Exploring Health System and Country Performance on Improving Health Conditions Around the Globe

1. Exploring Health System and Country Performance on Improving Health Conditions Around the Globe Dean T. Jamison University of California, Los Angeles and Fogarty International Center U.S. National Institutes of Health 1

2. Overview • Institutional Performance (brief) • Existing Studies at the Country Level • “Good Health at Low Cost” • China health finance study • Example: Country Performance in Reducing IMR • Example: Efficiency of Resource Use in the OECD 2

3. Explaining Performance Variation • Resource Availability ($$, # of providers, education, experience of provider…) • Productivity in Use of Health Resources (greater health impact per unit of resource) • Contextual Factors (environmental factors, health status of population, SES of population) *** 7

4. Measuring Performance at Different Levels Institutional Performance Health outcomes controlling for contextual factors Institutional Productivity Health outcome responsiveness to resource availability controlling for contextual factors Country Performance Health outcomes controlling for contextual factors ‘Health System Productivity’ Health outcome responsiveness to resource availability controlling for contextual factors 6

5. REPORT OF THE CALIFORNIA HOSPITALS OUTCOMES PROJECT Volume One: Study Overview and Results Summary May 1996 Pete Wilson, Governor State of California Sandra R. Smoley, R.N., Secretary Health and Welfare Agency David Werdegar, MD, MPH, Director Office of Statewide Health Planning and Development Prof. Hal Luft, Principal Investigator 3

6. Institutional Performance: AMI of California Hospitals 4

7. New York State Bypass Surgeons, 1991-93 Source: Marshall & Spiegelhalter (2001) 5

8. Infant mortality rate related to income Source: World Health Report 1999 (WHO) 8

9. Infant mortality rate relative to income, China, 1962-1992 Source: World Health Report 1999 (WHO) 9

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12. Disease Control Priorities Project Working Paper No. 14 October 22, 2003 Why Has Infant Mortality Decreased at Such Different Rates in Different Countries? Dean T. Jamison University of California, Los Angeles U.S. National Institutes of Health Martin E. Sandbu Columbia University Jia Wang University of California, Los Angeles 12

13. The Simplest Models Common intercept across countries • yit = ao + a1xit + a2t + error term Country-specific intercept (or fixed effect) • yit = aoi + a1xit + a2t + error term Country-specific intercept and slope • yit = aoi + a1xit + a2it 13

14. What Happens When You Take First Differences? Equation 1 or 2 gives: • yit+1 – yit = a1(xit+1 – xit) + a2[(t + 1) - t)] The constant term now effects the growth rate in mortality not the level. Equation 3 gives: • yit+1 – yit = a1xi + a2i The constant term is now a country-specific growth rate. 14

15. Model of Infant Mortality LIMRit = 0i + 1i TIMEt + 2 LY5it + 3 FEDUCit + 4 LDOCit + it LIMR = ln(IMR) LY5 = ln(Per capita income) FEDUC = Female education level LDOC = ln(Doctors per 1,000 population) 15

16. Assessing technical progress 0i = 00 + 01 TROPICSi + 02 COASTALi + 0i 1i = 10 + 11 TROPICSi + 12 COASTALi + 1i 16

17. Definition of terms 0i: Country- specific, unobserved effects on level of IMR 1i: Country-specific, unobserved effects on rate of technical progress in reducing IMR Total country-specific effect, 1962- 87 ( IMR as % of predicted), for country i: 100 x exp (0i + 25 1i) 17

18. IMR Relative to Predicted, Low- and Middle-Income Countries 18

19. IMR Relative to Predicted, High-Income Countries 19

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