LS iY D UB I7 Statistical annex The six tables in this technical annex present updated information on summary measures of population health, mortality and the burden of disease in WHO Member States and regions, and selected national health accounts aggregates for 1997-2001. Life expectancy and healthy life expectancy estimates and the national health accounts aggregates have been revised to take new data into account and, for many Member States, are not directly comparable with those published in The World Health Report 2002. The work leading to these annex tables was undertaken mostly by the WHO Global Programme on Evidence for Health Policy in colla boration with counterparts from WHO regional offices and representatives of WHO in Member States Where data are presented by country, initial WHO estimates and technical explanations were sent to Member States for comment. The estimates reported here should, however, still be interpreted as being the best estimates of Who rather than the official viewpoints of Member States
Statistical Annex 133 Statistical Annex The six tables in this technical annex present updated information on summary measures of population health, mortality and the burden of disease in WHO Member States and regions, and selected national health accounts aggregates for 1997–2001. Life expectancy and healthy life expectancy estimates and the national health accounts aggregates have been revised to take new data into account and, for many Member States, are not directly comparable with those published in The World Health Report 2002. The work leading to these annex tables was undertaken mostly by the WHO Global Programme on Evidence for Health Policy in collaboration with counterparts from WHO regional offices and representatives of WHO in Member States. Where data are presented by country, initial WHO estimates and technical explanations were sent to Member States for comment. The estimates reported here should, however, still be interpreted as being the best estimates of WHO rather than the official viewpoints of Member States
134 The World Health Report 2003
Statistical annex Explanatory notes The tables in this technical annex present updated information on summary measures of population health, mortality and the burden of disease in WHO Member States and regions, and selected national health accounts aggregates for 1997-2001. Life expectancy and healthy life expectancy estimates and the national health accounts aggregates have been revised to take new data into account and, for many Member States, are not directly comparable with those published in The World Health Report 2002. The work leading to these annex tables wa undertaken mostly by the WHo Global Programme on Evidence for Health Policy in col laboration with counterparts from WHO regional offices and representatives of WHO in Member States. These notes provide an overview of concepts, methods and data sources gether with references to more detailed documentation It is hoped that careful scrutiny and use of the results will lead to progressive improvements in the measurement of health attainment and health system financing in future editions of The World Health Report. The main results in the health attainment tables are reported with ncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure Where data are presented by country, initial WHO estimates and technical explanations were sent to Member States for comment. Comments or data provided in response were discussed with the Member State and incorporated where possi- ble. The estimates reported here should, however, still be interpreted as being the best esti ates of Who rather than the official viewpoints of Member States Annex Table 1 To assess overall levels of health achievement, it is crucial to develop the best possible ment of the life table for each country. New life tables have been developed for all 192 Mem ber States starting with a systematic review of all available evidence from surveys, censuses sample registration systems, population laboratories and vital registration on levels and trends in child mortality and adult mortality (1). This review benefited greatly from a collaborative assessment of child mortality levels for 2001 by WHO and UNICEF and from analyses of general mortality by the United States Census Bureau(2)and the United Nations Populatic All estimates of population size and structure for 2002 are based on the 2002 demographic assessments prepared by the United Nations Population Division(3). These estimates refer to the de facto population and not the de jure population in each Member State. To aid in
Statistical Annex 135 The tables in this technical annex present updated information on summary measures of population health, mortality and the burden of disease in WHO Member States and regions, and selected national health accounts aggregates for 1997–2001. Life expectancy and healthy life expectancy estimates and the national health accounts aggregates have been revised to take new data into account and, for many Member States, are not directly comparable with those published in The World Health Report 2002. The work leading to these annex tables was undertaken mostly by the WHO Global Programme on Evidence for Health Policy in collaboration with counterparts from WHO regional offices and representatives of WHO in Member States. These notes provide an overview of concepts, methods and data sources together with references to more detailed documentation. It is hoped that careful scrutiny and use of the results will lead to progressive improvements in the measurement of health attainment and health system financing in future editions of The World Health Report. The main results in the health attainment tables are reported with uncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure. Where data are presented by country, initial WHO estimates and technical explanations were sent to Member States for comment. Comments or data provided in response were discussed with the Member State and incorporated where possible. The estimates reported here should, however, still be interpreted as being the best estimates of WHO rather than the official viewpoints of Member States Annex Table 1 To assess overall levels of health achievement, it is crucial to develop the best possible assessment of the life table for each country. New life tables have been developed for all 192 Member States starting with a systematic review of all available evidence from surveys, censuses, sample registration systems, population laboratories and vital registration on levels and trends in child mortality and adult mortality (1). This review benefited greatly from a collaborative assessment of child mortality levels for 2001 by WHO and UNICEF and from analyses of general mortality by the United States Census Bureau (2) and the United Nations Population Division (3). All estimates of population size and structure for 2002 are based on the 2002 demographic assessments prepared by the United Nations Population Division (3). These estimates refer to the de facto population and not the de jure population in each Member State. To aid in Statistical Annex Explanatory notes
