII = key informant interview. A health financing scheme is a distinct system of rules that govern the provision and financing of health benefits. Examples include national health services, social health insurance, private health insurance, out-of-pocket payments, and donor-funded health programs. Each scheme has its own structure and rules on financing sources, beneficiaries, and resource distribution for health care services (see the Pooling module for more information). TABLE OF CONTENTS MODULE 1 Health System Context 125 OVERVIEW 1 SECTION 1 What Is a Health PER? ANNEX 2 Example 1: Kenya Health Care Provision SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 The Kenya health system is organized into four tiers based on the type of SECTION 3 health services delivered: community, primary care, county and subcounty Topic-Specific referral hospitals, and national referral hospitals. The community tier Analysis includes all community-based services per the MoH community strategy. Health System Context Primary health care includes services provided by public and private maternity homes, health centers, and dispensaries. County referral M-1: Health System Context services include first-level referral hospitals that are managed by counties, Health Financing except for the national referral hospitals, which are under the national Inputs government. All other facilities are managed by county governments. Service Delivery Outcomes Figure 1 presents the tiers in Kenya’s health system and the types of 4 List of Acronyms services delivered at each level; Figure 2 shows the distribution of health facilities by level and ownership type. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 1 Health System Context 126 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 1. Health System Organization and Services by Care Level, Kenya 2 SECTION 2 The Kenya health system is organized around four tiers of care system comprises both the public sector, including the MoH Cross-Cutting hierarchy that are based on the type of health services delivered: and parastatal organizations, and the private sector, such as Analysis on Efficiency and community, primary care, county and subcounty referral hospitals nongovernmental organizations (NGOs), private for-profit, and Equity 3 (secondary hospitals), and national referral hospitals. The health faith-based organizations (FBO) facilities. SECTION 3 County/ Topic-Specific Level of Care Type of Services Analysis National Health System Context NATIONAL REFERRAL HOSPITALS NATIONAL • Tertiary/highly specialized services, including high-level specialist M-1: Health System Context Level 6: Tertiary care hospitals medical care, reference laboratory support, blood transfusion Health Financing services, and research have a defined level of self-autonomy Inputs SECONDARY HOSPITALS COUNTY • Comprehensive inpatient diagnostic, medical, surgical, and Service Delivery Level 5: Secondary care hospitals rehabilitiative care, including reproductive health services Outcomes Level 4: Primary care hospitals • Specialized outpatient services • Hospitals managed by a county 4 List of Acronyms PRIMARY HEALTH CARE COUNTY • Disease prevention and health promotion services SECTION 4 Level 3: Health centers • Inpatient services for emergency clients awaiting referral, clients for Additional Guidance Level 2: Dispensaries and clinics observation, and normal delivery services Level 1: Community COUNTY • Community-based health services TABLE OF CONTENTS MODULE 1 Health System Context 127 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 2. Health Facility Distribution, Kenya, 2019 2 SECTION 2 LEGEND: Faith-Based Organizations Government Facilities Nongovernmental Organizations Private Facilities Cross-Cutting Analysis on Efficiency and 100% Equity 3 90% 24% SECTION 3 80% 42% 40% 42% Topic-Specific Analysis 70% Health System Context 60% 3% 3% 2% M-1: Health System Context 50% 100% Health Financing 62% Inputs 40% 48% 43% Service Delivery 30% 47% Outcomes 20% 4 List of Acronyms 10% 9% 13% 14% SECTION 4 8% Additional 0% Guidance LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 LEVEL 6 Source: Kenya Master Health Facility List (KMHFL) TABLE OF CONTENTS MODULE 1 Health System Context 128 OVERVIEW 1 SECTION 1 What Is a Health PER? Example 2: 2 FIGURE 3. POST-DEVOLUTION FUNDS FLOW FOR HEALTH IN KENYA Kenya Health SECTION 2 Cross-Cutting Systems Financing— Analysis on Efficiency and Equity 3 Intergovernmental SECTION 3 Fiscal Transfers and Funds Flow Topic-Specific Analysis Health System Context M-1: Health System Context Devolution has changed the way health care is Health Financing financed by introducing an intergovernmental Inputs fiscal transfer system that has drastically Service Delivery changed the funds flow landscape. Although this system has granted county governments Outcomes the fiscal autonomy to manage resources, the 4 List of Acronyms intergovernmental fiscal transfer system has introduced a complex flow of funds mechanism, SECTION 4 shown in Figure 3. The mechanism has created Additional Guidance several operational and administrative challenges that have led to inefficiency in Source: Mbuthia, B., I. Vîlcu, N. Ravishankar, and J. Ondera. 2019. “Purchasing at the Country Level in Kenya”. https:/./thinkwell.global/wp-content/ county health spending. uploads/2019/11/Kenya-county-purchasing-report-2019_11_01-Final.pdf. TABLE OF CONTENTS MODULE 1 Health System Context 129 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Chansa, Collins, Netsanet Workie Walelign, Moritz Otto Maria Alfons Piattifuenfkirchen, Thulani Clement Matsebula, and Katelyn Jison Yoo. 2019. Cross-Cutting Zambia—Health Sector Public Expenditure Review (English). Washington, DC: World Bank Group. http://documents.worldbank.org/curated/ Analysis on Efficiency and en/756921559624225552/Zambia-Health-Sector-Public-Expenditure-Review. Equity 3 Currie, Janet. 2009. “Healthy, Wealthy, and Wise: Socioeconomic Status, Poor Health in Childhood, and Human Capital Development.” Journal of Economic Literature 47 (1): 87–122. doi: 10.1257/jel.47.1.87. https://www.aeaweb.org/articles?id=10.1257/jel.47.1.87. SECTION 3 Topic-Specific Di Giorgio, Laura, Katelyn Jison Yoo, and Thomas Maina. 2022. Kenya Public Expenditure Review for the Health Sector FY2014/15–FY2019/20. Analysis Washington, DC: World Bank. Health System Context Gabani, J., S. Mazumdar, and M. Suhrcke. 2023. “The effect of health financing systems on health system outcomes: A cross-country panel analysis.” M-1: Health System Context Health Economics 32 (3): 574–619. March. doi: 10.1002/hec.4635. Published online December 8, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/ Health Financing PMC10107855/. Inputs Pickett, Kate E., and Richard G. Wilkinson. 2015. “Income inequality and health: A causal review.” Social Science & Medicine 128: 316-26. doi: 10.1016/j. Service Delivery socscimed.2014.12.031. Published online December 30, 2014. https://pubmed.ncbi.nlm.nih.gov/25577953/. Outcomes Raghupathi, V., and W. Raghupathi. 2020. “The influence of education on health: An empirical assessment of OECD countries for the period 1995– 4 List of Acronyms 2015.” Archives of Public Health 78 (20). https://doi.org/10.1186/s13690-020-00402-5. SECTION 4 Smith, James P. 1999. “Healthy Bodies and Thick Wallets: The Dual Relation Between Health and Economic Status.” Journal of Economic Perspectives Additional 13 (2): 144–66. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697076/pdf/nihms461647.pdf. Guidance Yazbeck, Abdo S., Agnes L. Soucat, Ajay Tandon, Cheryl Cashin, Joseph Kutzin, Julia Watson, Sarah Thomson, Son Nam Nguyen, and Tamas Evetovits. 2023. “Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance.” Social Science & Medicine, Vol. 320, March. https://www.sciencedirect.com/science/article/abs/pii/S0277953622004749?via%3Dihub. TABLE OF CONTENTS MODULE 1 Health System Context 130 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting A PER should evaluate whether resources are mobilized through an appropriate mix Analysis on Efficiency and SECTION 3 of sources, ensuring sufficient and sustainable financing to advance universal health Health Equity 3 coverage. Revenues should be pooled to minimize system fragmentation, efficiently manage health risks, promote financial protection for all, and reduce operational SECTION 3 costs. Proper benefit design and strategic purchasing should prioritize cost-effective Financing Topic-Specific services, prevent overprovision, manage cost escalation, and ensure equitable access Analysis to services across socioeconomic and geographic lines. Effective public financial management should promote transparency and timely flow of resources. The PER Health System Context can also examine whether the institutional arrangements, processes, and rules that Health Financing govern financing functions promote efficiency and equity. Inputs This section provides Service Delivery MODULE 2 RESOURCE MOBILIZATION guidance on assessing the Outcomes efficiency and equity of health MODULE 3 POOLING 4 List of Acronyms financing functions: resource SECTION 4 MODULE 4 BENEFITS SPECIFICATION Additional mobilization, pooling, benefit Guidance definition, purchasing, and MODULE 5 PURCHASING HEALTH SERVICES public financial management. MODULE 6 PUBLIC FINANCIAL MANAGEMENT CONTINUE TABLE OF CONTENTS OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific MODULE 2 Resource Analysis Health System Context Mobilization Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services AUTHORS M-6: Public Financial Management Inputs Jacopo Gabani, David Evans, Service Delivery Martin Schmidt, and Denise Silfverberg Outcomes 4 List of Acronyms START SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 132 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Cross-Cutting This module is designed to facilitate the analysis transfers part of those revenues from the general revenues pool Analysis on to a government health ministry, department, or agency (MDA). Efficiency and Equity of resource mobilization for health in the context 3 The second most common way used by governments to collect of a Public Expenditure Review (PER). Resource health revenues is via compulsory contributions to a public health SECTION 3 mobilization1 refers to the mobilization of insurance scheme (that is,, health-specific contributions), which Topic-Specific are also usually specified in law. Current health expenditure also Analysis financial resources by countries to develop and encompasses other sources of funding that are not part of domestic operate their health systems. Contributions government revenues: households’ out-of-pocket (OOP) payments, Health System Context typically come from individuals, households, and households’ and firms’ contributions to voluntary private health Health Financing firms, in the form of tax payments or through insurance, and development assistance for health (DAH).2 M-2: Resource Mobilization M-3: Pooling health-specific contributions. Understanding how resources are being mobilized for health is M-4: Benefits Specification crucial for assessing how a country can achieve intended health M-5: Purchasing Health Services Taxation is the most common system used to collect government system outcomes and accelerate progress toward universal M-6: Public Financial Management revenues. General revenues collected via taxes specified in law (for health coverage, as well as equity. Resource mobilization that Inputs example, direct tax on income or indirect tax on goods and services) efficiently generates sufficient and sustainable funding is central Service Delivery then become revenues for health when the central government to transformative health financing. Outcomes 4 List of Acronyms 1 Also called “raising revenues.” 2 For DAH, the report will detail later the difference between “on-budget DAH,” that is,, transfers from foreign origin distributed by government, which are part of general (not domestic) government health expenditures, and SECTION 4 “off-budget DAH.” Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 133 OVERVIEW 1 The literature on resource mobilization is vast. Resource mobilization SECTION 1 What Is a from compulsory sources and pooled by governments is crucial for Health PER? delivering on the promise of UHC. However, the reality is that out-of- 2 pocket expenditure remains high in several countries. In general, there SECTION 2 is an expansive literature on the effects of public health expenditures on Cross-Cutting Analysis on health (Nakamura et al. 2016). It has also recently focused on the effect Efficiency and of social health insurance and noncontributory schemes (Yazbeck et al. Equity 3 2020; Yazbeck et al. 2023; Gabani et al. 2023; Wagstaff et al. 2009). On the topic of government resources, there is a substantive literature on fiscal SECTION 3 space for health (Tandon 2010). DAH effectiveness and trends have also Topic-Specific Analysis received substantive attention (IHME 2024). Finally, the literature has assessed the effect of global shocks (for example, the COVID-19 pandemic, Health System Context and conflicts) on the ability of governments to mobilize resources for Health Financing health (Kurowski et al. 2022; Kurowski et al. 2023). M-2: Resource Mobilization M-3: Pooling The subsequent key questions aid the understanding of resource M-4: Benefits Specification mobilization in countries. The first section of this module informs PER M-5: Purchasing Health Services authors about the levels of health spending. The second section facilitates M-6: Public Financial Management introductory analyses of the mix of revenue sources. Finally, efficiency in Inputs mobilizing revenues is reviewed. The module concludes with a reflection Service Delivery on assessing the equity of resource mobilization. If significant issues (for example, inefficiency or inadequacy of public resources) related to Outcomes resource mobilization surface following the assessment described in this 4 List of Acronyms module, Authors should refer to the “Domestic Resource Mobilization for Increased Health Sector Fiscal Space Guidance Note” (Eozenou 2021) SECTION 4 for a deep dive into the topic. Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 134 OVERVIEW 1 SECTION 1 What Is a Health PER? ANALYSIS OF SPENDING LEVELS AND MIX OF REVENUE SOURCES 2 Analysis of the levels of spending on health SECTION 2 Cross-Cutting Analysis on Efficiency and Equity • What is the level of spending on health? 3 KEY QUESTIONS • What is the level of government health spending in the country? SECTION 3 Topic-Specific Analysis As a first step, PER authors should check the levels of spending on health from Health System Context Key indicators Sources any sources via current health expenditure per capita and as a share of GDP. Health Financing Current health • National M-2: Resource Mobilization Comparisons can be made across other countries and over time. It is important to expenditure Health M-3: Pooling note that capital expenditures are not included in current health expenditure: in per capita* Accounts M-4: Benefits Specification countries where capital expenditure is particularly important, PER authors might • WHO GHED M-5: Purchasing Health Services Current health M-6: Public Financial Management want to analyze that as well. expenditure • World Bank Inputs as a share of WDI Service Delivery To begin assessing public health expenditures, PER authors can use government health expenditures GDP Outcomes including on-budget donor spending, that is, as noted below, FS1+FS2+FS3 in WHO GHED and NHA. Note: GDP = gross domestic product; WHO GHED = World It should be noted that the indicator “compulsory financing agreements” will also be equivalent to 4 Health Organization Global Health Expenditure Database; List of Acronyms WDI = World Development Indicators. *Authors should government health spending in the vast majority of low- and middle-income countries.3 In addition, choose the most appropriate currency, usually the local currency in real terms. However, purchasing power parity (PPP) constant US$ can be used in certain cases, SECTION 4 for example, if the local currency is not used by the government, or in the country, due to hyperinflation. Additional 3 The only difference is that compulsory financing agreements would also include compulsory private health insurance, which is a very rare occurrence in low- and middle-income countries. Guidance FRONT MATTER MODULE 2 Resource Mobilization 135 OVERVIEW 1 SECTION 1 What Is a Health PER? to assess whether a country’s per capita health spending level is adequate, PER authors can compare current health expenditure per capita with suggested benchmarks—for example, Stenberg et al. Low levels of government health spending is often a reason for slow progress toward UHC and can also be a key driver of inequity and inefficiencies. When government health spending is 2 2017, country-specific cost estimates for universal health coverage relatively low, it is likely to be accompanied by high OOP spending, SECTION 2 Cross-Cutting (UHC), and peer countries (see also Annex 1 for further analyses which raises concerns about the efficiency and equity of current Analysis on on sufficiency of funding). Studying the time trend shows whether health expenditure. In addition, low levels of government health Efficiency and Equity spending levels are increasing or decreasing. A look at the current expenditure might be accompanied by higher levels of development 3 health expenditure share of GDP over time reveals whether health assistance for health (DAH) from several donors, which might not SECTION 3 spending growth is keeping up, falling behind, or overtaking GDP be well coordinated, and ultimately raise further concerns about Topic-Specific growth. A constant share indicates equal growth, a decreasing share efficiency as well as substantive efforts to coordinate and align DAH Analysis points to lower growth, and an increasing share signals faster growth. with country health sector policies. Health System Context Health Financing Key Indicators Sources M-2: Resource Mobilization General government health expenditure per capita (FS1+FS2+FS3) per capita* • National health accounts M-3: Pooling • Government (e.g., MoF) documents M-4: Benefits Specification • WHO GHED M-5: Purchasing Health Services Domestic general government health expenditure per capita* • National Health Accounts M-6: Public Financial Management Domestic general government health expenditure (% of general government • WHO GHED Inputs expenditure) Service Delivery • World Bank WDI Domestic general government health expenditure (% of current health Outcomes • Government budgets and spending reports (for more expenditure) recent data, unaudited figures may be available) 4 List of Acronyms Note: GDP = gross domestic product; MoF = Ministry of Finance; WDI = World Development Indicators; WHO GHED = World Health Organization Global Health Expenditure Database. The first indicator, general government health expenditure, includes on-budget external financing. However, the second indicator (domestic general government health expenditure (GGHE-D)) does not include on-budget external financing. The codes FS1, FS2, and FS3 in SECTION 4 parentheses refer to the WHO GHED codes, which are sourced from the 2011 System of Health Accounts. *PER authors should choose the most appropriate currency. Usually, that would be the local currency in real terms. However, purchasing power parity (PPP) constant US$ can be used in certain cases, for example, if the local Additional currency is not used by the government, or in the country, due to hyperinflation. PER authors might refer to the module on Public Financial Management for guidance on collecting government budget data. Guidance FRONT MATTER MODULE 2 Resource Mobilization 136 OVERVIEW 1 SECTION 1 What Is a Health PER? KEY QUESTION • How can fiscal policies contribute to decreased unhealthy behaviors, and Key Indicators Health tax revenues as % of total Sources • Government 2 government revenues documents increasing public resources available SECTION 2 Excise tax rates for: Alcohol; Tobacco; • Government Cross-Cutting for health? Sugar-sweetened beverages documents Analysis on Efficiency and Equity 3 When PER authors begin to evaluate general government health should generally be cause for concern, as it would suggest that expenditure, they can compare levels with government policy targets, government health expenditure is not keeping pace with population SECTION 3 Topic-Specific and peer countries from the same region, income groups, or other growth. In addition, PER authors would want to explore the trend of Analysis classification (for example, fragile and conflict-affected countries, government health expenditure per capita in real or constant terms, small island states, and others). Common, aspirational benchmarks that is, accounting for inflation (preferably, and if available, health Health System Context (for example, 15 percent of general government expenditure (Abuja care services inflation). Decreasing shares of government health Health Financing Declaration 2001),4 5 percent of GDP (WHO 2010)) could also be used, if expenditure in general government expenditure or GDP also merit M-2: Resource Mobilization authors deem them relevant for the country context. A comparatively further exploration. Authors may conduct a quick exercise to assess M-3: Pooling low share of domestic and/or general government health expenditure the relationship between government financing for health and GDP M-4: Benefits Specification as a percentage of GDP might be due to a low priority of health within to unpack the potential for increased government financing.6 The M-5: Purchasing Health Services general government expenditure5 or a limited ability and willingness analysis is linked to questions on sufficiency (that is, comparing M-6: Public Financial Management of the government to raise revenues (see Annex 1 questions related resource needs to resources available) and sustainability. Also of Inputs to the capacity of government to raise revenues). As government note, the Kenya 2022 (Di Giorgio et al. 2022) and the Zambia 2019 Service Delivery health spending levels in developing countries are typically low, (Chansa et al. 2019) health PERs are good examples of how to analyze Outcomes a downward trend of per capita government health expenditure government financing trends. 4 List of Acronyms 4 The Abuja Declaration is a pledge made by African Union (AU) member states in April 2001 to allocate at least 15 percent of their annual budgets to health care. 5 For clarity, general government expenditure includes on-budget development assistance. However, domestic general government health expenditure does not include on-budget development assistance for health. PER authors SECTION 4 might want to then calculate government health expenditure as a share of general government expenditure to ensure that on-budget donor funding is included in the numerator and the denominator of the share. Additional 6 See the “Domestic Resource Mobilization for Increased Health Sector Fiscal Space and Universal Health Coverage: A Health Financing System Assessment ‘Drill-Down’ Guidance Note” (Eozenou 2021) for an example of this. Guidance FRONT MATTER MODULE 2 Resource Mobilization 137 OVERVIEW 1 SECTION 1 What Is a Health PER? The indicators can be used to compare a country’s excise tax rates of health taxes with peer countries, and with WHO recommended analyze tobacco revenues.7 Health ‘taxes’ primary objective is to disincentivize unhealthy behaviors; they do not necessarily 2 levels of tax for each specific product (for example, WHO increase health revenues. For example, revenues from health taxes SECTION 2 recommends tobacco tax to be at least 75 percent of the retail might simply be pooled together with total general government Cross-Cutting Analysis on price of tobacco (WHO 2024)). This is particularly relevant for revenues, and therefore health revenues would grow only to the Efficiency and Equity countries where no such taxes exist or where the levels of taxation extent that health revenues grow the “pie” general revenues. In 3 are relatively low. In this context, PER authors may discuss the case health taxes are earmarked to the health sector, Ministries of opportunities and political environment to introduce or increase Finance might decrease the allocation to health by an equivalent SECTION 3 Topic-Specific sin taxes (tobacco, alcohol, sugar-sweetened beverages) that or similar amount: in this case, incremental health revenues from Analysis are generally earmarked to finance public health. Authors may health taxes might be very limited, if any. Finally, authors should consider conducting health tax simulations to assess the potential also consider that subsidies are another type of fiscal that might Health System Context for raising additional revenue in the country in collaboration with impact health negatively, for example, subsidies to fossil fuels. In Health Financing the Country Economist and other relevant colleagues. Authors this case, authors might consider how to decrease those subsidies M-2: Resource Mobilization must refer to the colleagues in the Macroeconomics, Trade and to limit their negative effect on health, and potentially how those M-3: Pooling Investment (MTI) Practice at the World Bank, including the Country resources could be redirected toward the health sector. M-4: Benefits Specification Economist. PER authors could also refer to the MTI toolkit to M-5: Purchasing Health Services M-6: Public Financial Management Inputs 7 https://www.worldbank.org/en/topic/nutrition/brief/health-taxes. Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 138 OVERVIEW 1 SECTION 1 What Is a Health PER? Mix of revenue sources 2 • What are the sources of financing for health? SECTION 2 KEY QUESTIONS Cross-Cutting • What proportion of financing for health is through public sources? Analysis on Efficiency and • What proportion of DAH is off budget? Equity 3 SECTION 3 The sources of financing for health Key indicators Sources Topic-Specific provide critical insight into how Analysis efficiently and equitably health is Health revenues, by health care financing scheme, % of current • National Health Accounts financed in the country. The level health expenditure: • Government budgets and Health System Context of government health expenditure • Domestic general government health expenditure (FS1+FS3), reports (for more recent Health Financing is critical for financial protection formed by: data, unaudited figures M-2: Resource Mobilization in health. It is also a prerequisite 1. Budget transfers from government domestic revenues (FS1) may be available) M-3: Pooling 2. Contributions to social health insurance (FS3) • Household surveys for sufficient bargaining power of M-4: Benefits Specification • Voluntary prepayment (i.e., voluntary private insurance • WHO GHED purchasers vis-à-vis providers and M-5: Purchasing Health Services premiums) (FS5) • Health Resource Tracking thereby impacts input and output M-6: Public Financial Management • Household out-of-pocket payments (FS6.1) exercises for the health prices in the health system. Inputs • Development assistance for health (DAH) (financial or in kind) sector (e.g., Resource Service Delivery (FS2 plus FS7). Note: DAH on-budget is FS2, DAH off-budget is FS7 Mapping) Outcomes Note: WHO GHED = World Health Organization Global Health Expenditure Database. 4 List of Acronyms The codes provided beside each indicator are the System of Health Accounts 2011 (Organisation for Economic Co-operation and Development, Eurostat, and World Health Organization 2011) codes for the revenues module that are used in the WHO GHED. PER authors interested in contributions to compulsory prepayments other than social health insurance (i.e., compulsory private health insurance schemes) can find these under FS.4 in the WHO GHED. For DAH, FS2 indicates on-budget DAH. PER authors should assess trends of DAH on budget (FS2), DAH off budget (FS7), as well as total DAH (see the following paragraph). SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 139 OVERVIEW 1 SECTION 1 What Is a Health PER? Using the preceding indicators, PER authors should analyze the trend in recent years for the country using government data, and contributions is HF 1.2.1 in the WHO GHED and National Health Accounts, which shows the expenditure channeled via SHI 2 then benchmark across similar, comparator, countries using World schemes, regardless of whether the sources are contributions SECTION 2 Bank WDI and/or WHO GHED. Trends can point to potential drivers or budget transfers. Similarly, HF 1.1 will show the expenditure of Cross-Cutting of changes in government health expenditures (for example, non-contributory schemes, thereby excluding the budget transfers Analysis on Efficiency and changes in DAH). The extent health expenditures are funded toward SHI usually used to fund non-contributory schemes. Finally, Equity 3 through prepaid and pooled government mechanisms (that is, PER authors should examine government health expenditure both general government health expenditure) is crucial for discussing including on-budget DAH and excluding on-budget DAH to assess SECTION 3 financial protection and barriers to accessing health services (see potential effects of on-budget DAH on domestic government Topic-Specific Analysis the module on Financial Risk Protection ). The level of revenues revenues for health. Again, the Kenya 2022 (Di Giorgio et al. 2022) from OOP health expenditure is important. A 20 percent share of and the Zambia 2019 (Chansa et al. 2019) health PERs are good Health System Context OOP payments is often used as a first benchmark (empirically, an and recent examples of how to analyze financing trends across Health Financing OOP share greater than 20 percent is associated with significant different sources. M-2: Resource Mobilization inequities, for example, a much higher incidence of impoverishing M-3: Pooling and catastrophic payments). External financing (donor financing) can be on budget (delivered M-4: Benefits Specification via the recipient government financial management systems, M-5: Purchasing Health Services In case there are different schemes of a substantial size (relative noted as FS2 in the WHO GHED and NHA) or off budget (delivered M-6: Public Financial Management to current health expenditure), such as a noncontributory scheme via nongovernmental organizations (NGOs), private health care Inputs and a contributory (SHI) scheme, PER authors could consider their providers, or similar organizations, noted as FS7 in the WHO GHED trends both together and separately. It should be noted that SHI and NHA). PER authors can start by analyzing the extent DAH is Service Delivery expenditure is often financed by both compulsory contributions contributing to current health expenditure. (This information was Outcomes and budget transfers from government revenues: the sources of provided in the previous section (DAH revenues as a percentage 4 List of Acronyms funding for each scheme is certainly policy-relevant information of current health expenditure) and is noted again here for that authors could uncover. A further indicator that they might completeness.) SECTION 4 consider when SHI is funded by budget transfers and mandatory Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 140 OVERVIEW 1 SECTION 1 What Is a Health PER? In some countries, usually low-income countries, a significant proportion of external financing is not channeled through the government’s budget processes, which can lead to inefficiencies when off-budget DAH-funded efforts are fragmented. Key indicators Share of Sources 2 • Health Resource Tracking Fragmentation of financing sources, including DAH, might result in large coordination off-budget DAH exercise for the health SECTION 2 Cross-Cutting costs and ultimately a possible loss of efficiency (Gabani et al. 2024, Martinez Alvarez in total DAH sector (e.g., Resource Analysis on and Acharya 2012). Mapping) Efficiency and Equity • Government 3 PER authors should analyze trends in recent years and benchmark across similar documentation/reports SECTION 3 countries. If authors find an upward trend in and/or an excessive share of off-budget • National Health Accounts Topic-Specific external financing, some of the following questions may be addressed through key • WHO GHED Analysis informant interviews: Note: WHO GHED = World Health Organization Global Health Expenditure Database. Health System Context If using the WHO GHED, this indicator is not readily available and needs to be • Are the health services financed through off-budget external financing aligned calculated by PER authors. Authors need to identify “transfers distributed by Health Financing government from foreign sources” (code FS2), which represents on-budget with the country’s health sector priorities? Are they coordinated with the external financing. Therefore, “transfers distributed by government from foreign M-2: Resource Mobilization sources” divided by total external financing (FS2 + FS7) provides the percentage government health system (for example, they might create competition for of external financing that is on budget. The percentage of external financing that M-3: Pooling is off budget can finally be calculated as 100 percent minus the percentage of scarce human resources, not be well integrated into care pathways, and/or external financing that is on budget. M-4: Benefits Specification focus on vertical programs)? M-5: Purchasing Health Services M-6: Public Financial Management • What are the main reasons for donors not using government systems? How can Inputs DAH (on and off budget) be tracked appropriately to enable coordination with government plans, and accountability of DAH financiers and implementers? Service Delivery Outcomes In this section, PER authors may also want to describe the donor financing landscape 4 List of Acronyms and highlight such issues as the concentration of external funding on specific diseases, and assess sustainability of DAH, for example,, how GHE can be increased SECTION 4 to finance DAH-supported areas in a volatile donor context. Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 141 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY OF RESOURCE MOBILIZATION 2 SECTION 2 Cross-Cutting • What is the level of revenue that is not collected due to evasion of taxes or Analysis on Efficiency and KEY QUESTION Equity mandatory contributions? 3 SECTION 3 Topic-Specific Analysis Health System Context As outlined in the introduction, taxation, defined by law (that is, direct tax, indirect tax, Revenue collection systems, particularly in low-income countries and lower-middle-income countries, are often inefficient, as they do not collect nearly the full amount that would be expected from the taxes and so on), is the most prevalent method for and charges (including social contributions, such as obligatory health Health Financing collecting government revenues. These general insurance) that are specified in law. For example, in some countries, the M-2: Resource Mobilization informal sector might not pay all the mandatory contributions required M-3: Pooling revenues become health revenues when the by law which would ultimately finance contributory health insurance M-4: Benefits Specification central government transfers a portion to a schemes (Yazbeck et al. 2020, Yazbeck et al. 2023, Gabani et al. 2023). M-5: Purchasing Health Services government health ministry, department, or M-6: Public Financial Management agency (MDA). Another common method for As with tax collection, evasion and other forms of inefficiency are Inputs also common when mandatory social or public health insurance Service Delivery governments to collect health revenues is contributions are collected (McGillivray 2001; Yazbeck et al. 2020). Where Outcomes through mandatory contributions to a public SHI contributions are collected separately from tax contributions, PER 4 List of Acronyms health insurance scheme, which are also often authors may be interested in understanding the extent the revenues expected from the mandated contributions are collected. legally mandated. SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 142 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors could also make their own estimates to assess the amount of taxes or mandatory contributions Key indicators Sources 2 not raised, for example, estimate the amount of income Estimated tax evaded (% of collected taxes) • Government estimates SECTION 2 tax to be paid per informal sector employee, and Cross-Cutting Analysis on multiply by informal sector employees. Authors should Efficiency and People or households not contributing to • Government estimates Equity refer to the Country Economists who usually conduct 3 health insurance scheme (% of total people these types of analyses. or households mandated to contribute) SECTION 3 Topic-Specific General government revenue (or tax revenue) as a share Tax revenues as % of GDP • Government estimates Analysis of GDP compared with countries with similar levels of • World Bank WDI GDP per capita could be used as a rough indicator of the Health System Context capacity and efficiency of revenue raising. This indicator Estimated unpaid mandatory health • Government estimates Health Financing needs to be interpreted cautiously, as it might reflect insurance contributions (% of total collected M-2: Resource Mobilization other factors (for example, the available tax base). contributions) M-3: Pooling Note: PER authors should consider that one or more of these indicators might not be relevant for their context. For example, “People or households not contributing to health insurance scheme (% of total people or households mandated to contribute)” M-4: Benefits Specification would not be relevant for a country without a health insurance scheme that mandates health insurance contributions. M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 143 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY 2 SECTION 2 PER authors might be interested in assessing the equity for existing financing incidence analyses that could be discussed Cross-Cutting as part of a PER (see, for example, Zambia—Health Sector Public Analysis on of health revenues. This can be done via a financing Efficiency and Expenditure Review (Chansa et al. 2019)). Of note, a financing Equity incidence analysis. The objective of a financing 3 incidence analysis is often accompanied by a benefit incidence incidence is to ascertain whether health care resources analysis, because equity in service delivery (assessed by a benefit SECTION 3 incidence analysis) and equity in resource mobilization (assessed are collected equitably. Topic-Specific by a financing incidence analysis) are two aspects of the same Analysis thing. Households pay taxes, and in exchange they receive health Usually, health revenues collection is considered equitable when Health System Context care benefits (when needed). When richer households contribute it is either proportional to household incomes (so that richer more taxes than poorer households, and poorer households Health Financing households contribute more than poorer households in absolute receive more health care benefits than richer households, the M-2: Resource Mobilization terms) or progressive, that is, a richer household’s contribution public health care sector could be redistributing resources M-3: Pooling to health revenues is more than proportional to the household toward poorer households and decreasing income inequality. M-4: Benefits Specification income. While equity can be defined in several ways, PER authors PER authors interested in assessing the income inequality effect M-5: Purchasing Health Services can define equity in health financing as the situation in which of the public health care system can also do so through a fiscal M-6: Public Financial Management households contribute to health revenues (at least) according to incidence analysis, which merges benefit and financing incidence Inputs their ability to pay (Ataguba et al. 2018). analyses (Gabani et al. 2024). For a better understanding of these Service Delivery assessments, authors can refer to World Bank publications on this Outcomes PER authors can run their own financing incidence analysis if the topic: (O’Donnell et al. 2008 for benefit and financing incidence necessary household survey data are available; guides on how to 4 List of Acronyms analysis, and Inchauste and Lustig 2017 for fiscal incidence run a financing incidence analyses are available (O’Donnell et al. analysis). SECTION 4 2008, Ataguba et al. 2014). Authors are also encouraged to look Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 144 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Ataguba, John E., Augustine D. Asante, Supon Limwattananon, and Virginia Wiseman. 2018 “How to do (or not to do) … a health financing incidence Cross-Cutting analysis.” Health Policy and Planning, Vol. 33, Issue 3: 436-44. April. https://doi.org/10.1093/heapol/czx188. Analysis on Efficiency and Equity Chansa, Collins, Netsanet Walelign Workie, Moritz Otto Maria Alfons Piattifuenfkirchen, Thulani Clement Matsebula, and Katelyn Jison Yoo. 2019. 3 Zambia—Health Sector Public Expenditure Review (English). Washington, DC: World Bank Group. http://documents.worldbank.org/curated/ en/756921559624225552/Zambia-Health-Sector-Public-Expenditure-Review. SECTION 3 Topic-Specific Di Giorgio, Laura, Katelyn Jison Yoo, and Thomas Maina. 2022. Staying Ahead of the Curve: Challenges and Opportunities for Future Spending on Analysis Health in Kenya, Kenya Public Expenditure Review for the Health Sector. Washington, DC: World Bank Group. https://documents1.worldbank.org/ Health System Context curated/en/099150006242224188/pdf/P175146046aa000170926707583dac4738d.pdf. Health Financing Eozenou, Patrick Hoang-Vu, Ajay Tandon, and Jewelwayne Salcedo Cain. 2021. Domestic Resource Mobilization for Increased Health Sector Fiscal M-2: Resource Mobilization Space and Universal Health Coverage: A Health Financing System Assessment “Drill-Down” Guidance Note (English). Washington, DC: World Bank M-3: Pooling Group. http://documents.worldbank.org/curated/en/776161637038610846/Domestic-Resource-Mobilization-for-Increased-Health-Sector-Fiscal- M-4: Benefits Specification Space-and-Universal-Health-Coverage-A-Health-Financing-System-Assessment-Drill-Down-Guidance-Note. M-5: Purchasing Health Services Gabani, Jacopo, Marc Suhrcke, Sven Neelsen, Patrick Hoang-Vu Eozenou, and Marc-Francois Smitz. 2024. “Does health aid matter to financial M-6: Public Financial Management risk protection? A regression analysis across 159 household surveys, 2000–2016.” Social Science & Medicine, Vol. 356. https://doi.org/10.1016/j. Inputs socscimed.2024.117148. Service Delivery Gabani, Jacopo, Sumit Mazumdar, Sylvester Bob Hadji, and Michael Matthew Amara. 2024. “The Redistributive Effect of the Public Health System: Outcomes The Case of Sierra Leone.” Health Policy and Planning, Vol. 39, Issue 1: 4–21. https://doi.org/10.1093/heapol/czad100. 4 List of Acronyms Gabani, Jacopo, Sumit Mazumdar, and Marc Suhrcke. 2023. “The effect of health financing systems on health system outcomes: A cross-country SECTION 4 panel analysis.” Health Economics, Vol. 32, Issue 3: 574–619. https://doi.org/10.1002/hec.4635. Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 145 OVERVIEW 1 SECTION 1 What Is a Health PER? Gaspar, Victor, Laura Jaramillo, and Philippe Wingender. 2016. “Tax Capacity and Growth: Is There a Tipping Point?” Working Paper 16/234. International Monetary Fund, Washington, DC. 2 Institute for Health Metrics and Evaluation (IHME). 2024. Financing Global Health 2023: The Future of Health Financing in the Post-Pandemic Era. SECTION 2 Seattle, WA: IHME. https://www.healthdata.org/sites/default/files/2024-05/FGH_2023_Accessible_Digital_Version_with_Translations_2024.05.13.pdf. Cross-Cutting Analysis on Inchauste, Gabriela, and Nora Lustig, eds. 2017. The Distributional Impact of Taxes and Transfers: Evidence from Eight Low- and Middle-Income Efficiency and Equity Countries. Directions in Development series. Washington, DC: World Bank. License: Creative Commons Attribution CC BY 3.0 IGO. doi:10.1596/978- 3 1-4648-1091-6. https://documents1.worldbank.org/curated/en/947831504161332955/pdf/119229-PUB-PUBLIC-pubdate-8-24-17.pdf. SECTION 3 Kaldor, Nicholas. 1963. “Will Underdeveloped Countries Learn to Tax?” Foreign Affairs, January 1, 1963. https://www.foreignaffairs.com/articles/ Topic-Specific Analysis asia/1963-01-01/will-underdeveloped-countries-learn-tax. Kurowski, Christoph, David B. Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Martin Schmidt, Alec Irwin, Jewelwayne Salcedo Cain, Eko Setyo Health System Context Pambudi, and Iryna Postolovska. 2022. “From Double Shock to Double Recovery—Implications and Options for Health Financing in the Time of Health Financing COVID-19, Technical Update 2: Old Scars, New Wounds.” Discussion Paper, Double Shock, Double Recovery series, World Bank, Washington, DC. M-2: Resource Mobilization https://openknowledge.worldbank.org/server/api/core/bitstreams/76d5786b-9501-5235-922a-caa71f99f0fc/content. M-3: Pooling Kurowski, Christoph, Anurag Kumar, Julio Cesar Mieses, Martin Schmidt, and Denise Valerie Silfverberg. 2023. “Health Financing in a Time of Global M-4: Benefits Specification Shocks: Strong Advance, Early Retreat.” Discussion Paper, Double Shock, Double Recovery series, World Bank, Washington, DC. http://hdl.handle. M-5: Purchasing Health Services net/10986/39864 License: CC BY-NC 3.0 IGO. M-6: Public Financial Management Inputs Martínez Álvarez, Melisa, and Arnab Acharya. 2012. “Aid Effectiveness in the Health Sector.” Working Paper No. 2012/69, United Nations University— Service Delivery Wider, Helsinki Outcomes McGillivray, Warren. 2022. “Contribution Evasion: Implications for Social Security Pension Schemes.” International Social Security Review, Vol. 54, 4 List of Acronyms No. 4: 3–22. https://doi.org/10.1111/1468-246X.t01-1-00102. O’Donnell, Owen, Eddy van Doorslaer, Adam Wagstaff, and Magnus Lindelow. 2008. Analyzing Health Equity Using Household Survey Data: A Guide SECTION 4 Additional to Techniques and Their Implementation. Washington, DC: World Bank. http://hdl.handle.net/10986/6896. Guidance FRONT MATTER MODULE 2 Resource Mobilization 146 OVERVIEW 1 SECTION 1 What Is a Health PER? Organisation for Economic Co-operation and Development, Eurostat, and World Health Organization. 2017. A System of Health Accounts 2011: Revised Edition. Paris: OECD Publishing. https://doi.org/10.1787/9789264270985-en. 2 Stenberg, Karin, Odd Hanssen, Tessa Tan-Torres Edejer, Melanie Bertram, Callum Brindley, Andreia Meshreky, et al. 2017. “Financing Transformative SECTION 2 Health Systems Towards Achievement of the Health Sustainable Development Goals: A Model for Projected Resource Needs in 67 Low-Income Cross-Cutting and Middle-Income Countries.” The Lancet, Vol. 5, Issue 9: e875–87. https://www.thelancet.com/action/showPdf?pii=S2214-109X%2817%2930263-2. Analysis on Efficiency and Equity Tandon, Ajay, and Cheryl Cashin. 2010. “Assessing Public Expenditure on Health from a Fiscal Space Perspective.” Discussion Paper, Health, 3 Nutrition, and Population, World Bank Group, Washington, DC. http://documents.worldbank.org/curated/en/333671468330890417/Assessing- public-expenditure-on-health-from-a-fiscal-space-perspective. SECTION 3 Topic-Specific Analysis Wagstaff, Adam, and Rodrigo Moreno-Serra. 2009. “Europe and central Asia’s great post-communist social health insurance experiment: Aggregate impacts on health sector outcomes.” Journal of Health Economics, Vol. 28, Issue 2: 322–40. https://doi.org/10.1016/j.jhealeco.2008.10.011. Health System Context World Health Organization. 2010. Health Systems Financing—The Path to Universal Coverage. Geneva: World Health Organization. https://iris.who. Health Financing int/bitstream/handle/10665/44371/9789241564021_eng.pdf?sequence=1. M-2: Resource Mobilization World Health Organization. 2024. “Promoting taxation on tobacco products,” accessed September 1, 2024. https://www.who.int/europe/activities/ M-3: Pooling promoting-taxation-on-tobacco-products. M-4: Benefits Specification M-5: Purchasing Health Services Yazbeck, A.S., W.D. Savedoff, W.C. Hsiao, J. Kutzin, A. Soucat, A. Tandon, A. Wagstaff, and W. Chi-Man Yip. 2020. “The Case Against Labor-Tax-Financed M-6: Public Financial Management Social Health Insurance for Low- and Low-Middle-Income Countries.” Health Affairs (Millwood), 39 (5): 892–97. doi: 10.1377/hlthaff.2019.00874. https:// Inputs pubmed.ncbi.nlm.nih.gov/32364862/. Service Delivery Yazbeck, A.S., A.L. Soucat, A. Tandon, C. Cashin, J. Kutzin, J. Watson, S. Thomson, S.N. Nguyen, and T. Evetovits. 2023. “Addiction to a Bad Idea, Outcomes Especially in Low- and Middle-Income Countries: Contributory Health Insurance.” Social Science & Medicine, Vol. 320: 115–168. doi: 10.1016/j. 4 List of Acronyms socscimed.2022.115168. https://pubmed.ncbi.nlm.nih.gov/36822716/. SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 147 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 ANNEX 1. HEALTH SPENDING SUFFICIENCY Topic-Specific Analysis AND SUSTAINABILITY Comparing Resources to Health Needs Health System Context Health Financing M-2: Resource Mobilization M-3: Pooling • How does health spending compare to health spending required to attain policy objectives? KEY QUESTIONS M-4: Benefits Specification • How does the revenue capacity compare to the health spending needs of the population? M-5: Purchasing Health Services M-6: Public Financial Management Inputs To assess whether health spending For developing countries, the spending needs to achieve health objectives are equated Service Delivery to what is required for the country to achieve the aspirational SDG 3 targets (see, for Outcomes (overall and government) is adequate, example, Stenberg et al. 2017). However, developing countries typically also have PER authors should compare the 4 List of Acronyms specific national health goals that are achievable in the short term with more modest spending levels to the spending needs to spending levels. For high-income countries, spending needs generally equal the SECTION 4 spending levels required to achieve national health goals. Additional achieve health objectives in the country. Guidance FRONT MATTER MODULE 2 Resource Mobilization 148 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors can estimate the gap between current actual government spending per capita and Key indicators Sources 2 government spending per capita needs to achieve Estimated spending necessary to achieve • Health sector plans SECTION 2 government health objectives. If government health SDG3 targets per capita (for LICs, LMICS, • Costing exercises Cross-Cutting Analysis on spending needs are not specified, authors can produce UMICs), and gap versus estimated available Efficiency and an estimate using benchmarks for government resources Equity 3 expenditures (see Stenberg et al. 2019). PER authors can Estimated spending necessary to achieve • Health sector plans conduct a deeper analysis of the adequacy of health SECTION 3 short-term or national health goals per capita • Costing exercises spending on health is needed, authors can consult Topic-Specific (for LICs, LMICS, UMICs, HICs), and gap versus Analysis the report on the Health Financing Sustainability and estimated available resources Resilience Assessment (HFSRA) framework (World Health System Context Bank 2024). Note: HIC = high-income country; LIC = low-income country; LMIC = lower-middle-income country; UMIC = upper- middle-income country. Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification Some points related to adequacy of funding should be noted. First, Key indicators Sources M-5: Purchasing Health Services global benchmarks might not be relevant for a specific country; indeed, M-6: Public Financial Management global benchmarks are a guidance rather than prescriptive funding General government revenue • IMF WEO Inputs needs. Costing exercises might be relevant in certain cases to ascertain as % of GDP Service Delivery the funding needs to deliver National Health Sector policies (see for Tax revenues as % of GDP • World Bank WDI example, the Joint Learning Network “Costing Manual Toolkit”). Second, Outcomes very often, and especially in low-income and lower-middle-income 4 List of Acronyms countries, the financing required to either reach global benchmarks Note: GDP = gross domestic product; IMF = International Monetary Fund; WDI = World Development Indicators; WEO = World Economic Outlook. SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 149 OVERVIEW 1 SECTION 1 What Is a Health PER? of health expenditures, or to cover the cost of a National Health Sector plan, might be infeasible (for example,, covering National as a share of gross domestic product (GDP) over the medium term. Comparing with peer countries and investigating the medium- 2 Health Sector plan costs or achieving a global benchmark on health term trend can point to subpar revenue mobilization and potential SECTION 2 expenditures requires government domestic health expenditure revenue threats. An essential aspect of a government’s revenue Cross-Cutting Analysis on to reach 75 percent of general government expenditure). In this mobilization capacity is its ability to collect taxes, measured Efficiency and Equity case, and when advocating for additional resources for health, by the tax-to-GDP ratio. Comparing with similar countries and 3 PER authors are encouraged to consider sequencing over time examining the medium-term trend can provide valuable insights. and sequencing by priority. Sequencing over time refers to It is also worth considering a recognized benchmark. Countries SECTION 3 Topic-Specific recommending the development of “roadmaps” or “paths to policy” that consistently collect taxes exceeding 15 percent of GDP tend Analysis documents, which show how governments can, incrementally to experience sustained and inclusive growth (for example, Kaldor and over time, ultimately reach the expected domestic health 1963, Gaspar et al. 2016). Health System Context expenditure target, via sequencing domestic health expenditure Health Financing increases. In addition, there can also be sequencing by priority. One It is also noteworthy that SHI contributions are usually M-2: Resource Mobilization possible recommendation is to identify high priority interventions considered social contributions, rather than tax, and that they M-3: Pooling by their cost-effectiveness (for example,, primary health care are considered part of general government revenues. Therefore, M-4: Benefits Specification interventions) and provide funding to cover financing needs for general government revenues as a percentage of GDP is preferred M-5: Purchasing Health Services those highly efficient interventions first. over tax revenues as a percentage of GDP if the focal country M-6: Public Financial Management or at least one comparator country collects substantial health Inputs Higher revenues can expand a government’s fiscal space and revenues via SHI contributions, or via any other government Service Delivery create opportunities for a larger health budget. The next indicators revenue source (for example,, natural resources). PER authors can Outcomes measure the revenue capacity of the government generally, not run both analyses, that is,, using only tax and using all general the health sector itself. The International Monetary Fund (IMF) government revenues. 4 List of Acronyms provides historical data and projects general government revenue SECTION 4 Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 150 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Sustainability Health Financing M-2: Resource Mobilization M-3: Pooling • How predictable are resource flows to the health sector? KEY QUESTIONS M-4: Benefits Specification • What are the levels of the country’s fiscal deficits and debts? M-5: Purchasing Health Services M-6: Public Financial Management Inputs Sustainability is the capacity to attain and maintain the levels of PER authors can also refer to the Health Financing Sustainability health spending necessary to achieve the desired levels of coverage and Resiliency Assessment report (World Bank 2024) for more Service Delivery over the medium term, considering possible sources of revenues in in-depth guidance on assessing health financing sustainability; it Outcomes the domestic public sector, private sectors, and from development also considers efficiency, equity, and resilience. 4 List of Acronyms partners. Threats to sustainability can arise either from increased costs and higher expenditure needs or from reduced revenues. The In this section, methods to assess resource flows and debt are SECTION 4 following questions focus on the revenue side of sustainability. proposed. It should be noted that further analyses on financial Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 151 OVERVIEW 1 SECTION 1 What Is a Health PER? flows, and financial management more broadly, are suggested in the Public Financial Management module. The budgeting Key indicators Sources 2 and planning process is critical for ensuring that there are Expected domestic • Medium-term expenditure SECTION 2 adequate government funds for achieving national health goals, government health framework (where available Cross-Cutting Analysis on especially in countries where the primary source of government ex-penditures (assuming for sector) Efficiency and health funding is via allocations from general government flat prioritization of health • Projections from SHI agencies Equity 3 revenues. This is usually the case for nearly all low-income if no sectoral MTEF) • IMF WEO countries and many upper-middle-income countries. Inefficient • World Bank estimates (e.g., SECTION 3 budgeting and planning processes of governments can impede Double Shock Double Recovery Topic-Specific Analysis attaining adequate spending levels. In addition, PER authors paper series estimates) are encouraged to connect with MTI colleagues on the topics of Deviations in domestic • Health accounts and WHO Health System Context debt and sustainability of health spending within the general government health GHED Health Financing government budget, including wage bills consideration. ex-penditure between the • Government budgets and M-2: Resource Mobilization last three years and the reports (for more recent data, M-3: Pooling First, PER authors should review the forecasts for government corresponding medium- unaudited figures may be M-4: Benefits Specification expenditures from the IMF World Economic Outlook (WEO), or term fiscal projections available) M-5: Purchasing Health Services from the country Article IV report, to form expectations of health • MTEF for health M-6: Public Financial Management expenditure (for example, use general government expenditure Inputs to forecast domestic health expenditures, assuming that the Trends in DAH per capita in • Health accounts and WHO Service Delivery domestic government health expenditures as a percentage of most recent 5 years GHED Outcomes general government expenditure remains flat). This will show • Health resource tracking whether there are large deviations in expected health expenditures exercises if available 4 List of Acronyms in the short to medium term. In case there are relevant analyses Note: DAH = development assistance for health; IMF WEO = International Monetary Fund World Economic from the World Bank (for example,, the Double Shock Double Outlook; MTEF = medium-term expenditure framework; WHO GHED = World Health Organization Global Health SECTION 4 Expenditure Database. Additional Recovery paper series estimates), these can be used. Guidance FRONT MATTER MODULE 2 Resource Mobilization 152 OVERVIEW 1 SECTION 1 What Is a Health PER? Second, PER authors should assess how a country’s health expenditures over the past three years compare to the PER authors should analyze past and future trends in DAH to see how DAH has changed over time and can also benchmark across 2 corresponding medium-term fiscal projections. The latter are laid similar countries. Authors may link the discussion to the earlier key SECTION 2 out in the country’s sectoral medium-term expenditure framework question about off-budget DAH and highlight whether the DAH is Cross-Cutting Analysis on (MTEF) or equivalent document. Some countries lack a MTEF for the largely channeled through the government. It is ideal to indicate Efficiency and Equity sector; however, governments may have set target commitments whether there is a transition plan in place, particularly for countries 3 for health spending to achieve health policy objectives that can where DAH comprises a significant proportion of financing the health serve as substitutes for fiscal projections. Health expenditure may sector. SECTION 3 Topic-Specific be measured in terms of government health expenditure (GHE) Analysis per capita, GHE as a percentage of GDP, or GHE as a percentage Countries with low levels of debt and low fiscal deficits are less of general government expenditure (GGE), depending on the burdened by interest payments. This supports the attainment and Health System Context format of the MTEF projections. Public expenditure and financial maintenance of spending levels across all sectors, including the Health Financing accountability (PEFA) assessments also evaluate the predictability health sector. M-2: Resource Mobilization of financing. Finally, authors are encouraged to take cost pressures M-3: Pooling into account: medical inflation, or new policies, might result in Key indicators Sources M-4: Benefits Specification either buying less goods/labor with the same amount of funding, M-5: Purchasing Health Services General government • IMF WEO or having less money to spend for existing services. M-6: Public Financial Management gross debt as % of GDP • Government financial forecast (e.g., in MTEF documents) Inputs Lastly, it is important to assess predictability of DAH and whether Service Delivery the government could, at least in principle, continue funding Debt service as % of GNI • World Bank WDI Outcomes DAH-funded if donors stop paying for those services (for example,, • Government financial forecast HIV or malaria). It is important to assess the predictability of DAH (e.g., in MTEF documents) 4 List of Acronyms in countries with a high DAH as a percentage of current health Note: GNI = gross national income; IMF WEO = International Monetary Fund World Economic Outlook; SECTION 4 expenditure (CHE) (for example, many low-income countries). MTEF = medium-term expenditure framework; WDI = World Development Indicators. Additional Guidance FRONT MATTER MODULE 2 Resource Mobilization 153 OVERVIEW 1 SECTION 1 What Is a Health PER? Data on gross debt, that is, the total amount of a government’s Finally, there is a growing interest in health taxes. Usually, these 2 outstanding debt obligations, and medium-term projections are types of taxes can be used to limit unhealthy behaviors (for SECTION 2 published biannually by the IMF. Data on interest payments are example,, smoking cigarettes) rather than increase resources Cross-Cutting more limited. Comparing a country’s debt level with peer countries for health. One main reason is that health tax revenues might Analysis on Efficiency and can point to sustainability challenges—especially when debt is be shared across all sectors rather than earmarked to the health Equity 3 not issued in local currency units and mainly held externally. A sector. In addition, even if health tax revenues are earmarked to the steadily increasing debt level is a potential cause for concern, as health sector, the Ministry of Finance might decrease other budget SECTION 3 it will often result in higher debt servicing, which in turn restricts transfers to compensate for the earmarked health revenues (that Topic-Specific Analysis sectorial spending. is,, earmarked health tax revenues are not incremental). Given the complexity of the topic, it is suggested that these analyses are Health System Context To estimate current and future interest payments, authors can done in collaboration and/or led by fiscal policy experts and by Health Financing draw on IMF projections and use the difference between primary Ministry of Finance counterparts.8 deficit and fiscal deficit. The difference equates to net interest M-2: Resource Mobilization M-3: Pooling payments, that is, the sum of debt servicing costs and interest M-4: Benefits Specification receipts from financial assets. In most countries, and particularly M-5: Purchasing Health Services most developing countries, debt servicing costs far exceed interest M-6: Public Financial Management receipts. Therefore, net interest payments can serve as a first approximation of debt servicing costs. Interest payments that rise Inputs quicker than government expenditure or government revenue can Service Delivery undermine health spending. Therefore, in countries where fiscal Outcomes health is weak, authors need to consider the implications for the 4 List of Acronyms sustainability of health spending. SECTION 4 Additional 8 https://www.worldbank.org/en/topic/nutrition/brief/health-taxes. Guidance FRONT MATTER MODULE 2 Resource Mobilization 154 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context MODULE 3 Pooling Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services AUTHORS M-6: Public Financial Management Somil Nagpal, Laura Di Giorgio, Inputs and Denise Silfverberg Service Delivery Outcomes 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 155 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Pooling involves the accumulation and providers, constitutes a pool (Mathauer, Saksen, and Kutzin 2019). Cross-Cutting management of prepaid revenues for health on Finally, pooled funds not only pay for individual-based health Analysis on Efficiency and services on behalf of beneficiaries, but they also pay for population- Equity behalf of a covered population. These funds are 3 based health services, pandemic preparedness, and cross-cutting used to purchase or provide health services so essential public health functions. SECTION 3 that beneficiaries can obtain services without Topic-Specific Analysis bearing the full cost. The funds can be pooled Pooling spreads the financial risks from health care among the and managed by the Ministry of Health, a public population of the pool. It does so through cross-subsidization Health System Context Health Financing or private insurance or purchasing agencies, or between the healthy and sick, and in some cases, the rich and poor. M-2: Resource Mobilization semiautonomous agencies that, for example, Effective pooling contributes to progress toward universal health coverage (UHC) in several ways. It can reduce financial barriers to M-3: Pooling manage programs for specific populations. M-4: Benefits Specification accessing health services, increasing coverage for needed services. M-5: Purchasing Health Services Consequently, it helps reduce forgone care caused by financial Although a pool is most often used to refer to insurance pools, M-6: Public Financial Management any arrangement that manages prepaid resources on behalf of barriers as well as exposure to financial hardship from paying out Inputs an eligible population is a pool. Examples of pooled or prepaid of pocket (OOP) for health services. Service Delivery health financing schemes include national health systems, social Outcomes health insurance (SHI), and voluntary health insurance schemes, PER authors analyzing pooling arrangements from the perspective 4 List of Acronyms including private health insurance. Supply side financing, where of a PER can explore whether current pooling arrangements SECTION 4 the health budget flows in a vertically integrated way to service promote efficiency and equity in financing and service use. Pooling Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 156 OVERVIEW 1 SECTION 1 What Is a Health PER? can be inefficient if it results in high administrative costs, inability to 2 spread risks evenly—with some pools serving high risk population while SECTION 2 others serve lower risk groups, overuse of services, or fragmented health Cross-Cutting Analysis on services1. Multiple pools and schemes can generate inequity if pooling Efficiency and Equity is fragmented across socioeconomic lines. For example, formal workers 3 obtain better services and coverage than informal workers or poorer SECTION 3 segments of the population, as they are covered by different insurance Topic-Specific schemes, with different providers and benefit packages. Analysis Health System Context The module is organized into two sections. The first section, on efficiency, Health Financing covers key questions around quantity, structure, and composition of M-2: Resource Mobilization financing schemes and pooling arrangements. Its aim is to help PER M-3: Pooling authors understand potential inefficiencies. The second section covers M-4: Benefits Specification key questions on equity of pooling arrangements. M-5: Purchasing Health Services M-6: Public Financial Management Inputs The box below presents definitions of terms used in this module.1 Service Delivery Outcomes 4 1 Fragmentation in care can result when the insurance system covers some benefits, say, consultation and a labo- List of Acronyms ratory test for HIV follow-up, while other services are covered by the MoH, such as ART treatment. The user will need to seek care through different provider networks that are often ill suited to coordinate care. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 157 OVERVIEW 1 BOX 1. DEFINITIONS OF TERMS SECTION 1 What Is a HEALTH RISK or covered by a government scheme. Moral hazard results in the increased Health PER? The probability of experiencing ill health by an individual or a population. use of services beyond what is optimal from a societal or individual welfare 2 perspective, creating allocative inefficiency. Methods to address moral hazard SECTION 2 include partial insurance, copayments, deductibles, waiting lists, gatekeeping, HEALTH FINANCING SCHEME Cross-Cutting Analysis on A financing scheme is a distinct system of rules that govern the provision and and limiting individual choice.2 Efficiency and financing of health benefits. Examples include national health insurance, Equity 3 social health insurance, private health insurance, OOP payments, and donor- ADVERSE SELECTION funded health programs. Each scheme has its own structure and rules When health insurance is voluntary, a situation may arise in which only those SECTION 3 regarding financing sources, beneficiaries, and resource distribution for health who are sick or anticipate needing health care buy or opt into the insurance Topic-Specific care services. Annex 1 contains further details, providing a classification of scheme, while those who are healthy will not insure. Adverse selection leads Analysis health financing schemes according to the National Health Accounts system. to insurance pools with primarily high-risk member profiles and high costs, and underinsurance among healthy individuals. Adverse selection will lead to Health System Context RISK POOL higher premium and may render insurance schemes financially unsustainable. Health Financing A health insurance risk pool is a group of individuals whose health risks and M-2: Resource Mobilization associated costs are combined and paid from a common pool of resources. In CREAM SKIMMING M-3: Pooling health financing, a pool can also refer to a fund used to finance services for an This occurs when insurance funds discourage enrollment by people who are at M-4: Benefits Specification eligible population. However, in this context, the term “pool” refers to a group high risk of incurring health costs and accept only potential low-cost enrollees. M-5: Purchasing Health Services of individuals under a single risk-sharing arrangement. There can be multiple M-6: Public Financial Management pools within one health financing scheme. For example, government schemes RISK EQUALIZATION might have pools for special populations, such as beneficiaries of social A method by which insurance entities are compensated by having a pool of Inputs assistance programs, children, or different regional pools. sicker individuals, risk equalization can mitigate cream skimming. Service Delivery Outcomes MORAL HAZARD UNBALANCED RISK POOLS 4 List of Acronyms This refers to the change in behavior by individuals when they do not bear Adverse selection and cream skimming might result in unbalanced risk pools— the full cost of care, either because they are privately or publicly insured pools with higher-than-average costs and health risks. SECTION 4 Additional Guidance 2 See https://www.sciencedirect.com/topics/economics-econometrics-and-finance/moral-hazard#:~:text=Moral%20hazard%20occurs%20when%20an,(ex%20ante%20moral%20hazard). TABLE OF CONTENTS MODULE 3 Pooling 158 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Pooling Arrangements Equity 3 • How many financing schemes exist in the country? SECTION 3 Topic-Specific KEY QUESTIONS • How many pools are in each scheme? Analysis • What are the size and composition of each pool? Health System Context Health Financing M-2: Resource Mobilization The number of health financing schemes is a systems. Fragmentation can be a barrier to cross-subsidization between the healthy and sick and between the rich and poor if M-3: Pooling starting indicator of the number of pooling M-4: Benefits Specification different pools cover each population, for example, if one pool is arrangements that exist in the country. There may designated only for the rich and another for the poor. It can also M-5: Purchasing Health Services M-6: Public Financial Management be more than one pooling arrangement in each lead to inefficiency due to duplication of administration costs, or duplication of services if each pool has its own service provision Inputs health financing scheme. network. Fragmentation in care can also arise if, for example, one Service Delivery scheme covers primary care while another covers secondary and Outcomes Where multiple pooling arrangements and health financing schemes tertiary care or if donor programs fund certain diseases while have developed, each one might have its own rules for participation 4 List of Acronyms national systems or health insurance fund others. and levels of coverage and can lead to the “fragmentation” of health SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 159 OVERVIEW 1 SECTION 1 What Is a Health PER? Key indicators Sources PER authors can map the various health financing schemes in a diagram for easy reference (the Resource Mobilization moduleffff 2 Number of prepaid financing • Policy documents covers sources of financing for health). In some countries, there SECTION 2 schemes in the country • KIIs might be a large number of smaller schemes that account for a small Cross-Cutting Analysis on share of current health expenditures (for example, community- Efficiency and Number of pools per financing • Policy and based health insurance schemes, private voluntary insurance, Equity 3 scheme organizational other nongovernmental-organization-run schemes). While authors structure documents can mention in the country’s PER the existence of such schemes, SECTION 3 of financing schemes Topic-Specific the discussion should focus on major financing schemes, usually Analysis compulsory public schemes3. PER authors should also note that Number of members per pool • Annual report or other reporting document of there may be one or more SHI funds in countries with primarily Health System Context financing schemes SHI-dominant schemes. Health Financing M-2: Resource Mobilization Percent of population covered by • Annual report or other The existence of multiple pools may indicate differences in terms M-3: Pooling each pool reporting document of of benefits and health risk profiles of the people who are covered, M-4: Benefits Specification financing schemes causing inequities in service coverage and financial protection. M-5: Purchasing Health Services Multiple pools can also be a source of inefficiency when there is Characteristics of members per • Annual report or other M-6: Public Financial Management duplication in coverage.3 pool: reporting document of Inputs • Age distribution financing schemes Service Delivery • Gender There may be multiple pools within each financing scheme. For • In-country studies Outcomes • Health risks instance, tax-financed government health care provision may be • Occupational groups 4 List of Acronyms • Income levels 3 The combination of a public mandate, regulation, and funding makes the schemes “public” even if they are managed by non-profit or for-profit private entities. SECTION 4 Note: KII = key informant interview. Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 160 OVERVIEW 1 SECTION 1 What Is a Health PER? divided across subnational units, operating subpools or separate pools (if there are no linkages to other subnational units). When When analyzing the composition of pools according to risk, authors can use the following guide:4 2 mapping the number of pools and discussing the potential SECTION 2 implications, PER authors should also consider whether the number • Low risk: primarily younger and healthier people, employed Cross-Cutting of pools has increased or decreased over time and whether there people Analysis on have been efforts to merge pools. Efficiency and • High risk: older and less healthy people, workers with greater Equity 3 exposure to health hazards, self-employed The size and demographic composition of each pool will show SECTION 3 the extent of fragmentation. As highlighted in earlier questions, Other groups that imply a greater need for health services include Topic-Specific fragmentation impacts the ability to cross-subsidize between very young children, women of childbearing age, and the elderly. Analysis groups, leading to both inefficiency and inequity. Small pools can In addition to using the key indicators on size and composition, also pose a threat to the financial sustainability of the pooling PER authors can conduct a descriptive analysis of the interaction Health System Context scheme. Large pools with diverse health risk profiles ensure that between different fund pools to ascertain whether there is a Health Financing the presence of a few people at risk of incurring high costs will not mechanism of cross-subsidization across different pools. For M-2: Resource Mobilization bankrupt the pool. noninsurance schemes, authors should identify the types of M-3: Pooling resource allocation or equalization mechanism5 used to distribute M-4: Benefits Specification Using the key indicators, PER authors should analyze the size resources across pools. For countries with SHI schemes, PER M-5: Purchasing Health Services and diversity of pools to assess the fragmentation level across authors should describe whether there are automatic stabilizers M-6: Public Financial Management the system. They then should link the results to questions in the in place, which may include formula-based transfers from the Inputs equity section to understand the equity impact of the pooling government to the SHI, transfers that adjust to any unexpected Service Delivery costs, or stabilization funds. arrangements in the country. Outcomes 4 List of Acronyms 4 The composition of pools may be estimated using household surveys if available, by looking at socioeconomic characteristics and income level by type of coverage scheme (public system, insurance scheme for formal workers, special populations). The composition of the pool can also be inferred from the eligible population, for example, contributory schemes for formal workers usually cover the better-off more educated groups. PER authors may be able to obtain this information from key informant interviews. Insurance agencies, whether public or private, participating in public compulsory schemes often publish reports detailing covered population by age. SECTION 4 5 “Risk equalization” refers to the transfer of funds between pools depending on the health risk profile of their enrollees. This reduces the incentive for the pools to seek to enroll only people projected to incur low costs. Countries may have developed their own approach to determining how and when funds are transferred between pools. Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 161 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Moral Hazard, Adverse Selection, and Administrative Costs Cross-Cutting Analysis on Efficiency and Equity • Are administrative costs of operating the schemes higher than optimal? 3 • Is membership voluntary or compulsory for the different schemes? Is there any KEY QUESTIONS SECTION 3 evidence of cream skimming? Topic-Specific Analysis • Is there evidence of overuse of services (adverse selection)? Health System Context Health Financing A typical inefficiency emerging from the existence of multiple pools Schemes or pools with voluntary membership will likely encounter M-2: Resource Mobilization is high administrative costs. Administrative costs as a percentage of the problem of adverse selection or cream skimming. PER authors M-3: Pooling total SHI costs can be benchmarked against the median observed can compare the demographic composition of each pool (see M-4: Benefits Specification in high-income countries of 3.5 percent (WHO 2010). Administrative the earlier question on size and composition of pools) with M-5: Purchasing Health Services costs tend to increase as GDP per capita decreases, with some lower- that of the overall population to assess the impact of voluntary M-6: Public Financial Management income countries spending more than 30 percent on administration. versus compulsory membership. When participation in a scheme Inputs This may be explained by lower-income and lower-middle-income is voluntary, there is a tendency for sicker people to join and Service Delivery countries having smaller programs, so that fixed costs become a healthier people to opt out or pick pools with lower (co)payments/ Outcomes larger share of total costs. contributions and/or deductibles. Pools with sicker people will ultimately have higher average costs than other pools. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 162 OVERVIEW 1 SECTION 1 What Is a Health PER? Key indicators Administrative cost as a share of current health Sources • Government budget PER authors should also assess whether schemes are able to deny membership and if so, on what grounds. In this discussion, 2 expenditure • Annual report or financial authors should highlight whether there is SECTION 2 statements of the insurance a “safety net” option (such as a publicly Cross-Cutting Administrative cost of public compulsory schemes Analysis on financed fund) for individuals who are not Efficiency and as a share of total government health expenditure scheme Equity accepted by any risk pool. PER authors 3 Administrative cost as a percentage of total SHI • Annual report or financial should link this analysis with the previous SECTION 3 costs statements of SHI scheme questions when discussing risk equalization Topic-Specific mechanisms for risk adjustments across Analysis Administrative cost per member per month • Annual report or financial pools. statements of SHI scheme Health System Context Health Financing Compulsory membership for schemes (Yes/No) • Government reports and M-2: Resource Mobilization normative documents M-3: Pooling • KIIs M-4: Benefits Specification Option for member to opt out of the scheme • Policy documents M-5: Purchasing Health Services (Yes/No) • KIIs M-6: Public Financial Management Inputs Is there evidence of cream skimming? (Yes/No) • KIIs Service Delivery Is there evidence of overuse of services due to • KIIs Outcomes adverse selection? (Yes/No) • Government reports 4 List of Acronyms • Academic studies SECTION 4 Note: KII = key informant interview; SHI = social health insurance. Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 163 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY 2 SECTION 2 Cross-Cutting • Are there differences in per capita spending by scheme? Analysis on Efficiency and Equity KEY QUESTIONS • Are there differences in benefits across schemes? 3 • Are there regressive subsidies across pools? SECTION 3 Topic-Specific Analysis Fragmented and ineffective pooling arrangements benchmark across other schemes within the financing system. Authors may also choose to benchmark against similar countries. Health System Context can lead to significant inequities in coverage, When doing this, they should ensure that the indicator is converted Health Financing reflected in the level of financial protection and to constant US dollars. In addition, PER authors should analyze M-2: Resource Mobilization health service use of its members. past trends in per capita spending. M-3: Pooling M-4: Benefits Specification PER authors should exclude administrative costs when calculating Different schemes may offer different levels of coverage to their M-5: Purchasing Health Services the per capita spending of a scheme in order to better account respective members. For instance, civil servant schemes typically M-6: Public Financial Management for the benefits members are receiving. Authors can analyze the have higher levels of government funding per person, resulting Inputs overall level of OOP spending as the percent of household income, in better service coverage and financial protection. In contrast, Service Delivery by scheme or by pool, if household data are available and report members of community-based health insurance schemes receive Outcomes the household’s health coverage scheme. When data are available, limited benefits. Authors can conduct a qualitative comparison of 4 List of Acronyms this may be taken a step further by looking at impoverishing benefits package contents across schemes. and catastrophic spending by beneficiary type. PER authors can SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 164 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context The discussion can be linked to key questions in the Benefits Health Financing Key indicators Sources Specification module. For countries with SHI schemes, PER M-2: Resource Mobilization Yearly per capita spending for a • Annual report or financial authors should determine whether the scheme covers the M-3: Pooling given scheme statements of financing range of lower-cost, frequent events typically found at the M-4: Benefits Specification scheme primary care level, as well as higher-level care. M-5: Purchasing Health Services M-6: Public Financial Management Out-of-pocket spending per • Household surveys Inequities can also arise when insurance schemes benefit the Inputs capita by scheme or by pool • In-country studies affluent only and rely on general taxes for the sustainability of Service Delivery Health service use by scheme • Household surveys the formal sector schemes (for example, by covering deficits). Outcomes or by pool (corrected for needs, PER authors can explore whether these types of transfers are • In-country studies 4 List of Acronyms creating regressive implicit or explicit subsidies. where possible) SECTION 4 Note: KII = key informant interview. Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 165 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Mathauer, Inke, Priyanka Saksena, and Joe Kutzin. 2019. “Pooling arrangements in health financing systems: a proposed classification.” International Cross-Cutting Journal for Equity in Health, Vol. 18: 1 -11. https://doi.org/10.1186/s12939-019-1088-x Analysis on Efficiency and Equity World Health Organization. 2010. Administrative costs of health insurance schemes: Exploring the reasons for their variability. No. HSS/HSF/DP. E. 3 10.8. https://iris.who.int/bitstream/handle/10665/85710/HSS_HSF_DP.E.10.8_eng.pdf?sequence=1 SECTION 3 Topic-Specific Analysis Health System Context Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 3 Pooling 166 OVERVIEW 1 ANNEX 1: Classification of Financing Schemes SECTION 1 Mode of Participation Benefit Entitlement Basic Method For Fundraising Pooling What Is a Health PER? HF.1.1 Government Automatic: for all citizens/ Non-contributory, typically universal or Compulsory: budget revenues (primary taxes). National, subnational, or programmer level. 2 Schemes residents; or specifics groups of the available for a specific population group or population (e.g., the poor) defined disease category defined by law (e.g., TB, HIV, by law/government regulation. oncology). SECTION 2 HF.1.2.1 Social Health Mandatory: for all citizens/ Contributory: based on payment by or on behalf Compulsory: non-risk-related health insurance National, subnational, or by scheme with multiple Cross-Cutting Insurance residents; or specific groups of of the insured person. contribution. Insurance contributions may be funds, extent of pooling will depend on risk- Analysis on the population defined by law/ paid by the government (from the state budget) equalization mechanisms across schemes. Efficiency and government regulation. In some on behalf of some non-contributing groups of Equity 3 cases, however, the enrollment the population, and the government may also requires actions to be taken by the provide general subsides to the scheme. eligible persons. SECTION 3 HF.1.2.2 Compulsory Mandatory: for all citizens/ Contributory: based upon the purchase of Compulsory health insurance premiums. Tax National, subnational, or by scheme; with multiple Topic-Specific Private Insurance residents; or specific groups of an insurance policy from a selected health credits may also be involved. funds, extent of pooling will depend on risk- Analysis the population defined by law/ insurance company (or other agency involved). equalization mechanisms across schemes. Also government regulation. depends on the extent of regulation of premium, and standardization of benefits across schemes. Health System Context HF.1.3 Compulsory Mandatory: for all citizens/ Contributory: based upon the purchase of MSAs; Compulsory, defined by law (e.g., as percent No interpersonal (except perhaps family members). Medical Saving Accounts residents; or specific groups of persons having MSAs can, however, only use the share of income). Health Financing (CMSA) the population defined by law/ money saved, regardless of whether the saving government regulation. covers the costs of the care necessary. M-2: Resource Mobilization HF.2.1 Voluntary Health Voluntary Contributory: based upon the purchse of Usually non-income-related premium (often Scheme level. M-3: Pooling Insurance Schemes voluntary health insurance policy (usually on directly or indirectly risk-related). Government the basis of a contract). may directly or indirectly (e.g., tax credits) M-4: Benefits Specification subsidise. M-5: Purchasing Health Services HF.2.2 Non-profit Voluntary Non-contributory, discretionary. Donations from the general public, Varies across programs, but typically program level. M-6: Public Financial Management Institution Financing governments (budget of national government Schemes or foreign aid), or corporations. Inputs Service Delivery HF.2.3 Enterprise Voluntary choice of particular Non-contributory, discretionary with regard to Voluntary: choice of the firm to use its revenues At an individual enterprise level. Financing Schemes (other corporation, with coverage based the type of services, though may sometimes be for this purpose. Outcomes than employer-based on employment at such a firm (e.g., specified by law. insurance) complusory occupational health 4 List of Acronyms care). HF.3 Household Out-of- Voluntary: willingness to pay of the Contributory: service provided if individual Voluntary: household disposable income and No interpersonal pooling. Pocket Expenditure household. pays. saving. SECTION 4 HF.4 RoW Financing Compulsory or voluntary. Criteria set by foreign entities. Grants and other voluntary transfers by foreign Varies across programs. Additional Schemes entities. Guidance Sources: IHAT for SHA 2011. TABLE OF CONTENTS MODULE 3 Pooling 167 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific MODULE 4 Benefits Analysis Health System Context Specification Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services AUTHORS M-6: Public Financial Management Inputs Olena Doroshenko, Denizhan Duran, Catalina Service Delivery Gutiérrez, and Thomas Wilkinson Outcomes 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 168 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Cross-Cutting Given that resources are limited, countries need services and service delivery platforms could generate gains of Analysis on Efficiency and to make choices about which benefits are funded 31,000 Disability Adjusted Life Years (DALY) in Armenia, 2 million Equity 3 DALY in Côte D’Ivoire, and 938,000 DALY in Zimbabwe—without and which are not. Even if decisions are not made increasing expenditure. SECTION 3 explicitly, funding is ultimately directed to some Topic-Specific Analysis services and not to other services. Allocative A benefits package is a designated set of health care services, efficiency requires that spending goes toward the funded from public resources, to which the population or its specific Health System Context services that produce the largest welfare gains groups are entitled.1 Benefits can be explicit, meaning that a Health Financing M-2: Resource Mobilization to a given population; in other words, allocative benefits package covers an explicit list of health care services that M-3: Pooling efficiency is about spending on the “right things.” is adhered to, and services that are not on the list are not covered. M-4: Benefits Specification Benefits can also be implicit, with no explicit list of entitlements.2 M-5: Purchasing Health Services Inefficient benefit specification can result in important losses for M-6: Public Financial Management health. For example, Fraser-Hurt, Hou, et al. (2021) conducted an Explicit benefits packages can enhance allocative efficiency by Inputs allocative efficiency analysis of benefits funded in three countries prioritizing spending on health care services for a medical condition Service Delivery and found that reallocating expenditure to cost-effective essential that yield the greatest health gain. They also create explicit Outcomes 4 List of Acronyms 1 A health benefits package defines what the government can deliver—and what citizens can demand—given budget realities. 2 See https://www.cgdev.org/sites/default/files/whats-in-whats-out-designing-benefits-final.pdf for a more detailed discussion on a health benefits package definition. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 169 OVERVIEW 1 SECTION 1 What Is a Health PER? entitlements for patients whose access to services might otherwise service provision are other tools for directing spending to priority 2 be largely determined by provider and geographic variability and services. Since resources are limited, when there are no explicit SECTION 2 Cross-Cutting availability, with the consequent potential for arbitrary variations rules for prioritizing expenditure, prioritization can happen Analysis on Efficiency and in access (Glassman, Giedion, and Smith 2017). This might be implicitly through patient waiting times and dilution of services, Equity 3 particularly disadvantageous for vulnerable groups and those and the resulting allocation might not be aligned with health living in remote and sparsely populated areas. By defining benefits system goals. SECTION 3 Topic-Specific explicitly, beneficiaries are empowered to claim their entitlements, Analysis which they might otherwise be unaware of. Additionally, explicit Implicit rationing can also happen when copayments are set benefits improve equity by allowing for better monitoring of service too high, by excluding certain population groups from accessing Health System Context delivery and addressing undue variations in access between covered benefits. Such exclusion leads to inequity and inefficiency, Health Financing M-2: Resource Mobilization population groups. They can also serve as a basis for planning, to particularly if the services are cost effective. M-3: Pooling align guaranteed services with service provision, ensuring that the M-4: Benefits Specification human resources, medicines and medical devices, and infrastructure PER authors exploring the equity and allocative efficiency of benefit M-5: Purchasing Health Services and equipment needed to deliver the services are available. specifications should assess whether publicly funded benefits and M-6: Public Financial Management their governance arrangements prioritize services that provide Inputs Explicit benefits packages are not the only tool that governments the largest welfare gains for a given level of resources and do Service Delivery have at their disposal to improve allocative efficiency. Payment so equitably. This involves examining whether the country has a Outcomes mechanisms, which are discussed in the module on Purchasing policy for prioritizing benefits, the criteria align with system goals 4 List of Acronyms Health Services , essential medicines list, pharmaceutical and population welfare, and the prioritization policies effectively SECTION 4 formularies, clinical guidelines, and monitoring of quality and allocate expenditures according to these goals. Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 170 OVERVIEW 1 SECTION 1 What Is a Health PER? Because de jure service coverage does not guarantee the facto coverage, 2 it is important to understand whether the de jure coverage translates SECTION 2 Cross-Cutting into effective coverage; PER authors can refer to the Service Coverage Analysis on Efficiency and moduledsdand the Universal Health Coverage module, which look at Equity 3 effective access, and financial protection. SECTION 3 Topic-Specific This module is organized into three sections. The first section, on efficiency, Analysis explores the priority-setting policies, what services are funded with public resources, as well as the criteria used to define them. In countries with Health System Context a health benefits package (HBP), the actual scope of and expenditures Health Financing M-2: Resource Mobilization on health services can be broader than those within the HBP, so it is M-3: Pooling important to define the share of government and of household financing M-4: Benefits Specification that is channeled to the HBP. The second section, on equity, provides M-5: Purchasing Health Services guidance on investigating whether differences in the breadth of benefits M-6: Public Financial Management or depth of coverage (with formal or informal cost-sharing mechanisms) Inputs among population groups compound existing inequalities. The last section Service Delivery considers whether the governance of benefits definition and monitoring Outcomes promotes allocative efficiency and equitable access to care. The following 4 List of Acronyms box presents definitions of terms used in the module. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 171 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS 2 EXPLICIT BENEFIT PACKAGES IMPLICIT RATIONING SECTION 2 Explicit benefits packages can be expressed as a positive list, There is no universal agreed-upon definition of rationing. In economics, Cross-Cutting Analysis on which specifies what services are covered by public funds, or as it refers to allocating scarce goods or services through price or non-price Efficiency and a negative list of services that are not covered. The granularity of Equity mechanisms when demand exceeds supply. In health care, rationing involves 3 service lists can vary from details of all the services, medicines, withholding potentially beneficial treatments based on non-clinical factors. and equipment covered to general functional categories, such as The health technology assessment literature focuses on rationing on the SECTION 3 “primary level services” or “promotion and prevention services.” grounds of insufficient budgetary resources. But rationing can also occur due Topic-Specific A middle ground that avoids undue complexity but still allows for Analysis to limited inputs, even when financial resources are available. For instance, clarity and effective prioritization is best (Glassman, Giedion, and heart transplants may be limited by donor availability, or cancer treatment Smith 2017). Health System Context access may be restricted by a shortage of oncologists. Implicit rationing is Health Financing the allocation of resources without clear and explicit criteria, and it is often, ESSENTIAL SERVICES though not always, determined at the point of care. M-2: Resource Mobilization There is no single list or definition of essential services, but in M-3: Pooling general, they refer to cost-effective services that every person HEATH TECHNOLOGY ASSESSMENT M-4: Benefits Specification who needs them should have access to, regardless of their This assessment is a systematic and multidisciplinary evaluation of the M-5: Purchasing Health Services economic or social conditions. Some academic and policy- properties (effectiveness, benefits, costs, budgetary impact, and so on) of M-6: Public Financial Management oriented definitions of essential health services emphasize that individuals have a reasonable claim to receive these services health technologies and interventions that projects both their direct and Inputs based on agreed societal values, economic capacity, and the indirect consequences. It determines the value (costs and effects) of a health Service Delivery technology (medicine, procedure, intervention, and so on) and informs health needs of the population. These definitions often stress Outcomes the importance of fairness and equity in providing health guidance on how these technologies can be used in health systems (see 4 List of Acronyms services that are deemed essential. PER authors may wish to the World Health Organization website’s multimedia section on health refer to Disease Control Priorities DCP3 for examples of essential technology assessments). The evaluation also provides evidence for decision SECTION 4 packages of health services. making, particularly on price and coverage in public health systems. Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 172 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting BOX 2. RECOMMENDED READING Analysis on Efficiency and Equity 3 Glassman, Amanda, Ursula Giedion, and Peter C. Smith, eds. World Bank Group. 2022. Making Explicit Choices on the Path 2017. “About This Book,” In What’s In, What’s Out: Designing to UHC: The JLN Health Benefits Package Revision Guide. Joint SECTION 3 Benefits for Universal Health Coverage: xv–xix. Washington, Learning Network for Universal Health Coverage, International Topic-Specific DC: Brookings Institution Press. http://www.jstor.org/ Decision Support Initiative (iDSI). Washington, DC: World Bank Analysis stable/10.7864/j.ctt21kk0p0.6. Group. https://www.jointlearningnetwork.org/wp-content/ Health System Context uploads/2022/12/Making-Explicit-choices.v4.pdf. Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 173 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY 2 SECTION 2 Cross-Cutting Analysis on Aggregate Spending Efficiency and Equity 3 • Are benefits defined implicitly or explicitly? SECTION 3 KEY QUESTIONS • What criteria are used to define the benefits? Are criteria aligned with system goals? Topic-Specific Analysis • What is the mix of interventions covered by the system with public resources and does it promote an efficient allocation of resources? Health System Context • What other policy tools are used to align the provision of services with system goals? Health Financing M-2: Resource Mobilization M-3: Pooling When conducting a Public Expenditure Review, PER A first step is to understand whether benefits offered in a health M-4: Benefits Specification system are explicit or implicit and what criteria and process M-5: Purchasing Health Services authors should try to determine whether the benefits are used to define or revise the HBP, if there is one. Countries M-6: Public Financial Management funded with public resources are aligned with the can combine explicit packages to prioritize some services (for Inputs health system goals. This includes addressing the most example, maternal and child services, communicable diseases Service Delivery or noncommunicable diseases (NCDs)), and implicit benefits for important causes of disease burden, using resources Outcomes other services (for example, defined annual number of high-cost rationally, and promoting sustainability, equity, and 4 List of Acronyms and limited effectiveness treatments), so it is also important to financial protection (covered later in the module). understand what share of spending is channeled to the explicit HBP. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 174 OVERVIEW 1 SECTION 1 What Is a Health PER? If benefits are implicit, PER authors should explore whether other policy tools are used to prioritize services, such as payment mechanisms, clinical guidelines, monitoring of Key indicators Which of the following mechanisms Sources • Policy document review 2 service delivery, or others, and how such policies and tools is used to define benefits (a • KIIs SECTION 2 country might use a combination)? prioritize (or do not) services. Cross-Cutting Analysis on There is an explicit list of services Efficiency and Equity An efficient allocation prioritizes essential and cost-effective that are not covered (negative list) 3 benefits over less essential ones, so authors should try (Yes/No) to qualitatively gage whether the mix of services covered SECTION 3 There is an explicit list of services Topic-Specific prioritizes essential services. Evidence of widespread that are covered (positive list) Analysis spending on services with low cost-effectiveness, or unproven (Yes/No) effectiveness, can also indicate allocative inefficiencies, Health System Context for example, experimental treatments, treatments used for There is no explicit definition of Health Financing conditions for which they are not approved, or high-cost benefits (Yes/No) M-2: Resource Mobilization specialized medicines with limited clinical benefit. There What share of expenditure is • Policy document review M-3: Pooling are no readily available indicators to assess allocative channeled to services included in • KIIs M-4: Benefits Specification efficiency of a HBP, but interviews with key informants, the explicit benefit package(s)? M-5: Purchasing Health Services academic studies, or official reports give insight on the • Budget execution reports M-6: Public Financial Management efficiency and effectiveness of processes and criteria used • Health insurance agencies reports Inputs to define and prioritize benefits in the country. The package • Claims systems Service Delivery devised by the Disease Control Priorities initiative (DCP3)3 Outcomes is widely accepted as a cost-effective package of services, Guaranteed health services in the • Policy documents review so the degree to which the package is aligned with the DCP3 country and degree of alignment 4 List of Acronyms • KIIs package is a helpful starting point for the analysis. with DCP3 list of services (descriptive) SECTION 4 Additional 3 https://www.dcp-3.org/. Note: KII = key informant interview. Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 175 OVERVIEW 1 SECTION 1 What Is a Health PER? Key indicators Essential services included in the HBP Non-essential services included in the HBP Sources • Policy document review 2 Prevention interventions included in the HBP • KIIs SECTION 2 Health promotion interventions included in the HBP Cross-Cutting Analysis on Essential medicines (outpatient and inpatient) included in the HBP Efficiency and Are copayments hindering access to any of the covered cost-effective services? (Yes/No) Equity 3 Are experimental treatments, high-cost drugs, drugs for unapproved uses, non-essential cosmetic surgeries, or other treatments that might provide low value for money financed from public funds? (Yes/No) SECTION 3 Note: HBP = health benefits package; KII = key informant interview. Topic-Specific Analysis PER authors can provide a descriptive overview of guaranteed can also review how certain services—such as preventive services, Health System Context health services in the country and specify how these benefits including immunization and screening; and other services, such as are defined or revised and whether they are codified for paying outpatient medicines and diagnostic or clinical interventions—are Health Financing providers or for monitoring service provision or spending. The guaranteed. If the benefits package(s) is(are) explicitly defined, the M-2: Resource Mobilization indicators in the table above may help shape the narrative. Authors interventions can be included in an annex. M-3: Pooling can either list all the services included in the HBP for each category, M-4: Benefits Specification or identify whether there is an explicit list or not . To evaluate the mix of services, PER authors can conduct a qualitative M-5: Purchasing Health Services assessment of essential versus less essential services included M-6: Public Financial Management As part of the descriptive overview, PER authors can explain how in the benefits package. When defining what is and what is not Inputs interventions and services delivered at the different levels of care essential, authors can refer to the national guidance, if it exists, or Service Delivery (for example, primary and community care, first-level hospital care, use the definition provided by the Disease Control Priorities (third Outcomes or tertiary or specialist-level care) are guaranteed, noting availability edition)4 or World Health Organization (WHO).5 Additionally, they 4 List of Acronyms and associated formal or informal copayments. If applicable, authors can assess how much of curative versus prevention and promotion SECTION 4 4 See “Universal Health Coverage and Essential Packages of Care,” Volume 9, Disease Control Priorities: http://dcp-3.org/chapter/2551/essential-universal-health-coverage. Additional Guidance 5 See the WHO UHC Compendium: https://www.who.int/universal-health-coverage/compendium. TABLE OF CONTENTS MODULE 4 Benefits Specification 176 OVERVIEW 1 SECTION 1 What Is a Health PER? interventions are explicitly included in the HBP. This can be tackled by diagnosis, disease, or more broadly for NCDs and communicable diseases, depending on Key indicators Is burden of disease considered? Sources • Policy documents 2 the country context. Finally, PER authors can check for the inclusion of essential (Yes/No) review SECTION 2 or nonessential medicines in the benefits package. Overall, authors should Cross-Cutting discuss whether some services are better defined and better covered than Are financial risks to households • Technical reports Analysis on considered? (Yes/No) review Efficiency and others and how benefits covered affect efficient health service use (for example, Equity in many post-communist countries in Europe and Central Asia, medicines are 3 Is equity in UHC outcomes • KIIs covered as part of the hospital service but not offered as part of outpatient considered? (Yes/No) • MoH normative SECTION 3 service, so patients delay using services at the outpatient level until their and regulatory Is access and service delivery Topic-Specific condition becomes acute, and then use inpatient care with better coverage). documents on Analysis capacity considered? (Yes/No) benefits covered Having explicit criteria to define what is covered can improve transparency Are costs of interventions Health System Context or paid and allocative efficiency. The table on the right explores criteria that are considered? (Yes/No) Health Financing frequently considered when specifying or revising benefits that are aligned Is evidence-based effectiveness of M-2: Resource Mobilization with system goals. interventions considered? (Yes/No) M-3: Pooling M-4: Benefits Specification Is cost-effectiveness considered? Using the key indicators above as a guide, PER authors can provide a M-5: Purchasing Health Services (Yes/No) description of the criteria used in the definition of the HBP. In conjunction with M-6: Public Financial Management the descriptive analysis, authors can assess whether criteria used promote Is budget impact considered? (Yes/ Inputs efficiency and/or sustainability and determine the process of applying these No) Service Delivery criteria. For instance, the use of health technology assessments in-country What mechanisms are in place to Outcomes can be discussed in this section. PER authors can also explore whether the include, revise, or rationalize among 4 List of Acronyms criteria are explicitly measured and assessed or are incorporated in more new drugs and technologies? informal ways (for example, through expert discussions). Note: KII = key informant interview; MoH = Ministry of Health; UHC = universal health coverage. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 177 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting GOVERNANCE Analysis on Efficiency and Equity • Are the benefits costed and does the costing translate into adequate funding? 3 • Are there explicit and formal processes and methods for defining inclusions and SECTION 3 Topic-Specific KEY QUESTIONS exclusions of benefits? Analysis • Are there grievance mechanisms for claiming the benefits? Health System Context • Are entitlements backed by legal provisions? Health Financing M-2: Resource Mobilization M-3: Pooling Governance involves how decisions Key principles for defining benefits and setting priorities include: • Transparency, which limits special interest influence and improves legitimacy, is M-4: Benefits Specification are made and institutionalized into M-5: Purchasing Health Services about ensuring that decision processes and reasons are public. continuous, stable, and transparent M-6: Public Financial Management • Consistent, stable, and coherent decision rules with clear responsibilities provide Inputs processes. Good governance features clarity to beneficiaries, payers, and providers. Service Delivery clear rules, processes, and defined • Stakeholder participation ensures legitimacy and improves prioritization by Outcomes roles and responsibilities. aligning benefits with population preferences and needs. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 178 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors interested in exploring the governance of benefits packages further can refer to the “Recommended Reading” box above. When conducting a PER, authors can focus on assessing whether governance arrangements for benefit definition align with efficiency and support 2 equitable health care access. The indicators below provide guiding questions for this assessment. SECTION 2 Cross-Cutting Key Indicators Sources Analysis on Efficiency and Equity Are the criteria and methods by which the inclusion or exclusion of benefits are • Policy documents review 3 made public? (Yes/No) • Technical reports review • MoH regulatory documents SECTION 3 Topic-Specific • KIIs Analysis Are the roles and responsibilities among institutions for establishing and updating • KIIs the benefits clearly defined? (Yes/No) • MoH regulatory documents Health System Context Is there a routine process for revision of benefits/inclusion/exclusion of services? • KIIs Health Financing (Yes/No, describe) • MoH regulatory documents M-2: Resource Mobilization Are benefits packages costed? If yes, what was the costing approach (top-down, • Policy documents review M-3: Pooling bottom-up, or mixed); did it cover all services included in the HBP; when was the • KIIs M-4: Benefits Specification latest costing conducted? • MoH regulatory documents M-5: Purchasing Health Services M-6: Public Financial Management Are there grievance and complaints reporting mechanisms for guaranteed • Usually available from the MoH or the relevant Inputs benefits? (Yes/No) purchasing agencies/insurance funds Service Delivery Are contracts with providers clearly defining the requirement of providing services • KIIs Outcomes per guaranteed benefits? (Yes/No) • MoH or HIF documents and contracts with providers 4 List of Acronyms Are entitlements backed by legal provision? (Yes/No) • Policy documents review SECTION 4 • KIIs Additional Note: HIF = Health Insurance Fund; KII = key informant interview; MoH = Ministry of Health. Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 179 OVERVIEW 1 SECTION 1 What Is a Health PER? Lack of coherence between the cost of the package and available 2 resources results in implicit rationing and undermines prioritization of benefits. Adequate recurrent costing of benefits is crucial. PER authors SECTION 2 Cross-Cutting should use key informant interviews and budget execution documents Analysis on to assess whether available funding is sufficient to cover benefits. Efficiency and Equity 3 PER authors can also investigate through interviews and regulatory SECTION 3 documents whether the benefits definition process follows the Topic-Specific principles mentioned above, such as criteria and methods that are Analysis public and accessible. Health System Context Providers may not have full information about the scope of services Health Financing they are obliged to provide with the public financing they receive. M-2: Resource Mobilization Therefore, it is important to check whether contracts with providers M-3: Pooling specify their obligations and breach of compliance procedures. M-4: Benefits Specification M-5: Purchasing Health Services To ensure beneficiaries can claim benefits, they need legal entitlements M-6: Public Financial Management and grievance redress mechanisms. PER authors should describe Inputs grievance redress setup (for example, platforms for complaints, Service Delivery response procedures) and communication to the public (for example, Outcomes dissemination of the “who, what, where, when, and how”). If relevant, 4 List of Acronyms authors should also evaluate the nature of complaints and identify frequently reported topics (for example, financial protection, access, SECTION 4 quality, or other aspects of health service delivery). Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 180 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY AND FINANCIAL PROTECTION COVERAGE 2 SECTION 2 Cross-Cutting • Are there differences across financing schemes in terms of depth and breadth of Analysis on Efficiency and services covered? How do guaranteed benefits vary across population groups? Equity 3 • Are there differences across beneficiaries or financing schemes in use of services SECTION 3 KEY QUESTIONS and financial protection; for example, are there groups that are exempt from Topic-Specific Analysis paying premiums or user fees at point of service? • How is eligibility of beneficiaries defined? What is the identification/targeting Health System Context mechanism and is it efficient? Health Financing M-2: Resource Mobilization • Are beneficiaries aware of their entitlements? M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services This section helps establish whether the existing For each benefit, PER authors should indicate who is covered (all M-6: Public Financial Management population groups versus some groups) and whether there are Inputs benefits provide adequate financial protection copayments (and whether copayments are explicitly indicated). Service Delivery to beneficiaries, especially for different income They should also indicate whether copayments differ for different Outcomes groups. It also reviews the determination of groups. If the list is comprehensive, this information can be placed in an annex, with a descriptive analysis of any differences in 4 List of Acronyms beneficiaries, and their awareness of their benefits provided in the main text. entitlements. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 181 OVERVIEW 1 SECTION 1 What Is a Health PER? Key indicators Are benefits different across population groups? (Yes/No) Sources • Review of financial and technical documentation 2 • KIIs SECTION 2 Provide a narrative description of any differential coverage across population Cross-Cutting groups. For groups with similar coverage, do vulnerable groups have the same level Analysis on Efficiency and of access and utilization of services? Include a discussion of any copayments that Equity might be hindering access to socioeconomically disadvantaged groups. 3 % of cost covered by type of benefit/entitlement • Review of financial and technical documentation SECTION 3 • Population or household surveys Topic-Specific Analysis % of population reporting membership in a health insurance scheme (for countries • Typically captured in household surveys with insurance schemes) • There may be variation in how these questions Health System Context % of households/population aware of benefit entitlements are asked in the survey, so the indicators can be Health Financing adjusted accordingly. M-2: Resource Mobilization Note: KII = key informant interview. M-3: Pooling M-4: Benefits Specification This qualitative analysis can be linked to the Financial Risk whether they are complementary, supplementary, or parallel) and M-5: Purchasing Health Services Protection module. PER authors can describe whether the the shares of people using these schemes. M-6: Public Financial Management eligibility criteria lead to the exclusion of certain population Inputs groups (for example, undocumented people—homeless persons, PER authors can benchmark across regions of the country, Service Delivery undocumented migrants, refugees). A description of whether types of settlements, and population groups to understand any Outcomes there is a difference in access to benefits across different groups disparities in awareness of benefits. To provide additional context, by income or social status (unemployed, people with disabilities, authors can also describe the mechanisms for communicating 4 List of Acronyms and so on) should be included. And authors can describe whether entitlements employed by the country and systems of reporting SECTION 4 people are using any private insurance schemes (for example, illegal copayment schemes within publicly financed guarantees. Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 182 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Fraser-Hurt, Nicole, Xiaohui Hou, Thomas Wilkinson, Denizhan Duran, Gerard J. Abou Jaoude, Jolene Skordis, et al. 2021. “Using allocative efficiency Cross-Cutting analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking Analysis on Efficiency and decision support.” PLOS ONE 16 (11): e0260247. https://doi.org/ 10.1371/journal.pone.0260247. Equity 3 Glassman, Amanda, Ursula Giedion, and Peter C. Smith, eds. 2017. “About This Book,” in What’s In, What’s Out: Designing Benefits for Universal Health Coverage: xv–xix. Washington, DC: Brookings Institution Press. http://www.jstor.org/stable/10.7864/j.ctt21kk0p0.6. SECTION 3 Topic-Specific Analysis Health System Context Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 4 Benefits Specification 183 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 MODULE 5 SECTION 3 Purchasing Topic-Specific Analysis Health Services Health System Context Health Financing M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification AUTHORS M-5: Purchasing Health Services M-6: Public Financial Management Xiaohui Hou, Alexandra Michele Beith, Inputs Riku Elovainio, and Priyanka Saksena Service Delivery Outcomes START 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 184 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 Purchasing is a fundamental function of health Payment methods create powerful financial incentives for service SECTION 2 providers. These incentives shape provider behaviors with both Cross-Cutting financing and critical for ensuring efficient and Analysis on desirable and undesirable consequences for health system Efficiency and equitable progress toward meeting health goals. performance, including efficiency and equity. Therefore, provider Equity 3 It specifies which services should be purchased, payment methods are chosen with different goals in mind. Some from whom, and how these services should be methods seek to promote cost control, others to decrease or SECTION 3 increase specific health-service provision; some seek to improve care Topic-Specific paid for. But purchasing and related instruments Analysis quality, while others aim to overcome service or treatment delays. help accomplish far more than simply the transfer Payment methods are increasingly blended to try to incentivize some Health System Context of funds. Indeed, the rules and processes that combination of these behaviors and improve efficiency. Health Financing govern purchasing influence provider as well as M-2: Resource Mobilization The objective of contracting is to formalize the relationship between patient behavior and can influence how health care M-3: Pooling health service providers and purchasers. Contracting establishes the M-4: Benefits Specification resources are allocated and services are delivered. nature and mechanisms of collaboration between purchasers and M-5: Purchasing Health Services providers, including elements like specifying the services that will M-6: Public Financial Management This module focuses primarily on instruments for contracting and be delivered and payments that will be made. Contracting can be Inputs paying providers and excludes the broader governance aspects of critical to providing confidence and clarity, making desired outcomes Service Delivery purchasing, such as the effectiveness of a purchaser-provider split. explicit, enhancing accountability, controlling fraud, and facilitating Provider payment methods refer to how funds are transferred dispute resolution. Contracting is increasingly used in countries Outcomes between purchasers and health service providers. Contracting transitioning from input-based financing to output-based financing, 4 List of Acronyms is a tool that formalizes arrangements between purchasers and for example, when public providers are given increased autonomy health service providers. These instruments are complementary or when service coverage is extended through contracting private SECTION 4 Additional and central to implementing purchasing efficiently and equitably. providers, including nongovernmental organizations (NGOs). Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 185 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 BOX 1. DEFINITIONS OF TERMS SECTION 2 Cross-Cutting Analysis on CONTRACTING HEALTH SERVICE PROVIDER Efficiency and Equity Contracting is an instrument that formalizes arrangements. Health service providers deliver health services to people. Important health 3 Relationships between purchasers and providers can be defined service provider attributes include the type of health services they provide— by regulations and contractual arrangements. In contexts primary care, secondary care, tertiary care, or long-term care—as well as SECTION 3 where regulations are weak, contracting can help clarify the provider structure and ownership. Examples of how providers can operate Topic-Specific Analysis purchaser-provider relationship. Indeed, contracting between include a for-profit solo practice with only one health worker offering purchasers and health service providers specifies aspects such limited health services or a large not-for-profit government health facility Health System Context as type and volume of services, rules of access to services with many health workers and services. Health Financing for beneficiaries, performance objectives, quality targets, data sharing, and reporting requirements as well as payment HEALTH CARE PURCHASER M-2: Resource Mobilization mechanisms, prices of services, and invoicing protocols. The purchaser is the organization that pays health providers. It is also the M-3: Pooling Contracting can be essential for ensuring accountability and fundholding organization. It negotiates or sets rates for provider services, M-4: Benefits Specification potential legal recourse, if needed, for both purchasers and processes provider claims for service, and pays provider claims using M-5: Purchasing Health Services providers. However, contracts in the health sector tend to collected premiums or tax revenues. Examples include social health insurance M-6: Public Financial Management be relational contracts—the purchaser-provider contractual funds, commercial health insurance plans, third-party health insurance plan Inputs relationship is often focused on renegotiation and adjustments administrators, and government institutions, such as the Ministry of Health Service Delivery rather than enforcement through litigation. (MoH), as well as local governments at the subnational level. Outcomes 4 List of Acronyms Box 1 continues on the following page SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 186 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS (continued) 2 SECTION 2 PROVIDER PAYMENT METHOD different levels of risk (that is, uncertainty of revenue) on providers Cross-Cutting Payment methods are the specific mechanisms through which relative to payers. Analysis on Efficiency and providers are paid. These include line-item budget, capitation, global Equity 3 budget, case-based payments like diagnosis-related groups (DRGs), PURCHASING per diems, and fee-for-service. There are often discussions about Refers to the allocation of public funds to health service providers SECTION 3 input-based payments as compared with output-based payments for for the delivery of services to the population. To move from passive Topic-Specific health services. The former pay directly for inputs used to produce payments to strategically purchasing health services, payments Analysis health services, for example, for human resources through salaries of are linked to information on population health needs and provider health workers, while the latter pay for the health services themselves, performance and behavior. Key questions governing purchasing Health System Context for example, a payment made to a health provider for each outpatient arrangements are what services to buy to respond to the needs of the Health Financing visit. All payment methods create incentives for specific types of population, from whom to buy to effectively deliver these services, and M-2: Resource Mobilization provider behaviors, for example, certain provider payments like how to buy services in terms of the agreements between the purchaser M-3: Pooling fee-for-service may incentivize overproduction of services. PER authors and provider on payments and accountability. M-4: Benefits Specification should also keep in mind that different provider payments place M-5: Purchasing Health Services M-6: Public Financial Management Inputs This module specifically examines whether purchasing providers in some contexts. PER authors can refer to the Public Service Delivery arrangements in a country promote the efficient delivery of health Financial Management module for more information on these Outcomes services, cost control, and payment accountability. It also examines topics. Interested PER authors can refer to the publications 4 List of Acronyms whether purchasing arrangements promote equitable service recommended in the following box. delivery. The module does not consider budgeting principles SECTION 4 and resource allocation formulas, which will govern payments to Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 187 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 2. RECOMMENDED READING 2 SECTION 2 Langenbrunner, John C., Sheila O’Dougherty, and Cheryl S. Preker, Alexander S., and John C. Langenbrunner, eds. Cross-Cutting Cashin. 2009. Designing and Implementing 2005. Spending Wisely: Buying Health Services for the Analysis on Efficiency and Health Care Provider Payment Systems. Washington, DC: World Poor. Washington, DC: World Bank. https://documents1. Equity 3 Bank. https://elibrary.worldbank.org/doi/abs/10.1596/978-0- worldbank.org/curated/ru/845591468137396770/ 8213-7815-1. pdf/344250PAPER0Sp101Official0use0only1.pdf. SECTION 3 Topic-Specific Analysis Mathauer, I., and F. Dkhimi. 2018. Analytical Guide to World Health Organization. 2019. “Purchasing Health Services Assess a Mixed Provider Payment System. Guidance for Universal Health Coverage: How to Health System Context Document WHO/UHC/HGF/Guidance/19.5. Geneva: World Make It More Strategic?” Policy Paper. World Health Health Financing Health Organization, Department of Health Systems Organization, Geneva. https://iris.who.int/bitstream/ M-2: Resource Mobilization Governance and Financing. https://iris.who.int/bitstream/ handle/10665/311387/WHO-UCH-HGF-PolicyBrief-19.6-eng. M-3: Pooling handle/10665/311020/9789241515337-eng.pdf?sequence=1. pdf?sequence=1. M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 188 OVERVIEW 1 SECTION 1 What Is a Health PER? THE LANDSCAPE 2 SECTION 2 Cross-Cutting PURCHASERS, PROVIDERS, AND PURCHASING ARRANGEMENTS Analysis on Efficiency and Equity 3 • What types of purchasers, providers, and provider payment methods exist? SECTION 3 • What are the contracting arrangements in place between purchasers and providers? Topic-Specific KEY QUESTIONS Analysis • What share of government health expenditure is allocated to private and public Health System Context health service providers through contracting? Health Financing M-2: Resource Mobilization M-3: Pooling Identification of main purchasers, providers, provider’s characteristics, such as its ownership, and the services M-4: Benefits Specification it is being paid to provide, for example, primary care—as much as and provider payment methods is critical to M-5: Purchasing Health Services possible into homogenous categories. M-6: Public Financial Management understanding purchasing arrangements, provider Inputs payments, and contracting in a country. Many situations in such a landscape mapping could signal overall Service Delivery efficiency issues. For example, having many purchasers paying one Outcomes PER authors can use a matrix like the one suggested on the provider using different provider payment methods can create following page to map purchasers, providers, and provider inefficiencies. If provider payment methods are not aligned, 4 List of Acronyms payment methods, including shares of provider revenue. Authors contradictory incentives could be created. For example, a global SECTION 4 should try to group types of providers across two dimensions—the budget without any supplemental funding places all financial risk Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 189 OVERVIEW 1 SECTION 1 What Is a Health PER? on the provider. This could be a good strategy for cost control from the Ministry of Health (MoH), for example, but may be undermined if another purchaser, like the national health insurance fund, pays through fee-for-service. Specific efficiency issues related to choices of provider payment methods for different types of services are explored later in this module. 2 SECTION 2 Cross-Cutting Analysis on Provider and Payer Matrix1 Efficiency and Equity PAYER (ALL MAJOR PURCHASERS) 3 Type of provider (grouped Ministry of Health National Health Government Private Payments from SECTION 3 into types of services/ Insurance Fund Employee Insurance People Topic-Specific provider characteristics) Insurance Fund Funds Analysis 1 The matrix uses fictitious information for illustrative purposes. Public primary care • Line-item budget – 40% of revenue Capitation – Fee-for-service facilities • Results-based financing – 10% of 30% of revenue – 20% of Health System Context revenue revenue Health Financing Private primary care Fee-for-service Fee-for-service Out-of-pocket M-2: Resource Mobilization facilities – 50% of – 10% of payments – M-3: Pooling revenue revenue 40% of revenue M-4: Benefits Specification Public secondary care • Line-item budget – 40% of revenue Case-based Per diem – Case-based M-5: Purchasing Health Services facilities • Results-based financing – 10% of payments – 20% of revenue payments – M-6: Public Financial Management revenue 20% of revenue 10% of revenue Inputs Private secondary care Case-based Per diem – Case-based Out-of-pocket Service Delivery facilities payments – 50% of revenue payments – payments – Outcomes 30% of revenue 10% of revenue 10% of revenue 4 List of Acronyms Public tertiary care • Line-item budget – 40% of revenue Case-based Case-based facilities • Results-based financing – 20% of payments – payments – SECTION 4 revenue 20% of revenue 20% of revenue Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 190 OVERVIEW 1 SECTION 1 What Is a Health PER? How contracting should be conducted and what Key Indicators Sources 2 contracts should include can vary. However, SECTION 2 having some basic regulatory instruments for Contracting arrangements (for systems with a purchaser-provider split) Cross-Cutting contracting can facilitate its implementation. Analysis on Are there legal and regulatory instruments defining • Documentation Efficiency and Equity contracting? (policy, legal), KIIs 3 For example, in some countries, regulation defines framework contracts as to be used Market entry contracting (Yes/No) • Documentation SECTION 3 between purchasers and a group of providers, (policy, legal), KIIs Topic-Specific Analysis while in others, individual purchasers have Collective contracting (Yes/No) • Documentation more freedom in negotiating with providers (policy, legal), KIIs Health System Context (or, usually, provider organizations). Framework Health Financing contracts and collective contracting can reduce Does the country have a specific contracting policy • National health M-2: Resource Mobilization transaction costs but also sometimes add for the health sector (standalone or a specific planning M-3: Pooling rigidity in purchaser-provider relationships, section in a national health strategy/plan)? (Yes/No) documentation M-4: Benefits Specification thus hampering efficient funding allocation. So-called “market entry contracts” enable Share of prepaid pooled health expenditure • National Health M-5: Purchasing Health Services providers that meet certain market entry criteria allocated to private providers through contracting Accounts data M-6: Public Financial Management Inputs (in many contexts, set by licensing criteria) to be • Health insurance data automatically enrolled by purchasers. Knowing Share of prepaid pooled health expenditure Service Delivery • MoH data which type of arrangements are available in allocated to public providers through contracting Outcomes a country can help PER authors understand (not passive-budget transfers) • Budget data 4 List of Acronyms how easily contracts can be used in the health Note: KII = key informant interview; MoH = Ministry of Health. Using national health accounts data, the share allocated through contracting would be determined by looking at the cross-classification from health financing schemes (HF) to health providers (HP). sector. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 191 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors should also note that some countries have specific contracting policies for the health sector, while others draw from of coverage, efficiency, equity, and quality gains—results and impact are highly context-specific and require in-depth analysis 2 contracting policies set at the whole-of-government level. The (Loevinsohn and Harding 2005; Patouillard et al. 2007). latter often raises the question of the suitability of these policies SECTION 2 Cross-Cutting for the health sector and for the health care market. In some countries, contracting can also occur between different Analysis on public or quasi-public entities, for example, between a local Efficiency and Equity PER authors should also understand the overall volume of funds, government and an autonomous health facility, or between a quasi- 3 which can be subject to improvements in purchasing. In many public health insurance purchaser and a public health facility. The SECTION 3 countries, only government expenditure through contractual goals of these public-public contractual arrangements are usually Topic-Specific agreements between a public or quasi-public purchaser and well aligned with the objectives of purchasing—often they aim Analysis a private health service provider can be modified to enhance to increase transparency of resource allocation and strengthen purchasing, as other government spending is governed by rigid efficiency of spending, for example, by defining objectives for Health System Context civil service or public provision regulations. As such, knowing the output and for quality. Thus, in some contexts, PER authors could Health Financing share of government funds flowing through contracting to private usefully look at the share of government funding allocated within M-2: Resource Mobilization providers can be important. However, authors should note that the public sector through purchaser-provider contracts (instead of M-3: Pooling evidence on contracting with the private sector is mixed in terms passive budget transfers). M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 192 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY 2 SECTION 2 • Are purchasing arrangements in place encouraging the provision of appropriate Cross-Cutting Analysis on Efficiency and health services? Equity 3 • Do provider payment modalities ensure incentives for providers in terms of over- or underprovision of services? SECTION 3 KEY QUESTIONS Topic-Specific • Do purchasing arrangements incentivize service provision at the appropriate level of care? Analysis • Are there high administrative costs for purchasing? Health System Context • Do provider purchasing arrangements ensure incentives for cost control? Health Financing • Are there high administrative costs for purchasing? M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification A primary objective of purchasing, from the public PER authors can begin to understand their country’s purchasing M-5: Purchasing Health Services efficiency by examining the types of payments between providers M-6: Public Financial Management perspective, is the delivery of appropriate health and purchasers (as described in the landscape mapping earlier): Inputs services in a cost-minimizing manner. So, looking do they incentivize under- or overprovision of services, or do they Service Delivery at the interaction of purchasing arrangements and incentivize providing care at the appropriate service delivery level? Outcomes To identify inefficiency, authors should look for payment methods the provision of health services can reveal potential 4 List of Acronyms that incentivize higher production of cost-ineffective interventions causes of inefficiency. or disincentivize production of cost-effective interventions, such SECTION 4 as preventive health services. Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 193 OVERVIEW 1 SECTION 1 Paying hospital admissions through fee-for-service, breaking down each intervention received during What Is a the stay, for example, or per-diem payments, may incentivize overproduction, while paying preventive Health PER? health services such as vaccinations through line-item budgeting may not incentivize high coverage. 2 Similarly, authors should assess whether purchasing arrangements are in place that aim to incentivize SECTION 2 service provision at the appropriate level of care. For example, exclusion of primary facilities from Cross-Cutting Analysis on contracting or provider payments that encourage more service provision are not uncommon, as these Efficiency and facilities are often only financed through input-based payments. While they cannot be solely attributed Equity 3 to purchasing arrangements, trends in the following indicators may provide information on the needs for purchasing or provider payment reforms. SECTION 3 Topic-Specific Analysis PER authors should also note that often payment methods lack incentives for quality improvement: providers are paid for the quantity of care that they deliver or the number of individuals enrolled, Health System Context and usually not for the impact of their services on the health status of their patients (Tai, Kalanithi, Health Financing and Milstein 2014). Results-based financing (RBF), performance-based financing (PBF), and pay-for- M-2: Resource Mobilization performance (P4P) models have become more popular as a way to incentivize quality service provision, M-3: Pooling as these models focus on creating incentives for specific provider behaviors, such as predefined M-4: Benefits Specification disease-specific quality targets. RBF/PBF/P4P models can provide complementary funding to providers M-5: Purchasing Health Services that meet specific criteria but typically involve only a small share of provider revenue. However, even M-6: Public Financial Management marginal complementary funding tied to specific performance outcomes can be an important incentive Inputs to drive provider behavior. Service Delivery Outcomes Authors can also consult the modules on Benefits Specification , Hospitals , and Primary Care and Essential Public Health Functions and the additional guidance note on Quality of Health 4 List of Acronyms Services to better understand services offered and provision issues. Finally, PER authors should consider provider payment issues discussed here with an equity and access mindset in conjunction SECTION 4 Additional with the last section of this module. Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 194 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Essential, non-essential, promotive, Sources • Policy documents review 2 preventive services and medicines in • KIIs SECTION 2 the health benefit package Cross-Cutting Analysis on Quality-of-care criteria are explicitly • Policy documents review Efficiency and used for provider payment/ • KIIs Equity 3 contracting agreements SECTION 3 Total number of outpatient visits or • National Health Services Topic-Specific services per enrolled person Survey Analysis • Official reports from insurers and governments Health System Context Total number of inpatient visits or • National Health Services Health Financing services per enrolled person Survey M-2: Resource Mobilization • Official reports from insurers M-3: Pooling and governments M-4: Benefits Specification M-5: Purchasing Health Services Proportion of visits during which a • National Health Services costly service (defined by country) Survey M-6: Public Financial Management occurred • Official reports from insurers Inputs and governments Service Delivery % of visits delivered at the primary • National Health Services Outcomes care level Survey 4 List of Acronyms Number of (hospital) admissions per • National Health Services SECTION 4 1,000 population Survey Additional Note: KII = key informant interview. Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 195 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors should also consider cost control issues more in depth, as they can be closely linked to efficiency. One proxy indicator for this is whether provider payment methods that naturally discourage Key Indicators Payment methods are in Sources • National facility-based 2 aggregate cost escalation are used. place that aim to control surveys SECTION 2 costs (i.e., capitation, global • KIIs Cross-Cutting budgets, salaries) Analysis on Additionally, authors can consider average payments over time, for Efficiency and Equity different services and by different providers. This can be obtained Average payment and its • Official reports from insurers 3 easily in countries with social health insurance with a robust financial trends by type of provider, and governments management information system database and a high-quality claims payment method, and • Government budget SECTION 3 database. It can be benchmarked across geopolitical entities and service documents Topic-Specific Analysis • Previous costing studies over time. These can be further broken down by average cost by Average cost and its trend by payment modality. In countries that rely on line-item budgeting for Health System Context type of provider and service their provider payments, costing methods to estimate costs to the Health Financing public purse for different types of providers and services can be used, Number of contracts under • Policy and legal documents M-2: Resource Mobilization or estimates from any previous costing studies. High administrative framework contracts review M-3: Pooling costs can also add to inefficiency in purchasing. • KIIs M-4: Benefits Specification Number of contracts that are individually negotiated M-5: Purchasing Health Services As administrative costs are often linked to institutional arrangements, contracts between M-6: Public Financial Management this topic is covered more in the module on Pooling. In addition, purchasers and providers Inputs purchasing arrangements such as framework contracting can Note: KII = key informant interview. Service Delivery also help reduce legal costs for purchasers as compared to costly Outcomes negotiations of individual contracts with different providers. So, PER authors in countries with significant reliance on contracting 4 List of Acronyms can also consider the degree of use of framework contracting when SECTION 4 considering administrative costs. Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 196 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and GOVERNANCE Equity 3 SECTION 3 Topic-Specific Analysis Health System Context KEY QUESTIONS • How is the amount paid to providers for services established? • Are payments to providers timely? • Do purchasers have effective mechanisms to monitor providers and identify fraud? Health Financing M-2: Resource Mobilization M-3: Pooling Accurately determining the amount to be paid to Collective negotiation of prices is, like contracting, typically M-4: Benefits Specification characterized by cooperation between parties and based on providers for services is important, as inappropriate M-5: Purchasing Health Services systematic information sharing and consultation processes to M-6: Public Financial Management payment levels can distort provider incentives. ensure that both purchasers and providers understand and accept Inputs The process of setting payment rates, the pricing, the evidence base for pricing decisions. Unfortunately, however, provider payment methods and prices are often set by regulations Service Delivery is in most cases either a unilateral administrative Outcomes without much data analytics. process (regulations) or a collective negotiation. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 197 OVERVIEW 1 SECTION 1 What Is a Health PER? Ideally, information underpinning the price- setting process includes cost data as well as Key Indicators Sources 2 estimates of the impact of rate changes on Criteria used for price setting: Historical • Policy/document review SECTION 2 provider revenues and behaviors, purchasers’ norms, spending patterns, time-based • National facility-based surveys Cross-Cutting expenditures, and overall system sustainability. activity costing, top-down costing, normative • KIIs Analysis on Efficiency and In many cases, price setting takes place within costing Equity 3 the constraints of expenditure ceilings. Data on provider costs available to • Policy/document review purchasers (Yes/No) (by type of provider) • KIIs SECTION 3 PER authors can explore which type of criteria Topic-Specific was used for price setting. Common options Average time taken from claim filing to • National facility-based surveys Analysis for price setting include using historical prices, payment • KIIs recent spending patterns, time-based activity- Health System Context Average time taken from claim approval to • National facility-based surveys based costing (which establishes unit costs by Health Financing payment • KIIs tracking the actual resource use and associated M-2: Resource Mobilization costs of care delivery for individual patients), Delays in health provider fund disbursement • Public financial management M-3: Pooling and top-down costing (which allocates total information systems M-4: Benefits Specification facility costs downward to departments and Delays in health worker salary payments • KIIs M-5: Purchasing Health Services then services, yielding average unit costs). M-6: Public Financial Management Purchaser has a data analysis unit (Yes/No) • Documentation Providers’ sharing this type of cost data with Inputs • KIIs purchasers and policymakers and academics Service Delivery can be an excellent tool for negotiations and % of contracted providers audited • Purchaser reports Outcomes cost control. This information can be collected % of flagged provider claims audited • Purchaser administrative data 4 List of Acronyms from providers regularly or through specific exercises. Price setting that is not supported by % of flagged provision statements audited • Purchaser administrative data SECTION 4 data may be a signal of potential inefficiencies. Note: KII = Key informant interview. Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 198 OVERVIEW 1 SECTION 1 What Is a Health PER? Overall, setting prices too low or too high is problematic from the perspective of providers and purchasers, respectively. When cash flow, ensure financial predictability, and facilitate smooth health facility operations. PER authors should describe any 2 prices are set too low, the financial sustainability of providers policies/contracts that mandate a maximum amount of time by SECTION 2 suffers and often results in practices like nonprovision of services, which provider claims must be paid (prompt payment laws) and Cross-Cutting implicit rationing of services, lower quality of delivered services explore whether this is respected in practice. After collecting this Analysis on Efficiency and and additional billing to patients. These problems are also information, authors can also compare the average time taken Equity 3 prevalent in systems that rely on passive budget transfers to across payers. providers without much accountability for performance or outputs. SECTION 3 Thus, setting prices too low in a way may eliminate some of the In systems with budgetary transfer to facilities, delays in Topic-Specific inherent benefits of purchasing as compared to passive transfers. disbursement of funds to facilities should be monitored. Delays Analysis can also be considered at different levels of fund disbursement, Health System Context Conversely, when prices are set too high, the financial sustainability for example, between different levels of government as well as of purchasers becomes precarious, with a need for additional to subordinate health facilities (for example, disbursement to a Health Financing government subsidization. If prices are set too high relative to smaller health facility that is administered by a larger facility). M-2: Resource Mobilization the purchasers’ revenues but not relative to the provider’s cost Finally, delays in receiving salaries could also be considered. PER M-3: Pooling of production, mechanisms like additional budget transfers, for authors can consult the Public Financial Management module for M-4: Benefits Specification example, from the government budget to the national health further guidance on this topic. M-5: Purchasing Health Services insurance fund can be deployed. These are considered preferable M-6: Public Financial Management as the monopsony (or monopsony-like) power of national health Lack of information systems is a major obstacle to effective Inputs insurance fund still will theoretically result in better prices from purchasing and mitigating against issues like fraud. Indeed, a good Service Delivery providers, lower transaction costs, and thus more efficiency. information system is a crucial prerequisite for ensuring value for Outcomes money for purchased health services. Accessing the information is, 4 List of Acronyms Usually, the time frame for reimbursement is specified in the however, not enough; purchasers also need the capacity to regularly contracts between purchasers and providers. Timely payment or process the information and analyze data at the granular level to SECTION 4 reimbursement is important for providers to maintain a healthy develop a long-term purchasing strategy. Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 199 OVERVIEW 1 SECTION 1 What Is a Health PER? Provider fraud is a significant drain on public spending. 2 Effective fraud detection hinges on monitoring, data SECTION 2 verification (particularly claims data), and information Cross-Cutting exchange. Incorporating auditing and data mining Analysis on Efficiency and into purchaser-provider contracts, contingent on the Equity information system’s capabilities, can enhance fraud 3 prevention. These measures enforce data sharing, SECTION 3 transparency, clear payment mechanisms, and provider Topic-Specific oversight. But contracting in the health sector tends to be Analysis relational, and as a result, relationship-building between the purchaser and providers beyond the contract can Health System Context also be an important tool to ensure accountability and Health Financing to prevent fraud. PER authors should try to explore M-2: Resource Mobilization the degree to which information systems, relational M-3: Pooling contracting, and data use foster fraud control. M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 200 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY 2 SECTION 2 • Does the selection of providers for contracting foster equitable access to health care? Cross-Cutting KEY QUESTIONS Analysis on • Do providers levy additional fees on patients? Efficiency and Equity 3 Purchasing can also be an important Key Indicators Sources SECTION 3 Topic-Specific driver of equity in a health system by Analysis Provider payments encourage provision of services • Documentation ensuring health services correspond in underserved areas and for at-risk populations • KIIs Health System Context to needs, irrespective of (Yes/No) Health Financing socioeconomic status of people. The criteria used to select which providers to • Documentation M-2: Resource Mobilization contract with discourage contracting with providers • KIIs M-3: Pooling operating in underserved arears (Yes/No) Provider payments can encourage provision of M-4: Benefits Specification services in underserved areas and for at-risk Balance billing is permitted in contract • Documentation M-5: Purchasing Health Services populations. This can be done by making • KIIs M-6: Public Financial Management supplemental payments, for example, to health Inputs % of claims where patients were also billed • National Health Services Survey providers or health workers who operate in rural Service Delivery additionally • Official reports from insurers areas. Similarly, hospitals that serve higher Outcomes risk populations are often allocated a higher and governments 4 List of Acronyms budget. PER authors can examine whether such % of people reporting having made informal • National Health Services Survey arrangements exist in their country. payments to providers, by type of provider SECTION 4 Note: KII = Key informant interview. Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 201 OVERVIEW 1 SECTION 1 What Is a Health PER? Another important driver of equity may simply be which providers can receive payments from purchasing arrangements. It is not and services. In some countries, for example, accredited health facilities receive more payments from health insurance funds 2 uncommon for rural facilities, particularly rural government than unaccredited facilities. In other countries, when entering a SECTION 2 facilities, to simply be excluded from payments by national health contract with specific unaccredited facilities, a time frame for the Cross-Cutting Analysis on insurance funds. This type of situation implies that these facilities facility to become accredited is stipulated. Efficiency and Equity may receive fewer funds as well as fewer funds that incentivize 3 higher service provision as compared to private facilities in urban There are also overlaps with efficiency issues in some situations. areas, generally frequented by wealthier patients. Similarly, if Provider selection is sometimes based on the range of services SECTION 3 Topic-Specific nurse- or midwife-led health consultations are excluded from a provider can offer. For example, the national health insurance Analysis purchasing arrangements and, at the same time, more likely to in the Philippines, PhilHealth, contracts for a specialized-service be frequented by poorer women, then the purchasing system package only with hospitals that have a certain level of readiness Health System Context is exacerbating existing inequities. In this context, PER authors to provide a defined set of specialized care (Dayrit et al. 2018). Health Financing should reconsider the landscape mapping exercise from an equity The situation is more extreme in other settings where selection is M-2: Resource Mobilization perspective. based on price and involves two scenarios. High-end private clinics M-3: Pooling usually contract only with high-end voluntary health insurance M-4: Benefits Specification PER authors can consider the criteria used by purchasers for schemes, which are limited in low-income countries and lower- M-5: Purchasing Health Services contracting with providers systematically to understand whether middle-income countries. The high-end private clinics usually M-6: Public Financial Management they are likely to result in systematic bias toward certain catchment choose not to contract with public purchasers (if this is an option) Inputs populations. A commonly used criterion is the provider’s or are excluded by public purchasers because of price. From a Service Delivery accreditation. Structural quality, which can be determined ex ante public spending perspective, some purchasers that can make a Outcomes (for example, staff numbers and skills mix, service hours, and so make-or-buy decision often face a choice between contracting on), is another example. Ideally, instead of excluding providers for high-price services in the private sector or developing those 4 List of Acronyms in underserved areas completely, purchasing arrangements can services in-house. The efficiency of make-or-buy decisions is SECTION 4 encourage a pathway for these facilities to improve their facilities context specific and additionally may differ between a specific Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 202 OVERVIEW 1 SECTION 1 What Is a Health PER? government purchaser and whole health system. At the same time, the exclusion of high-end services can 2 perpetuate existing inequalities and dual-track health SECTION 2 systems. Cross-Cutting Analysis on Efficiency and Equity The practice of providers levying additional payments 3 on patients—either formally through balance billing policies or informally through demanding extra SECTION 3 Topic-Specific payments for services—is an important concern for Analysis equity. Where balance billing is permitted, patients can face substantial out-of-pocket payments at the risk of Health System Context financial catastrophe or forgone care. This is also the Health Financing case when informal payments to providers are common. M-2: Resource Mobilization As such, PER authors can examine indicators related to M-3: Pooling these issues. M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 203 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on References Efficiency and Equity 3 Dayrit, M.M., L.P. Lagrada, O.F. Picazo, M.C. Pons, and M.C. Villaverde. 2018. “The Philippines Health System Review.” Health Systems in Transition 8 SECTION 3 (2). https://iris.who.int/handle/10665/274579. Topic-Specific Analysis Loevinsohn, Benjamin, and April Harding. 2005. “Buying Results? Contracting for Health Service Delivery in Developing Countries.” The Lancet 366 (9486): 676–81. https://doi.org/10.1016/S01406736(05)67140-1. Health System Context Patouillard, Edith, Catherine A. Goodman, Kara G. Hanson, and Anne J. Mills. 2007. “Can Working with the Private For-Profit Sector Improve Utilization Health Financing of Quality Health Services by the Poor? A Systematic Review of the Literature.” International Journal for Equity in Health 6 (November): 17. https:// M-2: Resource Mobilization doi.org/10.1186/1475-9276-6-17. M-3: Pooling M-4: Benefits Specification Tai, Waimei, Lucy Kalanithi, and Arnold Milstein. 2014. “What Can Be Achieved by Redesigning Stroke Care for a Value-Based World?” Expert Review M-5: Purchasing Health Services of Pharmacoeconomics & Outcomes Research 14 (5): 585–87. https://doi.org/10.1586/14737167.2014.946013. M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 5 Purchasing Health Services 204 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 MODULE 6 SECTION 3 Public Financial Topic-Specific Analysis Health System Context Management in Health Financing M-2: Resource Mobilization Health M-3: Pooling M-4: Benefits Specification M-5: Purchasing Health Services M-6: Public Financial Management Inputs AUTHOR Service Delivery Moritz Piatti-Fünfkirchen Outcomes 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 205 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 INTRODUCTION SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 Evidence that health outcomes are associated The module consists of three sections: SECTION 3 with better management of public finances is 1. The first section identifies some of the available diagnostic Topic-Specific Analysis growing (Tapsoba et al. 2024; Piatti-Fünfkirchen tools and online resources that are available to PER authors and Smets 2019; Welham et al. 2017). A health and offers some guidance on how to interpret and use them. Health System Context public expenditure review (PER) should therefore 2. The second section offers ways to assess the flow of funds to Health Financing comment on the adequacy of public financial identify areas for an in-depth analysis. M-2: Resource Mobilization management (PFM) systems for health. 3. The third section provides guidance on priority topics that M-3: Pooling may be selected for a drill-down analysis, such as how PFM M-4: Benefits Specification This module offers practical lines of inquiry for a PFM chapter in a relates to the payment of the health workforce. M-5: Purchasing Health Services M-6: Public Financial Management health PER. Before assessing the PFM context in the health sector, Inputs PER authors should check whether there is ongoing work from the Service Delivery Governance Global Practice or other partners. Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 206 OVERVIEW 1 SECTION 1 What Is a Health PER? CONSULT KEY PFM DIAGNOSTIC ASSESSMENTS 2 SECTION 2 Cross-Cutting A wide range of PFM diagnostics Tips on how to read a PEFA assessment Analysis on Efficiency and The Public Expenditure and Financial Accountability (PEFA) While a PEFA assessment is not sector specific, certain aspects are Equity 3 secretariat offers an overview of available tools in A Guide to relevant for sectors like health (Box 1). A country’s PEFA Annex 1 PFM Diagnostic Tools (PEFA 2018). A PEFA assessment evaluates a includes a performance indicator summary and shows progress SECTION 3 country’s PFM system, reviewing key aspects of the budget cycle made since the previous assessment. PEFA Annex 4 describes Topic-Specific and systemwide shortcomings. PER authors may wish to check if data used for scoring, including data for the health budget and Analysis a PEFA assessment was recently completed for their country and health execution, to help assess budget execution performance. Health System Context interpret results for the health sector.1 Authors may also wish to compare country performance with other countries, using a web-based tool2 that allows for quick Health Financing triangulation of data. M-2: Resource Mobilization M-3: Pooling M-4: Benefits Specification 1 See https://www.pefa.org/assessments. M-5: Purchasing Health Services 2 https://clever-albattani-34d259.netlify.app/. M-6: Public Financial Management Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 207 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. KEY COMPONENTS OF PEFA ASSESSMENTS MOST RELEVANT FOR THE HEALTH SECTOR Budget Policy-Based Fiscal Accounting, Recording, 2 1 3 5 Credibility Strategy and Budgeting and Reporting SECTION 2 Cross-Cutting Relevance: The health sector requires reliable Relevance: Health sector budgets should be Relevance: Accurate and timely financial Analysis on Efficiency and funding to provide services. PEFA evaluates aligned with national health policies or other records are essential for monitoring health Equity 3 whether actual expenditures align with long-term strategies. sector expenditures and evaluating the approved budgets Impact on health: Linking the health budget impact of health investments. SECTION 3 Impact on health: If the health budget to policy objectives should ensure that Impact on health: Regular and reliable Topic-Specific allocations are not executed as planned, health government spending targets critical areas, reporting supports better decision making Analysis services may suffer from funding shortfalls, such as immunization, maternal health, or in the health sector, enabling midyear affecting quality and access to care. disease prevention. adjustments to address emerging health Health System Context priorities or crises. Health Financing Comprehensiveness Predictability and Control M-2: Resource Mobilization 2 4 and Transparency in Budget Execution External Scrutiny M-3: Pooling 6 and Audit M-4: Benefits Specification Relevance: The clarity of health sector budgets, Relevance: Predictable fund flows and robust M-5: Purchasing Health Services the comprehensiveness of reporting, and the control mechanisms are vital for the efficient Relevance: External audits and legislative M-6: Public Financial Management availability of health-specific data in budget functioning of health systems. oversight help ensure accountability in health Inputs documents show how well health needs are Impact on health: Timely disbursement of spending and program implementation. Service Delivery understood and funded. funds ensures that health programs continue Impact on health: Audits of health programs Impact on health: Transparent allocation uninterrupted, while controls (like audits can uncover inefficiencies, corruption, or Outcomes allows stakeholders to track health spending, and expenditure tracking) prevent misuse or underperformance, ensuring that health 4 List of Acronyms ensuring funds are appropriately directed inefficiency in health spending. resources are used optimally to improve toward health priorities like hospitals, service delivery. SECTION 4 medicines, or preventive care. Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 208 OVERVIEW 1 SECTION 1 What Is a Health PER? Recent International Monetary Fund (IMF) Article IV report. PER budget formulation, execution, and monitoring within the health 2 authors can search the report for references to the health sector. sector. It illustrates why and when each tool can be used, giving SECTION 2 Authors may also use the fiscal table in Annex 1 to refer to gross examples of how tools were applied in particular countries. The Cross-Cutting domestic product (GDP), government expenditure, and fiscal World Health Organization (WHO) Montreux Collaborative offers a Analysis on Efficiency and deficit trends for the PER. repository for health-specific PFM work.3 The following tools are Equity 3 noteworthy: World Bank documents. The fiduciary assessment in Program • The Governance Global Practice developed the FinHealth SECTION 3 for Results (PforR) project appraisal documents or in the recent Topic-Specific tool (World Bank Group 2019), which describes the entire Analysis Development Policy Financing (DPF) identifies the main concerns budget cycle to guide PER authors through a problem-driven (for example, whether funds allocated to a program will also approach. Unlike the PEFA assessment, the FinHealth tool has Health System Context be spent on it). General government public finance reviews or no scoring or benchmarking system. Health Financing public expenditure reviews led by the Macroeconomics, Trade M-2: Resource Mobilization and Investment (MTI) Global Practice or the Governance Global • The WHO health financing progress matrix assessment4 lists M-3: Pooling Practice often have a PFM section to consult, as well as health PFM–in–health-related questions that can be relevant for M-4: Benefits Specification PERs with PFM chapters, such as the Namibia Health Sector Public health PERs. M-5: Purchasing Health Services Expenditure Review (Schneider et al. 2019) and the Zambia Health Sector Public Expenditure Review (Chansa et al. 2018). • The UNICEF public finance toolkit (UNICEF 2021) can be used M-6: Public Financial Management for a problem-driven approach to PFM challenges in health Inputs Documents with health–sector-specific PFM tools. A more service delivery, with an emphasis on the wellbeing of Service Delivery recent mapping (World Health Organization 2023) provides children. Outcomes information about key PFM tools for assessing challenges in 4 List of Acronyms 3 https://www.pfm4health.net/. SECTION 4 4 https://www.who.int/PER authors/health-financing-and-economics/health-financing/diagnostics/health-financing-progress-matrix. Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 209 OVERVIEW 1 SECTION 1 What Is a Health PER? • The Health, Nutrition, and Population Global Practice’s PBF 2 mainstreaming tool (Piatti-Fünfkirchen et al. 2021) provides SECTION 2 a methodology for assessing whether PFM systems offer Cross-Cutting Analysis on core functions needed to pay for primary health care (PHC) Efficiency and (whether PFM enables PHC provider autonomy and whether Equity 3 there is a unified payment system with sufficient capacity that is output oriented). SECTION 3 Topic-Specific PER authors would benefit from reviewing whether any of these Analysis assessments has already been completed for the country of Health System Context interest. They can summarize their findings and recommendations in the health PER and discuss how the recommendations have Health Financing been implemented. If no prior assessment has been conducted M-2: Resource Mobilization or there is a need to complement the previous analysis (or to M-3: Pooling complement a previous assessment), the authors may wish to map M-4: Benefits Specification the flow of funds and transactions profile in government, identify M-5: Purchasing Health Services areas of concern, and then conduct an in-depth review of specific M-6: Public Financial Management areas. These steps are discussed in the following sections. Inputs Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 210 OVERVIEW 1 SECTION 1 What Is a Health PER? MAP THE TRANSACTION PROFILE AND FLOW OF FUNDS WITHIN THE GOVERNMENT BUDGET TO IDENTIFY PFM BOTTLENECKS IN 2 SECTION 2 THE HEALTH SECTOR Cross-Cutting Analysis on Efficiency and Equity This section guides PER authors through identifying PFM bottlenecks in the health sector. The first step is to 3 collect the relevant data for the task. A PER should use expenditure data (not budget data) from the country’s SECTION 3 Topic-Specific government. Second, authors should develop a transaction profile and discuss in the PER the flow of funds. Analysis Finally, they can identify PFM bottlenecks in health using the insights generated during the previous steps. Health System Context Health Financing Collect the Relevant Data M-2: Resource Mobilization M-3: Pooling Global Health Expenditure Database.5 PER authors should only execution reports. For example, the Ministry of Finance and M-4: Benefits Specification use this database for cross-country comparisons of relevant Economic Planning (MINECOFIN) in Rwanda periodically publishes M-5: Purchasing Health Services indicators, such as government health expenditures in percent on its website6 its budget speech, budgets, budget execution M-6: Public Financial Management of GDP. reports, and various laws, strategies, guidelines, and data. Inputs MoF expenditure data from the MoF’s Financial Management Service Delivery PER authors can visit the country’s Ministry of Finance (MoF) Information System (FMIS) are usually available through the World Outcomes website for the published budget, revised budget, and budget Bank country economist. 4 List of Acronyms 5 Accessible through World Health Organization Global Health Expenditure Database (https://apps.who.int/nha/database) and the World Bank World Development Indicators (WDI) database (https://databank.worldbank.org/ SECTION 4 source/world-development-indicators). 6 https://www.minecofin.gov.rw/1/publications/report. Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 211 OVERVIEW 1 SECTION 1 What Is a Health PER? The Budget Enquirer tool7 from the Collaborative Africa Budget Reform Initiative (CABRI) is a valuable resource designed to give TABLE 1 RECOMMENDED FORMAT TO EXPORT HEALTH SECTOR BUDGET AND EXPENDITURE DATA FROM FMIS BY YEAR (WITH EXAMPLES) 2 quick access to public documents, including published budget SECTION 2 and expenditure reports. Admin code Local MoH Teaching hospital (1-3) vote government Cross-Cutting Analysis on Efficiency and The Governance BOOST initiative uses FMIS data and puts the Project Recurrent Capital (e.g., building Capital (e.g., labs, procuring an ICT investing in a CT Equity data into a user-friendly format. PER authors should consult with 3 scanner, etc.) scanner) the country economist and check the BOOST Open Budget Portal Program and PHC program SECTION 3 website8 for recent BOOST datasets relevant for the health sector. subprogram Topic-Specific If a National Health Accounts (NHA) exercise was conducted using Output Number Analysis the FMIS, the findings should be reported in the health PER. of persons reached Authors should cross-check FMIS expenditure data with the NHA. Health System Context Target X % of population Health Financing If more detailed health expenditure information is needed, PER in need M-2: Resource Mobilization authors should contact the MoF’s FMIS department for a set of Activity Outreach M-3: Pooling services comprehensive data for the health sector. They should make M-4: Benefits Specification sure the data will be structured in the tabular format shown in Econ 1-3 Allowance M-5: Purchasing Health Services Table 1. In almost all instances, the FMIS can support this data Source Govt. budget DP project M-6: Public Financial Management request. Exports in pdf should be avoided, as this format makes Inputs GFS code 16-digit code it difficult to analyze the data and may require timely and error- Service Delivery prone transcription. If data are shared in MS Excel, the file size Budget 100 Outcomes may be big; therefore, PER authors should be prepared with a USB Revised 85 4 List of Acronyms drive in case the file is too large to share as an email attachment. budget Actual 90 SECTION 4 7 https://www.cabri-sbo.org/en/budgets-in-africa/budget-enquirer. Additional Note: DP = development partner; MoH = Ministry of Health; PHC = primary health care. 8 https://www.worldbank.org/en/programs/boost-portal/about-boost. Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 212 OVERVIEW 1 SECTION 1 What Is a Health PER? The government budget and the expenditure reports in the FMIS example, a PHC program or hospital care program) or in 2 are structured according to the government’s chart of accounts vertical programs (a Reproductive, Maternal, Newborn, and SECTION 2 (COA). The following more detailed description of Table 1’s Child Health (RMNCH) program or a malaria or HIV program), Cross-Cutting categories may be helpful to PER authors when downloading which are often financed by development partners. The Analysis on Efficiency and FMIS data. purpose of programs is to allocate resources toward priority Equity 3 areas. A program may cut across multiple departments in • The admin code 1–3 (also often called “vote,” “subvote,” and the administration (under the “admin code” category in SECTION 3 “spending unit”) represents the administrative structure by the table). Allocating funds to programs while overseeing Topic-Specific Ministry, Department and Spending Unit. Often large hospitals Analysis the daily workload can lead to a complex administrative or insurance funds are at the vote level (treated like a arrangement that can become difficult to manage. It might ministry). The MoF is also at the vote level and may be relevant Health System Context mean, for example, that a primary care provider can access if subsidy payments are made directly to insurance funds. Health Financing funds from a maternal and child health program, a malaria M-2: Resource Mobilization • The project code shows whether spending relates to the program, a public health program, and possibly others. The M-3: Pooling recurrent budget or a dedicated project in the investment more direct the relationship between program structure and M-4: Benefits Specification budget. It often includes on-budget development partners administrative entities, the easier a program is to manage. M-5: Purchasing Health Services (including World Bank projects), even if the project • Output and targets are a set of indicators for programs to M-6: Public Financial Management finances recurrent expenditure items. The project code allocate resources to measurable results. Indicators should Inputs may include capital spending items, such as investment in be attributable to activities or interventions under the labs, refurbishment of facilities, and procurement of large Service Delivery program (for example, the number of children immunized equipment (for example, a CT scanner or ICT equipment). Outcomes under an immunization program). • The program and subprogram column lists the names of 4 List of Acronyms • Activities. Each program is further divided into activities programs. These can be organized by level of care (for (often used in a costing analysis). SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 213 OVERVIEW 1 SECTION 1 What Is a Health PER? • Economic classification lists the line items to be funded to administration; and can be used for other analytic purposes (such 2 implement each activity, including, for example, salaries, as a nutrition expenditure analysis; see Piatti-Fünfkirchen et al. SECTION 2 allowances, fuel, cleaning supplies, grants, and so on. Grants 2020) to inform the functioning of the health sector. Cross-Cutting Analysis on may reflect transfers to other government entities (for Efficiency and example, a subsidy to an insurance fund) or a transfer to a The usefulness of analysis from government expenditure data Equity 3 nongovernmental health provider. for a PER hinges on the quality of the underlying expenditure data. A PER based on partial government data that lack integrity SECTION 3 • Financing sources show where funds come from (for may result in misleading information. It is therefore important Topic-Specific example, the general budget, internally generated funds, or Analysis to verify the data and identify limitations, when appropriate, development partners). before presenting the findings. For example, the health chapter Health System Context • A unique GFS code (usually 16 digits) is associated with each in the Comoros PER health chapter (World Bank 2023) identifies Health Financing budget line to help with identification. substantial discrepancies between the spending data reported M-2: Resource Mobilization in the government’s budget execution report and the Integrated • The original budget, a revised budget, and actual spending M-3: Pooling Financial Management Information Systems (IFMIS) (see Table show the relevant amounts for each activity during the M-4: Benefits Specification 14 in the Comoros PER). To assess the quality of expenditure reporting period in local currency. M-5: Purchasing Health Services reporting, PER authors should examine the data for (1) provenance M-6: Public Financial Management and integrity; (2) comprehensiveness of reports; (3) usefulness; Inputs PER authors should access data for the three to five most recent (4) consistency; and (5) stability. Box 2 explains these concepts years to analyze trends. FMIS data will enable a detailed PER in more detail. Service Delivery analysis of budget execution by program (for example, a primary Outcomes care program) or activity (for example, outreach services) or 4 List of Acronyms line item (for example, salaries); will show the structure of the SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 214 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 2. CONSIDERATIONS FOR ASSESSING THE QUALITY OF GOVERNMENT EXPENDITURE DATA 2 Data Provenance 3 Usefulness difficult. Similarly, data structure should be SECTION 2 1 Cross-Cutting and Integrity consistent across systems so that, for example, PER authors should assess data according to Analysis on the financial management information system Efficiency and There should be evidence of where data came how the data are structured. For example, it Equity can interface with the human resources 3 from, who produced the data, where the data can be difficult to estimate maternal and child information system, the health information were stored, and whether the production of health spending if the government has no system, or the procurement system. SECTION 3 expenditure data is subject to appropriate means to make explicit budget provisions for Topic-Specific such. This needs to be noted instead of making controls to have integrity. Analysis 5 Stability unrealistic assumptions about shares and time spent on such services. Instead, it can be more Comparability over time is needed for analysis. Health System Context 2 Comprehensiveness useful for authors to review the administrative If structures change too much, it becomes Health Financing Do expenditure data cover all health structure (for example, how much is spent on difficult to analyze data (for example, if the M-2: Resource Mobilization spending across the government? Beyond use of programs significantly changes year various departments or programs) and then M-3: Pooling the MoH, data may include local government, on year, it becomes difficult to understand provide feedback on the services they offer. M-4: Benefits Specification insurance agencies, ministries of finance, and the real differences in spending priorities). M-5: Purchasing Health Services other agencies. Obtaining comprehensive 4 Consistency In Zimbabwe in 2021, for example, a program M-6: Public Financial Management data requires understanding the various and four subprograms were added, and four institutions’ mandate (for example, the MoF’s Consistency is needed to produce data that Inputs subprograms were removed, resulting in 35 payment to health care treatment overseas can interface across systems and over space Service Delivery percent of the 2020 approved budget being would be missed in a MoH budget review). and time to allow for meaningful analysis. allocated to programs that no longer existed in Outcomes For example, having different structures of the 2021 budget. 4 List of Acronyms expenditure data across levels of government or over time makes meaningful analysis SECTION 4 These terms are explained in more depth in The Government Analytics Handbook expenditure chapter (Piatti-Fünfkirchen et al. 2023). Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 215 OVERVIEW 1 SECTION 1 What Is a Health PER? Map the Transaction Profile and Flow of Funds 2 SECTION 2 Cross-Cutting The transaction profile in the health sector ranks all spending for by the government are appropriate for all types of transactions. Analysis on Efficiency and a fiscal year from lowest to highest value transaction using data Control protocols define how the budget line can be used. It may Equity from the FMIS (Figure 1). From this, PER authors can tell whether not be necessary to have the same type of controls in place for all 3 the transaction profile is skewed toward high-value transactions transactions, regardless of their risk profile. Often the low-value SECTION 3 and determine where the highest fiduciary risks lie. Hashim et transactions relate to frontline service provision. Authors could Topic-Specific al. (2019) show how to generate a transaction profile based on recommend in their PER risk-adjusted expenditure management, Analysis data from Cambodia and Pakistan. Generally, about 20 percent which ensures tight control for high-risk big transactions, such as of transactions make up about 80 percent of total volume of the wage bill, and more flexibility at the point of health service Health System Context spending. The Tanzania Health Sector Public Expenditure Review provision (such as charging paper clips under cleaning products Health Financing (Piatti-Fünfkirchen and Ally 2020) gives an example of a transaction in rural health facilities). M-2: Resource Mobilization profile (see Figure 19 in the PER). It shows the skewed nature of M-3: Pooling transactions: about 60,000 transactions make up only about 10 A simple analysis to assess how controls are applied in the health M-4: Benefits Specification percent of total spending; far fewer transactions (about 8,000) sector compares the total spending reflected in the FMIS to the M-5: Purchasing Health Services make up about 90 percent of spending. High-value transactions total expenditures from government financial statements. All M-6: Public Financial Management tend to be the wage bill, intergovernmental transfers or subsidies, spending in the FMIS goes through internal controls. Spending Inputs or large capital projects. PER authors’ PER analysis should focus that is not in the FMIS but in published expenditure reports Service Delivery on high-value transactions. (government budget execution reports) is processed outside the Outcomes FMIS and thus is not subject to those controls, as shown in the 4 List of Acronyms The PFM analysis in the PER can examine how these transactions above-mentioned example from the Comoros PER. are used and managed and whether the control protocols used SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 216 OVERVIEW 1 SECTION 1 What Is a Health PER? The PFM assessment should be informed by the flow of funds in the health sector. The FIGURE 1 A TYPICAL TRANSACTION PROFILE FROM THE HEALTH SECTOR: FEW TRANSACTIONS MAKE UP THE MAJORITY OF THE BUDGET 2 distribution (or flow) of funds shows where funds come from (government revenues, households, 100% SECTION 2 Cross-Cutting development partners), where they pass through Analysis on (government, health insurance), and where they 90% Efficiency and Equity go (health providers and functions of care such 3 as pharmaceuticals, inpatient care). The flow of 80% SECTION 3 funds can be shown by using the country’s NHA 70% Topic-Specific matrixes or it can be visualized in a flow chart. Analysis The recent National Health Accounts Estimates for VOLUME OF BUDGET 60% India (2018–19) (National Health Systems Resource Health System Context Centre 2022) presents this distribution of funds in 50% Health Financing the report’s Figure 1. The PFM analysis in the PER M-2: Resource Mobilization can assess what is most relevant based on the 40% M-3: Pooling amount of spending. For example, the analysis may M-4: Benefits Specification 30% show that local governments manage a large share M-5: Purchasing Health Services of total health spending, mostly on outpatient 20% M-6: Public Financial Management care. In this case, the PER analysis would therefore Inputs assess how well local government exercises its 10% Service Delivery mandate. Outcomes 0% 1 2719 5437 8155 10873 13591 16309 19027 21745 24463 27181 29899 32617 35335 38053 40711 43489 46207 48925 51643 54361 57079 59797 62515 65233 67951 4 List of Acronyms As a next step, the PFM chapter may (1) assess bottlenecks in the budget cycle; and (2) conduct a SECTION 4 deep dive into specific topics. NUMBER OF TRANSACTIONS Additional Source: Tanzania PER, Figure 19 (Piatti-Fünfkirchen and Ally 2020). Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 217 OVERVIEW 1 SECTION 1 What Is a Health PER? Identify Key Bottlenecks in Each Stage of the Budget Cycle 2 SECTION 2 Does the way the budget is organized make sense from a health for budget allocation, regularity and predictability of funding flows, Cross-Cutting Analysis on policy and prioritization perspective? PER authors should assess appropriateness and effectiveness of controls, and relevance and Efficiency and Equity how the budget is organized and whether the budgeting process quality of monitoring and accountability systems. Issues in budget 3 includes the relevant core functions to finance government health execution will affect a country’s ability to achieve universal health objectives. For example, if the government objective is to expand care (UHC) goals. They should be assessed in the PER based on SECTION 3 Topic-Specific PHC, does the budget structure allow for funding for primary the criteria and approach used (see Budget Execution in Health Analysis care? Or is there an allocation for preventive and public health (forthcoming)). functions? If the government uses functional classifications Health System Context in the chart of accounts (such as hospital services, outpatient Is the budget assessed at the end of the fiscal year? PER authors Health Financing services, public health services, medical products, and so on), as should examine how compliance audits inform whether the M-2: Resource Mobilization recommended by the Organisation for Economic Co-operation and budget has been spent against the original purpose or whether M-3: Pooling Development (OECD) and Eurostat, authors could consider how allocations to priority interventions have been diverted. Is there M-4: Benefits Specification meaningful underlying assumptions and corresponding reporting a performance audit in place, and is there a way to triangulate M-5: Purchasing Health Services are (see The Government Analytics Handbook, Table 11.2, in Piatti- expenditure with output/outcome data to inform the subsequent M-6: Public Financial Management Fünfkirchen et al. 2023). budget allocation process? Inputs Service Delivery What is the budget execution rate (expenditure over original Outcomes budget), and how sensitive are budget execution practices to health sector needs? The root causes for discrepancies between 4 List of Acronyms budgets and budget execution include budget structure and rules SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 218 OVERVIEW 1 SECTION 1 What Is a Health PER? OPTIONS FOR DETAILED ANALYSIS OF SPECIFIC TOPICS 2 SECTION 2 Several PFM deep dives can be undertaken in assess staff remuneration. PER authors can assess the following Cross-Cutting PFM issues in human resources management: Analysis on Efficiency and a health PER, including, for example, PFM of Equity • Wage payments. These are wages paid on time and in 3 the health workforce, effective procurement, full. Late and/or incomplete wage payments affect staff decentralization, development partners, arrears SECTION 3 engagement and morale and could lead to moonlighting in Topic-Specific management, retaining revenue at the provider the private health sector. Analysis level, and other topics. The relevance of the area • Payroll management. The appropriate staff should be Health System Context will depend on the country’s context. The topics paid the appropriate amount. Only payroll amendments authorized by the MoF should be made, and payment should Health Financing should be selected based on a discussion with M-2: Resource Mobilization be timely. policymakers of the relevant policy issues. M-3: Pooling • Wage forecasting. Estimates of the long-term fiscal impact M-4: Benefits Specification PER authors can explore whether there are PFM bottlenecks of changes to workforce recruitment and salary decisions M-5: Purchasing Health Services impeding effective management of the health workforce. The should be realistic. M-6: Public Financial Management health workforce tends to be the largest expenditure component • Allowance payment. Allowances can be critical for staff Inputs for governments. Many governments allocate more than half of recruitment and retention. PER authors can assess the number Service Delivery their health expenditures to health staff. If there are PFM issues, and types of allowances; the total amount paid as allowances Outcomes resolving them is likely to have a substantial impact on the health compared to salaries; whether allowances are transparent and 4 List of Acronyms system. The Ethiopia health workforce study Trained, but Not fair and are paid on time and in full; and whether allowances Gainfully Employed: An Assessment of Ethiopia’s Health Labor should be eliminated and instead included in salaries. SECTION 4 Market (World Bank 2023). This study includes examples of how to Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 219 OVERVIEW 1 SECTION 1 What Is a Health PER? • Workforce modeling. There are medium-term projections of the cost of the health workforce based on future trends in the PER authors can conduct payroll analysis to fulfill several objectives, such as: 2 population demographics, disease burden, and migration, • To understand the total government expenditures on staff SECTION 2 and under different pay and recruitment assumptions. Cross-Cutting payroll, including wages, salaries, allowances, overtime, and Analysis on • Training cost and risk forecasting. There are estimates of bonuses and benefits. Efficiency and Equity both the fiscal cost of human resources for health (HRH) 3 • To project future labor costs by tracking trends in budgeting training and the fiscal risk of student loans. and forecasting. SECTION 3 Topic-Specific • To evaluate compliance, including whether legal Analysis PER authors can analyze how PFM relates to human resources for requirements, such as tax regulations and wage laws, are health. Examples of PFM problems relating to human resources adhered to, by reviewing all sources, such as donor financing. Health System Context are numerous and include: the HRH budget is too low to fill the • To identify payroll processing inefficiencies or errors, such as Health Financing establishment list; there are fragmented allowance payments overpayments or incorrect deductions. M-2: Resource Mobilization that lead to inefficiencies and inequities; there are regular delays M-3: Pooling and shortfalls in allowances; or there are large numbers of ghost • To determine staffing levels based on payroll data, assess M-4: Benefits Specification workers, as the payroll is not maintained. Authors can identify vacancy rates, and help management make informed M-5: Purchasing Health Services whether there are PFM issues driving these problems, if any exists, decisions about workforce planning and optimization. M-6: Public Financial Management and develop recommendations to resolve them. For example, cash How effective is the procurement process? Procurement of drugs Inputs management reform can help improve the ability of government and medical supplies, vaccines, or technical equipment affects the Service Delivery to forecast and channel cash to budget priorities, and this should availability and effectiveness of health service delivery. Assessing Outcomes mitigate the problem where “wages are paid but there are regular whether procurement practices are appropriate is therefore delays and shortfall in allowances.” The existence of ghost workers 4 List of Acronyms important. PER authors can determine whether the definition could be addressed through payroll cleansing and audits to of roles in the procurement process and the division of roles remove these workers and periodic payroll integrity checks to SECTION 4 between the MoF and MoH are clear. Also, authors could determine Additional ensure the payroll is robust. Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 220 OVERVIEW 1 SECTION 1 What Is a Health PER? whether framework agreements and multiyear contracts allow for the flexibility and responsiveness required for health facilities care, expanding access to services, and enhancing the efficiency of health care delivery. Good PFM practices are crucial for ensuring 2 to procure essential medicines and commodities directly and effective capital spending. Key practices include a complex set SECTION 2 achieve value for their money (Arney and Yadav 2014). The Zambia of aspects, including strategic planning, budgeting, forecasting, Cross-Cutting Analysis on PER (Chansa et al. 2018) assessed whether the FMIS has the transparent procurement, cost-benefit analysis, risk management, Efficiency and functionality to process multiyear commitments to avoid large and project monitoring and evaluation. Capital investments Equity 3 contracts being processed outside the FMIS and procurement require running costs and a maintenance budget, which need to system and evade the necessary controls. PER authors could assess be considered and accommodated for in the budget. SECTION 3 whether their country’s health sector procurement personnel Topic-Specific Analysis have the technical capacity for contract management and the A PER can explore how well the public finance systems cater to ability to continually prepare, negotiate, manage, evaluate, and nutrition needs. To address nutrition needs, sufficient resources Health System Context conduct performance reviews. This is especially important in need to be allocated, and public financial management systems Health Financing countries where nongovernmental organization (NGO) providers need to be responsive to nutrition needs. This includes ensuring M-2: Resource Mobilization are contracted by the MoH to provide services (and therefore that government can exercise a stewardship function over M-3: Pooling becomes a PFM question) and in fragility, conflict, and violence sectors, ensure collaboration and coordination, leverage the M-4: Benefits Specification (FCV)-affected countries where service delivery is outsourced budget as an instrument for prioritization and monitor progress in M-5: Purchasing Health Services to NGOs. Annex 7 of the Project Appraisal Document (PAD) for implementation. The multisectoral nature of nutrition that involves M-6: Public Financial Management “Improving Healthcare Services in Somalia (Damal Caafimaad)” a wide range of actors and implementors makes it challenging Inputs (World Bank 2021) provides excellent guidance on contract to cover in a public expenditure review. Wang et al. (2022) offer Service Delivery management arrangements. Loevinsohn (2008) offers a valuable guidance on preparing nutrition PERs and Piatti-Fünfkirchen et al. Outcomes toolkit on performance-based contracting. (2023) on supporting a nutrition responsive PFM system. 4 List of Acronyms Capital expenditures are the investment in long-term assets, such PER authors could explore how primary health care is reflected in as hospitals, medical equipment, and technology infrastructure. the budget and whether it is possible to make payments to PHC SECTION 4 Additional Capital expenditures are essential for improving the quality of providers directly. Estimating primary care spending in a PER Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 221 OVERVIEW 1 SECTION 1 What Is a Health PER? can be difficult unless it is explicitly budgeted for. Making this point and recommending a budget structure reform to identify this is the case and how the sources can be consolidated (see the 2020 Tanzania PER (Piatti-Fünfkirchen and Ally 2020) or the 2022 2 PHC expenditures is useful. Having primary care explicit in the Zimbabwe PER (Lao Peña and Piatti-Fünfkirchen 2022). SECTION 2 Cross-Cutting budget allows for a prioritization process. Also, authors should Analysis on clarify the role of local government in PHC management. Local Countries, such as Uganda, that make budgetary transfers directly Efficiency and Equity governments frequently have the mandate for the delivery of to facilities need to ensure that these transfers are timely and 3 primary care services, which needs to be analyzed in the context of executed in full. In such arrangements, the PFM system executes SECTION 3 the decentralization policy and recommendations on direct facility the transfer, which will appear as a line item in the economic Topic-Specific financing reform. Countries with a program budget structure classification of the COA (see discussion above). Once transfers are Analysis can benefit from making primary care an explicit program (or executed, they are recorded as spent. Facilities then treat these subprogram) within that structure. If actual PHC spending data are as revenue and should use funds according to a separate set of Health System Context not available, PER authors could identify the relevant spending rules and good bookkeeping practices. This can help provide the Health Financing unit (for example, a clinic) or appropriate budget lines in the necessary flexibility by allowing facilities to spend as needed and M-2: Resource Mobilization local government budget as a proxy. It may not be constructive only report on spending on a line-item basis in their financial M-3: Pooling to recommend for earmarking PHC budget lines, as this leads to accounts. M-4: Benefits Specification rigidities in the budget. M-5: Purchasing Health Services How funds are allocated is part of the budget formulation process. M-6: Public Financial Management Authors should assess how fragmented financing at the provider PER authors can review whether resources that are allocated on Inputs level affects management and the provision of care. Health a historical basis are becoming inefficient and inequitable over Service Delivery facilities often receive revenue from multiple sources, including time or whether there is a formula in place to correct for need, Outcomes the government budget, user fees, insurance payments, and poverty, and geographic inequities. This is the case in Tanzania, 4 List of Acronyms development partners. This can lead to management challenges, where budget allocation decisions are guided by an overarching as different sources can be subject to different rules and reporting formula that can reflect purchasing principles. SECTION 4 requirements. The assessment could usefully explore whether Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 222 OVERVIEW 1 SECTION 1 What Is a Health PER? The role of development partners in many low-income countries is to finance the largest share of total health expenditures in the Namibia PER (Schneider et al. 2019) give good examples of estimating arrears and discuss the implications on expenditure management. 2 sector. Some development partners are committed to making use Findings can be triangulated with PEFA indicator PI-22.9 SECTION 2 of government systems to the extent possible. It would imply the Cross-Cutting use of the PFM system, including partners’ spending being on plan, Can health providers retain their revenue from user fees? Some Analysis on Efficiency and on budget, on treasury, and on report. In their paper “Following the PFM systems require hospitals and health facilities to transfer Equity 3 Government Playbook? Channeling Development Assistance for any revenue from user fees to the general treasury. This may Health through Country Systems,” Piatti-Fünfkirchen et al. (2021) not be an efficient way to manage funds and may undermine SECTION 3 identify questions on what aspects of a PFM system development provider autonomy. The Namibia PER explores this problem, Topic-Specific Analysis partners are using. Beyond PFM, it is perhaps even more important showing that internally generated funds were significant for to assess how partners finance health providers. This would hospital management but overall were an insignificant amount Health System Context require development partners to channel funds through existing to warrant treasury’s concern about any efficiency losses from Health Financing service delivery structures in government (for example, through cash management considerations. If helpful to the PER country’s local government authorities) rather than create new ones (such government, a calculation can be made to estimate the cost M-2: Resource Mobilization as sending money directly to providers through, for example, to treasury of keeping funds in commercial bank accounts of M-3: Pooling performance-based financing). hospitals/clinics: total amount in accounts*average interest M-4: Benefits Specification rate of the year; the solution is equal to borrowing the same M-5: Purchasing Health Services Expenditure arrears in the health sector can lead to operations amount from the private sector. If the amount is not significant, M-6: Public Financial Management efficiency problems. Arrears are often not captured by the it still could be worth occurring this cost to provide the necessary Inputs government’s FMIS. PER authors can determine whether arrears liquidity to health providers. Service Delivery are an issue in the health sector by studying audit reports. They Outcomes can explore both stock and flow of arrears and what drives the flow 4 List of Acronyms of arrears. The 2019 Zambia PER (Chansa et al. 2019) and the 2019 SECTION 4 Additional 9 https://www.pefa.org/node/4603. Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 223 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Arney, L., and P. Yadav. 2014. Improving Procurement Practices in Developing Country Health Programs. William Davidson Institute (WDI), University Cross-Cutting Analysis on of Michigan. https://wdi.umich.edu/wp-content/uploads/WDI-_-Improving-Procurement-Practice-in-Developing-Country-Health-Programs_Final- Efficiency and Report_2.pdf. Equity 3 Chansa, Collins, Netsanet Walelign Workie, Moritz Piatti-Fünfkirchen, Maria Alfons Otto, Clement Thulani, and Katelyn Jison Yoo. 2019. Zambia Health SECTION 3 Sector Public Expenditure Review (English). Washington, DC: World Bank. http://documents.worldbank.org/curated/en/756921559624225552/Zambia- Topic-Specific Health-Sector-Public-Expenditure-Review. Analysis Hashim, Ali, Moritz Piatti-Fünfkirchen, Maria Alfons Otto, Winston Percy Onipede Cole, Ammar Naqvi, Akmal Minallah, Maun Prathna, and Sok Bunthoeun Health System Context So. “The Use of Data Analytics Techniques to Assess the Functioning of a Government’s Financial Management Information System: An Application Health Financing to Pakistan and Cambodia (English).” Policy Research Working Paper, WPS 8689. World Bank Group, Washington, DC. http://documents.worldbank. M-2: Resource Mobilization org/curated/en/226121546531748578/The-Use-of-Data-Analytics-Techniques-to-Assess-the-Functioning-of-a-Governments-Financial-Management- M-3: Pooling Information-System-An-Application-to-Pakistan-and-Cambodia. M-4: Benefits Specification Lao Peña, Christine, and Moritz Piatti-Fünfkirchen. 2022. Zimbabwe Health Section Public Expenditure Review. Washington, DC: World Bank. https:// M-5: Purchasing Health Services documents1.worldbank.org/curated/en/099730506292238494/pdf/P16556501fc556037089b80ca23e3977f6c.pdf. M-6: Public Financial Management Inputs Loevinsohn, Benjamin. 2008. Performance-Based Contracting for Health Services in Developing Countries: A Toolkit. Health, Nutrition, and Population Series. Washington, DC: World Bank. http://hdl.handle.net/10986. Service Delivery Outcomes National Health Systems Resource Centre. 2022. National Health Accounts Estimates for India (2018-19). New Delhi: Ministry of Health and Family Welfare, Government of India. 4 List of Acronyms Piatti-Fünfkirchen, Moritz, Ali Subandoro, Timothy Williamson, and Kyoko Okamura, Shibata. 2023. “Driving Nutrition Action Through the Budget: A SECTION 4 Guide to Nutrition-Responsive Budgeting.” World Bank, Washington, DC. http://hdl.handle.net/10986/39856. Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 224 OVERVIEW 1 SECTION 1 What Is a Health PER? Piatti-Fünfkirchen, Moritz, and Lodewijk Smets. 2019. Public Financial Management, Health Financing and Under-Five Mortality: A Comparative Empirical Analysis. Washington, DC: Inter-American Development (IDB). https://publications.iadb.org/en/public-financial-management-health-financing-and- 2 under-five-mortality-comparative-empirical. SECTION 2 Piatti-Fünfkirchen, Moritz, and Mariam Ally. 2020. Tanzania Health Sector Public Expenditure Review. Washington, DC: World Bank. https://documents1. Cross-Cutting Analysis on worldbank.org/curated/en/601271602042236487/pdf/Tanzania-Health-Sector-Public-Expenditure-Review-2020.pdf. Efficiency and Equity 3 Piatti-Fünfkirchen, Moritz, Liying Liang, Jonathan Kweku Akuoku, and Patrice Mwitende. 2020. Rwanda Nutrition Expenditure and Institutional Review 2020. Washington, DC: World Bank. https://documents1.worldbank.org/curated/en/588131604469825169/pdf/Rwanda-Nutrition-Expenditure-and- SECTION 3 Institutional-Review-2020.pdf. Topic-Specific Analysis Piatti-Fünfkirchen, Moritz, Sierd Hadley, and Benoit Mathivet. 2021. “Alignment of Performance-Based Financing in Health with the Government Budget: A Principle-Based Approach.” Health, Nutrition, and Population (HNP) Discussion Paper. World Bank, Washington, DC. https://documents1.worldbank. Health System Context org/curated/en/935821632462316181/pdf/Alignment-of-Performance-Based-Financing-in-Health-with-the-Government-Budget-A-Principle-Based- Health Financing Approach.pdf. M-2: Resource Mobilization Piatti-Fünfkirchen, Moritz, Maria Alfons Otto, Ali Hashim, Sarah Alkenbrack, and Gurazada Srinivas. 2021. “Following the Government Playbook? M-3: Pooling Channeling Development Assistance for Health through Country Systems (English).” World Bank, Washington, DC. http://documents.worldbank.org/ M-4: Benefits Specification curated/en/332531634794859261/Following-the-Government-Playbook-Channeling-Development-Assistance-for-Health-through-Country-Systems. M-5: Purchasing Health Services M-6: Public Financial Management Piatti-Fünfkirchen, Moritz, James Brumby, and Ali Hashim. 2023. “Government Analytics Using Expenditure Data,” Chapter 11 in Daniel Rogger and Inputs Christian Schuster, eds., The Government Analytics Handbook: Leveraging Data to Strengthen Public Administration. Washington, DC: World Bank. Service Delivery http://hdl.handle.net/10986/39857.Public Expenditure and Financial Accountability (PEFA). 2018. A Guide to PFM Diagnostic Tools. PEFA Secretariat. https://www.pefa.org/resources/guide-pfm-diagnostic-tools. Outcomes 4 List of Acronyms Schneider, Pia, Claire Jones, Liying (Annie) Liang, Thulani Matsebula, Fedja Pivodic, and Moritz Piatti-Fünfkirchen. 2019. Namibia Health Sector Public Expenditure Review. Washington, DC: World Bank. https://documents1.worldbank.org/curated/en/268141563376806867/pdf/Namibia-Health-Sector- SECTION 4 Public-Expenditure-Review.pdf. Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 225 OVERVIEW 1 SECTION 1 What Is a Health PER? Tapsoba, Y., A. Silim, K.A. Frimpong, and H. Barroy. 2024. “Does Public Financial Management Save Life? Evidence from a Quantitative Review of PFM and Health Outcomes in Sub-Saharan African Countries.” Health Systems & Reform, 10 (1). https://doi.org/10.1080/23288604.2023.2298190. 2 UNICEF. 2021. The UNICEF Public Finance Toolkit. New York: United Nations Children’s Fund. https://www.unicef.org/documents/public-finance-toolkit. SECTION 2 Cross-Cutting Wang et al. 2022. A Guiding Framework for Nutrition Public Expenditure Reviews. Available at https://documents.worldbank.org/en/publication/ Analysis on Efficiency and documents-reports/documentdetail/870061642743645361/a-guiding-framework-for-nutrition-public-expenditure-reviews. Equity 3 Welham, Bryn, Tom Hart, Shakira Mustapha, and Sierd Hadley. 2017. Public financial management and health service delivery: Necessary, but not sufficient? London: Overseas Development Institute. https://cdn.odi.org/media/documents/Public_financial_management_and_health_service_ SECTION 3 delivery_necessary_but_not_sufficient.pdf. Topic-Specific Analysis World Bank. 2021. “Improving Healthcare Services in Somalia (Damal Caafimaad) Project Appraisal Document.” Health, Nutrition, and Population Global Practice, World Bank, Washington, DC. https://documents1.worldbank.org/curated/en/671481625191487648/pdf/Somalia-Improving-Healthcare- Health System Context Services-in-Somalia-Damal-Caafimaad-Project.pdf. Health Financing M-2: Resource Mobilization World Bank. 2023. “Trained, but Not Gainfully Employed: An Assessment of Ethiopia’s Health Labor Market.” Health, Nutrition, and Population Global M-3: Pooling Practice, World Bank, Washington, DC. https://documents1.worldbank.org/curated/en/099112723152522987/pdf/P1796950ac3c1a0d09e830230f7b52 M-4: Benefits Specification be09.pdf?_gl=1*l7yn7c*_gcl_au*NzkzNzY2ODY3LjE3MjI1OTA4NDc. M-5: Purchasing Health Services World Bank Group. 2019. FinHealth: PFM in Health Toolkit. Washington, DC: World Bank Group. https://documents1.worldbank.org/curated/ M-6: Public Financial Management en/099191502152313348/pdf/P1551930f15bf400f09a0b0b954409dc97a.pdf. Inputs Service Delivery World Bank Group. 2023. 2022 Comoros Public Expenditure Review: Addressing Fiscal Challenges to Foster an Inclusive Growth. Washington, DC: World Bank Group. https://openknowledge.worldbank.org/server/api/core/bitstreams/23a78f62-04b0-485d-a2cc-cd4cc637e1c0/content?_gl=1*uglqj*_gcl_ Outcomes au*NzkzNzY2ODY3LjE3MjI1OTA4NDc. 4 List of Acronyms World Health Organization. 2023. Mapping of public financial management tools for assessing bottlenecks in the health sector. Geneva: World Health SECTION 4 Organization. https://iris.who.int/bitstream/handle/10665/374019/9789240080096-eng.pdf?sequence=1. Additional Guidance TABLE OF CONTENTS MODULE 6 Public Financial Management 226 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Medicines and human resources are often the largest items in government health Equity SECTION 3 3 budgets. A Public Expenditure Review (PER) should evaluate whether this spending Inputs is guaranteeing the availability and sustainability of quality health services and SECTION 3 progress toward universal health coverage (UHC). Spending should ensure that Topic-Specific equitable distribution of inputs across sociodemographic and geographic lines, and Analysis that inputs are used rationally, combined appropriately, and purchased at reasonable Health System Context prices to avoid inefficiency. The PER must also examine whether processes, rules and This section offers guidance institutional arrangements used to purchase and allocate inputs promote efficiency Health Financing on assessing the efficiency and their equitable deployment. Inputs Service Delivery and equity of spending on Outcomes human resources for health, MODULE 7 HUMAN RESOURCES FOR HEALTH 4 List of Acronyms infrastructure and equipment, MODULE 8 PHYSICAL INFRASTRUCTURE AND EQUIPMENT and medicines and medical SECTION 4 Additional supplies. MODULE 9 MEDICINES AND MEDICAL SUPPLIES Guidance CONTINUE TABLE OF CONTENTS OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 MODULE 7 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Human Resources for Health Health Financing Inputs M-7: Human Resources for Health M-8: Infrastructure & Equipment AUTHORS M-9: Medicines & Medical Supplies Edson Correia Araujo, Service Delivery Bernardo D.P. Coelho, Outcomes and Priyanka Saksena 4 List of Acronyms SECTION 4 START Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 228 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Human resources for health (HRH) are a key input worker shortages, countries face maldistribution challenges, inadequate training capacity, weak human resources management Cross-Cutting Analysis on of any health care system: health workers are systems, skill-mix imbalances, and suboptimal combinations of Efficiency and Equity essential to producing health services, and labor financial and nonfinancial incentives (Jimba et al. 2010). These 3 is by far the largest category of expense in most issues can result in inefficient and inequitable spending. SECTION 3 health systems. Overall, payments of salaries and Topic-Specific TABLE 1 Analysis benefits to the health workforce account for over HEALTH WORKERS’ REMUNERATION, one-third of total government expenditure (GGHE) BY COUNTRY INCOME GROUP Health System Context Health Financing on health globally and one-fifth of total health Share of THE Share of GGHE Inputs expenditure (THE), with the share varying across Country Income Group % % M-7: Human Resources for Health country income groups (Hernandez et al. 2013). M-8: Infrastructure & Equipment High 18 31.2 However, shortages of health workers are common, even in M-9: Medicines & Medical Supplies Upper middle 23.4 38.2 Organisation for Economic Co-operation and Development (OECD) Service Delivery countries. The world needs many millions of additional health Lower middle 18.7 34.7 Outcomes workers to meet the Sustainable Development Goal (SDG) health Low 18.7 34.7 4 List of Acronyms targets: global estimates of current health worker shortages range from about 15 million to over 43 million, depending on the All 18.1 33.2 SECTION 4 methodology used (Boniol, Kunjumen, et al. 2022; GBD 2019; Human Source: Hernandez et al. (2013). Additional Resources for Health Collaborators 2022). In addition to health Note: GGHE = general government health expenditure; THE = total health expenditure. Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 229 OVERVIEW 1 SECTION 1 What Is a Health PER? HRH challenges have labor market roots, which are becoming Issues related to availability, distribution, and performance result 2 increasingly complex. In most countries, health worker employment in inefficiencies and inequities. Often problems are multifaceted, SECTION 2 is not just governed by civil service regulations for public sector with complex and sometimes contradictory effects. For example, in Cross-Cutting employees. Instead, health workers are often employed by the Ghana, it was estimated that there were about 40,000 unemployed Analysis on private sector, work independently, or work under a combination of nurses in 2019, while the estimated shortage of health workers Efficiency and Equity public, private, and self-employed arrangements (Soucat, Scheffler, within the public health system alone was over 45,000 (Asamani 3 and Ghebreyesus 2013). Labor market conditions such as incentive et al. 2020; Asamani, Christmals, and Reitsma 2021). In addition to SECTION 3 structures and working conditions often result in health workers’ funding shortages, such imbalances are a result of changing needs Topic-Specific making employment decisions that are not aligned with priority for health care and service delivery models and varying degrees Analysis public health needs. For example, health workers may be attracted of regulation of different health worker education programs to positions that do not respond to such needs or choose to migrate combined with economic cycles and poor planning (Asamani et Health System Context in search of alternative employment opportunities (McPake, al. 2020; Limpin and Artiaga 2023). Health Financing Scott, and Edoka 2014). Rigidity in human resources management, Inputs particularly in the public sector, also results in mismatches between The aim of this module is to allow PER authors to rapidly assess the M-7: Human Resources for Health supply and needs. general efficiency in HRH spending by examining basic indicators M-8: Infrastructure & Equipment of HRH related to aggregate spending and availability, input mix, PER authors can examine inefficiency and inequity related to HRH productivity, governance and processes, as well as general equity M-9: Medicines & Medical Supplies through the following interconnected domains: (1) availability, which considerations. Overall, an assessment of HRH should be made Service Delivery involves the supply of qualified health workers; (2) distribution and alongside an assessment of other health system characteristics. Outcomes skill mix, which pertain to the recruitment and retention of health Authors should examine the size, distribution, and productivity of 4 List of Acronyms workers where they are needed most and with the necessary skills; HRH in conjunction with other input and service delivery aspects, and (3) performance, which relates to the productivity of health which are considered in other modules. SECTION 4 workers and the quality of care they provide. Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 230 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors should also note that the guidance 2 in this module is not a substitute for a more SECTION 2 thorough analysis of the HRH situation in a Cross-Cutting country, which requires significant time and Analysis on capacity. A health labor market analysis allows Efficiency and Equity for a more in-depth look into HRH issues. This 3 tool can comprehensively document different HRH SECTION 3 challenges, including sources of inefficiencies and Topic-Specific inequities, as well as potential solutions. PER Analysis authors interested in conducting such an analysis can consult guidance documents from the World Health System Context Bank as well as the World Health Organization Health Financing (WHO) on health labor market analyses (McPake, Inputs Scott, and Edoka 2014; World Health Organization M-7: Human Resources for Health 2021; Scheffler et al. 2016; Herbst, Liu, and Akala M-8: Infrastructure & Equipment 2022). Also, additional guidance note 2 on Health Labor Market Analysis and Health Workforce M-9: Medicines & Medical Supplies Projections provides additional guidance. Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 231 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 BOX 1. DEFINITIONS OF TERMS Cross-Cutting Analysis on Efficiency and HEALTH WORKFORCE HEALTH WORKFORCE NEEDS Equity 3 Health workers are clinical and nonclinical personnel whose job is to The need for health workers is not the same as the labor market demand. protect and improve the health of people. Highly qualified and trained Rather it is the estimated number of health workers needed to deliver SECTION 3 professionals such as physicians, pharmacists, nurses, and midwives specific health services. It is usually estimated based on an analysis of Topic-Specific usually constitute the largest part of the health workforce. They are current and future demographic and health profiles. Shortages of health Analysis supported by other professionals such as nurse assistants or personal workers are often based on estimating health workforce needs. support workers in health facilities. Community health workers, who Health System Context provide health education and basic diagnosis, and care and referral in AVAILABILITY Health Financing communities, are also an important component of the health workforce in The concept of availability is not tied to a classical economic supply- Inputs many countries. demand framework. Rather it refers to the number of workers who are M-7: Human Resources for Health employed or trained health workers who can be employed, while supply LABOR MARKET SUPPLY refers to all people who are willing to work at a given wage (price). M-8: Infrastructure & Equipment Supply of health workers is the total number of individuals willing to M-9: Medicines & Medical Supplies work at a given wage (price). This is influenced by the wages as well as DISTRIBUTION OF HEALTH WORKERS Service Delivery non-wage dimensions. The distribution of health workers concerns the relative presence Outcomes of health workers in different contexts. Health workers are unevenly LABOR MARKET DEMAND distributed within countries, and this can be an important contributor to 4 List of Acronyms Demand for health workers is the number of workers that employers are health inequities. willing to hire. This is influenced by factors such as availability of funding for SECTION 4 employing health workers and consumer preferences about health services. Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 232 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY 2 SECTION 2 Cross-Cutting Aggregate Spending and Availability Analysis on Efficiency and Equity 3 • How much is spent on HRH and how has spending evolved? KEY QUESTIONS SECTION 3 • Are there sufficient numbers of human resources? Topic-Specific Analysis Health System Context Human resources represent an important In fact, while expenditure on salaries and benefits for health Health Financing workers constitutes the majority of health expenditure in most expenditure category, as discussed earlier. For Inputs countries, spending is even higher in some settings. When spending M-7: Human Resources for Health example, in Europe and Central Asia, salaries as a on HRH reaches 70–80 percent, it could leave insufficient room M-8: Infrastructure & Equipment share of government health expenditure ranged for financing other essential inputs needed to deliver health care. PER authors should also note how spending on HRH as a share of M-9: Medicines & Medical Supplies from about 20 percent to 60 percent, with one expenditure has evolved. Increasing shares of spending on HRH, Service Delivery outlier, as shown in Figure 1. with stagnating overall general government health expenditure,1 Outcomes may signal a diminishing capacity of facilities to deliver quality care. Here all spending on HRH should be included, not only salary 4 List of Acronyms expenditure, as not all health workers are salaried employees. SECTION 4 Additional 1 PER authors should note that this module relies on indicators from the SHA 2011 framework for health accounts. In this framework, general government health expenditure includes budget spending as well as spending by poole Guidance prepaid compulsory financing schemes like social health insurance. TABLE OF CONTENTS MODULE 7 Human Resources for Health 233 OVERVIEW 1 Salaries as % of total public health expenditure SECTION 1 FIGURE 1 What Is a SALARIES AS PERCENT OF TOTAL PUBLIC HEALTH EXPENDITURE Health PER? 2 100 SECTION 2 Cross-Cutting Analysis on Efficiency and 75 Equity 3 SECTION 3 Topic-Specific Analysis Health System Context 50 25 Health Financing Inputs 0 M-7: Human Resources for Health aijan Malta s gdom ia … rra ine nd gal zstan nia vina us e… l Italy dova ark n ro tion arino ia lkans ria n ce ds donia t… s a nia istan 20… nia a ia Israe ntrie Cypru Serbi Latvi kista khsta nform Eston Alban Czech eneg Gree Belar erlan ent S Icela Bulga lth N Ando Portu ithua Ukra Slove Roma Denm edera rzego May f Mol Azerb Tajik M-8: Infrastructure & Equipment San M Kyrgy rn Ba d Kin Mace l cou Uzbe Kaza Mont Neth pend e Hea lics I L after d He ian F blic o M-9: Medicines & Medical Supplies e Smal Unite North West epub f Inde urop ia an Russ e EU Repu Service Delivery ian R ern E alth o of th Bosn Outcomes al As -east onwe bers 4 List of Acronyms Centr South Mem Comm SECTION 4 Additional Guidance Source: World Health Organization, “WHO European Health Information at Your Fingertips” (n.d.). TABLE OF CONTENTS MODULE 7 Human Resources for Health 234 OVERVIEW 1 SECTION 1 What Is a Health PER? CASE EXAMPLE: TUNISIA 2 In Tunisia, public facilities remain important providers of health care. Spending on HRH in these facilities is extremely high—about 80 percent of the SECTION 2 Ministry of Health’s (MoH) budget. This leaves insufficient room for expenditure on other inputs required for delivering health care. Overall, about 15 Cross-Cutting percent of the GDP in Tunisia is on the public sector wage bill. Analysis on Efficiency and Equity 3 FIGURE 2.A FIGURE 2.B SPENDING ON HRH AND OTHER RECURRENT COSTS IN PUBLIC SECTOR WAGE BILL AS A SHARE OF GDP, SECTION 3 THE MINISTRY OF HEALTH’S BUDGET, 2010–19 2010–18 Topic-Specific Analysis Other Recurrent Costs 20 Tax Credits 2000 Health System Context Wages and Salaries 10% Ministries of Defense and Interior 7% 16 Health Financing 9% 8% Wages and Salaries 1500 7% Inputs 6% 12 7% MILLIONS (TND) M-7: Human Resources for Health 11% 1000 10% M-8: Infrastructure & Equipment 7% 82% 77% 8 83% 84% 84% M-9: Medicines & Medical Supplies 88% 84% 500 79% 82% 4 Service Delivery 82% Outcomes 0 0 4 List of Acronyms 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2010 2011 2012 2013 2014 2015 2016 2017 2018 SECTION 4 Sources: IMF. 2019. IMF Country Report No. 19/223. “Tunisia: Fifth Review Under the Extended Fund Facility, and Requests for Waivers of Nonobservance and Modification of Performance Criteria and for Additional Rephasing of Access.” International Monetary Fund, Middle East and Central Asia Department, Washington, DC. https://doi.org/10.5089/9781498325301.002. Guidance Ministere des Finances, Tunisie. N.d. “Analyse Budgétaire: Santé, Période 2010–2021.” TABLE OF CONTENTS MODULE 7 Human Resources for Health 235 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 3 PHYSICIAN DENSITY PER 10,00 POPULATION (LATEST DATA AVAILABLE) Source: World Health Organization. 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity VALUE 3 80 SECTION 3 60 Topic-Specific Analysis 40 Health System Context 20 Health Financing Inputs M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies PER authors can use basic indicators of the availability of HRH to 100,000 population in Chad. The number of nurses and midwives Service Delivery screen for underlying efficiency problems. For example, too low an also varies substantially, with densities ranging from over 17 per Outcomes investment in HRH prevents scaling up health services, including 1,000 population in Norway and Iceland to fewer than one per 1,000 4 List of Acronyms services that require certain coverage thresholds to be optimal, population in many countries in Sub-Saharan Africa and South Asia. such as vaccinations or epidemiological monitoring. Indeed, the SECTION 4 density of health workers varies substantially across countries. Despite these vastly different numbers, shortages of health workers Additional For example, the density of physicians (Figure 3) ranges from are found in almost all countries. When determining numbers of Guidance more than eight per 1,000 population in Italy and Cuba to five per health workers, PER authors should try to identify comparator TABLE OF CONTENTS MODULE 7 Human Resources for Health 236 OVERVIEW 1 SECTION 1 What Is a Health PER? countries with similar socioeconomic and geographical profiles and health systems, as well as countries that could serve as best HRH requirements for countries associated with achieving at least the median score on 12 SDG health targets (World Health 2 practice cases. The additional guidance note on country comparisons, Organization 2018). Various other needs-based estimates for HRH SECTION 2 Benchmarking,fffff provides guidance in this area. Comparisons have been made based on different criteria, and PER authors should Cross-Cutting Analysis on with relevant countries could also reveal potential inefficiencies, for check whether such estimates are available for their country. Efficiency and example, if there are widely differing numbers of specific types of Equity 3 workers.1 PER authors should also analyze trends in HRH availability The resources available to employ health workers frequently do not and composition. For example, an increasing trend might indicate match the amount required to cover the level of services required to SECTION 3 progress in reducing availability gaps, while a decreasing trend, meet population health care needs.2 Conversely, the number of health Topic-Specific Analysis including for specific types of health workers, would merit further workers willing to work in the sector is not equal to the number of analysis. It would also be useful to identify the number of practicing trained workers. Once health workers are trained, their employment Health System Context health workers versus all licensed health workers, some of whom may decisions and the employment opportunities that influence these Health Financing not be working in the health sector. The MoH or professional councils decisions are not necessarily aligned with population health care Inputs or associations for different professions usually have this information. needs. For example, experienced health workers migrating to M-7: Human Resources for Health Trends also need to be analyzed in relation to spending to understand other countries is commonplace in many low- and middle-income if increases in health spending are improving the number of HRH. countries. It is also common for trained health workers to instead be M-8: Infrastructure & Equipment If reliable data are available, spending on different types of health employed in other industries in some countries. M-9: Medicines & Medical Supplies workers can be examined, including community health workers. Service Delivery Mismatches between the supply and demand of health workers, as Outcomes A minimum threshold of 44.5 health workers per 10,000 population well as their skill mix, can also result in unfilled vacancies. Vacancies is often cited. This is based on work by WHO to identify the minimum can be due to a variety of reasons, including low wages, which are 4 List of Acronyms SECTION 4 1 For international comparisons, PER authors can also refer to the International Standard Classification of Occupations if needed to ensure comparability of different types of health workers. The technical annex to this document contains further information related to this. Additional 2 Health workforce demand is not the equivalent of health workforce needs. Both the need and demand for health workers derive from the need and demand for health services. Health workforce need is a normative and val- Guidance ue-based concept that takes into consideration the workforce required to provide the health services corresponding to the health status of a population, without considering willingness and capacity to pay. There are several ways to estimate health workforce needs. Usually it requires information on population epidemiological and demographic profiles and/or some priority health service delivery objectives. TABLE OF CONTENTS MODULE 7 Human Resources for Health 237 OVERVIEW 1 insufficient to attract health workers. It is possible that the SECTION 1 Key indicators Sources What Is a vacancy rate differs by level of provider, with fewer unfilled Health PER? positions in hospitals. Poor human resource management Government spending (from all • MoH expenditure data 2 practices such as delays in recruitment and deployment can sources) on HRH as a percentage of • National health accounts SECTION 2 contribute to vacancies, and resolving these issues would be current health expenditure • Government budget document Cross-Cutting Analysis on quick wins in terms of efficiency. Government spending (from all Efficiency and Equity sources) on HRH as a percentage 3 A high vacancy rate in conjunction with significant of general government health unemployment among health workers signals system-level SECTION 3 expenditure efficiency issues reflecting mismatches between training Topic-Specific Analysis programs and employer needs. If health worker education is Ratio of medical doctors, nurses and • MoH reports provided through subsidized public universities or through midwifes and other health workers • Human resource information system Health System Context training in subsidized hospitals, there is an additional per 10,000 population • National Health Workforce accounts Health Financing inefficiency due to unproductive public investments, which do • Professional councils and associations Inputs not result in returns for society. Labor market surveys or data • WHO Global Health Workforce Statistics from professional councils and associations (for example, • OECD Health Statistics M-7: Human Resources for Health licensing and registering bodies for medical doctors, dentists, • World Bank Open Data M-8: Infrastructure & Equipment and nurses and midwives) could be sources for information Vacancy rates by type of provider • MoH reports M-9: Medicines & Medical Supplies on unemployment. A recent Ethiopia health labor market • MoH administrative data Service Delivery analysis provides a good example on how to conduct analysis • Labor force surveys Outcomes of the health workforce, including in relation to availability, • Professional councils and associations recruitment, and needs as well as issues covered later in 4 List of Acronyms this module, such as remuneration and management of the Unemployment rate by type of trained • MoH reports health workforce.3 health worker • Labor force surveys SECTION 4 Additional • Professional councils and associations Guidance 3 https://documents.worldbank.org/en/publication/documents-reports/documentde- Note: HRH = Human Resources for Health; MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Development; tail/099112723152522987/p1796950ac3c1a0d09e830230f7b52be09. WHO = World Health Organization. TABLE OF CONTENTS MODULE 7 Human Resources for Health 238 OVERVIEW 1 SECTION 1 What Is a Health PER? Input Mix 2 SECTION 2 • What is the mix of health workers across cadres? Cross-Cutting KEY QUESTIONS Analysis on • How do different types of health workers work together? Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Health care is usually delivered through multidisciplinary PER authors of health workers. Even when a patient interacts with only one health worker, behind the scenes, other health workers are supporting the delivery of services. The mix of health workers is The ratio of nurses to physicians is often used to assess the appropriateness of the mix of health workers or the skill mix. While there is no global benchmark, a ratio closer to one physician to three nurses has been widely used, a number that reflects the an important determinant of efficiency, for example, if specialist ratio in OECD countries in 2013 (OECD Statistics). In the EU, the Health Financing physicians are performing tasks that could be done by other ratio is currently closer to one physician to two nurses. Inputs health workers. M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 239 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 4 RATIO OF NURSES TO DOCTORS IN THE EU, 2019 2 SECTION 2 Source: State of Health in the EU: Companion Report 2021. https://health.ec.europa.eu/ Cross-Cutting system/files/2022-02/2021_companion_en.pdf. Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Health Financing Inputs M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Service Delivery Of note, the roles different workers perform are not consistent workers can do and do independently. As such, there is significant Outcomes across health systems in different countries. Unfortunately, this policy work regarding upscaling and redefining skills as well as 4 List of Acronyms is often not just linked to qualifications but also due to outdated responsibilities, particularly of nonphysician health workers, to scopes of practices as well as interprofessional territoriality, support team-based health care delivery (Winkelmann et al. 2022). SECTION 4 leading to legal restrictions on what different types of health Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 240 OVERVIEW to do with historical legacy and an absence of regulatory structures for nursing 1 before 1990. Since then, there has been progress in developing nursing SECTION 1 competency standards and curricula, and the number of nursing schools doubled What Is a CASE EXAMPLE: between 2005 and 2015. VIETNAM Midwifery education at the university level started in Health PER? 2013, and national competency standards were developed in 2015. While the 2 In addition ratio to the of nurses relatively and low density midwives of health has to physicians workers, the ratio improved, itof nurses and remains midwives to physicians is very low in Vietnam. Some of this low. SECTION 2 underinvestment has to do with historical legacy and an absence of regulatory structures for nursing before 1990. Since then, there has been progress Cross-Cutting in developing nursing competency standards and curricula, and the number of nursing schools doubled between 2005 and 2015. Midwifery education Analysis on Efficiency and at the university level started in 2013, and national competency standards were developed in 2015. While the ratio of nurses and midwives to physicians Equity 3 has improved, it remains low. Ratio of nurses and midwives to physicians SECTION 3 in Vietnam, FIGURE 5 RATIO OF NURSES 2001-2016 AND MIDWIVES TO PHYSICIANS IN VIETNAM, 2001-2016 Topic-Specific Analysis 2 Ratio of nurses/midwives to physicians Health System Context 1.8 References: Fujita, Noriko, Sadatoshi Matsuoka, Kyoko Koto-Shimada, Megumi Ikarashi, Indrajit Hazarika, and Anthony B. Zwi. 2019. “Regulation Health Financing 1.6 of Nursing Professionals in Cambodia and Vietnam: A Review of the Evolution and Key Influences.” Human Resources for Health 17 (1): 48. Inputs 1.4 https://doi.org/10.1186/s12960-019-0388-y. World Health Organization. N.d. “WHO European Health Information at M-7: Human Resources for Health 1.2 Your Fingertips.” Accessed February 22, 2024. World Health Organization, Geneva. https://gateway.euro.who.int/en/indicators/hfa_582-6810- M-8: Infrastructure & Equipment salaries-as-of-total-public-health-expenditure/. 1 Huynh, Hong T.P., and Carol Windsor. 2022. “The Concepts of Social Space M-9: Medicines & Medical Supplies and Social Value: An Interpretation of Clinical Nursing Practice in Vietnam 0.8 Các Khái Niệm về Không Gian Xã Hội và Giá Trị Xã Hội: Diễn Giải về Thực Service Delivery Hành Điều Dưỡng Lâm Sàng ở Việt Nam.” Global Qualitative Nursing 0.6 Research 9 (March):23333936211070267. https://doi.org/10.1177/23333936211070267. Outcomes 0.4 Le, Tung Thanh, Anh Tuan Truong, Thanh Van Vu, Ha Thi Viet Tran, Huong 4 List of Acronyms Thi Thanh Pham, Huong Thi Thanh Nguyen, and Anh Thi Lan Mai. 2024. “Vietnam National Competency Standards for Midwifery: A Delphi Study.” 0.2 F1000Research. https://doi.org/10.12688/f1000research.138350.2. SECTION 4 0 Additional 2001 2002 2005 2006 2007 2008 2009 2010 2012 2014 2015 2016 Guidance TABLE OF CONTENTS MODULE 7 Human References: Resources Fujita, for Health Noriko, Sadatoshi Matsuoka, Kyoko Koto-Shimada, Megumi Ikarashi, Indrajit Hazarika, and 241 OVERVIEW 1 SECTION 1 What Is a Health PER? Productivity 2 SECTION 2 KEY QUESTION • What are the performance and productivity of health workers? Cross-Cutting Analysis on Efficiency and Equity 3 Low performance of health workers is an inherent cause of to perform well, but not always. The model allows observers inefficiency and is influenced by a complex set of worker incentives. to conclude that motivation is the main driver behind the SECTION 3 It can be caused by low motivation due to management practices transformation of capacity into performance. Levels of motivation Topic-Specific and modes of remuneration, but also an absence of support can be assessed using questionnaires and other instruments. Analysis systems (including inputs like medicines and equipment) as well Indeed, in many contexts, the key question is how best to motivate Health System Context as inadequate training and supportive supervision (Scheffler et health workers to improve effort and, consequently, performance— al. 2016). closing the gap between what health workers know how to do and Health Financing what they do (the “know-do gap”). Inputs The World Bank offers a schematic model for health workforce M-7: Human Resources for Health performance (Figure 6), which considers performance to be a While information on the performance of health workers may be M-8: Infrastructure & Equipment result of health workers’ capacity and effort, which are determined hard to gather in a measurable and monitorable way, PER authors M-9: Medicines & Medical Supplies by workers’ education and experience as well as the workplace can use some basic indicators of productivity to assess efficiency. environment and policies (Leonard and Mæstad 2016; Herbst, Liu, Health workforce productivity is defined as the average rate of Service Delivery and Akala 2022). Not all health workers have received good quality output produced per unit of labor input during a given period Outcomes training (during their initial education or in-service training) to (Reinhardt 1972; Folland, Goodman, and Stano 2012). Ideally, 4 List of Acronyms have skills and competencies to perform well. Even well-trained productivity should be measured in terms of health gains of health workers with inadequate working conditions, for example, individual patients, but due to the difficulty to translate this to an SECTION 4 may perform poorly (low motivation). If working conditions operational measure and data availability, economists have opted Additional Guidance are adequate, health workers are more likely to be motivated to measure health labor productivity of measurable intermediate TABLE OF CONTENTS MODULE 7 Human Resources for Health 242 OVERVIEW 1 SECTION 1 outputs, such as visits (Reinhardt 1972; Hollingsworth 2008). Health The number of consultations per day per doctor (and per nurse/ What Is a labor input is defined as head counts (persons engaged) or hours midwife, depending on their roles in health care provision) is one Health PER? worked. Hours worked is a better measurement of health workers’ measure of basic productivity. To understand efficiency issues 2 availability, as it is adjusted for part-time work, differences in better, PER authors can examine this indicator across different SECTION 2 working hours, absenteeism, and hours worked in the public and types of health facilities, for example, primary facilities versus Cross-Cutting Analysis on private sectors. secondary facilities, and across different parts of the country. Efficiency and Since productivity is heavily influenced by workplace environment, Equity FIGURE 6 3 including supplies and equipment, authors should consider the THREE SOURCES OF PERFORMANCE readiness of health facilities to deliver services when inferring SECTION 3 about health workers’ productivity. Further information on this can Topic-Specific Analysis be found in the additional guidance note Service Availability and Readiness. Health System Context Health Financing Additionally, if possible, given the comprehensive nature of Inputs universal health coverage goals, PER authors can consider M-7: Human Resources for Health measuring health workers’ productivity across a spectrum of priority interventions for different cadres of health workers.4 M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Another indicator of productivity that could inform efficiency Service Delivery concerns is absenteeism. The data on absenteeism are commonly Outcomes available and sensitive enough to capture major performance issues in many countries. For example, a study involving 4 List of Acronyms unannounced visits to primary health facilities documents rates Source: Herbst, Liu, and Akala 2022. SECTION 4 Additional 4 The desired attributes of these priority interventions could be (1) policy relevance to inform specific policy interventions; (2) data availability to quantify the composite indicators; (3) simplicity to allow ease of comprehension, Guidance interpretation, and duplication; (4) comprehensiveness to capture efficiency across services; and (5) standardization to allow aggregation and comparison. The spectrum of priority interventions could be defined using different criteria, for example, the burden of disease of a country, the top 10 interventions related to maternal and child health, or the level of care (tertiary, secondary, and primary care). TABLE OF CONTENTS MODULE 7 Human Resources for Health 243 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 Key Indicators Sources SECTION 2 Cross-Cutting Number of consultations per day for full-time equivalent doctors, nurses/ • Facility surveys Analysis on midwives Efficiency and • Administrative data from MoH/health insurance fund Equity 3 % of days absent during a given period for different types of full-time • Facility surveys equivalent health workers • Administrative data SECTION 3 Topic-Specific Note: MoH = Ministry of Health. Analysis of absenteeism of 35 percent in Bangladesh, 37 percent in Uganda, and other health workers. Productivity is also influenced by Health System Context and 40 percent in India and Peru (Chaudhury et al. 2006). While the assignment of work, management practices, modes of Health Financing unannounced visits may produce reliable data, PER authors should remuneration, the motivation of workers, and regulation (Scheffler Inputs be aware that data collected on absenteeism from administrative et al. 2016). In this context, health worker productivity and any M-7: Human Resources for Health sources may have significant biased or unbiased underreporting. efficiency concerns should be tempered by information about the availability of other inputs (see the modules on Medicines and M-8: Infrastructure & Equipment Overall, however, measurable and comparable indicators of Medical Supplies, and Infrastructure and Equipment). PER M-9: Medicines & Medical Supplies performance and motivation of health workers on a national and authors can also consult existing analyses of HRH such as health Service Delivery international scale are limited, including in relation to efficiency labor market analyses that may have documented reasons for low Outcomes concerns. productivity more systematically. 4 List of Acronyms Also, authors should keep in mind that the productivity of a health SECTION 4 worker is affected by the availability of equipment, infrastructure, Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 244 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY 2 SECTION 2 Cross-Cutting Analysis on Distribution Efficiency and Equity 3 • What is the distribution of the available health workers between urban and rural/ KEY QUESTION SECTION 3 remote areas? Topic-Specific Analysis Health System Context Worldwide, the geographic distribution of health resulting in worse health outcomes. For example, in China, higher Health Financing pediatrician density was associated with lower under-5 mortality workers is skewed toward urban and wealthier Inputs rates (Zhang et al. 2021). Similarly, an analysis of nursing personnel areas. This pattern is found in nearly every country in 58 countries found that the Gini coefficient of inequality was M-7: Human Resources for Health in the world, regardless of the level of economic correlated with maternal mortality as well as life expectancy M-8: Infrastructure & Equipment (Boniol, McCarthy, et al. 2022). development and health system organization, M-9: Medicines & Medical Supplies including in OECD countries. In this context, examining the distribution of the density of Service Delivery Outcomes health workers across different parts of a country, particularly The problem is especially acute in developing countries. The rural and remote areas in comparison to urban areas, provides 4 List of Acronyms geographic imbalances in the health workforce further exacerbate useful information about equity. Overall, authors should conduct inequities in the health sector, as the services are not available their analyses of these indicators across geopolitical entities in SECTION 4 where needs are higher and the impact greater, sometimes a country. Additionally, numbers of health workers employed Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 245 OVERVIEW 1 SECTION 1 What Is a Health PER? at different levels of providers should also be considered. Data on this should be easily FIGURE 7 PHYSICIAN DENSITY ACROSS DIFFERENT AREAS IN SELECTED COUNTRIES, 2021 2 available for government health facilities. (OR NEAREST YEAR) SECTION 2 This information can be compared against any Cross-Cutting Analysis on staffing norms and guidelines for these facilities. Efficiency and PER authors should note that overstaffing Equity 3 can also be an issue. For example, a study of efficiency in general/acute-care public hospitals SECTION 3 in the Portuguese National Health Service found Topic-Specific Analysis that in general, almost half were overstaffed (Ferreira, Nunes, and Marques 2018). Health System Context Health Financing There is substantial evidence on the factors Inputs that discourage health workers from choosing M-7: Human Resources for Health to work in rural and remote areas. Commonly reported factors, sometimes described as “pull” M-8: Infrastructure & Equipment or “push” factors, include unsuitable preservice M-9: Medicines & Medical Supplies training for rural and remote areas practice, Service Delivery lack of opportunities for further training and Outcomes career development, low salaries, poor work environments, limited availability of equipment 4 List of Acronyms and drugs, insufficient family support, and SECTION 4 inadequate management and unsupportive Additional supervision (Araujo and Maeda 2013). Guidance Source: OECD (2023a). TABLE OF CONTENTS MODULE 7 Human Resources for Health 246 OVERVIEW 1 SECTION 1 What Is a Health PER? Key indicators Sources richer densely populated urban areas. In this context, it will be important to identify workable solutions to address labor market 2 Ratio of practicing • MoH reports demand issues such as increasing autonomy and finances available SECTION 2 medical doctors, nurses to rural health facilities (Herbst, Liu, and Akala 2022). • Human resource information system Cross-Cutting Analysis on and midwifes and • National Health Workforce accounts Efficiency and other health workers It should also be noted that there can also be interplay between Equity • WHO Global Health Workforce 3 per 10,000 population inequity and inefficiency. While a more balanced distribution of Statistics across geopolitical health workers is desirable and, in many cases, necessary, PER SECTION 3 • OECD Health Statistics entities in a country authors should consider the efficiency issues related to maintaining Topic-Specific Analysis • World Bank Open Data the same health–worker-to-population ratio in a sparsely populated Ratio of practicing • MoH reports region as in an urban region more closely. In some cases, the low Health System Context availability of health workers in rural areas can be circularly linked medical doctors, nurses • Human resource information system Health Financing and midwifes and other to the population’s low use of health services and health care • National Health Workforce accounts Inputs health workers by level facilities’ inability to maintain minimum caseloads to function • Professional councils and efficiently, as people avoid local facilities and travel to more densely M-7: Human Resources for Health of provider associations populated urban areas for care. For example, district hospitals in M-8: Infrastructure & Equipment Note: MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Development; WHO = World India have a relatively low bed occupancy rate, 57 percent, and only Health Organization. M-9: Medicines & Medical Supplies 86 percent and 60 percent of those hospitals meet national staffing Service Delivery Low financial capacity to employ health workers in rural areas norms for physicians and nurses, respectively (Sarwal, Kalal, and Outcomes will also contribute to an inequitable distribution. Availability of Iyer 2021). In this context, for certain types of health services, it private financing for health care through out-of-pocket payments or may be more appropriate to introduce alternate models of service 4 List of Acronyms health insurance will be lower in remote and rural areas in low- and delivery. These can involve a different skill mix and organization of SECTION 4 middle-income countries. When coupled with limited autonomy and staff, for example greater use of telemedicine, outreach services, Additional financial means for rural facilities to hire and retain health workers, and community health workers, to make more efficient the use of Guidance the distribution of health workers will be even more skewed toward the limited health workforce. TABLE OF CONTENTS MODULE 7 Human Resources for Health 247 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 GOVERNANCE AND PROCESSES SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 Good HRH policy and management are essential Unfortunately, there is no one-size-fits-all human resources SECTION 3 strategy that can guarantee success. Premature adoption Topic-Specific for having adequately trained health professionals of a specified set of HR policies is unlikely to realize positive Analysis in the right numbers; effectively distributed across organizational results. The same bundle of HR policies is not Health System Context facilities, levels of health care provision, and universally applicable to all health systems, as each system has unique needs and challenges. Further, HRH issues are often Health Financing regions; and sufficiently motivated to deliver quality complex and interlinked with other aspects of a health system. Inputs services. While this area had been historically Thus, as discussed in the introduction, it may be difficult for PER M-7: Human Resources for Health overlooked, in recent years, policymakers have authors to gain an in-depth understanding of the challenges and M-8: Infrastructure & Equipment recognized the importance of effective HRH policy solutions in this area through just the simple analysis proposed M-9: Medicines & Medical Supplies as part of a health sector PER. Interested authors can consider and management, for example, through SDG health other instruments for conducting more in-depth analysis, such Service Delivery targets related to HRH. as health labor market analyses. This section aims, however, to Outcomes point PER authors toward a few areas related to HRH policy and 4 List of Acronyms explains which can be considered. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 248 OVERVIEW 1 SECTION 1 What Is a Health PER? Governance and Overall Policy 2 KEY QUESTION • Is there a comprehensive national HRH strategy? SECTION 2 Cross-Cutting Analysis on Efficiency and PER authors can begin to examine the governance of HRH by seeing capacity, and tools for making strategic decisions and are occupied Equity 3 whether there are recent policy and planning documents that with human resources management issues such as ensuring timely outline the national HRH strategy/approach in a comprehensive and payroll. Thus, some countries have created a department focused SECTION 3 coordinated manner. Ideally, this HRH strategy should be detailed, on strategic HRH issues, for example, human resources for health Topic-Specific costed, and have indicators for monitoring commitment toward observatories. The presence of such an institution would be a good Analysis its implementation, including through government financing. The sign for HRH governance in a country. Previous health labor market Health System Context alignment of the HRH strategy with national health policy/strategy analyses that had ownership from the MoH and other institutions should also be studied. In countries where the government is responsible for health sector policy would also signal interest in Health Financing an important employer, alignment of the HRH strategy with civil strategic thinking and solving HRH issues. Inputs service or public service planning will also be important. Authors M-7: Human Resources for Health can assess the quality of the documents and progress toward their Overall, an interest and capacity for HRH planning and development M-8: Infrastructure & Equipment implementation in this manner. of strategy and policy based on good quality information will be a M-9: Medicines & Medical Supplies positive indicator of governance in this area. Unfortunately, this is In addition to the presence of a HRH strategy/plan and policy, found more rarely than would be expected, even in high-income Service Delivery centralized data and evidence for HRH decision making are countries. Outcomes important. MoH human resources departments often lack the time, 4 List of Acronyms Key indicators Sources SECTION 4 Is there a national HRH policy/strategy? • MoH policy documents Additional Guidance Is there a unit/department looking at strategic data and evidence to support decision making for HRH? • KIIs Note: KII = key informant interview; MoH = Ministry of Health. TABLE OF CONTENTS MODULE 7 Human Resources for Health 249 OVERVIEW 1 SECTION 1 What Is a Health PER? Human Resource Management Practice 2 SECTION 2 Cross-Cutting Analysis on • Is there a sufficient degree of autonomy in human resource decision making? Efficiency and KEY QUESTIONS Equity • Are there adequate incentives for health workers? 3 SECTION 3 Topic-Specific Analysis Health System Context A robust human resource management approach integrates into a comprehensive management system what are frequently isolated functions in an organization: recruitment, hiring, retention, talent PER authors could consider closely examining the degree of autonomy for making HR decisions available to providers. This can be a source of inefficiency, for example, when unproductive workers management, payroll, human resource information systems, cannot be fired. Policies and practices, however, vary significantly Health Financing supervision, and staff development. across different countries’ health systems. For example, an OECD Inputs survey of health system characteristics found that in several OECD M-7: Human Resources for Health While assessing human resource management is complex without countries, hospital managers have autonomy over recruitment M-8: Infrastructure & Equipment in-depth analysis, common characteristics often identified as and remuneration levels of medical staff. However, in Canada and M-9: Medicines & Medical Supplies successful practices in this area include an emphasis on providing Türkiye, national or local governments make decisions regarding employment security, the use of self-managed PER authors, the medical staff recruitment. Table 2 provides an overview of hospital Service Delivery decentralization of decision making, on-the-job training and recruitment and remuneration in selected OECD countries. Authors Outcomes supportive supervision, the selective hiring of new personnel, can consider similar areas of autonomy when exploring human 4 List of Acronyms and some compensation linked to performance. resource decision making in their countries, also keeping in mind the capacity needed to make HR decisions. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 250 OVERVIEW 1 SECTION 1 What Is a Health PER? TABLE 2 HOSPITAL STAFF RECRUITMENT AND REMUNERATION, SELECTED OECD COUNTRIES 2 Recruitment of medical Remuneration level of Recruitment of other Remuneration level of SECTION 2 Country staff medical staff health professionals other health professionals Cross-Cutting Analysis on Efficiency and Australia* Hospital managers have Hospital managers have Hospital managers have Hospital managers have Equity complete autonomy autonomy within state- complete autonomy autonomy within state-level 3 level negotiated pay negotiated pay scales SECTION 3 scales Topic-Specific Analysis Brazil* Decentralized with Decentralized with State and Municipal State and Municipal Health System Context Governments having Governments having Health Financing autonomy autonomy Inputs Canada Hospitals must A pay scale is set or Central or subnational A pay scale is set or M-7: Human Resources for Health negotiate with local negotiated at the government decides negotiated at the national M-8: Infrastructure & Equipment authorities national level level M-9: Medicines & Medical Supplies Türkiye Central or subnational A pay scale is set or Central or subnational A pay scale is set or Service Delivery government decides negotiated at the government decides negotiated at the national Outcomes national level level 4 List of Acronyms United Kingdom Hospital managers have A pay scale is set or Hospital managers have A pay scale is set or complete autonomy negotiated at the complete autonomy negotiated at the national SECTION 4 national level level Additional Guidance Source: Paris, Devaux, and Wei (2010). TABLE OF CONTENTS MODULE 7 Human Resources for Health 251 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors should also explore staff incentives—important levers inefficiency. For example, certain measures like long average times 2 that organizations can use to attract, retain, motivate, satisfy, for recruitment could be indicative of problems. While the reasons SECTION 2 and improve the performance of health workers. Incentives can for this could be varied, improving recruitment practices could be Cross-Cutting Analysis on be applied to individuals, groups of workers, PER authors, or a quick win, as discussed earlier. However, overall, efficiency and Efficiency and Equity organizations; they can also vary according to the type of employer. equity implications related to HR management practices will be 3 Incentives can be positive or negative, financial or nonfinancial, context dependent. Often the most wasteful practices are only tangible or intangible (Global Health Workforce Alliance 2013). For discovered in audits or other detailed investigations—for example, SECTION 3 Topic-Specific example, hardship financial allowances in addition to salaries may payments to “ghost workers” have been documented in some Analysis be offered to health workers who work in remote areas. Indeed, countries (Kohler 2020).5 in some countries these types of additional payments to health Health System Context workers can be a large component of budgets. Authors can conduct Generally, because there are no standard indicators for HR Health Financing quantitative and qualitative analysis to better understand health management, PER authors should rely on other sources to Inputs worker incentives and assess how satisfied health workers are with identify areas of focus. For example, any prior health labor market M-7: Human Resources for Health them. While such work is intensive in the context of a PER, health analyses may have identified concern. Additionally, the national labor market analyses or existing research or reports on these HRH strategy/policy or the work of strategic units for HRH in M-8: Infrastructure & Equipment factors can provide useful information. the country may also point to the priorities for human resource M-9: Medicines & Medical Supplies management that might impact efficiency and equity. Service Delivery Other HR management practices such as cumbersome recruitment Outcomes or de-linkage of payroll and HR databases can result in significant 4 List of Acronyms 5 “Ghost workers” are examples of payroll fraud where nonexistent or terminated employees continue to be paid. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 252 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Cross-Cutting Araujo, Edson, and Akiko Maeda. 2013. “How to Recruit and Retain Health Workers in Rural and Remote Areas in Developing Countries.” https:// Analysis on documents1.worldbank.org/curated/en/273821468154769065/pdf/785060WP0HRHDC00Box377346B00PUBLIC0.pdf. Efficiency and Equity 3 Asamani, James Avoka, Ninon P. Amertil, Hamza Ismaila, Francis Abande Akugri, and Juliet Nabyonga-Orem. 2020. “The Imperative of Evidence-Based Health Workforce Planning and Implementation: Lessons from Nurses and Midwives Unemployment Crisis in Ghana.” Human Resources for Health 18 SECTION 3 (1): 16. https://doi.org/10.1186/s12960-020-0462-5. Topic-Specific Analysis Asamani, James Avoka, Christmal Dela Christmals, and Gerda Marie Reitsma. 2021. “The Needs-Based Health Workforce Planning Method: A Systematic Scoping Review of Analytical Applications.” Health Policy and Planning 36 (8): 1325–43. https://doi.org/10.1093/heapol/czab022. Health System Context Health Financing Boniol, Mathieu, Teena Kunjumen, Tapas Sadasivan Nair, Amani Siyam, James Campbell, and Khassoum Diallo. 2022. “The Global Health Workforce Stock and Distribution in 2020 and 2030: A Threat to Equity and ‘Universal’ Health Coverage?” BMJ Global Health 7 (6): e009316. https://doi.org/10.1136/ Inputs bmjgh-2022-009316. M-7: Human Resources for Health Boniol, Mathieu, Carey McCarthy, Deen Lawani, Gilles Guillot, Michelle McIsaac, and Khassoum Diallo. 2022. “Inequal Distribution of Nursing Personnel: M-8: Infrastructure & Equipment A Subnational Analysis of the Distribution of Nurses across 58 Countries.” Human Resources for Health 20 (1): 22. https://doi.org/10.1186/s12960-022- M-9: Medicines & Medical Supplies 00720-5. Service Delivery Chaudhury, Nazmul, Jeffrey Hammer, Michael Kremer, Karthik Muralidharan, and F. Halsey Rogers. 2006. “Missing in Action: Teacher and Health Worker Outcomes Absence in Developing Countries.” Journal of Economic Perspectives 20 (1): 91–116. https://doi.org/10.1257/089533006776526058. 4 List of Acronyms Folland, Sherman, Allen C. Goodman, and Miron Stano. 2012. The Economics of Health and Health Care. 7th edition. Bosten München: Routledge. SECTION 4 Global Health Workforce Alliance. 2013. “A Universal Truth: No Health without a Workforce.” World Health Organisation (WHO) Report 2013:1–104. Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 253 OVERVIEW 1 SECTION 1 What Is a Health PER? Haakenstad, Annie, et al. 2019. “Measuring the Availability of Human Resources for Health and Its Relationship to Universal Health Coverage for 204 Countries and Territories from 1990 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019.” 2022. The Lancet 399 (10341): 2 2129–54. https://doi.org/10.1016/S0140-6736(22)00532-3. SECTION 2 Cross-Cutting Herbst, Christopher H., Jenny X. Liu, and Francisca Ayodeji Akala. 2022. “Health Workforce in Low and Middle Income Countries: Concepts and Dynamics Analysis on Efficiency and Unpacked.” In Making Health Systems Work in Low and Middle Income Countries: Textbook for Public Health Practitioners, edited by Awad Mataria, Equity Katherine D. Rouleau, Meesha Iqbal, and Sameen Siddiqi, 83–101. Cambridge: Cambridge University Press. https://doi.org/10.1017/9781009211086.007. 3 Hollingsworth, Bruce. 2008. “The Measurement of Efficiency and Productivity of Health Care Delivery.” Health Economics 17 (10): 1107–28. https:// SECTION 3 doi.org/10.1002/hec.1391. Topic-Specific Analysis Jimba, Masamine, Giorgio Cometto, Tami Yamamoto, Laura Shiao, Luis Huicho, and Mubashar Sheik. 2010. “Health Workforce: The Critical Pathway to Universal Health Coverage.” Background Paper for the Global Symposium on Health Systems Research. https://healthsystemsresearch.org/ Health System Context hsr2010/images/stories/10health_workforce.pdf. Health Financing Inputs Kohler, Jillian Clare. 2020. “Findings From a Rapid Review of Literature on Ghost Workers in the Health Sector: Towards Improving Detection and Prevention.” https://tspace.library.utoronto.ca/handle/1807/107933. M-7: Human Resources for Health M-8: Infrastructure & Equipment Leonard, Kenneth, and Ottar Mæstad. 2016. “Measuring the Performance of Health Workers.” In Health Labor Market Analyses in Low- and Middle- Income Countries: An Evidence-Based Approach, 163–95. Directions in Development—Human Development. World Bank, Washington, DC. https:// M-9: Medicines & Medical Supplies doi.org/10.1596/978-1-4648-0931-6_ch7. Service Delivery McPake, Barbara, Anthony Scott, and Ijeoma Edoka. 2014. Analyzing Markets for Health Workers: Insights from Labor and Health Economics. Outcomes Directions in Development—Human Development. World Bank, Washington, DC. https://doi.org/10.1596/978-1-4648-0224-9. 4 List of Acronyms Reinhardt, U. 1972. “A Production Function for Physician Services.” The Review of Economics and Statistics 54 (1): 55–66. https://doi.org/10.2307/1927495. SECTION 4 Sarwal, R., S. Kalal, and V. Iyer. 2021. “Best Practices in the Performance of District Hospitals.” New Delhi: NITI Aayog. Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 254 OVERVIEW 1 SECTION 1 What Is a Health PER? Scheffler, Richard M., Christopher H. Herbst, Christophe Lemiere, and Jim Campbell. 2016. Health Labor Market Analyses in Low- and Middle-Income Countries: An Evidence-Based Approach. Washington, DC: World Bank Publications. 2 SECTION 2 Soucat, Agnes, Richard Scheffler, and Tedros Adhanom Ghebreyesus. 2013. The Labor Market for Health Workers in Africa. Directions in Development— Cross-Cutting Human Development. Washington, DC: World Bank. https://doi.org/10.1596/978-0-8213-9555-4. Analysis on Efficiency and Winkelmann, Juliane, Giada Scarpetti, Gemma A. Williams, and Claudia B. Maier. 2022. “How Can Skill-Mix Innovations Support the Implementation of Equity 3 Integrated Care for People with Chronic Conditions and Multimorbidity?” European Observatory on Health Systems and Policies. https://www.ncbi. nlm.nih.gov/books/NBK589251/. SECTION 3 Topic-Specific World Health Organization. 2021. “Health Labour Market Analysis Guidebook.” https://apps.who.int/iris/bitstream/handle/10665/348069/9789240035546- Analysis eng.pdf. Health System Context Zhang, Xi, Jian Wang, Li-Su Huang, Xin Zhou, Julian Little, Therese Hesketh, Yong-Jun Zhang, and Kun Sun. 2021. “Associations between Measures of Health Financing Pediatric Human Resources and the Under-Five Mortality Rate: A Nationwide Study in China in 2014.” World Journal of Pediatrics 17 (3): 317–25. https:// Inputs doi.org/10.1007/s12519-021-00433-0. M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 7 Human Resources for Health 255 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity MODULE 8 3 SECTION 3 Topic-Specific Analysis Physical Health System Context Health Financing Infrastructure and Equipment Inputs M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies AUTHORS Service Delivery Dominic Haazen, with contributions from Andreas Outcomes Seiter, Denise Silfverberg, and Catalina Gutiérrez 4 List of Acronyms SECTION 4 START Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 256 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Physical infrastructure that functions effectively Capital health expenditure will typically capture both infrastructure and equipment. This module covers mainly physical Cross-Cutting Analysis on and efficiently and is optimally and equitably infrastructure, given that data on equipment are harder to come Efficiency and Equity distributed is critical to providing high-quality by. Annex 1 to this module provides guidance on analyzing 3 health care and improving health outcomes. equipment expenditure. Whenever data are available, PER authors SECTION 3 should assess the availability, distribution, and productivity of However, from a Public Expenditure Review Topic-Specific equipment. Facilities that are not adequately equipped or have Analysis (PER) perspective, ongoing spending for physical nonfunctional equipment are unable to provide quality care, and infrastructure (capital expenditures and operating this amounts to wasted resources (see Box 1 for a definition of Health System Context expenditures for maintenance) typically is not one “medical equipment”). Health Financing Inputs of the larger categories in the health sector. To fully exploit available resources, countries need to optimize M-7: Human Resources for Health infrastructure use and space allocation and ensure that buildings M-8: Infrastructure & Equipment Physical infrastructure includes health facility buildings, related are suitable for their specified purpose. This involves optimizing medical and nonmedical vehicles, and nonmedical equipment. the geographic distribution of infrastructure according to the level M-9: Medicines & Medical Supplies Nonmedical equipment includes such items as heating, ventilation, of care needed in different areas and establishing an efficient Service Delivery and air conditioning; water and sanitation; and information and referral system among facilities and services. Outcomes communications equipment, including digital technology. Medical 4 List of Acronyms vehicles include ambulances and other specialized vehicles, such Having too few or undersourced primary care facilities can result as blood transfusion vans, while nonmedical vehicles include in patients not receiving care or seeking care at a higher-level SECTION 4 general transport automobiles and trucks. facility than needed. Hospital and emergency room overuse for Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 257 OVERVIEW 1 SECTION 1 What Is a Health PER? conditions that should be treated at a lower level of complexity is documented worldwide. This overuse 2 not only makes care more expensive for patients, but SECTION 2 also diverts scarce health professionals to providing Cross-Cutting Analysis on care that does not require their advanced services. Efficiency and Equity 3 Investments in infrastructure that is not properly purposed or sustained are the most evident form SECTION 3 of waste. Topic-Specific Analysis Hospitals that are inappropriately sized and/ Health System Context or ineffectively positioned can also result in Health Financing significant inefficiencies. Past literature has Inputs shown that considerable gains can be made by M-7: Human Resources for Health guiding the capacity of the hospital sector toward better geographic distribution, more economical M-8: Infrastructure & Equipment scale, and better configuration of services across M-9: Medicines & Medical Supplies facilities (see, for example, La Forgia and Couttolenc Service Delivery 2008). Inadequate distribution of infrastructure Outcomes exacerbates the ineffective allocation of financial resources, as recurrent government funding for 4 List of Acronyms services is frequently influenced by the distribution SECTION 4 of infrastructure. Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 258 OVERVIEW 1 SECTION 1 What Is a Health PER? The geographic distribution of facilities is also important for equitable accress to care across the population. Often, the modules on service delivery (Hospitals Module Health Care and Essential Public Health Functions and Primary ), which contain 2 infrastructure is concentrated in large cities and populated areas, indicators on availability of equipment, supplies, and medicines SECTION 2 out of reach of the most vulnerable people. PER authors should to understand whether the facilities have the medical equipment Cross-Cutting Analysis on look at whether the country’s infrastructure is sufficient for the size necessary to provide the services. Efficiency and of the population and efficiently distributed according to the level Equity 3 of care in a given area and by population subgroup. Authors should The module is divided into three sections: efficiency, equity, also review whether all facilities are equipped with the basic and governance. Each section provides indicators that can be SECTION 3 amenities to provide a minimum level of quality care, whether there constructed from data most readily available in low- and middle- Topic-Specific Analysis is under- or overuse of facilities, and whether optimal processes income countries. For PER authors wishing to dive deeper, Annex to plan and monitor infrastructure are in place. Additionally, an 1 provides additional indicators for laboratory and diagnostic Health System Context important element in the public expenditure analysis is the extent facilities, digital health, and expenditure on utilities and Health Financing the level of ongoing spending on maintenance, replacement, and equipment. Box 1 defines terms used in the module. Inputs enhancement of physical infrastructure can ensure that the level M-7: Human Resources for Health of quality and efficiency of the provided health services can be maintained. Process and governance arrangements for planning, M-8: Infrastructure & Equipment commissioning, maintaining, and using health infrastructure are M-9: Medicines & Medical Supplies a key determinant to guide efficient infrastructure spending. Service Delivery Outcomes Optimized infrastructure alone is not sufficient to provide efficient and equitable health services, as infrastructure is only one factor 4 List of Acronyms in service delivery. The availability of human resources (see the SECTION 4 module on Human Resources ) determines whether facilities can Additional be adequately staffed. Additionally, PER authors may wish to look at Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 259 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS 2 HEALTH FACILITIES pediatrics) are classified as secondary-care PRIMARY CARE FACILITIES SECTION 2 Buildings or other structures where health facilities; and larger hospitals staffed by Facilities where primary care is provided. Cross-Cutting care is provided. These include health posts, specialists and subspecialists offering advanced Analysis on Efficiency and health centers, hospitals of different levels of medical services are classified as providers of NONMEDICAL EQUIPMENT Equity 3 complexity and size, outpatient care centers, tertiary-level care. Such items as heating, ventilation, and air pharmacies, laboratories, and specialized conditioning; water and sanitation; and SECTION 3 care centers, such as birthing centers and PRIMARY CARE information and communications equipment, Topic-Specific psychiatric care centers. For the purpose of this The Organisation for Economic Co-operation including digital technology. Analysis module, mobile clinics are excluded from the and Development (OECD) defines primary care definition, as they are included under vehicles. as “the first level of contact for the population MEDICAL EQUIPMENT Health System Context with the healthcare system, bringing healthcare Medical devices requiring calibration, Health Financing LEVEL OF CARE as close as possible to where people live and maintenance, repair, user training, and Inputs The degree of complexity of the medical cases work. It addresses the main health problems decommissioning. They are used for the M-7: Human Resources for Health doctors and other health care professionals treat in the community, providing preventive, specific purposes of diagnosis and treatment M-8: Infrastructure & Equipment and the skills and specialties of the providers. curative and rehabilitative services. Primary of disease or rehabilitation following disease Each country has its own categorization of care goes beyond services provided by primary or injury and can be used either alone or in M-9: Medicines & Medical Supplies facilities by level of care. Typically, health centers, care physicians to encompass other health combination with any accessory, consumable, Service Delivery health posts, and community outreach programs professionals such as nurses, pharmacists, or other piece of medical equipment. Medical Outcomes are considered providers of first-level care; auxiliaries, and community health workers.”1 equipment excludes implantable, disposable, outpatient clinics and small hospitals staffed Primary health care is a broader concept that or single-use medical devices.2 4 List of Acronyms by physicians trained in the basic specialties encompasses a model of care, public health, (gynecology, family medicine, internal medicine, and population health. SECTION 4 Additional Guidance 1 https://www.oecd.org/health/primary-care.htm. 2 https://www.who.int/PER authors/health-product-policy-and-standards/assistive-and-medical-technology/medical-devices (accessed March 2022). TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 260 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY 2 Aggregate Spending SECTION 2 Cross-Cutting Analysis on Efficiency and Equity • What is the level of spending on infrastructure for health in the country? 3 KEY QUESTIONS • What is the overall supply of infrastructure in the country? SECTION 3 Topic-Specific ⭘ Is it sufficient? Analysis ⭘ Is there an over- or undersupply of infrastructure? ⭘ How has the overall supply of infrastructure evolved? Health System Context Health Financing Inputs PER authors should analyze the level of spending often greater than new “greenfield” construction, M-7: Human Resources for Health for infrastructure relative to the existing capital especially if potentially hazardous materials were M-8: Infrastructure & Equipment base (current investment in infrastructure) as well used in the initial construction. However, many M-9: Medicines & Medical Supplies as relevant plans for upgrading and/or expansion. countries do not have a large capital base, and Service Delivery Outcomes Countries with a large out-of-date capital base thus capital spending may be needed to bring may require capital spending in order to repurpose the existing infrastructure up to national and/or 4 List of Acronyms existing facilities for providing modern health international standards or norms. SECTION 4 Additional care services. The costs of such renovations are Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 261 OVERVIEW 1 SECTION 1 What Is a Health PER? Beyond the initial capital construction costs, ongoing funding is needed to ensure a continued high level of functionality. This is on the equipment working properly within the defined technical parameters. While depreciation is often considered strictly an 2 often an issue in countries with national health insurance systems accounting exercise, the funding of depreciation allows health care SECTION 2 where capital construction and/or equipment costs are provided by providers to accumulate funds for the eventual replacement of the Cross-Cutting one entity, such as the Ministry of Health (MoH), while the costs of capital stock once it has reached the end of its useful life. In the Analysis on Efficiency and service provision are financed by a health insurance fund. absence of a robust capital expenditure or replacement program Equity 3 in the MoH (or whichever entity funds the initial capital costs), this In this case, PER authors should drill down to determine whether the would be the only way to ensure that the capital stock provides SECTION 3 amounts paid for service provision include appropriate allowances high-quality care. Topic-Specific for the use of capital in service provision. This could be an allocation Analysis for the use of capital assets over their useful life (depreciation) or It is important for PER authors to examine the trend over time, Health System Context the amounts needed to ensure that assets are kept in prime working as spending on infrastructure and equipment may be a one-time Health Financing condition (for example, through maintenance and minor repairs) investment and may appear high in one year and low in another. If to provide high-quality care. Regular maintenance, including data are available, comparing public versus private expenditure on Inputs preventive maintenance, is especially important for biomedical equipment over time may also provide additional insights into any M-7: Human Resources for Health equipment, where the clinical efficacy of the equipment depends changes in trends. M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Key Indicators for Assessing Spending Levels Sources Service Delivery Level and trends of capital health expenditure as a percentage of total health expenditure MoF, MoH, World Bank HNP Outcomes (or GDP) HealthStats, WHO SEARO, 4 List of Acronyms WHO AFRO SECTION 4 Operating expenditure on maintenance of the capital stock (preventive maintenance, minor upgrading) as MoF, MoH, health insurance Additional a percentage of total health expenditure, broken down by medical and nonmedical equipment if possible funds Guidance Note: GDP = gross domestic product; HNP = Health, Nutrition, and Population; MoF = Ministry of Finance; MoH = Ministry of Health; WHO = World Health Organization; regional offices: AFRO = Africa, SEARO = South-East Asia. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 262 OVERVIEW 1 FIGURE 1 SECTION 1 CAPITAL COSTS AS A PERCENT OF TOTAL HEALTH EXPENDITURES, The available data can be benchmarked across What Is a Health PER? similar countries and geopolitical entities SELECTED ECA AND EU COUNTRIES, 1990–2006 2 (urban/rural; subnational entities). Capital Azerbaijan SECTION 2 health expenditure will typically capture both Belarus Bosnia Cross-Cutting infrastructure and equipment. If disaggregation Analysis on Bulgaria Efficiency and is not readily available, it can be analyzed together Czech… Equity 3 with equipment. When possible, PER authors Estonia should also distinguish between expenditure Georgia SECTION 3 on new construction and on rehabilitation or Hungary Kazakhstan Topic-Specific Analysis the upgrade of existing facilities. This analysis Kyrgyzstan can be linked to assessing efficiency, reviewing Lithuania Health System Context certification of the need for infrastructure. Moldova Romania Health Financing Slovenia Figure 1 shows a comparison of capital costs as a Tajikistan Inputs percent of total health expenditures among Europe Macedonia M-7: Human Resources for Health and Central Asia (ECA) and EU countries, including Turkey Ukraine M-8: Infrastructure & Equipment the minimum, maximum, and latest values over Uzbekistan M-9: Medicines & Medical Supplies the period 1990–2006 (Kutzin et al. 2010). These Service Delivery data show that despite the considerable variation, Austria Denmark capital costs averaged around 5 percent across all Outcomes Germany of the countries included in the sample. While the 4 Greece List of Acronyms variation in ECA countries was much greater, the Ireland average over time between those countries and Italy SECTION 4 Portugal those in the EU was the same (5.1 percent). Additional 0 5 10 15 20 Guidance Percent Source: WHO. Note: ECA = Europe and Central Asia region. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 263 OVERVIEW 1 SECTION 1 What Is a Health PER? Capital health expenditures should guarantee the adequate availability of infrastructure. Availability is the first step toward ensuring that the population Key Indicators on Availability Sources 2 has access to the necessary health infrastructure to achieve positive health SECTION 2 outcomes. Without adequate physical access, patients need to travel farther to Health facility density • Can be estimated through Cross-Cutting obtain health services, leading to increased patient costs and potentially poorer per 10,000 population SARA, SDI, SPA surveys Analysis on Efficiency and health outcomes, due to delays in receiving care. Conversely, an oversupply of Equity • MoH for infrastructure 3 infrastructure can lead to inefficiencies in the use of scarce health resources, maps, inventory of facilities, including monetary and human resources. including geospatial mapping SECTION 3 Topic-Specific Facility geographic density is a standard indicator for judging sufficiency. In Hospital beds (per • WHO regional observatories Analysis addition to the aggregate availability of facilities, whenever possible, PER 10,000 population) • WDI Health System Context authors should understand the distribution of facilities across subnational governments. The distribution in urban and rural areas is addressed in the • MOH annual reports Health Financing section on equity. Inputs M-7: Human Resources for Health Percentage of population • DHS While computers, internet access, and communications are basic requirements, living five kilometers or M-8: Infrastructure & Equipment the delivery of modern medical care requires at least a minimal level of digital • Household surveys 30 minutes or one hour M-9: Medicines & Medical Supplies health infrastructure, including hardware and software. There are various from a facility (PHC or • In-country studies on access approaches to assessing and improving digital health infrastructure. The Global Service Delivery specialized) to care Digital Health Monitor (GDHM) features a series of key indicators, spread across Outcomes seven categories, to track progress and allows countries to benchmark against Overall phase of digital • DGHM 4 List of Acronyms each other. For each indicator, the GDHM includes different development health phases, and countries select the phase that best describes the status of their SECTION 4 Note: DGHM = Digital Global Health Monitor; DHS = Demographic and Health Surveys; PHC = primary digital health infrastructure.3 health care; SARA = Service Availability and Readiness Assessment; SDI = Service Delivery Indicators; Additional SPA = Service Provision Assessment; WDI = World Development Indicators; WHO = World Health Guidance Organization. 3 The Global Digital Health Monitor replaces the previous Global Digital Health Index. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 264 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 Ideally, PER authors should also analyze trends and benchmark Organisation for Economic Co-operation and Development (OECD) SECTION 2 the indicators shown in the table across similar countries, and definition of total hospital beds includes curative (or acute) care Cross-Cutting Analysis on depending on the extent they are included in the regional WHO beds, rehabilitative care beds, long-term care beds, and other Efficiency and databases, this should be feasible in most cases. However, if these beds in hospitals. Depending on the country in question, PER Equity 3 data are not readily available, PER authors could benchmark authors may need to differentiate between available capacity according to international benchmarks. The WHO SARA Reference and the proportion of that capacity that is actually in operation. SECTION 3 Manual (2015) proposes the following standards: 25 beds per Topic-Specific Analysis 10,000 and two facilities per 10,000 population. Depending on the Combining bed and facility density with output measures, such as country context, PER authors may wish to analyze the availability bed occupancy rates (see the following), should also help identify Health System Context of maternity beds. SARA guidance proposes a benchmark of 10 over- or undersupply of physical infrastructure. Lower-than- Health Financing beds per 1,000 pregnant women (see Annex 2 for guidance on how average density with high occupancy rates may signal undersupply, Inputs to estimate the number of pregnant women). This indicator does while higher-than-average density with low occupancy rates might not take into account the size of the facilities—a major limitation of be a sign of oversupply. A similar analysis can be performed for M-7: Human Resources for Health using the number of facilities to assess infrastructure availability different geographic or subnational units. Significant differences M-8: Infrastructure & Equipment and to benchmark results against similar countries or WHO SARA in occupancy and density can signal an inefficient distribution of M-9: Medicines & Medical Supplies benchmarks. Authors should also consider country targets, if the facilities or a problem with access and quality. Service Delivery country has established targets, to supplement the analysis. Outcomes If data are available, PER authors can analyze the density of As inclusions in total hospital beds may vary by country, it is facilities other than primary care (PC) facilities and hospitals. 4 List of Acronyms important to clarify the definitions for the indicators presented, These could include pharmacies, laboratories, and specialized including when benchmarking across similar countries. The care facilities, such as psychiatric hospitals (see Annex 1 ). SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 265 OVERVIEW 1 SECTION 1 What Is a Health PER? Infrastructure Mix 2 KEY QUESTION • What is the facility distribution across different levels of care? Is it the right mix? SECTION 2 Cross-Cutting Analysis on Efficiency and Equity Information on the availability and distribution of health Key indicators of Facility Mix Sources 3 facilities at various levels of care is vital for assessing Number of PHC facilities MoH infrastructure maps, SECTION 3 efficiency. Accessible, adequately equipped and staffed Topic-Specific per 100,000 population inventory of facilities, Analysis primary care (PC) facilities should be able to treat most (disaggregated by level, including geospatial of a population’s health care needs and prevent patients such as community versus mapping Health System Context health center/dispensary) • WHO regional Health Financing from unnecessarily seeking care in facilities offering more observatories (WHO EURO, Inputs advanced care. WHO EMRO) M-7: Human Resources for Health Total density per 100,000 • MoH infrastructure maps, There is no global normative guidance on the optimal primary care M-8: Infrastructure & Equipment population: Hospitals (may inventory of facilities, facility density and distribution. Optimal allocation depends on demand, M-9: Medicines & Medical Supplies be further disaggregated by including geospatial population density, health system organization—including availability of size in terms of number of mapping Service Delivery outreach services—and geography. However, looking at the percentage beds) Outcomes of the population that lives five kilometers or 30 minutes from a facility • WHO regional can show the adequacy and distribution of facilities as a first point of Number of total acute care observatories (WHO EURO, 4 List of Acronyms contact for people with health care needs. The availability of acute care hospital beds per 10,000 WHO AMRO/PAHO) beds, in contrast, indicates the capacity of a country to respond to more population SECTION 4 Additional complex conditions; a standard of five beds per 10,000 people for acute Note: MoH = Ministry of Health; PHC = primary health care; WHO = World Health Organization; regional Guidance care has been suggested (OECD). offices: AMRO/PAHO = Americas/Pan American Health Organization, EMRO = Eastern Mediterranean Health Observatory, EURO = Europe, SEARO = South-East Asia. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 266 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 2 DENSITY OF HEALTH INFRASTRUCTURE PER 10,000 POPULATION, SELECTED COUNTRIES, 2020 OR LATEST YEAR 2 3.0 36 SECTION 2 2.5 30 Hospital Beds Cross-Cutting Analysis on 2.0 24 Efficiency and PHC Equity 1.5 18 3 1.0 12 SECTION 3 0.5 6 Topic-Specific 0.0 0 Analysis Djibouti Egypt Libya Morocco Oman Somalia Sudan Tunisia Yemen Health System Context PHC Hospital Beds Health Financing Source: World Bank staff calculations based on WHO EMRO Health Observatory Data Depository. Note: PHC = primary health care. Inputs M-7: Human Resources for Health MoH infrastructure maps and/or inventory of facilities, including whether or how a lack of data has been addressed. There may be geospatial mapping if available, should provide information on the different types of PC facilities (for example, clinics, health centers) M-8: Infrastructure & Equipment number of facilities by type, and some regional WHO observatories in the country. If so, PER authors should explain the differences M-9: Medicines & Medical Supplies also collect data on facilities by type. However, in many low- and between the facilities and disaggregate the indicator by facility Service Delivery lower-middle-income countries, facility maps and infrastructure type.4 Figure 2 charts data on hospitals and PC facilities for selected Outcomes inventories are not up to date. It is important for PER authors to WHO EMRO countries.5 Authors should also consider the trends for frame such limitations upfront to show the extent these key data such indicators. 4 List of Acronyms are available (or not) in their particular country and to indicate SECTION 4 Additional 4 See Weiss and Nelson et al. (2020) for an application of geospatial open-source tools to calculate global maps of travel time to health care facilities and for estimates of the percent of population living 10, 30, or more than 60 Guidance minutes from a health care facility, for 200 countries in 2019. 5 WHO EMRO Health Observatory Data Depository (https://rho.emro.who.int/by-name), accessed May 31, 2022. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 267 OVERVIEW 1 SECTION 1 What Is a Health PER? Productivity 2 KEY QUESTIONS • Are facilities equipped with basic amenities? SECTION 2 • Are health facilities appropriately sized? Cross-Cutting Analysis on Efficiency and Equity While having physical infrastructure 3 Productivity Key Indicators Sources in place is important, it is equally or SECTION 3 % of facilities with power (I1) Can be estimated using data Topic-Specific perhaps even more important to ensure from SARA Analysis that health facilities are equipped with % of facilities with improved water source inside Can be estimated using SARA Health System Context basic amenities to provide an appropriate or within the ground of the facility (I2) Health Financing minimum level of quality care. % of facilities with room with auditory and visual Can be estimated using data Inputs privacy for patient consultations (I3) from SARA M-7: Human Resources for Health Investments in facilities that are not adequately % of facilities with access to adequate sanitation Can be estimated using data maintained or equipped and are unable to provide M-8: Infrastructure & Equipment facilities for clients (I4) from SARA care amount to a waste of resources. Amenities M-9: Medicines & Medical Supplies include utilities, such as power, water, and internet, % of facilities with communication equipment (I5) Can be estimated using data Service Delivery as well as well-designed patient care areas and from SARA Outcomes adequate sanitation and medical waste disposal % of facilities with access to a computer with Can be estimated through SARA facilities. Poor access to electricity, for example, is email and internet access (I6) 4 List of Acronyms a significant barrier to providing high-quality health % of facilities with emergency transportation (I7) Can be estimated through SARA care. Without a stable electricity supply, the ability SECTION 4 Additional to use many diagnostic, therapeutic, and monitoring Bed occupancy rate WHO EURO, MoH Guidance tools is extremely limited (Adhair-Rohani et al. 2013). Note: MoH = Ministry of Health; SARA = Service Availability and Readiness Assessment; the indicator ID is included in parentheses; WHO EURO = World Health Organization Regional Office for Europe. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 268 OVERVIEW 1 FIGURE 3 SECTION 1 PER authors can use indicators from the AVAILABILITY OF BASIC INFRASTRUCTURE IN PUBLIC VERSUS PRIVATE What Is a Health PER? Service Provision Assessment (SPA) or FACILITIES, SENEGAL, 2017–19 2 Service Delivery Indicators (SDI) surveys in 77 81 SECTION 2 the absence of the Service Availability and 68 71 71 69 70 Cross-Cutting Readiness Assessment (SARA) indicators. 60 62 64 Analysis on 55 Efficiency and The MoH might have its own indicators 50 Equity 3 to track availability of basic equipment, including through national accreditation SECTION 3 systems. Again, authors can benchmark Topic-Specific Analysis across geopolitical entities (urban/rural; subnational entities) or between private Regular electricity Communications Computer with internet Emergency transport equipment Health System Context and public facilities. Health Financing PUBLIC Percent of health facilities 2017 2018 2019 Figure 3 compares selected Senegalese Inputs public facilities’ infrastructure indicators M-7: Human Resources for Health 97 with those of private facilities in Senegal 95 83 82 80 80 M-8: Infrastructure & Equipment over time (ANSD and ICF 2020). 70 65 64 M-9: Medicines & Medical Supplies 50 44 Service Delivery 33 Outcomes 4 List of Acronyms Regular electricity Communications Computer with internet Emergency transport equipment SECTION 4 Additional PRIVATE Percent of health facilities 2017 2018 2019 Guidance Source: 2015 Senegal Service Provision Assessment. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 269 OVERVIEW 1 SECTION 1 What Is a Health PER? It is critical that health facilities be an appropriate size to ensure the efficient use of available public spending. Directing public funding to staff and maintain FIGURE 4 BED OCCUPANCY RATE FOR ACUTE CARE HOSPITALS FOR SELECTED COUNTRIES, 2020 2 infrastructure that is not being used effectively leads to waste by diverting SECTION 2 the limited funding from service delivery improvements that could lead to Cross-Cutting better health outcomes. Because of the high fixed costs inherent in operating Armenia Analysis on Efficiency and hospitals, it is important that the number of beds per hospital be kept at an Equity 3 efficient level. Azerbaijan SECTION 3 The analysis of the Bed Occupancy Rate (BOR) can be conducted jointly with Topic-Specific Analysis the analysis of undersupply. Where data are available, PER authors can Georgia compare across countries; in most cases, data are available from the MoH Health System Context for subnational comparisons. Facility size is assessed using the BOR. While Health Financing there is no consensus on the optimal BOR, a study by the National Institute for Kazakhstan Health and Care Excellence (NICE) suggests that a rate of 85 percent minimizes Inputs the chances of a patient who requires immediate admission not having a bed M-7: Human Resources for Health available (NICE 2018). In smaller cities and rural areas, lower bed occupancy Kyrgyz Republic M-8: Infrastructure & Equipment targets may be set, recognizing that a minimum number of beds may be M-9: Medicines & Medical Supplies required per service (for example, medical, surgical, pediatrics, maternity) in order to administer a viable program in each area. Figure 4 presents BOR data Tajikistan Service Delivery for selected Commonwealth of Independent States countries in 2020.6 Authors Outcomes should assess the BOR in the context of average length of stay, given the other 4 List of Acronyms Turkmenistan factors contributing to occupancy rates. SECTION 4 0 20 40 60 80 100 Additional Source: World Bank staff calculations based on WHO European Health Information Gateway. Guidance 6 Bed occupancy rate (percent), acute care hospitals only. WHO European Health Information Gateway (who.int), accessed Note: When 2020 data were not available, data for the latest year available were used. May 29, 2022. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 270 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY 2 SECTION 2 Cross-Cutting KEY QUESTION • What is the distribution of facilities across populations? Analysis on Efficiency and Equity 3 While comparisons across Such comparisons may indicate equity issues, SECTION 3 common in many countries. For example, hospital countries are important for Topic-Specific beds may be concentrated in major cities, leading Analysis benchmarking, comparisons to problems of access in rural areas, especially for across administrative divisions specialist services. When possible, PER authors Health System Context should differentiate facilities by sector (public, Health Financing within countries (districts private-for-profit, private-not-for-profit). This Inputs or regions) are also relevant again may provide some indication of equity issues, M-7: Human Resources for Health to public spending and because for-profit facilities may also tend to be M-8: Infrastructure & Equipment health outcomes. Because more heavily concentrated in urban areas. M-9: Medicines & Medical Supplies the majority of health care The distribution of facilities across subpopulations Service Delivery delivery is facility based (either can be performed by differentiating by political Outcomes primary health care facilities subdivision or catchments area, poor versus 4 List of Acronyms nonpoor, or by quantile of income, ethnicity, or rural or hospitals), public spending versus urban, depending on the dimensions where SECTION 4 generally flows to the locations inequality is expressed in the country. Additional Guidance where facilities exist. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 271 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Sources When highlighting the distribution across geopolitical entities (urban/rural; subnational entities), PER authors could include relevant policy norms or 2 Number of health facilities • Can be estimated through standards, if available. Figure 5 on the following page compares distribution SECTION 2 per 10,000 population (or SARA, SDI, SPA surveys in Ethiopian cities and regions as of 2012/2013. Cross-Cutting subpopulation per health Analysis on • Infrastructure maps/plans Efficiency and facility) If the relevant subnational data are available, PER authors could use one of the of countries, including Equity 3 Hospital beds per following measures to assess the distribution of physical infrastructure across geospatial mapping 10,000 population (or the population: (1) the concentration index; or (2) the concentration curves.7 SECTION 3 • World Bank HNP These measures are useful in analyzing the degree of socioeconomic inequality subpopulation per health Topic-Specific HealthStats, WHO AFRO, in the health system related to the distribution of such infrastructure. Analysis facility) WHO AMRO/PAHO, WHO Distribution of total acute EMRO, WHO EURO, WHO Health System Context Providing care in remote or sparsely populated areas to improve equitable care hospital beds per SEARO Health Financing distribution might have efficiency tradeoffs. These tradeoffs need to be 1,000 subpopulation acknowledged and accounted for. Inputs Note: HNP = Health, Nutrition, and Population; SARA = Service Availability and Readiness M-7: Human Resources for Health Assessment; SDI = Service Delivery Indicators; SPA = Service Provision Assessment; WHO = World Health Organization; regional offices: AFRO = Africa, AMRO/PAHO = Americas/Pan American Health 7 For methods on how to calculate the concentration index and concentration curves, see O’Donnell and van Doorslaer et Organization, EMRO = Eastern Mediterranean, EURO = European Region SEARO = South-East Asia. al. (2008). M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 272 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 5 NUMBER OF HEALTH CENTERS AND HEALTH POSTS AVAILABLE THROUGHOUT ETHIOPIA, 2012/2013 2 SECTION 2 Cross-Cutting Analysis on CENTERS POSTS Efficiency and Equity 3 Addis Ababa Addis Ababa Dire Dawa Dire Dawa SECTION 3 Harari Harari Topic-Specific Analysis Afar Afar Benishangul Gumuz Benishangul Gumuz Health System Context Gambella Gambella Health Financing Inputs Somali Somali M-7: Human Resources for Health Amhara Amhara M-8: Infrastructure & Equipment Oromia Oromia M-9: Medicines & Medical Supplies SNNP SNNP Service Delivery Tigray Tigray 0 1000 2000 3000 4000 5000 6000 0 2000 4000 6000 8000 10000 12000 14000 Outcomes 4 List of Acronyms Population per health center Population per health center Urban standard for health center Standard for health posts Rural standard for health center SECTION 4 Additional Guidance Source: Ethiopia Demographic and Health Survey 2012/2013. Note: SNNP = Southern Nations, Nationalities, and Peoples’ Region. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 273 OVERVIEW 1 SECTION 1 What Is a Health PER? GOVERNANCE 2 Processes for the Management of Infrastructure SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 KEY QUESTION • Is there an infrastructure plan? SECTION 3 Topic-Specific Analysis The “purchasing of inputs” in the context of physical Considering the existence of such a plan, PER authors should describe whether the national or state health planning agency must Health System Context infrastructure is both a capital-intensive and long- approve major capital expenditures for certain health care facilities Health Financing term decision. Because a new hospital or other health and whether this type of regulation aims to restrict duplicative Inputs facility will likely last for 40 or more years, many services and ensure that new capital expenditures meet population needs. PER authors should also describe any fragmentation in M-7: Human Resources for Health countries develop an infrastructure master plan or a infrastructure spending and what master planning processes M-8: Infrastructure & Equipment similar document for long-term decision making. are in place. For instance, the construction of new infrastructure, M-9: Medicines & Medical Supplies including health facilities, might fall under the management of Service Delivery Key Indicators Sources other spending entities (for example, the planning ministry or the Outcomes prime minister’s office). The World Bank 2016 report Support to Availability of infrastructure KIIs Develop a Health System Strategy for Priority Disease Areas in Latvia 4 List of Acronyms master plan (Y/N) provides an example of the master planning process (used under SECTION 4 Note: KII = key informant interview. a Reimbursable Advisory Services arrangement). Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 274 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 Adair-Rohani, H., K. Zukor, S. Bonjour, S. Wilburn, A.C. Kuesel, R. Hebert, and E.R. Fletcher. 2013. “Limited Electricity Access in Health Facilities of SECTION 2 Sub-Saharan Africa: A Systematic Review of Data on Electricity Access, Sources, and Reliability.” Global Health Science and Practice 1 (2): 249–61. Cross-Cutting Analysis on African Union. 2020. The Digital Transformation Strategy for Africa (2020–2030). Addis Ababa, Ethiopia: African Union. Efficiency and Equity 3 Agence Nationale de la Statistique et de la Démographie (ANSD) and ICF. 2020. Sénégal: Enquête Continue sur la Prestation des Services de Soins de Santé (ECPSS) 2019. Dakar, Sénégal: ANSD; Rockville, MD, USA: ICF. Translated from the original French. SECTION 3 Topic-Specific Haazen, D.S., A. Slote, N. Al-Shorbaji, and M. D’Adamo. 2015. “Measurement and Accountability for Results in Health,” eHealth Technical Paper, World Analysis Bank Health Summit, June. Health System Context Habicht T., M. Reinap, K. Kasekamp, R. Sikkut, L. Aaben, and E. van Ginneken. 2018. “Estonia: Health System Review.” Health Systems in Transition Health Financing 20 (1): 1–193. Inputs Myles, P.S., and G. Haller. 2010. “Global Distribution of Access to Surgical Services.” The Lancet, Vol. 376, No. 9746: 1027–28. M-7: Human Resources for Health Kutzin, J., C. Cashin, and M. Jakab, eds. 2010. “Implementing Health Financing Reform: Lessons from Countries in Transition,” chapter 8, in Financing M-8: Infrastructure & Equipment Capital Costs and Reducing the Fixed Costs of Health Systems. World Health Organization Regional Office for Europe. https://apps.who.int/iris/ M-9: Medicines & Medical Supplies handle/10665/326420. Service Delivery La Forgia, G.M., and B.F. Couttolenc. 2008. Hospital Performance in Brazil: The Search for Excellence. Washington, DC: World Bank. http://hdl.handle. Outcomes net/10986/6516. 4 List of Acronyms National Institute for Health and Care Excellence (NICE). 2018. “Bed Occupancy: Emergency and Acute Medical Care in Over 16s: Service Delivery and Organisation,” chapter 39, page 18, in NICE Guideline 94. https://www.nice.org.uk/guidance/ng94/evidence/39.bed-occupancy-pdf-172397464704. SECTION 4 Additional O’Donnell, O., E. van Doorslaer, A. Wagstaff, and M. Lindelow. 2008. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques Guidance and Their Implementation. Washington, DC: World Bank. http://hdl.handle.net/10986/6896. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 275 OVERVIEW 1 SECTION 1 What Is a Health PER? Organisation for Economic Co-operation and Development. 2017. Tackling Wasteful Spending on Health. Paris: OECD Publishing. Weiss, D.J., A. Nelson, C.A. Vargas-Ruiz, et al. 2020. “Global Maps of Travel Time to Healthcare Facilities.” Nature Medicine 26, 1835–38. https:// 2 doi.org/10.1038/s41591-020-1059-1. SECTION 2 Cross-Cutting World Bank. 2013. Mauritius Policy Notes: Building Analytical Capacity to Raise Public Sector Efficiency. Washington, DC: World Bank. Analysis on Efficiency and World Bank. 2016. Ethiopia Public Expenditure Review 2015. Washington, DC: World Bank Group. Equity 3 World Bank. 2016. Support to Develop a Health System Strategy for Priority Disease Areas in Latvia. Washington, DC: World Bank. https://www. SECTION 3 vmnvd.gov.lv/lv/media/1373/download. Topic-Specific Analysis World Health Organization. 2015. Service Availability and Readiness Assessment (SARA) Reference Manual. Geneva: World Health Organization. World Health Organization and International Telecommunication Union. 2012‎. National eHealth Strategy Toolkit. Geneva: World Health Health System Context Organization, International Telecommunication Union. https://apps.who.int/iris/handle/10665/75211. Health Financing Inputs M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 276 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 ANNEX 1: DEEP DIVES SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 Availability of Other Types Facilities SECTION 3 Topic-Specific Analysis KEY QUESTION • What is the availability of other types of facilities? Health System Context Health Financing If data are available, PER Key Indicators Sources Inputs M-7: Human Resources for Health authors can analyze the Number of laboratories per 100,000 population • Can be estimated through SARA, SDI, SPA M-8: Infrastructure & Equipment distribution of facilities other surveys Number of pharmacies per 100,000 population M-9: Medicines & Medical Supplies than primary care (PC) and • Infrastructure maps/plans of countries, Number of specialized care facilities per 100,000 Service Delivery hospitals. These could include population including geospatial mapping Outcomes pharmacies, laboratories, • World Bank WDI 4 List of Acronyms and specialized care facilities, Note: SARA = Service Availability and Readiness Assessment; SDI = Service Delivery Indicators; SPA = Service Provision Assessments; WDI = World Development Indicators. such as psychiatric hospitals. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 277 OVERVIEW 1 SECTION 1 What Is a Health PER? State of Digital Infrastructure 2 SECTION 2 KEY QUESTION • What is the state of digital health infrastructure? Cross-Cutting Analysis on Efficiency and Equity While computers, internet access, and Various approaches exist for assessing the current state of digital health 3 infrastructure and for planning improvements to such infrastructure. communications are basic requirements, the SECTION 3 Perhaps the most prevalent is the National eHealth Strategy Toolkit Topic-Specific delivery of modern medical care requires (WHO and ITU 2012). More recently, the Global Digital Health Monitor8 Analysis at least a minimal level of digital health (GDHM) was created; the monitor “is an interactive web-based resource that aims to track, monitor, and assess the enabling environment for Health System Context infrastructure, including hardware and software. digital health throughout the world.” The GDHM includes a series of key Health Financing indicators (23 main indicators plus eight subindicators), spread across Inputs According to a technical paper prepared for the Measurement seven categories, to track progress and allows countries to benchmark and Accountability for Results in Health Summit in June 2015, M-7: Human Resources for Health against each other. For each indicator, the GDHM describes various digital health “strategies have the potential to improve the M-8: Infrastructure & Equipment phases of development, and countries are required to indicate the quality of health services, reduce costs, improve equity of phase that most closely describes their current situation. The following M-9: Medicines & Medical Supplies access, and empower citizens in a person-centered healthcare table highlights the categories and indicators included in the monitor. Service Delivery system. As such, they can be critical to maximizing performance To date, about 25 countries have input their data on the GDHM website. Outcomes monitoring and accountability at all levels of the health system, Another useful resource is the Digital Health Atlas, which “is a WHO from citizens to front-line health workers to facility managers 4 List of Acronyms global technology registry platform aiming to strengthen the value and to the highest political levels” (Haazen et al. 2015). and impact of digital health investments, improve coordination, and SECTION 4 facilitate institutionalization and scale.” Additional Guidance 8 Global Digital Health Monitor (https://monitor.digitalhealthmonitor.org/). TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 278 OVERVIEW 1 SECTION 1 What Is a Health PER? In assessing and planning for digital health infrastructure, PER authors should consider the full range of digital health interventions in the health system. Figure A1.1, from The Digital Transformation Strategy for Africa (2020–2030) (African Union 2020), puts these various interventions in context. Patient Data 2 SECTION 2 Patient Data FIGURE A1.1 INTEGRATED NATIONAL DIGITAL HEALTH SYSTEM Cross-Cutting Analysis on INTEGRATED NATIONAL Patient Data Efficiency and Equity DIGITAL HEALTH SYSTEM 3 Level: SECTION 3 Primary Schedule medical Topic-Specific Management Private Clinic Telemedicine System Clinical appointments, Analysis (and CHW) System Systems Systems & reminders, via SMS Electronic Health System Context Management Patient Private Hospital Hospital Health Financing System Record Systems Claims information PUBLIC Inputs Disease PORTAL M-7: Human Resources for Health Health Anonymous Notifiable disease registry info Health information Insurance patient Insurance M-8: Infrastructure & Equipment information and System activity data M-9: Medicines & Medical Supplies Public Surveillance Access to health Disease Service Delivery Health Systems Registries promotion Information on information, (CD/NCD) births and deaths to statistics, and Outcomes Region/ Management CRVS agency financial and District System 4 List of Acronyms performance data for the health SECTION 4 Central Management Human Drugs/Supplies system System Resources System Additional Guidance Source: African Union, Addis Ababa, Ethiopia. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 279 OVERVIEW 1 Key Indicators Sources SECTION 1 What Is a GDHM Health PER? LEADERSHIP & GOVERNANCE LEGISLATION, POLICY, & STANDARDS & INTEROPERABILITY COMPLIANCE 2 Indicator 1 - Digital health prioritized at the Indicator 15 - National digital health architecture national level through dedicated bodies/ Indicator 7 - Legal Framework for Data and/or health information exchange SECTION 2 mechanisms for governance Protection (Security/Cybersecurity) Indicator 16 - Health information standards Cross-Cutting Indicator 2 - Digital health prioritized at the Indicator 8 - Laws or regulations for Analysis on Efficiency and national level through planning privacy, consent, confidentiality, and Equity INFRASTRUCTURE 3 Indicator 2a -Health prioritized in national access to health information (privacy) Indicator 17 - Network readiness digital transformation and data governance Indicator 9 - Protocol for regulating Indicator 18 - Planning and support for ongoing policies or certifying devices and/or health SECTION 3 digital health infrastructure maintenance Indicator 3 - Readiness for emerging services, including provisions for AI and Topic-Specific Analysis technologies adoption and governance algorithms (at higher stages of maturity) Indicator 4 - Diversity, equity, and human Indicator 9a - Protocol for regulating and SERVICES & APPLICATIONS rights analysis, planning, and monitoring certifying AI within health services Indicator 19 - Nationally scaled digital health Health System Context included in national digital health strategies Indicator 10 - Cross-border data security systems Health Financing Indicator 20 - Digital identity management of service and plans and sharing Inputs Indicator 4a - Gender considerations providers, administrators, and facilities for digital accounted for in digital health strategies and health, including location data for GIS mapping M-7: Human Resources for Health WORKFORCE Indicator 21 - Digital identity management of digital health governance Indicator 11 - Digital health integrated M-8: Infrastructure & Equipment individuals for health in health and related professional Indicator 21a - Digital identity management of M-9: Medicines & Medical Supplies STRATEGY & INVESTMENT pre-service training (prior to deployment) individuals for health – master patient index Service Delivery Indicator 5 - National eHealth/Digital Health Indicator 12 - Digital health integrated Indicator 21b - Digital identity management of Strategy or Framework in health and related professional Outcomes individuals for health – birth registry Indicator 5a - National digital strategy in-service training (after deployment) Indicator 21c - Digital identity management of 4 List of Acronyms alignment with Universal Health Coverage Indicator 13 - Training of digital health individuals for health – death registry (UHC) Core Components workforce Indicator 22 - Secure Patient Feedback Systems Indicator 6 - Public funding for digital health Indicator 14 - Maturity of public sector SECTION 4 Indicator 23 - Population health management Indicator 6a - Private sector participation and digital health professional careers Additional contribution of digital health Guidance investments in digital health Note: GDHM= Global Digital Health Monitor; GIS = geographic information system. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 280 OVERVIEW 1 SECTION 1 What Is a Health PER? Figure A1.2 shows an example of the output from the GDHM for the country of Côte d’Ivoire for 2023, with data for each of the seven categories. As shown, these data also include a comparison to the world average, but the website allows comparisons to other regions 2 as well. Detailed data are also available for each of the indicators, showing the phase attributable to each indicator. SECTION 2 Cross-Cutting Analysis on PHASE OVERVIEW Efficiency and Equity FIGURE A1.2 3 DIGITAL HEALTH INFRASTRUCTURE SECTION 3 PHASES Leadership & Governance Topic-Specific Analysis Services & Applications Strategy & Investment Health System Context CÔte d’Ivoire Health Financing Inputs Global Average M-7: Human Resources for Health M-8: Infrastructure & Equipment Infrastructure Legislation, Policy, & Compliance M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms Standards & Interoperability Workforce SECTION 4 Additional Guidance Source: GDHM database (accessed May 25, 2024). TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 281 OVERVIEW 1 SECTION 1 What Is a Health PER? Recurrent Spending on Utility Bills 2 SECTION 2 KEY QUESTION • How much of the recurrent health care budget is spent on utility bills? Cross-Cutting Analysis on Efficiency and Equity Excessive spending on utilities and related overhead 3 Key Indicators Sources costs diminish the financial resources available to SECTION 3 Percentage of facility recurrent budget spent on utilities MoF, MoH Topic-Specific provide high-quality care and may indicate that there Note: MoF = Ministry of Finance; MoH = Ministry of Health. Analysis are opportunities for improving the efficiency of the Health System Context physical plant. Health Financing FIGURE A1.3 A general guideline is that hospitals should not spend more than 5–10 UTILITIES SPENDING AS A PERCENT OF Inputs percent of their recurrent budget on utilities (Health Financing System RECURRING EXPENDITURE, MAURITIUS, 2013 M-7: Human Resources for Health Assessment—HFSA). There are limited available data for cross-country M-8: Infrastructure & Equipment Grand Total comparisons; even within-country comparisons would require a Region 5 M-9: Medicines & Medical Supplies suitable level of detail in the charts of accounts of health facilities. Region 4 Service Delivery PER authors may wish to use the World Bank BOOST database to Region 3 Outcomes extract such information if it exists. Figure A1.3 on utilities spending Region 2 4 List of Acronyms was extracted from BOOST for the 2013 Mauritius Public Expenditure Region 1 Review (World Bank 2013). 9 SECTION 4 0% 1% 2% 3% 4% Additional Source: World Bank staff calculations based on database used for 2013 Mauritius Public Expenditure Review. Guidance 9 BOOST is a World Bank program aimed at collecting and providing access to budget data and can be accessed through the BOOST Open Budget Portal: https://www.worldbank.org/en/programs/boost-portal. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 282 OVERVIEW 1 SECTION 1 What Is a Health PER? Availability, Distribution, and Productivity of Equipment 2 SECTION 2 Cross-Cutting KEY QUESTIONS • What is the availability of equipment in the country? Analysis on Efficiency and Equity • What is the distribution of equipment across geopolitical entities? 3 • What is the availability of functional equipment? SECTION 3 Topic-Specific Analysis Availability of equipment in general is critical When assessing availability of equipment, PER authors should focus first on equipment that is most relevant for the country context. In to ensuring patients’ access to necessary health Health System Context low-income countries, for example, elemental equipment necessary Health Financing services and procedures required for the health to perform basic surgery may be the most relevant. In the Lancet Inputs system to achieve positive outcomes. It is also study on global distribution of access to surgical services (Myles and Haller 2010), availability of pulse oximeters in operating theaters M-7: Human Resources for Health important to look at the availability of specific was an indicator of anesthetic and surgical resources. The Primary M-8: Infrastructure & Equipment types of equipment, depending on the country Health Care Performance Initiative (PHCPI) also defines a list of M-9: Medicines & Medical Supplies context (such as basic surgical equipment necessary basic equipment essential for delivering services at the primary Service Delivery for conducting procedures safely and diagnostic care facility level, including scales, measuring tape, thermometers, Outcomes blood pressure apparatus, and stethoscopes. The disease burden equipment for different types of diseases). and consideration of other health outcomes can also be used to 4 List of Acronyms determine the choice of equipment to assess. WHO publishes a list of essential medical devices for management of various medical SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 283 OVERVIEW 1 SECTION 1 What Is a Health PER? conditions and for different levels of care.10 For instance, sonography scanners may be important in countries where maternal and child health indicators are Key Indicators Sources 2 lagging, while x-ray machines and molecular testing diagnostic equipment Minimum equipment, any child or adult scale (%) SARA, SDI, SECTION 2 may be relevant for countries with a high incidence of tuberculosis. Other SPA Cross-Cutting examples of advanced equipment include MRIs, CT scanners, PET scanners, Minimum equipment, refrigerator (%) SARA, SDI, Analysis on Efficiency and and ventilators. The following table lists additional indicators of both SPA Equity 3 basic equipment and more specialized medical equipment. When data on Minimum equipment, sphygmomanometer (%) SARA, SDI, equipment are not available, PER authors should use patients’ waiting times SECTION 3 SPA for diagnostic tests as an indicator for availability of medical equipment. This Topic-Specific Analysis indicator may need to be assessed in conjunction with human resources for Minimum equipment, sterilizing equipment (%) SARA, SDI, health (HRH), as the availability of appropriate health workers may influence SPA Health System Context patients’ waiting times. Minimum equipment, stethoscope (%) SARA, SDI, Health Financing SPA If data are available, PER authors should benchmark the availability of Inputs equipment indicators against similar countries to see how the reviewed Minimum equipment, thermometer (%) SARA, SDI, M-7: Human Resources for Health SPA country compares, as well as across geopolitical entities (subnational; M-8: Infrastructure & Equipment urban/rural). Income group is an important criterion to consider when Mammography units per 100,000 population WHO EURO, M-9: Medicines & Medical Supplies conducting country comparisons. Authors should also assess the availability WHO AFRO Service Delivery of equipment across types of health facilities when assessing the equity of Note: SARA = Service Availability and Readiness Assessment; SDI = Service Delivery distribution of equipment. The figure shows an example of the availability Indicators; SPA = Service Provision Assessments; WHO = World Health Organization; Outcomes WHO regional offices AFRO = Africa, EURO = Europe. of different medical equipment in selected countries in various years.11 4 List of Acronyms SECTION 4 10 https://www.who.int/activities/prioritizing-medical-devices. Additional 11 https://databank.worldbank.org/source/service-delivery-indicators# (accessed May 28, 2022). Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 284 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE A1.4 AVAILABILITY OF MEDICAL 100 2 EQUIPMENT (PERCENT 80 SECTION 2 OF FACILITIES)—SERVICE 60 Cross-Cutting DELIVERY INDICATORS Analysis on (VARIOUS YEARS) Efficiency and 40 Equity 3 Source: Service Delivery Indicators database, World Bank. 20 SECTION 3 0 Topic-Specific Urban Rural Urban Rural Urban Rural Urban Rural Analysis Kenya (2012) Madagascar (2016) Tanzania (2014) Uganda (2013) Health System Context refrigerator (%) sphygmonometer (%) stethoscope (%) thermometer (%) Health Financing Inputs In addition to equipment being available, it also needs to be functional to Key Indicators Sources M-7: Human Resources for Health deliver health services or procedures effectively. Spending on nonfunctional M-8: Infrastructure & Equipment equipment is inefficient and causes waste, as such equipment cannot Domain score for readiness of • SARA produce outputs necessary for optimum health outcomes. PER authors basic equipment M-9: Medicines & Medical Supplies should also consider equity, as nonfunctional equipment may be more Percentage of functional • PHCPI vital indicators data Service Delivery prevalent in facilities serving disadvantaged population groups. Data essential equipment at a • KIIs Outcomes on the percentage of functional equipment are not readily available. health facility • MoH inventory of equipment However, ministries of health may have inventories of equipment by 4 List of Acronyms facility and may record whether the equipment is functional or not. If data • National studies are not available, interviews with key informants may be able to show SECTION 4 Note: KII = key informant interview; MoH = Ministry of Health; PHCPI = Primary Health whether maintenance and functionality of equipment is hampering service Care Performance Initiative; SARA = Service Availability and Readiness Assessment. Additional Guidance provision or wasting resources. TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 285 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 ANNEX 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Estimating the Number of Pregnant Women in a Given Period The following is the 1. Estimated number of live births = (CBR per 1,000 * total population) Health Financing recommendation from the Inputs SARA reference manual on 2. Estimated live births expected per month = (a / 12) M-7: Human Resources for Health how to estimate the number 3. Estimated number of pregnancies ending in stillbirths or miscarriages = (a * 0.15) M-8: Infrastructure & Equipment of pregnant women, deriving it 4. Estimated pregnancies expected in the year = (a + c) M-9: Medicines & Medical Supplies from the crude birth rate (CBR) 5. Estimated number of women pregnant in a given month = (0.70 * d) Service Delivery for the country of interest and Outcomes 6. Estimated percent of total population who are pregnant in a given period = (e / total population * 100) the following equations: 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 8 Physical Infrastructure and Equipment 286 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity MODULE 9 3 SECTION 3 Topic-Specific Analysis Medicines & Medical Supplies Health System Context Health Financing Inputs M-7: Human Resources for Health AUTHORS M-8: Infrastructure & Equipment Ana Mercado, Andreas Seiter, and Catalina Gutiérrez, M-9: Medicines & Medical Supplies with contributions from Thomas Wilkinson and Olena Service Delivery Doroshenko Outcomes 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 287 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity From a public expenditure perspective, expenditure (OECD 2017; Garcia-Goñi 2022). It shows that eliminating 3 medicines are typically one of the biggest waste not only would reap savings but could also improve health outcomes. SECTION 3 spending categories in the health sector— Topic-Specific Analysis between 20 and 30 percent of health Purchasing medicines with high prices and/or low cost- budgets—and, therefore, constitute an area effectiveness, or brand medicines instead of generics, is an Health System Context inefficiency that results in greater spending yet no or little clinical where there is potential to achieve cost savings Health Financing benefit. Estimates for five European countries and the United States Inputs and make significant efficiency gains. suggest that savings from using generics and biosimilars reached an M-7: Human Resources for Health estimated EUR 50 billion in 2020 (OECD 2017). A study by the Center Medicine expenditure is also one of the fastest growing for Global Development (Bonnifield 2019) found that purchasers in M-8: Infrastructure & Equipment expenditure items in some countries. For example, inpatient low- and middle-income countries pay as much as 20 to 30 times a M-9: Medicines & Medical Supplies pharmaceutical expenditure increased on average 4.5 percent per minimum international reference price for basic generic medicines. Service Delivery year in real terms for 14 Organisation for Economic Co-operation Some high-cost medicines have limited or uncertain effectiveness, Outcomes and Development (OECD) countries during 2010–19 (OECD 2021), and better health outcomes could be achieved if resources were and in Latin America and the Caribbean, spending on medicine redirected to improve access and close gaps in essential health 4 List of Acronyms grew about 12 percent per year from 2013 to 2017 (IDB 2018). services (Gutiérrez 2023). SECTION 4 The literature cites significant inefficiencies in pharmaceutical Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 288 OVERVIEW 1 SECTION 1 What Is a Health PER? Underuse or unavailability of cost-effective medicines can result health challenge. Increased antimicrobial resistance is the cause 2 in higher health costs due to hospitalizations and complications of severe infections, complications, longer hospital stays, and SECTION 2 and can lead to lower health outcomes (see, for example, Cutler increased mortality (Llor and Bjerrun 2014). Worldwide, some 1.27 Cross-Cutting et al. 2009; Buxbaum et al. 2020). Inequitable access to life-saving million deaths in 2019 were attributed to antimicrobial resistance Analysis on medicines can increase the already large disparities in outcomes (Antimicrobial Resistance Collaborators 2022). Efficiency and Equity that result from the vast discrepancies in the social determinants 3 of health. In addition, pharmaceutical spending is one of the In the public expenditure review, the PER authors should explore: SECTION 3 highest household expenditures, accounting for more than 60 1. The growth, level, and share of spending on pharmaceuticals; Topic-Specific percent of out-of-pocket spending in several countries, including 1 Analysis 2. Prices at which pharmaceuticals are being procured; Brazil, Mexico, Poland, and the Slovak Republic (OECD 2023). 3. The mix of pharmaceutical spending; and Health System Context Inefficiencies in supply chains, for example, and in purchasing 4. The efficiency of policies and institutional arrangements Health Financing and procurement of medicines result in paying higher prices, governing pharmaceutical regulation, procurement, Inputs unnecessary transactional costs, and stockouts. The Mexican prescription, and coverage. M-7: Human Resources for Health health system overcame such challenges by centralizing M-8: Infrastructure & Equipment procurement, and saved the country $28 billion between 2007 To explore more, PER authors could evaluate the effectiveness and 2010 (OECD 2017). of supply chain management in preventing expiration, damage, M-9: Medicines & Medical Supplies and stockouts, and unnecessary administrative costs. In countries Service Delivery Another inefficiency is the overprescription of medicines—wasteful where stockouts of essential medicines are an issue, the authors Outcomes as well as harmful to patients. Overuse of antibiotics in particular should try to understand its causes. 4 List of Acronyms can diminish their effectiveness; this has become a global public SECTION 4 Additional 1 In 2021 or the nearest year. Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 289 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 For countries that fund high-cost specialized pharmaceuticals, in multicountry datasets and local administrative data, and that SECTION 2 exploring expenditure on high-cost drugs might reveal important can reveal inefficiencies in pharmaceutical spending. Annex 1 lists Cross-Cutting Analysis on inefficiencies. In countries where counterfeit medicines or additional indicators for PER authors wishing to dive deeper into Efficiency and Equity low-quality pharmaceuticals is a recognized issue, measuring other areas: supply chain management, overuse of antibiotics, 3 and quantifying expenditure in counterfeit medicines and and coverage of high-cost drugs. understanding the causes might illuminate significant waste and SECTION 3 Topic-Specific help identify policies to address them. Data on overconsumption The module is divided into two sections: efficiency and pricing Analysis of antibiotics are becoming readily available for an increasing and procurement processes/policies. A case study at the end number of countries, and PER authors may wish to explore data of the module illustrates the use of the indicators to analyze Health System Context availability for the country under study.2,3 pharmaceutical spending. Authors may also wish to refer to IDB Health Financing (2018) and OECD (2017) for further reference on measuring the Inputs Analyzing pharmaceutical spending requires data that are often efficiency of pharmaceutical expenditure. Box 1 on the following M-7: Human Resources for Health not readily available in low- and middle-income countries. For this page presents definitions of terms used in this module. reason, the body of this module prioritizes an abbreviated set of M-8: Infrastructure & Equipment indicators that can most easily be constructed with data available M-9: Medicines & Medical Supplies Service Delivery Outcomes 2 Although overprescription or inadequate prescription and adherence to treatment may be significant sources of inefficiency, with the exception of overprescription of antibiotics, there are seldom data in low- and in middle-in- come countries to assess these sources. Expenditure on high-cost drugs can result in significant inefficiencies, but its analysis requires complex methods and data, which are outside the scope of a traditional PER. For some 4 middle-income countries, this is an important issue. PER authors wishing to dive deeper into inefficient spending on high-cost drugs can refer to Gutiérrez, Palacio, et al. op. cit. List of Acronyms 3 Inequities in access to pharmaceuticals have been reported in academic literature by income level, by geographic location, and for marginalized populations, and medicines are often the largest item in out-of-pocket spending on health (OECD op. cit). Incidence of out-of-pocket spending are often higher for low-income, rural, and marginalized populations. However, there are no readily available data to track inequities in access to pharmaceutical products. This module does not address equity, but some household and health surveys track pharmaceutical access and spending. These surveys can be used to understand the distribution of pharmaceutical spending among SECTION 4 geographic areas and socioeconomic groups. Alternatively, PER authors can search for available academic studies that refer to the country under study. Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 290 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS 2 SECTION 2 MEDICINE be on-patent (exclusive) or off-patent (open, medicines requires that the efficacy of generics Cross-Cutting Any dosage form containing a substance because the original patent has expired). For must be demonstrated by a bioequivalence Analysis on Efficiency and approved by a regulatory agency for the the purposes of this module, the first product assessment (the two drugs release the active Equity 3 prevention and treatment of disease. The to hit the market is considered “innovative.” ingredient in the same amount and rate and terms “pharmaceutical product” and “drug” have the same quality). A generic drug is SECTION 3 can be used interchangeably with “medicine.” PATENT made up of the same active ingredient as its Topic-Specific However, “pharmaceutical” can refer to the A patent grants the holder the exclusive right innovative drug. It can be marketed using the Analysis “active ingredient,” while “medicine” refers to to use and exploit an invention, and it prevents international nonproprietary name, in which pharmaceutical substances that have a defined others from using the invention without the case it is an unbranded generic, or under a Health System Context dosing and presentation (pill, syrup, and so on). holder’s consent. When a company develops an proprietary brand, in which case it is a branded Health Financing active ingredient, it can apply for a patent that generic. Branded generics are generally more Inputs ACTIVE INGREDIENT grants it exclusivity for 20 years. expensive than their unbranded equivalents. M-7: Human Resources for Health The chemical contained in a drug that achieves the desired effect on the target tissue. GENERIC DRUGS EX-MANUFACTURER, WHOLESALE, AND RETAIL M-8: Infrastructure & Equipment These drugs are pharmaceuticals, usually PRICE M-9: Medicines & Medical Supplies PHARMACEUTICAL PRODUCT intended to be interchangeable with original Prices for pharmaceuticals are typically Service Delivery See “Medicine.” brand drugs, that are manufactured and measured at three points in the distribution Outcomes marketed without a license from the original chain: the ex-manufacturer price, the INNOVATIVE PRODUCT manufacturer after the expiry of the patent ex-wholesale price, and the retail price. 4 List of Acronyms The first brand of the active ingredient to or other exclusivity rights (Sargel and Isadore Manufacturers typically sell their products receive marketing approval. The patent may 2013). In developed countries, the regulation of to wholesalers for a price that is usually SECTION 4 Additional Guidance Box 1 continues on the following page. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 291 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS (continued) 2 SECTION 2 referred to as “ex-factory,” “ex-manufacturer,” safe, and cost‐effective drugs for treating high- REFERENCE PRICE Cross-Cutting Analysis on or “wholesale acquisition.” Wholesalers apply priority illnesses and running a functioning This is used as a benchmark to inform the Efficiency and a markup before selling these products to health care system. purchase of medicines. The reference price is Equity 3 pharmacies, and this is usually referred to usually calculated based on public available as the “ex-wholesale” or “wholesale price.” TRACER MEDICINES data for several countries. SECTION 3 Pharmacies apply a markup over this price These comprise a subset of essential Topic-Specific Analysis before selling to final consumers on the medicines that countries use as a proxy to DEFINED DAILY DOSE (DDD) retail market at the “‘retail price.” monitor availability of essential medicines. The DDD is the assumed average maintenance Health System Context In several countries, this price dose per day for a drug used for its main includes a value-added tax. COUNTERFEIT MEDICINES indication in adults. It is calculated by WHO Health Financing WHO defines counterfeit medicines as those as a unit of measurement for the volume of Inputs OVER-THE-COUNTER MEDICINES whose identity and/or source are deliberately consumption of a particular medicine. Not all M-7: Human Resources for Health OTC medicines can be purchased in retail and fraudulently mislabeled. medicines have a DDD. M-8: Infrastructure & Equipment pharmacies by final consumers without a physician’s prescription. SUBSTANDARD MEDICINES STOCKOUT M-9: Medicines & Medical Supplies Medicines that do not meet the quality A stockout occurs when a medicine required Service Delivery ESSENTIAL MEDICINES standard or specifications defined in national by a patient or patients is not available. Outcomes These medicines are on the World Health regulations. Source: https://www.ncbi.nlm.nih. Stockouts can occur at the facility, local, or Organization (WHO) Essential Medicines List gov/pmc/articles/PMC4137817/. 4 List of Acronyms national level. (EML). The list includes the most effective, SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 292 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY 2 SECTION 2 Cross-Cutting Analysis on Aggregate Spending Efficiency and Equity 3 • What is the level of spending on medicines in the country? SECTION 3 KEY QUESTIONS • What percent of the budget is absorbed by pharmaceutical spending? Topic-Specific Analysis • How has pharmaceutical spending increased relative to total health spending? Health System Context Health Financing The share of the budget spent and the level of per a conclusion might also entail looking at coverage Inputs capita spending on pharmaceuticals can reveal (PER authors may want to refer to the Service M-7: Human Resources for Health inefficiencies. When they are substantially higher Coverage module). M-8: Infrastructure & Equipment than countries with a similar level of income, this M-9: Medicines & Medical Supplies might indicate that the country is paying higher If possible, authors should focus on government Service Delivery prices. It can also indicate unnecessary prescription pharmaceutical spending as a share of total Outcomes or larger consumption of high-cost medicines. government spending on health. 4 List of Acronyms However, higher share and level of spending can SECTION 4 also indicate better access to medicines, so drawing Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 293 OVERVIEW 1 SECTION 1 What Is a Health PER? When comparing pharmaceutical spending between countries, Key Sources for Data for 2 it’s important to differentiate between outpatient and inpatient Indicators Local Data Benchmarking SECTION 2 information and determine whether the data include over-the- Cross-Cutting counter (OTC) medicines, prescription drugs, or both. GHED data The share of total • GHED Analysis on follow the National Health Accounts methodology and capture pharmaceutical Efficiency and • National Health Equity expenditure on prescription medicines purchased in outpatient 3 expenditure in total Accounts and retail (OTC) settings.4 Spending in hospital (inpatient) settings health expenditure is aggregated with hospital spending and can add another 20 • OECD Statistics on SECTION 3 Topic-Specific percent or more to pharmaceutical spending. Domestic government health have data Analysis spending on for a few middle- PER authors should also analyze the growth in pharmaceutical pharmaceuticals as a income countries. Health System Context spending relative to the growth of total health spending to identify percentage of general • MoH budgets Health Financing whether the share of pharmaceuticals is increasing. A rising share government health • GHED or expenditure Inputs of pharmaceutical spending in a country with a low baseline of expenditure, level and reports M-7: Human Resources for Health spending on medicines (relative to similar countries) might be trends • National M-8: Infrastructure & Equipment a sign of improved access. A rising share of pharmaceuticals in a expenditure country that is already spending more than similar countries might M-9: Medicines & Medical Supplies tracking signal an inefficient procurement process that leads to higher prices Total pharmaceutical Service Delivery information and should raise concerns about the sustainability of such growth. spending per capita, Outcomes systems level and trends • For population 4 List of Acronyms data, WDI 4 Account HC.5 corresponds to Domestic General Government Expenditure on Medical Goods not differ- SECTION 4 entiated by function; it aggregates medical devices and medicines. Some countries further disaggre- Note: GHED = Global Health Expenditure Database; MoH = Ministry of Health; OECD = Organisation for Economic gate between medicines and medical devices. Co-operation and Development; WDI = World Development Indicators. Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 294 OVERVIEW 1 SECTION 1 What Is a Health PER? Prices 2 SECTION 2 Cross-Cutting KEY QUESTION • Is the country paying high prices for medicines? Analysis on Efficiency and Equity 3 Paying high prices for medicines can be a major source of Key Sources for Data for SECTION 3 inefficiency, and low- and middle-income countries often pay higher Topic-Specific Indicators Local Data Benchmarking Analysis prices for medicines than high-income countries (UNAIDS 2023). The use of brand name drugs when generic drugs are available Unit price paid for • Procurement • Prices published Health System Context is another example of inefficiency, as generics provide the same key medicines: information by pooled Health Financing clinical benefit at a lower cost. • Antiretrovirals systems procurement agencies such as Inputs • Antimalarials • Reports There are two approaches that can be used to identify inefficiencies UNICEF and PAHO M-7: Human Resources for Health from MoH, in the purchase of pharmaceuticals: (1) compare unit prices for • Vaccines or health • Academic research M-8: Infrastructure & Equipment tracer medicines between countries and determine generic uptake; • Insulin insurance M-9: Medicines & Medical Supplies and (2) study pricing policies and procurement practices. This • WHO medicine price agency section looks at price comparisons; generic uptake is addressed • Other selected information sources Service Delivery in the section that analyzes the mix of pharmaceuticals. The section medications • Pharmacy Outcomes on governance covers pricing policies and procurement practices. according to information 4 List of Acronyms burden of systems The unit prices paid for key medicines should be compared disease SECTION 4 Additional with an international reference price. PER authors can choose Note: MoH = Ministry of Health; PAHO = Pan American Health Organization; UNICEF = United Nations Guidance to focus on core essential medicines and additional priority Children’s Fund; WHO = World Health Organization. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 295 OVERVIEW 1 SECTION 1 What Is a Health PER? medicines according to the burden of disease, depending on the PER authors should ensure that the same or equivalent formulations 2 country context. PER authors can pick a number of medicines and pack sizes are used for comparison. They should also compare SECTION 2 (the selection may vary depending on the international reference equivalent prices at a point in the supply chain, for example, the Cross-Cutting price list used) and benchmark their prices against the prices of ex-manufacturer price is typically the price the manufacturer Analysis on Efficiency and the same medicines in similar countries. This will enable authors charges a wholesaler or government depot, whereas the pharmacy Equity to ascertain the amount the country may be overpaying for certain or retail price likely includes the pharmacy’s markup and dispensing 3 medicines—one of the main sources of inefficiency, according to fees, wholesaler and supply chain fees, and any value-added tax SECTION 3 evidence in the literature. WHO hosts a site with links to pricing (see definitions in Box 1). Topic-Specific agencies around the world. Academic literature can also provide Analysis sources for benchmarking. For example, using a standard WHO When analyzing prices, PER authors should flag certain caveats, measurement methodology, Ewen, Joosse, et al. (2018) evaluate such as potential statutory discounts or the implementation Health System Context insulin prices for 15 low- and middle-income countries. of special confidential agreements between manufacturers Health Financing and sellers (for example, simple, price-volume, or outcome- Inputs Another approach to comparing prices is to select some tracer based discounts). These can be established by interviewing key M-7: Human Resources for Health medicines that can be purchased through pooled procurement informants. M-8: Infrastructure & Equipment arrangements with multilateral organizations and use these M-9: Medicines & Medical Supplies prices as benchmarks. UNICEF5 for example, publishes the prices Authors should attempt to identify any dynamic reasons for pricing at which it purchases vaccines, antiretrovirals, and antimalarial variability, including low volumes of sales, a complex or long Service Delivery medication, and the Pan American Health Organization (PAHO)6 regulatory environment or limited competition, and the time taken Outcomes publishes reference prices for some medicines in 12 therapeutic to pay for the delivery of medicines, as prices are typically higher in 4 List of Acronyms areas, including cardiovascular disease. contexts where payment to manufacturers is delayed or uncertain. SECTION 4 5 For more information, visit UNICEF Price Data Overview database: https://www.unicef.org/supply/pricing-data. Additional 6 For more information, visit PAHO Strategic Fund: https://www.paho.org/en/paho-strategic-fund#q2. Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 296 OVERVIEW 1 SECTION 1 What Is a Health PER? Input Mix 2 SECTION 2 Cross-Cutting KEY QUESTION • Is the country buying the right mix of medicines? Analysis on Efficiency and Equity 3 There is no one formula that can indicate whether a country is key points of contact (such as health facilities, pharmacies, and SECTION 3 purchasing the right mix of medicines, but an efficient allocation drug outlets) is vital for assessing equity and efficiency, as is the Topic-Specific Analysis should address the largest causes of disease burden, include availability of specific groups of medicine. WHO defines “essential most of the medicines in the WHO Essential Medicines List medicines” as “those that satisfy the priority health care needs Health System Context (EML),7 avoid medicines that have uncertain effectiveness or low of a population; [and] are selected with due regard to disease Health Financing cost-effectiveness, and purchase generics and biosimilars for prevalence and public health relevance, evidence of efficacy and off-patent medicines. This section provides some indicators to safety, and comparative cost-effectiveness. They are intended to be Inputs aid understanding of the mix of medicines. available in functioning health systems at all times, in appropriate M-7: Human Resources for Health dosage forms, of assured quality and at prices [that] individuals and M-8: Infrastructure & Equipment health systems can afford.” The latest version of the EML, updated M-9: Medicines & Medical Supplies AVAILABILITY OF ESSENTIAL MEDICINES every two years, includes 502 medicines, including vaccines. Service Delivery Countries that prioritize medicines in the EML to define coverage Availability is a precondition for ensuring that the population tend to have a more efficient mix. When assessing the availability Outcomes has access to the essential medicines needed to achieve positive of medicines, PER authors should focus first on core essential 4 List of Acronyms health outcomes. Information on their availability at various medicines, using the EML as a reference. SECTION 4 Additional 7 https://list.essentialmeds.org/. Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 297 OVERVIEW 1 SECTION 1 What Is a Health PER? Data on the availability of medicines are usually collected through facility-based surveys, which use a standardized methodology; GENERIC DRUGS 2 other possible sources are MoH inventories of public facilities and The use of generics can significantly reduce the cost of medicines for SECTION 2 purchasers. Underuse of generics is a major source of inefficiency supply chain management information systems. PER authors have Cross-Cutting Analysis on the option to include additional medicines for specific conditions in pharmaceutical spending. Measuring the share of generics in Efficiency and if relevant to the country context and if data are available. For volume and in value can illustrate whether the country has a low Equity 3 instance, the country context might warrant a focus on essential penetration of generics. In 2021, the average share of generics in noncommunicable disease medicines, priority medicines for pharmaceutical spending for 13 OECD countries was 22 percent, and SECTION 3 women and children, or antiretroviral drugs. the average share in volume was 51 percent. The country with the Topic-Specific Analysis highest pharmaceutical volume share was Canada, with 78 percent, When there is an explicit benefit package or a formulary, one way and the country with the highest share in value was Türkiye, with Health System Context 30 percent (OECD Statistics). of assessing efficiency is to see whether it includes the essential Health Financing medicines list and review the criteria for defining the package. Inputs Explicit benefit packages that consider the burden of disease The World Health Organization’s Global Health Observatory8 M-7: Human Resources for Health and cost-effectiveness criteria to define coverage tend to be collects data on the proportion of health facilities that have a more efficient than those that do not. The module on Benefits core set of relevant essential medicines available and affordable M-8: Infrastructure & Equipment Specification addresses the process and criteria used to define on a sustainable basis (Indicator 3.b.3), which is a composite M-9: Medicines & Medical Supplies which medicines are covered by public funds. construction of availability of a core set of medicines, their price, Service Delivery and a measure of quality. The most recent data are for 2016. If the Outcomes country carries out its own survey of facilities with a locally defined list of medicines, PER authors are encouraged to use the local 4 List of Acronyms indicator contingent on data quality. SECTION 4 Additional 8 https://www.who.int/data/gho. Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 298 OVERVIEW 1 When looking at the market for generics, PER authors should the value of pharmaceutical sales might reflect low prices of generic SECTION 1 What Is a make explicit whether the data are for the total pharmaceutical medicines rather than low volume. If data are available, PER authors Health PER? market, the market paid by third parties (insurance schemes or should also look at the volume of pharmaceutical sales, which is 2 government budgets), or the retail market and ensure comparability usually measured by the number of defined daily doses, but this SECTION 2 if benchmarking against other countries. A low share of generics in information is harder to come by. Cross-Cutting Analysis on Efficiency and Key Indicators Sources for Local Data Data for Benchmarking Equity 3 Does the country’s formulary or SECTION 3 benefit package follow/use/consult/ • KIIs Topic-Specific include the EML for reimbursement/ Analysis coverage/payment? (Y/N) Health System Context • National facility-based surveys • The percentage of facilities with Health Financing Percentage of facilities with a core • KIIs availability of essential medicines in high- Inputs set of essential medicines • Ministries of Health inventories of public facilities income countries is above 90%.9 M-7: Human Resources for Health • Reports from national purchasing or distribution agencies • PER authors can also use national targets. M-8: Infrastructure & Equipment • Procurement information systems • PER authors can use the share of generics Share of generics in the volume of M-9: Medicines & Medical Supplies • Reports from the MoH, or health insurance agency in the value of sales in OECD countries. For sales example, for 2021, Canada had the highest Service Delivery • OECD Statistics share of generics in the total volume Outcomes Share of sales of generic medicines • Pharmaceutical market of pharmaceutical sales, 78.1%, with in the value of total pharmaceutical 4 List of Acronyms • Grey or published literature, studies on pharmaceutical the lowest values among the countries sales 99 markets included in the dataset being around 30%. SECTION 4 Additional Note: EML = Essential Medicines List; KII = key informant interview; MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Guidance Development; WHO = World Health 9 https://www.who.int/data/gho . Organization. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 299 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 GOVERNANCE SECTION 2 Cross-Cutting Analysis on Efficiency and Policies and institutional arrangements for pharmaceutical Equity 3 SECTION 3 Topic-Specific Analysis Health System Context prices, procurement, prescription, and coverage Adequate policies and institutional arrangements can improve the efficiency of Health Financing pharmaceutical spending. This section presents a reduced number of indicators, which Inputs can be obtained through key informant interviews and regulatory documents. Most of M-7: Human Resources for Health the indicators query whether certain policies, which are thought or known to improve the M-8: Infrastructure & Equipment efficiency of pharmaceutical spending, are in place (yes/no questions). Still, PER authors M-9: Medicines & Medical Supplies should discuss whether there are mechanisms in place to enforce any existing policies Service Delivery and whether informants perceive that the policies achieve the intended outcomes. Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 300 OVERVIEW 1 SECTION 1 What Is a Health PER? Prices 2 SECTION 2 Cross-Cutting Analysis on Efficiency and KEY QUESTION • Are policies and regulations in place to secure lower prices of medicines? Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Price regulations establish a range or maximum price for which a medicine can be sold in the country or purchased by the public sector. The most common practice is to use the prices paid by other countries as reference to set the national price around or below the median price observed in the reference list. Key Indicators Is there a system for tracking and measuring the unit cost of drugs Sources • KIIs • Policy and medical supplies periodically? Health Financing documents Purchasing pharmaceuticals through centralized mechanisms, rather than (Y/N) Inputs allowing each provider or pharmacy to independently purchase medicines, M-7: Human Resources for Health Are prices regulated? (Y/N) If so, strengthens the negotiation capacity of the buyer and results in lower prices. how are prices regulated? M-8: Infrastructure & Equipment Pooled procurement mechanisms, where several countries purchase medicines M-9: Medicines & Medical Supplies through one buyer, also results in lower prices. In the tendering process, when Are all or some medicines Service Delivery there are several products for the same active ingredient, countries can purchase procured centrally? (Y/N) medicines only from the bidder offering the lowest price. Monitoring prices will Outcomes Note: KII = key informant interview; INN = international nonproprietary names; WHO = help governments assess whether they are overpaying for inputs. World Health Organization; OECD = Organisation for Economic 4 List of Acronyms Co-operation and Development. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 301 OVERVIEW 1 SECTION 1 What Is a Health PER? Mix 2 SECTION 2 KEY QUESTIONS • Are there policies in place to track expenditure on and prescription of generics? Cross-Cutting Analysis on • Are there policies in place to promote the uptake of generic medicines? Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context The uptake of generics can be improved if prescribers and dispensers are required to use the international nonproprietary name instead of the brand name, or if the pharmacist is allowed to substitute the brand name for the generic alternative. Key Indicators Is there an appropriately equipped and qualified national entity that establishes the interchangeability of generics with the originator brand using WHO Sources • KIIs • Policy internationally agreed standards? (Y/N) documents Health Financing Alternatively, consumers can purchase the brand version but pay Is there an information system in place that can track Inputs the price difference (copayment). The availability of generics can prescribing and dispensing generics? (Y/N) M-7: Human Resources for Health be promoted through simplified market entry processes and/ Is there legislation in place on prescription and/or M-8: Infrastructure & Equipment or lower import tariffs. A precondition for promoting the use dispensing by INN)? (Y/N) M-9: Medicines & Medical Supplies of generics, particularly unbranded generics, is the existence Is there a copayment in place for proprietary medicines of a regulatory agency that can establish the quality and when generic equivalents are available? (Y/N) Service Delivery interchangeability of the generic with the originator medicine, Outcomes Does the country offer incentives to encourage generics using agreed international standards. to enter the market (tendering for market exclusivity, 4 List of Acronyms no import tariffs, low fees, and expedited approval process)? (Y/N) If so, list these policies. SECTION 4 Note: KII = key informant interview; INN = international nonproprietary names; WHO = World Health Organization. Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 302 OVERVIEW 1 SECTION 1 What Is a Health PER? Quality 2 SECTION 2 Cross-Cutting KEY QUESTION • Are there policies and regulations to guarantee the adequate quality of medicines? Analysis on Efficiency and Equity 3 The government, through regulatory authorities, should Key Indicators Sources establish and enforce the rules, law, and policies that SECTION 3 Is there an appropriately equipped and • KIIs guarantee that medicines are safe, effective, and adhere Topic-Specific Analysis to the quality specifications stated by the manufacturer. qualified national entity able to control the • Policy documents quality of medicines and perform testing? Health System Context (Y/N) WHO has set international standards and guidelines Health Financing Are there mechanisms in place to carry out for establishing these agencies and their processes. frequent controls or sampling? (Y/N) Inputs Low quality and ineffective medicines waste patient M-7: Human Resources for Health and health system resources. Strong regulatory and Is there a way to track counterfeit drugs? • Studies or reports on enforcement capacity translate into better health M-8: Infrastructure & Equipment (Y/N) If so, what is the value of counterfeit counterfeit medicines outcomes, lower availability of substandard and M-9: Medicines & Medical Supplies drugs seized in the country? counterfeit medicines, and more efficient spending. • OECD database Service Delivery • Pharmaceutical Security Outcomes Institute database 4 List of Acronyms • WHO SECTION 4 • Customs Additional Note: KII = key informant interview; OECD = Organisation for Economic Co-operation and Development; WHO = World Health Guidance Organization. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 303 OVERVIEW CASE STUDY: 1 SECTION 1 What Is a Health PER? IMPROVING THE EFFICIENCY OF PHARMACEUTICAL SPENDING IN THE DOMINICAN REPUBLIC 2 The Dominican Republic spent The two health financing schemes in Spending on medical devices and medicines as a share of current health expenditure, 2019 SECTION 2 about $700 million on medical the country have different purchasing 30 Cross-Cutting Analysis on devices and medicines in 2019. mechanisms for pharmaceuticals, although 25 Efficiency and The share of spending on medical both cover the list of medicines included in Equity 3 20 devices and medicines is about the Seguro Familiar de Salud. Beneficiaries of Percent 15 18 percent of total current health the subsidized scheme receive 100 percent SECTION 3 expenditure, on par with similar coverage of ambulatory medicines, which 10 Topic-Specific upper-middle-income countries they get in the public pharmacies (farmacias 5 Analysis in the region, and has remained del pueblo). Beneficiaries in the contributive 0 Brazil Costa Rica Dominican Guyana Mexico Paraguay Suriname Health System Context stable for the past five years. A scheme receive coverage of 80 percent up Republic large share of pharmaceutical to an annual maximum and purchase their Health Financing Government spending on medical devices and medicines as a outpatient and retail spending medicines in retail pharmacies. While the share of total government spending on health, 2019 Inputs (80 percent) is paid for by the subsidized scheme purchases medicines 14 M-7: Human Resources for Health private sector. Data on out-of- through competitive bidding, each of the 12 M-8: Infrastructure & Equipment pocket (OOP) payment spending 14 insurance agencies in the contributive 10 Percent indicate that households assume scheme (administradoras de riesgos 8 M-9: Medicines & Medical Supplies about 30 percent of current health de salud, ARS) has its own purchasing 6 Service Delivery expenditure, and a study by Azael processes. Further, the subsidized regime 4 Outcomes Lorenxo and Penson (2018)10 found is able to procure medicines at low prices 2 that medicines account for the due to the competitive bidding, while the 4 - List of Acronyms Chile Costa Rica Dominican Guyana Haiti Suriname 1010 highest share of OOP spending (46 purchases by the contributory regime can Republic percent). reach double those prices. SECTION 4 Source: World Bank staff calculations based on GHED data. Additional Guidance 10 Azael Lorenzo, G., and E. Penson. 2018. “Análisis del gasto de bolsillo en salud de los hogares en República Dominicana a partir de datos de la ENIGH del 2018.” Technical Report. Oficina Nacional de Estadística, Gobierno de la República Dominicana. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 304 OVERVIEW CASE STUDY: 1 SECTION 1 What Is a Health PER? IMPROVING THE EFFICIENCY OF PHARMACEUTICAL SPENDING IN THE DOMINICAN REPUBLIC 2 SECTION 2 Cross-Cutting PRICES, PRICE REGULATION, AND PROCUREMENT Unit of Year of Ratio of Median Retail Analysis on Medicine Price in DR to Average Measurement Comparison Efficiency and This table compares prices of six drugs.11 Insulin glargine and ertapenem Price in the Region Equity 3 are drugs recommended for second line treatment of diabetes and Insulin Daily dose 2017 0.6 infections, respectively. Amoxicillin and paracetamol are widely used glargine SECTION 3 as an antibacterial and a pain reliever, respectively. Losartan is a statin Topic-Specific Ertapenem Daily dose 2017 1 Analysis for the treatment of high blood pressure, and levothyroxine treats hypothyroidism. All these drugs treat prevalent conditions in Latin Amoxicillin Presentation 2021 0.37 Health System Context America and the Caribbean. The table presents the ratio of the median 500 mg x 15 Health Financing price observed in the retail market in the Dominican Republic to the tablets Inputs average price for other countries in the region. The results indicate that Paracetamol Presentation 2021 1.63 M-7: Human Resources for Health most medicines are purchased at equal or higher prices than similar 500 mg x 20 countries in the region. The price of losartan is 9.4 times higher than tablets M-8: Infrastructure & Equipment the average for the countries in the study. Losartan Presentation 2021 9.4 M-9: Medicines & Medical Supplies 100 mg x 50 Service Delivery High prices in the retail market may be explained by the absence of tablets Outcomes regulations in the margins at different points in the distribution chain. Levotiroxin Presentation 2021 1.2 The country does not regulate prices either.12 4 List of Acronyms 100 mg x 50 tablets SECTION 4 11 The table is presented for illustrative analysis and should not be used as a reference. The ratio corresponds to Sources: For insulin glargine, World Bank staff calculation using IDB (2018). For other medicines, World Bank Additional the median price in the retail market to the average price reported for the countries in the studies. staff calculations using Gómez and Oglietti 2021.12 The table is an illustrative example only. Guidance 12 Gómez, Gerardo. E., and Guillermo Ogliett. 2021. “Informe sobre los precios de medicamentos en América Lati- Note: DR = Dominican Republic. na.” Technical Report. Laboratorio de Precios CELAG. https://www.celag.org/informe-sobre-los-precios-de-me- dicamentos-en-america-latina/. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 305 OVERVIEW CASE STUDY: 1 SECTION 1 What Is a Health PER? IMPROVING THE EFFICIENCY OF PHARMACEUTICAL SPENDING IN THE DOMINICAN REPUBLIC 2 SECTION 2 are interchangeable, but it has not been fully implemented and Cross-Cutting MIX OF MEDICINE there seems to be low confidence in generic medicines. This may Analysis on Efficiency and help explain why consumers do not buy generics, despite their Although there are no systems to track the use of generic Equity lower prices. The country has a regularly updated list of essential 3 medicines, a study by Atal et al. (2023)13 finds that unbranded medicines that follows WHO guidance. generics are, on average, 3.5 times more expensive than their SECTION 3 branded alternatives (branded generics or innovator drugs). Topic-Specific Analysis Although generic medicines account for 77 percent of the value of sales, only 7 percent are unbranded generics (the rest are branded AVAILABILITY AND SUPPLY CHAIN Health System Context generics or innovators). The study authors estimate that switching MANAGEMENT Health Financing to unbranded alternatives could reduce outpatient pharmaceutical The country tracks the availability of medicines through the supply Inputs spending by 14 percent in the contributive regime. The study chain, and many improvements have been implemented during M-7: Human Resources for Health authors also find that 48 percent of pharmaceutical sales are for the past decade. In 2022 and 2023, the central warehouse met the active ingredients where substitution is not possible, because minimum availability in months of stock for tracer medicines in M-8: Infrastructure & Equipment there are no unbranded alternatives despite the innovators having primary-level care (Servicio Nacional de Salud 2023).14 However, M-9: Medicines & Medical Supplies lost patent protection. in December 2023, there were stockout alerts for antiretroviral, Service Delivery tuberculosis, and family planning pharmaceuticals in the central Outcomes Prescriptions in the Dominican Republic use the international warehouse (though not in regional warehouses) (op. cit). No nonproprietary name of the drug. The Dominican Republic also 4 List of Acronyms information was available on the frequency of expired medicines. approved regulation to ensure that generics and biosimilars SECTION 4 Additional 13 Atal, Juan Pablo, Ursula Giedion, Catalina Gutiérrez, and Natalia Jorgensen. 2023. ¿Cuál es el costo de oportunidad de financiar medicamentos de marca? El caso de República Dominicana. Washington, DC: Inter-American Development Bank. Guidance 14 Servicio Nacional de Salud. 2023. Boletín Nacional de Información Estratégica del SUGEMI. https://sns.gob.do/sugemi/#391-1510-wpfd-2023-boletines-trimestrales. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 306 OVERVIEW CASE STUDY: 1 SECTION 1 What Is a Health PER? IMPROVING THE EFFICIENCY OF PHARMACEUTICAL SPENDING IN THE DOMINICAN REPUBLIC 2 SECTION 2 Cross-Cutting Analysis on CONCLUSIONS Efficiency and Equity 3 The review suggests that the Dominican Republican can improve the efficiency of its pharmaceutical spending by improving generic SECTION 3 uptake, implementing regulation on the interchangeability of Topic-Specific Analysis medicines, strengthening the regulatory agency, and promoting the entry of generics. Introducing price regulation and referencing Health System Context in the retail market and continuing to strengthen supply chain Health Financing management might also yield efficiency gains. OOP spending still Inputs represents a challenge for Dominican Republic households, and M-7: Human Resources for Health medicines comprise the highest share of this spending. Reducing prices and improving generic update can reduce OOP spending and M-8: Infrastructure & Equipment generate savings for the contributory regime. M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 307 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Antimicrobial Resistance Collaborators. 2022. “Global Burden of Bacterial Antimicrobial Resistance in 2019: A Systematic Analysis.” The Lancet Cross-Cutting 399 (10325): 629–59. https://doi.org/10.1016/S0140-6736(21)02724-0. Analysis on Efficiency and Equity Bonnifield, Rachel Silverman, Janeen Madan Keller, Amanda Glassman, and Kalipso Chalkidou. 2019. Tackling the Triple Transition in Global 3 Health Procurement. Washington, DC: Center for Global Development. SECTION 3 Buxbaum, Jason D., Michael E. Chernew, A. Mark Fendrick, and David M. Cutler. 2020. “Contributions of Public Health, Pharmaceuticals, and Topic-Specific Other Medical Care to US Life Expectancy Changes, 1990–2015.” Health Affairs 39 (9). https://doi.org/10.1377/hlthaff.2020.00284. Analysis Cutler, David M., Genia Long, Ernst R. Rernt, Jimmy Royer, Andrée-Anne Fournier, Alicier Sasser, and Pierce Cremiaux. “The Value of Health System Context Antihyperintensive Drugs: A Perspective on Medical Innovation.” Health Affairs 26 (1). https://doi.org/10.1377/hlthaff.26.1.97. Health Financing Ewen, Margaret, Huibert-Jan Joosse, David Beran, and Richard Laing. 2019. “Insulin Prices, Availability and Affordability in 13 Low-Income and Inputs Middle-Income Countries.” BMJ Global Health, 4 (3): e001410. M-7: Human Resources for Health Garcia-Goñi, Manuel. 2022. “Rationalizing Pharmacological Spending.” IMF Working Paper WP/22/190. International Monetary Fund, M-8: Infrastructure & Equipment Washington, DC. M-9: Medicines & Medical Supplies Gutiérrez, Catalina. 2023. The Hidden Trade-Offs of High-Cost Drugs: The Case of Colombia. Washington, DC: Inter-American Development Bank. Service Delivery Outcomes IDB. 2018. Better Spending for Better Lives: How Latin America and the Caribbean Can Do More for Less. Washington, DC: Inter-American Development Bank. 4 List of Acronyms Llor, Carl, and Lars Bjerrum. 2014. “Antimicrobial Resistance: Risk Associated with Antibiotic Overuse and Initiatives to Reduce the Problem.” SECTION 4 Therapeutic Advances in Drug Safety, 5 (6): 229–41. Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 308 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 OECD (Organisation for Economic Co-operation and Development). 2017. Tackling Wasteful Spending on Health—Highlights (revised). Paris: Cross-Cutting OECD Publishing. Analysis on Efficiency and Equity OECD (Organisation for Economic Co-operation and Development). 2021. Health at a Glance 2021: OECD Indicators. Paris: OECD Publishing. 3 http://doi.org/10.1787/ae3016b9-en. SECTION 3 OECD (Organisation for Economic Co-operation and Development). 2023. Health at a Glance 2023: OECD Indicators. Paris: OECD Publishing. Topic-Specific http://doi.org/10.1787/7a7afb35-en. Analysis Shargel, Leon, and Isadore Kanfer, eds. Generic drug product development: solid oral dosage forms. CRC Press, 2013. Health System Context Health Financing Inputs M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 309 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on ANNEXES Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Annex 1: Deep Dives Health Financing PER authors wishing to dive deeper Inputs into the efficiency of pharmaceutical M-7: Human Resources for Health spending can study indicators of supply M-8: Infrastructure & Equipment chain management and antibiotic M-9: Medicines & Medical Supplies overuse. Service Delivery Outcomes 4 List of Acronyms SECTION 4 Additional Guidance CONTINUED TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 310 OVERVIEW 1 SECTION 1 What Is a Health PER? Supply Chain Management 2 SECTION 2 Cross-Cutting KEY QUESTION • Are supply chains and storage facilities effective? Analysis on Efficiency and Equity 3 Ineffective supply chains and storage Key Indicators Sources SECTION 3 facilities not only reduce the supply Supply chain Topic-Specific Analysis of medicines in the system but are Number of stockouts of key medicines • Facility surveys also a major source of inefficiency caused by wasteful expired drugs • MoH reports Health System Context Health Financing and delayed provision of services, • Facility inventory control reports leading to poorer health outcomes. Storage facilities Inputs M-7: Human Resources for Health Improving a country’s supply chain Number or percentage of expired drugs • Facility surveys can help reduce stockouts at the local M-8: Infrastructure & Equipment and facility levels, whereas national • Facility inventory control reports Governance M-9: Medicines & Medical Supplies stockouts are an indication of a limited or zero supply of a particular Is there a mechanism to track medicines through the • KIIs Service Delivery supply chain, particularly an electronic system that allows medicine within the country, which Outcomes real-time access to data on stocks, shelf life (expiration), can represent a serious threat to and other types of information? (Y/N) 4 List of Acronyms public health. Does the country regulate minimal standards on the • KIIs SECTION 4 storage of facilities? (Y/N) Are these enforced? (Y/N) Additional Note: KII = key informant interview; MoH = Ministry of Health. Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 311 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Overuse of Antibiotics Health Financing Inputs KEY QUESTION • Is there evidence of overuse of antibiotics? M-7: Human Resources for Health M-8: Infrastructure & Equipment M-9: Medicines & Medical Supplies The Global Antimicrobial Resistance and Surveillance Key Indicators Sources Service Delivery System (GLASS) tracks antimicrobial consumption per Outcomes thousand inhabitants per day by class of antimicrobial, Consumption of antibiotics for including antibiotics, for system use. PER authors can systemic use expressed as DDD per • WHO GLASS-AMR database1 4 List of Acronyms benchmark this indicator against other countries in the 1,000 inhabitants per day dataset with similar epidemiological profiles (incidence of SECTION 4 Additional infectious disease) or level of income. 1 https://worldhealthorg.shinyapps.io/glass-dashboard/wf3af945c/#!/amc. Guidance Note: DDD = daily defined dose; WHO GLASS-AMR = World Health Organization Global Antimicrobial Resistance and Surveillance System-Antimicrobial Resistance. TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 312 OVERVIEW 1 SECTION 1 What Is a Health PER? Annex 2: Indicators. Definitions, Measurement, and Sources 2 SECTION 2 Cross-Cutting Indicators Definitions Numerators Denominators Sources Analysis on Efficiency and Equity Total pharmaceutical Expenditure, by health Current health • GHED (2022) 3 spending as a percentage of function: expenditure current health expenditure HC.5. Medical goods • Medical goods (nonspecified (nonspecified, by function) by function) SECTION 3 (LCU million), GHED Topic-Specific • Pharmaceutical and other Analysis medical durable goods (Total of Current, Domestic general government, (prescribed medicines, OTC Health System Context External, Domestic private medicines, other medical Health Financing health expenditure, by nondurable goods) health care function) Inputs • OECD Statistics M-7: Human Resources for Health • Pharmaceutical spending M-8: Infrastructure & Equipment Government spending HC.5 (G). HC. General government • GHED on pharmaceuticals as General government Health expenditure, by M-9: Medicines & Medical Supplies a percentage of current Expenditure on medical health function • National Health Accounts government health goods—pharmaceuticals Service Delivery expenditure and other medical durable Outcomes goods • GHED 4 List of Acronyms Pharmaceutical spending per HC.5. Medical goods Total population capita (nonspecified, by function) (LCU million), GHED • WDI for population SECTION 4 Additional Annex 2 continues on the following page. Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 313 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 Annex 2: Indicators, Definitions, Measurement, and Sources (continued) SECTION 2 Cross-Cutting Analysis on Efficiency and Indicators Definitions Numerators Denominators Sources Equity 3 Unit price of key medicines Median or weighted average For comparison purposes, For comparison purposes, • Local prices can be obtained price of medicines with the the ratio of the domestic the ratio of the domestic from national procurement SECTION 3 same active ingredient price to the reference price price to the reference agencies, national Topic-Specific can be used. price can be used. observatories of prices, or Analysis The price can be for a a sample of pharmacies in particular presentation, i.e., Domestic price in Reference price in selected cities. concentration and number international currency international currency; Health System Context of units in the presentation average price for • Reference prices can be obtained from reports by Health Financing (e.g., amoxicillin 500 mg x 30 For comparisons with other reference countries, in international or regional capsules). countries, the price has to international currency Inputs pooled procurement agencies be measured at the same (for example, PAHO), regional M-7: Human Resources for Health Alternatively, the price per point in the distribution For comparisons with price observatories, published tablet, capsule, defined daily chain (ex-manufacturer, other countries, the price M-8: Infrastructure & Equipment literature, or monitoring dose, or milliliter can be wholesaler, or retail). has to be measured at reports by procurement used. If the unit price is not Market exchange rates can the same point in the M-9: Medicines & Medical Supplies agencies in a set of selected available, the implicit unit be used to convert to the distribution chain (ex- countries. WHO has a list Service Delivery price in all the presentations same currency. manufacturer, wholesaler, of local sources for prices: available in the market needs or retail). Market Outcomes Medicine price information to be estimated. exchange rates can be sources. 4 List of Acronyms used to convert to the same currency. SECTION 4 Annex 2 continues on the following page. Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 314 OVERVIEW 1 SECTION 1 What Is a Health PER? Annex 2: Indicators. Definitions, Measurement, and Sources (continued) 2 Indicators Definitions Numerators Denominators Sources SECTION 2 Cross-Cutting Proportion of health facilities Proportion of health facilities Facilities with available Surveyed facilities • WHO GHO that have a core set of that have a core set of and affordable basket of Analysis on Efficiency and relevant essential medicines relevant essential medicines medicines • National purchasing or distribution agencies’ reports Equity available and affordable on available and affordable 3 on availability and levels of a sustainable basis (latest on a sustainable basis. The stocks of tracer medicines 2019, 17 countries) indicator is a multidimensional SECTION 3 index reported as a proportion Topic-Specific Alternatively, PER authors (%) of health facilities that Analysis can use local measures of have a defined core set of medicines’ availability. In quality-assured medicines that Health System Context some countries, months of are available and affordable stock of tracer medicines is relative to the total number Health Financing used and compared against a of surveyed health facilities at Inputs target. the national level. M-7: Human Resources for Health Share of generics in the Value of sales of generic Total value of • Reports from the MoH, or value of sales medicines in local pharmaceutical sales in health insurance agency M-8: Infrastructure & Equipment currency local currency • National procurement M-9: Medicines & Medical Supplies agencies Service Delivery • OECD Statistics Outcomes • Studies on pharmaceutical markets in grey or published 4 List of Acronyms literature SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 315 OVERVIEW 1 SECTION 1 What Is a Health PER? Annex 2: Indicators. Definitions, Measurement, and Sources (continued) 2 Indicators Definitions Numerators Denominators Sources SECTION 2 Cross-Cutting Proportion of health facilities Proportion of health facilities Facilities with available Surveyed facilities • WHO GHO that have a core set of that have a core set of and affordable basket of Analysis on Efficiency and relevant essential medicines relevant essential medicines medicines • National purchasing or distribution agencies’ reports Equity available and affordable on available and affordable 3 on availability and levels of a sustainable basis (latest on a sustainable basis. The stocks of tracer medicines 2019, 17 countries) indicator is a multidimensional SECTION 3 index reported as a proportion Topic-Specific Alternatively, PER authors (%) of health facilities that Analysis can use local measures of have a defined core set of medicines’ availability. In quality-assured medicines that Health System Context some countries, months of are available and affordable stock of tracer medicines is relative to the total number Health Financing used and compared against a of surveyed health facilities at Inputs target. the national level. M-7: Human Resources for Health Share of generics in the Value of sales of generic Total value of • Claims data value of sales medicines in local pharmaceutical sales in M-8: Infrastructure & Equipment currency local currency • National procurement agencies M-9: Medicines & Medical Supplies • OECD Statistics Service Delivery • Studies on pharmaceutical Outcomes markets in grey or published literature 4 List of Acronyms GHED = Global Health Expenditure Data; MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Development; PAHO = Pan American Health Organization; WDI = World Development Indicators; WHO GHO = World Health Organization Global Health Observatory. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 9 Medicines & Medical Supplies 316 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity SECTION 3 3 Service lt also offers guidance to understand whether the rules and processes governing SECTION 3 the organization and delivery of care contribute to improved efficiency and equity. Topic-Specific Hospitals account for a significant portion of health care expenditure. By improving Delivery Analysis efficiency, hospitals can increase their capacity to treat more patients with existing resources. Equitably distributed services can help counter socioeconomic inequalities. Health System Context An efficient and effective primary care system—one that is patient centered and well Health Financing coordinated across levels of care—should meet most health needs in a cost-effective Inputs way. This approach reduces unnecessary hospital use and helps prevent complications Service Delivery This section provides guidance on that affect quality of life. Outcomes assessing the efficiency of health 4 List of Acronyms service delivery and evaluating MODULE 10 HOSPITALS SECTION 4 equitable access. Additional MODULE 11 PRIMARY CARE AND ESSENTIAL PUBLIC HEALTH Guidance CONTINUE TABLE OF CONTENTS OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis MODULE 10 Health System Context Health Financing Hospitals Inputs Service Delivery AUTHORS M-10: Hospitals Priyanka Saksena, Catalina Gutiérrez, M-11: Primary Care & Public Health and Christoph Kurowski, with contributions Outcomes from Christophe Lemiere 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 318 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Cross-Cutting Given the large share of health spending on inefficient hospital processes that can result in, for instance, overly Analysis on long hospital stays (OECD 2017). Efficiency and hospitals, inefficiencies can have important Equity 3 impacts on the health system. On average, hospital Health facilities are generally categorized by levels: primary, expenditures represented more than 35 percent secondary, and tertiary. Hospitals are typically categorized as SECTION 3 Topic-Specific of current health expenditure in 2019, with wide secondary or tertiary level, with tertiary hospitals providing more Analysis specialized and technologically advanced services. However, the variation across countries (Figure 1). The variation classification can vary, and some countries have additional levels Health System Context is mostly explained by the degree of reliance on based on infrastructure and clinical capacity. Terminology for these Health Financing hospitals to provide health care. facilities differs by country. The key difference between hospitals Inputs from other facilities is their capacity to provide 24/7 care and Service Delivery Countries face various hospital-related issues, such as having supervision of patients, including in relation to emergency care as M-10: Hospitals numerous small hospitals with poor-quality care due to well as high technology and skill-intensive services. Additionally, inadequate capacity, which nevertheless shifts focus to curative some hospitals specialize in areas like maternity care, infectious M-11: Primary Care & Public Health care. Conversely, some areas have too few hospitals, causing diseases, or cancer. When someone is admitted to a hospital for Outcomes equity issues or overutilization of higher-quality hospitals. an overnight stay, this is considered inpatient care. Hospitals also 4 List of Acronyms provide outpatient services, like consultations with specialist physicians for emergencies and accidents, or radiology examinations These scenarios all result in inefficiency. Major sources of SECTION 4 like CT scans. A hospital’s outpatient services sometimes includes inefficiency in hospitals also stem from unnecessary use overall. Additional even more complex care, such as certain surgeries. Guidance Specific examples include excessive emergency room visits or hospitalizations that adequate primary care could prevent and TABLE OF CONTENTS MODULE 10 Hospitals 319 OVERVIEW 1 Guinea FIGURE 1 Niger Afghanistan This module considers different aspects of hospital efficiency SECTION 1 EXPENDITURE Guinea-Bissau Mali and explains how PER authors can assess them during a What Is a ON HOSPITALS United Republic of Tanzania AS A SHARE OF Madagascar Malawi PER. These aspects include the spending on hospitals and Health PER? Central African Republic CURRENT HEALTH spending trends, hospital infrastructure and capacity, types 2 Senegal Mauritania EXPENDITURE, Nepal of hospitals and expenditure within hospitals. The module SECTION 2 2019 Togo Haiti Cross-Cutting Canada also explores productivity, quality, integration of services, Cameroon Analysis on Mexico Gambia and processes/governance to help authors determine Efficiency and Source: World Health United States of America Equity Organization Global Health whether resources are being used efficiently. Finally, the 3 Liberia Expenditure Database. Tunisia Accessed May 3, 2023. https:// apps.who.int/nha/database/ Israel Côte d'Ivoire module discusses equity dimensions related to hospitals. Switzerland SECTION 3 ViewData/Indicators/en. Gabon PER authors can also refer to the “Recommended Readings” Iran (Islamic Republic of) Topic-Specific Hungary Eswatini in the box on the following page. Analysis Ireland France Ethiopia Chile Austria Some indicators discussed in the section on productivity, Health System Context Belgium Norway quality, and integration of services can vary based on subtle Health Financing Iraq Uganda United Kingdom of Great Britain… clinical differences; these may be difficult to understand, Inputs Burkina Faso especially for nonspecialists. Further, without a culture Nigeria Zimbabwe Service Delivery Cabo Verde focused on patient safety and quality improvement, clinicians Sao Tome and Principe M-10: Hospitals Australia Seychelles and their managers may be reluctant to discuss clinical Greece Cyprus choices. Thus, as noted in many places in this module, PER M-11: Primary Care & Public Health Spain Italy Estonia authors should rely on existing reports and studies rather Outcomes Czechia Republic of Korea than conduct novel analysis based on primary data. 4 Democratic Republic of the Congo List of Acronyms Mongolia Lebanon Paraguay South Africa In some countries, hospital performance assessment SECTION 4 Congo South Sudan Kenya frameworks exist, and their data are available in a centralized Additional Comoros Guidance Namibia location. The aim of these frameworks is to measure and Costa Rica Sierra Leone Jordan improve a hospital’s functioning, including by identifying and Saudi Arabia collecting standardized indicators of performance from different 0 10 20 30 40 50 60 70 TABLE OF CONTENTS MODULE 10 Hospitals 320 OVERVIEW 1 facilities. Included indicators might be related to clinical effectiveness, While these are not considered in this module, authors can refer to SECTION 1 What Is a patient-centeredness, safety, responsive governance, staff orientation, Annex 1: Considerations in Hospital Efficiency Measurement, y Health PER? timeliness, equity, and utilization as well as efficiency.1 These data, if and Annex 2: How to conduct a Data Envelopment Analysis (DEA) for 2 available, could be an excellent resource for this module. Hospitalsfffff for more information. Box 3 at the end of this section SECTION 2 explores common approaches to hospital efficiency analysis and Cross-Cutting Analysis on PER authors should also note that formalized frameworks for offers guidance on avoiding common pitfalls when applying them. Efficiency and studying comparative hospital efficiency have been developed. Equity 3 SECTION 3 Topic-Specific Analysis Health System Context 1 Different frameworks for assessing hospital performance have been developed and use different standardized indicators of performance. Some frameworks use indicators that focus on high-income countries, like the US-oriented Major Hospital Quality Measurement Sets and the UK’s NHS Outcomes Framework, while others, such as the World Health Organization’s European Path and balanced scorecard approaches, have a broader scope (Groene, Skau, and Frølich 2008; “Major Hospital Quality Measurement Sets,” n.d.; “NHS Outcomes Framework (NHS OF),” n.d.; Veillard et al. 2005; Carini et al. 2020). BOX 1. RECOMMENDED READING Health Financing James, C., C. Berchet, and T. Muir. 2017. “Addressing Operational Preker, Alexander S., and April Harding. 2003. Innovations Inputs Waste by Better Targeting the Use of Hospital Care,” in Tackling in Health Service Delivery: The Corporatization of Public Service Delivery Wasteful Spending on Health. Paris: OECD Publishing. https:// Hospitals. Washington, DC: World Bank. M-10: Hospitals doi.org/10.1787/9789264266414-8-en. https://documents1.worldbank.org/ M-11: Primary Care & Public Health curated/en/286701468150875482/ Outcomes La Forgia, Jerry, and Bernard Couttolenc. 2008. Hospital pdf/261000REVISED00ing0Preker020030book.pdf. Performance in Brazil: The Search for 4 List of Acronyms Excellence. Washington, DC: World Bank. Veillard, J., F. Champagne, N. Klazinga, V. Kazandjian, O.A. Arah, SECTION 4 https://openknowledge.worldbank.org/entities/ and A.-L. Guisset. 2005. “A Performance Assessment Framework Additional publication/6d5af25a-424b-5fd5-ba07- for Hospitals: The WHO Regional Office for Europe PATH Guidance 72d045ba16d4. Project.” International Journal for Quality in Health Care 17 (6): 487–96. https://doi.org/10.1093/intqhc/mzi072. TABLE OF CONTENTS MODULE 10 Hospitals 321 OVERVIEW 1 SECTION 1 What Is a Health PER? INEFFICIENCY 2 SECTION 2 Cross-Cutting Spending, Infrastructure, and Capacity Analysis on Efficiency and Equity 3 • How much is spent on hospitals? How has this spending evolved? KEY QUESTIONS SECTION 3 • What hospital infrastructure and capacity exist in the country? Topic-Specific Analysis Health System Context PER authors should look at hospital expenditure as This information is readily available in country documents including MoH budgets. When doing country comparisons, authors should Health Financing a share of current health expenditure,2 expenditure take care to understand whether data on expenditure includes Inputs on hospitals as a share of government spending, and the procurement of medicines, which is sometimes accounted Service Delivery the expenditure on public hospitals as a share of separately and can make up an important share of expenditure. M-10: Hospitals the Ministry of Health (MoH) budget, particularly for M-11: Primary Care & Public Health The share of spending on hospitals depends on the characteristics countries with public provision. of the health and health financing system in a country, and there Outcomes are no international benchmarks in this area. For example, hospital 4 List of Acronyms SECTION 4 2 This is an indicator calculated in the National Health Accounts (NHA), using the breakdown of expenditure by providers. Specifically, NHA are calculated using the System of Health Accounts 2011, or SHA 2011, which is an Additional international accounting framework for systematically tracking health spending. Most countries have conducted this exercise and many conduct it regularly, with an aim to guide future policies and investments to make health Guidance systems more responsive to people’s needs. However, detail and quality of data may vary significantly from country to country depending on the level of institutionalization of National Health Accounts. Also of note, current health expenditure under SHA 2011 includes expenditure on maintenance but excludes capital expenditure, or, more specifically, gross fixed capital formation, which is separated in capital expenditure. Current health expenditure is now the standard denominator for international reporting. However, many countries also report in their national publications the total health expenditure, which includes capital expenditure. TABLE OF CONTENTS MODULE 10 Hospitals 322 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Sources 2 Hospital expenditure as a percentage of current health expenditure • MoH SECTION 2 • National Health Accounts Cross-Cutting Hospital expenditure as a percentage of government health expenditure • National budget documents Analysis on (including both public and private hospitals) Efficiency and • WHO GHED Equity 3 Public sector hospital expenditure as a percentage of government health expenditure • OECD Statistics SECTION 3 Number of hospitals per 100,000 population • MoH Topic-Specific • WHO GHO Analysis Hospital beds per 10,000 population • MoH Health System Context • WHO GHO Health Financing Note: MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Development; WHO = World Health Organization; WHO GHED = Global Health Expenditure Database; WHO GHO = Global Health Observatory. Inputs Service Delivery expenditure as a share of current health expenditure was 39 PER authors to examine trends in expenditure on different levels of M-10: Hospitals percent, on average, in Organisation for Economic Co-operation and hospitals and expenditure over time within a country. M-11: Primary Care & Public Health Development (OECD) countries in 2019, ranging from 27.4 percent in Canada to 51.4 percent in Türkiye (OECD Statistics). To understand whether there is adequate availability of hospital Outcomes services, PER authors can investigate the overall hospital 4 List of Acronyms However, a large budgetary allocation of government funds to infrastructure and capacity in a country by identifying the number hospitals could result in lower overall efficiency in the system if such of hospitals per 100,000 population and density of hospital beds per SECTION 4 funding undermines other essential health facilities and services, 10,000 population. Overall, there is significant variation in hospital Additional Guidance like promotive or preventive care, which usually makes cost-effective infrastructure and capacity across countries, with some countries investments (Jamison 2018). Additionally, it would be useful for simply without enough facilities, resulting in higher mortality. TABLE OF CONTENTS MODULE 10 Hospitals 323 OVERVIEW 1 SECTION 1 What Is a Health PER? CASE EXAMPLE: VIET NAM 2 SECTION 2 Cross-Cutting Hospitals in Viet Nam are often overcrowded. It is not 166 hospital discharges from public hospitals for every 1,000 Analysis on Efficiency and unusual to have two or even four patients per bed. And this inhabitants. These discharge rates are higher than the OECD Equity 3 overcrowding is indeed reflected by high Bed Occupancy average and than many comparator countries in the region, Rates (BOR), which have reached 129 percent recently. For including China, Japan, Malaysia, and Thailand. SECTION 3 some policymakers, these are clear signs that additional Topic-Specific investments in hospital capacities are needed. But is it ? Third, a large part of hospitalizations is avoidable. In Analysis 2020, a World Bank study found that over 30 percent of all Health System Context Other indicators strongly suggest that this overcrowding inpatient episodes paid by the health insurance fund were is not due to undersized hospitals but rather to an over- for ambulatory care sensitive conditions (ACSC). ACSCs are Health Financing utilization of hospitals. conditions that, if effectively dealt with in primary health Inputs care (PHC) or ambulatory care, could avoid hospitalization. Service Delivery First, bed density (number of hospital beds per 10,000 people M-10: Hospitals in the population) in Viet Nam is in line with the OECD average Fourth—and above all—, 45 percent of current health M-11: Primary Care & Public Health and with other countries in East Asia and Pacific. Viet Nam expenditures (CHE) are absorbed by inpatient care Outcomes is actually slightly better equipped with inpatient beds than expenditures. This is one of the highest levels in Asia. Even aspirational peers such as Thailand, Singapore, and Malaysia. globally, among lower middle-income countries, the average 4 List of Acronyms is 24 percent, while among upper-middle-income countries, Second, Viet Nam’s hospitalization rate is somewhat high. it is 30 percent. SECTION 4 Additional The latest MOH estimates (2020) show that Viet Nam had Guidance Source: World Bank, forthcoming, “Why is Vietnam spending so many resources in its hospital sector? And what can be done about it?” Box continues on the following page. TABLE OF CONTENTS MODULE 10 Hospitals 324 OVERVIEW 1 SECTION 1 What Is a Health PER? CASE EXAMPLE: VIET NAM (continued) 2 SECTION 2 Cross-Cutting FIGURE 1 Sri lanka FIGURE 2 Sri lanka Analysis on Efficiency and INTERNATIONAL Mongolia INTERNATIONAL Viet nam Equity COMPARISON COMPARISON OF 3 Hong Kong (China) China OF DISCHARGE China INPATIENT CARE Tajikstan RATES, 2020 OR Australia EXPENDITURE Indonesia SECTION 3 LATEST YEAR SHARE OF CHE, Viet nam OECD Average India Topic-Specific LATEST YEAR Analysis Discharges per 1,000 Korea Kazakhstan inhabitants New Zealand Malaysia Inpatient share Health System Context Asia Pacific-H Kyrgyzstan Source: OECD Health (%) of CHE – Figure 5.12. Hospital Thailand Seychelles Health Financing discharges per 1 000 Source: WHO latest year. population, latest year Japan Mongolia Viet Nam 2019. Inputs available. Version 1-Last OECD Myanmar updated: 25 November Service Delivery 2022. Viet Nam 2020 Asia Pacific-LM/L Japan figure from MOH. Asia Pacific-UM Australia M-10: Hospitals Note: H-high income; UM-upper middle Singapore Republic of Korea income; LM/L-lower M-11: Primary Care & Public Health middle and lower Brunei Darussalam Pakistan income Macau (China) Uzbekistan Outcomes Fiji Maldives 4 List of Acronyms Myanmar Fiji Nepal Lao PDR SECTION 4 Cambodia Bangladesh Additional Bangladesh Nepal Guidance 0 50 100 150 200 250 300 350 400 0 10 20 30 40 50 60 TABLE OF CONTENTS MODULE 10 Hospitals 325 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 For example, maternal mortality is associated with a lower number political economic factors often favor investment in hospitals. For Cross-Cutting of and farther distance from hospitals. Countries lacking sufficient example, in the Middle East and North Africa region, Ravaghi et Analysis on Efficiency and and well-distributed emergency obstetric services have higher al. (2019) identified excess hospital workforce, excess beds, and Equity 3 maternal deaths, almost all of which are preventable—there were inappropriate hospital sizes as the main sources of inefficiency nearly 15 million deaths due to maternal hemorrhage in 2019 in the health system. SECTION 3 worldwide (Vos et al. 2020; Hanson et al. 2015; Tian and Pan 2021). Topic-Specific WHO, the United Nations Children’s Fund (UNICEF), and the United PER authors can benchmark hospital density and hospital bed Analysis Nations Population Fund (UNFPA) recommend that at least one density against other countries in the region as well as countries Health System Context facility provide emergency obstetric care per 100,000 population with similar socioeconomic and health system characteristics. The (World Health Organization et al. 2009). Other estimates suggest that additional guidance note on country comparisons, Benchmarking,ffff Health Financing over 50 percent of annual deaths in low-middle-income countries provides guidance in this area. Also, Sustainable Development Goal Inputs could be averted by the implementation of quality emergency (SDG) indicator 3.8.1, on universal health coverage, has a threshold Service Delivery care systems (Hirner et al. 2023). Ensuring that at least 80 of the of 18 beds per 10,000 population, which is considered full coverage.3 M-10: Hospitals population lives within two hours of essential surgical services has M-11: Primary Care & Public Health also been proposed as a benchmark (Meara et al. 2015). Authors who want to explore infrastructure and service availability Outcomes issues in more detail can also consult the module on Physical Conversely, other settings have an abundance of hospital Infrastructure and Equipment and the additional guidance note 4 List of Acronyms capacity, at the risk of being inefficiently used or underused, and on Service Availability and Readiness. SECTION 4 Additional 3 The threshold of 18 beds per 10,000 population for full coverage was based on the average number of beds in OECD countries in 2015. Guidance TABLE OF CONTENTS MODULE 10 Hospitals 326 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 3 HOSPITAL BEDS PER 10,000 POPULATION, LATEST AVAILABLE YEAR 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 VALUE SECTION 3 Topic-Specific 200 Analysis 150 Health System Context 100 Health Financing 50 Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms Source: World Health Organization Global Health Observatory. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 327 OVERVIEW 1 SECTION 1 What Is a Health PER? Input Mix 2 SECTION 2 • How many types of hospitals are in the country? Cross-Cutting Analysis on KEY QUESTIONS Efficiency and • How much is spent on human resources and maintenance in hospitals? Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Exploring the evolution of the numbers, types, and expenditures across hospitals in a country can be useful in examining efficiency. For example, even though, in general, there should be far fewer tertiary hospitals than secondary Key Indicators Number, density of hospitals and expenditure by type of hospital Sources • MoH • National Health Accounts data hospitals, there has been a rapid increase in tertiary hospitals Health Financing in some countries. Having too many tertiary hospitals HRH expenditure as % of total • MoH Inputs compared to secondary hospitals can result in care being expenditure in hospitals • National Health Accounts data Service Delivery delivered at higher levels of complexity than needed. The Capital expenditure + maintenance • MoH M-10: Hospitals numbers of specialized hospitals (that is, single specialty expenditure as % of total • National Health Accounts data M-11: Primary Care & Public Health such as cancer or tuberculosis) as compared to general expenditure in hospitals hospitals would also be useful to monitor. A large share of Outcomes specialized hospitals (and beds in specialized hospitals) Number of magnetic resonance • MoH 4 List of Acronyms may unnecessarily disperse staff and technology if there imaging units per 1,000,000 • WHO GHO population are not enough patients with specialized needs, and limits SECTION 4 care possibilities for patients with multiple health problems. Additional Number of computed tomography Guidance scanners per 1,000,000 population Note: MoH = Ministry of Health; WHO GHO = World Health Organization Global Health Observatory. TABLE OF CONTENTS MODULE 10 Hospitals 328 OVERVIEW 1 SECTION 1 What Is a Health PER? In some countries, hospitals that exclusively serve one population whether a disproportionate share of hospital budgets is allocated 2 group also exist, for example, tertiary hospitals run by large to human resources to the detriment of other inputs. Very high SECTION 2 contributory insurance funds for their beneficiaries. Different relative spending on human resources in hospital budgets may Cross-Cutting Analysis on hospitals run by different levels of government can also be found indicate that these facilities in fact serve a function closer to patient Efficiency and Equity in the same location. Having these types of facilities can signal supervision or hotel services—since they may not have enough 3 inefficiency, especially if coupled with low productivity and resources to spend on other essential components of good quality duplication across facilities. medical care, or that the burden of paying for these components SECTION 3 Topic-Specific falls on patients. For example, in many countries, people have to Analysis To explore other potential inefficiencies, PER authors should purchase medicines for their hospitalized family members from consider the input mix within hospitals. Indicators like ratios of external pharmacies through out-of-pocket payments. Health System Context nurses and physicians to patients have been linked to hospital Health Financing mortality rates in many studies (Dall’Ora et al. 2023). While no Certain high-tech equipment typically used in hospitals can also Inputs general benchmarks exist, the relative number of physicians, be considered, for example, magnetic resonance imaging (MRI) Service Delivery nurses, and other health workers can be important for productivity, machines and computed tomography (CT) scanners. While their M-10: Hospitals based on more efficient distribution of tasks (see the Human availability remains low in many countries, these costly technologies Resources for Health module for more information). PER are overused in other settings, which in turn leads to even more M-11: Primary Care & Public Health authors should also compare the numbers of different health demand for them. Both issues are worth looking into for a PER. For Outcomes workers in hospitals with any specific country norms if they exist. example, the number of CT and MRI exams have more than doubled 4 List of Acronyms Since hospitals also need to spend on medicines, equipment, and in some OECD countries in the past 10 years (OECD 2023). regular maintenance to remain operational, authors should assess SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 329 OVERVIEW 1 Key Indicators Sources SECTION 1 Number of • MoH Productivity What Is a Health PER? inpatient • National health insurance fund 2 admissions per • Hospital performance assessment framework data SECTION 2 100,000 population Cross-Cutting • Are hospitals being Analysis on Case mix index • National health insurance fund Efficiency and used efficiently? Equity KEY QUESTIONS Bed occupancy rate • MoH 3 • Is hospital productivity • National health insurance fund SECTION 3 • Hospital performance assessment framework data adequate? Topic-Specific Analysis Procedures per • MoH equipment • Hospital performance assessment framework data There are many standard indicators that PER authors can use for Health System Context a general evaluation of hospital productivity. These should be Intensity of • MoH Health Financing surgical theater used primarily for comparisons across hospitals within a country • Hospital performance assessment framework data Inputs but can also be used to make comparisons with other countries. use Service Delivery For countries with national hospital performance assessment Length of stay for • MoH M-10: Hospitals frameworks or similar approaches, PER authors easily can study selected services • National health insurance fund M-11: Primary Care & Public Health variations in hospital productivity within a country, including • Hospital performance assessment framework data variation among hospital groups of different types, and geographic Outpatient visits • MoH Outcomes region. At the national level, the OECD collects data on some of per 100,000 • National health insurance fund 4 List of Acronyms the indicators discussed here, which could be a useful source of population in • Hospital performance assessment framework data relatively standardized information for international benchmarking. 4 hospitals SECTION 4 Additional Day surgery for • MoH Guidance 4 https://stats.oecd.org/. tracer services • National health insurance fund • Hospital performance assessment framework data Note: MoH = Ministry of Health. TABLE OF CONTENTS MODULE 10 Hospitals 330 OVERVIEW 1 SECTION 1 What Is a Health PER? The number of hospital admissions per 100,000 population, information is presented as the hospital discharge rate instead. 2 or the hospitalization rate, is a commonly available indicator While hospitalization rates vary substantially across countries, as SECTION 2 that shows the number of hospital admissions relative to the shown in Figure 4, an increasing rate within a country could signal Cross-Cutting population in a given year (Figure 4). In some countries, the inefficiency from overreliance on hospitals. Analysis on Efficiency and Equity 3 FIGURE 4 SECTION 3 HOSPITALIZATION RATE PER 1,000 POPULATION, 41 SELECTED COUNTRIES, 2011–21 Figure 5.20. Hospital discharge rates, 2011, 2019 and 2021 (or nearest year) Topic-Specific Analysis 2011 2019 2021 Per 1 000 population Health System Context 350 Health Financing 300 250 Inputs 200 Service Delivery 150 M-10: Hospitals 100 M-11: Primary Care & Public Health 50 104 209 109 103 107 130 130 218 148 128 144 144 134 126 159 159 149 139 139 165 145 125 293 173 163 143 152 132 122 177 157 157 151 121 93 52 80 75 75 46 0 30 Outcomes D e i ye la y Ne m e n la ¹ OE i a ra a¹ Es lic¹ R o ark ¹² Au ny Po ai n ic Lu w 5 B e y¹ pu ¹ Tü a¹ Ki land ² itz in a al g ¹ Ge ar ia ¹³ Po m t ia ¹ ⁴ ex ² ec Fra a ov a o v Fi ael st z il R e e¹ No i a Cr a¹ ua d i te Ic n¹ Hu ² ⁴ nd l na ³ Ja ² Re n d y ga M i ca Ca nd s 3 Ire gar m ile Li la n bl i re a al ¹ i en an ¹ ni tv a iu ra h nc CD Ze ur ni da xe ed a Au str i co nd oa la rk li a nm do r rw 4 b d Sp Sw Ch a k la Ko pu rtu p rm t R Ch lg lg La Is to n e List of Acronyms B m an w bo I er n Bu ng a th S er Sl st th Co d Ne Cz Un Sl SECTION 4 Additional Guidance 1. Data exclude Source: discharges OECD Health Statistics 2023,of healthy babies. https://www.oecd-ilibrary.org/sites/7a7afb35-en/1/3/5/8/index.html?itemId=/content/publication/7a7afb35-en&_csp_=6cf33e24b6584414b81774026d82a571&itemIGO=oecd&itemContentType=book. 2. Data include activity in public or publicly funded hospitals only (in Ireland, private hospitals account for about 15-20% of hospital discharges). 3. Includes discharges for curative (acute) care only. 4. 2021 data refer to 2020. Source: OECD Health Statistics 2023. TABLE OF CONTENTS MODULE 10 Hospitals 331 OVERVIEW 1 FIGURE 5 VALUE SECTION 1 The number of hospitalizations can be further broken down by regions and What Is a hospital catchment population for comparison between different facilities BED OCCUPANCY RATE, Health PER? ACUTE CARE BEDS, LATEST 90 in a country.5 When comparing hospitalization numbers within a country, 2 AVAILABLE YEAR 80 PER authors should note that the case load can vary between different types SECTION 2 of hospitals. A case mix index can summarize information on the types of 70 Cross-Cutting Source: World Health Organization Global Analysis on hospitalizations more comprehensively, including information on specialty Health Observatory. Efficiency and 50 related to the admission as well as other characteristics. For example, some Equity 3 hospitals may deal with more complex cases, which require longer stays. 50 SECTION 3 The case mix index for different facilities can be used to adjust or qualify 40 Topic-Specific Analysis other metrics of hospital productivity and quality to make comparisons across hospitals more valid. In countries that use case-based payments Health System Context for hospitals (for example diagnosis-related groups, or DRGs), the case Health Financing mix index can be calculated by averaging the case weights for admissions Inputs in each facility.6 Service Delivery A hospital’s bed occupancy rate is defined as the number of days a bed is M-10: Hospitals occupied in one year. It is a standard metric that is collected in almost all M-11: Primary Care & Public Health hospitals. Figure 5 shows bed occupancy rates for acute care hospitals in Outcomes Europe and parts of Asia; the rates ranged from 36 percent in Azerbaijan to 4 List of Acronyms 93 percent in Ireland, on average. SECTION 4 5 The catchment area of a hospital is the population that a hospital is supposed to serve. This can be the population of Additional the neighborhood or the city where the hospital is located or the number of beneficiaries of the program that a facility exclusively serves. To determine the hospitalization rate by catchment population, the number of hospitalizations can Guidance be divided by the catchment population instead of 100,000. 6 The World Bank has recently conducted a cross-country analysis of case-mix in hospitals that PER authors can refer to for more information (Doroshenko et al. 2023). However, given its complexity, authors should rely on existing work in this area as much as possible rather than conduct novel analysis. TABLE OF CONTENTS MODULE 10 Hospitals 332 OVERVIEW 1 SECTION 1 What Is a Health PER? Bed occupancy should never reach 100 percent. While an 85 Ensuring appropriate lengths of stay decreases wasteful use 2 percent target occupancy rate is often cited, there are risks of of resources and improves quality of care for patients. PER SECTION 2 overcrowding at this threshold (Proudlove 2020). In some low- authors can compare the average length of stay for selected Cross-Cutting Analysis on and middle-income countries, practices such as bed sharing health conditions with national clinical guidelines and practices. Efficiency and Equity during peak occupancy greatly impact quality of care. However, Longer stays may indicate poor facility organization and/or poor 3 occupancy rates of 50–60 percent are too low to be efficient. PER incentives for timely discharge, while shorter stays may flag authors should examine trends in bed occupancy rates over time, a shortage of beds, staff, medicines, or supplies or a financial SECTION 3 Topic-Specific compare different hospitals within a country, and benchmark burden on patients. In some countries, inadequate investment in Analysis against countries with better-performing health systems. primary care, long-term care facilities, and hospice care can be an important source of inappropriate admission and length of stay. Health System Context Other indicators related to the use of physical resources, such as Health Financing the intensity of surgical theater use (which shows the time surgical For example, evidence-based guidelines for childbirth usually Inputs facilities are used for clinical care) and the number of procedures suggest a length of stay of about 24–48 hours after delivery and Service Delivery per equipment, may also be available. These can indicate an then significant follow-up care for the next six weeks (World Health M-10: Hospitals underutilization of resources, signaling too few human resources Organization 2022; Zhao et al. 2020). However, the actual length of to provide continuous care or too many health workers for a low stay varies greatly, as shown in an international study (Campbell M-11: Primary Care & Public Health overall utilization of hospitals, for example, due to an oversupply et al. 2016). Figure 6 presents strong evidence of both excessive Outcomes of hospitals. PER authors can also consider whether national length of stay after delivery as well as patients discharged too 4 List of Acronyms staffing norms for hospitals could lead to less productivity. For early. In some contexts, trends could be explained partially by example, perhaps too few radiological technicians are allotted differing practices and national guidelines, as well as a lower SECTION 4 to each secondary hospital in the national staffing norms to reliability of post-discharge follow-up care. Additional efficiently use existing imaging equipment. Guidance TABLE OF CONTENTS MODULE 10 Hospitals 333 OVERVIEW 1 SECTION 1 What Is a Health PER? A B C 2 FIGURE 6 PROPORTION OF DELIVERY TYPE BY SECTION 2 LENGTH OF STAY, 30 SELECTED COUNTRIES Cross-Cutting Analysis on (PERCENT), VARIOUS YEARS Efficiency and Equity 3 Proportion of vaginal singleton, vaginal multiple, and cesarean deliveries by SECTION 3 category of length of stay, for 30 countries Topic-Specific Analysis with DHS data. (A) cesarean deliveries; (B) vaginal multiple deliveries; (C) vaginal Health System Context singleton deliveries. Health Financing Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Source: Campbell et al. 2016. Guidance TABLE OF CONTENTS MODULE 10 Hospitals 334 OVERVIEW 1 SECTION 1 What Is a Health PER? Hospitals also provide outpatient services, such as consultations and palliative services (Jamison 2018; Laxminarayan et al. 2006). 2 and diagnostics, without the need for an inpatient stay. To monitor So, PER authors should also assess whether large volumes of SECTION 2 the productivity of a hospital, the volume of outpatient visits per outpatient visits can be explained by the inappropriate use of Cross-Cutting Analysis on 100,000 population can also be considered through the number of hospitals for care that should be delivered in lower-level facilities Efficiency and Equity outpatient visits adjusted for the catchment population. In some instead. 3 contexts, the number of outpatient visits and inpatient stays in a hospital in one year are combined to present an aggregate estimate In contrast with ordinary outpatient services, some more complex SECTION 3 Topic-Specific of overall productivity by facility. This aggregated “adjusted procedures can be completed without an inpatient stay, for Analysis admissions” can be made based on the relative average revenues example, laparoscopic surgeries. Depending on the national or costs of an outpatient visit as compared to an inpatient stay clinical guidelines and practices, PER authors may be able to Health System Context or another formula. These types of metrics can be useful for PER find useful information on “day surgeries” versus inpatient Health Financing authors in comparing the productivity of different hospitals. admissions, or inpatient admissions for procedures that do not Inputs require a hospital stay.7 Because choices to perform procedures Service Delivery However, relying on hospitals for primary care is inefficient. Quality as outpatient services are clinically sensitive, authors should rely M-10: Hospitals health services can be delivered cost-effectively at the community on existing studies and reports whenever possible rather than level and by primary facilities. These services include the majority collect and analyze primary data. M-11: Primary Care & Public Health of preventive, protective, preventative, curative, rehabilitative, Outcomes 4 List of Acronyms 7 Guidance on the expansion of day surgeries by the National Health Service in England, which contains information on useful considerations as well as potential procedures that can be further considered for day surgeries (Nation- al Health Service England 2020). This could be a useful reference for PER authors interested in learning more about this area. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 335 OVERVIEW 1 SECTION 1 What Is a Health PER? Quality 2 SECTION 2 KEY QUESTION • Are services of appropriate quality that prevents waste of resources? Cross-Cutting Analysis on Efficiency and Equity 3 There are also indicators related to efficiency that Key Indicators Sources are closely linked to effectiveness and quality. SECTION 3 Topic-Specific Patient safety information, such as data on Readmission rates • MoH Analysis hospital-acquired infections, is one such area. Data • National health insurance fund may exist on specific types of hospital-acquired • Hospital performance assessment framework data Health System Context infections, for example, urinary tract infections Health Financing Hospital-acquired • MoH associated with catheters. Alternatively, PER infection rates • National health insurance fund Inputs authors could consider process indicators related • Hospital performance assessment framework data Service Delivery to infection prevention in hospitals such as domain M-10: Hospitals scores for standard precautions. Hospital mortality rate • MoH • Hospital performance assessment framework data M-11: Primary Care & Public Health Readmissions are another useful indicator that Outcomes Are volume thresholds • MoH straddles common spaces between effectiveness, established to maintain • Hospital performance assessment framework data 4 List of Acronyms quality, and integration of care as well as efficiency, quality and safety where high rates signal substandard care during of select hospital SECTION 4 hospitalization or after discharge. Some countries Additional interventions? Guidance use general readmission rates, while others look Note: MoH = Ministry of Health. TABLE OF CONTENTS MODULE 10 Hospitals 336 OVERVIEW 1 SECTION 1 What Is a Health PER? at readmission rates for specific conditions or procedures, for 2017; Chou, Hwang, and Tung 2021). Some studies hypothesize 2 example, readmission to a hospital after a heart attack (Barrenho that this relationship results from repeatedly performing and SECTION 2 et al. 2022). perfecting these services, as well as quality-improvement Cross-Cutting Analysis on processes likely to exist more systematically in hospitals with high Efficiency and Equity In some countries, PER authors may wish to examine intrahospital volume. Based on this, certain countries have defined minimum 3 mortality, particularly if other information is not available. volume standards for hospitals receiving public financing for More sophisticated versions of this information are used in specific procedures care such as deliveries, cardiac interventions, SECTION 3 Topic-Specific many settings to monitor hospital performance. For example, and cancer treatments (Morche et al. 2018). As PER authors Analysis standardized hospital mortality rates—which control for patient explore the quality-efficiency connection through indicators like characteristics or mortality rates for specific tracer conditions, specific readmission and mortality rates, they can also consider Health System Context such as stroke or heart attack or related to perinatality—or specific the volume of those procedures performed in hospitals. In this Health Financing procedures can be used. Authors should exercise caution when case, authors should keep in mind that patient preferences may Inputs interpreting these data, as they may be driven by subtle clinical sometimes undermine any planned volume objectives. Service Delivery and socioeconomic differences. M-10: Hospitals PER Authors interested in exploring quality issues in more detail There is also significant evidence that quality of care is correlated can consult the additional guidance note on Quality of Health M-11: Primary Care & Public Health with the volume of hospitals’ outputs of certain types of services, Services. Outcomes including surgeries (Scharfe et al. 2023; Bauer and Honselmann 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 337 OVERVIEW 1 SECTION 1 What Is a Health PER? Integration of Services 2 SECTION 2 • What are the trends in emergency room visits? KEY QUESTIONS Cross-Cutting Analysis on • How many hospitalizations are for “ambulatory care sensitive conditions?” Efficiency and Equity 3 Integration of health services is an approach to strengthening the Key Indicators Sources SECTION 3 comprehensive delivery of quality health services. This is done through a Emergency room visits per 1,000 • MoH Topic-Specific coordinated multidisciplinary team of providers working across settings and Analysis population • National health levels of care (World Health Organization Regional Office for the European insurance fund Region 2016). This type of care model improves health outcomes and Health System Context • Hospital performance minimizes the use of inappropriate health services. Health Financing assessment framework Inputs data An absence of integrated health services results in services delivered in an Service Delivery • Household surveys with uncoordinated manner or at an inappropriate level. For example, people health service utilization M-10: Hospitals who do not receive follow-up care from their primary care providers after information (e.g., DHS) M-11: Primary Care & Public Health a hospital stay for diverse reasons are more likely to be readmitted to the hospital (Moneme et al. 2023; Saxena et al. 2022). Similarly, people without Avoidable admissions as a • MoH Outcomes a regular primary care provider are more likely to seek care at hospital proportion of total admissions • National health 4 List of Acronyms emergency rooms (Fung et al. 2015). Overall, a lack of integration of services Avoidable admissions for insurance fund selected conditions such as • Hospital performance can be a major source of inefficiency. This section focuses on integration SECTION 4 diabetes, COPD, mental health assessment framework and efficiency issues that can be assessed by analyzing hospital data. In Additional disorders, etc. data Guidance complement, the Primary Care and Essential Public Health Services module considers integration in that setting. Note: DHS = Demographic and Health Surveys; MoH = Ministry of Health. TABLE OF CONTENTS MODULE 10 Hospitals 338 OVERVIEW 1 FIGURE 7 EMERGENCY ROOM VISITS PER 100,000 POPULATION AND PERCENTAGE OF ADMISSIONS THEREIN, 2006–15 SECTION 1 What Is a Rate of ER Visits Percentage of ER Visits Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Health Financing Source: Sun, Karaca, and Wong 2006. Inputs Data on the number of visits to hospital emergency rooms and Examining hospitalization rates for conditions that typically should Service Delivery related trends are readily available and can indicate efficiency not require hospitalization if properly managed in primary health M-10: Hospitals issues. For example, a high (or increasing) number of visits may care settings can reveal efficiency problems related to service signify care-seeking at an inappropriate level. Figure 7 shows integration. For example, hospitalizations caused by diabetes M-11: Primary Care & Public Health the number of emergency room visits per 100,000 population complications usually indicate poor management of the disease Outcomes (left) and the percentage of hospital admissions among these by patients and lower-level health providers. Another example is 4 List of Acronyms visits (right) in the US from 2006 to 2015. While the number of respiratory illnesses like adult asthma. These hospitalizations for visits increased over this period, the rate of admission decreased, “ambulatory care sensitive conditions” (ACSC)8 indicate situations SECTION 4 suggesting that patients may have been able to receive adequate where effective and accessible primary care could have prevented Additional Guidance care outside of a hospital setting (Sun, Karaca, and Wong 2006). the need for hospitalization. 8 “Ambulatory care sensitive conditions” (ACSC) are conditions for which care delivered at the primary level could potentially prevent the need for hospitalization. While there are some differences in which conditions are consid- ered ACSC, hospitalization for diabetes, chronic obstructive pulmonary disease, asthma, hypertension, and congestive heart failure feature in many countries’ monitoring of avoidable admissions. TABLE OF CONTENTS MODULE 10 Hospitals 339 OVERVIEW 1 SECTION 1 What Is a Health PER? CASE EXAMPLE: ESTONIA 2 A study by the Estonian Health Insurance Fund and the TABLE 1 SECTION 2 World Bank found that over 17.5 percent of hospital AVOIDABLE HOSPITALIZATIONS, BY HOSPITAL TYPE, ESTONIA, 2013 Cross-Cutting Analysis on admissions in the country in 2013 were avoidable Efficiency and Total Admissions (2013) Equity (Table 1). In lower-level hospitals, over 22 percent of Provider Type % Avoidable 3 Respiratory, Endocrine, and Circulatory hospitalizations were for ambulatory care sensitive conditions (Estonian Health Insurance Fund 2015). Regional 22,903 14.69% SECTION 3 Topic-Specific Central 20,612 18.58% Analysis Overall, the study noted a tendency toward acute General 18,144 22.33% inpatient care with extended hospital stays, many of Health System Context them avoidable, as well as weaknesses in pre- and Non HNDP Providers 10,138 14.01% Health Financing post-acute coordination, including the absence of All Providers 71,797 17.64% Inputs adequate follow-up care at the primary level. Source: Estonian Health Insurance Fund, 2015. Service Delivery Note: Referrals and transfers to other facilities were excluded from the analysis. M-10: Hospitals M-11: Primary Care & Public Health Admissions for these types of conditions are used to reveal care the definition of ACSC (Organisation for Economic Co-operation Outcomes integration problems in contexts where reliable data are available. and Development 2017). Data on admissions for mental health 4 List of Acronyms However, because hospital data do not always include underlying disorders could be useful here, as many countries rely too heavily causes of diagnoses, this analysis requires some technical choices, on hospitalization in this area. Annex 3, Costs Associated with SECTION 4 and PER authors should rely on existing analyses. Similarly, cross- Hospital Admissions for Ambulatory Care Sensitive Conditions, Additional Guidance country analyses can be tricky, as there is significant variation in includes details for PER authors’ deeper exploration. TABLE OF CONTENTS MODULE 10 Hospitals 340 OVERVIEW 1 SECTION 1 What Is a Health PER? WHICH APPROACH FOR HOSPITAL EFFICIENCY ANALYSIS? 2 SECTION 2 A Data Envelopment Analysis (DEA) is always considered • As for the number of bed days (inpatient days), not all Cross-Cutting preferable to various alternative approaches, such as bed countries endorse the international OECD definition Analysis on Efficiency and occupancy rate (BOR) or Pabon-Lasso analyses. DEA has its of “inpatient care.” For instance, some countries (for Equity 3 limitations (see Annex 1), but remains a much more accurate example, Sri Lanka and Viet Nam) will declare an starting point for efficiency analyses. admission after a patient has stayed for a minimum SECTION 3 number of hours in a hospital bed, which could lead to Topic-Specific BED OCCUPANCY RATE counting multiple bed days on the same calendar day. Analysis As hospitals are fixed-cost businesses, one could think that Second, and more importantly, there are major scale Health System Context the BOR is a good indicator for efficiency. BOR is certainly an effects with BOR. In other words, the maximum BOR that a important parameter to consider, but it needs to be adjusted Health Financing hospital can achieve heavily depends on its bed capacity. and handled with extra care. Inputs The biggest source of the scale effect results from patient Service Delivery flow variability. For instance, using an Erlang-B formula, De First, at least two component variables of BOR are prone to Bruin (2007) finds that small hospitals will have to keep a M-10: Hospitals measurement issues. rather low BOR so as to keep a (bed) capacity buffer and thus M-11: Primary Care & Public Health • Regarding the number of beds, PER authors may face not have to refuse admission for too many patients. This is Outcomes several definitions, sometimes in the same hospital. why the 85 percent benchmark for BOR is rather misleading 4 List of Acronyms By “Bed capacity” can mean (1) the officially approved (see Proudlove 2019). number of beds; or (2) the number of physical beds; or SECTION 4 (3) the number of staffed beds; or (4) the number of acute Additional beds and so on. Guidance TABLE OF CONTENTS MODULE 10 Hospitals 341 OVERVIEW 1 SECTION 1 What Is a Health PER? WHICH APPROACH FOR HOSPITAL EFFICIENCY ANALYSIS? (continued) 2 LENGTH OF AVERAGE STAY (DAYS) 2 3 4 5 SECTION 2 PABON-LASSO APPROACH (PL) 60 Cross-Cutting Analysis on Pabon-Lasso (1986) presents his approach as comparing 6 Efficiency and SECTOR 2 SECTOR 3 Equity hospitals along three dimensions: bed turnover (BTR), 3 50 bed occupancy rate (BOR) and length of stay (LOS). This is 7 illustrated in the figure on the right. SECTION 3 AVERAGE ANNUAL DISCHARGES PER BED Topic-Specific 8 40 Analysis LENGTH OF AVERAGE STAY (DAYS) 9 A first concern with the PL approach is that these indicators 10 Health System Context are in fact inherently related to each other. Indeed, one can 30 11 Health Financing 12 easily see that BOR can be expressed as BTR adjusted with Inputs average length of stay (ALOS). No wonder then that, in many SECTOR 1 SECTOR 4 Service Delivery 20 PL analyses, BTR and BOR are highly correlated. M-10: Hospitals M-11: Primary Care & Public Health Second, the PL approach is based on two fragile or even biased 10 Outcomes indicators. We have seen earlier that BOR is a tricky indicator for hospital efficiency. Similarly, even when adjusted on case- 4 List of Acronyms mix index (CMI) data, LOS cannot really be used as an indicator 0 for efficiency. 0 10 20 30 40 50 60 70 80 90 SECTION 4 Additional AVERAGE BED OCCUPANCY (%) Guidance Source: Pabon-Lasso 1986 TABLE OF CONTENTS MODULE 10 Hospitals 342 OVERVIEW 1 SECTION 1 What Is a Health PER? WHICH APPROACH FOR HOSPITAL EFFICIENCY ANALYSIS? (continued) 2 Third, and more fundamentally, the PL approach is based on a wrong economic model of hospitals. The PL approach totally ignores SECTION 2 the fact that hospitals are multi-product entities. Another flaw in the PL approach is that it assumes that the hospitals’ main asset is Cross-Cutting Analysis on their bed capacity, while staff number and skill-mix better reflect capacity to handle patients. Efficiency and Equity 3 DATA ENVELOPMENT APPROACH (DEA) Overall, PL analyses should be avoided. A DEA approach will allow addressing many of the issues mentioned before. In particular, a SECTION 3 Topic-Specific DEA will include several outputs (usually inpatients and outpatients) and several inputs (usually beds and staff). The Annex 1 provides Analysis some guidance on how to conduct DEAs with hospitals. Health System Context Reference De Bruin et al. 2007. “Modeling the emergency cardiac in-patient flow: an application of queuing theory”, Health Care Health Financing Management Science 10: 125–37 Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 343 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY 2 SECTION 2 • What is the distribution of hospital services across the country? KEY QUESTIONS Cross-Cutting Analysis on • Are hospitalization-related outcomes equitable? Efficiency and Equity 3 Geographic imbalance in the distribution SECTION 3 Hospitalization rates across population groups are a simple Topic-Specific indicator of equity and are available in household surveys with Analysis of hospitals and its intersectionality with data on health service utilization. Generally, lower access to socioeconomic inequities make hospital access technologically intensive and more expensive care for poorer Health System Context inequitable. This is not only the case in low- and and disadvantaged populations is widely documented in low- Health Financing and middle-income countries. For example, in 2018 in Indonesia, middle-income countries but even in high-income Inputs people in the poorest wealth quintile had an almost 75 percent Service Delivery countries. lower probability of using hospital services as compared with the M-10: Hospitals richest quintile. The difference between uninsured and insured For example, analysis of admissions for ambulatory care sensitive populations was even more staggering, with a nearly 88 percent M-11: Primary Care & Public Health conditions and preventable mortality across Canada shows the lag for the poorest quintile (Wulandari et al. 2022). PER authors Outcomes worst performance in northern communities, particularly in remote can also examine the distribution of hospitals, hospital beds, and 4 List of Acronyms areas where populations are among the most disadvantaged in the specific types of health workers per bed across different parts country (Figure 8) (Young et al. 2019). of the country. When the number of health workers, particularly SECTION 4 specialist physicians, is low in rural settings, there is a lack of Additional Guidance equity of access to hospital services. TABLE OF CONTENTS MODULE 10 Hospitals 344 OVERVIEW 1 SECTION 1 What Is a Health PER? Many other indicators discussed previously can also be used to analyze equity. For example, indicators related to quality and integration of Key Indicators Hospital admissions per 100,000 by Sources 2 • MoH care, such as readmission rates and hospital socioeconomic status • National health insurance fund SECTION 2 Cross-Cutting mortality rates, may be quite different in large • Hospital performance assessment Analysis on wealthier areas as compared with poorer framework data Efficiency and Equity areas. PER authors can consider these types of • Household surveys with health service 3 indicators if there are quality data disaggregated utilization information (e.g., DHS) SECTION 3 by geographic and socioeconomic dimensions or Number, density of hospitals, type • MoH Topic-Specific existing analyses in this area. Analysis of hospital by region For example, during the COVID-19 pandemic, Hospital beds per 10,000 • MoH Health System Context there was significant evidence of differing population by region Health Financing hospital mortality rates among disadvantaged Inputs Specialist physicians per hospital • MoH populations in many high-income countries, bed by region Service Delivery including racialized populations in the UK, even M-10: Hospitals after controlling for clinical and socioeconomic Outcomes for hospitalized patients • MoH factors (Aldridge et al. 2020; Perkin et al. 2020). by socioeconomic status • National health insurance fund M-11: Primary Care & Public Health Data from Brazil point to the same types of • Hospital performance assessment Outcomes trends in hospital mortality outcomes (Baqui framework data 4 List of Acronyms et al. 2020). The results of these analyses are Information on responsiveness and • MoH troubling: fundamentally, they point to the SECTION 4 patient experience in hospitals by • Hospital performance assessment existence of underlying structural biases in Additional socioeconomic status framework data Guidance hospitals and health systems—exacerbating • Existing studies social inequities instead of decreasing them. Note: DHS = Demographic and Health Surveys; MoH = Ministry of Health. TABLE OF CONTENTS MODULE 10 Hospitals 345 OVERVIEW 1 FIGURE 8 SECTION 1 RATES OF HOSPITALIZATION AND PREVENTABLE MORTALITY, REGIONS OF NORTHERN CANADA, 2011–14 What Is a Health PER? 2 Canada Canada Canada Canada Saguenay [QC] Saguenay [QC] Saguenay Saguenay [QC] [QC] SECTION 2 Côte-Nord [QC] Côte-Nord [QC] Nord [QC] Nord [QC] Cross-Cutting Northeast Northeast [BC] [BC] Côte-Nord Côte-Nord [QC] [QC] Preventable Preventable Analysis on Labrador Labrador [NL] [NL] N-Interior N-Interior [BC] [BC] Treatable Treatable Efficiency and Yukon Yukon N-Interior N-Interior [BC] [BC] Equity 3 Bay [ON]Bay [ON] ThunderThunder North North Zone Zone [AB] [AB] Northwestern Northwestern [ON] [ON] Yukon Yukon SECTION 3 Labrador Labrador [NL] [NL] Northwest Northwest [BC] [BC] Topic-Specific Northwest [BC] Northwest [BC] Bay [ON]Bay [ON] ThunderThunder Analysis North Zone North Zone [AB] [AB] NWT NWT Nord [QC] Nord [QC] Porcupine Porcupine [ON] [ON] Health System Context Porcupine Porcupine [ON] [ON] Baie-James Baie-James [QC] [QC] NWT NWT Northeast Northeast [BC] [BC] Health Financing Northern Northern [MB] [MB] Northwestern Northwestern [ON] [ON] Inputs NunavutNunavut Ma-Ke-At Ma-Ke-At [SK] [SK] Ma-Ke-At [SK] Ma-Ke-At [SK] Northern Northern [MB] [MB] Service Delivery Baie-James Baie-James [QC] [QC] NunavutNunavut M-10: Hospitals [QC] Nunavik Nunavik [QC] [QC] Nunavik Nunavik [QC] 0 500 0 500 1000 1500 1000 2000 1500 2000 2500 2500 0 0 200 200 400 400 600 600 800 800 M-11: Primary Care & Public Health Hospitalizations Hospitalizations per 100,000 per 100,000 Deaths Deaths per per 100,000 100,000 Source: Young et al. 2019. Outcomes 4 List of Acronyms Thus, it could be useful for PER authorsto consider the intersection Access to hospitals is also correlated with indicators such as SECTION 4 of diversity and inclusion issues in addition to equity dimensions. maternal and neonatal mortality rates, which may be available Additional Further, authors could leverage existing quantitative and qualitative across different parts of a country, as well as possibly across Guidance data on responsiveness and patient experience in hospitals; this different socioeconomic groups. PER authors can consult the would add considerable depth to PER authors’ analysis. module on Health Status and Health Risks for more information. TABLE OF CONTENTS MODULE 10 Hospitals 346 OVERVIEW 1 SECTION 1 What Is a Health PER? PROCESSES AND GOVERNANCE 2 • Is there a good hospital sector strategy in the country? SECTION 2 KEY QUESTIONS Cross-Cutting Analysis on • Do hospitals have the autonomy to make decisions and respond to financial incentives? Efficiency and Equity 3 Hospital governance Key Indicators Sources SECTION 3 and related processes Topic-Specific Is there a comprehensive and coherent hospital sector strategy/plan? • KIIs Analysis impact inefficiency and (Yes/No) • MoH hospital sector inequity (La Forgia 2023). Considerations for PER authors to assess comprehensiveness and documents Health System Context coherence: Hospital governance can Health Financing • Is the role of hospitals as part of an integrated network of health Inputs be assessed at the national facilities defined? Service Delivery policy level and at the • Are referral networks across different hospitals and lower-level providers clearly specified? M-10: Hospitals individual hospital level. • Do current hospital infrastructure and capacity correspond with M-11: Primary Care & Public Health these roles and networks? At the national level, PER authors can Outcomes • Are mechanisms for improving quality and patient safety specified? start by checking the existence and • Are data for monitoring hospital performance routinely collected? 4 List of Acronyms quality of a national hospital sector strategy or policy for the country. Stock of arrear hospitals payments, by type of facility • KIIs SECTION 4 • MoH hospital sector While this may not be a single or Additional Guidance standalone document, authors can strategy documents assess whether hospital-related Note: KII = key informant interview; MoH = Ministry of Health. • Budget documents TABLE OF CONTENTS MODULE 10 Hospitals 347 OVERVIEW 1 SECTION 1 What Is a Health PER? issues have recently been considered holistically in the country, for example, as part of the national health policy or strategy. FIGURE 9 FRAMEWORKS FOR HOSPITAL 2 CHARACTERISTICS AND REFORMS Importantly, hospitals’ role should be defined as part of an integrated SECTION 2 Budgetary Autonomized Corporatized Privatized Cross-Cutting network of care alongside other levels of care, with clearly defined Unit Unit Unit Unit Analysis on regional and referral networks among facilities that consider the B A C P Efficiency and Equity physical distribution of hospital infrastructure and capacity. 3 Additionally, person-centered care,9 patient safety, and quality Critical Factors Influencing Organizational Behavior DECISION Vertical Management SECTION 3 improvement must be sufficiently and coherently addressed, RIGHTS Hierarchy Autonomy Topic-Specific including through instruments like structures and incentives for Analysis accreditation as well as monitoring and evaluation. For the latter, MARKET Direct Nonbudgetary routine data collection from hospitals, including through hospital EXPOSURE Budget Allocation Revenues Health System Context performance assessment frameworks, is important. PER authors can Health Financing refer to technical documents from WHO for elements to consider in a A C Inputs RESIDUAL Public Private comprehensive hospital strategy/policy (WHO 2018; WHO EMRO n.d.). CLAIMANT Purse Owner Service Delivery M-10: Hospitals At the individual hospital level, a framework of hospital governance such ACCOUNT- Direct Rules, Regulations, M-11: Primary Care & Public Health as the one presented below can be used for the analysis (Preker and ABILITY Hierarchical Control and Contracts Harding 2003). This framework considers the dimensions of (1) decision Outcomes rights or autonomy; (2) market exposure, including competitiveness; SOCIAL Unspecified and Specified, Funded, 4 List of Acronyms (3) residual claimants (who have the claim over the net proceeds); (4) FUNCTIONS Unfunded Mandate and Regulated accountability; and (5) performance of social functions. SECTION 4 Additional Source: Preker and Harding 2003. Guidance 9 Person-centered care emphasizes the holistic needs of people. To attain this, care must be delivered in a way that is more respectful and responsive to the needs of people and their communities. See the Primary Care and Essential Public Health Services module for more information. TABLE OF CONTENTS MODULE 10 Hospitals 348 OVERVIEW 1 SECTION 1 What Is a Health PER? Hospitals that have greater autonomy can respond better to easier to provide more funding for hospitals, which deal with more 2 incentives. For example, to respond to output-based financing, complex cases.10 Authors can refer to other modules in the series, SECTION 2 hospitals need autonomy over their inputs and revenue. including Purchasing Health Services, for more information. Cross-Cutting Analysis on Conversely, just changing provider payment methods for hospitals Efficiency and Equity that function like a budgetary unit may not yield any meaningful The existence of deficits and arrears—when the financial liabilities 3 impact, as they do not have enough scope or incentive to change of a facility exceed revenue—also signals problems of governance, behaviors. However, autonomy without accountability can prove either at the level of individual facilities or in the hospital sector SECTION 3 Topic-Specific disastrous (Lemiere, Turbat, and Puret 2012). Thus it is important as a whole. Persistent deficits can indicate insufficient funding Analysis to ensure that hospitals are accountable to payers, regulators, for hospitals; examples include low budgetary allocations or as well as patients and communities. PER authors can consider misalignments in provider payments; poor accountability, such as Health System Context this framework to thoroughly assess hospital functioning through weak incentives for managers to control expenditures or financial Health Financing these different dimensions of governance. leakages; and high production costs due to wastage or excess Inputs capacity. As a result, health workers’ salaries or payments to Service Delivery Alternatively, authors can focus just on issues related to vendors for medicines and other inputs can be severely delayed. M-10: Hospitals autonomy and hospital financing because of their magnified Sometimes just a handful of hospitals are responsible for a large importance for performance and efficiency. Overall, as individual share of arrears in the sector. However, depending on the legal M-11: Primary Care & Public Health providers, hospitals should be professionally managed by trained arrangements, legal liability for the arrears may not actually fall Outcomes administrators who have the tools and resources to ensure good with the facility. As such, examining the volume of payments 4 List of Acronyms performance and productivity. There can be significant efficiency in arrears for hospitals and its trend over time can be a useful gains in paying hospitals according to their outputs, rather than indicator of governance issues. SECTION 4 based on inputs. Case-based payment systems can also make it Additional Guidance 10 A case-based payment system pays hospitals for each discharged inpatient at rates that are prospectively established for groups of cases with similar clinical profiles and resource requirements. TABLE OF CONTENTS MODULE 10 Hospitals 349 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Acknowledgments Efficiency and Equity 3 This module builds on the concepts and content of the other modules and additional guidance notes in the series, SECTION 3 Topic-Specific including the additional guidance on Service Availability and Analysis Readiness and Quality of Health Services . We would like to acknowledge the work and contribution of the authors of Health System Context these documents. Health Financing Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 350 OVERVIEW 1 SECTION 1 What Is a Health PER? ANNEXES Overall, results vary. Studies have demonstrated differing levels of outputs with the same level of inputs across different hospitals as well as different 2 countries (Nabyonga-Orem et al. n.d.; Nepomuceno et al. 2022). For example, SECTION 2 a study of Organisation for Economic Co-operation and Development Cross-Cutting Analysis on Annex 1: Considerations (OECD) countries found that, on a scale of zero to one, mean technical Efficiency and Equity in Hospital Efficiency efficiency ranged from 0.27 to 1.00 across the countries, depending on 3 the specification of the model (Varabyova and Schreyögg 2013). Factors Measurement that were correlated with efficiency in the study included higher health SECTION 3 Topic-Specific expenditure per capita, higher hospital density and lower length of stay, Analysis alongside broader socioeconomic factors such as lower income inequality Hospital efficiency is an area of study and higher employment (Varabyova and Schreyögg 2013). Health System Context that has garnered significant interest in Health Financing Illustrative of the subtlety in understanding hospital efficiency, factors Inputs the economics literature. Measurement that contribute to efficiency in one setting—for example, increasing health Service Delivery of hospital technical efficiency using expenditure per capita in contexts where expenditure is low—could conversely M-10: Hospitals quantitative models, such as data hamper efficiency in other contexts. The performance and efficiency of specific hospitals are products of the broader socioeconomic context, M-11: Primary Care & Public Health envelopment analysis or stochastic frontier the health profile of patients, hospital management, as well as the health Outcomes analysis, has been studied extensively in system in which they operate. For example, hospitals with patients who are 4 List of Acronyms many settings. A recent narrative review by poorer and have worse health may seem to “underperform” compared with hospitals operating in wealthier regions (Barnett, Hsu, and McWilliams 2015; Andrews and Emvalomatis (2024) provides SECTION 4 Cournane et al. 2015; Löfqvist et al. 2014). Given this complexity, PER authors Additional a good overview of the methodologies and are advised not to apply a simplistic quantitative approach to examining Guidance their historical development. hospital efficiency and performance. TABLE OF CONTENTS MODULE 10 Hospitals 351 OVERVIEW 1 SECTION 1 What Is a Health PER? ANNEXES What are the main features 2  SECTION 2 of a sound DEA ? Cross-Cutting Analysis on Efficiency and Annex 2: How to Conduct a Data While one may want to include many outputs Envelopment Analysis (DEA) for Hospitals Equity 3 and inputs in a DEA, there are some limitations in doing this. A usual rule of thumb is the one SECTION 3 recommended by Bowlin (1998): the number of Topic-Specific data points (that is, the number of hospitals) Analysis This annex (1) looks at the best practices in designing a DEA should be at least three times the combined Health System Context (2) then explores approaches for decomposing DEA findings numbers of input and output variables. When this rule is ignored, the small size of the sample Health Financing and ends with (3) some thoughts on DEA limitations and (especially for some hospital types) will not allow Inputs (4) a checklist summarizing the key points. This text is not a DEA algorithm to identify the most efficient Service Delivery an introduction to DEA and assumes very basic knowledge facilities. The price to pay with this constraint M-10: Hospitals is that the DEA may not fully take into account of the DEA approach. Cooper (2007) remains the standard M-11: Primary Care & Public Health heterogeneities across hospitals when analyzing textbook and is highly readable. Other useful introductions are Outcomes them collectively, rather than segregating them Huguenin (2012), Pascoe (2003) or Toloo (2014). There are many by types of hospital. 4 List of Acronyms open-source software packages for DEA. A very user-friendly Outputs selected for a DEA should reflect the SECTION 4 one is OSDEA. It can be downloaded at https://opensourcedea. Additional complexity of hospital production. A DEA should Guidance org/. A more powerful package is DeaR (for Rstudio). at least include (1) the number of outpatient TABLE OF CONTENTS MODULE 10 Hospitals 352 OVERVIEW 1 SECTION 1 What Is a Health PER? visits (OP) and (2) the number of inpatient cases (IP). Ideally, the IP number should be adjusted by the case-mix index (CMI). If no CMI data are available, IP TABLE 1 TYPES OF HOSPITAL OUTPUTS TO 2 could be disaggregated in three categories (medicine, obstetrics-gynecology, BE INCLUDED IN A DEA SECTION 2 and surgery).1 The three options are summarized in Table 1. Cross-Cutting Ideal case • OP Analysis on Efficiency and • IP (CMI-adjusted ) Inputs selected for DEA should reflect the main hospital cost items. The number Equity 3 of beds is an obvious proxy for capital costs. Staff numbers are also crucial. Second-best • OP Ideally, the number of staff should be disaggregated by specialist doctors, case SECTION 3 • IPs disaggregated by: non-specialist doctors, nurses, and other staff (clinical and non-clinical). Topic-Specific - medicine, Analysis Finally, a few DEA researchers include an input reflecting non-labor operating - obstetrics-gynecology costs or drug costs. Health System Context - surgery Health Financing A Variable Return to Scale (VRS) approach should be preferred, when possible, Minimal • OP Inputs to a Constant Return to Scale (CRS). A DEA researcher will have to choose a case • IP Service Delivery scale assumption. There are basically two possible assumptions. M-10: Hospitals Note: [ital] CMI = case-mix index; IP = input; OP = • One considers that returns to scale are constant. In other words, doubling output. M-11: Primary Care & Public Health the quantity of inputs will always lead to doubling the quantity of outputs. Outcomes This is the CRS assumption. It is used by the Charnes-Cooper-Rhodes, or 4 List of Acronyms CCR, DEA model. Unfortunately, for hospitals, this CRS assumption is very unlikely to be true (see, for instance, Giancotti (2017) for a review of scale SECTION 4 effects in hospitals). Additional Guidance 1 A hospital focusing on surgical production is likely to be more productive than a general hospital combining medical and surgical cases. TABLE OF CONTENTS MODULE 10 Hospitals 353 OVERVIEW 1 SECTION 1 What Is a Health PER? • The alternative is to assume that returns to scale are FIGURE 1 2 variable (that is, they can decrease or increase). This VARIABLE RETURN TO SCALE SECTION 2 is the VRS assumption (used by the Banker-Charnes- Cross-Cutting Analysis on Cooper, or BCC, model) and should be preferred Efficiency and Equity when conducting a DEA with hospitals.2 Outputs 3 CRS Frontier SECTION 3 Figure 1 illustrates the point. The selected DEA approach Topic-Specific should be the output-oriented approach (instead of Analysis input-oriented), although this choice may not have a Health System Context significant impact on DEA findings. One can assume that hospitals can more easily maximize their outputs O3 VRS Frontier Health Financing Inputs than reducing their inputs (which are mostly fixed). That O2 C means that the DEA will be more realistic if the output- Service Delivery oriented feature is selected. Anyway, the two approaches M-10: Hospitals (output-oriented versus input-oriented) tend to produce O1 B similar results. M-11: Primary Care & Public Health A Outcomes 4 List of Acronyms SECTION 4 Additional 2 A caveat with VRS: By construction, the efficiency frontier of a VRS DEA will better envel- op data points. As a result, if scale effects are weak, “small and large units will tend to Source: Pascoe 2003. Fixed Inputs Guidance be over-rated in the efficiency assessment” (Dyson 2001). TABLE OF CONTENTS MODULE 10 Hospitals 354 OVERVIEW 1 SECTION 1 What Is a Health PER?  How to decompose DEA efficiency values? TABLE 2 SCALE EFFICIENCY AND RETURNS TO SCALE OF HOSPITALS, INDIA, 2009-10 2 The overall efficiency score may not be very helpful for policymakers. A DEA SECTION 2 Code OTE PTE SE RTS allows for further disaggregation of findings. Two possible decompositions Cross-Cutting Analysis on are important and are presented here. H1 .566 .596 .950 DRS Efficiency and Equity H2 .620 .647 .959 DRS 3 DECOMPOSING INEFFICIENCIES BETWEEN PURE H3 .906 .925 .980 DRS TECHNICAL EFFICIENCY AND SCALE EFFICIENCY H4 1 1 1 - SECTION 3 Topic-Specific To identify whether a hospital is operating at scale, let us first define two H5 .734 .807 .910 DRS Analysis concepts (Cooper 2007). H6 .634 .658 .964 DRS Health System Context • A first concept is Overall Technical Efficiency (OTE). It is equal to the H7 1 1 1 - Health Financing efficiency score produced by a CCR DEA model, as the CCR model H8 .759 .761 .986 DRS assumes Constant Return to Scale (CRS). H9 1 1 1 - Inputs Service Delivery • The second concept is Pure Technical Efficiency (PTE) and is equal to H10 .452 .458 .986 DRS M-10: Hospitals the efficiency score produced by a BCC DEA model. H11 .735 .787 .934 IRS M-11: Primary Care & Public Health H12 .600 .616 .974 IRS Following Cooper, one can express Scale Efficiency as the ratio of OTE to Outcomes PTE. A hospital operates at scale if SE = 1 (or equivalently if OTE = PTE). If SE H13 1 1 1 - is lower than 1, a hospital will be in a situation of decreasing or increasing H14 1 1 1 - 4 List of Acronyms returns to scale. Returns to scale can then be further decomposed in H15 .655 .662 .990 DRS SECTION 4 Decreasing Returns to Scale (DRS) and Increasing Returns to Scale (IRS).3 H16 .701 .753 .931 DRS Additional Table 2 (from Mogha 2018) illustrates this very simple analysis. H17 .538 .544 .988 IRS Guidance Source: Mogha 2018. H1-H17 = hospital units. Note: OTE = Overall Technical Efficiency; PTE = Pure Technical. Efficiency; RTS = Returns to Scale; SE = Scale Efficiency. 3 DeaR produces this indicator. OSDEA does not. TABLE OF CONTENTS MODULE 10 Hospitals 355 OVERVIEW 1 SECTION 1 What Is a Health PER? DECOMPOSING INEFFICIENCIES BY INPUTS AND OUTPUTS TABLE 3 SLACKS: 2010 2 Possible Reduction SECTION 2 All DEA packages include data on projections, that is to say, Cross-Cutting Regions BED (%) DOC (%) NUR (%) Analysis on data on how much each input should be reduced (for input- Efficiency and oriented DEA) or on how much each output should be increased Riyadh 0.0 0 0 Equity 3 (for output-oriented DEA) to improve efficiency. For instance, in Makkah 24.8 26 25 a DEA applied to hospitals in Saudi Arabia, Almiman (2018) finds Jeddah 34.9 33 25 SECTION 3 that, to become efficient, Medinah hospital (see Table 3) should Taif 32.7 24 35 Topic-Specific Analysis reduce its number of beds, doctors, and nurses by 18 percent, Medinah 18.0 22 20 22 percent, and 20 percent respectively (while maintaining its Source: Almiman 2018. Health System Context current level of output). Health Financing Inputs  Some limitations of DEA approaches more powerful approach is to estimate confidence intervals Service Delivery with bootstrapping (see Simar and Wilson 1998 for the overall A first limitation is that DEA does not include any statistical approach and Staat 2007 for a hospital DEA example). M-10: Hospitals noise. This is an issue inherent to the non-parametric approach, M-11: Primary Care & Public Health but it can be addressed rather easily. One simple (but partial) DEAs are very sensitive to extreme values. A DEA assumes that Outcomes solution is proposed by Mogha (2016). It is based on the idea the set of DMU is roughly homogenous. As a consequence, a single outlier can considerably distort the efficiency frontier. 4 List of Acronyms that the more peers an efficient DMU has, the more reliable its efficiency estimate. In practice, one has simply to look at the This is the homogeneity assumption. This limitation is not easy SECTION 4 number of peers per efficient hospital. The main limitation of to address, mostly because homogeneity is not a very clear Additional this approach is that it works only for the group of efficient concept. At a minimum, before starting a DEA, PER authors Guidance hospitals (and thus not for the other hospitals). A second and should make sure that (1) hospitals have been clustered by ownership and size; (2) the sample includes only acute care TABLE OF CONTENTS MODULE 10 Hospitals 356 OVERVIEW 1 SECTION 1 What Is a Health PER? hospitals (that is, no mental health or subacute hospitals, no TB hospitals, and so forth) and (3)  A checklist for conducting a DEA with hospitals 2 all included hospitals have both inpatient and Before designing the DEA SECTION 2 outpatient production and preferably have both • Performing cluster analysis of hospital data Cross-Cutting medical and surgical activities. Another, more 4 Analysis on Efficiency and rigorous approach, is to conduct a cluster analysis Defining key parameters for DEA Equity 3 before starting the DEA (see Zarrin 2022). • Selecting outputs and inputs (with the above-mentioned rule of thumb) SECTION 3 DEA projection estimates may sometimes be • Selecting input or output oriented approaches Topic-Specific Analysis unrealistic. It is not unusual that DEA projection • Selecting VRS estimates suggest dramatic increases of outputs • Running the DEA Health System Context (when output-oriented) or decreases of inputs Health Financing (when input-oriented) (Chen 2005). For instance, Further analyzing the DEA findings Inputs in his analysis of German hospitals, despite careful • Assessing robustness of findings clustering of data, Zarrin (2022) found that one • Decomposing efficiency score Service Delivery hospital should increase its surgical output by A. By Pure Technical Efficiency (PTE) and Scale Efficiency (SE) M-10: Hospitals almost 900 percent. Similarly, some studies would B. By inputs and outputs M-11: Primary Care & Public Health suggest that inputs (staff, for instance) of a given Outcomes hospital should be reduced by 40 percent to achieve Some studies would suggest that inputs (staff for instance) of a given efficiency. None of these suggestions is realistic. hospital should be reduced by 40 percent to achieve efficiency. None 4 List of Acronyms Therefore, a DEA can only be considered as a starting of these suggestions is realistic. Therefore, DEA can only be considered SECTION 4 point for further efficiency analysis. as a starting point for further efficiency analysis. Additional Guidance 4 In case a hospital has a mostly surgical production, PER authors can add the number of surgeries in the list of DEA outputs. TABLE OF CONTENTS MODULE 10 Hospitals 357 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 Almiman, M.A. 2018. “Measuring the efficiency of public hospitals in Saudi Arabia using the data envelopment analysis approach.” International SECTION 2 Cross-Cutting Journal of Business and Management 13 (12): 111. Analysis on Efficiency and Andrews, Antony, and Grigorios Emvalomatis. 2024. “Efficiency Measurement in Healthcare: The Foundations, Variables, and Models—A Nar- Equity 3 rative Literature Review.” Economics. 18 (1). http://doi.org/10.1515/econ-2022-0062. SECTION 3 Aldridge, Robert W., Dan Lewer, Srinivasa Vittal Katikireddi, Rohini Mathur, Neha Pathak, Rachel Burns, Ellen B. Fragaszy, et al. 2020. “Black, Topic-Specific Asian and Minority Ethnic Groups in England Are at Increased Risk of Death from COVID-19: Indirect Standardisation of NHS Mortality Data.” Analysis Wellcome Open Research 5 (June): 88. https://doi.org/10.12688/wellcomeopenres.15922.2. Health System Context Baqui, Pedro, Ioana Bica, Valerio Marra, Ari Ercole, and Mihaela van der Schaar. 2020. “Ethnic and Regional Variations in Hospital Mortality Health Financing from COVID-19 in Brazil: A Cross-Sectional Observational Study.” The Lancet Global Health 8 (8): e1018–26. https://doi.org/10.1016/S2214- Inputs 109X(20)30285-0. Service Delivery Barnett, Michael L., John Hsu, and J. Michael McWilliams. 2015. “Patient Characteristics and Differences in Hospital Readmission Rates.” JAMA M-10: Hospitals Internal Medicine 175 (11): 1803–12. https://doi.org/10.1001/jamainternmed.2015.4660. M-11: Primary Care & Public Health Barrenho, Eliana, Philip Haywood, Candan Kendir, and Nicolaas S. Klazinga. 2022. “International Comparisons of the Quality and Outcomes Outcomes of Integrated Care: Findings of the OECD Pilot on Stroke and Chronic Heart Failure.” Paris: Organisation for Economic Co-operation and De- velopment. https://doi.org/10.1787/480cf8a0-en. 4 List of Acronyms Bauer, Hartwig, and Kim C. Honselmann. 2017. “Minimum Volume Standards in Surgery—Are We There Yet.” Visceral Medicine 33 (2): 106–16. SECTION 4 https://pubmed.ncbi.nlm.nih.gov/28560225/. Additional Guidance Bowlin, W.F. 1998. “Measuring Performance: An Introduction to Data Envelopment Analysis (DEA).” The Journal of Cost Analysis 15 (2), 3–27. https://doi.org/10.1080/08823871.1998.10462318. TABLE OF CONTENTS MODULE 10 Hospitals 358 OVERVIEW 1 SECTION 1 What Is a Health PER? Campbell, Oona, M.R., Luca Cegolon, David Macleod, and Lenka Benova. 2016. “Length of Stay After Childbirth in 92 Countries and Associated Factors in 30 Low- and Middle-Income Countries: Compilation of Reported Data and a Cross-Sectional Analysis from Nationally Representa- 2 tive Surveys.” Edited by Jenny E. Myers. PLOS Medicine 13 (3): e1001972. https://doi.org/10.1371/journal.pmed.1001972. SECTION 2 Chen, A., Y. Hwang, and B. Shao. 2005. “Measurement and sources of overall and input inefficiencies: Evidences and implications in hospital Cross-Cutting Analysis on services.” Eur J Oper Res 161 (2): 447–68. Efficiency and Equity Chou, Ying-Yi, Juey-Jen Hwang, and Yu-Chi Tung. 2021. “Optimal Surgeon and Hospital Volume Thresholds to Reduce Mortality and Length of 3 Stay for CABG.” PLOS ONE 16 (4): e0249750. https://doi.org/10.1371/journal.pone.0249750. SECTION 3 Cooper, W.W., L.M. Seiford, and K. Tone. 2007. Data envelopment analysis: a comprehensive text with models, applications, references and DEA- Topic-Specific Analysis solver software. Vol. 2: 489. New York: Springer. Cournane, Seán, Declan Byrne, Richard Conway, Deirdre O’Riordan, Seamus Coveney, and Bernard Silke. 2015. “Social Deprivation and Hos- Health System Context pital Admission Rates, Length of Stay and Readmissions in Emergency Medical Admissions.” European Journal of Internal Medicine 26 (10): Health Financing 766–71. https://doi.org/10.1016/j.ejim.2015.09.019. Inputs Dall’Ora, Chiara, Bruna Rubbo, Christina Saville, Lesley Turner, Jane Ball, Cheska Ball, and Peter Griffiths. 2023. “The Association between Service Delivery Multi-Disciplinary Staffing Levels and Mortality in Acute Hospitals: A Systematic Review.” Human Resources for Health 21 (1): 30. https://doi. M-10: Hospitals org/10.1186/s12960-023-00817-5. M-11: Primary Care & Public Health Doroshenko, Olena, Marta Kuzmyn, Kristiina Kahur, Sarah Bales, and Solomiya Kasyanchuk. 2023. “Cross-Country Analysis of Case-Mix in Outcomes Selected Hospitals.” Discussion Paper, World Bank Group-Korea World Bank. https://openknowledge.worldbank.org/server/api/core/bitstre 4 List of Acronyms ams/03c17144-168c-44b2-b1ae-ee7b17cd9a43/content. Dyson, R.G., R. Allen, A.S. Camanho, V.V. Podinovski, C.S. Sarrico, and E.A Shale. 2001. “Pitfalls and protocols in DEA.” European Journal of SECTION 4 Additional operational research 132 (2): 245–59. Guidance Fung, Colman S.C., Carlos K.H. Wong, Daniel Y.T. Fong, Albert Lee, and Cindy L.K. Lam. 2015. “Having a Family Doctor Was Associated with Low- er Utilization of Hospital-Based Health Services.” BMC Health Services Research 15 (1): 42. https://doi.org/10.1186/s12913-015-0705-7. TABLE OF CONTENTS MODULE 10 Hospitals 359 OVERVIEW 1 SECTION 1 What Is a Health PER? García, Jesús Rodríguez. 2012. “Serie sobre hospitalizaciones evitables y fortalecimiento de la atención primaria en salud: El caso de Colom- bia.” IDB Publications, December. https://publications.iadb.org/es/publicacion/15309/serie-sobre-hospitalizaciones-evitables-y-fortalec- imiento-de-la-atencion-primaria. 2 SECTION 2 Gutiérrez, Catalina, Santiago Palacio, Úrsula Giedion, and Marcela Distrutti. 2023. “¿En que gastan los países sus recursos en salud?: el caso Cross-Cutting de Colombia.” IDB Publications, September. https://doi.org/10.18235/0005157. Analysis on Efficiency and Hanson, Claudia, Jonathan Cox, Godfrey Mbaruku, Fatuma Manzi, Sabine Gabrysch, David Schellenberg, Marcel Tanner, Carine Ronsmans, Equity 3 and Joanna Schellenberg. 2015. “Maternal Mortality and Distance to Facility-Based Obstetric Care in Rural Southern Tanzania: A Secondary Analysis of Cross-Sectional Census Data in 226 000 Households.” The Lancet Global Health 3 (7): e387–95. https://doi.org/10.1016/S2214- SECTION 3 109X(15)00048-0. Topic-Specific Analysis Hirner, Sarah, Jyotshila Dhakal, Morgan Carol Broccoli, Madeline Ross, Emilie J Calvello Hynes, and Corey B Bills. 2023. “Defining Measures of Emergency Care Access in Low-Income and Middle-Income Countries: A Scoping Review.” BMJ Open 13 (4): e067884. https://doi.org/10.1136/ Health System Context bmjopen-2022-067884. Health Financing Inputs Huguenin, J.M. 2012. “Data envelopment analysis (DEA). A pedagogical guide for decision makers in the public sector.” Swiss Graduate School of Service Delivery Public Administration, Lausanne. M-10: Hospitals Jamison, Dean T. 2018. “Disease Control Priorities, 3rd Edition: Improving Health and Reducing Poverty.” The Lancet 391 (10125): e11–14. M-11: Primary Care & Public Health https://doi.org/10.1016/S0140-6736(15)60097-6. Outcomes La Forgia, Jerry. 