David B Evans, Director Department of Health System Financing, Expenditure & Resource Allocation

1. Evidence and Information as International Public Goods: The Role of the World Health Organization David B Evans, Director Department of Health System Financing, Expenditure & Resource Allocation Evidence and Information for Policy

2. OUTLINE WHO work on Evidence and Information particularly relating to health systems Evidence and Information as an international public good Evidence and Information for Policy

3. Selected History of WHO • WHO not a funding agency: technical agency • Large part of mandate is standards and guidelines, provision of information, advocacy for health Examples: • International Classifications; ICD and ICF; international health regulations • Information on the spread of SARS • Health for All Evidence and Information for Policy

4. Evidence and Health Systems: Objectives of health systems performance assessment 1) Monitor and evaluate attainment of critical outcomes and the efficiency of the health system in a way that allows comparison overtime and across systems 2) Build an evidence-base on the relationship between the design of the health system and performance 3) Feed back into the policy debate - national & international 4) Empower the public with information relevant to their well-being Evidence and Information for Policy

5. BOUNDARIES and ACCOUNTABILITY C O V E R A G E HEALTH Personal medical services Non-personal health services Intersectoral action Other factors Evidence and Information for Policy

6. HEALTH SYSTEM GOALS LEVEL DISTRIBUTION Health   Responsiveness Efficiency   Fairness in Financial Contribution  Quality Equity Evidence and Information for Policy

7. Attainment and Efficiency • Attainment = achievement of goals - singly or together • Efficiency - attainment related to resources available and other non-health system inputs to the production of health system outcomes Evidence and Information for Policy

8. Scatter Plot of Health Expenditure per Capita vs. HALEs, 191 countries 4.31704 Log health 3.25458 2.40351 8.30935 Log of health expenditure per capita Evidence and Information for Policy

9. FUNCTIONS THE SYSTEM PERFORMS GOALS / OUTCOMES OF THE SYSTEM Stewardship (oversight) Responsiveness Creating resources (investment and training) Delivering services (provision) Health Fair financial contribution Financing (collecting, pooling and purchasing Evidence and Information for Policy

10. Evidence and Information for Policy

11. Country Use • Many countries undertaking components: e.g. measuring health, health inequalities, catastrophic payments, responsiveness, examining functions and how to improve: e.g. over 70 countries have estimated % of households with catastrophic and % impoverished as a result of out-of-pocket payments for health • Some using or adapting the entire framework: e.g. Sub-national performance assessment: initially in collaboration with Mexico, Uganda and Indonesia Evidence and Information for Policy

12. Health System Performance Assessment as International Public Good • Framework: consistent way of assessing health system development - outcomes focused, ethical basis • Tools for measuring components: can be used or adapted by all countries • Lessons from international comparisons and experiences: can be used by all countries to learn • Data on particular countries: not necessarily an international public good Evidence and Information for Policy

13. Illustration: catastrophic health payments Cross country comparisons of the risk of catastrophic payments: higher risk where • Higher proportion of out-of-pocket payments • Greater proportion of poor • Greater availability of services Xu K et al. “Understanding household catastrophic health expenditures: a multi-country analysis”, Lancet, 362: 111-117, 2003. • INTERNATIONAL PUBLIC GOOD Evidence and Information for Policy

14. Use of Health Services Uganda (1997 – 2003) Evidence and Information for Policy

15. Percentage of Households Incurring High Levels of Spending, Uganda (1997 - 2003) Evidence and Information for Policy

16. Households Characteristics and Catastrophic Payments Higher Risk: • Use private services (use of public does not protect fully); poor; aged people in the household Lower Risk: • higher education; urban dwelling Probably not an international public good Evidence and Information for Policy

17. Patterns of Inequality 100 90 Exclusion 80 Uzbekistan 70 Queuing: 60 Utilization of services eg Turkey 50 40 Escape 30 20 eg Niger 10 0 Poorest quintile Quintile 2 Quintile 3 Quintile 4 Richest quintile Deprivation - Wealth Evidence and Information for Policy

18. Conclusions Evidence and information as an international public good • Frameworks • Tools to assess progress • Comparative analysis or data that allow this • Experience from one or more countries that might be generalizable Country specific data probably not an international public good Evidence and Information for Policy

19. Sources of Information • Murray C.J.L & D.B. Evans (eds). Health systems performance assessment: debates, methods and empiricism. WHO, 2003. • More than 20 papers in internationally peer reviewed journals and 4 other books - available at: Web site: www.who.int/health-systems-performance Evidence and Information for Policy