The World Health Report 2003 demographic, cause-of-death and burden-of-disease analyses, the 192 Member States have been divided into five mortality strata on the basis of their level of child and adult male mortality. The matrix defined by the six WHO regions and the five mortality strata leads to 14 subregions, since not every mortality stratum is represented in every region. These subregions are defined on pages 184-185 and used in Tables 2 and 3 for presentation of Because of increasing heterogeneity of patterns of adult and child mortality, WHO has devel oped a model life table system of two-parameter logit life tables using a global standard, and with additional age-specific parameters to correct for systematic biases in the application of a two-parameter system(4). This system of model life tables has been used extensively in the development of life tables for those Member States without adequate vital registration and in projecting life tables to 2002 when the most recent data available are from earlier year Demographic techniques(Preston-Coale method, Brass Growth-Balance method, General- ized Growth-Balance method and Bennett-Horiuchi method)have been applied, as appro- priate, to assess the level of completeness of recorded mortality data for Member States with vital registration systems. For Member States without national vital registration systems, all available survey, census and vital registration data were assessed, adjusted and averaged to estimate the probable trend in child mortality over the past few decades. This trend was projected to estimate child mortality levels in 2002. In addition, adult sibling survival data from available population surveys were analysed to obtain additional information on adult ortalit WHO uses a standard method to estimate and project life tables for all Member States with comparable data. This may lead to minor differences compared with official life tables pre pared by Member States. Life expectancies for the year 2002 for many Member States have been revised from those published for 2000 and 2001 in The World Health Report 2002 to take into account more recently available mortality data To capture the uncertainty resulting from sampling, indirect estimation technique or projec tion to 2002, a total of 1000 life tables have been developed for each Member State. Uncer- tainty bounds are reported in Annex Table l by giving key life table values at the 2. 5th percentile and the 97. 5th percentile. This uncertainty analysis was facilitated by the development of new methods and software tools(5). In countries with a substantial HIV/AIDS epidemic, recent estimates of the level and uncertainty range of the magnitude of the epidemic have been incorporated into the life table uncertainty analysis. Annex Tables 2 and 3 Causes of death in the 14 subregions and the world have been estimated based on data from 112 national vital registration systems that capture about 18.6 million deaths annually, repre senting one-third of all deaths occurring in the world. In addition, information from sample registration systems, population laboratories and epidemiological analyses of specific condi tions has been used to improve estimates of the cause-of-death patterns(6-16). These data are used to estimate death rates by age and sex for underlying causes of death as defined by the International Statistical Classification of Diseases and Related Health Problems(IcD classification rules Cause-of-death data have been carefully analysed to take into account incomplete coverage of vital registration in countries and the likely differences in cause-of-death patterns that would be expected in uncovered and often poorer sub-populations. Techniques to
136 The World Health Report 2003 demographic, cause-of-death and burden-of-disease analyses, the 192 Member States have been divided into five mortality strata on the basis of their level of child and adult male mortality. The matrix defined by the six WHO regions and the five mortality strata leads to 14 subregions, since not every mortality stratum is represented in every region. These subregions are defined on pages 184–185 and used in Tables 2 and 3 for presentation of results. Because of increasing heterogeneity of patterns of adult and child mortality, WHO has developed a model life table system of two-parameter logit life tables using a global standard, and with additional age-specific parameters to correct for systematic biases in the application of a two-parameter system (4). This system of model life tables has been used extensively in the development of life tables for those Member States without adequate vital registration and in projecting life tables to 2002 when the most recent data available are from earlier years. Demographic techniques (Preston–Coale method, Brass Growth–Balance method, Generalized Growth–Balance method and Bennett–Horiuchi method) have been applied, as appropriate, to assess the level of completeness of recorded mortality data for Member States with vital registration systems. For Member States without national vital registration systems, all available survey, census and vital registration data were assessed, adjusted and averaged to estimate the probable trend in child mortality over the past few decades. This trend was projected to estimate child mortality levels in 2002. In addition, adult sibling survival data from available population surveys were analysed to obtain additional information on adult mortality. WHO uses a standard method to estimate and project life tables for all Member States with comparable data. This may lead to minor differences compared with official life tables prepared by Member States. Life expectancies for the year 2002 for many Member States have been revised from those published for 2000 and 2001 in The World Health Report 2002 to take into account more recently available mortality data. To capture the uncertainty resulting from sampling, indirect estimation technique or projection to 2002, a total of 1000 life tables have been developed for each Member State. Uncertainty bounds are reported in Annex Table 1 by giving key life table values at the 2.5th percentile and the 97.5th percentile. This uncertainty analysis was facilitated by the development of new methods and software tools (5). In countries with a substantial HIV/AIDS epidemic, recent estimates of the level and uncertainty range of the magnitude of the epidemic have been incorporated into the life table uncertainty analysis. Annex Tables 2 and 3 Causes of death in the 14 subregions and the world have been estimated based on data from 112 national vital registration systems that capture about 18.6 million deaths annually, representing one-third of all deaths occurring in the world. In addition, information from sample registration systems, population laboratories and epidemiological analyses of specific conditions has been used to improve estimates of the cause-of-death patterns (6–16). These data are used to estimate death rates by age and sex for underlying causes of death as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD) classification rules. Cause-of-death data have been carefully analysed to take into account incomplete coverage of vital registration in countries and the likely differences in cause-of-death patterns that would be expected in uncovered and often poorer sub-populations. Techniques to