2023. “What Matters? Improving Key Dimensions of Hospital Efficiency and Performance.” October 3. https://events.iadb.org/ events/handler/geteventdocument.ashx?AFCF784DCD0CBF43BE2C6862BF334401E225B5973D9346DDB05CBECA7D248D3620D71CADF8E621ECA9 4 List of Acronyms 460FD2A7EA1568CD08F452BE594F5B551873F9CF7AB0CD7D149080B4DFF02B. SECTION 4 Laxminarayan, Ramanan, Anne J. Mills, Joel G. Breman, Anthony R. Measham, George Alleyne, Mariam Claeson, Prabhat Jha, et al. 2006. Additional Guidance “Advancement of Global Health: Key Messages from the Disease Control Priorities Project.” The Lancet 367 (9517): 1193–1208. https://doi. org/10.1016/S0140-6736(06)68440-7. TABLE OF CONTENTS MODULE 10 Hospitals 360 OVERVIEW 1 SECTION 1 What Is a Health PER? Lemiere, Christophe, Vincent Turbat, and Juliette Puret. 2012. “A Tale of Excessive Hospital Autonomy? An Evaluation of the Hospital Reform in Senegal.” World Bank Publications—Reports May. https://ideas.repec.org//p/wbk/wboper/11880.html. 2 Löfqvist, Therese, Bo Burström, Anders Walander, and Rickard Ljung. 2014. “Inequalities in Avoidable Hospitalisation by Area Income and SECTION 2 the Role of Individual Characteristics: A Population-Based Register Study in Stockholm County, Sweden.” BMJ Quality & Safety 23 (3): 206–14. Cross-Cutting https://doi.org/10.1136/bmjqs-2012-001715. Analysis on Efficiency and Equity Meara, John G., Andrew J.M. Leather, Lars Hagander, Blake C. Alkire, Nivaldo Alonso, Emmanuel A. Ameh, Stephen W. Bickler, et al. 2015. 3 “Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development.” The Lancet 386 (9993): 569–624. https://doi.org/10.1016/S0140-6736(15)60160-X. SECTION 3 Topic-Specific Ministry of Health, Malaysia. 2021. Malaysia National Health Accounts Health Expenditure Report 1997-2021. https://www.moh.gov.my/moh/ Analysis resources/Penerbitan/Penerbitan%20Utama/MNHA/MNHA_Health_Expenditure_Report_1997-2019_02092021.pdf. Health System Context Mogha, S.K., S.P. Yadav, and S.P. Singh. 2016. “Estimating technical efficiency of public sector hospitals of Uttarakhand (India).” International Health Financing Journal of Operational Research 25 (3): 371–99. Inputs Mogha, S.K., S.P. Yadav, and S.P. Singh. 2018. “Performance Evaluation of Indian Private Hospitals Using DEA Approach With Sensitivity Analysis.” Service Delivery International Journal of Advances in Management and Economics, April. M-10: Hospitals Moneme, Adora N., Christopher J. Wirtalla, Sanford E. Roberts, Luke J. Keele, and Rachel R. Kelz. 2023. “Primary Care Physician Follow-Up M-11: Primary Care & Public Health and 30-Day Readmission After Emergency General Surgery Admissions.” JAMA Surgery 158 (12): 1293–1301. https://doi.org/10.1001/jama- Outcomes surg.2023.4534. 4 List of Acronyms Morche, Johannes, Daniela Renner, Barbara Pietsch, Laura Kaiser, Jan Brönneke, Sabine Gruber, and Katja Matthias. 2018. “International Comparison of Minimum Volume Standards for Hospitals.” Health Policy 122 (11): 1165–76. https://doi.org/10.1016/j.healthpol.2018.08.016. SECTION 4 Additional National Health Service England. 2020. “National Day Surgery Delivery Pack.” https://www.gettingitrightfirsttime.co.uk/wp-content/up- Guidance loads/2020/10/National-Day-Surgery-Delivery-Pack_Sept2020_final.pdf. TABLE OF CONTENTS MODULE 10 Hospitals 361 OVERVIEW 1 OECD. 2017. Tackling Wasteful Spending on Health. Paris: Organisation for Economic Co-operation and Development. https://www.oecd-ili- SECTION 1 What Is a brary.org/social-issues-migration-health/tackling-wasteful-spending-on-health_9789264266414-en. Health PER? OECD. 2023. Health at a Glance 2023: OECD Indicators. OECD Publishing, Paris. https://doi.org/10.1787/7a7afb35-en. 2 SECTION 2 “OECD Statistics.” n.d. Accessed February 20, 2024. https://stats.oecd.org/Index.aspx?ThemeTreeId=9. Cross-Cutting Analysis on Pai, D.R., F. Pakdil, and N. Azadeh-Fard. 2024. “Applications of data envelopment analysis in acute care hospitals: a systematic literature review, Efficiency and Equity 1984-2022.” Health Care Management Science. Science 27 (2): 284–312. June. 3 Pascoe, S., J.E. Kirkley, D. Gréboval. C.J. Morrison-Paul. 2003. “Measuring and assessing capacity in fisheries. 2. Issues and methods.” FAO SECTION 3 Fisheries Technical Paper No. 433/2. Rome, Food and Agriculture Organization of the United Nations. Topic-Specific Analysis Perkin, Michael Richard, Sarah Heap, Agatha Crerar-Gilbert, Wendy Albuquerque, Serena Haywood, Zoe Avila, Richard Hartopp, Jonathan Ball, Kate Hutt, and Nigel Kennea. 2020. “Deaths in People from Black, Asian and Minority Ethnic Communities from Both COVID-19 and Health System Context Non-COVID Causes in the First Weeks of the Pandemic in London: A Hospital Case Note Review.” BMJ Open 10 (10): e040638. https://doi. Health Financing org/10.1136/bmjopen-2020-040638. Inputs Piran, F.S., D.P. Lacerda, and L.F.R. Camargo. 2020. “Data Envelopment Analysis (DEA).” In Analysis and Management of Productivity and Service Delivery Efficiency in Production Systems for Goods and Services, (pp. 49-87). CRC Press. M-10: Hospitals Preker, Alexander S., and April Harding. 2003. Innovations in Health Service Delivery: The Corporatization of Public Hospitals. Washington, M-11: Primary Care & Public Health DC: World Bank Publications. Outcomes Saxena, Farah E., Arlene S. Bierman, Richard H. Glazier, Xuesong Wang, Jun Guan, Douglas S. Lee, and Therese A. Stukel. 2022. “Association 4 List of Acronyms of Early Physician Follow-up With Readmission Among Patients Hospitalized for Acute Myocardial Infarction, Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease.” JAMA Network Open 5 (7): e2222056. https://doi.org/10.1001/jamanetworkopen.2022.22056. SECTION 4 Additional Scharfe, Julia, Stefanie Pfisterer-Heise, Charlotte Mareike Kugler, Eni Shehu, Tobias Wolf, Tim Mathes, and Dawid Pieper. 2023. “The Effect of Guidance Minimum Volume Standards in Hospitals (MIVOS)—Protocol of a Systematic Review.” Systematic Reviews 12 (1): 11. https://doi.org/10.1186/ s13643-022-02160-7. TABLE OF CONTENTS MODULE 10 Hospitals 362 OVERVIEW 1 Simar, L., and P.W. Wilson. 1998. “Sensitivity Analysis of Efficiency Scores: How to Bootstrap in Nonparametric Frontier Models.” Management SECTION 1 Science 44 (1): 49–61. What Is a Health PER? Staat, M. 2006. “Efficiency of hospitals in Germany: a DEA-bootstrap approach.” Applied Economics, 38 (19): 2255–63. https://doi.org/10.1080/00 2 036840500427502. SECTION 2 Cross-Cutting Sun, Ruirui, Zeynal Karaca, and Herbert S. Wong. 2006. “Trends in Hospital Emergency Department Visits by Age and Payer, 2006–2015.” In Analysis on Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US). http:// Efficiency and Equity www.ncbi.nlm.nih.gov/books/NBK513766/. 3 Tian, Fan, and Jay Pan. 2021. “Hospital Bed Supply and Inequality as Determinants of Maternal Mortality in China between 2004 and 2016.” SECTION 3 International Journal for Equity in Health 20 (1): 51. https://doi.org/10.1186/s12939-021-01391-9. Topic-Specific Analysis Toloo, M. 2014. Data envelopment analysis with selected models and applications. Series on Advanced Economic Issues, Vol. 30. Czechia: VŠB- TU Ostrava. Health System Context Health Financing Varabyova, Yauheniya, and Jonas Schreyögg. 2013. “International Comparisons of the Technical Efficiency of the Hospital Sector: Panel Data Analysis of OECD Countries Using Parametric and Non-Parametric Approaches.” Health Policy (Amsterdam, Netherlands) 112 (1–2): 70–79. Inputs https://doi.org/10.1016/j.healthpol.2013.03.003. Service Delivery M-10: Hospitals Vos, Theo, Stephen S. Lim, Cristiana Abbafati, Kaja M. Abbas, Mohammad Abbasi, Mitra Abbasifard, Mohsen Abbasi-Kangevari, et al. 2020. “Global Burden of 369 Diseases and Injuries in 204 Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Dis- M-11: Primary Care & Public Health ease Study 2019.” The Lancet 396 (10258): 1204–22. https://doi.org/10.1016/S0140-6736(20)30925-9. Outcomes World Health Organization. 2018. “The Transformative Role of Hospitals in the Future of Primary Health Care”. https://www.who.int/docs/ 4 List of Acronyms default-source/primary-health-care-conference/hospitals.pdf. World Health Organization, Geneva. SECTION 4 World Health Organization. 2022. WHO Recommendations on Maternal and Newborn Care for a Positive Postnatal Experience. World Health Additional Organization. https://books.google.ca/books?hl=en&lr=&id=N3RyEAAAQBAJ&oi=fnd&pg=PR4&dq=WHO+recommendations+on+mater- Guidance nal+and+newborn+care+for+a+positive+postnatal+experience&ots=RXf3q5Ndks&sig=7rKuvNGLx9gA8zRkslPmzw7q9-s. Geneva: World Health Organization. TABLE OF CONTENTS MODULE 10 Hospitals 363 OVERVIEW 1 World Health Organization Regional Office for the European Region. 2016. “Integrated Care Models: An Overview.” SECTION 1 What Is a World Health Organization Regional Office for the Eastern Mediterranean. n.d. “Introducing the Framework for Action for the Hospital Sector Health PER? in the Eastern Mediterranean Region.” Accessed February 27, 2024. https://applications.emro.who.int/docs/RC_Technical_Papers_2019_5_ 2 en.pdf. SECTION 2 Cross-Cutting World Health Organization, United Nations Population Fund, Mailman School of Public Health Averting Maternal Death and isability, and Analysis on Efficiency and United Nations Children’s Fund (UNICEF). 2009. Monitoring Emergency Obstetric Care : A Handbook. https://iris.who.int/handle/10665/44121. Equity 3 Geneva: World Health Organization. Wulandari, Ratna Dwi, Agung Dwi Laksono, Zainul Khaqiqi Nantabah, Nikmatur Rohmah, and Zuardin Zuardin. 2022. “Hospital Utilization in SECTION 3 Indonesia in 2018: Do Urban–Rural Disparities Exist?” BMC Health Services Research 22 (1): 491. https://doi.org/10.1186/s12913-022-07896-5. Topic-Specific Analysis Young, T. Kue, Susan Chatwood, Carmina Ng, Robin W. Young, and Gregory P. Marchildon. 2019. “The North Is Not All the Same: Comparing Health System Performance in 18 Northern Regions of Canada.” International Journal of Circumpolar Health 78 (1): 1697474. https://doi.org/1 Health System Context 0.1080/22423982.2019.1697474. Health Financing Inputs Zarrin, M., J. Schoenfelder, and J.O. Brunner. 2022. “Homogeneity and Best Practice Analyses in Hospital Performance Management: An Ana- Service Delivery lytical Framework.” Health Care Management Science 25 (3) (September): 406–25. M-10: Hospitals Zhao, Y., H. Lu, Y. Zang, and X. Li. 2020. “A Systematic Review of Clinical Practice Guidelines on Uncomplicated Birth.” BJOG: An International M-11: Primary Care & Public Health Journal of Obstetrics & Gynaecology 127 (7): 789–97. https://doi.org/10.1111/1471-0528.16073. Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 364 OVERVIEW 1 SECTION 1 What Is a Health PER? ANNEXES When considering the costs associated with ACSCs, PER authors should keep in mind that this type of analysis 2 requires time and is data intensive. Therefore, authors SECTION 2 should rely on the country’s existing recent studies on the Cross-Cutting Analysis on Annex 3: Costs Associated with number of ACSC admissions and their costs In the absence Efficiency and Equity Hospital Admissions for Ambulatory of existing studies, PER authors can calculate the costs 3 associated with ACSC admissions in three steps: (1) define Care Sensitive Conditions a list of conditions that should be considered ACSCs for the SECTION 3 Topic-Specific country; (2) analyze data sources to estimate the number Analysis of ACSC admissions; and (3) estimate costs associated with Ambulatory care sensitive conditions (ACSCs) are these hospital admissions. Health System Context conditions for which required care delivered at the Health Financing The second step may be the most challenging for PER primary level could potentially prevent hospitalization. Inputs authors, as quality of admission data can vary considerably, Service Delivery For example, hospitalization related to serious including how primary and secondary diagnoses are coded M-10: Hospitals complications from diabetes should largely be in health records. For example, while hospital admissions related to diabetes are largely preventable in all settings, how M-11: Primary Care & Public Health preventable, as treatment in ambulatory settings should reliably information on diabetes-related hospitalizations Outcomes control the progression of the disease. As such, hospital can be extracted from admission data sources varies widely admissions where the primary diagnosis is diabetes 4 List of Acronyms among countries. Because this type of information is clinical related could be considered an ACSC and thus indicate in nature, it might be difficult for non-clinicians to fully SECTION 4 understand. PER authors should consult existing studies on Additional wasteful use of hospital resources and poor integration preventable or overall admissions, including studies that Guidance of care, signaling inefficiency. don’t delve into costs, to better understand the feasibility of any new analysis. TABLE OF CONTENTS MODULE 10 Hospitals 365 OVERVIEW 1 SECTION 1 What Is a Health PER? If it is feasible to conduct a new ACSC analysis, PER authors should calculated by looking at their and negotiated price from claims 2 establish the list of conditions that will be considered ACSCs. First, databases. Using systems with other payments for hospitals, such SECTION 2 authors can check whether the causes of preventable admissions as input-based payments, PER authors can explore other methods Cross-Cutting Analysis on have been previously elaborated for the country or comparator to evaluate the costs associated with ACSC admissions, such as Efficiency and Equity countries. If not, they can consider using the lists of the Organisation activity-based costing based on cost centers. Overall, authors 3 for Economic Co-operation and Development (OECD), the US Agency should keep in mind the data, time, and effort needed to derive for Healthcare Research and Quality, or the Canadian Institute reliable costing data from the different approaches. Alternatively, SECTION 3 Topic-Specific for Health Information, which cover conditions like diabetes, PER authors can try to use existing hospital admissions costing Analysis chronic obstructive pulmonary disease, asthma, hypertension, studies from their countries if they think these studies can estimate and congestive heart failure. The lists can be modified based on ASCS costs sufficiently. Health System Context the country epidemiology and context. Pinto et al. (2020) provides Health Financing further information on how to select ACSCs. Inputs Service Delivery Subsequently, information on the number of admissions that M-10: Hospitals are related to ACSC conditions must be extracted from hospital admission information systems/databases, which typically use M-11: Primary Care & Public Health International Classification of Disease (ICD) coding. Costs associated Outcomes with these ACSC admissions can then be estimated. Because PER 4 List of Acronyms authors will be undertaking this analysis in the context of a public expenditure review, only costs for the public system should be SECTION 4 considered. In countries with only output-based payments to Additional hospitals, such as diagnosis-related groups, the payment made Guidance to hospitals by the purchaser for these ACSC admissions can be TABLE OF CONTENTS MODULE 10 Hospitals 366 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 CASE EXAMPLE: COSTS OF ACSC FOR THE SUBSIDIZED AND CONTRIBUTORY REGIMES IN COLOMBIA SECTION 2 Cross-Cutting Analysis on A 2023 study by the Inter-American Development Bank (IDB) presented information on the costs of ACSC in Colombia (Gutiérrez et al. 2023). Efficiency and The study analyzed data from insurance claims for hospitalization in the two main public coverage regimes in Colombia: the subsidized Equity 3 regime and the contributory regime, each of which finances hospitals. SECTION 3 The study relied on a list of ACSCs developed in a 2012 study (García 2012) on avoidable admissions and strengthening primary care. Topic-Specific Analysis The study defined these ACSCs based on a Brazilian 2009 study, which was validated by the Colombian health authorities. The 2012 list identified 20 ACSCs using ICD-10 coding. It included conditions like anemia, malnutrition, and diseases preventable through immunization, Health System Context as well as cardiovascular diseases like diabetes, asthma, and congestive heart failure. Of note, this is an expanded list of conditions Health Financing compared with the OECD and other ACSC lists mentioned earlier, and it reflects country context and priorities. Inputs Service Delivery Based on this list of ACSCs, the 2023 IDB study estimated the payment to providers in the subsidized regime and the contributory regime. M-10: Hospitals It found that 17 percent of hospitalization expenditure under these regimes was for ACSCs, with a higher share in the subsidized regime. Overall, this represented 1.7 billion pesos, or 3 percent of government health expenditure in Colombia. M-11: Primary Care & Public Health Outcomes Among ASCSs, cardiovascular diseases absorb 30 percent of the costs in both regimes, followed by respiratory system diseases (26 4 List of Acronyms percent); genitourinary system diseases, including kidney disease (12 percent); and endocrine, nutritional, and metabolic conditions (9 percent), mainly diabetes. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 10 Hospitals 367 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific MODULE 11 Primary Care and Analysis Health System Context Essential Public Health Financing Inputs Health Functions Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes AUTHORS 4 List of Acronyms Priyanka Saksena and Catalina Gutiérrez SECTION 4 Additional Guidance START TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 368 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION FIGURE 1 2 Ensuring adequate investment in primary health THREE COMPONENTS OF PRIMARY HEALTH CARE SECTION 2 Cross-Cutting care (PHC) is a major policy concern (Pan American Analysis on Efficiency and Health Organization/WHO 2023). Spending Equity 3 on promotive and preventive care is highly cost-effective and returns on investments in SECTION 3 Topic-Specific interventions are often multiples of their costs. Analysis Increased investments in this area are expected to avert more Health System Context than 60 million deaths by 2030 and reduce the use of hospital care Health Financing as well as overall health costs (WHO 2018a; Hanson et al. 2022; Inputs OECD 2020). Additionally, the majority of curative, rehabilitative, Service Delivery Source: Rajan et al. (2024). and palliative health services can be delivered at the primary or M-10: Hospitals community level rather than through hospitals, resulting in cost savings (Laxminarayan et al. 2006). Primary health care has resulted PHC integrates population- and individual-level health interventions M-11: Primary Care & Public Health in reduced socioeconomic inequality and improved outcomes for and moves away from a focus on illness toward a more holistic Outcomes populations with lower socioeconomic status (Rajan et al. 2024). approach to health. A PHC-oriented health system aims to take a 4 List of Acronyms comprehensive approach to health needs and determinants and PHC encompasses three interrelated components: (1) integrating maximize equity and solidarity. As such, having PHC-oriented health SECTION 4 system is a major objective of many countries’ health policies. The health services to meet people’s health needs throughout their Additional Guidance lives; (2) addressing the broader determinants of health through public-facing health services component of PHC is often considered multisectoral policy and action; and (3) empowering people and the most important aspect—it is referred to as “primary care.” (The communities to take charge of their own health. box “What Is Primary Health Care?” explains these concepts further). TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 369 OVERVIEW 1 SECTION 1 What Is a Health PER? Primary care aims to deliver health services close to where people live and work. Inputs like primary care workers are critical for this In many countries, the hospital sector observes a high share of expenditure, while spending on public health, promotive, preventive, 2 and directly impact efficiency and equity. Work by Starfield and and other first-level care remains low. This higher expenditure SECTION 2 colleagues from the US, for example, shows that an increase of on hospitals could be due to more severe health needs, some of Cross-Cutting one primary care physician per 10,000 population would lead to an which were not tackled upstream or due to care being delivered at Analysis on Efficiency and average mortality decline of 5.3 percent, or 49 deaths per 100,000 a higher level than needed. Increased investment in primary care Equity 3 population, per year (Macinko, Starfield, and Shi 2007). Similar and towards a PHC-oriented health system is thus likely to improve work has been done in other countries, such as Brazil, where an health outcomes as well as equity for the same level of resources. SECTION 3 increase of one primary care physician per 10,000 population Topic-Specific Analysis is associated with a decrease in the infant mortality rate (IMR) This module advises PER authors conducting public expenditure of over 7 per 10,000 live births (Russo et al. 2019). The data for reviews (PERs) for the health sector on how to assess the efficiency Health System Context other primary health workers, such as nurses and midwives, show and equity of primary care and essential public health functions, the Health Financing similarly improved health outcomes. key service delivery components of PHC. This includes the amounts, Inputs trend and share of expenditure, capital and human resources, As the COVID-19 pandemic has shown, health systems can productivity, quality, integration of services, and processes and Service Delivery quickly crumble in emergencies. Investment in public health governance dimensions for these aspects. The module focuses on M-10: Hospitals services, including population-level health services, is essential PHC-aligned health services offered outside of hospitals, described M-11: Primary Care & Public Health for ensuring the capacity to respond quickly to health threats, in the following box. A separate module in this series focuses on Outcomes continue providing health services during crises, and build efficiency and equity aspects of Hospitals. fffffTogether these two resilient health systems. Essential public health functions, for modules enable PER authors to examine efficiency and equity of 4 List of Acronyms example, surveillance and emergency preparedness, have often health services in a country. In complement, there are also a module SECTION 4 been neglected until there is a health emergency. on Human Resources for Health fffffand additional guidance notes Additional on Service Availability and Readiness fffffand Quality of Health Guidance Overall, expenditure on primary care and essential public health Services. functions is not always commensurate with their importance. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 370 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 2. WHAT IS PRIMARY HEALTH CARE? 2 SECTION 2 Cross-Cutting The concept of “primary health care” is inspired delivery of primary care, such as disease prevention. Key public Analysis on health capacities and services are referred to as “essential Efficiency and by the Alma Ata Declaration of 1978 and significant Equity public health functions.” 3 academic and policy work since then. PHC has been a major driver of health system thinking. In addition to strengthening health services, PHC aims to SECTION 3 Topic-Specific empower people and communities to take ownership of Analysis Strengthening primary care and greater investment in promotive, their own health and tackle determinants of health through protective, preventive care is a core component of PHC advocacy, multisectoral policy and action, including by using a “Health in Health System Context alongside designing effective referral systems to deliver All” approach, whereby health considerations are considered Health Financing integrated health services. In fact, strong primary care—primary in all policymaking. While these are important and useful to Inputs level and community health services—is the bedrock of the PHC keep in mind conceptually, they are not covered in depth in this Service Delivery approach, as these are often closer to people, more equitable, module. Rather, this module focuses on efficiency and equity M-10: Hospitals and more person centered. But services delivered in secondary issues related to primary care and essential public health and tertiary facilities—that is, hospitals—can all be a part of the functions, or health services not offered by hospitals. M-11: Primary Care & Public Health concept of PHC if they are integrated with primary care. Outcomes 4 List of Acronyms PHC is equally concerned with public health capacities and services—population health services like the surveillance of SECTION 4 emerging threats. Many of these are also directly linked to the Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 371 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS 2 PRIMARY HEALTH CARE care aims to support first-contact, accessible, continued, SECTION 2 Primary health care (PHC) is an overall approach to comprehensive, coordinated person-centered care. Cross-Cutting Analysis on strengthening health systems to respond to people’s health Efficiency and needs effectively. A PHC approach focuses on (1) integrated ESSENTIAL PUBLIC HEALTH FUNCTIONS Equity 3 health services to meet people’s health needs throughout their Public health aims to protect, promote, and restore health lives; (2) addressing the broader determinants of health through through collective actions, with the goals of reducing disease, SECTION 3 multisectoral policy and action; and (3) empowering individuals, premature death, and disability. Essential public health Topic-Specific Analysis families, and communities to take charge of their own health. functions (EPHF) operationalize a core list of roles to ensure effective public health action in countries. The World Health Health System Context PRIMARY CARE Organization (WHO) defined a list of EPHFs in 2021, and some Health Financing Primary care refers to the personal health service delivery countries have defined their EPHFs at the national level. Public Inputs component of PHC, specifically, the first level of contact for the health service-oriented functions—public health emergency Service Delivery population with the health care system, aiming to bring care as management, including preparedness, health protection, close as possible to where people live and work. This includes health promotion disease prevention and detection, and M-10: Hospitals services provided by primary care health workers, such as cross-cutting functions of surveillance and monitoring—are M-11: Primary Care & Public Health physicians and nurses, as well as services provided in the particularly synergized with primary care. Outcomes community, including by community health workers. Primary 4 List of Acronyms care can be offered in facilities like health outposts, primary PER authors interested in learning more about the broader PHC care centers, doctors’ offices, polyclinics, community health concept can refer to literature by WHO on this topic, including SECTION 4 centers, and mobile clinics or through outreach activities the 2024 publication Implementing the Primary Health Care Additional in people’s homes and communities. PHC-oriented primary Approach: A Primer (Rajan et al. 2024). Guidance Sources: WHO 2022a; WHO 2018b; Rajan et al. 2024. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 372 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 3. RECOMMENDED READING 2 SECTION 2 Hanson, Kara, Nouria Brikci, Darius Erlangga, Abebe Alebachew, Manuela De Allegri, Dina Balabanova, Mark Blecher, et al. 2022. “The Lancet Cross-Cutting Analysis on Global Health Commission on Financing Primary Health Care: Putting People at the Centre.” Lancet Global Health 10 (5): e715–72. https://doi. Efficiency and Equity org/10.1016/S2214-109X(22)00005-5. 3 OECD. 2020. Realising the Potential of Primary Health Care. Paris: OECD Publishing. Organisation for Economic Co-operation and SECTION 3 Development. https://www.oecd-ilibrary.org/social-issues-migration-health/realising-the-potential-of-primary-health-care_a92adee4-en. Topic-Specific Analysis Rajan, Dheepa, Katherine Rouleau, Juliane Winkelmann, Dionne Kringos, Melitta Jakab, and Faraz Khalid, eds. 2024. Implementing the Health System Context Primary Health Care Approach: A Primer. Geneva: World Health Organization European Observatory on Health Systems and Policies. https:// Health Financing eurohealthobservatory.who.int/publications/i/implementing-the-primary-health-care-approach-a-primer. Inputs Service Delivery WHO and UNICEF. 2022. Primary Health Care Measurement Framework and Indicators: Monitoring Health Systems through a Primary Health Care Lens. Geneva: World Health Organization; New York: United Nations Children’s Fund. https://iris.who.int/bitstream/ M-10: Hospitals handle/10665/352205/9789240044210-eng.pdf?sequence=1. M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 373 OVERVIEW 1 SECTION 1 What Is a Health PER? EFFICIENCY AND SPENDING ON PHC 2 SECTION 2 Cross-Cutting Efficiency can be assessed by examining input-output PHC spending per capita or as a share of total health expenditure, Analysis on along with the proportion allocated to preventive care, serve as Efficiency and ratios, comparing outcomes across countries that have Equity indicators of efficiency due to the high cost-effectiveness of PHC. A 3 similar spending and income levels, or identifying similar logic applies to the utilization, availability, and effectiveness SECTION 3 indicators of potential waste. While the guide employs of primary health care services. Indicators of inefficiency, such as Topic-Specific poor-quality primary care, lack of essential medicines, and avoidable Analysis a combination of these approaches, this module relies hospitalizations, are also valuable for assessing both the efficiency on benchmarking outcomes across countries with of PHC spending and efficiency of the overall allocation of health Health System Context comparable spending and income levels, as well as resources. Health Financing Inputs identifying indicators of waste. Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 374 OVERVIEW 1 SECTION 1 What Is a Health PER? Spending 2 KEY QUESTIONS • How much is spent on primary health care? How has this spending evolved? SECTION 2 Cross-Cutting • How much is spent on preventive care and essential public health functions? Analysis on Efficiency and Equity 3 Total health expenditure on primary health care (financed expenditure as a share of current health expenditure is reported under the breakdown of expenditure by health care functions (WHO SECTION 3 by all sources) gives a useful starting point for examining 2021a). Alternatively, authors can use or conduct a government Topic-Specific Analysis efficiency. However, as discussed earlier, the concept budget and expenditure analysis as presented in the Public Financial of primary health care is broad, and this is reflected in Management module. Health System Context some different approaches to its measurement, which Health Financing Using the NHA data, most countries for which comparable data interested PER authors can explore further. 1 are available spent between 30 percent and 80 percent of their Inputs Service Delivery current health expenditure on primary health care based on this PER authors should use the methodology of the WHO Global Health methodology (Figure 1). This is quite a wide range and reflects the M-10: Hospitals Expenditure Database (GHED), which relies on the standardized difference in priority attributed to primary health care and the state M-11: Primary Care & Public Health National Health Accounts (NHA) 2 data. Primary health care of health systems. Outcomes 4 List of Acronyms 1 What to include and exclude in primary health care expenditure has been discussed in literature and different exercises documenting primary health care expenditure. For example, the definition of expenditure on primary health care by the National Health Accounts/WHO also includes a substantial share of administrative expenditure being attributed to primary health care. Other authors have modified this definition to limit administrative expenditure but include certain types of hospital expenditure. PER authors interested in the different methodological approaches can refer to literature on this topic, particularly from the Lancet Commission on financing primary health care and SECTION 4 WHO (Hanson et al. 2022; Van de Maele et al. 2019). 2 NHA and, more specifically, the System of Health Accounts 2011, or SHA 2011, is an international accounting framework for systematically tracking health spending. Most countries have conducted this exercise and many do so regular- Additional ly to guide future policies and investments that make health systems more responsive to people’s needs. However, detail and quality of data may vary significantly from country to country, depending on the level of institutionaliza- Guidance tion of NHA. Also of note, current health expenditure under SHA 2011 includes expenditure on maintenance but excludes capital expenditure, or, more precisely, gross fixed capital formation, which is separated in capital expenditure. Current health expenditure is now the standard denominator for international reporting. However, many countries also report total health expenditure in their national publications, and that includes capital expenditure. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 375 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Expenditure on primary health care (or primary level care) as a percentage of current health expenditure Sources • National Health Account reports/MoH 2 • National budget documents SECTION 2 • WHO GHED Cross-Cutting Analysis on • OECD Statistics Efficiency and Equity Government expenditure on primary health care (or primary level care) as a 3 • National Health Accounts reports/MoH percentage of government health expenditure • National budget documents SECTION 3 • WHO GHED Topic-Specific Analysis • OECD Statistics Out-of-pocket expenditure as a share of total PHC spending • National Health Accounts reports/MoH Health System Context Health Financing • National budget documents Inputs • WHO GHED Service Delivery • OECD Statistics M-10: Hospitals Government expenditure on preventive care as a percentage of current health • National Health Accounts reports/MoH expenditure M-11: Primary Care & Public Health • National budget documents Outcomes • WHO GHED 4 List of Acronyms • OECD Statistics Government expenditure on early disease detection, healthy condition monitoring, • National Health Accounts reports/MoH SECTION 4 epidemiological surveillance and risk and disease control programs, preparing Additional • National budget documents Guidance for disaster and emergency response programs as a percentage of current health • WHO GHED expenditure • OECD Statistics Note: MoH = Ministry of Health; OECD = Organisation for Economic Co-operation and Development; PHC = primary health care; WHO GHED = World Health Organization Global Health Expenditure Database. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 376 OVERVIEW 1 SECTION 1 FIGURE 2 PER authors should note that there is no accepted What Is a TOTAL benchmark for spending on primary health care and it Health PER? EXPENDITURE ON PRIMARY is generally considered more cost-effective than most 2 HEALTH CARE hospital care. International empirical analysis has SECTION 2 AS A SHARE Cross-Cutting suggested that higher government spending on primary OF CURRENT Analysis on health care results in better universal health coverage Efficiency and TOTAL HEALTH Equity EXPENDITURE, (UHC) service coverage. However, countries spending $50 3 SELECTED or less per capita display a wide range of UHC service COUNTRIES, coverage outcomes (Hanson et al. 2022). SECTION 3 2018 Topic-Specific Analysis Source: WHO GHED. PER authors can also examine expenditure on primary health care as a share of government spending or as a Health System Context share of the Ministry of Health (MoH) budget, as well Health Financing as expenditure on primary level providers (refer to the Inputs module on Public Financial Management ). Information Service Delivery related to the MoH budget may be available at the M-10: Hospitals country level in the health budget or through national health accounting data (refer to the module on Public M-11: Primary Care & Public Health Financial Management). Outcomes 4 List of Acronyms Internationally, about 50 percent of PHC expenditure was made through out-of-pocket payments (OOP) in low- and SECTION 4 middle-income countries, while the share of OOP for Additional Guidance non-PHC expenditure was substantially lower in 2018, suggesting government inefficiencies in purchasing and TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 377 OVERVIEW 1 SECTION 1 What Is a Health PER? paying for these health services (Hanson et al. 2022). As such, PER authors should monitor the trend of OOP as a share of total PHC expenditure in a country over time to assess whether the costs of all preventive care and spending on the four essential public health functions listed above. If reliable data on the levels and trends in subcategories of prevention expenditure are available in country 2 PHC services are being borne by the public purse. NHA reports, they could be used to understand the amount of SECTION 2 Cross-Cutting funding dedicated to these types of essential services—for example, Analysis on Countries should evaluate whether they are investing adequately immunization services or epidemiological surveillance programs. Efficiency and Equity in preventive care—especially in essential public health activities, There are estimates of costs for ensuring preparedness against 3 which are crucial for maintaining health security and resilience future health threats at the international level as well as in some SECTION 3 against health threats, including pandemics like COVID-19 and other countries (Clarke et al. 2022), and these estimates can provide some Topic-Specific events like natural disasters. These activities include public health benchmarks to assess country spending. Estimates have largely Analysis surveillance, disease prevention, early detection programs, and relied on frameworks for assessing the capacity of countries to emergency planning (WHO 2022a). They are implemented through respond to health threats that pre-date the COVID-19 pandemic. Health System Context various platforms such as reference laboratories, national and Eaneff et al. (2022) found that, on average, about $16 per capita over Health Financing regional public health bodies, and cross-sectoral collaborations. five years would be required globally for all countries to reach a Inputs satisfactory level of preparedness based on the criteria of the Joint Service Delivery The WHO GHED based on SHA 2011 presents information on External Evaluation of WHO4 (Table 1). While the spending reported M-10: Hospitals preventive care. 3 Preventive care includes expenditure on in explicit SHA 2011 categories on essential public health functions M-11: Primary Care & Public Health immunization, health promotion and the essential public health does not cover all areas of preparedness, any available country data functions of early disease detection, healthy condition monitoring, on expenditure on preparedness could be assessed against these Outcomes epidemiological surveillance and risk, and disease control programs. types of estimates5. 4 List of Acronyms For assessment purposes, PER authors should examine spending on SECTION 4 3 Preventive expenditure can be found under the Classification of Health Care Functions in SHA 2011, specifically HC.6. Additional 4 The Joint External Evaluation is an assessment of country-specific status and progress in developing the capacity to prevent, detect, and rapidly respond to public health threats, whether naturally occurring, deliberate, or acci- Guidance dental. The first external evaluation establishes a baseline measurement of the country’s capacity and capabilities, and subsequent evaluations identify progress made and sustainability of improvements. It is a tool related to the International Health Regulations (IHR). 5 The catchment area of a primary care facility is the population that the facility is supposed to serve. This can be the population of the neighborhood or the town where the facility is located or the number of beneficiaries regis- tered to be served at the facility. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 378 OVERVIEW 1 SECTION 1 What Is a Health PER? TABLE 1 AVOIDABLE HOSPITALIZATIONS, BY HOSPITAL TYPE, ESTONIA, 2013 2 SECTION 2 World Bank Income Total per capita cost (over 5 years) Total per capita cost (over 5 years) Cross-Cutting Analysis on Low income $66.84 $45.9 billion Efficiency and Equity 3 Lower middle income $17.79 $52.5 billion Upper middle & high income $6.19 $25.5 billion SECTION 3 Topic-Specific TOTAL $15.98 $123.8 billion Analysis Source: Eaneff et al. 2022. Health System Context Health Financing CASE EXAMPLE: MALAYSIA Inputs Service Delivery Malaysia regularly conducts NHA exercises. and preventive care, was 7 percent of total spending generally about 21 percent in recent M-10: Hospitals The latest National Health Account report health expenditure. years. This is much lower than spending on M-11: Primary Care & Public Health tracks expenditure from 1997 to 2019. This hospitals, which ranged from 46 percent to report presents expenditure on primary The report also presents expenditure by 55 percent of total health expenditure. In Outcomes health care, which was 22 percent of total level of provider, consistent with the low 2019, out-of-pocket payments represented 4 List of Acronyms health expenditure as well as 22 percent of spending on PHC. Expenditure on providers the biggest source of financing to ambulatory MoH health expenditure in 2019. Spending on of ambulatory care ranged from 16 percent to care providers at over 45 percent (Ministry of SECTION 4 public health services, including promotive 25 percent of total health expenditure, with Health, Malaysia 2021). Additional Guidance Box continues on the following page. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 379 OVERVIEW 1 SECTION 1 What Is a Health PER? CASE EXAMPLE: MALAYSIA (continued) 2 SECTION 2 While the public primary care system is heavily subsidized and away from a hospital-centric acute care model. Some progress Cross-Cutting Analysis on payments to the private primary care system are regulated, the has been made in this area, for example, through government Efficiency and overall priority of primary health care remains low in terms of financing for a new noncommunicable disease program targeted at Equity 3 expenditure. However, there is recognition for the need to move low-income groups (WHO 2023). SECTION 3 Topic-Specific FIGURE 1 Analysis PRIMARY HEALTH CARE EXPENDITURE AS PERCENTAGE OF TOTAL EXPENDITURE ON HEALTH, 2019 Health System Context Health Financing RM13,965 Primary Health Care RM13,965 Primary Health Care Million Million Inputs 22% 22% Others Others Service Delivery M-10: Hospitals Total Expenditure on Total MOH Expenditure Health 2019: 2019: (RM64,306 Million) (RM28,860 Million) M-11: Primary Care & Public Health Outcomes RM50,341 RM50,341 4 List of Acronyms Million Million 78% 78% SECTION 4 Additional Guidance Source: Malaysia National Health Accounts Health Expenditure Report 1997–2019. Box continues on the following page. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 380 OVERVIEW 1 SECTION 1 What Is a Health PER? CASE EXAMPLE: MALAYSIA (continued) 2 SECTION 2 FIGURE 2 FIGURE 3 Cross-Cutting TOTAL EXPENDITURE ON HEALTH TO PROVIDERS OF HEALTH PUBLIC SECTOR HEALTH EXPENDITURE TO PROVIDERS OF Analysis on Efficiency and CARE, 2019 HEALTH CARE, 2019 Equity 3 5% 60% Hospitals 55.3% Percent of providers of health care 1% SECTION 3 50% 4% Ambulatory health care Topic-Specific 40% Analysis General health admin. & 30% Public Sector Health insurance 12% Expenditure: 21.3% Health System Context 20% 52.5% of TEH Institutions (RM33,731 Million) 8.5% 8.5% Health Financing 10% 6.4% 0% Provision and administration Inputs All hospitals Providers of General Retail sale & All other of public health programmes 60% ambulatory health admin. medical goods providers 18% Service Delivery health care & insurance providers All other providers M-10: Hospitals M-11: Primary Care & Public Health Source: Malaysia National Health Accounts Health Expenditure Report 1997–2019. Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 381 OVERVIEW 1 SECTION 1 What Is a Health PER? Infrastructure and Inputs 2 KEY QUESTIONS • What primary care infrastructure exists in the country? SECTION 2 • What are the numbers of key health workers for primary care? Cross-Cutting Analysis on • What is the availability of medicines and other health products in primary facilities? Efficiency and Equity 3 Key Indicators Sources SECTION 3 Number of primary care health facilities • Health facility surveys (WB SDI, WHO SARA, DHS SPA, HHFA) Topic-Specific Analysis Density of primary care health facilities (number of facilities per 100,000) • MoH infrastructure maps, inventory of facilities Number of primary care health workers by type (generalist, nurse, • MoH Health System Context midwife, community) per 10,000 population • Human resource information system Health Financing • Professional councils and associations Inputs • Reports on HRH (will typically have the latest available numbers) • OECD Service Delivery M-10: Hospitals Share of primary care health workers as a percentage of total health • MoH workers, by cadre • Human resource information system M-11: Primary Care & Public Health • Professional councils and associations Outcomes • Reports on HRH (will typically have the latest available numbers) • OECD 4 List of Acronyms Percentage of primary care health facilities where essential medicines • MoH SECTION 4 are available • Health facility surveys (WB SDI, WHO SARA, DHS SPA, HHFA) Additional Guidance Note: DHS SPA = Demographic and Health Surveys Service Provision Assessment; HHFA = Harmonized Health Facility Assessment; HRH = human resources for health; MoH = Ministry of Health; OECD = Organisation for Economic Co- operation and Development; WB SDI = World Bank Service Delivery Indicators; WHO SARA = World Health Organization Service Availability and Readiness Assessment. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 382 OVERVIEW 1 SECTION 1 What Is a Health PER? In contrast to hospital services, there are different ways of delivering primary care to populations. These methods include facility- As mentioned earlier, the density of the availability of health workers often plays a more important role for primary care as 2 based services but also other models, such as outreach services service delivery than physical infrastructure. PER authors should SECTION 2 or community care. In this context, the availability of health workers examine the numbers of generalist physicians (including physicians Cross-Cutting is a primary determinant of efficient primary care. Additionally, who have trained in the specialties of family medicine or primary Analysis on Efficiency and not having sufficient equipment and supplies is not uncommon care in countries where these exist), nurses and midwives, as Equity 3 and can result in underproductive health workers and underused well as community health workers and professions such as nurse infrastructure, resulting in inefficiencies. practitioners (in countries where they exist) and their evolution SECTION 3 over time. The share of these health workers can also be compared Topic-Specific Analysis This section covers some basic indicators of primary care to their overall cadre, for example, generalist physicians as a share infrastructure and inputs for PER authors to evaluate its sufficiency of all physicians, to assess whether sufficient policy and societal Health System Context and mix. Authors can consult the module Human Resources for importance has been given to ensure the availability of human Health Financing Health fffff and the additional guidance note Service Availability resources for primary care. The share has been declining in many Inputs and Readiness fffff for more details. countries, with physicians not attracted to careers in primary care due to several factors, such as a lower financial prospects Service Delivery A useful starting point can be assessing the availability of the and perceived poorer working conditions (OECD 2020). Overall, M-10: Hospitals overall physical infrastructure for primary care by determining decreasing numbers and densities of primary care workers is likely M-11: Primary Care & Public Health the number of primary care facilities per 100,000 population in to signal less efficient use of financial and human resources in Outcomes the country and their breakdown by type of facility. PER authors improving the population’s health status. should rely on the national classifications of primary care facilities, 4 List of Acronyms which typically consist of multiple levels and often include the Data on the availability of other critical inputs, such as essential SECTION 4 simplest kind of hospitals (facilities with inpatient services) as medicines and diagnostics at primary care facilities, can also Additional part of the primary care system. While these can be analyzed as provide important information on the capacity to deliver quality Guidance well, information on them should be separated from facilities with services. Data on the overall availability of essential medicines in only outpatient services. health facilities are collected in health facility surveys and are also TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 383 OVERVIEW 1 SECTION 1 What Is a Health PER? part of the means of implementation targets for Sustainable Development Goal (SDG) 3 (WHO and 2 UNICEF 2022). The same health facility surveys also SECTION 2 document the availability of medicine and other Cross-Cutting commodities for specific health services. Thus, PER Analysis on Efficiency and authors can further examine the capacity to deliver Equity 3 specific high-priority health services, the choice of which can be tailored according to the population SECTION 3 of and the disease priorities in each given context. Topic-Specific Analysis The additional guidance note Service Availability and Readiness provides more information. Health System Context Health Financing Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 384 OVERVIEW 1 SECTION 1 What Is a Health PER? Use of primary care 2 KEY QUESTIONS • How much are primary care services used? SECTION 2 • What is the coverage of key primary care services? Cross-Cutting Analysis on • Are primary care services effectively organized? Efficiency and Equity 3 Key Indicators Sources SECTION 3 Topic-Specific Number of visits to primary care providers per capita per year, by area • Health utilization surveys Analysis • MoH • National health insurance fund Health System Context Outpatient visits per capita per year, by area • Health utilization surveys Health Financing • MoH Inputs • National health insurance fund Service Delivery Coverage of immunization services, by area • Health utilization surveys M-10: Hospitals • MoH M-11: Primary Care & Public Health • National health insurance fund Outcomes Screening for cervical cancer, by area • Health utilization surveys • MoH 4 List of Acronyms • National health insurance fund SECTION 4 Percent of children under 5 with diarrhea who received zinc and oral • Demographic and health surveys Additional rehydration services • UNICEF Data Guidance Table continues on the following page. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 385 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Unmet need for health services, by area Sources • Health utilization surveys 2 • MoH SECTION 2 • National health insurance fund Cross-Cutting Analysis on Percentage of population with a regular primary care provider, by area • Health utilization surveys Efficiency and • MoH Equity 3 • National health insurance fund Information on waiting times for a primary care consultation, by area • Health utilization surveys SECTION 3 Topic-Specific • MoH Analysis • National health insurance fund Information on gatekeeping/referrals by primary care providers, by • Health utilization surveys Health System Context area • MoH Health Financing • National health insurance fund Inputs Note: MoH = Ministry of Health. Service Delivery Effective primary care reduces the unnecessary use of more care services are cost-effective in a similar manner across settings. M-10: Hospitals expensive hospital services and improves health outcomes in a The number of visits to primary care providers per capita per year M-11: Primary Care & Public Health cost-effective way. Indeed, use of primary care services, particularly is collected in health service utilization surveys. These surveys Outcomes for first-contact care, is a major policy goal for countries looking to and administrative data sources also have more basic information 4 List of Acronyms improve the efficiency and equity of their overall health spending. on the number of outpatient visits per capita, which include visits As such, basic indicators on the use and quality of primary care to hospital outpatient departments. The number of visits can be SECTION 4 services can be used to assess efficiency, as explained in the further broken down by the provider’s catchment population for Additional introduction to this section. This relies on the premise that primary comparison between different providers.6 Guidance 6 The catchment area of a primary care facility is the population that the facility is supposed to serve. This can be the population of the neighborhood or the town where the facility is located or the number of beneficiaries regis- tered to be served at the facility. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 386 OVERVIEW 1 SECTION 1 What Is a Health PER? Unmet need for health services is an indicator that is routinely collected in health surveys FIGURE 2 PERCENTAGE OF WOMEN AGES 15–49 WITH FAMILY PLANNING NEEDS SATISFIED BY 2 such as the Demographic and Health Survey MODERN METHODS SECTION 2 and used to measure the effectiveness of Cross-Cutting PHC. High unmet need is strongly associated Analysis on Efficiency and with weak primary care systems and Equity 3 multiple dimensions of inequity and their intersectionality. For example, unmet need SECTION 3 for family planning services/contraceptives Topic-Specific Analysis can be used as an indicator of effective primary care but varies considerably across Health System Context countries as well as within countries, with Health Financing less educated, rural poor women having the Inputs highest unmet need. It may also indicate inefficiency in overall allocation of resources Service Delivery given its high cost-effectiveness as well as its M-10: Hospitals contribution to reduced mortality. Globally, M-11: Primary Care & Public Health it is estimated that addressing 90 percent of Outcomes the unmet need for contraceptive services would reduce maternal deaths by 22 percent, 4 List of Acronyms stillbirths by 22 percent, and child deaths by SECTION 4 8 percent (Black et al. 2016). Additional Source: World Health Organization. Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 387 OVERVIEW 1 SECTION 1 What Is a Health PER? Ensuring that people have a regular primary care provider is considered important for the effectiveness of the primary care doctors through a referral from a primary care provider. A high number of visits to specialists without a referral suggests a weaker 2 system, and the number who do can be approximated through primary care system, which often leads to higher health care costs. SECTION 2 the percentage of population empaneled with a primary care Finally, some countries have primary care monitoring frameworks Cross-Cutting provider (Rajan et al. 2024). Long waiting times for primary care (or (similar to hospital performance assessment frameworks), which Analysis on Efficiency and unavailability at night or during weekends) tend to lower use and are used for monitoring and also in relation to financing health Equity 3 effectiveness, as people may seek alternative care, for example, in providers. If such a framework exists, PER authors can examine its hospital emergency rooms. PER authors can examine administrative indicators to assess general productivity of primary care facilities. SECTION 3 data for waiting times to consult a primary care provider, including Topic-Specific Analysis insurance data, as well as some health and other household surveys. The Primary Health Care Performance Initiative (PHCPI), which concluded in 2022, was an international framework for monitoring Health System Context Similarly, how primary care is organized, for example, through key and improving primary health care, The PHCPI has been used Health Financing practices such as gatekeeping and referrals to other providers, is a in many low- and middle-income countries. Data collected and Inputs significant determinant of its effectiveness. If data are available in compiled for the PHCPI may be helpful to PER authors in assessing health insurance or Ministry of Health information systems or annual primary health care. Service Delivery reports, PER authors can look at the share of visits to specialist M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 388 OVERVIEW 1 SECTION 1 What Is a Health PER? Quality of primary care 2 KEY QUESTIONS • Are antibiotics prescribed/used appropriately? SECTION 2 • Do diagnosis and treatment in primary care services follow guidelines? Cross-Cutting Analysis on • Does primary care result in better health for selected conditions? Efficiency and Equity 3 Quality of health services is assessed with SECTION 3 Key Indicators Sources comprehensive frameworks covering domains Topic-Specific Analysis such as accessibility, effectiveness, safety, Data on the prescription/use of • MoH, AMR monitoring patient-centeredness, timeliness, equity, and antibiotics • National health insurance fund • Prescription audits or specialized studies Health System Context integration (Primary Health Care Performance Health Financing Initiative, n.d.; Agency for Healthcare Research Diagnostic accuracy • World Bank SDI Inputs and Quality, n.d.). The aim of this section is to present a few indicators of quality that may Adherence to standard care protocols • Health facility surveys (World Bank SDI, Service Delivery WHO SARA, DHS SPA, HHFA) shed light on efficiency. PER authors can also M-10: Hospitals consult the additional guidance note Quality of Percentage of population with • Health surveys with biomarker data M-11: Primary Care & Public Health Health Services for more in-depth guidance on uncontrolled hypertension, by area • Administrative data Outcomes the measurement of quality. • Quality assessment information systems 4 List of Acronyms Percentage of population with • Health surveys with biomarker data The inappropriate use of antibiotics leads to the uncontrolled diabetes, by area • Administrative data SECTION 4 waste of financial resources, reflects poor quality • Quality assessment information systems Additional care and contributes to anti-microbial resistance, Guidance Note: AMR = antimicrobial resistance; DHS SPA = Demographic and Health Surveys Service Provision Assessment; HHFA = a major health threat that is often common in Harmonized Health Facility Assessment; MoH = Ministry of Health; SDI = Service Delivery Indicators; WHO SARA = World Health Organization Service Availability and Readiness Assessment. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 389 OVERVIEW 1 SECTION 1 What Is a Health PER? primary care. A meta-analysis of studies from low-income countries found that 52 percent of patient visits to primary care providers Diagnostic accuracy in primary care is an area that has received significant attention, including through the work on standardized 2 resulted in a prescription of antibiotics. Among the studies that patients and clinical vignettes. Provider knowledge is assessed in SECTION 2 assessed the appropriateness of antibiotic prescriptions, all but some health facility surveys through clinical vignettes, including Cross-Cutting one showed 50 percent or more inappropriate use, and often all the World Bank SDI survey. Health facility surveys may also examine Analysis on Efficiency and prescriptions for antibiotics were inappropriate (Sulis et al. 2020). patients’ medical records data to check adherence to standard care Equity 3 protocols. This would be useful to examine in countries where such Information on the prescription of antibiotics in primary care information exists. SECTION 3 settings may exist in health insurance databases or specific studies Topic-Specific Analysis related to medicines or to antimicrobial resistance, for example, Finally, indicators of “effective coverage” capture information on studies on prescribing practices or prescription audits based quality and could be useful to monitor. While these indicators are also Health System Context on patient data, or academic studies. However, representative impacted by access to primary care, poor quality of care also plays Health Financing national information may not be available in most countries. a role. For example, high prevalence of uncontrolled hypertension Inputs So, PER authors could consider trends in the overall use of indicates poor screening, diagnosis, and/or inadequate treatment antibiotics (across providers), particularly for medicines that are by primary care providers. The same logic would apply to diabetes, Service Delivery not considered first-line treatments according to well-established for example. While it has been difficult to assess the extent of these M-10: Hospitals international guidance in this area (WHO, n.d.-b). Many countries issues historically, health surveys with biomarker information are M-11: Primary Care & Public Health have national anti-microbial resistance plans that may collect now more common. As such, PER authors can use these indicators Outcomes information on the general use of antibiotics in line with such to assess the quality of primary care services in a country, in relation plans, including the international WHO-GLASS framework (WHO, to efficiency through preventable morbidity and mortality based on 4 List of Acronyms n.d.-a). Authors can consult the Medicines and Medical Supplies the burden of disease. The module on Service Coverage provides SECTION 4 module for more information. additional guidance. Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 390 OVERVIEW 1 SECTION 1 What Is a Health PER? Integration of services 2 SECTION 2 Cross-Cutting Analysis on Efficiency and KEY QUESTIONS • How many hospitalizations are avoidable? Equity • What are the trends in emergency room visits? 3 SECTION 3 Topic-Specific Analysis Health System Context Primary care and specialized/hospital care should complement each other, with the health system providing a continuum of coordinated care across different levels to people throughout Hospitalizations for “ambulatory care sensitive conditions” (ACSC) are hospitalizations that could have been prevented with access to effective primary care. These are problematic both from an efficiency their life course with care always delivered in the most appropriate and quality of care perspective Similarly, a high number of visits to Health Financing setting. This type of care model improves health outcomes and hospital emergency rooms compared to other countries is indicative Inputs minimizes the use of inappropriate health services. Different of a weak primary care system. For example, people without a Service Delivery avenues exist for providing coordinated services through integrated regular primary care provider are more likely to seek care at hospital M-10: Hospitals models of care. For the purposes of a PER, authors should focus emergency rooms (Fung et al. 2015). While ACSC hospitalizations and M-11: Primary Care & Public Health on indicators of integration. emergency room visits could also be related to poor quality of care at the primary level, they are often related to poor integration of Outcomes Overall, a lack of integration of services can be a major source services. PER authors can refer to the module on Hospitals and 4 List of Acronyms of inefficiency due to duplication of services, and ineffective and its annexes for more detailed information on these topics. untimely care, which may result in the use of more expensive levels SECTION 4 Additional of care. Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 391 OVERVIEW 1 SECTION 1 What Is a Health PER? Equity 2 SECTION 2 Cross-Cutting Analysis on KEY QUESTIONS • How is unmet need for care distributed across different population groups? Efficiency and Equity • What is the coverage of key interventions across different population groups? 3 SECTION 3 Topic-Specific Analysis Health System Context Equity concerns are central to the concept of primary health care. Here, equity is analyzed by disaggregating data on coverage of primary care services across socioeconomic Key Indicators Unmet need for health services Sources • Health surveys dimensions, with inequity represented by the difference by socioeconomic status Health Financing between better-off and vulnerable populations. As a Reasons for forgoing care by Inputs starting point, PER authors can explore some of the socioeconomic status Service Delivery indicators discussed previously but disaggregated across Coverage of selected health • Health surveys M-10: Hospitals socioeconomic dimensions7. Broader linkages between services by socioeconomic M-11: Primary Care & Public Health inequality and primary health care are discussed in the box status later in this section. Outcomes Information on responsiveness • MoH 4 List of Acronyms and patient experience by • Existing studies 7 It is also possible to disaggregate primary care inputs, such as financing or human resourc- es, across some socioeconomic dimensions, such as urban versus rural areas. Similarly, socioeconomic status SECTION 4 primary care health status outcomes, such as prevalence of diseases like diabetes, can be disaggregated across socioeconomic dimensions. The module on Health Status and Health Note: MoH = Ministry of Health. Additional Risks fffffand those on different inputs like Human Resources for Health fffffdiscuss these aspects. Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 392 OVERVIEW 1 SECTION 1 What Is a Health PER? Unmet need for care is strongly associated with socioeconomic differences. For example, girls and women ages 15–49 were more care highlight different challenges including social norms and practices, such as women’s autonomy and independence (Figure 2 likely to forgo needed health care if they lived in rural areas, 3). Financial barriers to access could be addressed with the SECTION 2 were less educated, or from poorer income groups across surveys expansion of financial risk protection (see module on Financial Cross-Cutting and countries (WHO SEARO 2024). Their reasons for forgoing Risk Protection). Analysis on Efficiency and Equity 3 FIGURE 3 REASONS FOR FORGOING HEALTH CARE AMONG FEMALES AGES 15–49 YEARS (HOUSEHOLD SURVEYS, 2011–21) SECTION 3 Topic-Specific Analysis Health System Context Health Financing Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance Source: WHO SEARO 2024. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 393 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors can also examine socioeconomic and regional variation in service use based on household health surveys. These the number of primary health facilities and primary care health workers in different parts of a country can also be considered. 2 services include, for example, childhood immunizations, delivery Goals for coverage in these services may be part of the monitoring SECTION 2 by a skilled birth attendant/in a health facility, cervical cancer frameworks for the national health policy or subsectoral strategies. Cross-Cutting screening, and hypertension or diabetes control. The number PER authors interested in exploring these issues further can also Analysis on Efficiency and of visits to primary care providers per 100,000 population or consult the Service Coverage module of this series. Equity 3 SECTION 3 Topic-Specific Analysis Health System Context COUNTRY EXAMPLE: DTP3 COVERAGE IN NIGERIA Health Financing Nigeria increased coverage of three doses of the DTP vaccine among 2018 in the southeast, at 83.4 percent, compared to 29.8 percent in 1-year-olds, from 22.2 percent in 2003 to over 50 percent in 2018 the northwest. Analysis of the 2018 data also shows that complete Inputs (WHO Health Inequality Data Repository, n.d.). Through examining vaccination coverage among infants ages 12–23 months also strongly Service Delivery multiple rounds of DHS data, however, it is clear that this progress varied across ethnicities, with only 18.2 percent of Hausa/Fulani M-10: Hospitals is not consistent across different population groups. Inequity children fully vaccinated compared to 40.8 percent of Yoruba M-11: Primary Care & Public Health in coverage across socioeconomic dimensions such as wealth and 56.3 percent of Igbo children. Even after controlling for other quintile, education level of the mother, and age of the mother has socioeconomic factors, significant differentials in coverage across Outcomes not consistently declined. There is also a huge gradient from the ethnic lines remained (Afolabi et al. 2021). 4 List of Acronyms north to the south of the country, with the highest coverage in SECTION 4 Additional Box continues on the following page. Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 394 OVERVIEW 1 SECTION 1 What Is a Health PER? COUNTRY EXAMPLE: DTP3 COVERAGE IN NIGERIA (continued) 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context Health Financing Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance Source: Figure from the WHO Global Health Observatory. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 395 OVERVIEW 1 SECTION 1 What Is a Health PER? INEQUALITY IN PRIMARY HEALTH CARE 2 SECTION 2 As described earlier, the concept of primary health care addresses When conducting a PER, it is important to consider the different Cross-Cutting the broader determinants of health through multisectoral policy and populations—particularly marginalized groups—in the country and Analysis on Efficiency and action as well as empower individuals, families, and communities their experiences with health service delivery. For example, distrust Equity 3 to take charge of their own health. Both these aspects are central of health providers or the government stemming from discrimination to PHC’s aim of reducing inequalities and social justice. Addressing against persons or communities, often reflecting structural biases SECTION 3 social and commercial determinants directly are key for reducing in health systems, can result in lower use of health services, higher Topic-Specific inequality in health. Similarly, empowerment entails changing power unmet health needs, and poorer health status, despite higher Analysis dynamics and giving people a stronger voice. This is closely linked overall health needs. Therefore, PER authors should consider the to the idea of “people-centered” or “person-centered” care, which intersection of diversity and inclusion issues relevant to each Health System Context emphasizes the holistic needs of people and communities. To meet context (for example, disability, sexuality) in addition to traditional Health Financing those needs, care must be delivered in a way that is more respectful equity dimensions such as income. Authors could draw on existing Inputs and responsive. quantitative and qualitative data on responsiveness and patient Service Delivery satisfaction, which would add significant depth to analysis. M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 396 OVERVIEW 1 SECTION 1 What Is a Health PER? Processes and governance 2 KEY QUESTIONS • Is country policy oriented toward a primary health care approach to health? SECTION 2 • Is there a robust national response plan for health emergencies and disasters? Cross-Cutting Analysis on • Are primary care services included in benefit packages? Efficiency and Equity • How are primary care facilities managed? Are there many staff vacancies in 3 primary care facilities? SECTION 3 Topic-Specific Analysis There are many factors to consider when exploring Key Indicators Sources primary health care governance and processes in a Health System Context Is the national health policy/ • KIIs country. Overall, a good starting point is for PER authors Health Financing to assess whether national health policy is oriented strategy oriented toward primary • Health policy/strategy documents Inputs toward a primary health care approach to health. This health care? (Yes/No) Service Delivery could be supported through political or normative Is there a robust health emergency • KIIs M-10: Hospitals recognition and adoption of primary health care and preparedness plan? (Yes/No) • Health policy/strategy documents related concepts, such as integrated health services M-11: Primary Care & Public Health Does the country have a PHC • KIIs and Health in All Policies. It is critical for authors to Outcomes monitoring framework? • Health policy/strategy documents study the national health policy/strategy: at the very 4 List of Acronyms least, this document should recognize the importance How much autonomy do providers • KIIs of primary care and of strengthening non-hospital- have in decision making? SECTION 4 based health services to be considered PHC oriented. Additional Vacancies in primary care facilities • MoH Guidance Note: KII = key informant interview; MoH = Ministry of Health. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 397 OVERVIEW 1 SECTION 1 What Is a Health PER? For public health and essential public health functions, the existence of a robust health emergency preparedness plan is n.d.). PER authors may explore whether the country has such frameworks in place and whether it monitors PHC performance. 2 important. WHO guidance on plans for health emergencies and SECTION 2 disasters can be used to assess the existing country approach Efficient primary care hinges on well-managed facilities and PER Cross-Cutting (WHO 2021b). Additionally, a Joint External Evaluation assessment authors overseen by trained managers equipped with necessary Analysis on Efficiency and of the country’s preparedness can be used if it has been conducted tools and resources. Granting facilities autonomy, for example, Equity 3 recently (WHO 2022). in decisions related to human resources management, enhances responsiveness to financial incentives and improves performance. SECTION 3 Some countries have also embraced primary care performance High staff vacancy rates in primary care impact efficiency and may Topic-Specific Analysis monitoring and developed or adopted frameworks for this, such stem from inadequate and unattractive staffing conditions or as the international PHCPI framework. Some countries also use delayed recruitment, despite secured funding for positions (see Health System Context primary care performance monitoring for funding purposes, the Human Resources for Health module). Health Financing including the well-known Quality and Outcomes Framework, Inputs which has been used to partially determine payments to general practitioners in the UK’s National Health Service since 2004 (NHS, Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 398 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Acknowledgments Efficiency and Equity 3 This module builds on the concepts and content of the other modules and additional guidance notes, including SECTION 3 Topic-Specific the Service Availability and Readiness, and Quality of Analysis Health Services, notes. We would like to acknowledge the work and contribution of the authors of these documents. Health System Context We are also extremely thankful to Manuela Villar Uribe for Health Financing a thorough review and feedback on this module. Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 399 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Afolabi, Rotimi Felix, Mobolaji M. Salawu, Babatunde Makinde Gbadebo, Adetokunbo T. Salawu, Adeniyi Francis Fagbamigbe, and Ayo Ste- Cross-Cutting Analysis on phen Adebowale. 2021. “Ethnicity as a Cultural Factor Influencing Complete Vaccination among Children Aged 12-23 Months in Nigeria.” Hu- Efficiency and Equity man Vaccines & Immunotherapeutics 17 (7): 2008–17. https://doi.org/10.1080/21645515.2020.1870394. 3 Agency for Healthcare Research and Quality. n.d. “AHRQ Quality Indicators.” Accessed May 3, 2024. https://qualityindicators.ahrq.gov/Down- SECTION 3 loads/Modules/V2023/AHRQ_QI_Indicators_List.pdf. Topic-Specific Analysis Black, Robert E., Carol Levin, Neff Walker, Doris Chou, Li Liu, and Marleen Temmerman. 2016. “Reproductive, Maternal, Newborn, and Child Health: Key Messages from Disease Control Priorities 3rd Edition.” The Lancet 388 (10061): 2811–24. https://doi.org/10.1016/S0140- Health System Context 6736(16)00738-8. Health Financing Clarke, Lorcan, Edith Patouillard, Andrew J. Mirelman, Zheng Jie Marc Ho, Tessa Tan-Torres Edejer, and Nirmal Kandel. 2022. “The Costs of Inputs Improving Health Emergency Preparedness: A Systematic Review and Analysis of Multi-Country Studies.” eClinicalMedicine 44 (February). Service Delivery https://doi.org/10.1016/j.eclinm.2021.101269. M-10: Hospitals GHED. n.d. Accessed May 3, 2023. Global Health Expenditure Database, World Health Organization, Geneva. https://apps.who.int/nha/data- M-11: Primary Care & Public Health base/ViewData/Indicators/en. Outcomes Gmeinder, Michael, David Morgan, and Michael Mueller. 2017. “How Much Do OECD Countries Spend on Prevention?” Paris: OECD Publishing. 4 List of Acronyms Organisation for Economic Co-operation and Development. https://doi.org/10.1787/f19e803c-en. SECTION 4 Government of Chile, PAHO, and WHO. “Investing in the Radical Reorientation of Health Systems towards Primary Health Care.” Side event Additional at the UN General Assembly, 78th session. September 21, 2023. Pan American Health Organization, Washington, DC; World Health Organiza- Guidance tion, Geneva. https://www.paho.org/en/events/investing-radical-reorientation-health-systems-towards-primary-health-care. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 400 OVERVIEW 1 SECTION 1 What Is a Health PER? Hanson, Kara, Nouria Brikci, Darius Erlangga, Abebe Alebachew, Manuela De Allegri, Dina Balabanova, Mark Blecher, et al. 2022. “The Lancet Global Health Commission on Financing Primary Health Care: Putting People at the Centre.” The Lancet Global Health 10 (5): e715–72. https:// 2 doi.org/10.1016/S2214-109X(22)00005-5. SECTION 2 Cross-Cutting Khatri, Resham B., Eskinder Wolka, Frehiwot Nigatu, Anteneh Zewdie, Daniel Erku, Aklilu Endalamaw, and Yibeltal Assefa. 2023. “People-Cen- Analysis on tred Primary Health Care: A Scoping Review.” BMC Primary Care 24 (1): 236. https://doi.org/10.1186/s12875-023-02194-3. Efficiency and Equity 3 Laxminarayan, Ramanan, Anne J. Mills, Joel G. Breman, Anthony R. Measham, George Alleyne, Mariam Claeson, Prabhat Jha, et al. 2006. “Advancement of Global Health: Key Messages from the Disease Control Priorities Project.” The Lancet 367 (9517): 1193–1208. https://doi. SECTION 3 org/10.1016/S0140-6736(06)68440-7. Topic-Specific Analysis Macinko, James, Barbara Starfield, and Leiyu Shi. 2007. “Quantifying the Health Benefits of Primary Care Physician Supply in the United States.” International Journal of Health Services: Planning, Administration, Evaluation 37 (1): 111–26. https://doi.org/10.2190/3431-G6T7- Health System Context 37M8-P224. Health Financing Ministry of Health, Malaysia. 2021. Malaysia National Health Accounts Health Expenditure Report 1997-2021. https://www.moh.gov.my/moh/ Inputs resources/Penerbitan/Penerbitan%20Utama/MNHA/MNHA_Health_Expenditure_Report_1997-2019_02092021.pdf. Service Delivery M-10: Hospitals NHS. n.d. Quality and Outcomes Framework. Accessed March 11, 2024. UK National Health Service. https://qof.digital.nhs.uk/. M-11: Primary Care & Public Health OECD. 2020. Realising the Potential of Primary Health Care. Paris: OECD Publishing. Organisation for Economic Co-operation and Develop- Outcomes ment. https://www.oecd-ilibrary.org/social-issues-migration-health/realising-the-potential-of-primary-health-care_a92adee4-en. 4 List of Acronyms Primary Health Care Performance Initiative. n.d. Accessed July 10, 2024. https://www.improvingphc.org/measuring-progress-phc. Rajan, Dheepa, Katherine Rouleau, Juliane Winkelmann, Dionne Kringos, Melitta Jakab, and Faraz Khalid, eds. 2024. Implementing the Prima- SECTION 4 ry Health Care Approach: A Primer. European Observatory on Health Systems and Policies, World Health Organization, Geneva. https://euro- Additional Guidance healthobservatory.who.int/publications/i/implementing-the-primary-health-care-approach-a-primer. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 401 OVERVIEW 1 SECTION 1 What Is a Health PER? Russo, Letícia Xander, Anthony Scott, Peter Sivey, and Joilson Dias. 2019. “Primary Care Physicians and Infant Mortality: Evidence from Bra- zil.” PLOS ONE 14 (5): e0217614. https://doi.org/10.1371/journal.pone.0217614. 2 Sulis, Giorgia, Pierrick Adam, Vaidehi Nafade, Genevieve Gore, Benjamin Daniels, Amrita Daftary, Jishnu Das, Sumanth Gandra, and Madhu- SECTION 2 Cross-Cutting kar Pai. 2020. “Antibiotic Prescription Practices in Primary Care in Low- and Middle-Income Countries: A Systematic Review and Meta-Analy- Analysis on sis.” PLOS Medicine 17 (6): e1003139. https://doi.org/10.1371/journal.pmed.1003139. Efficiency and Equity 3 Van de Maele, Nathalie, Ke Xu, Agnes Soucat, Lisa Fleisher, Maria Aranguren, and Hong Wang. 2019. “Measuring Primary Healthcare Expendi- ture in Low-Income and Lower Middle-Income Countries.” BMJ Global Health 4 (1): e001497. https://doi.org/10.1136/bmjgh-2019-001497. SECTION 3 Topic-Specific WHO. 2018a. Building the Economic Case for Primary Health Care: A Scoping Review. https://www.who.int/publications-detail-redirect/ Analysis WHO-HIS-SDS-2018.48. Geneva: World Health Organization. Health System Context WHO. 2018b. Essential Public Health Functions, Health Systems and Health Security: Developing Conceptual Clarity and a WHO Roadmap for Health Financing Action. Geneva: World Health Organization. https://iris.who.int/handle/10665/272597. Inputs WHO. 2021a. “Measuring Primary Health Care Expenditure under SHA 2011.” Technical Note. World Health Organization, Geneva. https://cdn. Service Delivery who.int/media/docs/default-source/health-accounts/measuring-primary-health-care-expenditure-under-sha-2011.pdf?sfvrsn=7613b97e_3. M-10: Hospitals WHO. 2021b. WHO Guidance on Preparing for National Response to Health Emergencies and Disasters. Geneva: World Health Organization. M-11: Primary Care & Public Health https://www.who.int/publications-detail-redirect/9789240037182. Outcomes WHO. 2022a. Essential Public Health Functions. Geneva: World Health Organization. https://www.who.int/publications/m/item/essen- 4 List of Acronyms tial-public-health-functions. WHO. 2022b. Joint External Evaluation Tool: Third Edition. Geneva: World Health Organization. https://iris.who.int/bitstream/handle/10665/ SECTION 4 357087/9789240051980-eng.pdf?sequence=1. Additional Guidance WHO. 2023. Malaysia: A Primary Health Care Case Study in the Context of the COVID-19 Pandemic. Geneva: World Health Organization. https://iris.who.int/handle/10665/372662. TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 402 OVERVIEW 1 SECTION 1 What Is a Health PER? WHO Antibiotics Portal. n.d. Accessed March 7, 2024. World Health Organization, Geneva. https://aware.essentialmeds.org/groups. WHO Health Inequality Data Repository. n.d. Accessed March 8, 2024. https://www.who.int/data/inequality-monitor/data. 2 SECTION 2 WHO SEARO. 2024. To Meet the Unmet: Preparing for Health Equity Challenges in WHO South-East Asia Region. World Health Organization Cross-Cutting South-East Asia Regional Office. https://www.who.int/publications-detail-redirect/9789290211099. Analysis on Efficiency and Equity WHO and UNICEF. 2022. Primary Health Care Measurement Framework and Indicators: Monitoring Health Systems through a Primary Health 3 Care Lens. Geneva: World Health Organization; New York: United Nations Children’s Fund. SECTION 3 WHO. n.d. GLASS Dashboard. Accessed July 23, 2024. https://worldhealthorg.shinyapps.io/glass-dashboard/_w_7a31ac2b/#!/home. Topic-Specific Analysis Health System Context Health Financing Inputs Service Delivery M-10: Hospitals M-11: Primary Care & Public Health Outcomes 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 11 Primary Care and Essential Public Health Functions 403 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Efficient, equitable and effective health systems achieve this by improving Equity 3 SECTION 3 financial protection and effective service coverage, which are the components of Final and Universal Health Coverage (UHC). This section provides guidance on evaluating SECTION 3 whether public health spending achieves its goals by examining health Topic-Specific outcomes and their distribution across population groups. It includes modules Analysis Intermediate on Universal Health Coverage, service coverage, financial risk protection, and Health System Context health status and risks. Intermediate and final health outcomes can be used to asses macro-efficiency by comparing outcomes among countries with similar Health Financing Outcomes levels of health expenditure, as explained in the cross-cutting Analysis. Inputs Service Delivery Outcomes MODULE 12 SERVICE COVERAGE 4 List of Acronyms The ultimate goal of health MODULE 13 FINANCIAL RISK PROTECTION SECTION 4 systems is to improve final health Additional MODULE 14 HEALTH STATUS AND HEALTH RISKS Guidance outcomes: better population health and lower health risks. MODULE 15 UNIVERSAL HEALTH COVERAGE CONTINUE TABLE OF CONTENTS OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis MODULE 12 Service Health System Context Health Financing Coverage Inputs Service Delivery Outcomes M-12: Service Coverage M-13: Financial Risk Protection AUTHOR M-14: Health Status and Health Risks Jacopo Gabani M-15: Universal Health Coverage 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 405 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 Under universal health coverage (UHC), all It is important to clarify that although service coverage and SECTION 2 utilization are often considered to be similar concepts, utilization Cross-Cutting individuals and communities receive the health Analysis on might not be equivalent to coverage, and coverage might not be Efficiency and services they need, when and where they need equivalent to effective coverage, as shown in Figure 1. Utilization Equity 3 them, without suffering financial hardship (WHO represents the percentage of people obtaining a service regardless of their needs. Coverage represents the percentage of people in SECTION 3 2023). UHC includes the full range of essential need using a service regardless of whether the service provided Topic-Specific Analysis health services, and it applies to an entire is the correct one (for example, children 12-23 months needing a population, that is, all individuals regardless of vaccination taken to a provider, or people 20-65 living with HIV/ Health System Context AIDS taken to a provider). Finally, effective coverage means that socioeconomic background, geographic location, Health Financing people in need use a service and obtain correct treatment (for among other factors. Therefore, service coverage Inputs example, receipt of three doses of DTP vaccine among children Service Delivery is an integral part of UHC. 12-23 months old, or people 20-65 living with HIV/AIDS on anti- Outcomes retroviral therapy (ART)). In addition, PER authors should note that The development of service coverage aggregate indexes mirrors the de jure coverage is not service coverage: being enrolled in a health M-12: Service Coverage progress of UHC in the global agenda, from the first UN resolution insurance plan does not mean being effectively covered. This M-13: Financial Risk Protection M-14: Health Status and Health Risks on the topic in 2012 onward (see Wagstaff 2013 and UHC2030 2019 for module focuses on how to analyze and measure service coverage, M-15: Universal Health Coverage a history of the UHC concept). In fact, the first release of the Service while the efficiency of expenditures on delivering service coverage Coverage Index was in 2017 (UN Stats),1 and the IHME Effective is addressed in the Cross-Cutting Module on Efficiency. 4 List of Acronyms Coverage Index (GBD 2019 Universal Health Coverage Collaborators SECTION 4 2020), noted in this module, was developed recently. Additional Guidance 1 https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdf. TABLE OF CONTENTS MODULE 12 Service Coverage 406 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 1 2 UTILIZATION, COVERAGE, AND EFFECTIVE COVERAGE SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis Health System Context UTILIZATION • % population using a service • E.g., % children taken to a COVERAGE • % population in need using a service • % children needing a DTP vaccine dose EFFECTIVE COVERAGE • % population in need using a service and getting the optimal treatment Health Financing health provider taken to a health provider • % of children 12–23 months who needed and received three doses of Inputs • But does everyone need a • But do children get the correct DTP vaccine Service Delivery consultation? treatment? Outcomes M-12: Service Coverage Source: World Bank 2022. M-13: Financial Risk Protection M-14: Health Status and Health Risks Of note, service coverage is tracked as part of the SDG target 3.8, The module is divided into two sections: the level (and progress) of M-15: Universal Health Coverage “Achieve universal health coverage.” For the same reason, service service coverage and the equity of service coverage. PER authors 4 List of Acronyms coverage is reviewed in the UHC module as well, though in less may also wish to refer to the module on UHC , which includes detail than this module provides. both financial risk protection and service coverage. The following SECTION 4 box defines terms used in this module. Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 407 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS 2 SECTION 2 Cross-Cutting EFFECTIVE COVERAGE UHC SERVICE COVERAGE INDEX Analysis on The percentage of people in need of a particular service who obtain Used to track SDG indicator 3.8.1, “Coverage of essential health Efficiency and Equity the optimal treatment. services,” the index is calculated as the unweighted geometric mean 3 of 14 tracers, of which 11 are service coverage tracers and three are EFFECTIVE COVERAGE INDEX service capacity tracers. Full details are provided in Annex 1. SECTION 3 Topic-Specific An index developed by the Institute of Health Metrics and Evaluation Analysis (IHME), University of Washington, encompassing 41 indicators, of UNIVERSAL HEALTH COVERAGE (UHC) which nine are related to service coverage and 32 are related to Under UHC, all individuals and communities receive the health Health System Context outcomes. Full details are provided in Annex 1, as well as in the services they need, when and where they need them, without suffering Health Financing UHC module. financial hardship. It includes the full range of essential health Inputs services and applies to an entire population, that is, all individuals COVERAGE regardless of socioeconomic background, geographic location, or Service Delivery The percentage of people, out of all people in need, who obtain other factors. “Achieve universal health coverage” is SDG target 3.8. Outcomes treatment from a health provider. M-12: Service Coverage UTILIZATION M-13: Financial Risk Protection FINANCIAL RISK PROTECTION The percentage of people using a particular service, regardless of M-14: Health Status and Health Risks A household is protected from financial risk when it is not suffering need and whether the treatment is optimal. M-15: Universal Health Coverage financial hardship due to catastrophic health expenditures, 4 List of Acronyms impoverishing health expenditures, or forgoing care due to financial reasons. The Financial Risk Protection module provides more SECTION 4 details on the topic and its related measures, mentioned below. Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 408 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 PROGRESS IN THE LEVEL OF SERVICE COVERAGE SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 KEY QUESTION • What is the level and trend of service coverage? SECTION 3 Topic-Specific Analysis Health System Context To answer this question, PER authors To ascertain whether the service coverage level (whether at the aggregate level or representing single service) is satisfactory, PER authors can compare Health Financing would usually need to (1) assess the level current service coverage levels with past levels, as well as compare service Inputs of service coverage using the aggregate coverage levels with those of comparator countries (for example, countries Service Delivery indicator UHC Service Coverage Index; in the same region, with the same income group, and similar context and Outcomes epidemiological profile). and (2) select the most relevant service M-12: Service Coverage M-13: Financial Risk Protection coverage indicators, or “tracers,” for their When selecting indicators, PER authors should attempt to select indicators that M-14: Health Status and Health Risks own country, and then assess the level comprehensively cover different disease areas, as well as cover different types M-15: Universal Health Coverage and trend for those indicators. of service, for example, health promotion, screening, and treatment programs. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 409 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Aggregate measure Sources 2 • UHC Service Coverage Index2 • WHO/World Bank UHC annual Global Monitoring Report SECTION 2 Cross-Cutting • Country MoH report Analysis on Efficiency and • UHC Effective Coverage Index • IHME Global Burden of Disease (GBD) Study 20193 Equity 3 Reproductive, Maternal, Neonatal, and Child Health SECTION 3 Pregnant women receiving prenatal care of at least four • World Bank HNP Statistics database Topic-Specific Analysis visits (% pregnant women)4 • Household surveys (for example, DHS) • WHO GHO Health System Context Immunization (DPT),5 (% of children 12-23 months) • World Bank HNP Statistics database Health Financing • Household surveys (for example, DHS) Inputs • Administrative system Service Delivery • WHO GHO Outcomes M-12: Service Coverage Contraceptive prevalence, any modern method (% of • World Bank WDI, HNP Statistics database M-13: Financial Risk Protection married women ages 15-49) • Household surveys (for example, DHS) M-14: Health Status and Health Risks ARI treatment (% children under-5 taken to a health • World Bank HNP Statistics database M-15: Universal Health Coverage ff 3 ff4 ff 5 ff provider) 2 • Household surveys (for example, DHS) 4 List of Acronyms SECTION 4 2 UHC Service Coverage Index, SDG indicator 3.8.1 (https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdf). Additional 3 Global Burden of Disease Collaborative Network. 2019. Global Burden of Disease (GBD) Study 2019 (GBD 2019). UHC Effective Coverage Index 1990–2019. 2020. Seattle, Washington: Institute for Health Metrics and Evaluation (IHME). Guidance 4 This indicator in the WHO GHO is “Antenatal care, at least four visits (% pregnant women 15–49).” 5 Similar immunization coverage indicators for other diseases can also be used TABLE OF CONTENTS MODULE 12 Service Coverage 410 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Sources 2 Nutrition6 SECTION 2 Early initiation of breastfeeding (% of newborns), or • Household surveys (for example, DHS) Cross-Cutting Analysis on Proportion of mothers/caregivers who receive • Administrative Health information systems Efficiency and Equity breastfeeding counseling during postnatal care visits • UNICEF Data 3 Vitamin A supplementation SECTION 3 (% of children aged 6–59 months) Topic-Specific Analysis Children with diarrhea who received zinc and ORS (% of children under five with diarrhea) Health System Context Health Financing Women who took iron-folic acid (or any iron- containing) supplements more than 90 days in the Inputs current or last pregnancy, or Service Delivery Outcomes % women aged 15-49 years who took Multiple M-12: Service Coverage Micronutrient Supplements in the current or last M-13: Financial Risk Protection pregnancy M-14: Health Status and Health Risks M-15: Universal Health Coverage ff6 4 List of Acronyms SECTION 4 6 There is a suite of high-impact cost-effective nutrition services for low- and lower-middle-income countries identified in DCP and Lancet nutrition series (Bhutta et al. 2008, 2013) . See also the Investment Framework for Nutrition (2024) and Optima for additional guidance on high/impact nutrition interventions. Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 411 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Infectious diseases Sources 2 Tuberculosis treatment success rate (% of new cases) • World Bank WDI • Household surveys (for example, DHS) SECTION 2 Cross-Cutting • Administrative system • WHO estimates Analysis on Efficiency and Antiretroviral therapy coverage (% people living with • World Bank WDI, HNP statistics • Household surveys (for example, DHS) Equity 3 HIV) • WHO GHO • Surveillance system • Administrative system • UNAIDS estimates SECTION 3 Topic-Specific Proportion of children under five years of age who • WHO GHO • Household surveys (for example, DHS) Analysis slept under an insecticide-treated mosquito net (%) • Administrative system • WHO/Malaria Atlas Project estimates Health System Context Noncommunicable diseases Health Financing Prevalence of hypertension among adults aged 30-79 • Household surveys (for example, DHS) • WHO GHO Inputs years Service Delivery Outcomes Mean fasting plasma glucose (mmol/L) • Household surveys (for example, DHS) • WHO GHO M-12: Service Coverage (age-standardized estimate) M-13: Financial Risk Protection Prevalence of cervical cancer screening among • Household surveys (for example, DHS) • WHO GHO M-14: Health Status and Health Risks women aged 30-49 years (%) M-15: Universal Health Coverage Prevalence of current tobacco use (% adults) • World Bank HNP statistics • Household surveys (for example, DHS) 4 List of Acronyms • World Bank WDI • WHO GHO SECTION 4 Note: ARI = acute respiratory infections; DHS = Demographic and Health Surveys; HNP = Health, Nutrition, and Population; IHME = Institute for Health Metrics and Evaluation; MoF = Ministry of Finance; UHC = Universal Health Coverage; Additional ORS = oral rehydration solutions; WDI = World Development Indicators; WHO GHO = World Health Organization Global Health Observatory. We have used the indicator name used at the linked source. However, we recognize that in some Guidance cases, different datasets, and in some cases, even the same dataset, might use slightly different names for the same indicator. PER authors should use the links provided and be mindful of different naming across and within datasets to avoid confusion. TABLE OF CONTENTS MODULE 12 Service Coverage 412 OVERVIEW 1 SECTION 1 What Is a Health PER? The list of indicators above is not exhaustive, and different PER authors could investigate different indicators, as relevant, from either household surveys 2 (for example, Demographic and Health Surveys (DHS)) or global datasets SECTION 2 (for example, World Bank Health, Nutrition, and Population (HNP) Statistics Cross-Cutting or the World Health Organization Global Health Observatory (WHO GHO)). Analysis on Efficiency and Equity 3 It is important to note that the WHO service coverage index is meant to capture progress at the global level. This imposes important constraints related to the SECTION 3 set of tracers chosen. While the WHO service coverage index could be used Topic-Specific Analysis for a high-level analysis (for example, a comparison across countries), for country-level monitoring, the choice of the service tracers should be more Health System Context closely aligned with (1) the country’s burden of disease; (2) the country’s health Health Financing priorities; and (3) the availability of specific data on the country. Inputs Annex 1 provides a definition of the aggregate service coverage indicators Service Delivery and a list of all the tracers used to build them. These tracers may serve as Outcomes inspiration for PER authors selecting their own service coverage indicators. M-12: Service Coverage M-13: Financial Risk Protection While the indicators obtained from the World Bank World Development M-14: Health Status and Health Risks Indicators (WDI) and HNP Statistics databases are useful for comparison at M-15: Universal Health Coverage the regional and country levels, they will not be useful at the subnational 4 List of Acronyms level. In order to run analyses at the subnational level, authors will need to check whether Demographic and Health Surveys or other household surveys SECTION 4 provide subnational-level data, and run subnational-level analysis if data Additional Guidance are available. TABLE OF CONTENTS MODULE 12 Service Coverage 413 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY OF SERVICE COVERAGE 2 SECTION 2 KEY QUESTION • Is service coverage distributed equitably? Cross-Cutting Analysis on Efficiency and Equity 3 This section analyzes how service coverage indicators PER authors can assess the equity of service coverage by following these steps: are distributed across income quintiles in order to assess SECTION 3 1. Select service coverage indicators based on local Topic-Specific UHC equity. Thus far, there is no dataset available that Analysis context or from the list of service coverage indicators disaggregates service coverage aggregate indexes (the UHC used to generate the UHC Service Coverage Index Health System Context Service Coverage Index or UHC Effective Coverage Index) by (see Annex 1). Health Financing income quintile. However, HEFPI and the World Bank HNP 2. Analyze progress for each indicator across quintiles Inputs Statistics by wealth quintile disaggregate service coverage (see “Sources” in the preceding table). It is possible Service Delivery indicators by income quintile. that progress is more marked for top quintiles and Outcomes less marked for lower quintiles, or vice versa. M-12: Service Coverage M-13: Financial Risk Protection PER authors are encouraged to explore equity of service Key Indicators Sources M-14: Health Status and Health Risks coverage further using data from household surveys, which M-15: Universal Health Coverage Service • World Bank HEFPI dataset would allow for disaggregation beyond socioeconomic coverage • World Bank HNP Statistics database, by wealth quintile quintiles (for example, rural/urban, age, geographic 4 List of Acronyms indicators • WHO Health Equity Monitor location, and so on). When using household surveys, across • Household surveys (for example, DHS) authors can calculate the concentration indexes for each SECTION 4 Additional quintiles • Administrative dataset service coverage indicator as a summary measure for equity Guidance Note: DHS = Demographic and Health Surveys; HEFPI = Health Equity and Financial Protection Indicators; HNP = Health, Nutrition, and Population; WHO = World Health Organization. TABLE OF CONTENTS MODULE 12 Service Coverage 414 OVERVIEW 1 SECTION 1 What Is a Health PER? across socioeconomic groups. Other summary measures commonly used are (1) the difference between the top and bottom quintile (for example, DPT immunization coverage (percentage of children younger than 5 years) for top quintile Q5 minus the same measure for bottom FIGURE 2 COMPARISON OF DIFFERENCE IN DPT IMMUNIZATION COVERAGE BETWEEN TOP AND 2 BOTTOM QUINTILES IN LOWER-MIDDLE-INCOME quintile Q1); or (2) the ratio of the top and bottom quintile (for example, DPT immunization COUNTRIES IN WEST AFRICA, 2018 (PERCENT) SECTION 2 coverage (percentage of children younger than 5 years) for top quintile Q5 divided by the Cross-Cutting same measure for bottom quintile Q1). Figure 2 compares quintiles for selected West African 60% Analysis on Efficiency and Equity countries. The chart shows that immunization coverage is highly inequitable in Nigeria, while 3 children in Ghana (and to some extent, Senegal) have similar DPT immunization coverage regardless of whether they are in the top or bottom income quintile. We note that summary 50% SECTION 3 Immunization DPT (% children): di erence Q5 - Q1 Topic-Specific measures (that is, concentration indexes, or Q1-Q5 differences and ratio) do not provide a full Analysis picture across income levels, and therefore are complements, not substitutes, of analyses across all income levels and/or income groups. 40% Health System Context Health Financing The analysis in Figure 2 can be helpful to assess the equity of service coverage at the country Inputs level, and at a rather high level. PER authors interested in equity, including at the subnational 30% Service Delivery level, would need to assess coverage indicators, for example, by district/region (or similar Outcomes administrative level). Authors could, for example, produce graphs of primary health care M-12: Service Coverage expenditures per capita across different districts in the region, which might be available from 20% M-13: Financial Risk Protection health resource tracking or government budget documents, and compare them with measures M-14: Health Status and Health Risks of health need, for example, from Demographic Health Surveys. In addition, PER authors might M-15: Universal Health Coverage use benefit incidence analysis to assess the equity of expenditures for service delivery in a 10% more granular way (O’Donnell et al. 2008; Gabani et al. 2024). Authors interested in whether 4 List of Acronyms the public health care system redistributes resources could also run, together with benefit incidence analyses, financing and fiscal incidence analysis (O’Donnell et al. 2008; Gabani et SECTION 4 0% Additional al. 2024; Lustig et al. 2015). Benin Cameroon Cote d'Ivoire Nigeria Senegal Ghana Guidance Source: World Bank staff. TABLE OF CONTENTS MODULE 12 Service Coverage 415 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Cross-Cutting Bhutta, Zulfiqar A., Tahmeed Ahmed, Robert E. Black, Simon Cousens, Kathryn Dewey, Elaine Giugliani, Batool A. Haider, Betty Kirkwood, Saul Analysis on Efficiency and S. Morris, Harshpal S. Sachdev, and Meera Shekar; Maternal and Child Undernutrition Study Group. 2008. “What Works? Interventions for Equity 3 Maternal and Child Undernutrition and Survival.” The Lancet 371 (9610): 417–40. https://doi.org/10.1016/S0140-6736(07)61693-6. SECTION 3 Bhutta, Zulfiqar A., Jai K. Das, Arjumand Rizvi, Meera F. Gaffey, Neff Walker, Susan Horton, Patrick Webb, Anna Lartey, and Robert E. Black; Topic-Specific The Lancet Nutrition Interventions Review Group, the Maternal and Child Nutrition Study Group. 2013. “Evidence-Based Interventions for Analysis Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” Lancet 382 (9890): 452–77. https://doi.org/10.1016/S0140- 6736(13)60996-4. Health System Context Health Financing Gabani, Jacopo, Sumit Mazumdar, Sylvester Bob Hadji, and Michael Matthew Amara. 2024.“The Redistributive Effect of the Public Health Inputs System: The Case of Sierra Leone.” Health Policy and Planning, Vol. 39, Issue 1, January: 4–21. https://doi.org/10.1093/heapol/czad100. Service Delivery GBD. 2019. Universal Health Coverage Collaborators. 2020. “Measuring Universal Health Coverage Based on an Index of Effective Coverage of Outcomes Health Services in 204 Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019.” The Lancet M-12: Service Coverage 396 (10258) :1250–84. August 27. doi:10.1016/S0140-6736(20)30750-9. https://www.healthdata.org/research-analysis/library/measuring- M-13: Financial Risk Protection universal-health-coverage-based-index-effective-coverage-health. M-14: Health Status and Health Risks Lustig, Nora. 2015. Chapter 16, “The Redistributive Impact of Government Spending on Education and Health: Evidence from Thirteen M-15: Universal Health Coverage Developing Countries in the Commitment to Equity Project.” In Inequality and Fiscal Policy. Washington, DC: International Monetary Fund. 4 List of Acronyms O’Donnell, Owen, Eddy van Doorslaer, Adam Wagstaff, and Magnus Lindelow. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation. Washington, DC: World Bank. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 416 OVERVIEW 1 SECTION 1 What Is a Health PER? Optima Nutrition Learning Tool. n.d. “Optima Nutrition Learning Tool.” World Bank, Washington, DC. https://www.worldbank.org/en/topic/ health/brief/optima-nutrition-learning-tool. 2 UHC2030. 2019. “A History of Universal Health Coverage in the UN.” UN 2019 High-level Meeting on Universal Health Coverage. SECTION 2 Cross-Cutting Wagstaff, Adam. 2013. “Universal health coverage: Old wine in a new bottle? If so, is that so bad?” World Bank Blogs. February 12. https:// Analysis on blogs.worldbank.org/en/developmenttalk/universal-health-coverage-old-wine-in-a-new-bottle-if-so-is-that-so-bad. Efficiency and Equity 3 Wang, Huihui, Kyoko Shibata Okamura, Ali Winoto Subandoro, Yurie Tanimichi Hoberg, Lubina Fatimah Qureshy, and Mamata Ghimire. 2022. A Guiding Framework for Nutrition Public Expenditure Reviews. International Development in Practice. Washington, DC: World Bank. https:// SECTION 3 doi.org/10.1596/978-1-4648-1853-0. Topic-Specific Analysis World Health Organization (WHO). 2023. “Universal Health Coverage (UHC).” Fact Sheet/Detail. World Health Organization, Geneva. https:// www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc). October 5. Health System Context Health Financing Inputs Service Delivery Outcomes M-12: Service Coverage M-13: Financial Risk Protection M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 417 OVERVIEW 1 SECTION 1 What Is a Health PER? Data Sets 2 SECTION 2 World Bank Health Equity and Financial Protection Indicators (HEFPI), https://datatopics.worldbank.org/health-equity-and-financial-protection/. Cross-Cutting Analysis on World Bank Health, Nutrition and Population Statistics, https://datatopics.worldbank.org/health/. Efficiency and Equity 3 World Bank World Development Indicators, https://datatopics.worldbank.org/world-development-indicators/. World Health Organization (WHO) Health Equity Monitor, https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/health- SECTION 3 equity-monitor. Topic-Specific Analysis Health System Context Health Financing Inputs Service Delivery Outcomes M-12: Service Coverage M-13: Financial Risk Protection M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 418 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and ANNEX 1 Equity 3 SECTION 3 Detail of UHC Measures Topic-Specific Analysis from WHO/World Bank and IHME Health System Context Health Financing Inputs This annex is organized in three parts: Service Delivery (1) an overview of UHC indexes in the Outcomes literature, shown in the table; (2) a list M-12: Service Coverage of the tracers used to generate the UHC M-13: Financial Risk Protection Service Coverage Index; and (3) a list of M-14: Health Status and Health Risks M-15: Universal Health Coverage the tracers used to generate the UHC Effective Coverage Index. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 419 OVERVIEW 1 UHC MONITORING TOOLS SECTION 1 What Is a UHC Service Coverage Index (SDG indicator 3.8.1)* UHC Effective Coverage Index Health PER? 2 Number and type of indicators 14 tracers covering service coverage (11) and service capacity (3) 41 indicators in total SECTION 2 Categorization or list of tracers Indicator groups: 9 service coverage indicators Cross-Cutting 1. Reproductive, maternal, newborn, and child health (4 tracers) 32 outcome-based indicators Analysis on 2. Infectious diseases (4 tracers) Efficiency and Equity 3. Noncommunicable diseases (3 tracers) Detail of all tracers is provided below. 3 4. Service capacity and access (3 tracers) Detail of all tracers is provided below. SECTION 3 Topic-Specific Data source Household survey, administrative and institutional data Household and administrative data Analysis Modeling when data are missing Extensive Extensive Health System Context Compilation method Geometric mean, unweighted Weighting of indicators according to disease burden Health Financing Number of countries included 183 204 Inputs Reference UHC Service Coverage Index, SDG 3.8.1, metadata GBD 2019 Universal Health Coverage Collaborators. 2020. “Measuring Service Delivery Universal Health Coverage Based on an Index of Effective Coverage Outcomes of Health Services In 204 Countries and Territories, 1990–2019: A M-12: Service Coverage Systematic Analysis for the Global Burden of Disease Study 2019. The Lancet. August 27, 2020. doi:10.1016/S0140-6736(20)30750-9. M-13: Financial Risk Protection M-14: Health Status and Health Risks Data download https://datacatalog.worldbank.org/int/search/dataset/0060802 http://ghdx.healthdata.org/record/ihme-data/gbd-2019-uhc- M-15: Universal Health Coverage effective-coverage-index-1990-2019 Additional source (with same data, available online without 4 List of Acronyms downloading the dataset): https://data.worldbank.org/indicator/SH.UHC.SRVS.CV.XD SECTION 4 Additional Guidance Source: World Bank staff. *Reminder: SDG target 3.8, “Achieve universal health coverage,” is monitored via SDG indicator 3.8.1 as well as SDG indicator 3.8.2, “Catastrophic health spending (and related indicators).” SDG 3.8.2 is measured using CATA at the 10 percent and 25 percent levels. These measures are also reviewed in the Financial Risk Protection module. TABLE OF CONTENTS MODULE 12 Service Coverage 420 OVERVIEW 1 SECTION 1 What Is a Health PER? UHC SERVICE COVERAGE INDEX TRACERS 9. Malaria: Percentage of population in malaria-endemic areas who slept under an insecticide-treated net the previous 2 REPRODUCTIVE AND MATERNAL HEALTH night (only for countries with high malaria burden) SECTION 2 3. Family planning: Percentage of women of reproductive ages 10. Water, sanitation, and hygiene: Percentage of population Cross-Cutting (15−49 years) who are married or in union who have their Analysis on using at least basic sanitation services Efficiency and need for family planning satisfied with modern methods Equity 3 4. Pregnancy care: Percentage of women ages 15–49 years with NONCOMMUNICABLE DISEASES a live birth in a given time period who received antenatal 11. Hypertension: Percentage of treatment (taking medicine) SECTION 3 care four or more times for hypertension among adults ages 30–79 years with Topic-Specific Analysis hypertension (age-standardized estimate) 5. Child immunization: Percentage of infants receiving three doses of diphtheria-tetanus-pertussis containing vaccine 12. Diabetes: Age-standardized mean fasting plasma glucose Health System Context 6. Child treatment: Percentage of children younger than 5 years (mmol/L) for adults ages 18 years and older Health Financing with symptoms of acute respiratory infection (cough and 13. Tobacco: Age-standardized prevalence of adults ages Inputs fast or difficult breathing due to a problem in the chest and 15 years and older currently using any tobacco product Service Delivery not due to a blocked nose only) in the two weeks preceding (smoked and/or smokeless tobacco) on a daily or nondaily Outcomes the survey for whom advice or treatment was sought from a basis (SDG indicator 3.a.1; see metadata at https://www.who. M-12: Service Coverage health facility or provider int/data/gho/indicator-metadata-registry/imr-details/ M-13: Financial Risk Protection prevalence-of-current-tobacco-use-among-persons-aged- M-14: Health Status and Health Risks COMMUNICABLE DISEASES 15-years-and-older-(age-standardized-rate) M-15: Universal Health Coverage 7. Tuberculosis: Percentage of incident TB cases that are 4 List of Acronyms detected and treated SERVICE CAPACITY AND ACCESS 8. HIV/AIDS: Percentage of adults and children living with HIV 14. Hospital access: Hospital beds density, relative to a SECTION 4 currently receiving antiretroviral therapy maximum threshold of 18 per 10,000 population Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 421 OVERVIEW 1 SECTION 1 What Is a Health PER? 15. Health workforce: Health professionals (physicians, psychiatrists, and surgeons) per capita, relative to maximum thresholds for each cadre (partial overlap with SDG indicator 3.c.1; see metadata at https://unstats.un.org/sdgs/ 2 metadata/files/Metadata-03-0C-01.pdf) SECTION 2 Cross-Cutting 16. Health security: International Health Regulations (IHR) core capacity index, Analysis on Efficiency and which is the average percentage of attributes of 13 core capacities that have Equity 3 been attained (SDG indicator 3.d.1; see metadata at https://www.who.int/data/ gho/indicator-metadata-registry/imr-details/4672) SECTION 3 Topic-Specific IHME EFFECTIVE COVERAGE INDEX INDICATORS7 Analysis Intervention coverage Health System Context 1. Met need for family planning with modern contraception 2. ANC1 Health Financing 3. ANC4 Inputs 4. Skilled birth attendance Service Delivery 5. In-facility delivery rate Outcomes 6. DTP3 M-12: Service Coverage 7. Polio3 M-13: Financial Risk Protection 8. MCV1 M-14: Health Status and Health Risks 9. ART coverage M-15: Universal Health Coverage 4 List of Acronyms 7 Sources: Section 4 of the supplementary appendix to GBD 2019 Universal Health Coverage Collaborators. 2020. “Measuring Uni- SECTION 4 versal Health Coverage Based on an Index of Effective Coverage of Health Services in 204 Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019. The Lancet 396 (10258): 1250–84. August 27, 2020. doi:10.1016/ Additional S0140-6736(20)30750-9. https://www.healthdata.org/research-analysis/library/measuring-universal-health-coverage-based-index-ef- Guidance fective-coverage-health. For additional details, PER authors can also refer to World Health Organization (WHO). 2019. “An Updated Method for the Essential Health Services Coverage Index.” World Health Organization, Geneva. https://unstats.un.org/sdgs/files/ meetings/webex17jan2019/1_3.8.1_Tier%20Reclassification%20Request_WHO.pdf. TABLE OF CONTENTS MODULE 12 Service Coverage 422 OVERVIEW 1 SECTION 1 What Is a Health PER? Outcome-based (risk-standardized death rates or mortality-to- incidence ratios) 23. Peptic ulcer disease 24. Appendicitis 2 1. Tuberculosis 25. Hernia SECTION 2 2. Diarrheal diseases 26. Gallbladder and biliary diseases Cross-Cutting 3. Lower respiratory infections 27. Epilepsy Analysis on Efficiency and 4. Upper respiratory infections 28. Diabetes Equity 3 5. Asthma, diphtheria 29. Chronic kidney disease 6. Whooping cough 30. Chronic obstructive pulmonary disease SECTION 3 7. Tetanus 31. Congenital heart anomalies Topic-Specific Analysis 8. Measles 32. Adverse effects of medical treatment 9. Maternal disorders Health System Context 10. Neonatal disorders Health Financing 11. Colon and rectum cancer 12. Nonmelanoma skin cancer Inputs 13. Breast cancer Service Delivery 14. Cervical cancer Outcomes 15. Uterine cancer M-12: Service Coverage 16. Testicular cancer M-13: Financial Risk Protection 17. Hodgkin lymphoma M-14: Health Status and Health Risks 18. Leukemia M-15: Universal Health Coverage 19. Rheumatic heart disease 4 List of Acronyms 20. Ischemic heart disease 21. Cerebrovascular disease SECTION 4 22. Hypertensive heart disease Additional Guidance TABLE OF CONTENTS MODULE 12 Service Coverage 423 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 MODULE 13 Topic-Specific Financial Risk Analysis Health System Context Protection Health Financing Inputs Service Delivery Outcomes M-12: Service Coverage AUTHOR M-13: Financial Risk Protection Patrick Hoang-Vu Eozenou M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 424 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION 2 SECTION 2 Cross-Cutting This module is designed to help PER authors Financial protection is one of the two foundations of Universal Analysis on Health Coverage (UHC), the other being service coverage (see, for Efficiency and assess financial risk protection in the context Equity example, Wagstaff and Neelsen 2020), and represents one of the 3 of a Public Expenditure Review (PER). It defines final coverage goals of the health system. Financial protection is “financial risk protection” and its measurement. achieved when (1) there are no financial barriers to access; and (2) SECTION 3 Topic-Specific The indicators from this module can be used direct payments (out-of-pocket (OOP) health spending) required Analysis to assess whether prepaid and pooled health to obtain health services are not a source of financial hardship. Health System Context expenditures are providing financial protection The literature on this topic is vast and has explored the topics of Health Financing efficiently. catastrophic health expenditures. Examples include a seminal Inputs paper exploring catastrophic health expenditure in Vietnam Service Delivery This could be done, for example, by reviewing the levels of (Wagstaff and Doorslaer 2003), and an assessment of catastrophic Outcomes public health expenditures and financial protection across health expenditure across countries (Wagstaff et al. 2018a); a paper M-12: Service Coverage comparator countries (such as countries in the same region or in on impoverishment (Wagstaff et.al 2018b); and later, forgone care, M-13: Financial Risk Protection the same income group). For example, countries with (relatively) for example, a cross-country review (Kakietek et al. 2022) as well M-14: Health Status and Health Risks limited financial protection, and (relatively) high public health as an example from Liberia (Gabani and Guinness 2019). Recent M-15: Universal Health Coverage expenditures, are not providing financial protection efficiently, discussions also underlined the importance of considering a as they need more resources to produce lower levels of financial “societal poverty line” (Jolliffe and Beer Prydz 2021) for measuring 4 List of Acronyms protection. This module focuses on how to analyze and measure impoverishment due to OOP health spending. SECTION 4 financial protection, while the link with efficiency is addressed in Additional the cross-cutting module on Efficiency. Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 425 OVERVIEW 1 SECTION 1 What Is a Health PER? Several Sustainable Development Goals (SDGs) have targets that relate to health. 2 SDG 3 focuses specifically on ensuring healthy lives and promoting wellbeing for all SECTION 2 at all ages. SDG 3’s target 3.8—“Achieve universal health coverage, including financial Cross-Cutting risk protection, access to quality essential healthcare services and access to safe, Analysis on effective, quality and affordable essential medicines and vaccines for all”—is key to Efficiency and Equity attaining SDG 3 overall as well as the health-related targets of other SDGs. Target 3 3.8 has two indicators: 3.8.1 on coverage of essential health services and 3.8.2 on the SECTION 3 proportion of a country’s population with catastrophic spending on health, defined Topic-Specific as large household expenditure on health as a share of household total consumption Analysis or income. These indicators must be measured together to obtain a clear picture of those who are unable to access health care and those who face financial hardship Health System Context due to spending on health care. Health Financing Inputs To assess these two criteria, PER authors should consider all the population in Service Delivery need of health care services and/or health products rather than a subgroup with Outcomes a specific health need or in need of a specific intervention (Figure 1). Some people M-12: Service Coverage seeking care face barriers to access because of financial constraints, unacceptability, M-13: Financial Risk Protection inaccessibility, or unavailability of services, among other frequent factors. All such M-14: Health Status and Health Risks barriers contribute to delaying, interrupting, or entirely preventing people from using M-15: Universal Health Coverage services (hereafter referred to as “forgone care”). Even when contact is established, as 4 List of Acronyms (Figure 1) shows, access to care can be a source of financial hardship if OOP health spending is high in relation to a household’s welfare. If health spending is SECTION 4 proportional, then access to care does not result in financial hardship. Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 426 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 1 FINANCIAL PROTECTION, FORGONE CARE, AND FINANCIAL HARDSHIP 2 SECTION 2 All people in need of health care goods and services Cross-Cutting Analysis on Efficiency and Equity 3 Non financial Financial Utilization barriers barriers SECTION 3 Topic-Specific Out-of-pocket No out-of-pocket Analysis No, or spending payment postponed, Health System Context utilization Health Financing Neither Inputs Catastrophic Impoverishing catastrophic, nor payments OOP Service Delivery impoverishing Outcomes M-12: Service Coverage M-13: Financial Risk Protection M-14: Health Status and Health Risks Non financial Financial M-15: Universal Health Coverage Financial hardship due No financial hardship due barriers barriers to out-of-pocket spending to out-of-pocket spending ➡ Forgone care ➡ Forgone care 4 List of Acronyms SECTION 4 Lack of financial protection Additional Guidance Source: World Bank and WHO (2023). TABLE OF CONTENTS MODULE 13 Financial Risk Protection 427 OVERVIEW 1 SECTION 1 What Is a Health PER? It is important to note that “equity disaggregation” can be done and is strongly recommended across all measures noted in this module. PER authors should focus 2 on socioeconomic inequalities in order to compare the level of financial protection SECTION 2 between socioeconomic groups in terms of forgone care, as well as in terms of financial Cross-Cutting Analysis on hardship. A synthetic measure of inequalities in health OOP can be constructed Efficiency and using concentration indexes or by comparing average OOP or budget shares across Equity 3 expenditure quintiles. In addition to socioeconomic inequalities, differences across specific population subgroups, especially more vulnerable groups, using factors SECTION 3 defined based on the country context (groups based on gender or age of the head Topic-Specific Analysis of the household, rural/urban location, regional location, household belonging to minority groups, single-headed households, and so on), can also be highlighted. All Health System Context the indicators presented in this module, except forgone care, are available in the Health Financing Health Equity and Financial Protection Indicators dataset (HEFPI) at the aggregate Inputs country level. HEFPI often provides the indicators disaggregated by income quintile. Service Delivery PER authors who want to explore financial protection across different population Outcomes subgroups defined by country-relevant factors (for example, as noted above: gender and age of the head of household, rural/urban location, and so on) can do so by M-12: Service Coverage analyzing data from household surveys. M-13: Financial Risk Protection M-14: Health Status and Health Risks It should also be noted that the Universal Health Coverage module discusses M-15: Universal Health Coverage both service coverage and financial risk protection. However, in the UHC module, 4 List of Acronyms financial risk protection is not discussed in substantive detail. This module provides an in-depth review of financial risk protection (see the following Box 1 for definitions SECTION 4 Additional for key financial risk protection concepts and indicators used in this module). Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 428 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS 2 SECTION 2 Cross-Cutting OUT-OF-POCKET HEALTH SPENDING Analysis on Any spending incurred by a household when any member uses a health good or service to receive any type of care (that is, preventive, curative, Efficiency and Equity rehabilitative, or long-term care); provided by any type of provider; for any type of disease, illness, or health condition; in any type of setting (for 3 example, outpatient, inpatient, or home). OOP health spending includes formal and informal expenses directly related to the cost of seeking care, as mapped in division 06 of the UN Classification of Individual Consumption According to Purposes (COICOP-2018)1 (that is, on medicines and medical SECTION 3 Topic-Specific products (06.1); outpatient care services, including dental care (06.2); inpatient care services, including inpatient dental care (06.3); diagnostic Analysis imaging services and medical laboratory services (06.4.1); and patient emergency transportation services and emergency rescue (06.4.2)). It excludes prepayment (for example, taxes, contributions, or premiums) and reimbursement to the household by a third party, such as the government, a Health System Context health insurance fund, or a private insurance company. It also excludes indirect expenses (for example, nonemergency transportation cost) and the Health Financing opportunity cost of seeking care (for example, lost income). Inputs CATASTROPHIC HEALTH SPENDING Service Delivery A sufficient, but not necessary, condition for financial hardship to occur. The definition of catastrophic health spending used in relation to SDG Outcomes indicator 3.8.2 is focused on relatively large OOP health spending, in effect, those exceeding 10 percent and 25 percent of the household’s total M-12: Service Coverage consumption or income (budget), respectively, in a given year. For poor and near-poor people (that is, people who are living below a poverty line M-13: Financial Risk Protection per person per day ($1.90 or $3.20) or near the poverty line or a relative poverty line), it is the absolute level of OOP health spending that is crucial, M-14: Health Status and Health Risks because even OOP health expenditures that are less than 10 percent of the household budget might push them below the poverty line (if they are just M-15: Universal Health Coverage above it) or further into poverty (if they are already below the poverty line). For this reason, indicators of impoverishing health spending are also used 4 List of Acronyms to track financial hardship. SECTION 4 1 The Classification of Individual Consumption According to Purpose (COICOP) was revised in 2018 to provide more information on important components of household care consumption. Additional Guidance Box continues on the following page. TABLE OF CONTENTS MODULE 13 Financial Risk Protection 429 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 BOX 1. DEFINITIONS OF TERMS (continued) Cross-Cutting Analysis on Efficiency and IMPOVERISHING OOP HEALTH SPENDING Equity 3 Occurs when a household is forced by an adverse health event to divert spending from nonmedical budget items, such as food, shelter, or clothing, to the extent that its spending on such items is reduced to below or further below the level indicated by a poverty line. Impoverishment is defined as SECTION 3 occurring when (1) a household’s consumption including OOP spending is more than the poverty line but its consumption excluding OOP spending is Topic-Specific less than the poverty line, that is, when nonpoor households become poor because of OOP; or (2) household consumption net and gross of OOP are Analysis both below the poverty line, and there is OOP, that is, poor households are pushed further below the poverty line because of OOP. Health System Context FINANCIAL PROTECTION AND WELFARE Health Financing Financial hardship through catastrophic or impoverishing health spending can be established within a framework where welfare is measured by Inputs income or by total consumption expenditure.2 (For a more recent discussion of financial hardship measurement and welfare, see Wagstaff 2019). Service Delivery Moreover, households may also adopt suboptimal risk-coping strategies (for example, dissaving, borrowing, selling assets) to address adverse health Outcomes shocks in the short term, with long-term or permanent consequences for their welfare.3 M-12: Service Coverage M-13: Financial Risk Protection 2 For more details on the measurement of welfare through income or consumption, see Mancini et al. (2022) and O’Donnell et al. (2008), chapter 6. M-14: Health Status and Health Risks 3 The potential welfare implications of these strategies are studied in Chetty and Looney (2005) and analyzed empirically in Flores et al. (2008). M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 430 OVERVIEW 1 SECTION 1 What Is a Health PER? LEVEL OF FINANCIAL PROTECTION 2 SECTION 2 Cross-Cutting Analysis on KEY QUESTIONS • What is the level of financial protection? Efficiency and Equity - What is the proportion of households forgoing care because of financial barriers? 3 - What is the proportion of households exposed to financial hardship because of OOP health expenditures? SECTION 3 Topic-Specific Analysis There may be variations of this indicator (for example, Key Indicators Sources the use of health care services in a given period as a Health System Context Measuring forgone care due to financial barriers percentage of population in need, barriers to service use Health Financing for health care services). PER authors can analyze the Percentage of population • Nationally representative surveys Inputs indicator as presented in Figure 2 and disaggregate by forgoing needed health care with information on health service Service Delivery wealth or income quintile if data are available. because of financial barriers use and nonuse (for example, LSMS) Outcomes Note: LSMS = Living Standard Measurement Surveys. M-12: Service Coverage M-13: Financial Risk Protection M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 431 OVERVIEW 1 FIGURE 2 FIGURE 3 USE OF OUTPATIENT SERVICES IN PAST 30 DAYS BARRIERS TO SERVICE USE FOR OUTPATIENT CARE, PERCENT SECTION 1 What Is a 100 Health PER? 90 Poorest 20% 0.7 14.1 33.4 10.5 2 (Percentage of Population Need) 80 SECTION 2 70 Q2 1.0 11.9 29.5 12.8 Cross-Cutting 60 Analysis on Use of OP services, national average (49.1%) Efficiency and 50 Q2 1.2 10.4 23.7 10.8 Equity 3 40 30 Q4 0.5 8.0 21.3 15.6 SECTION 3 20 Topic-Specific 10 Analysis Richest 20% 0.3 4.8 21.8 14.5 0 Poorest 20% Q2 Q3 Q4 Richest 20% Distance Financial Automedication Other barriers Health System Context Source: Mali EHCVM (2018), individually weighted averages. Health Financing Note: Percentages are conditional on need of outpatient care. Inputs Using household surveys, PER authors should assess the level of financial risk due to health OOP by wealth or income quintile. Figure 3 shows the share Service Delivery of the population in each income quintile that experiences catastrophic health expenditures. If data permit, authors can disaggregate the distribution Outcomes within each population quintile to differentiate between those who are impoverished and those who have been pushed further below the poverty line. M-12: Service Coverage M-13: Financial Risk Protection Key Indicators Sources M-14: Health Status and Health Risks Measuring catastrophic health expenditures M-15: Universal Health Coverage Proportion of population spending more than 10% of • HEFPI 4 List of Acronyms household consumption or income on out-of-pocket • Nationally representative income or consumption expenditure surveys with SECTION 4 health care expenditure (%) information on OOP and on total consumption or income (for example, LSMS) Additional Guidance Note: HEFPI = Health Equity and Financial Protection Indicators; LSMS = Living Standard Measurement Surveys; OOP = out-of-pocket. TABLE OF CONTENTS MODULE 13 Financial Risk Protection 432 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 4. Financial Risk Due to Health OOP (by quintile) Key Indicators Measuring impoverishing spending on health Sources 2 80 SECTION 2 75 Proportion of population • HEFPI Cross-Cutting 70 pushed below the $2.15 Analysis on • Nationally representative income or Efficiency and 65 ($ 2017 PPP) poverty Equity consumption expenditure surveys 3 60 line by OOP health care with information on OOP and on total 55 expenditure (%) consumption or income (for example, LSMS) SECTION 3 50 Topic-Specific Population (%) Analysis 45 Proportion of population • HEFPI 40 pushed below the $3.65 • Nationally representative income or Health System Context 35 ($ 2017 PPP) poverty consumption expenditure surveys line by OOP health care Health Financing 30 with information on OOP and on total expenditure (%) Inputs 25 consumption or income (for example, LSMS) Service Delivery 20 Proportion of population • HEFPI 15 Outcomes pushed below the 60% M-12: Service Coverage 10 • Nationally representative income or median consumption M-13: Financial Risk Protection 5 consumption expenditure surveys poverty line by OOP health M-14: Health Status and Health Risks 0 with information on OOP and on total Poorest 20% Q2 Q3 Q4 Richest 20% care expenditure (%) M-15: Universal Health Coverage consumption or income (for example, LSMS) 4 List of Acronyms OOP share over 10% Over 10% and impoverished Note: HEFPI = Health Equity and Financial Protection Indicators; LSMS = Living Standard Measurement Surveys; OOP = out-of-pocket; PPP = purchasing power parity. Poverty lines are per person per day. HEFPI datasets still use outdated poverty lines ($1.90 and Impoverished (OOP share <10%) Pushed further below PL $3.20 2011 PPP). However, the UHC Global Monitoring Report 2023 uses the updated poverty lines, which are noted in this table. PER SECTION 4 authors ideally should use the updated poverty lines and should always note the exact poverty line used. Additional Source: Mali EHCVM (2018), household weighted averages. Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 433 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors should conduct trend analysis and benchmarking for all key indicators cited in the table. Trend analysis for recent years will provide some insight into progress over those years as well as a future trajectory. Authors should benchmark across similar countries to see how the 2 country in question compares, as well as across geopolitical entities (subnational, urban/rural). If data permit, authors can also present the SECTION 2 analysis as illustrated in Figure 5 (a brief introduction to Pen’s Parade is provided by Chan 2022). Cross-Cutting Analysis on Efficiency and Equity 3 Pop. spending 10% or more: 8.2% 6 FIGURE 5 Poverty line Pop. pushed below the PL: 2.4% SECTION 3 Pop. poor and pushed further below the PL: 22.2% Financial Risk Due (multiple of the poverty line) Topic-Specific 5 to Health OOP Per Capita Consumption Analysis (Pen’s Parade) 4 Health System Context Source: Mali EHCVM (2018), Consumption gross of OOP Health Financing household weighted averages. 3 Note: Per capita consumption Consumption net of OOP Inputs is expressed in multiple of the national poverty line. The upper Service Delivery 1% of the distribution is trimmed. 2 The Pen’s Parade or the Income Outcomes Parade is a concept described in a 1971 book published by the Dutch economist Jan Pen describing the 1 M-12: Service Coverage ranking of a population across the socioeconomic distribution. OOP = M-13: Financial Risk Protection out-of-pocket; PL = poverty line. 0 M-14: Health Status and Health Risks M-15: Universal Health Coverage Cumulative Population Ranked by Per Capita Expenditure 4 List of Acronyms OOP share over 10% Over 10% and impoverished SECTION 4 Impoverished (OOP share <10%) Pushed further below PL Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 434 OVERVIEW 1 SECTION 1 What Is a Health PER? OUT-OF-POCKET EXPENDITURES AS A 2 SECTION 2 Cross-Cutting SHARE OF TOTAL HEALTH EXPENDITURE Analysis on Efficiency and Equity 3 KEY QUESTION • What is the share of aggregate OOP expenditures in total health expenditure? SECTION 3 Topic-Specific Analysis In cases where no recent household expenditure survey data are Key Indicators Sources available to document the level of financial protection in the country, Health System Context OOP expenditure (% of • WHO Global Health Expenditure PER authors can use National Health Accounts data as a proxy indicator Health Financing to the extent that aggregate OOP over total health expenditure, or over current health expenditure) Dataset Inputs aggregate consumption, is positively correlated with household OOP • World Bank WDI Service Delivery budget shares and with indicators of catastrophic and impoverishing Note: OOP = out-of-pocket; WDI = World Development Indicators; WHO = World Health Outcomes health expenditures. Organization. M-12: Service Coverage M-13: Financial Risk Protection M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 435 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 Chan, D. 2022. “The Parade of Inequality: Investigating Exacerbated Disparities,” Accessed May 2024. https://econreview.studentorg.berkeley. SECTION 2 edu/the-parade-of-inequality-investigating-exacerbated-disparities/. Cross-Cutting Analysis on Chetty, R., and A. Looney. 2005. “Consumption Smoothing and the Welfare Consequences of Social Insurance in Developing Economies.” NBER Efficiency and Equity Working Paper. National Bureau of Economic Research, Cambridge, MA. https://www.nber.org/system/files/working_papers/w11709/w11709.pdf. 3 Flores, G., J. Krishnakumar, O. O’Donnell, and E. van Doorslaer. 2008. “Coping with Health-Care Costs: Implications for the Measurement of SECTION 3 Catastrophic Expenditures and Poverty.” Health Economics, 17(12): 1393–1412. https://onlinelibrary.wiley.com/doi/epdf/10.1002/hec.1338. Topic-Specific Analysis Gabani, J., and L. Guinness, L. 2019. “Households forgoing healthcare as a measure of financial risk protection: an application to Liberia.” International Journal for Equity in Health 18, 193. https://doi.org/10.1186/s12939-019-1095-y. Health System Context Health Financing Jolliffe, D., and E. Beer Prydz. 2021. “Societal Poverty: A Relative and Relevant Measure.” The World Bank Economic Review, 35(1): 180–206. https://doi.org/10.1093/wber/lhz018. Inputs Service Delivery Kakietek, J.J., J.D. Eberwein, N. Stacy, D. Newhouse, and N. Yoshida. 2022. “Foregone healthcare during the COVID-19 pandemic: early survey Outcomes estimates from 39 low- and middle-income countries.” Health Policy and Planning 37(6): 771–78. https://academic.oup.com/heapol/ M-12: Service Coverage article/37/6/771/6546909?login=false. M-13: Financial Risk Protection Mancini, G., and G. Vecchi. 2022. On the Construction of a Consumption Aggregate for Inequality and Poverty Analysis (English). Washington, DC: M-14: Health Status and Health Risks World Bank Group. http://documents.worldbank.org/curated/en/099225003092220001/P1694340e80f9a00a09b20042de5a9cd47e. M-15: Universal Health Coverage O’Donnell, O., E. van Doorslaer, A. Wagstaff, and M. Lindelow. 2008. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques 4 List of Acronyms and Their Implementation. Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/6896. SECTION 4 Wagstaff, A. 2019. “Measuring Catastrophic Medical Expenditures: Reflections on Three Issues.” Health Economics 28(6): 765–81. https:// Additional onlinelibrary.wiley.com/doi/full/10.1002/hec.3881. Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 436 OVERVIEW 1 SECTION 1 What Is a Health PER? Wagstaff, A., and E. van Doorslaer. 2003. “Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993–1998.” Health Economics 12(11): 921–33. 2 Wagstaff, A., G. Flores. J. Hsu, M. Smitz, K. Chepynoga, and L.R. Buisman. 2018a. “Progress on catastrophic health spending in 133 countries: SECTION 2 a retrospective observational study.” The Lancet Global Health 6(2): e169–79. https://www.thelancet.com/journals/langlo/article/PIIS2214- Cross-Cutting 109X(17)30429-1/fulltext#articleInformation. Analysis on Efficiency and Equity Wagstaff, A., G. Flores, M. Smitz, J. Hsu, K. Chepynoga, and P. Eozenou. 2018b. “Progress on impoverishing health spending in 122 countries: a 3 retrospective observational study.” The Lancet Global Health 6(2): e180–92. https://www.thelancet.com/journals/langlo/article/PIIS2214- 109X(17)30486-2/fulltext. SECTION 3 Topic-Specific Analysis Wagstaff, A., and S. Neelsen. 2020. “A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.” The Lancet Global Health, 8(1): 39–49. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30463-2/fulltext. Health System Context World Bank and World Health Organization. 2023. Tracking Universal Health Coverage: 2023 Global Monitoring Report. Washington, DC: World Health Financing Bank; Geneva: World Health Organization. https://openknowledge.worldbank.org/entities/publication/1ced1b12-896e-49f1-ab6f-f1a95325f39b. Inputs Service Delivery Outcomes M-12: Service Coverage M-13: Financial Risk Protection M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 13 Financial Risk Protection 437 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 MODULE 14 SECTION 3 Health Status Topic-Specific Analysis Health System Context and Health Risks Health Financing Inputs Service Delivery Outcomes AUTHORS M-12: Service Coverage M-13: Financial Risk Protection Nejma Cheikh, Zara Shubber, and Priyanka Saksena M-14: Health Status and Health Risks M-15: Universal Health Coverage START 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 438 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION global community for reporting across the range of global health priorities. PER authors can consider further refining their choice 2 of indicators for monitoring health status and risks in a specific SECTION 2 Improving the health status of the population country by referring to this document. Cross-Cutting and reducing health risks is the goal of the Analysis on Authors should note that indicators related to service coverage, Efficiency and Equity health sector. “Health status” refers broadly 3 effective coverage, and quality of health care services are addressed to all aspects of the health of an individual or in other modules. Cross-analysis with other key modules—including SECTION 3 population (NCBI 2006). Indicators of health Financial Risk Protection , Service Coverage , Hospitals , Topic-Specific status include prevalence of specific diseases, life and Primary Health Care and Public Health Services —will provide Analysis a more comprehensive analysis. expectancy, and mortality rate. Health risks are Health System Context factors that raise the likelihood of adverse health Finally, PER authors can use the key indicators listed in this module Health Financing Inputs outcomes. These factors are numerous and across to compare between countries and to measure changes over time. International or regional benchmarking with countries of similar Service Delivery different domains but are modifiable through income level (using World Bank income classification by income level Outcomes effective public policy, including health policy. or gross national income per capita, for example) and/or geography M-12: Service Coverage can enable authors to identify countries that have achieved significant M-13: Financial Risk Protection The module presents indicators for monitoring health status progress in health outcomes. This type of comparison involves both M-14: Health Status and Health Risks and health risks. Indicators for health status will be objectively showing differences in health outcomes between countries and M-15: Universal Health Coverage measured through health outcome indicators, while health risks trying to determine possible factors accounting for such differences 4 List of Acronyms and identifies instructive best practices. Similarly, PER authors can will focus on factors that are not only influenced by the health sector. The indicators in this module are part of the World Health use benchmarking to draw comparisons across geopolitical entities SECTION 4 Organization’s (WHO) 2018 Global Reference List of 100 Core Health (for example, subnational, urban versus rural) within the reviewed Additional Guidance Indicators, a standardized set of core indicators ranked by the country. The following box defines terms used in the module. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 439 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS HEALTH STATUS DISABILITY-ADJUSTED LIFE YEARS (DALYS) 2 Health status is a broad concept that outlines the level of physical and DALYs are an aggregate measure that sums the years of life lost SECTION 2 mental health of an individual or a population. Measurement of health (YLLs) due to premature mortality and the years lived with a Cross-Cutting status typically focuses on health outcomes, including well-known aggregate disability (YLDs) due to diseases and injuries. One DALY represents Analysis on Efficiency and population level outcomes, such as life expectancy at birth or the prevalence the loss of the equivalent of one year of full health, and countries Equity 3 of specific diseases like tuberculosis or diabetes. These types of health with higher DALYs have a higher disease burden. The estimates outcomes are particularly useful in understanding the net result of public of YLL are based on biological and demographic data, while SECTION 3 health interventions alongside the influence of social, environmental, and YLD additionally applies a discounting weight depending on Topic-Specific commercial determinants of health. the severity of disease/injury. Time and age discounting is also Analysis applied. The WHO and Global Burden of Disease project uses a HEALTH RISKS standard methodology and has country-specific estimates that Health System Context A health risk is a factor that influences the likelihood of an adverse health PER authors can use. Health Financing outcome, for example, premature mortality due to noncommunicable Inputs diseases. Health risks span different areas, such as behavioral, physiological, HEALTH-ADJUSTED LIFE EXPECTANCY (HALE) Service Delivery environmental, or occupational factors. Certain health risks are highly Health-adjusted life years is the converse of DALYs, or the number Outcomes amenable to interventions in the health system. For example, high levels of of years a person lives in full health through discounting for the M-12: Service Coverage lipids in the blood or cholesterol and hypertension or high blood pressure number of years of life lived with a disease or injury. Health- M-13: Financial Risk Protection are important risk factors for cardiovascular diseases. As such, interventions adjusted life expectancy aggregates this across the population M-14: Health Status and Health Risks in the health system to screen people and give medicines to patients with to arrive at the life expectancy at a given age. HALE (and life M-15: Universal Health Coverage high cholesterol and hypertension are effective in reducing the prevalence of expectancy in general) is typically compared at birth. PER authors cardiovascular disease and premature mortality from cardiovascular disease. should note that the variation in HALE is less than the variation in 4 List of Acronyms Health risks primarily amenable to health system interventions are covered life expectancy. For example, global life expectancy increased by 6.6 in other modules. This module focuses on health risks that require broader years between 2000 and 2019. However, HALE increased by just 5.4 SECTION 4 public policy as well as public health attention—for example, malnutrition years during the same period. This was due to declining mortality Additional Guidance among children or exposure to high levels of air pollution. but not reduced years lived with disease or injury. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 440 OVERVIEW 1 SECTION 1 What Is a Health PER? PROGRESS ON HEALTH STATUS AND HEALTH RISKS 2 SECTION 2 Cross-Cutting Analysis on Health Status Efficiency and Equity 3 KEY QUESTION • What are the health outcomes in the country? SECTION 3 Topic-Specific Analysis The defining goal of the health system is to improve the health of the population. This encompasses improvements in both the average level Health System Context and the distribution of health outcomes within the population (WHO Health Financing 2000). Progress in this area can be examined through objective health Inputs outcomes indicators. When selecting indicators, PER authors should try Service Delivery to select some aggregate indicators, such as life expectancy, alongside Outcomes other indicators that capture the specific disease burden of the country, M-12: Service Coverage focusing on the leading causes of death. In addition to life expectancy M-13: Financial Risk Protection and other mortality-focused indicators, authors can consider summary M-14: Health Status and Health Risks measures or mortality and morbidity in a population, such as health- M-15: Universal Health Coverage adjusted life expectancy (HALE) or disability-adjusted life years (DALYs) (Lajoie 2015). However, when making cross-country comparisons, PER 4 List of Acronyms authors should keep in mind that the latter have more limited variation SECTION 4 than life expectancy. Additional Guidance TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 441 OVERVIEW 1 SECTION 1 What Is a Health PER? Health Status 2 SECTION 2 Key Indicators Sources Cross-Cutting Analysis on Efficiency and Mortality Equity 3 Neonatal mortality The main sources of infant mortality data are vital registration systems and direct or indirect estimates based on SECTION 3 rate (per 1,000 live population-based household surveys (such as Demographic and Health Surveys—DHS) and population censuses. Topic-Specific births) Data can be found in: Analysis • World Bank Open Data • WHO GHO Health System Context • UNICEF Data Warehouse Health Financing • UN Inter-agency Group for Child Mortality Estimation database Inputs • STATcompiler Service Delivery • Institute for Health Metrics and Evaluation Global Burden of Disease Outcomes Infant mortality rate The main sources of infant mortality data are vital registration systems and direct or indirect estimates based on M-12: Service Coverage (per 1,000 live births) population-based household surveys (such as DHS) and population censuses. Data can be found in: M-13: Financial Risk Protection • World Bank Open Data M-14: Health Status and Health Risks • WHO GHO M-15: Universal Health Coverage • UNICEF Data Warehouse 4 List of Acronyms • UN Inter-agency Group for Child Mortality Estimation database • STATcompiler SECTION 4 • Institute for Health Metrics and Evaluation Global Burden of Disease Additional Guidance Table continues on the following page. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 442 OVERVIEW 1 Key Indicators Sources SECTION 1 What Is a Health PER? Mortality (Continued) 2 Under-5 mortality rate The main sources of under-5 mortality data are vital registration systems and direct or indirect estimates based on SECTION 2 (per 1,000 live births) population-based household surveys (such as DHS) and population censuses. Data can be found in: Cross-Cutting • World Bank Open Data Analysis on Efficiency and • WHO GHO Equity 3 • UNICEF Data Warehouse • UN Inter-agency Group for Child Mortality Estimation database SECTION 3 • STATcompiler Topic-Specific • Institute for Health Metrics and Evaluation Global Burden of Disease Analysis Maternal mortality The main sources of mortality data are vital registration systems and direct or indirect estimates based on Health System Context ratio (per 100,000 live population-based household surveys (such as DHS) and population censuses. Data can be found in: Health Financing births) • World Bank Open Data Inputs • WHO GHO Service Delivery • UNICEF Data Warehouse • UN Inter-agency Group for Maternal Mortality Estimation database Outcomes • Institute for Health Metrics and Evaluation Global Burden of Disease M-12: Service Coverage • STATcompiler M-13: Financial Risk Protection M-14: Health Status and Health Risks Aggregate indicators M-15: Universal Health Coverage Life expectancy at Preferred data sources include civil registration with complete coverage as well as direct and indirect estimates 4 List of Acronyms birth (years) based on population-based household surveys (such as DHS) and population censuses. Data can be found in: • World Bank Open Data SECTION 4 • WHO GHO Additional • Institute for Health Metrics and Evaluation Global Burden of Disease Guidance Table continues on the following page. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 443 OVERVIEW 1 Key Indicators Sources SECTION 1 What Is a Health PER? Burden of disease 2 Health-adjusted life Indicator is statistically derived; data can be found in: SECTION 2 expectancy at birth • WHO GHO Cross-Cutting (years) • Institute for Health Metrics and Evaluation Global Burden of Disease Analysis on Efficiency and Equity Health-adjusted life Indicator is statistically derived; data can be found in: 3 years • WHO GHO SECTION 3 • Disability-adjusted • Institute for Health Metrics and Evaluation Global Burden of Disease Topic-Specific life years Analysis • Years of life lost from mortality Health System Context Disease-specific Preferred data sources include population-based household surveys (such as DHS) and other representative special Health Financing prevalence rates surveys. Data can be found in: Inputs • World Bank Open Data Service Delivery • WHO GHO Outcomes • STATcompiler M-12: Service Coverage • Institute for Health Metrics and Evaluation Global Burden of Disease M-13: Financial Risk Protection • Other special health repositories such as AIDSInfo M-14: Health Status and Health Risks • Articles published in peer-reviewed journals M-15: Universal Health Coverage Note: DHS = Demographic and Health Surveys; WHO GHO = World Health Organization Global Health Observatory. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 444 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 Health Risks SECTION 3 Topic-Specific Analysis KEY QUESTION • What are the main health risks for the population? Health System Context Health Financing To identify the main health risks, PER authors should examine the are considered in other modules, namely the Service Coverage Inputs burden of disease and leading causes of death. For instance, a module and Primary Health Care and Public Health Service Service Delivery low-income country context may call for a focus on malnutrition- module. However, if PER authors do not conduct these other Outcomes related risks, while a middle-income country context may modules in their PERs, they can also choose to examine additional M-12: Service Coverage require greater focus on environmental risks, such as exposure health risks as part of this module. M-13: Financial Risk Protection to high levels of air pollution. Some important risk factors for M-14: Health Status and Health Risks consideration are listed in the following table. To choose the most important health risks for a country, PER authors M-15: Universal Health Coverage can also analyze and compare causes and risks within a country using As discussed earlier, this module focuses on health risks that the Institute for Health Metrics and Evaluation (IHME) Global Burden 4 List of Acronyms require broad public policy as well as public health attention. Risk of Disease (GBD) Compare tool,1 which provides estimates for 87 factors that are more directly attributable to the health sector behavioral, environmental, metabolic, and occupational risk factors. SECTION 4 Additional Guidance 1 https://www.healthdata.org/data-tools-practices/interactive-visuals/gbd-compare. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 445 OVERVIEW 1 SECTION 1 What Is a Health PER? Health Risks 2 SECTION 2 Cross-Cutting Key Indicators Sources Analysis on Efficiency and Equity 3 Child malnutrition Preferred data sources include household and specific population-based household • Stunting prevalence among children under 5 years (%) surveys such as DHS, MICS, and RHS, as well as surveillance systems. Data can be SECTION 3 • Wasting prevalence among children under 5 years (%) found in: Topic-Specific • World Bank Open Data Analysis • WHO GHO • UNICEF Open Data Health System Context • STATcompiler Health Financing Inputs Unsafe water, sanitation, hygiene Preferred data sources include census data and population-based household Service Delivery • Population using improved drinking-water sources (%) surveys such as DHS, as well as administrative reporting systems. Data can be found • Population using improved sanitation services (%) in: Outcomes • WHO GHO M-12: Service Coverage • UNICEF Data Warehouse M-13: Financial Risk Protection • STATcompiler M-14: Health Status and Health Risks M-15: Universal Health Coverage Indoor smoke from solid fuels Preferred data sources include population censuses and household surveys such as • Population using solid fuels (%) DHS and MICS. Data can be found in: 4 List of Acronyms • Percentage of households that use solid fuels for • WHO GHO cooking (averages) • STATcompiler SECTION 4 Additional Table continues on the following page. Guidance TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 446 OVERVIEW 1 SECTION 1 Key Indicators Sources What Is a Health PER? Tobacco use* Preferred data source is a population-based survey, such as STEPS, DHS, National 2 • Prevalence of current tobacco use (%) Drug Abuse Surveys, Global Adult Tobacco Survey. Data can be found in: SECTION 2 • Smoking impact ratio (%) • WHO Global Health Observatory Cross-Cutting • STATcompiler Analysis on Efficiency and Alcohol use Preferred data sources include population-based (preferably nationally Equity 3 • Alcohol, consumers in past 12 months (%) representative) surveys, such as STEPS. For per capita consumption, administrative • Prevalence of heavy episodic drinking (≥60 grams reporting systems provide data for recorded per capita alcohol consumption, SECTION 3 alcohol on at least one occasion weekly) among adults while survey data are the preferred sources for unrecorded per capita alcohol Topic-Specific Analysis • Total (recorded and unrecorded) alcohol per capita consumption. Data can be found in: (age 15+ years) consumption within a calendar year in • World Bank Open Data Health System Context liters of pure alcohol • WHO GHO Health Financing Physical inactivity Preferred data sources include population-based surveys (such as the Global Inputs • Prevalence of insufficiently physically active Physical Activity Questionnaire), school health surveys, and surveillance systems. Service Delivery adolescents (defined as less than 60 minutes of Data can be found in: Outcomes moderate to vigorous intensity activity daily) • WHO GHO M-12: Service Coverage • Prevalence of insufficiently physically active persons age 18+ years (defined as less than 150 minutes of M-13: Financial Risk Protection moderate-intensity activity per week, or equivalent) M-14: Health Status and Health Risks M-15: Universal Health Coverage Low fruit and vegetable intake Preferred data sources are population-based (preferably nationally representative) 4 List of Acronyms • Adults who eat less than five servings of fruit and/or surveys such as household surveys with health information and STEPS. Data can be vegetables (400 grams) on average per day (%) found in: SECTION 4 • WHO GHO Additional Guidance Table continues on the following page. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 447 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Urban outdoor air pollution Sources Concentrations of PM2.5 are typically measured from fixed-site, population-oriented 2 • Annual mean concentration of particulate matter of monitors located within metropolitan areas. Data can be found in: SECTION 2 less than 2.5 microns of diameter (PM2.5) [ug/m3] • World Bank Open Data Cross-Cutting • Annual mean concentration of particulate matter of • National/subnational/monitoring reports and websites Analysis on Efficiency and less than 10 microns of diameter (PM10) [ug/m3] • Relevant national agencies Equity 3 Occupational risks Data sources vary and include civil registration systems and other administrative SECTION 3 • Incidence, frequency, and severity rates of fatal and records (e.g., insurance records, notification records, and labor inspection records), Topic-Specific non-fatal occupational injuries (number of cases per establishment censuses and surveys, labor force surveys and other special surveys, Analysis hours worked)** and surveillance systems. Data can be found in: • Percentage of workers employed in industries at high • ILOSTAT Health System Context risk for Occupational Injury • National/subnational/monitoring reports and websites Health Financing • Proportion of workers exposed to background, low, and • Relevant national agencies Inputs high levels of workplace carcinogens Service Delivery • Proportion of workers with background, low, and high levels of exposure to airborne particulates Outcomes • Proportion of workers with high, moderate, and low M-12: Service Coverage exposure to ergonomic stressors M-13: Financial Risk Protection • Proportion of workers with high and moderate M-14: Health Status and Health Risks exposure categories to noise (>90 dBA and 85-90 dBA) M-15: Universal Health Coverage Note: DHS = Demographic and Health Surveys; ILOSTAT = International Labor Organization statistical database; MICS = Multiple Indicator Cluster Surveys; RHS = Reproductive Health Surveys; STEPS = WHO STEPwise approach to NCD risk 4 List of Acronyms factor surveillance; UNICEF = United Nations Children’s Fund; WHO GHO = World Health Organization Global Health Observatory. * Two measures are commonly used to estimate tobacco use exposure: prevalence of current tobacco use and smoking impact ratio (SIR). Whereas the prevalence-based measure takes into account the current prevalence of tobacco SECTION 4 use, SIR provides an indication of cumulative exposure to smoking in a population (Kong et al. 2016). It is defined as population lung cancer mortality greater than the background lung cancer mortality rate recorded in never-smokers in the population, relative to the excess lung cancer mortality rate recorded in a known reference group of smokers (Reitsma et al. 2017). Additional ** The most common rates used in occupational safety are incidence rates (the number of occupational injuries during the reference period for a given number of workers in the reference group), frequency rates (the number of Guidance occupational injuries during the reference period for a given number of hours worked by workers in the reference group), and severity rates (the number of days lost due to new cases of occupational injury during the reference period for a given number of hours worked by workers in the reference group) (ILO 2020). TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 448 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting EQUITY OF HEALTH STATUS AND HEALTH RISKS Analysis on Efficiency and Equity 3 KEY QUESTION • Are health status and health risks the same across different population groups? SECTION 3 Topic-Specific Analysis Typically, health outcomes are inequitable. Seminal work by the However, reliable disaggregated data on health outcomes and health Commission on Social Determinants and Health, for example, risks doesn’t always exist in low- and middle-income countries. Health System Context illustrated a more than 25-year difference in life expectancy for Indeed, information from civil registration and vital statistics and Health Financing boys born in different areas of Glasgow. Analysis by key dimensions other administrative information systems often have systematic Inputs of equity (for example, age, gender, education level, socioeconomic biases in coverage, with lower reporting among rural, poor, and Service Delivery status, place of residence) over time will indicate whether a given marginalized population groups. In this case, only health status Outcomes situation is improving, stagnating, or worsening. Knowing where and health risk information that relies on household surveys like progress has been achieved can offer lessons for programs and MICS/DHS may be reliably disaggregated. In addition, PER authors M-12: Service Coverage policies that can be applied to other health risks where progress may also wish to search for academic country or regional studies in M-13: Financial Risk Protection remains slow. If possible, all indicators used for health status this area, which may rely on different sources and methodologies, M-14: Health Status and Health Risks and health risk monitoring should be examined across different to examine health status through an equity lens. M-15: Universal Health Coverage socioeconomic and geographic groups in a country, with particular 4 List of Acronyms attention to poor and marginalized populations. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 449 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 Bolnick, H., A.L. Bui, A. Bulchis, C. Chen, A. Chapin, L. Lomsadze, A. Mokdad, et al. 2020. “Health-Care Spending Attributable to Modifiable Risk SECTION 2 Factors in the USA: An Economic Attribution Analysis.” The Lancet 5 (10): 525–35. https://www.thelancet.com/journals/lanpub/article/PIIS2468- Cross-Cutting Analysis on 2667(20)30203-6/fulltext. Efficiency and Equity International Labour Organization. 2020. Quick Guide on Sources and Uses of Statistics on Occupational Safety and Health. Geneva: International 3 Labour Organization. https://ilo.org/wcmsp5/groups/public/---dgreports/---stat/documents/publication/wcms_759401.pdf. SECTION 3 Kong, K.A., K.H. Jung-Choi, D. Lim, H.A. Lee, W.K. Lee, S.J. Baik, S.H. Park, et al. 2016. “Comparison of Prevalence- and Smoking Impact Ratio-Based Topic-Specific Analysis Methods of Estimating Smoking-Attributable Fractions of Deaths.” Journal of Epidemiology 26 (3): 145–54. https://pubmed.ncbi.nlm.nih.gov/26477995/. Lajoie, J. 2015. “Understanding the Measurement of Global Burden of Disease.” National Collaborating Centre for Infectious Diseases. https:// Health System Context nccid.ca/publications/understanding-the-measurement-of-global-burden-of-disease/#:~:text=Healthy%20life%20expectancy%20(HALE%2C%20 Health Financing also,to%20live%20in%20good%20health. Inputs Murray, C.J.L., A.Y. Aravkin, P. Zheng, K.M. Abbas, M. Abbasi-Kangevari, F. Abd-Allah, A. Abdelalim, et al. 2020. “Global Burden of 87 Risk Factors in 204 Service Delivery Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019.” The Lancet, Vol. 396, No. 10258: 1129–1306. Outcomes https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30752-2/fulltext. M-12: Service Coverage M-13: Financial Risk Protection National Center for Biotechnology Information (NCBI). 2006. Global Burden of Disease and Risk Factors. Bethesda, MD: National Center for M-14: Health Status and Health Risks Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK11818/. M-15: Universal Health Coverage Nixon, J., and P. Ulmann. 2006. “The Relationship between Health Care Expenditure and Health Outcomes.” The European Journal of Health Economics 4 List of Acronyms 7: 7–18. https://link.springer.com/article/10.1007/s10198-005-0336-8. Reitsma, M.B., N. Fullman, M. Ng, J.S. Salama, A.A. Abajobir, K.H. Abate, C. Abbafati, et al. 2017. “Smoking Prevalence and Attributable Disease Burden SECTION 4 Additional in 195 Countries and Territories, 1990–2015: A Systematic Analysis from the Global Burden of Disease Study.” The Lancet, Vol. 389, No. 10082: 1885– Guidance 1906. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/fulltext. TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 450 OVERVIEW 1 SECTION 1 What Is a Health PER? World Bank. 2008. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation. Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/6896. 2 World Bank. 2018. Analyzing Health Equity Using Household Survey Data. Washington, DC: World Bank. https://www.worldbank.org/en/topic/health/ SECTION 2 publication/analyzing-health-equity-using-household-survey-data. Cross-Cutting Analysis on World Health Organization. 2000. A Framework for Assessing the Performance of Health Systems. Geneva: World Health Organization. https://www. Efficiency and Equity ncbi.nlm.nih.gov/pmc/articles/PMC2560787/pdf/10916909.pdf. 3 World Health Organization. 2003. How Summary Measures of Population Health Are Affecting Health Agendas. Geneva: World Health Organization. SECTION 3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2572457/pdf/12856047.pdf. Topic-Specific Analysis World Health Organization. 2009. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: World Health Organization. https://apps.who.int/iris/handle/10665/44203. Health System Context Health Financing World Health Organization. 2014. The Case for Investing in Public Health: The Strengthening Public Health Services and Capacity. Geneva: World Health Organization. https://www.euro.who.int/data/assets/pdf_file/0009/278073/Case-Investing-Public-Health.pdf. Inputs Service Delivery World Health Organization. 2016. Addressing and Managing Conflicts of Interest in the Planning and Delivery of Nutrition Programmes at Country Outcomes Level. Geneva: World Health Organization. https://apps.who.int/iris/handle/10665/206554. M-12: Service Coverage World Health Organization. 2018‎. Health in All Policies as Part of the Primary Health Care Agenda on Multisectoral Action. Geneva: World Health M-13: Financial Risk Protection Organization. https://apps.who.int/iris/handle/10665/326463. M-14: Health Status and Health Risks M-15: Universal Health Coverage World Health Organization. 2020. SCORE Global Report on Health Data Systems and Capacity Report. Geneva: World Health Organization. https:// apps.who.int/iris/bitstream/handle/10665/339125/9789240018709-eng.pdf. 4 List of Acronyms World Health Organization. 2022. Health Inequality Monitor. Geneva: World Health Organization. https://www.who.int/data/health-equity. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 14 Health Status and Health Risks 451 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis MODULE 15 Health System Context Health Financing Universal Health Inputs Service Delivery Outcomes Coverage M-12: Service Coverage AUTHORS M-13: Financial Risk Protection Jacopo Gabani and Sven Neelsen M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms START SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 452 OVERVIEW 1 SECTION 1 What Is a Health PER? INTRODUCTION background, geographic location, among other factors. For service 2 coverage to be effective, the services received must be of sufficient SECTION 2 quality to obtain potential health gains (Figure 1). Cross-Cutting The module discusses both assessing progress Analysis on Efficiency and toward Universal health coverage (UHC) and The literature on UHC has largely focused on assessing service Equity 3 coverage and financial risk protection (see the World Bank and evaluating the equity of service coverage and WHO Universal Health Coverage Global Monitoring Reports 2021, SECTION 3 financial risk protection, the key components of 2022, and 2023). These reports show substantial progress in the Topic-Specific Analysis UHC measurement. UHC is recognized as a policy UHC service coverage index (from 45 to 68 in the 2000–21 period). priority in many countries. Because the objective However, they also show that in 2021, about 2 billion people faced Health System Context financial hardship and 4.5 billion people were not covered by of public expenditure reviews (PERs) is typically Health Financing essential health services. to assess the consistency of public expenditures Inputs Service Delivery with policy priorities, and the results achieved, Both service coverage and financial protection indicators need to be assessed to track the progress toward UHC. Accordingly, Sustainable Outcomes then it is of crucial importance to assess the Development Goal (SDG) target 3.8, “Achieve UHC,” is monitored via M-12: Service Coverage progress toward UHC. SDG indicator 3.8.1 for service coverage and SDG indicator 3.8.2 for M-13: Financial Risk Protection financial risk protection. Looking at both indicators is important M-14: Health Status and Health Risks because citizens may forgo care to avoid financial hardship. The M-15: Universal Health Coverage Under universal health coverage, all individuals and communities resulting low incidence of financial hardship comes at the expense receive the health services they need, when and where they need 4 List of Acronyms of low coverage. Conversely, service coverage might increase, but them, without suffering financial hardship (WHO 2023). UHC includes if service coverage increases are financed by out-of-pocket (OOP) the full range of essential health services, and it applies to an entire SECTION 4 health expenditures, the incidence of financial hardship due to OOP Additional population, that is, all individuals regardless of socioeconomic Guidance health expenditures might increase. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 453 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 1 UTILIZATION, COVERAGE, AND EFFECTIVE COVERAGE 2 SECTION 2 Cross-Cutting UTILIZATION COVERAGE EFFECTIVE COVERAGE Analysis on Efficiency and Equity 3 • % population using a service • % population in need using a service • % population in need using a service and getting the optimal treatment • E.g., % children taken to a health provider • % children needing a DTP vaccine dose SECTION 3 Topic-Specific taken to a health provider • % of children 12–23 months who needed • But does everyone need a consultation? Analysis and received three doses of DTP vaccine • But do children get the correct treatment? Health System Context Source: World Bank 2022. Health Financing Financial protection is achieved for an individual or household service and obtain the correct treatment. In addition, PER authors Inputs when two conditions are met: (1) those who obtain adequate care should note that de jure coverage is not service coverage: being Service Delivery do not suffer financial hardship in the form of (a) catastrophic or (b) enrolled in insurance doesn’t mean that those who are enrolled Outcomes impoverishing OOP health spending; and (2) no one in need forgoes by insurance receive care when needed. Finally, we note that M-12: Service Coverage adequate care for financial reasons. different terms are used to identify people “covered” by health M-13: Financial Risk Protection insurance (for example, “enrolled” in Thailand, “insured” in Estonia, M-14: Health Status and Health Risks An important caveat is that utilization might not be equivalent “covered” in Ghana). In this module we use “enrolled” to avoid M-15: Universal Health Coverage to coverage, and coverage might not be equivalent to effective confusion with service coverage definitions. coverage, as shown in Figure 1. Utilization represents the 4 List of Acronyms percentage of people obtaining a service regardless of their needs. The module is divided into two sections: progress and equity. PER SECTION 4 Coverage represents the percentage of people in need utilizing a authors may also refer to the modules on Service Coverage and Additional service regardless of whether the service provided is the correct Financial Risk Protection separately. The following box defines Guidance one. Finally, effective coverage means that people in need use a terms used in this module. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 454 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS EFFECTIVE COVERAGE FINANCIAL RISK PROTECTION 2 The percentage of people in need of a particular service who obtain the A household is protected from financial risk when it is not suffering SECTION 2 optimal treatment. financial hardship due to catastrophic health expenditures, Cross-Cutting impoverishing health expenditures, or forgoing care due to financial Analysis on Efficiency and EFFECTIVE COVERAGE INDEX reasons. The Financial Risk Protection module provides more Equity 3 An index developed by the Institute of Health Metrics and Evaluation details on the topic and its related measures mentioned below. (IHME), University of Washington, encompassing 41 indicators, of which nine SECTION 3 are related to service coverage and 32 are related to outcomes. Full details FORGOING CARE Topic-Specific are provided in Annex 1, as well as in the Service Coverage module. A household forgoes needed care when it does not initiate, or Analysis interrupt, requesting a health care service, despite needing it. For CATASTROPHIC HEALTH EXPENDITURE example, an individual might decide not to undergo a needed surgery Health System Context A household incurs catastrophic health expenditure when its total OOP due to its financial costs. Health Financing health expenditures, as a percentage of total consumption, are above Inputs a certain threshold. Commonly used thresholds are 10 percent and 25 IMPOVERISHING HEALTH EXPENDITURE Service Delivery percent. For example, a household incurs catastrophic health expenditures OOP health expenditures are impoverishing if they (1) push or (2) Outcomes when its OOP health expenditures are above 10 percent (or 25 percent) further push households below a poverty line. Households are pushed M-12: Service Coverage of total consumption. Note that the proportion of people incurring into poverty by OOP health spending if their total consumption M-13: Financial Risk Protection catastrophic health expenditures at the 10 percent level, and 25 percent lies above a poverty line but their consumption net of OOP health M-14: Health Status and Health Risks level, are used to track Sustainable Development Goal (SDG) indicator 3.8.2, payments lies below it. And households are pushed further into M-15: Universal Health Coverage “Catastrophic health expenditures (and related measures).” poverty by OOP health expenditures if their total consumption already lies below a poverty line and they incur any OOP health payments. The 4 List of Acronyms COVERAGE population incurring impoverishing health expenditures is tracked as The percentage of people, out of all people in need, who obtain treatment part of SDG indicator 3.8.2, using poverty lines of $2.15 and $3.65 per SECTION 4 from a health provider. person per day, but other absolute and relative poverty lines should Additional Guidance be considered according to context. Box 1 continues on the following page. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 455 OVERVIEW 1 SECTION 1 What Is a Health PER? BOX 1. DEFINITIONS OF TERMS (continued) 2 UHC SERVICE COVERAGE INDEX SECTION 2 Used to track SDG indicator 3.8.1, it is Cross-Cutting Analysis on calculated as the unweighted geometric mean Efficiency and Equity of 14 tracers, of which 11 are service coverage 3 tracers and three are service capacity tracers. Full details are provided in Annex 1 as well as SECTION 3 the Service Coverage module. Topic-Specific Analysis UNIVERSAL HEALTH COVERAGE (UHC) Health System Context Under UHC, all individuals and communities Health Financing receive the health services they need, when Inputs and where they need them, without suffering financial hardship. It includes the full range Service Delivery of essential health services, and it applies to Outcomes an entire population, that is, all individuals M-12: Service Coverage regardless of socioeconomic background, M-13: Financial Risk Protection geographic location, or other factors. M-14: Health Status and Health Risks “Achieving UHC” is SDG target 3.8. M-15: Universal Health Coverage UTILIZATION 4 List of Acronyms The percentage of people using a particular SECTION 4 service, regardless of need and whether the Additional treatment is optimal. Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 456 OVERVIEW 1 SECTION 1 What Is a Health PER? PROGRESS TOWARD UNIVERSAL HEALTH COVERAGE 2 SECTION 2 Cross-Cutting KEY QUESTIONS • What is the country’s progress toward UHC? Analysis on Efficiency and • What is the progress on service coverage and financial protection? Equity 3 SECTION 3 Topic-Specific Analysis Health System Context This section focuses on the UHC index and aggregate measures of service coverage and the two most common indicators of financial risk protection. Key Indicators UHC service coverage index Sources • WHO/World Bank UHC annual Global Monitoring Report Health Financing PER authors interested in conducting • Country MoH reports more detailed analyses of service Inputs coverage and financial risk protection UHC service coverage index • IHME Global Burden of Disease Service Delivery (GBD) study, 2019 should refer to those modules. Outcomes Financial risk protection indicator(s). If using one indicator, the • World Bank HEFPI dataset M-12: Service Coverage PER authors may use the following most common indicator used is the “proportion of population (see also the Financial Risk M-13: Financial Risk Protection indicators to measure progress spending more than 10% of household consumption or income Protection module ) and M-14: Health Status and Health Risks toward universal health coverage. on out-of-pocket health care expenditure (%)” (CATA) (Wagstaff the WHO GHO M-15: Universal Health Coverage The following table contains contains and Neelsen 2020). Other options are CATA at the 25% level, and 4 List of Acronyms more information about these UHC “proportion of population pushed below the $1.90 or $3.20 (2011 monitoring tools. PPP) poverty line by out-of-pocket health care expenditure (%).” SECTION 4 Note: HEFPI = Home Equity and Financial Protection Indicators; IHME = Institute of Health Metrics and Evaluation, University of Washington; MoH = Ministry of Health; OOP Additional = out-of-pocket; PPP = purchasing power parity; UHC = universal health coverage; WHO = World Health Organization; WHO GHO = World Health Organization Global Health Guidance Observatory. The poverty lines of $1.90 and $3.20 are per person per day. The most recent UHC Global Monitoring Report 2023 and the WHO Global Health Observatory use updated poverty lines of $2.10 and $3.65. PER authors can use data in HEFPI, which still applies the $1.90 and $3.20 poverty lines, or the WHO Global Health Observatory data, making sure that the source and poverty line used are clearly stated. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 457 OVERVIEW 1 SECTION 1 What Is a Health PER? When assessing the country’s progress toward UHC, PER authors should consider both service coverage and financial protection. Authors should note that there are caveats for the suggested that are of particular relevance to the country’s context. Authors may refer to the HEFPI dataset for a compilation of service coverage variables. For example, countries with high malnutrition burdens 2 indicators to monitor this progress (caveats for service coverage may opt to include nutrition service coverage indicators, which are SECTION 2 Cross-Cutting indicators were noted earlier). Further, UHC indexes have not been not captured by the existing UHC Service Coverage Index (see the Analysis on developed at the subnational level, so distributional analysis by Service Coverage module for possible nutrition indicators) Efficiency and Equity region, wealth quintile, ethnic group, or coverage group cannot 3 be conducted. Such analysis is, however, possible at the level of These tracer indicators may be used to monitor coverage of SECTION 3 individual indicators, which can be sourced from household survey essential health services. If possible, PER authors should focus on Topic-Specific data or the Home Equity and Financial Protection Indicators (HEFPI) essential health services that reflect the success of effective health Analysis dataset, which also offers corresponding visualizations.1 promotion, screening, and treatment programs when assessing the effectiveness of service coverage. See Annex 1 for a list of tracer Health System Context The World Health Organization (WHO) service coverage index (like indicators that may be used. Health Financing the Institute of Health Metrics and Evaluation (IHME) effective Inputs coverage index) is largely modeled and available until 2021 for A final caveat is that advancing toward UHC is dependent on a Service Delivery all countries. The challenge is that only a minority of points are country’s ability and willingness to track UHC. Household surveys Outcomes not modeled, and this can hinder country dialogue if clients don’t with detailed consumption modules are required for financial M-12: Service Coverage accept the modeled estimates. Additional caveats include that risk protection tracking. PER authors are therefore encouraged to M-13: Financial Risk Protection noncommunicable disease (NCD) services are underrepresented in collaborate with relevant client institutions (for example, national M-14: Health Status and Health Risks the WHO service coverage index.2 This may be an issue for countries statistics institutes) leading the surveys, to ensure that relevant M-15: Universal Health Coverage with a high burden of NCDs. It is worth noting that PER authors may health sector questions are included. Similar reasoning applies to opt to look at the additional key indicators as a supplement to service coverage tracking, as administrative data are often used in 4 List of Acronyms analyzing service coverage levels in the country, focusing on those addition to household surveys. SECTION 4 Additional 1 See https://datatopics.worldbank.org/health-equity-and-financial-protection/. Guidance 2 A discussion of this issue can be found in chapter 1.4 of the 2021 UHC Global Monitoring Report: https://openknowledge.worldbank.org/handle/10986/36724. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 458 OVERVIEW 1 SECTION 1 What Is a Health PER? There may be significant disparities in service coverage across population groups or geographic FIGURE 2 EFFECTIVE COVERAGE INDEX ACROSS INCOME GROUPS 2 entities. Depending on the country’s context, PER 100 authors should assess distribution across geopolitical SECTION 2 Cross-Cutting entities (urban/rural and subnational entities), gender, 90 Analysis on socioeconomic characteristics (income/wealth/ Efficiency and Equity consumption; see also the next section on “Equity of 3 80 UHC”), and other population dimensions (for example, Kyrgyz Republic IHME effective health service coverage index 70 SECTION 3 sexual orientation, health benefits entitlement). Topic-Specific Analysis 60 Tajikistan PER authors should benchmark the UHC service coverage index or the effective coverage index against 50 Kazakhstan Health System Context comparator countries. PER authors may conduct cross- Health Financing 40 country comparisons, examining positioning relative Inputs to regional and income group peers. Figure 2 shows Turkmenistan 30 Service Delivery an example using the IHME effective coverage index Uzbekistan Outcomes over (log) GNI per capita and linear regression line, 20 M-12: Service Coverage highlighting Central Asian countries. M-13: Financial Risk Protection 10 M-14: Health Status and Health Risks As noted in the introduction, to meaningfully interpret Low-income Lower-middle-income Upper-middle-income High-income 0 M-15: Universal Health Coverage progress toward UHC, PER authors should look at the 4 List of Acronyms progress in service coverage vis-à-vis the progress in 250 500 1,035 2000 4,045 7000 12,535 25,000 50,000 100,000 financial protection to check whether one is improving Log of GNI per capital, 2019 ($US) SECTION 4 at the expense of the other; ideally, both service Source: Tajikistan Public Expenditure Review 2021. Additional coverage and financial risk protection should improve Guidance at the same time. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 459 OVERVIEW 1 SECTION 1 What Is a Health PER? A comparison of trends in service coverage and financial risk protection can be made in several ways, including in a single graph (Figure 3) or in two separate graphs showing the trend sets separately and then providing a unified comment for both indicators. 2 SECTION 2 Cross-Cutting FIGURE 3 Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific Analysis on TRENDS IN UHC Efficiency and SERVICE COVERAGE An increase in service coverage is better Equity 3 INDEX AND UHC service coverage index (SDG indicator 3.8.1) INCIDENCE OF CATASTROPHIC 10 20 30 40 50 60 70 80 90 100 Catastrophic out of pocket health spending (SDG indicator 3.8.2, 10% threshold) SECTION 3 0 HEALTH SPENDING Topic-Specific QUADRANT IV QUADRANT I Analysis BY WHO REGION, 2000–17 Less Health System Context 5 people with 2000 2017 catastrophic 2000 Health Financing Source: SDG indicator 3.8. 1: WHO 2000 global service coverage database, health 2017 2017 Inputs 2021 update; SDG indicator 3.8.2: 2000 WHO and World Bank global spending is financial protection Service Delivery database, 2021 update. https:// better 10 2000 www.who.int/publications/i/ Outcomes item/9789240040618. 2000 Note: The vertical axis 2017 M-12: Service Coverage corresponds to the 2017 global M-13: Financial Risk Protection incidence rate of catastrophic 15 health spending defined as the M-14: Health Status and Health Risks proportion of the population- 2017 weighted population with household out-of-pocket health M-15: Universal Health Coverage expenditure exceeding 10% of household budget (13.2% in 2017). 