Statistical annex undertake this analysis have been developed based on the global burden of disease study (17) and further refined using a much more extensive database and more robust modelling tech Special attention has been paid to problems of misattribution or miscoding of causes of death in cardiovascular diseases, cancer, injuries and in general ill-defined categories. A correction algorithm for reclassifying ill-defined cardiovascular codes has been developed (19).Cancer mortality by site has been evaluated using both vital registration data and population-based cancer incidence registries. The latter have been analysed using a complete age, period cohort Annex Table 3 provides estimates of the burden of disease for the 14 epidemiological subregions using disability-adjusted life years(DALYs). One DALY can be thought of as one lost year of healthy life and the burden of disease as a measurement of the gap between the current health of a population and an ideal situation in which everyone in the population lives into old age in full health(20, 21). DALYs for a disease or health condition are calculated as th sum of the years of life lost(YLL) through premature mortality in the population and the years lost through disability(YLD) for incident cases of the health condition. DALYs for 2002 have been estimated using cause-of-death information for each subregion and regional or country-level assessments of the epidemiology of major disabling conditions. For this report, burden-of-disease estimates have been updated for many of the cause categories included in the Global Burden of Disease 2000 study, based on the wealth of data on major diseases and njuries available to WHO technical programmes and through collaboration with scientists worldwide(16). These data, together with new and revised estimates of deaths by cause, and sex, for all Member States, have been used to develop internally consistent estimates of incidence, prevalence, duration and DALYs for over 130 major causes, for 14 subregions of the world WHO programme participation in the development of these estimates and con sultation with Member States ensures that estimates reflect all information and knowledge available to WHO. Estimates of incidence and point prevalence for selected major causes by subregionarealsoavailableontheWhowebsiteatwww.who.int/evidence/bod. Annex Table 4 Annex Table 4 reports the average level of population health for WHO Member States in terms of health-adjusted life expectancy(HALE). HALE is based on life expectancy at birth (Annex Table 1)but includes an adjustment for time spent in poor health. It is most easil understood as the equivalent number of years in full health that a newborn can expect to live based on current rates of ill-health and mortality(22, 23). The methods used by WHo to calculate hale have been developed to maximize compara bility across populations. WHO analyses of more than 50 existing national health surveys fo the calculation of healthy life expectancy identified severe limitations in the comparability of self-reported health status data from different populations, even when identical survey struments and methods were used(24). These comparability problems are a result of unmeasured differences in expectations and norms for health, so that the meaning different populations attach to the labels used for response categories in self-reported questions (such as mild, moderate or severe)can vary greatly (25). To resolve these problems, WHO under- took a Multi-Country Survey Study(MCSS )in 2000-2001 in collaboration with Member States, using a standardized health status survey instrument together with new statistical nethods for adjusting biases in self-reported health(25, 26)
Statistical Annex 137 undertake this analysis have been developed based on the global burden of disease study (17) and further refined using a much more extensive database and more robust modelling techniques (18). Special attention has been paid to problems of misattribution or miscoding of causes of death in cardiovascular diseases, cancer, injuries and in general ill-defined categories. A correction algorithm for reclassifying ill-defined cardiovascular codes has been developed (19). Cancer mortality by site has been evaluated using both vital registration data and population-based cancer incidence registries. The latter have been analysed using a complete age, period cohort model of cancer survival in each region (15). Annex Table 3 provides estimates of the burden of disease for the 14 epidemiological subregions using disability-adjusted life years (DALYs). One DALY can be thought of as one lost year of “healthy” life and the burden of disease as a measurement of the gap between the current health of a population and an ideal situation in which everyone in the population lives into old age in full health (20, 21). DALYs for a disease or health condition are calculated as the sum of the years of life lost (YLL) through premature mortality in the population and the years lost through disability (YLD) for incident cases of the health condition. DALYs for 2002 have been estimated using cause-of-death information for each subregion and regional or country-level assessments of the epidemiology of major disabling conditions. For this report, burden-of-disease estimates have been updated for many of the cause categories included in the Global Burden of Disease 2000 study, based on the wealth of data on major diseases and injuries available to WHO technical programmes and through collaboration with scientists worldwide (16). These data, together with new and revised estimates of deaths by cause, age and sex, for all Member States, have been used to develop internally consistent estimates of incidence, prevalence, duration and DALYs for over 130 major causes, for 14 subregions of the world. WHO programme participation in the development of these estimates and consultation with Member States ensures that estimates reflect all information and knowledge available to WHO. Estimates of incidence and point prevalence for selected major causes by subregion are also available on the WHO web site at www.who.int/evidence/bod. Annex Table 4 Annex Table 4 reports the average level of population health for WHO Member States in terms of health-adjusted life expectancy (HALE). HALE is based on life expectancy at birth (Annex Table 1) but includes an adjustment for time spent in poor health. It is most easily understood as the equivalent number of years in full health that a newborn can expect to live based on current rates of ill-health and mortality (22, 23). The methods used by WHO to calculate HALE have been developed to maximize comparability across populations. WHO analyses of more than 50 existing national health surveys for the calculation of healthy life expectancy identified severe limitations in the comparability of self-reported health status data from different populations, even when identical survey instruments and methods were used (24). These comparability problems are a result of unmeasured differences in expectations and norms for health, so that the meaning different populations attach to the labels used for response categories in self-reported questions (such as mild, moderate or severe) can vary greatly (25). To resolve these problems, WHO undertook a Multi-Country Survey Study (MCSS) in 2000–2001 in collaboration with Member States, using a standardized health status survey instrument together with new statistical methods for adjusting biases in self-reported health (25, 26)
The World Health Report 2003 The MCSS carried out 71 representative household surveys in 61 Member States in 2000 and 2001 using a new health status instrument based on the International Classification of Fun tioning, Disability and Health(27), which seeks information from a representative sample of respondents on their current states of health according to seven core domains. To overcome the problem of comparability of self-report health data, the WHO survey instrument used performance tests and vignettes to calibrate self-reported health in each of the core domains (26). The calibrated responses are used to estimate the prevalence of different states of health by age and sex. Building on the findings from the MCSS, WHO is now carrying out the world Health Survey, in collaboration with Member States(further details are available from th Whowebsiteatwww.who.int/evidence/whs).Duringthefirsthalfof2003,73Member States conducted the World Health Survey, and its results will contribute to future analysis of The measurement of time spent in poor health is based on combining condition-specific estimates from the Global Burden of Disease 2000 study with estimates of the prevalence of ferent health states by age and sex derived from the MCSS, and weighted using health state valuations(28). Data from the global Burden of Disease 2000 study were used to estimate severity-adjusted prevalences for health conditions by age and sex for all 192 WHO Member States for 2002. Data from 62 surveys in the MCSS were used to make independent estimates of severity-adjusted prevalences by age and sex. Finally, posterior prevalences for all Member States for 2002 were calculated using prevalences based on the Global Burden of Disease 2000 and the survey prevalences Household surveys including a valuation module were conducted in 14 countries: China, Colombia, Egypt, Georgia, India, Indonesia, the Islamic Republic of Iran, Lebanon, Mexico, Nigeria, Singapore, Slovakia, the Syrian Arab Republic and Turkey. Data on nearly 500 000 health state valuations from over 46 000 respondents were used to develop average global health state valuations for the calculation of HALE (29) The methods used by WHO to calculate healthy life expectancy were peer-reviewed during 2001 and 2002 by the Scientific Peer Review Group(SPRG)established by the Director-Gen- eral in response to a request by the WHO Executive Board. The SPRG's final report to the Director-General(30)stated that the methodology for the measurement of hale was well advanced and made a number of technical recommendations which have been followed with regard to the calculations reported in Annex Table 4. In particular, steps have been taken to include residents in health institutions, and dependent comorbidity. The MCSS survey sam ples did not include older people resident in nursing homes or other health institutions Because these people generally have worse health than those resident in households, an ad- justment was made based on the estimated proportion of the population aged 60 years and over who were resident in health institutions Summation of condition-specific prevalences across all causes in the Global Burden of Dis- ease 2000 would result in overestimation of health state prevalences because of comorbidity between conditions. In previous editions of The World Health Report, adjustments have been made for independent comorbidity (22 ). Following the scientific peer review, further work was undertaken to take dependent comorbidity properly into account. Data from five large national health surveys were analysed by age and sex to estimate the degree of dependent comorbidity for pairs of conditions. There was surprising consistency across the five surveys and the results were used for all Member States to adjust for dependent comorbidity in sum- ation of condition-specific prevalences(16)
138 The World Health Report 2003 The MCSS carried out 71 representative household surveys in 61 Member States in 2000 and 2001 using a new health status instrument based on the International Classification of Functioning, Disability and Health (27), which seeks information from a representative sample of respondents on their current states of health according to seven core domains. To overcome the problem of comparability of self-report health data, the WHO survey instrument used performance tests and vignettes to calibrate self-reported health in each of the core domains (26). The calibrated responses are used to estimate the prevalence of different states of health by age and sex. Building on the findings from the MCSS, WHO is now carrying out the World Health Survey, in collaboration with Member States (further details are available from the WHO web site at www.who.int/evidence/whs). During the first half of 2003, 73 Member States conducted the World Health Survey, and its results will contribute to future analysis of healthy life expectancy. The measurement of time spent in poor health is based on combining condition-specific estimates from the Global Burden of Disease 2000 study with estimates of the prevalence of different health states by age and sex derived from the MCSS, and weighted using health state valuations (28). Data from the Global Burden of Disease 2000 study were used to estimate severity-adjusted prevalences for health conditions by age and sex for all 192 WHO Member States for 2002. Data from 62 surveys in the MCSS were used to make independent estimates of severity-adjusted prevalences by age and sex. Finally, posterior prevalences for all Member States for 2002 were calculated using prevalences based on the Global Burden of Disease 2000 and the survey prevalences. Household surveys including a valuation module were conducted in 14 countries: China, Colombia, Egypt, Georgia, India, Indonesia, the Islamic Republic of Iran, Lebanon, Mexico, Nigeria, Singapore, Slovakia, the Syrian Arab Republic and Turkey. Data on nearly 500 000 health state valuations from over 46 000 respondents were used to develop average global health state valuations for the calculation of HALE (29). The methods used by WHO to calculate healthy life expectancy were peer-reviewed during 2001 and 2002 by the Scientific Peer Review Group (SPRG) established by the Director-General in response to a request by the WHO Executive Board. The SPRG’s final report to the Director-General (30) stated that the methodology for the measurement of HALE was well advanced, and made a number of technical recommendations which have been followed with regard to the calculations reported in Annex Table 4. In particular, steps have been taken to include residents in health institutions, and dependent comorbidity. The MCSS survey samples did not include older people resident in nursing homes or other health institutions. Because these people generally have worse health than those resident in households, an adjustment was made based on the estimated proportion of the population aged 60 years and over who were resident in health institutions. Summation of condition-specific prevalences across all causes in the Global Burden of Disease 2000 would result in overestimation of health state prevalences because of comorbidity between conditions. In previous editions of The World Health Report, adjustments have been made for independent comorbidity (22). Following the scientific peer review, further work was undertaken to take dependent comorbidity properly into account. Data from five large national health surveys were analysed by age and sex to estimate the degree of dependent comorbidity for pairs of conditions. There was surprising consistency across the five surveys and the results were used for all Member States to adjust for dependent comorbidity in summation of condition-specific prevalences (16)