4 List of Acronyms The horizontal axis corresponds 20 2017 to the 2017 global population- weighted average UHC SCI (65) in 2017. SECTION 4 QUADRANT III QUADRANT II Additional 25 Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 460 9 31 Not wanting to go alone OVERVIEW 1 8 39 Distance to facility SECTION 121 FIGURE 4 58 Getting money What Is a ISSUES REPORTED BY TAJIK Health PER? 9 25 WOMEN AS BIG PROBLEMS 66 Any of the problems 30 Getting permission to go 2 THAT PREVENT THEM FROM SECTION 2 ACCESSING HEALTH CARE 9 31 Not wanting to go alone 0 Cross-Cutting 10 20 30 WHEN 40 SICK, BY 50WEALTH 60 70 80 90 100 Analysis on QUINTILE, 2017 8 Percentage of women age 15-49 reporting issue is a big problem for accessing care when sick (%) 39 Distance to facility Efficiency and Equity 3 21 58 Getting money Richest quintile Poorest quintile SECTION 3 25 66 Any of the problems Topic-Specific Source: Data from Demographic and Health Survey 2017. Analysis Note: Lines connecting the average values of the poorest quintile (teal dots) and the richest quintile 0 10 20 30 40 50 60 70 80 90 100 (blue dots) indicate the magnitude of inequality. Percentage of women age 15-49 reporting issue is a big problem for accessing care when sick (%) Health System Context Health Financing Richest quintile Poorest quintile Inputs PER authors can also plot the service coverage index against Where data are available, PER authors may also consider analyzing Service Delivery impoverishing out-of-pocket spending. Quadrant I implies high levels the two using forgone care for financial and other reasons across Outcomes of service coverage and low levels of catastrophic health spending; socioeconomic groups. Figure 4 helps one visualize this analysis. Quadrant II implies high levels of service coverage but also relatively Authors may obtain data from Demographic Health Surveys or M-12: Service Coverage high levels of catastrophic health spending; Quadrant III implies low country-specific household budget surveys (including Living M-13: Financial Risk Protection service coverage and high catastrophic payments; and Quadrant IV Standards Measurement Study surveys), which often include M-14: Health Status and Health Risks implies low service coverage and low catastrophic payments. Authors questions on forgone care.4 M-15: Universal Health Coverage can find the latest data from the most recent publication of Tracking 4 List of Acronyms Universal Health Coverage: Global Monitoring Report.3 SECTION 4 Additional 3 Data can be downloaded from https://datacatalog.worldbank.org/int/search/dataset/0060802/. Guidance 4 Living Standards Measurement Study and many national multipurpose household surveys include questions about forgone care explicitly (for example., “Did you use care when ill? If not, why not?”). The actual question in DHS is about “problems when accessing” rather than “forgone care”—similar but not entirely the same thing. This being said, data from DHS serve as a good proxy and are readily available from StatCompiler. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 461 OVERVIEW 1 SECTION 1 What Is a Health PER? EQUITY OF UNIVERSAL HEALTH COVERAGE 2 SECTION 2 Cross-Cutting Analysis on Efficiency and Equity KEY QUESTION • Is progress in service coverage and financial risk protection distributed equitably? 3 SECTION 3 Topic-Specific Analysis Health System Context This section focuses on analyzing how UHC indicators are distributed across income quintiles, in order to assess UHC equity. Thus far, there is no dataset available that disaggregates UHC indexes by income quintile. However, there is a dataset that disaggregates health expenditure at the 10 percent level, and proportion of population facing impoverishing OOP expenditures at the $2.15 or $3.65 per person per day poverty lines (for example, low-income countries might prefer the $2.15 threshold, Health Financing service coverage indicators by income quintile. and lower-middle-income countries might prefer the $3.65 Inputs threshold). Other absolute and relative poverty lines—for Service Delivery PER authors can assess the equity of UHC by following these steps: example, the societal poverty line of 60 percent of median 1. Select service coverage indicators (preferably no more than consumption that is included in the Tracking Universal Outcomes three) based on local context or from the list of service Health Coverage: 2023 Global Monitoring Report—should be M-12: Service Coverage coverage indicators used to generate the UHC index (see considered according to context. M-13: Financial Risk Protection M-14: Health Status and Health Risks Annex 1 and/or the Service Coverage module). 3. Analyze progress for each indicator across quintiles (see M-15: Universal Health Coverage 2. Select financial risk protection indicators (preferably no “Sources” in the following table). It is possible that progress is more marked for top quintiles and less marked for lower 4 List of Acronyms more than three) based on local context. Indicators typically used are the proportion of population facing catastrophic quintiles, and vice versa. SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 462 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Service coverage indicators across quintiles Sources • World Bank HEFPI dataset 2 SECTION 2 • World Bank HNP statistics by wealth quintile Cross-Cutting Analysis on • Household surveys Efficiency and Equity 3 • Administrative dataset Financial risk protection indicators across quintiles • World Bank HEFPI dataset SECTION 3 Topic-Specific • Household surveys Analysis Note: HEFPI = World Bank Health Equity and Financial Protection Indicators; HNP = Health, Nutrition, and Population. Health System Context Health Financing It is noteworthy that equity considerations for service coverage and catastrophic health expenditures (at the 10 percent level). Given the Inputs financial risk protection are also discussed, respectively, in the Service high percentage of people covered by insurance in Chile, the results Service Delivery Coverage and Financial Risk Protection modules. suggest that these households might have needed or opted to go to Outcomes private providers for their care. However, data limitations did not allow An important caveat is that data across quintiles are not readily available; comparing these indicators from the same year. M-12: Service Coverage therefore, data limitations might affect the ability of PER authors to run M-13: Financial Risk Protection equity analyses. Finally, we should note that equity in service delivery or financial risk M-14: Health Status and Health Risks protection need not be explored only across income quintiles. PER M-15: Universal Health Coverage Figure 5 on the following page presents a simple example of an equity authors can use household surveys to assess the equitable distribution 4 List of Acronyms analysis of catastrophic health expenditure (for financial risk protection) of services across different dimensions, for example, gender, geographic and inpatient care access in the past 12 months (for service coverage). location (different regions, or rural versus urban regions), or other SECTION 4 The figure shows that in Chile, the lowest quintile had good access to minorities relevant for the country in question. Additional Guidance inpatient care compared with other quintiles, but also faced the highest TABLE OF CONTENTS MODULE 15 Universal Health Coverage 463 OVERVIEW 1 SECTION 1 What Is a Health PER? FIGURE 5.1 CATASTROPHIC 25.0 20.0 2 20.0 HEALTH % households 17.1 17.1 16.8 16.3 SECTION 2 EXPENDITURE 15.0 Cross-Cutting 15.0 (10%), 2016 Analysis on Efficiency and 10.0 Equity 3 Source: World Bank staff. 5.0 SECTION 3 0.0 Topic-Specific Analysis Total Q1 - poorest Q2 Q3 Q4 Q5 - richest Catastrophic health expenditure (10%), 2016 Health System Context Health Financing Inputs FIGURE 5.2 16.0 % INPATIENT 14.7 13.3 Service Delivery CARE IN PAST 14.0 12 MONTHS, 12.0 % households Outcomes 9.7 10.0 9.2 M-12: Service Coverage 2011 10.0 8.4 M-13: Financial Risk Protection 8.0 Source: World Bank staff. M-14: Health Status and Health Risks 6.0 4.0 M-15: Universal Health Coverage 2.0 4 List of Acronyms 0.0 Total Q1 - poorest Q2 Q3 Q4 Q5 - richest SECTION 4 Additional % inpatient care in past 12 months, 2011 Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 464 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and References Equity 3 de Walque, Damien, Eeshani Kandpal, Adam Wagstaff, Jed Friedman, Sven Neelsen, Moritz Piatti-Fünfkirchen, Anja Sautmann, Gil Shapira, and Ellen SECTION 3 Topic-Specific Van de Poel. 2022. Improving Effective Coverage in Health: Do Financial Incentives Work? Policy Research Report. Washington, DC: World Bank. Analysis Hogan, Daniel R., Gretchen A. Stevens, Ahmad Reza Hosseinpoor, and Ties Boerma. 2018. “Monitoring Universal Health Coverage within the Sustainable Health System Context Development Goals: Development and Baseline Data for an Index of Essential Health Services.” The Lancet Global Health 2018 6(2): e152-e68. Health Financing Lozano, Rafael, Nancy Fullman, John Everett Mumford, et al. 2019. “Measuring Universal Health Coverage Based on an Index of Effective Coverage Inputs of Health Services in 204 Countries and Territories, 1990-2019: A Systematic Analysis for the Global Burden of Disease Study, 2019.” The Lancet 2020 Service Delivery 396(10258): 1250–84. Outcomes World Health Organization. 2024. “Universal Health Coverage” fact sheet. World Health Organization, Geneva. M-12: Service Coverage World Health Organization and World Bank. 2021. Tracking Universal Health Coverage: 2021 Global Monitoring Report. Geneva: World Health M-13: Financial Risk Protection Organization and Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/36724. M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 465 OVERVIEW 1 SECTION 1 What Is a Health PER? 2 SECTION 2 Cross-Cutting Analysis on Efficiency and ANNEX 1 Equity 3 SECTION 3 Detail of UHC Measures Topic-Specific Analysis from WHO/World Bank and IHME Health System Context Health Financing Inputs This annex is organized into three Service Delivery parts: (1) an overview of the two UHC Outcomes indexes, in the table; (2) a list of the M-12: Service Coverage tracers used to generate the UHC M-13: Financial Risk Protection service coverage index; and (3) a list of M-14: Health Status and Health Risks M-15: Universal Health Coverage the tracers used to generate the UHC effective coverage index. 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 466 OVERVIEW 1 UHC MONITORING TOOLS SECTION 1 What Is a UHC Service Coverage Index (SDG indicator 3.8.1)* UHC Effective Coverage Index Health PER? 2 Number and type of indicators 14 tracers covering service coverage (11) and service capacity (3) 41 indicators in total SECTION 2 Categorization or list of tracers Indicator groups: 9 service coverage indicators Cross-Cutting 1. Reproductive, maternal, newborn, and child health (4 tracers) 32 outcome-based indicators Analysis on 2. Infectious diseases (4 tracers) Efficiency and Equity 3. Noncommunicable diseases (3 tracers) Detail of all tracers is provided below. 3 4. Service capacity and access (3 tracers) Detail of all tracers is provided below. SECTION 3 Topic-Specific Data source Household survey, administrative and institutional data Household and administrative data Analysis Modeling when data are missing Extensive Extensive Health System Context Compilation method Geometric mean, unweighted Weighting of indicators according to disease burden Health Financing Number of countries included 183 204 Inputs Reference UHC Service Coverage Index, SDG 3.8.1, metadata GBD 2019 Universal Health Coverage Collaborators. 2020. “Measuring Service Delivery Universal Health Coverage Based on an Index of Effective Coverage Outcomes of Health Services In 204 Countries and Territories, 1990–2019: A M-12: Service Coverage Systematic Analysis for the Global Burden of Disease Study 2019. The Lancet. August 27, 2020. doi:10.1016/S0140-6736(20)30750-9. M-13: Financial Risk Protection M-14: Health Status and Health Risks Data download https://datacatalog.worldbank.org/int/search/dataset/0060802 http://ghdx.healthdata.org/record/ihme-data/gbd-2019-uhc- M-15: Universal Health Coverage effective-coverage-index-1990-2019 Additional source (with same data, available online without 4 List of Acronyms downloading the dataset): https://data.worldbank.org/indicator/SH.UHC.SRVS.CV.XD SECTION 4 Additional Guidance Source: World Bank staff. *Reminder: SDG target 3.8, “Achieve universal health coverage,” is monitored via SDG indicator 3.8.1 as well as SDG indicator 3.8.2, “Catastrophic health spending (and related indicators).” SDG 3.8.2 is measured using CATA at the 10 percent and 25 percent levels. These measures are also reviewed in the Financial Risk Protection module. TABLE OF CONTENTS MODULE 15 Universal Health Coverage 467 OVERVIEW 1 SECTION 1 What Is a Health PER? UHC SERVICE COVERAGE INDEX TRACERS COMMUNICABLE DISEASES 5. Tuberculosis: Percentage of incident TB cases that are 2 detected and treated SECTION 2 See the Service Coverage module for more information about 6. HIV/AIDS: Percentage of adults and children living with HIV Cross-Cutting assessing service coverage (as opposed to UHC). Analysis on currently receiving antiretroviral therapy Efficiency and Equity REPRODUCTIVE AND MATERNAL HEALTH 7. Malaria: Percentage of population in malaria-endemic areas 3 who slept under an insecticide-treated net the previous 1. Family planning: Percentage of women of reproductive ages SECTION 3 night (only for countries with high malaria burden) (15−49 years) who are married or in union who have their Topic-Specific Analysis need for family planning satisfied with modern methods 8. Water, sanitation, and hygiene: Percentage of population using at least basic sanitation services 2. Pregnancy care: Percentage of women ages 15–49 years with Health System Context a live birth in a given time period who received antenatal Health Financing care four or more times NONCOMMUNICABLE DISEASES Inputs 9. Hypertension: Percentage of treatment (taking medicine) 3. Child immunization: Percentage of infants receiving three for hypertension among adults ages 30–79 years with Service Delivery doses of diphtheria-tetanus-pertussis containing vaccine hypertension (age-standardized estimate) Outcomes 4. Child treatment: Percentage of children younger than 5 years 10. Diabetes: Age-standardized mean fasting plasma glucose M-12: Service Coverage with symptoms of acute respiratory infection (cough and (mmol/L) for adults ages 18 years and older M-13: Financial Risk Protection fast or difficult breathing due to a problem in the chest and M-14: Health Status and Health Risks not due to a blocked nose only) in the two weeks preceding 11. Tobacco: Age-standardized prevalence of adults ages M-15: Universal Health Coverage the survey for whom advice or treatment was sought from a 15 years and older currently using any tobacco product (smoked and/or smokeless tobacco) on a daily or nondaily 4 List of Acronyms health facility or provider basis (SDG indicator 3.a.1; see metadata at https://www.who. SECTION 4 int/data/gho/indicator-metadata-registry/imr-details/ Additional prevalence-of-current-tobacco-use-among-persons-aged- Guidance 15-years-and-older-(age-standardized-rate) TABLE OF CONTENTS MODULE 15 Universal Health Coverage 468 OVERVIEW 1 SECTION 1 What Is a Health PER? SERVICE CAPACITY AND ACCESS 12. Hospital access: Hospital beds density, 2 relative to a maximum threshold of 18 per SECTION 2 10,000 population Cross-Cutting Analysis on 13. Health workforce: Health professionals Efficiency and Equity (physicians, psychiatrists, and surgeons) 3 per capita, relative to maximum thresholds for each cadre (partial overlap with SDG SECTION 3 Topic-Specific indicator 3.c.1; see metadata at https:// Analysis unstats.un.org/sdgs/metadata/files/ Metadata-03-0C-01.pdf) Health System Context 14. Health security: International Health Health Financing Regulations (IHR) core capacity index, which Inputs is the average percentage of attributes of Service Delivery 13 core capacities that have been attained Outcomes (SDG indicator 3.d.1; see metadata at M-12: Service Coverage https://www.who.int/data/gho/indicator- M-13: Financial Risk Protection metadata-registry/imr-details/4672) M-14: Health Status and Health Risks M-15: Universal Health Coverage 4 List of Acronyms SECTION 4 Additional Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 469 OVERVIEW 1 SECTION 1 What Is a Health PER? IHME EFFECTIVE COVERAGE INDEX INDICATORS 11. Colon and rectum cancer 2 Intervention coverage 12. Nonmelanoma skin cancer SECTION 2 1. Met need for family planning with modern contraception 13. Breast cancer Cross-Cutting 2. ANC1 14. Cervical cancer Analysis on Efficiency and 3. ANC4 15. Uterine cancer Equity 16. Testicular cancer 3 4. Skilled birth attendance 5. In-facility delivery rate 17. Hodgkin lymphoma SECTION 3 6. DTP3 18. Leukemia Topic-Specific 7. Polio3 19. Rheumatic heart disease Analysis 8. MCV1 20. Ischemic heart disease 9. ART coverage 21. Cerebrovascular disease Health System Context Outcome-based (risk-standardized death rates or mortality-to- 22. Hypertensive heart disease Health Financing incidence ratios) 23. Peptic ulcer disease Inputs 1. Tuberculosis 24. Appendicitis Service Delivery 2. Diarrheal diseases 25. Hernia Outcomes 26. Gallbladder and biliary diseases 3. Lower respiratory infections M-12: Service Coverage 4. Upper respiratory infections 27. Epilepsy M-13: Financial Risk Protection 5. Asthma, diphtheria 28. Diabetes M-14: Health Status and Health Risks 6. Whooping cough 29. Chronic kidney disease M-15: Universal Health Coverage 7. Tetanus 30. Chronic obstructive pulmonary disease 4 List of Acronyms 8. Measles 31. Congenital heart anomalies 9. Maternal disorders 32. Adverse effects of medical treatment SECTION 4 10. Neonatal disorders Additional Guidance TABLE OF CONTENTS MODULE 15 Universal Health Coverage 470 OVERVIEW 1 SECTION 1 ACRONYMS What Is a Health PER? ACSC DRGs HEFPI 2 Ambulatory Care Sensitive Conditions Diagnosis-Related groups Health Equity and Financial Protection SECTION 2 Indicators ARI EML Cross-Cutting Analysis on Acute Respiratory Infections Essential Medicines List HIF Efficiency and Health Insurance Fund Equity CABRI EPHF 3 Collaborative Africa Budget Reform Essential Public Health Functions HNP Initiative Health, Nutrition, and Population SECTION 3 FMIS Topic-Specific COA Financial Management Information HRH Analysis Chart of Accounts System Human Resources for Health COICOP GBD ICD Health System Context Classification of Individual Consumption Global Burden of Disease International Classification of Disease Health Financing According to Purpose GDP IHME Inputs CPIA Gross Domestic Product Institute for Health Metrics and Evaluation Service Delivery Country Policy and Institutional GHED ILO Outcomes Assessment Global Health Expenditure Database International Labour Organization 4 List of Acronyms DAH GHO ILOSTAT Development Assistance for Health World Health Organization Global International Labour Organization SECTION 4 DALYs Health Observatory statistical database Additional Disability-Adjusted Life Years Guidance GNI IMF DHS Gross National Income International Monetary Fund Demographic and Health Surveys HALE KII DPF Health-Adjusted Life Expectancy Key Informant Interview Development Policy Financing HBP LSMS Health Benefits Package Living Standard Measurement Surveys TABLE OF CONTENTS OVERVIEW 1 SECTION 1 ACRONYMS What Is a Health PER? MDA PFM UNICEF 2 Ministry, Department, or Agency Public Financial Management United Nations Children’s Fund SECTION 2 MICS PforR WDI Cross-Cutting Analysis on Multiple Indicator Cluster Surveys Program for Results World Development Indicators Efficiency and Equity MoF PHC WEO 3 Ministry of Finance Primary Health Care World Economic Outlook SECTION 3 MoH PPP WHO Topic-Specific Ministry of Health Purchasing Power Parity World Health Organization Analysis MTI RHS Macroeconomics, Trade and Investment Reproductive Health Surveys Health System Context Health Financing NHA RMNCH National Health Accounts Reproductive, Maternal, Newborn, and Inputs Child Health Service Delivery ODA Official Development Assistance SDG Outcomes Sustainable Development Goal OECD 4 List of Acronyms Organisation for Economic Co-operation SHI and Development Social Health Insurance SECTION 4 Additional OOP STEPS Guidance Out-of-Pocket Payments WHO STEPwise approach to NCD risk factor surveillance PEFA Public Expenditure and Financial UHC Accountability Universal Health Coverage PER UNFPA Public Expenditure Review United Nations Population Fund TABLE OF CONTENTS OVERVIEW 1 ADDITIONAL GUIDANCE 1 SECTION 1 What Is a Health PER? BENCHMARKING 2 SECTION 4 SECTION 2 Additional Cross-Cutting ADDITIONAL GUIDANCE 2 Analysis on Efficiency and Equity HEALTH LABOR MARKET ANALYSIS AND 3 HEALTH WORKFORCE PROJECTIONS SECTION 3 Topic-Specific Analysis Guidance ADDITIONAL GUIDANCE 3 4 SERVICE AVAILABILITY AND READINESS This section offers more detailed technical SECTION 4 Additional information for PER authors wishing to Guidance ADDITIONAL GUIDANCE 4 complement their analysis or looking for additional guidance on labor market analysis, QUALITY OF HEALTH SERVICES measuring quality of health services, measuring service readiness and availability, benchmarking ADDITIONAL GUIDANCE 5 and cross-country comparisons, how to best GUIDING PRINCIPLES FOR CRAFTING communicate policy recommendations, and on IMPACTFUL RECOMMENDATIONS IN PUBLIC EXPENDITURE REVIEWS data sources for measuring health expenditures. CONTINUE ADDITIONAL GUIDANCE 6 HEALTH EXPENDITURE DATA SOURCES OVERVIEW 1 SECTION 1 What Is a Health PER? ADDITIONAL GUIDANCE 1 2 SECTION 2 Cross-Cutting BENCHMARKING Analysis on Efficiency and Equity Benchmarking is the process of systematically across subnational entities). Guidance on international 3 benchmarking, as discussed in this note, is centered around finding comparing performance against recognized best comparator countries when conducting benchmarking. SECTION 3 practices or comparator organizations or units of Topic-Specific Analysis performance. Alternatively, benchmarking makes a PER authors can identify comparator countries using four sets 4 of criteria: country characteristics, economic structure and comparison based on average performance, relative socioeconomic performance, health sector characteristics, and SECTION 4 to the best performer, relative to a clinical norm or client preference. Additional Guidance target, or relative to past performance (Hafez 2020). For country characteristics, PER authors can consider the following Additional Guidance 1 The objectives of benchmarking for the Health PER are to (1) assess characteristics: Additional Guidance 2 performance objectively; and (2) expose areas where improvement • Island or landlocked Additional Guidance 3 is needed and aid in the prioritization of responses. • Small state Additional Guidance 4 Additional Guidance 5 There are two types of benchmarking in the Health PER guidance— • Fragile or post-conflict country international benchmarking and benchmarking across geopolitical Additional Guidance 6 • Regions and subregions, in terms of geography, language, and entities. Guidance on benchmarking across geopolitical entities is List of Acronyms culture provided within the module and is specific to the indicators (for example, benchmarking across urban and rural, benchmarking TABLE OF CONTENTS ADDITIONAL GUIDANCE 1 Benchmarking 474 OVERVIEW 1 SECTION 1 What Is a Health PER? For economic structure and socioeconomic characteristics, PER authors can look at the following characteristics: • Size of government (share of GGE in GDP) • Size of the private sector involvement in service delivery – implications on efficiency and equity of service delivery in the country 2 For client preference, PER authors can consider: SECTION 2 • Demographics (population density, age structure, population Cross-Cutting size)—implications for economic productivity and • Government stakeholders may have specific countries they Analysis on Efficiency and implications for the health sector would ask to serve as benchmarks. An example may be Equity 3 countries that stakeholders would like to emulate in terms • Education (literacy rate) of health sector performance. SECTION 3 • Governance (level of decentralization)—implications for how Topic-Specific health is financed and how services are delivered Analysis When choosing comparator countries, PER authors should give 4 • Income level (GNI per capita) priority to technical criteria and add according to client preference. • Poverty (percentage of population living below the poverty line) For ease of interpretation, limit the number of comparator countries SECTION 4 to four to six. In addition, authors may choose to include income Additional Guidance • Labor force (unemployment rate, level of informality, group and regional averages (simple mean or median). employment in agriculture) Additional Guidance 1 Additional Guidance 2 Additional Guidance 3 For health sector characteristics, PER authors can consider: • Burden of disease (HIV/AIDS and TB burden, NCDs)—high References Additional Guidance 4 spending on these diseases may be driving spending on Additional Guidance 5 health Hafez, R., ed. 2020. Measuring Health System Efficiency in Low- and Middle-Income Countries: A Resource Guide. Joint Learning Additional Guidance 6 • Health financing (for example, mix of revenue sources— Network for Universal Health Coverage. List of Acronyms predominantly general tax financed versus predominantly social health insurance (SHI), dependency on development assistance for health (DAH), level of fragmentation) TABLE OF CONTENTS ADDITIONAL GUIDANCE 1 Benchmarking 475 OVERVIEW 1 SECTION 1 What Is a Health PER? ADDITIONAL GUIDANCE 2 HEALTH LABOR MARKET ANALYSIS AND 2 HEALTH WORKFORCE PROJECTIONS SECTION 2 Cross-Cutting Analysis on Efficiency and Equity AUTHORS 3 Edson Correia Araujo, Bernardo D.P. Coelho, and Priyanka Saksena SECTION 3 Topic-Specific Analysis Health Labor Market Analysis 4 SECTION 4 Additional Guidance Additional Guidance 1 Applying economic frameworks to analyze the labor market helps in understanding the diverse and interrelated constraints affecting human resources professional characteristics of the health professional. Empirical studies have shown relatively small, but usually statistically significant, effects of wage changes on labor supply. As such, issues around the supply of health workers are more likely to be Additional Guidance 2 for health, the impact of health policies on these addressed when PER authors consider broader issues, such as occupational choice, education and training issues, demographic Additional Guidance 3 resources, and the employment dynamics in the and household characteristics, and specialty choice and career Additional Guidance 4 health sector. Supply and demand underpin this pathways, alongside compensation. Additional Guidance 5 economic perspective. Additional Guidance 6 The demand for health workers is the number of workers employers List of Acronyms The supply of health workers is the total number of individuals who are willing to hire. Employers can be public (civil service, a national are qualified and willing to provide health services. It depends on or regional health authority, hospitals, health centers), private the wage rate, the nonpecuniary job attributes, and personal and for-profit, or not-for-profit health care providers. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 476 OVERVIEW 1 SECTION 1 What Is a Health PER? The demand for health workers is shaped by a complex set of determinants subject to time and context, such as (1) economic • Availability and characteristics of employment in the public, private for-profit, and other (for example, non-profit) sectors 2 factors (budget allocated to the health sector and the proportion from a demand-side perspective that shape health worker SECTION 2 Cross-Cutting of it allocated to health workers, financing mechanisms); (2) decisions. Analysis on technology (how health services are produced and delivered Efficiency and • The governance structure and regulatory system in place, Equity and by consequence the demand for health workers in terms of 3 which influence the health labor market by setting rules and their numbers and their profile); (3) regulations (which set the establishing the role of public policy in the market. SECTION 3 division of labor in health); and (4) different models of care. For Topic-Specific example, employers may want to use a mix of workers they regard • Health worker performance at the individual and Analysis institutional levels, which will be influenced not only by as more efficient and less costly, but they may be constrained by 4 the rigidity of the definition of scopes of practice. workers’ education, but also how they are compensated and incentivized, supervised and supported, and their access to SECTION 4 A Health Labour Market Analysis (HLMA) is a tool that can help relevant resources, such as training, physical infrastructure, Additional Guidance in understanding factors that influence labor market outcomes equipment, and supplies. systematically. It allows policymakers to identify constraints and Additional Guidance 1 opportunities to devise better interventions. PER authors can consult from World Bank and World Health Additional Guidance 2 Organization (WHO) guidance documents on health labor market Additional Guidance 3 A HLMA can focus on the following factors: analyses for further details on HLMAs (McPake, Scott, and Edoka Additional Guidance 4 • A country’s capacity to educate and train qualified health 2014; World Health Organization 2021). Additional Guidance 5 workers from a supply-side perspective. This determines the Additional Guidance 6 pool of available workers, including their skills mix and level of competence, but is offset by those who move abroad or List of Acronyms leave practice. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 477 OVERVIEW 1 SECTION 1 What Is a Health PER? Health Workforce Projections 2 SECTION 2 Policymakers face challenges in training, deploying, and retaining There are several methods to help policymakers estimate how many Cross-Cutting Analysis on health workers in sufficient numbers and with the necessary skill health professionals are needed to meet population health needs. Efficiency and Equity mix. The growing demand for health care services, a result of The choice depends on data availability and on a clearly defined 3 demographic and epidemiological transitions, will exacerbate objective or problem. Different approaches can lead to different the pressures on an already weak health labor market. Health results; therefore, an accurate evaluation of the practicality and SECTION 3 Topic-Specific workforce projections aim to equip governments with the feasibility of applying each approach is critical. Analysis information and tools required to determine how many health 4 professionals are needed to meet population health needs, both The table below summarizes main methodological approaches for now and in the future. generating health workforce projections. SECTION 4 Additional Guidance Approaches Assumptions Advantages Limitations Additional Guidance 1 NEEDS-BASED APPROACH It assumes that (1) population Compared to other HRH It does not capture changes in Additional Guidance 2 Estimate health workforce gaps epidemiological demographic projection methods, it is easier medical or other technologies that Additional Guidance 3 based on the epidemiological profiles will be a perfect proxy to explain and understand, and alter service delivery efficiency. Additional Guidance 4 and demographic profiles (the for health care needs and access therefore can be valuable for The definition of “needs” does Additional Guidance 5 projected health service needs, to services; and (2) the use of advocacy. not explicitly take into account Additional Guidance 6 both met and unmet) of the resources will be prioritized based coverage and quality. And it does population. on need. not adjust for disparities in the List of Acronyms distribution of health services. Table continues on the following page. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 478 OVERVIEW 1 Approaches Assumptions Advantages Limitations SECTION 1 What Is a Health PER? UTILIZATION-BASED APPROACH It assumes that (1) the population Given that future health service It does not capture future changes 2 It uses present health service currently uses an appropriate utilization rates are closely in behavior patterns, employment utilization to estimate future mix of health services; and (2) linked to present utilization trends, or environmental factors. SECTION 2 Cross-Cutting health service requirements future health care needs can be rates, the projected health Additionally, it may not address Analysis on (and health workforce needs). It estimated based on predictable workforce numbers tend to existing shortcomings in the Efficiency and Equity incorporates projected trends in trends in population fertility, remain financially realistic. quality or accessibility of health 3 the current workforce, such as mortality, and migration. services. demographics, turnover, attrition SECTION 3 rates, etc., to estimate future Topic-Specific Analysis health workforce needs. 4 HEALTH WORKFORCE-TO- It assumes that (1) the relative It is relatively simple and may It does not consider the effects SECTION 4 POPULATION RATIO proportion of health workers in be satisfactory if realistic of changes in health services Additional It uses a given health worker- each area is the most important assumptions are made about utilization or changes in health Guidance to-population ratio to achieve a determinant of ability to deliver health workforce growth rates. workforce mix, productivity, task desirable health or health service health services; and (2) desired shifting, etc. Additionally, existing Additional Guidance 1 delivery goal. For example, the ratios may be based on the ratio imbalances in health worker Additional Guidance 2 World Health Report (World Health of a region or reference. It can distribution will likely persist. Additional Guidance 3 Organization 2006) states that also consider constant aspects Additional Guidance 4 countries need a population such as efficiency, productivity, density of at least 2.28 doctors, and economies of scale should be Additional Guidance 5 nurses, and midwives per 1,000 considered. Additional Guidance 6 population to ensure skilled List of Acronyms attendance at birth. Table continues on the following page. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 479 OVERVIEW 1 SECTION 1 What Is a Health PER? Approaches SERVICE TARGET-BASED Assumptions It assumes that health services Advantages It considers the complexity Limitations It depends on strict service 2 APPROACH standards can be met by health of the relationships between delivery assumption and with risk SECTION 2 It sets targets for specific health workers and facilities within a variables (efficiency, of inaccuracy (expert opinion, Cross-Cutting Analysis on care services (targets based specified amount of time. productivity, demand, etc.) and e.g.). Efficiency and on current services provided, can complement other Equity 3 technologies in use, demand, and projection methods; expert opinion) that are translated additionally, the approach is SECTION 3 into staffing requirements. particularly valuable in planning Topic-Specific Analysis for critical health care services 4 or services for small populations served by a single institution. SECTION 4 ADJUSTED SERVICE TARGET-BASED It assumes that evidence-based Estimates are based on the It requires a significant amount Additional Guidance APPROACH interventions can be effectively skills and competencies of information, including a It uses pre-established targets implemented in all circumstances. required to provide health comprehensive review of Additional Guidance 1 for priority health service needs services, rather than positions. the health workforce skills, Additional Guidance 2 (determined by population It also can consider efficiency competencies, and accurate demographics, expert opinion, and through optimization of skills expert opinion on service delivery Additional Guidance 3 the incidence and prevalence of mix (reduction of overlapping requirements. Additional Guidance 4 health problems). Functional job skills, and the combination of Additional Guidance 5 analyses are used to determine skill sets that work in synergy). Additional Guidance 6 the health worker skills and time List of Acronyms required to achieve those targets (HRH full-time equivalents for each intervention). Table continues on the following page. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 480 OVERVIEW 1 SECTION 1 What Is a Health PER? Approaches SERVICE TARGET-BASED Assumptions It assumes that health services Advantages It considers the complexity Limitations It depends on strict service 2 APPROACH standards can be met by health of the relationships between delivery assumption and with risk SECTION 2 It sets targets for specific health workers and facilities within a variables (efficiency, of inaccuracy (expert opinion, Cross-Cutting Analysis on care services (targets based specified amount of time. productivity, demand, etc.) and e.g.). Efficiency and on current services provided, can complement other Equity 3 technologies in use, demand, and projection methods; expert opinion) that are translated additionally, the approach is SECTION 3 into staffing requirements. particularly valuable in planning Topic-Specific Analysis for critical health care services 4 or services for small populations served by a single institution. SECTION 4 ADJUSTED SERVICE TARGET-BASED It assumes that evidence-based Estimates are based on the It requires a significant amount Additional Guidance APPROACH interventions can be effectively skills and competencies of information, including a It uses pre-established targets implemented in all circumstances. required to provide health comprehensive review of Additional Guidance 1 for priority health service needs services, rather than positions. the health workforce skills, Additional Guidance 2 (determined by population It also can consider efficiency competencies, and accurate demographics, expert opinion, and through optimization of skills expert opinion on service delivery Additional Guidance 3 the incidence and prevalence of mix (reduction of overlapping requirements. Additional Guidance 4 health problems). Functional job skills, and the combination of Additional Guidance 5 analyses are used to determine skill sets that work in synergy). Additional Guidance 6 the health worker skills and time List of Acronyms required to achieve those targets (HRH full-time equivalents for each intervention). Table continues on the following page. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 481 OVERVIEW 1 SECTION 1 What Is a Health PER? Approaches Assumptions Advantages Limitations 2 FACILITIES-BASED APPROACH It assumes that adjustments to the It provides more detailed It does not consider information SECTION 2 It focuses on improving individual number, size, and type of health information, and more suitable about the quality of health Cross-Cutting Analysis on health center capacity, facility care facilities will improve the to assessing different policy services or population health Efficiency and Equity mix, and geographic distribution ability of the entire health sector options, while remaining focused needs. 3 of health care facilities (specific to address health service needs on the point of services delivery. targets are set for each type of (bottom-up approach). SECTION 3 facility). Topic-Specific Analysis Source: Adapted from McQuide, Stevens, and Settle 2008. 4 SECTION 4 Additional Guidance Additional Guidance 1 References Additional Guidance 2 McPake, Barbara, Anthony Scott, and Ijeoma Edoka. 2014. Analyzing Markets for Health Workers: Insights from Labor and Health Economics. Directions Additional Guidance 3 in Development—Human Development. Washington, DC: World Bank. https://doi.org/10.1596/978-1-4648-0224-9. Additional Guidance 4 Additional Guidance 5 McQuide, P., J. Stevens, and D. Settle. 2008. An Overview of Human Resources for Health. IntraHealth International. Additional Guidance 6 List of Acronyms World Health Organization. 2021. Health Labour Market Analysis Guidebook. Geneva: World Health Organization. https://iris.who.int/bitstream/ handle/10665/348069/9789240035546-eng.pdf. TABLE OF CONTENTS ADDITIONAL GUIDANCE 2 Health Labor Market Analysis and Health Workforce Projections 482 OVERVIEW 1 SECTION 1 What Is a Health PER? ADDITIONAL GUIDANCE 3 2 SECTION 2 Cross-Cutting SERVICE AVAILABILITY AND READINESS Analysis on Efficiency and AUTHORS Equity 3 Kathryn Gilman Andrews and Jigyasa Sharma SECTION 3 Topic-Specific Analysis Introduction 4 This additional guidance includes information on service to meet the needs of the client” (Wyszewianski 2002). Also on SECTION 4 availability and readiness and highlights the key questions the supply side, accommodation “reflects the extent to which Additional and potential tracer indicators that need to be considered in the provider’s operation is organized in ways that meet the Guidance benchmarking progress in these areas. Access to care is driven constraints and preferences of the client” (Wyszewianski 2002). Additional Guidance 1 by both supply-side and demand-side factors, and this guidance Together, these supply-side readiness factors can be grouped focuses on the supply side. A common definition of access to together and referred to as “service availability and readiness.” Additional Guidance 2 care (Penchansky and Thomas 1981) encompasses affordability, The three demand-side elements of the five “As” (affordability, Additional Guidance 3 availability, accessibility, accommodation, and acceptability. Of accessibility, and acceptability)1 are covered in the “Demand Additional Guidance 4 these five “As,” availability and accommodation are supply-side for Health Services” module, while the “Quality of Care” module Additional Guidance 5 indicators. Availability “measures the extent to which the provider discusses issues relating to areas of care quality. Additional Guidance 6 has the requisite resources, such as personnel and technology, List of Acronyms 1 “Affordability is determined by how the provider’s charges relate to the client’s ability and willingness to pay for services. ... Accessibility refers to geographic accessibility, which is determined by how easily the client can physical- ly reach the provider’s location. ... finally, acceptability captures the extent to which the client is comfortable with the more immutable characteristics of the provider, and vice versa.” https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1464050/. TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 483 OVERVIEW 1 SECTION 1 What Is a Health PER? Service availability and readiness can be further divided into general and service-specific elements. The World Health comprehensive health care needs of the population. 2 Organization (WHO) defines general service availability as “the WHO defines general service readiness as “the overall capacity of SECTION 2 Cross-Cutting physical presence of items required for the delivery of services health facilities to provide basic services at minimum standards” Analysis on and encompasses health infrastructure, core health personnel, (O’Neill et al. 2013). Readiness, therefore, refers to the presence Efficiency and Equity and aspects of service utilization” (O’Neill et al. 2013). This is a of amenities and equipment, clinical guidelines, diagnostics and 3 measure of whether health facilities and staff are present and lab testing capacity, and essential medicines and commodities. SECTION 3 offer services in accordance with their mandate and whether these Service readiness differs from service availability in that readiness Topic-Specific health facilities provide care that accommodates patients’ needs measures the functional capacity of available facilities and staff Analysis (in keeping with the definition of “accommodation” above). to deliver care up to a minimum standard level. 4 WHO defines service-specific availability as “whether a specific The definition of service-specific readiness is “the ability of health SECTION 4 Additional type of health intervention is offered” (O’Neill et al. 2013). facilities to offer a specific service and the capacity to provide Guidance The interventions of interest can be defined either by target that service measured through selected tracer items that include population and/or by specific disease. While the choice of which trained staff, clinical guidelines, equipment, diagnostic capacity, Additional Guidance 1 tracer services to examine should be based on contextual factors, and medicines and commodities.” 2 As with service-specific Additional Guidance 2 WHO’s universal health coverage (UHC) service coverage index availability, which tracer items are relevant depends substantially Additional Guidance 3 uses tracer indicators covering the service-specific domains of on the context; key areas of interest (with their associated Additional Guidance 4 reproductive, maternal, newborn, and child health; infectious indicators) may include reproductive, maternal, newborn and Additional Guidance 5 diseases; and noncommunicable diseases (Hogan et al. 2017). It child health; infectious diseases; noncommunicable diseases; and Additional Guidance 6 is also important to assess health facilities’ inpatient and surgical inpatient care and surgical capacity (Hogan et al. 2017). care capacity to evaluate how well they are responding to the List of Acronyms 2 https://www.data4impactproject.org/prh/service-delivery/access-to-sexual-and-reproductive-health-services/service-availability-and-readiness-assessment-sara/. TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 484 OVERVIEW 1 SECTION 1 What Is a Health PER? General Service Availability 2 KEY QUESTION • What is general service availability? SECTION 2 Cross-Cutting Analysis on Efficiency and Ensuring the availability of health facilities and health staff is the The extent to which female healthcare providers are available Equity 3 first step toward providing access to health services. Inherent in has implications for women’s access to health care, equity, and understanding general service availability is understanding the women’s empowerment and economic outcomes (Boniol 2019). The SECTION 3 models of care that are used in a given context, so documentation list also contains indicators of the availability of infrastructure for Topic-Specific Analysis of service availability should begin with a description of levels differently abled persons and the accessibility of health facilities 4 and types of care, how they interact with one another, and how in terms of transportation, opening hours, and scheduling. The they are organized to be accessed by patients. The suggested extent to which the services available are patient-centered and SECTION 4 indicators below highlight basic information on the density responsive to the needs of the population is covered in the Additional Guidance of health facilities by type of facility in any given country, the “Quality of Care” module. availability of beds, the density of health care providers by cadre, Additional Guidance 1 and the elements of “accommodation” as defined above. Additional Guidance 2 Additional Guidance 3 Key Indicators Sources Additional Guidance 4 Health facility density (total number of health facilities per 10,000 population) • WHO Global Health Observatory database Additional Guidance 5 • Country-specific facility census (master Additional Guidance 6 Health facility density stratified by facility level (numbers of primary care facilities such facility list) and/or (HMIS) as health posts, health centers, hospitals, and specialized care facilities) List of Acronyms Health facility density stratified by ownership (such as public, private, for-profit, or NGO) Hospital bed density (number of inpatient beds per 10,000 population) TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 485 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Sources 2 Number of health care providers per 10,000 population (all clinical staff—such as • WHO Global Health Observatory database SECTION 2 doctors, nurses, midwives, and community health workers) • National Health Workforce Accounts, Cross-Cutting country-specific healthcare provider Analysis on Efficiency and registry/roster, or HMIS Equity 3 Numbers of health care providers per 10,000 population stratified by cadre (such as • Health facility surveys SDI, SARA, SPA doctors, nurses, midwives, and community health workers; as possible, stratification by SECTION 3 health care providers providing primary care vs. secondary or tertiary care) Topic-Specific Analysis 4 Number of female health care providers per 10,000 population (all clinical staff—such as • National Health Workforce Accounts, doctors, nurses, midwives, and community health workers) country-specific healthcare provider SECTION 4 registry/roster, or HMIS Additional Guidance • Health facility surveys SDI, SARA, SPA Numbers of female health care providers per 10,000 population stratified by cadre (such Additional Guidance 1 as doctors, nurses, midwives, community health workers) Additional Guidance 2 Additional Guidance 3 Total number and % of health facilities with at least one health care provider (clinical • World Bank’s Service Delivery Indicators Additional Guidance 4 staff such as doctor, nurse, or midwife) present on the day of an unannounced visit (SDI) surveys Additional Guidance 5 Total number and % of health facilities with at least one female health care provider Additional Guidance 6 (clinical staff such as doctor, nurse, or midwife) present on the day of an unannounced List of Acronyms visit TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 486 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Total number and % of health facilities with infrastructure that is accessible to Sources • Country-specific facility census (master 2 differently abled persons, such as: facility list) and/or HMIS SECTION 2 • Any assistive technologies, such as signage with braille, to help those who are blind • World Bank’s SDI surveys Cross-Cutting Analysis on or visually impaired Efficiency and Equity • At least one functional ramp/lift for people with limited mobility to go up or down 3 inclines within or at the entrance to the health facility SECTION 3 Total number and % of health facilities offering 24/7 medical care Topic-Specific Analysis Total number and % of health facilities offering appointments for medical care 4 Total number and % of health facilities offering telemedicine for medical care SECTION 4 Total number and % of health facilities that have conducted drills/simulations Additional Guidance for disasters/emergencies (such as on managing surge capacity, fire safety, safety procedures in the event of natural disasters/weather events, etc.) Additional Guidance 1 Total number and % of health facilities that are connected to a motorable road (road Additional Guidance 2 that can be driven on by motorized vehicles) Additional Guidance 3 Total number and % of health facilities that can be accessed via public transportation Additional Guidance 4 Additional Guidance 5 Note: HMIS = health management information system; SARA = Service Availability and Readiness Assessment”; SDI = Service Delivery Indicators; SPA = Service Provision Assessment Additional Guidance 6 List of Acronyms TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 487 OVERVIEW 1 SECTION 1 What Is a Health PER? WHO’s Global Health Observatory (GHO) Database3 contains high- level internationally comparable information on many of the What is the distribution of general service availability? 2 indicators described above. However, if more detailed information If the necessary data are available, PER authors can compare SECTION 2 Cross-Cutting is available from country-specific health facility and healthcare countries with their income peers or with neighboring countries Analysis on provider rosters, PER authors should use those data to enable using the indicators listed above to identify those high-performing Efficiency and Equity analysis at the most granular level. Facility rosters (also known as countries from which others can learn. Similarly, making within- 3 master facility lists) are often available from ministries of health, country comparisons of the above indicators over time and by SECTION 3 and some are publicly available, as is the case in Kenya.4 Also, geopolitical strata (for example, comparing urban versus rural Topic-Specific some health management information systems (HMIS) may collect areas, comparing different subnational administrative levels, or Analysis information on available staff, services, equipment, and supplies. comparing among different catchment populations—stratified 4 In the absence of country-specific provider rosters or a robust by income levels or other measures of degrees of vulnerability HMIS, health facility surveys, such as the World Bank’s Service or marginalization, and so on.) can reveal areas of progress, SECTION 4 Additional Delivery Indicators (SDI) health surveys, WHO’s Service Availability disparities, and opportunities for improvement. Guidance and Readiness (SARA) surveys, and USAID’s Service Provision Assessment (SPA) surveys often collect information on numbers Additional Guidance 1 of healthcare providers working at a nationally representative Additional Guidance 2 sample of facilities, which could be used to estimate total provider Additional Guidance 3 numbers and density. The World Bank’s SDI health surveys go Additional Guidance 4 one step further by collecting information on the presence or Additional Guidance 5 absence of a sample of healthcare providers at their facility of Additional Guidance 6 employment during an unannounced visit, which helps illustrate effective availability of staff to deliver care. List of Acronyms 3 https://www.who.int/data/gho/data/indicators/indicators-index. 4 http://kmhfl.health.go.ke/. TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 488 OVERVIEW 1 SECTION 1 What Is a Health PER? Service-Specific Availability 2 SECTION 2 Cross-Cutting KEY QUESTION • What is service-specific availability? Analysis on Efficiency and Equity 3 Availability applies not only to health facilities and health care WHO recommends measuring whether a facility provides a defined SECTION 3 providers but also to specific high-priority services that are set of subservices. For example, the service-specific availability Topic-Specific Analysis needed to treat a country’s burden of disease. PER authors must of family planning is defined as whether a facility provides a list 4 tailor their selection of service-specific indicators to reflect the of 13 tracer subservices (including male sterilization, injectable population of and the disease priorities in each given context. contraceptives, and female condoms) (WHO 2015). Depending on SECTION 4 As described above, WHO’s UHC service coverage index uses the the context and the research questions, PER authors may choose Additional service-specific areas of reproductive, maternal, newborn, and to select the tracer subservices listed in Table 3.4.1 of WHO’s SARA Guidance child health; infectious diseases; and noncommunicable diseases reference manual (WHO 2015). Importantly, the epidemiologic, Additional Guidance 1 (Hogan et al. 2017). demographic, and perhaps even income profile of each country will inform the selection of relevant indicators that reflect key Additional Guidance 2 The indicators suggested below reflect key services and subservices context-specific priorities. For example, in countries that are not Additional Guidance 3 within these areas (in addition to the availability of primary and malaria-endemic, availability of diagnostic and treatment services Additional Guidance 4 inpatient care) but do not capture the effectiveness, safety, or for malaria may not be relevant, and instead other diseases or Additional Guidance 5 quality of the services provided (this is covered in the “Quality technologies may be prioritized. Additional Guidance 6 of Care” module). To further define service-specific availability, List of Acronyms TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 489 OVERVIEW 1 Key Indicators Sources SECTION 1 Total number and % of facilities providing the following reproductive, maternal, newborn, and child health services: • Country-specific facility census What Is a Health PER? 1. Family planning services (master facility list) and/or 2 2. Antenatal care services HMIS SECTION 2 3. Intrapartum care (labor, delivery, and newborn) services including basic emergency obstetric and newborn care • Health facility surveys SDI, Cross-Cutting (BEmONC) services SARA, and SPA Analysis on Efficiency and 4. Intrapartum care (labor, delivery, and newborn) services including comprehensive emergency obstetric and newborn Equity care (CEmONC) services 3 5. Neonatal intensive care services SECTION 3 6. Child immunization services Topic-Specific 7. Pediatric (sick child) care services Analysis Total number and % of facilities providing diagnostic and treatment services for the following infectious diseases: • Country-specific facility census 4 1. Tuberculosis (master facility list) and/or 2. HIV/AIDS HMIS SECTION 4 3. Malaria • Health facility surveys SDI, Additional Guidance Total number and % of facilities providing diagnostic and treatment services for the following noncommunicable SARA, and SPA diseases/health conditions: Additional Guidance 1 1. Cardiovascular diseases (including the management of chronic hypertension) Additional Guidance 2 2. Diabetes Additional Guidance 3 3. Cancer 4. Mental health Additional Guidance 4 5. Health promotion and prevention services including tobacco control Additional Guidance 5 Total number and % of health facilities offering primary care Additional Guidance 6 Total number and % of health facilities offering inpatient care services: List of Acronyms 1. Any inpatient care 2. Basic surgery 3. Blood transfusion Note: HMIS = health management information system; SARA = Service Availability and Readiness Assessment”; SDI = Service Delivery Indicators; SPA = Service Provision Assessment. TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 490 OVERVIEW 1 SECTION 1 What Is a Health PER? What is the distribution of service-specific availability? If the necessary data are available, comparing countries with time and by geopolitical strata (for example, comparing urban versus rural areas, comparing different subnational administrative 2 their income peers or with neighboring countries in terms of levels, or comparing among different catchment populations— SECTION 2 the indicators listed above can identify those high-performing stratified by income levels or other measures of degrees of Cross-Cutting Analysis on countries from which others can learn. Similarly, PER authors can vulnerability or marginalization, and so on.) to reveal areas of Efficiency and Equity make within-country comparisons of the above indicators over progress, disparities, and opportunities for improvement. 3 SECTION 3 Topic-Specific Analysis 4 General Service Readiness SECTION 4 Additional Guidance KEY QUESTION • What is general service readiness? Additional Guidance 1 Additional Guidance 2 The general service readiness of health facilities relates to their each country will inform the selection of relevant indicators that Additional Guidance 3 capacity to provide services that meet at least minimum standards, reflect key context-specific priorities. For example, in countries Additional Guidance 4 which depends on the availability of basic amenities, equipment, that are not malaria-endemic, availability of blood smear or Additional Guidance 5 supplies, and medicines. While the list of key indicators below is rapid test for malaria may not be relevant, and instead other Additional Guidance 6 derived from WHO’s recommended tracer items for general service commodities may be prioritized. As another example, in settings List of Acronyms readiness (O’Neill et al. 2013), the specific items (in the table where electrification is universal, tracking availability of other notes) must be adapted to each country’s context. Specifically, amenities may be prioritized. the epidemiologic, demographic, and even income profile of TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 491 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Total number and % of facilities with available and functioning basic amenities and equipment* Sources • Supply-chain management 2 information system or health SECTION 2 Total number and % of facilities meeting basic infection prevention and control standards** management information Cross-Cutting system (HMIS) Analysis on Efficiency and Total number and % of facilities with basic diagnostic (laboratory and testing) capacity*** • Health facility surveys SDI, Equity 3 SARA, or SPA Total number and % of facilities meeting the minimum standard for essential medicines and commodities† SECTION 3 Topic-Specific Total number and % of facilities: (1) with basic amenities and equipment; (2) meeting basic infection prevention and Analysis control standards; (3) with basic diagnostic capacity; and (4) with essential medicines and commodities 4 Note: *Amenities: electric power; improved water source within 500 meters of facility; room with auditory and visual privacy for patient consultations; adequate sanitation facilities for clients; communication equipment (phone or shortwave radio); computer with email/internet access; emergency transportation. Equipment: weighing scales (child, adult); thermometer; stethoscope; blood pressure apparatus; light SECTION 4 source; refrigerator. Additional **Infection prevention and control standard: safe final disposal of sharps, safe final disposal of infectious wastes; appropriate storage of sharps, appropriate storage of infectious waste; disinfectant; single-use Guidance standard disposable or auto‐disposable syringes; soap and running water or alcohol-based hand rub; latex gloves; guidelines. ***Diagnostic capacity: blood hemoglobin; blood glucose; blood smear or rapid test for malaria parasites; urine dipstick protein; urine dipstick glucose; HIV antibody test; syphilis rapid test; urine pregnancy test. † Essential medicine: amoxicillin, atenolol, captopril, ceftriaxone, ciprofloxacin, co-trimoxazole suspension, diazepam, diclofenac, glibenclamide, omeprazole, amitriptyline, paracetamol suspension, salbutamol, Additional Guidance 1 simvastatin. SARA = Service Availability and Readiness Assessment”; SDI = Service Delivery Indicators; SPA = Service Provision Assessment. Additional Guidance 2 For more information: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845262/pdf/BLT.12.116798.pdf and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845262/. Additional Guidance 3 Additional Guidance 4 What is the distribution of general service readiness? time and by geopolitical strata (for example, comparing urban Additional Guidance 5 If the necessary data are available, PER authors can compare versus rural areas, comparing different subnational administrative countries with their income peers or with neighboring countries levels, or comparing among different catchment populations— Additional Guidance 6 in terms of the indicators listed above to identify those high- stratified by income levels or other measures of degrees of List of Acronyms performing countries from which others can learn. Similarly, vulnerability or marginalization, and so on.) can reveal areas of making within-country comparisons of the above indicators over progress, disparities, and opportunities for improvement. TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 492 OVERVIEW 1 SECTION 1 What Is a Health PER? Service-Specific Readiness 2 KEY QUESTION • What is service-specific readiness? SECTION 2 Cross-Cutting Analysis on Efficiency and The readiness of health facilities to provide key high-priority number of items for each service across all health facilities. Again, Equity 3 services depends on the availability of trained staff and the epidemiologic, demographic, and even income profile of each clinical guidelines, equipment, diagnostics, and medicines and country will inform the selection of relevant indicators that reflect SECTION 3 commodities for each of these services. As with service-specific key context-specific priorities. For example, in countries that are Topic-Specific Analysis availability, while which tracer items are relevant will depend not malaria-endemic, the tracer indicators for malaria may not be 4 substantially on the context, key areas of interest may include relevant, and instead other tracer indicators may be prioritized. reproductive, maternal, newborn, and child health; infectious SECTION 4 diseases; and non-communicable diseases (Hogan et al. 2017). What is the distribution of service-specific readiness? Additional The list of suggested key indicators below is drawn from WHO’s If the necessary data are available, comparing countries with their Guidance list of tracer guidelines on the equipment, diagnostics, medicines, income peers or with neighboring countries using the indicators Additional Guidance 1 and commodities needed for each service. For example, family listed above can identify those high-performing countries from Additional Guidance 2 planning service-specific readiness is defined as whether a which others can learn. Similarly, PER authors can compare within- facility has a list of eight tracer items (including guidelines on country the above indicators over time and by geopolitical strata Additional Guidance 3 family planning, staff trained in family planning, blood pressure (for example, comparing urban versus rural areas, comparing Additional Guidance 4 apparatus, and contraceptive pills) (WHO 2015). Table 3.4.1 of different subnational administrative levels, or comparing among Additional Guidance 5 WHO’s SARA reference manual provides the specific tracer items different catchment populations—stratified by income levels or Additional Guidance 6 (WHO 2015), counts of which are provided in the table below. The other measures of degrees of vulnerability or marginalization, and List of Acronyms suggested indicators in the table include the percentage of health so on) to reveal areas of progress, disparities, and opportunities facilities that have all tracer items for each service (for example, for improvement. all eight in the case of family planning services) and the mean TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 493 OVERVIEW 1 Key Indicators Sources SECTION 1 % of facilities providing the following 1. Family planning services (8) • Country-specific What Is a Health PER? reproductive, maternal, newborn, and child 2. Antenatal care services (11) facility census 2 health services that achieve all tracer indicators 3. Intrapartum care (labor, delivery, and newborn) services including basic (master facility SECTION 2 and the mean number of tracer indicators emergency obstetric and newborn care (BEmONC) services (25) list) and/or HMIS Cross-Cutting achieved: 4. Intrapartum care (labor, delivery, and newborn) services including • Health facility Analysis on Efficiency and comprehensive emergency obstetric and newborn care (CEmONC) services (20) surveys (SDI, Equity 5. Child immunization services (18) SARA, and SPA) 3 6. Pediatric (sick child) care services (19) SECTION 3 % of facilities providing diagnostic and treatment 1. Tuberculosis (12) Topic-Specific services for the following noncommunicable 2. HIV clinical and supportive care* (24) Analysis diseases/health conditions that achieve all 3. Malaria (9) 4 tracer indicators and the mean number of tracer indicators achieved: SECTION 4 Additional % of facilities providing diagnostic and treatment 1. Cardiovascular diseases (including chronic hypertension) (12) Guidance services for the following noncommunicable 2. Diabetes (13) diseases/health conditions that achieve all 3. Cancer** Additional Guidance 1 tracer indicators and the mean number of tracer 4. Mental health*** Additional Guidance 2 indicators achieved: 5. Health promotion and prevention services including tobacco control† Additional Guidance 3 % of facilities providing secondary and tertiary 1. Basic surgery (17) Additional Guidance 4 level care for inpatients that achieve all tracer 2. Blood transfusion (7) indicators and the mean number of tracer Additional Guidance 5 indicators achieved: Additional Guidance 6 Note: *HIV clinical and supportive care readiness indicators for “care and support services,” “antiretroviral prescription and client management,” and “prevention of mother to child transmission (PMTCT) List of Acronyms services.” **WHO’s SARA survey does not currently list the requirements for specific cancer service readiness, except for cervical cancer; in the absence of such guidance, based on a country’s burden of disease and national guidelines, the readiness indicators should include appropriate tracer items for staff and clinical guidelines, equipment, and diagnostics. ***WHO’s SARA survey does not include mental health, despite its importance; in the absence of guidance, based on a country’s burden of disease and national guidelines, the readiness indicators should include appropriate tracer items for staff and clinical guidelines, equipment, and diagnostics. †Tracer items for health promotion and prevention services for staff and clinical guidelines, equipment, and diagnostics should be adapted based on national guidelines and treatment and counseling protocols. HMIS = health management information system; “SARA = Service Availability and Readiness Assessment”; SDI = Service Delivery Indicators; SPA = Service Provision Assessment. TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 494 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Boniol, M., M. McIsaac, L. Xu, T. Wuliji, K. Diallo, and J. Campbell. 2019. “Gender Equity in the Health Workforce: Analysis of 104 Countries.” Health Cross-Cutting Workforce Working Paper 1. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/311314/WHO-HIS-HWF-Gender-WP1- Analysis on Efficiency and 2019.1-eng.pdf. Equity 3 Hogan, D.R., G.A. Stevens, A.R. Hosseinpoor, and T. Boerma. 2017. “Monitoring Universal Health Coverage within the Sustainable Development Goals: Development and Baseline Data for an Index of Essential Health.” Lancet Global Health, 6: e152–68. https://www.thelancet.com/action/ SECTION 3 Topic-Specific showPdf?pii=S2214-109X%2817%2930472-2. Analysis O’Neill, K., M. Takane, A. Sheffel, C. Abou-Zahr, and T. Boerma. 2013. “Monitoring Service Delivery for Universal Health Coverage: The Service Availability 4 and Readiness Assessment.” Bulletin of the World Health Organization, 91(12): 923–31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845262/. SECTION 4 Penchansky, R., and J.W. Thomas. 1981. “The Concept of Access: Definition and Relationship to Consumer Satisfaction.” Medical Care, 19(2): 127–40. Additional Guidance https://pubmed.ncbi.nlm.nih.gov/7206846/. World Health Organization. 2015. Service Availability and Readiness Assessment (SARA): An Annual Monitoring System for Service Delivery Additional Guidance 1 Reference Manual. 2015. Geneva: World Health Organization. https://cdn.who.int/media/docs/default-source/service-availability-and- Additional Guidance 2 readinessassessment(sara)/sara_reference_manual_chapter3.pdf?sfvrsn=7a0f3a33_3&ua=1. Additional Guidance 3 Wyszewianski, L. 2002. “Access to Care: Remembering Old Lessons.” Health Services Research, 37(6): 1441–43. https://www.ncbi.nlm.nih.gov/pmc/ Additional Guidance 4 articles/PMC1464050/. Additional Guidance 5 Additional Guidance 6 List of Acronyms TABLE OF CONTENTS ADDITIONAL GUIDANCE 3 Service Availability and Readiness 495 OVERVIEW 1 SECTION 1 What Is a Health PER? ADDITIONAL GUIDANCE 4 2 SECTION 2 QUALITY OF HEALTH SERVICES Cross-Cutting Analysis on Efficiency and Equity 3 AUTHORS SECTION 3 Ian Forde and Lubina Fatima Qureshy Topic-Specific Analysis Introduction 4 SECTION 4 Additional Guidance Additional Guidance 1 This additional guidance is designed to collect information on the quality of care in the delivery of health services, and highlights the key questions and potential indicators needed to measure the effectiveness and equity of care. estimated 7 percent of all hospitalized patients acquire a health care-related infection (WHO 2020a). Recognizing this, there has been a recent paradigm shift to Additional Guidance 2 addressing health care through the lens of quality of care rather Additional Guidance 3 It is estimated that high-quality care can avert 2.5 million deaths than service provision alone. The expansion of population Additional Guidance 4 from cardiovascular disease, nearly a million deaths from health programs to improve coverage subsumed quality in Additional Guidance 5 tuberculosis, and as many as half of all maternal and a million service provision. Health indicators may not respond favorably newborn deaths annually. In low- and middle-income countries, to increased coverage without also assuring quality. Users of Additional Guidance 6 three-fifths of deaths from conditions that require health care are health services would then lose confidence in such substandard List of Acronyms attributable to poor-quality care. In high-income countries, an services and therefore avoid them (see, for example, Hanefield et TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 496 OVERVIEW 1 SECTION 1 What Is a Health PER? al. 2017). Thus, quality of care should be aimed at quality of health equity, and efficiency are presented in other modules in this series 2 services or improvements in health outcomes rather than simply including the Primary Health Care and Public Health Services and SECTION 2 increasing the quantity of health services (Peabody et al. 2006). Hospital modules. Cross-Cutting Analysis on Poor quality of services is wasteful and has a high opportunity cost Efficiency and Equity in terms of diverting resources from other pressing needs such The indicators listed under the key questions include those that 3 as funding schools, providing social assistance, and enhancing are more relevant to low- and middle-income countries that align infrastructure. In effect, the burden of waste contributes to with SDG indicators. Key question indicators also include those SECTION 3 Topic-Specific discounting human capital and reducing future productivity. that are relevant to all countries but may currently lack organized Analysis Embedding quality in health systems is affordable for all countries, data collection, especially in low- and middle-income countries. 4 regardless of their level of economic development (WHO, OECD, For each of the key questions discussed below, PER authors and World Bank 2018). should use relative comparators, such as cross-country or regional SECTION 4 comparisons and benchmarking, where possible in order to enrich Additional Guidance However, precisely defining “quality of care” is as challenging the analysis and make the measures easier to interpret. Country as identifying ways to measure it. Measures of quality of monitoring should also bear in mind the Donabedian framework, Additional Guidance 1 care are multifaceted, spanning different levels of care and striving to continually improve structures and processes to Additional Guidance 2 different country settings. This guidance considers measurable produce better outcomes, rather than just focusing on values of Additional Guidance 3 characteristics of health care quality alongside indicators in the indicators (Donabedian 1966; Berwick and Fox 2016). Additional Guidance 4 areas of effectiveness, safety, timeliness, and responsiveness. Additional Guidance 5 Indicators for other aspects related to quality such as integration, Additional Guidance 6 List of Acronyms TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 497 OVERVIEW 1 SECTION 1 Input Quality What Is a Health PER? KEY QUESTION 2 • Are health services effective? SECTION 2 Cross-Cutting Analysis on Effectiveness refers to health care that is delivered in accordance (WHO and UNICEF 2022). Ineffective care may occur because Efficiency and Equity with scientific knowledge and evidence-based guidelines, subject evidence and/or guidelines do not exist in a given setting, because 3 to the availability of basic structures—physical infrastructure, the provider of care may not know about them or may choose including electricity, water and sanitation, and health care not to comply with them. Ineffective care is likely to waste inputs SECTION 3 Topic-Specific buildings; adequate health workforce; medicines and other related and unlikely to improve outcomes such as health risk and health Analysis health products; as well as functioning health information systems status, thereby jeopardizing public spending. 4 Key Indicators Sources SECTION 4 Additional Diagnostic accuracy provided in five clinical vignettes • SDI surveys1 for low- and middle-income countries Guidance Adherence to clinical guidelines • SDI surveys for low- and middle-income countries Additional Guidance 1 Treatment accuracy • SDI surveys for low- and middle-income countries Control of glycemia during pregnancy • In-country studies and surveys Additional Guidance 2 • KIIs Additional Guidance 3 Excess mortality for patients diagnosed with a severe • OECD.Stat for OECD countries and selected nonmember countries Additional Guidance 4 mental illness Additional Guidance 5 Cholera case fatality rate in endemic countries • WHO Global Health Observatory, https://www.who.int/data/gho/data/ Additional Guidance 6 indicators/indicators List of Acronyms Use of antibiotics to treat diarrhea • Demographic and health surveys in low- and middle-income countries* gg 1 * “Use of antibiotics to treat diarrhea” is an indicator of safety as well as effectiveness of health services. KII = key informant interview; OECD = Organisation for Economic Co-operation and Development; Note: SDI = service delivery indicators; WHO = World Health Organization. 1 Since 2010, 26 SDI surveys have been completed in 12 countries in Africa. The surveys are planned for a number of other African countries. Data collection for the first SDI surveys in Latin America (Guatemala), East Asia and Pacific (Indonesia), Europe and Central Asia (Armenia, Moldova, and Ukraine), Middle East and North Africa (Iraq), and South Asia (Bhutan) are underway or being considered (https://www.sdindicators.org/faq). TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 498 OVERVIEW 1 SECTION 1 What Is a Health PER? PER authors can consider the analysis in this section in conjunction with the additional guidance on Service Readiness of diarrhea cases that did not warrant this treatment (Rhee et al. 2019). Authors can also evaluate indicators for other public 2 and Availability, which suggests data on the quantity and quality health programs in the country. These may include the cholera SECTION 2 Cross-Cutting of health personnel and the availability of basic equipment, as case fatality rate for countries that are endemic. Analysis on well as the module on Primary Health Care. Efficiency and Equity 3 Depending on the scope of the country’s PER, in addition to the KEY QUESTION • Are health services Safe? SECTION 3 indicators listed above, PER authors can assess the effectiveness Topic-Specific of care by inspecting facilities’ medical records, patient exit Safe care minimizes harm, including health care-acquired Analysis interviews, direct observation of provider-client interactions, infections (such as a urinary tract infection from a poorly 4 standardized patients, or clinical vignettes. While clinical maintained urinary catheter), preventable injuries (such as a vignettes measure a provider’s knowledge of evidence-based fall in a health care setting), and preventable medical errors on SECTION 4 Additional protocols for defined medical cases, other forms of measurement the patient (such as wrong-site surgery). Unsafe care is likely to Guidance predominantly capture compliance with these guidelines. In worsen outcomes such as health status and may be wasteful if particular, standardized patients provide consistent cases of additional inputs or resources are needed to address the impacts Additional Guidance 1 illness to providers and allow for comparison of quality of care of a preventable error. For example, safety failures contribute to Additional Guidance 2 across providers. about 15 percent of hospital expenses in OECD countries. Often, Additional Guidance 3 the cost of safety failures is higher than the cost of prevention. Additional Guidance 4 The indicator antibiotic treatment for diarrheal disease is Estimates suggest a savings of US$28 billion between 2010 and Additional Guidance 5 included to assess effectiveness and safety. In order to indicate 2015 in the US in Medicare hospitals that improved patient safety. Additional Guidance 6 inappropriate use (overuse or underuse) of antibiotics to treat In low- and middle-income countries, at least a third of the diarrhea, PER authors may need to benchmark the data against adverse events occur in noncomplex situations and a majority of List of Acronyms statistics or studies in the literature. For example, a study in these are likely avoidable (Institute of Medicine 2001; Slawomirski Kenya found that antibiotics were prescribed in 20–50 percent et al. 2017). TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 499 OVERVIEW 1 SECTION 1 What Is a Health PER? Key Indicators Overall volume of opioids prescribed Sources • OECD.Stat for OECD countries and selected non-member countries 2 Total volume of antibiotics for systemic use • OECD.Stat for OECD countries and selected non-member countries SECTION 2 Domain score for standard precautions for infection prevention • SARA, WHO (metadata archive under development) Cross-Cutting Note: OECD = Organisation for Economic Co-operation and Development; SARA = Service Availability and Readiness Assessment; WHO = World Health Organization. Analysis on Efficiency and Equity 3 There are limited and often low-quality data available for Zervos 2021). Authors can use data from key informant surveys or indicators of the provision of safe health services in low- and interviews to enrich their analysis and look for in-country studies SECTION 3 middle-income countries. More recently, WHO has used data to inform this part of the PER. Topic-Specific Analysis from the Service Availability and Readiness Assessment (SARA). 4 However, the metadata archive was under development at the time of writing this report. KEY QUESTION • Are health services timely? SECTION 4 Additional PER authors can also consider additional indicators of safety such Beyond reducing unnecessary delays in providing and receiving Guidance as a surgical item left behind, other post-operative complications services, most importantly, timely care means recognizing Additional Guidance 1 such as embolisms after knee/hip replacement surgery, wound situations requiring urgent intervention as quickly as possible Additional Guidance 2 dehiscence or sepsis, and obstetric trauma after delivery. Data and taking appropriate action, thus preventing avoidable on these are available in some settings, including many OECD hospital conditions. Conversely, delaying less urgent services Additional Guidance 3 countries. Countries with good adverse-event reporting systems may be justified if a reasonable waiting time allows planning Additional Guidance 4 may additionally have data on medical errors. and delivering services in a more financially sustainable manner. Additional Guidance 5 Care that is excessively delayed risks worsening a patient’s health Additional Guidance 6 Additionally, data on health-care associated infections could be status and/or health risk. Further, the health care service is List of Acronyms considered, as discussed in the Hospitals module. Although there ultimately less effective (if a patient’s condition has deteriorated), is a paucity of data on health care-associated infections for low- implying ineffective public spending. The following table presents and middle-income countries, a recent analysis reports infection indicators of timely noncommunicable disease (NCD) care. rates between 17 and 33 percent in some countries (Maki and TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 500 OVERVIEW 1 Key Indicators Sources SECTION 1 What Is a Adults with up-to-date NCD screening • Check for in-country studies and data Health PER? Proportion of cancer cases treated in early stages • Check for in-country studies and data 2 • Also see Global Cancer Observatory data (https://gco.iarc.fr/projects) for all countries and SECTION 2 the SURVCAN project for low- and middle-income countries (https://survival.iarc.fr/survcan) Cross-Cutting Analysis on Cancer five-year net survival rate (for different types) • OECD.Stat for OECD countries and selected nonmember countries Efficiency and Equity 3 Note: NCD = noncommunicable disease; OECD = Organisation for Economic Co-operation and Development; SURVCAN = Cancer Survival in Countries in Transition. The availability of data to measure delivery timeliness is skewed surgery for a hip fracture after a patient is admitted. PER authors SECTION 3 Topic-Specific toward OECD countries. PER authors need to check for in-country data can consider these types of indicators after discussion with the Analysis and studies for low- and middle-income countries; the WHO Global country clinical authorities if reliable data on them are available. 4 Cancer Observatory recently began collecting data on cancer survival SECTION 4 in low- and middle-income countries. Its website also contains data KEY QUESTION • Are health services integrated? on cancer rates in individual countries; these data can be compared Additional Guidance with the regional or global averages to assess quality of care. Although Integrated care is coordinated across the different providers a the focus of the Cancer Survival in Countries in Transition (SURVCAN) patient interacts with during an episode of care as well as throughout Additional Guidance 1 project of the WHO International Agency for Research on Cancer, is the life course. This may include both health and social care, and Additional Guidance 2 to measure the effectiveness of cancer services, this could also be is particularly important for the increasing burden of NCDs. The Additional Guidance 3 used as an indicator of delivery timeliness, as timely initiation of complex and chronic needs associated with NCDs require a cohesive Additional Guidance 4 treatment is critical for cancer survival (see, for example, Stokstad team of professionals, each performing individual tasks. Poorly et al. 2021). PER authors should note, however, that SURVCAN-3, the integrated care jeopardizes public spending, mainly through wasteful Additional Guidance 5 third project initiative, was recently launched and data are sparse. inputs (redundant investigations or incompatible treatment plans, Additional Guidance 6 for example), and also risks a patient’s worsening health if care is List of Acronyms In countries with good hospital information systems, there may ineffective. PER authors can learn more about indicators related to also be data on things like the administration of oxytocin right service integration in the Hospitals and Primary Health Care and after vaginal delivery to prevent hemorrhage or timeliness of Public Health Services modules. TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 501 OVERVIEW 1 KEY QUESTION • Are health services responsive to people’s needs? SECTION 1 What Is a Health PER? Key Indicators Sources 2 Community engagement efforts • Check for in-country case studies SECTION 2 Note: OECD = Organisation for Economic Co-operation and Development. Cross-Cutting Analysis on Patient-centeredness care respects and responds to a patient’s needs. There is evidence to support the role of community engagement Efficiency and Equity preferences, needs, and values. Care that is not patient centered may in reducing inequities, improving benefits, and sharing responsibility 3 have negative impacts on public spending if a patient is unwilling or toward public health (Yuan et al. 2021). PER authors can provide SECTION 3 unable to comply with a treatment plan prescribed without considering qualitative information on responsiveness and community engagement, Topic-Specific patient preferences, needs, and values. More information about this including case studies, where specific indicators are not available. For Analysis is presented in the Primary Health Care and Public Health Services example, in the rural highlands of Guatemala, the engagement of and 4 module. Community engagement can also be a part of responsiveness consultation with traditional community birth attendants helped to and implies involving different stakeholders who work together to establish the correct location of birthing facilities. The centers were set SECTION 4 Additional (1) address health-related issues, enabling changes in behaviors and up close to patients’ homes. The staff at the facility were also employed Guidance practices within communities; and (2) promote their involvement in from the community, providing a sense of ownership; spoke the local public health programs, resulting in programs that address people’s dialect; and respected the local culture. Additional Guidance 1 Additional Guidance 2 KEY QUESTION • Do different population groups have access to quality care? Additional Guidance 3 Additional Guidance 4 High-quality health care needs to be available and affordable for all to efficiency. Healthier populations need less health care. Patients’ Additional Guidance 5 people, regardless of underlying social disadvantages. Equitable health inability to access and use health care services in a timely manner, Additional Guidance 6 care does not vary according to demographic characteristics such as however, could lead to excess spending on emergency services and later List of Acronyms gender, race, ethnicity, geographic location, and socioeconomic status. treatment, which preventive care and early intervention could avoid It should be closely linked to patient-centeredness and should show (see, for example, Asamani et al. 2021). Indicators related to equity concern for individuals’ or groups’ values and preferences. Inequitable are presented in other modules in this series, including the Service care can jeopardize public spending, because inequity is closely tied Coverage and Primary Health Care and Public Health Services modules. TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 502 OVERVIEW 1 SECTION 1 What Is a Health PER? References 2 SECTION 2 Asamani, J.A., S.A. Alugsi, H. Ismaila, and J. Nabyonga-Orem. 2021. “Balancing Equity and Efficiency in the Allocation of Health Resources—Where Is Cross-Cutting the Middle Ground?” Healthcare, 9(10): 1257. https://doi.org/10.3390/healthcare9101257. Analysis on Efficiency and Equity Berwick, Donald, and Daniel M. Fox. 2016. “Evaluating the Quality of Medical Care: Donabedian’s Classic Article 50 Years Later.” The Milbank Quarterly, 3 94(2): 237–41. Published online June 6. doi: 10.1111/1468-0009.12189. PMCID: PMC4911723PMID: 27265554. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4911723/. SECTION 3 Topic-Specific Donabedian, A. 1966. “Evaluating the Quality of Medical Care.” The Milbank Memorial Fund Quarterly, 44(3) (suppl): 166–206. Reprinted in The Analysis Milbank Quarterly, 2005, 83(4): 691–729. 4 Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America. SECTION 4 Washington, DC: National Academies Press. Additional Guidance Maki, G., and M. Zervos. 2021. “Health Care-Acquired Infections in Low- and Middle-Income Countries and the Role of Infection Prevention and Control.” Infectious Disease Clinics of North America, 35(3): 827–39. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8331241/. Additional Guidance 1 Additional Guidance 2 Peabody, J., R. Shimkhada, O. Adeyi, H. Wang, E. Broughton, et al. 2018. “Quality of Care,” chapter 10. In: D.T. Jamison, H. Gelband, S. Horton, P. Jha, Additional Guidance 3 R. Laxminarayan, C.N. Mock, and R. Nugent (editors). Disease Control Priorities (Third Edition), Volume 9: Improving Health and Reducing Poverty. Washington, DC: World Bank. Additional Guidance 4 Additional Guidance 5 Rhee, C., G. Aol, A. Ouma, et al. 2019. “Inappropriate Use of Antibiotics for Childhood Diarrhea Case Management—Kenya, 2009–2016.” BMC Public Additional Guidance 6 Health, 19 (Suppl 3): 468. https://doi.org/10.1186/s12889-019-6771-8. List of Acronyms WHO. 2018. Handbook for National Quality Policy and Strategy: A Practical Approach for Developing Policy and Strategy to Improve Quality of Care. Geneva: World Health Organization. https://www.who.int/publications/i/item/9789241565561. TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 503 OVERVIEW 1 SECTION 1 What Is a Health PER? WHO. 2020a. “Quality Health Services.” Fact Sheet. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/quality-health- services. 2 WHO. 2020b. “Newborns: Improving Survival and Well-Being,” Fact Sheet. World Health Organization. https://www.who.int/news-room/fact-sheets/ SECTION 2 detail/newborns-reducing-mortality. Cross-Cutting Analysis on WHO. 2020c. Community Engagement: A Health Promotion Guide for Universal Health Coverage in the Hands of the People. Geneva: World Health Efficiency and Equity Organization. License: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/9789240010529. 3 WHO. 2022. The Global Health Observatory: “Composite Coverage Index (%) (Health Inequality Monitor).” https://www.who.int/data/gho/indicator- SECTION 3 metadata-registry/imr-details/4489. Accessed October 12, 2022. Topic-Specific Analysis WHO, OECD, and World Bank. 2018. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. Geneva: World Health 4 Organization, Paris: Organisation for Economic Co-operation and Development, Washington, DC: World Bank. SECTION 4 WHO and UNICEF. 2022. Primary Health Care Measurement Framework and Indicators: Monitoring Health Systems through a Primary Health Care Additional Lens. Geneva: World Health Organization; New York: United Nations Children’s Fund. https://www.who.int/publications/i/item/9789240044210. Guidance Yuan, M., H. Lin, H. Wu, et al. 2021. “Community Engagement in Public Health: A Bibliometric Mapping of Global Research.” Archives of Public Health, Additional Guidance 1 79(6). https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-021-00525-3. Additional Guidance 2 Additional Guidance 3 Additional Guidance 4 Additional Guidance 5 Additional Guidance 6 List of Acronyms TABLE OF CONTENTS ADDITIONAL GUIDANCE 4 Quality of Health Services 504 OVERVIEW 1 SECTION 1 What Is a Health PER? ADDITIONAL GUIDANCE 5 2 SECTION 2 GUIDING PRINCIPLES FOR CRAFTING IMPACTFUL RECOMMENDATIONS Cross-Cutting Analysis on Efficiency and IN PUBLIC EXPENDITURE REVIEWS Equity 3 The key to driving change is maintaining a strong focus. The • Specific: A specific recommendation identifies exactly what is to be SECTION 3 Human Development PER guidelines (2004) identified that many achieved, by whom, and in what context or timeline. Topic-Specific Bank Public Expenditure Reviews (PERs) suffer from a lack of Analysis • Measurable: A measurable recommendation includes criteria for prioritization, resulting in a lengthy list of important issues that 4 neither the client nor the Bank can effectively address.1 While measuring progress and outcomes, ensuring that it is possible to track providing multiple recommendations can be useful for technical and evaluate the success of the action. SECTION 4 Additional staff, policymakers and the Bank should concentrate on a limited • Actionable: An actionable recommendation provides clear steps that can Guidance number of critical issues— the Human Development guidance be taken and specifies who is responsible for carrying out these actions. recommends around three. Identifying these key areas where Additional Guidance 1 • Realistic and feasible: Feasible and achievable given the available progress will be most impactful is essential for resolving public Additional Guidance 2 resources, constraints, and context, including political viability. A realistic expenditure challenges in the sector. In addition to having a limited Additional Guidance 3 recommendation considers the practical limitations and ensures that the number of prioritized recommendations, generic recommendations goals set can be attained. Additional Guidance 4 that do not include specific actionable strategies and policies Additional Guidance 5 to achieve the intended goal should be avoided. When making • Technical: Based on sound technical knowledge, expertise, and Additional Guidance 6 recommendations teams may find it useful to check their write-up principles. A technical recommendation relies on evidence-based List of Acronyms against the SMART acronym, ensuring that recommendations are: practices and scientific or technical data to ensure its validity and effectiveness. Recommendations should be clearly linked to the 1 Abu-Ghaida, D. N., Berryman, S. E., Chernichovsky, D., Grosh, M. E., & Lundberg, M. K. A. (2004). Guide- challenges identified in the PER. lines for public expenditure reviews in the human development sectors*. Office of the Chief Econo- mist, HDNVP. World Bank TABLE OF CONTENTS ADDITIONAL GUIDANCE 5 Benchmarking 505 OVERVIEW 1 SECTION 1 What Is a Health PER? ADDITIONAL GUIDANCE 6 2 SECTION 2 HEALTH EXPENDITURE DATA SOURCES Cross-Cutting Analysis on Efficiency and Equity 3 SECTION 3 Topic-Specific Analysis 4 SECTION 4 Additional NOTE FORTHCOMING Guidance Additional Guidance 1 Additional Guidance 2 Additional Guidance 3 Additional Guidance 4 Additional Guidance 5 Additional Guidance 6 List of Acronyms TABLE OF CONTENTS ADDITIONAL GUIDANCE 6 Health Expenditure Data Sources 506 OVERVIEW 1 SECTION 1 ACRONYMS What Is a Health PER? 2 BEmONC NCD TB SECTION 2 Basic Emergency Obstetric and Newborn Noncommunicable Disease Tuberculosis Cross-Cutting Analysis on Care Efficiency and NGO UHC Equity CEmONC Nongovernmental Organization Universal Health Coverage 3 Comprehensive Emergency Obstetric and OECD UNICEF SECTION 3 Newborn Care Organisation for Economic Co- United Nations Children’s Fund Topic-Specific Analysis GDP operation and Development USAID 4 Gross Domestic Product SARA United States Agency for International GHED Service Availability and Readiness Development SECTION 4 Additional Global Health Expenditure Database Assessments WHO Guidance GHO SDI World Health Organization Additional Guidance 1 Global Health Observatory Service Delivery Indicators Additional Guidance 2 GNI SPA Additional Guidance 3 Gross National Income Service Provision Assessment Additional Guidance 4 HLMA SURVCAN Additional Guidance 5 Health Labour Market Analysis Cancer Survival in Countries in Additional Guidance 6 Transition HMIS List of Acronyms Health Management Information System TABLE OF CONTENTS SECTION 4 Acronyms 507