Statistical annex Annex Table 4 reports for all Member States for 2002 the following: average HALE at birth, HALE at age 60, expected lost healthy years(LHE)at birth, percentage of total life expectancy E)lost, and 95%uncertainty intervals. LHE is calculated as LE-HALE and is the equivalent number of years of full health lost through living in health states other than full health. LHE expressed as a percentage of total LE represents the proportion of total life ex- pectancy that is lost through living in health states of less than full health. Healthy life expect ancies for 2002 are not comparable with those published for 2001 in The World Health Report 2002 for many Member States, as they incorporate new epidemiological information,new data from health surveys, and new information on mortality rates, as well as the improve ments in methods described above. In particular, the implementation of improved methods for dealing with comorbidity has resulted in a reduction in estimated proportion of healthy years of life lost at older ages compared to estimates published in previous years. Annex Table 5 National health accounts(NHA)are a synthesis of the financing and spending flows recorded in the operation of a health system, with a potential to monitor all transactions from funding sources to the distribution of benefits across geographical, demographic, socioeconomic and epidemiological dimensions. NHA are related to the macroeconomic and macrosocial ac- counts whose methodology they borrow Annex Table 5 provides estimates for each of the 192 Member States. Although more and more countries collect health expenditure data, only a limited number have produced full national health accounts. Nationally and internationally available information that has been dentified and obtained has been compiled for each country Standard accounting estimation and extrapolation techniques have been applied to provide adequate time series. a polic relevant breakdown of the data(for example, public/private expenditure) is also provided Each year draft templates are sent to ministers of health for their comments and their ance in obtaining additional information should that be necessary. The constructive responses from ministries have provided valuable information for the NHA estimates reported here An important methodological contribution to producing national health accounts is now available in the Guide to producing national health accounts with special applications for lo income and middle-income countries(31). This guide is based on the Organisation for Eco nomic Co-operation and Development( OECD) System of health accounts(32). Both reports are built on the principles of the United Nations System of national accounts(commonl referred to as SNA93)(33) The principal international references used to produce the tables are the International Mon- etary Fund(IMF) Government finance statistics yearbook, 2002(34), International financial statistics yearbook, 2003(35)and International Financial Statistics(September 2003)(36); the Asian Development Bank Key indicators 2002 (37); OECD health data 2003 ( 38)and Interna- tional development statistics(39); and the United Nations National accounts statistics: main aggregates and detailed tables, 2000(40). The organizations charged with producing thes reports facilitated the supply of advanced copies for WHO and gave additional related info mation, and their contributions are acknowledged with gratitude here National sources include: national health accounts reports, public expenditure reports, sta- tistical yearbooks and other periodicals, budgetary documents, national accounts reports, statistical data on official web sites, nongovernmental organization reports, academic
Statistical Annex 139 Annex Table 4 reports for all Member States for 2002 the following: average HALE at birth, HALE at age 60, expected lost healthy years (LHE) at birth, percentage of total life expectancy (LE) lost, and 95% uncertainty intervals. LHE is calculated as LE – HALE and is the expected equivalent number of years of full health lost through living in health states other than full health. LHE expressed as a percentage of total LE represents the proportion of total life expectancy that is lost through living in health states of less than full health. Healthy life expectancies for 2002 are not comparable with those published for 2001 in The World Health Report 2002 for many Member States, as they incorporate new epidemiological information, new data from health surveys, and new information on mortality rates, as well as the improvements in methods described above. In particular, the implementation of improved methods for dealing with comorbidity has resulted in a reduction in estimated proportion of healthy years of life lost at older ages compared to estimates published in previous years. Annex Table 5 National health accounts (NHA) are a synthesis of the financing and spending flows recorded in the operation of a health system, with a potential to monitor all transactions from funding sources to the distribution of benefits across geographical, demographic, socioeconomic and epidemiological dimensions. NHA are related to the macroeconomic and macrosocial accounts whose methodology they borrow. Annex Table 5 provides estimates for each of the 192 Member States. Although more and more countries collect health expenditure data, only a limited number have produced full national health accounts. Nationally and internationally available information that has been identified and obtained has been compiled for each country. Standard accounting estimation and extrapolation techniques have been applied to provide adequate time series. A policyrelevant breakdown of the data (for example, public/private expenditure) is also provided. Each year draft templates are sent to ministers of health for their comments and their assistance in obtaining additional information should that be necessary. The constructive responses from ministries have provided valuable information for the NHA estimates reported here. An important methodological contribution to producing national health accounts is now available in the Guide to producing national health accounts with special applications for lowincome and middle-income countries (31). This guide is based on the Organisation for Economic Co-operation and Development (OECD) System of health accounts (32). Both reports are built on the principles of the United Nations System of national accounts (commonly referred to as SNA93) (33). The principal international references used to produce the tables are the International Monetary Fund (IMF) Government finance statistics yearbook, 2002 (34), International financial statistics yearbook, 2003 (35) and International Financial Statistics (September 2003) (36); the Asian Development Bank Key indicators 2002 (37); OECD health data 2003 (38) and International development statistics (39); and the United Nations National accounts statistics: main aggregates and detailed tables, 2000 (40). The organizations charged with producing these reports facilitated the supply of advanced copies for WHO and gave additional related information, and their contributions are acknowledged with gratitude here. National sources include: national health accounts reports, public expenditure reports, statistical yearbooks and other periodicals, budgetary documents, national accounts reports, statistical data on official web sites, nongovernmental organization reports, academic
The World Health Report 2003 studies, and reports and data provided by central statistical offices, ministries of health, min istries of finance and economic development, planning offices, and professional and trade Annex Table 5 provides both updated and revised figures for 1997-2000 and new data for 2001. Figures have been updated when new information that changes the original estimates has become available. This category includes benchmarking revisions, whereby an occasional wholesale revision is made by a country owing to a change in methodology, when a more extensive NHA effort is undertaken, or when shifting the denominator from SNA68 to SNA93 Total expenditure on health has been defined as the sum of general government expenditure on health(GGHE or public expenditure on health), and private expenditure on health( PvtHE All estimates are calculated in millions of national currency units(million NCU). The est mates are presented as ratios to gross domestic product(GDP), to total health expenditure (THE), to total general government expenditure(GGE), or to total private expenditure on GDP is the value of all goods and services provided in a country by residents and non-resi- dents without regard to their allocation among domestic and foreign claims. This(with small adjustments)corresponds to the total sum of expenditure(consumption and investment)of the private and government agents of the economy during the reference year. The United Nations National accounts statistics: main aggregates and detailed tables, 2000(40), table I was the main source of gDP estimates. For the 30 Member countries of the oecd, the mac roeconomic accounts have been imported from the National accounts of OECD countries 1990/ 2001,2003 edition, volume Il(41), table 1. Collaborative arrangements between WHO and the United Nations Statistics Division and the Economic Commission for Europe of the United Nations have permitted the receipt of advance information on 2001 When United Nations data were unavailable, GDP data reported by the IMF (International Financial Statistics, September 2003)have been used. In the few cases where none of the preceding institutions reported updated GDP information, WHO has used data from other institutions or national series. National series were used for Andorra, the Federated States of Micronesia, Nicaragua, Niue, Palau, Samoa, Solomon Islands and Tonga. Figures for Kiribati were obtained from the Asian Development Bank. The estimates for Afghanistan, the Demo cratic People's Republic of Korea, Irag, Somalia and Timor-Leste originate from policy re- ports, as no standard statistical sources had any information on these countries. The data for China exclude estimates for Hong Kong Special Administrative Region and Macao Special Administrative Region. The health expenditure data for Jordan exclude the contribu tions from United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), which provided basic health services support to Palestinian refugees residing on Jordanian territories, but include UNRWA expenditures to UNRWA clinics. The 1997 and 1998 health expenditure data for Serbia and Montenegro included the provinces of Kosovo and Metohia, but for 1999 and 2000 the data excluded Kosovo and Metohia, since these terri tories have been placed under the administration of the United Nations. The estimate for 2001 was also extrapolated without Kosovo and Metohia. General government expenditure(GGE)includes consolidated direct outlays and indirect outlays(for example, subsidies to producers, transfers to households), including capital of all levels of government(central/federal, provincial/regional/state/district, and municipal/local authorities), social security institutions, autonomous bodies, and other extrabudgetary funds
140 The World Health Report 2003 studies, and reports and data provided by central statistical offices, ministries of health, ministries of finance and economic development, planning offices, and professional and trade associations. Annex Table 5 provides both updated and revised figures for 1997–2000 and new data for 2001. Figures have been updated when new information that changes the original estimates has become available. This category includes benchmarking revisions, whereby an occasional wholesale revision is made by a country owing to a change in methodology, when a more extensive NHA effort is undertaken, or when shifting the denominator from SNA68 to SNA93. Colombia is a case in point. Total expenditure on health has been defined as the sum of general government expenditure on health (GGHE or public expenditure on health), and private expenditure on health (PvtHE). All estimates are calculated in millions of national currency units (million NCU). The estimates are presented as ratios to gross domestic product (GDP), to total health expenditure (THE), to total general government expenditure (GGE), or to total private expenditure on health (PvtHE). GDP is the value of all goods and services provided in a country by residents and non-residents without regard to their allocation among domestic and foreign claims. This (with small adjustments) corresponds to the total sum of expenditure (consumption and investment) of the private and government agents of the economy during the reference year. The United Nations National accounts statistics: main aggregates and detailed tables, 2000 (40), table 1.1, was the main source of GDP estimates. For the 30 Member countries of the OECD, the macroeconomic accounts have been imported from the National accounts of OECD countries 1990/ 2001, 2003 edition, volume II (41), table 1. Collaborative arrangements between WHO and the United Nations Statistics Division and the Economic Commission for Europe of the United Nations have permitted the receipt of advance information on 2001. When United Nations data were unavailable, GDP data reported by the IMF (International Financial Statistics, September 2003) have been used. In the few cases where none of the preceding institutions reported updated GDP information, WHO has used data from other institutions or national series. National series were used for Andorra, the Federated States of Micronesia, Nicaragua, Niue, Palau, Samoa, Solomon Islands and Tonga. Figures for Kiribati were obtained from the Asian Development Bank. The estimates for Afghanistan, the Democratic People’s Republic of Korea, Iraq, Somalia and Timor-Leste originate from policy reports, as no standard statistical sources had any information on these countries. The data for China exclude estimates for Hong Kong Special Administrative Region and Macao Special Administrative Region. The health expenditure data for Jordan exclude the contributions from United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), which provided basic health services support to Palestinian refugees residing on Jordanian territories, but include UNRWA expenditures to UNRWA clinics. The 1997 and 1998 health expenditure data for Serbia and Montenegro included the provinces of Kosovo and Metohia, but for 1999 and 2000 the data excluded Kosovo and Metohia, since these territories have been placed under the administration of the United Nations. The estimate for 2001 was also extrapolated without Kosovo and Metohia. General government expenditure (GGE) includes consolidated direct outlays and indirect outlays (for example, subsidies to producers, transfers to households), including capital of all levels of government (central/federal, provincial/regional/state/district, and municipal/local authorities), social security institutions, autonomous bodies, and other extrabudgetary funds
Statistical annex 141 National accounts of OECD countries: detailed tables 1990/2001, 2003 edition, volume Il, table 12, row 51, supplies the information for 27 member countries. The IMF Government finance statistics yearbook supplies an aggregate figure for 133 central/federal governments with com plements for 23 regional and 45 local/ municipal governments (as well as some social security payments for health data received from the IMF). It reports central government disburse ment figures in its International Financial Statistics, row 82. Several other public finance au- dits, executed budgets, budget plans, statistical yearbooks, web sites, World Bank and Regional Development Bank reports, and academic studies have been consulted to verify total govern ment expenditure Extrapolations were made on incomplete time series using, inter alia, the differential between current disbursement plus savings in the United Nations National ac- counts up to 1995 and the IMF central government disbursement level. Several national au- thorities have also confirmed the gge series during the consultative process GGHE comprises the outlays earmarked for the enhancement of the health status of popula tion segments and/or the distribution of medical care goods and services among populatio a central/federal, state/provincial/regional, and local/municipal authorities I extrabudgetary agencies, principally social security schemes, which operate in several a external resources(mainly grants and credits with high grant components to governments) The figures for social security and extrabudgetary expenditure on health include purchases of health goods and services by schemes that are compulsory, under governmental control, and covering a sizeable segment of the population. A major hurdle has been the need to verify that no double counting occurs and that no cash benefits for sickness and/or loss of employ- ment are included in the estimates, as these are classified as income maintenance expenditure All expenditures are to be accounted for, including final consumption, subsidies to produc ers,transfers to households(chiefly reimbursements for medical and pharmaceutical bills) nvestment and investment grants (also referred to as capital transfers). The classification of the functions of government, promoted by the United Nations, IME, OECD and other insti- tutions,sets the boundaries. In many instances, the data contained in the publications are limited to those supplied by ministries of health. Expenditures on health, however, should include expenditures where the primary intent is for health regardless of the implementing entity. An effort has been made to obtain data on health expenditures by other ministries, the armed forces, prisons, schools, universities and others, to ensure that all resources account ing for health expenditures are included. Information on external resources was received courtesy of the Development Action Committee of the OECD(DAC/OECD). a quarter of Member States explicitly monitor the external resources entering their health system, infor mation that has been used to validate or amend the order of magnitude derived from the DAC entries OECD health data 2003 supplies GGHE entries for its member countries, with some gaps for the year 2001. In addition, the data for the year 2001 for Austria, Belgium, Iceland, Japan, Luxembourg, Republic of Korea and Turkey have been largely developed by WHO as they were not yet available through the OECD. Those have been projected by WHO. NHA studies were available for 54 non-OECD countries for one or more years. The detailed information in these reports permitted a more reliable basis for estimation than in other years. The IMF Government finance statistics reports central government expenditure on health for 122 coun- tries,regional government outlays for health for 23 countries, and local government outlays on health for 45 countries. The gfS entries are not continuous time series for all countries
Statistical Annex 141 National accounts of OECD countries: detailed tables 1990/2001, 2003 edition, volume II, table 12, row 51, supplies the information for 27 member countries. The IMF Government finance statistics yearbook supplies an aggregate figure for 133 central/federal governments with complements for 23 regional and 45 local/municipal governments (as well as some social security payments for health data received from the IMF). It reports central government disbursement figures in its International Financial Statistics, row 82. Several other public finance audits, executed budgets, budget plans, statistical yearbooks, web sites, World Bank and Regional Development Bank reports, and academic studies have been consulted to verify total government expenditure. Extrapolations were made on incomplete time series using, inter alia, the differential between current disbursement plus savings in the United Nations National accounts up to 1995 and the IMF central government disbursement level. Several national authorities have also confirmed the GGE series during the consultative process. GGHE comprises the outlays earmarked for the enhancement of the health status of population segments and/or the distribution of medical care goods and services among population segments by: ■ central/federal, state/provincial/regional, and local/municipal authorities; ■ extrabudgetary agencies, principally social security schemes, which operate in several countries; ■ external resources (mainly grants and credits with high grant components to governments). The figures for social security and extrabudgetary expenditure on health include purchases of health goods and services by schemes that are compulsory, under governmental control, and covering a sizeable segment of the population. A major hurdle has been the need to verify that no double counting occurs and that no cash benefits for sickness and/or loss of employment are included in the estimates, as these are classified as income maintenance expenditure. All expenditures are to be accounted for, including final consumption, subsidies to producers, transfers to households (chiefly reimbursements for medical and pharmaceutical bills), investment and investment grants (also referred to as capital transfers). The classification of the functions of government, promoted by the United Nations, IMF, OECD and other institutions, sets the boundaries. In many instances, the data contained in the publications are limited to those supplied by ministries of health. Expenditures on health, however, should include expenditures where the primary intent is for health regardless of the implementing entity. An effort has been made to obtain data on health expenditures by other ministries, the armed forces, prisons, schools, universities and others, to ensure that all resources accounting for health expenditures are included. Information on external resources was received courtesy of the Development Action Committee of the OECD (DAC/OECD). A quarter of Member States explicitly monitor the external resources entering their health system, information that has been used to validate or amend the order of magnitude derived from the DAC entries. OECD health data 2003 supplies GGHE entries for its member countries, with some gaps for the year 2001. In addition, the data for the year 2001 for Austria, Belgium, Iceland, Japan, Luxembourg, Republic of Korea and Turkey have been largely developed by WHO as they were not yet available through the OECD. Those have been projected by WHO. NHA studies were available for 54 non-OECD countries for one or more years. The detailed information in these reports permitted a more reliable basis for estimation than in other years. The IMF Government finance statistics reports central government expenditure on health for 122 countries, regional government outlays for health for 23 countries, and local government outlays on health for 45 countries. The GFS entries are not continuous time series for all countries
The World Health Report 2003 but the document serves as an indicator that a reporting system exists in the 122 countries. a thorough search was conducted for the relevant national publications in those countries. In some cases it was observed that expenditures reported under the government finance classi- fication of the GFS were limited to those of the ministry of health rather than all expendi- tures on health regardless of ministry. In such cases, other series were used to supplement that source. Government finance data, together with external resources data, statistical year- books, public finance reports, and analyses reporting on the implementation of health poli cies. have led to gghe estimates for most who member States. Information on brunei Darussalam, for example, was accessed from national sources, but also from an International Medical Foundation of Japan data compendium(42). This source provided a means for do ole checking health budget data for seven countries Several processes have been used to judge the validity of the data. For example, the aggregate expenditure obtained has been compared against in-patient care expenditure, pharmaceuti l expenditure data and other records(including programme administration and other costs entering the System of health accounts classifications)to cross-validate the information, in order to ensure that: the outlays for which details have been assembled constitute the bulk of the government expenditure on health; intra-government transfers are consolidated; and the estimates obtained are judged plausible in terms of systems' descriptions. The aggregate gov ernmental health expenditure data have also been compared with total GGe, providing an additional source of verification. Sometimes the GGHE and, therefore, the figures for total health expenditure, may be an underestimate if it is not possible to estimate for local govern ment, nongovernmental organizations and insurance. For example ThE for India may not include some agents that could result in an underestimate of between 0.3% and 0.6% of GDP. Information for Afghanistan and Iraq was received from the Regional Office for the Eastern Mediterranean, and for Cambodia from the country office Private expenditure on health has been defined as the sum of expenditures by the following entities. Doling arrangements: the outlays of private and private (with no government control over payment rates and participating providers but broad guidelines from government)insurance schemes, commercial and non-profit(mu tual)insurance schemes, health maintenance organizations, and other agents managing prepaid medical and paramedical benefits(including the operating costs of these schemes) a Firms' expenditure on health: outlays by public and private enterprises for medical care and health-enhancing benefits other than payment to social security. a Non-profit institutions serving mainly households: resources used to purchase health goods nd services by entities whose status does not permit them to be a source of income, profit or other financial gain for the units that establish, control or finance them. This includes funding from internal and external sources. a Household out-of-pocket spending: the direct outlays of households, including gratuities and in-kind payments made to health practitioners and suppliers of pharmaceuticals, thera- peutic appliances, and other goods and services, whose primary intent is to contribute to the restoration or to the enhancement of the health status of individuals or population groups. This includes household payments to public services, non-profit institutions or nongovernmental organizations and non-reimbursable cost sharing, deductibles, Co-pay ments an d fee-for-service. It excludes payments made by enterprises which deliver med al and paramedical benefits, mandated by law or not, to their employees and payments for overseas treatment
142 The World Health Report 2003 but the document serves as an indicator that a reporting system exists in the 122 countries. A thorough search was conducted for the relevant national publications in those countries. In some cases it was observed that expenditures reported under the government finance classification of the GFS were limited to those of the ministry of health rather than all expenditures on health regardless of ministry. In such cases, other series were used to supplement that source. Government finance data, together with external resources data, statistical yearbooks, public finance reports, and analyses reporting on the implementation of health policies, have led to GGHE estimates for most WHO Member States. Information on Brunei Darussalam, for example, was accessed from national sources, but also from an International Medical Foundation of Japan data compendium (42). This source provided a means for double checking health budget data for seven countries. Several processes have been used to judge the validity of the data. For example, the aggregate expenditure obtained has been compared against in-patient care expenditure, pharmaceutical expenditure data and other records (including programme administration and other costs entering the System of health accounts classifications) to cross-validate the information, in order to ensure that: the outlays for which details have been assembled constitute the bulk of the government expenditure on health; intra-government transfers are consolidated; and the estimates obtained are judged plausible in terms of systems’ descriptions. The aggregate governmental health expenditure data have also been compared with total GGE, providing an additional source of verification. Sometimes the GGHE and, therefore, the figures for total health expenditure, may be an underestimate if it is not possible to estimate for local government, nongovernmental organizations and insurance. For example THE for India may not include some agents that could result in an underestimate of between 0.3% and 0.6% of GDP. Information for Afghanistan and Iraq was received from the Regional Office for the Eastern Mediterranean, and for Cambodia from the country office. Private expenditure on health has been defined as the sum of expenditures by the following entities: ■ Prepaid plans and risk-pooling arrangements: the outlays of private and private social (with no government control over payment rates and participating providers but with broad guidelines from government) insurance schemes, commercial and non-profit (mutual) insurance schemes, health maintenance organizations, and other agents managing prepaid medical and paramedical benefits (including the operating costs of these schemes). ■ Firms’ expenditure on health: outlays by public and private enterprises for medical care and health-enhancing benefits other than payment to social security. ■ Non-profit institutions serving mainly households: resources used to purchase health goods and services by entities whose status does not permit them to be a source of income, profit or other financial gain for the units that establish, control or finance them. This includes funding from internal and external sources. ■ Household out-of-pocket spending: the direct outlays of households, including gratuities and in-kind payments made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services, whose primary intent is to contribute to the restoration or to the enhancement of the health status of individuals or population groups. This includes household payments to public services, non-profit institutions or nongovernmental organizations and non-reimbursable cost sharing, deductibles, co-payments and fee-for-service. It excludes payments made by enterprises which deliver medical and paramedical benefits, mandated by law or not, to their employees and payments for overseas treatment