143 Statistical annex The tables in this annex present new concepts and measures which lay the 1 basis for pe the report provides detail on the different goals for health systems and the measures of performance. The material in these tables will be presented on an annual basis in each World health report. As with any innovative approach, methods and data sources can be refined and improved. It is hoped that careful scrutiny and use of results will lead to progressively better meas- urement of health system performance in the coming World health re ports. All the main results are reported with uncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure
143 tatistical nnex The tables in this annex present new concepts and measures which lay the empirical basis for assessing health system performance. The main body of the report provides detail on the different goals for health systems and the measures of performance. The material in these tables will be presented on an annual basis in each World health report. As with any innovative approach, methods and data sources can be refined and improved. It is hoped that careful scrutiny and use of results will lead to progressively better measurement of health system performance in the coming World health reports. All the main results are reported with uncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure. 143
144 STATISTICAL ANNEX EXPLANATORY NOTES The tables in this technical annex present new concepts and measures which lay the empirical basis for assessing health system performance. The main body of the report provides detail on the different goals for health systems and the measures of performance Both the text of the report and the annex are based on the WHO framework for health stem performance assessment. 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 the Regional Offices of WHO. This analytical effort was organized in eleven working groups. Membership of these working groups is listed in the Appendix. The material in these tables will be presented on an annual basis in each World health report. Because this is the first year of presentation for the material in Annex Tables 1 and 5-10, working papers have been prepared which provide details on the concepts, methods and results that are only briefly mentioned here. The footnotes to these technical notes include a complete listing of the detailed working papers As with any innovative approach, methods and data sources can be refined and im proved. It is hoped that careful scrutiny and use of the results will lead to progressively better measurement of performance in the coming World health reports. All the main results are reported with uncertainty intervals in order to communicate to the user the plausibl range of estimates for each country on each measure Although not provided in any table, extensive use has been made of estimates of in ome per capita in international dollars, average years of schooling for the population over age 15 years, percentage of the population in absolute poverty and the income Gini coeffi cient. In all cases, there are multiple and often conflicting sources of information from inter- national agencies on these indicators; in addition, there are many countries for which there are no published estimates To facilitate the analyses presented here, consistent and com plete estimates of these key indicators have been developed through a variety of tech- niques including factor analysis, multiple imputation methods for missing data, remote sensing data from public use satellites and systematic reviews of household survey data The details on methods and data sources for the final figures on income per capita, educa tional attainment, poverty and income distribution are outlined elsewhere. ANNEX TABLE 1 Annex Table 1 is designed as a guide for using Annex Tables 5-7, 9 and 10. Each measure of goal attainment and performance -disability-adjusted life expectancy, health equality in terms of child survival, responsiveness level, responsiveness distribution, fairness of finan- cial contribution, performance on level of health, and overall health system performance reported as a league table ranked from the highest level of achievement or performance to the lowest level. Annex Table 1 lists countries alphabetically and provides the ranks on each of the measures reported in the other tables. The reader can use Annex Table 1 to identify quickly where a particular country falls in each table
144 The World Health Report 2000 STATISTICAL ANNEX EXPLANATORY NOTES T he tables in this technical annex present new concepts and measures which lay the empirical basis for assessing health system performance. The main body of the report provides detail on the different goals for health systems and the measures of performance. Both the text of the report and the annex are based on the WHO framework for health system performance assessment.1 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 the Regional Offices of WHO. This analytical effort was organized in eleven working groups. Membership of these working groups is listed in the Appendix. The material in these tables will be presented on an annual basis in each World health report. Because this is the first year of presentation for the material in Annex Tables 1 and 5-10, working papers have been prepared which provide details on the concepts, methods and results that are only briefly mentioned here. The footnotes to these technical notes include a complete listing of the detailed working papers. As with any innovative approach, methods and data sources can be refined and improved. It is hoped that careful scrutiny and use of the results will lead to progressively better measurement of performance in the coming World health reports. All the main results are reported with uncertainty intervals in order to communicate to the user the plausible range of estimates for each country on each measure. Although not provided in any table, extensive use has been made of estimates of income per capita in international dollars, average years of schooling for the population over age 15 years, percentage of the population in absolute poverty and the income Gini coefficient. In all cases, there are multiple and often conflicting sources of information from international agencies on these indicators; in addition, there are many countries for which there are no published estimates. To facilitate the analyses presented here, consistent and complete estimates of these key indicators have been developed through a variety of techniques including factor analysis, multiple imputation methods for missing data, remote sensing data from public use satellites and systematic reviews of household survey data. The details on methods and data sources for the final figures on income per capita, educational attainment, poverty and income distribution are outlined elsewhere.2 ANNEX TABLE 1 Annex Table 1 is designed as a guide for using Annex Tables 5-7, 9 and 10. Each measure of goal attainment and performance - disability-adjusted life expectancy, health equality in terms of child survival, responsiveness level, responsiveness distribution, fairness of financial contribution, performance on level of health, and overall health system performance -is reported as a league table ranked from the highest level of achievement or performance to the lowest level. Annex Table 1 lists countries alphabetically and provides the ranks on each of the measures reported in the other tables. The reader can use Annex Table 1 to identify quickly where a particular country falls in each table
Statistical annex ANNEX TABLE 2 To assess the performance of health systems in terms of health achievement, it was crucial to develop the best possible assessment of the life table for each country. New life tables have been developed for all 191 Member States starting with a systematic review of all available evidence from surveys, censuses, sample registration systems, population labo ratories and vital registration on levels and trends in child mortality and adult mortality This review benefited greatly from the work undertaken on child mortality by UNICEPS and the UN Population Division 1998 demographic assessment. To aid in demographic, cause of death and burden of disease analysis, the 191 Member States have been divided into 5 mortality strata on the basis of their level of child(5q0) and adult male mortality (45q15) The matrix defined by the six WHO Regions and the 5 mortality strata leads to 14 ubregions, since not every mortality stratum is represented in every Region. These subregic are used in Tables 3 and 4 for presentation of results. Because of increasing heterogeneity of patterns of adult and child mortality, WHO has developed a system of two-parameter logit life tables for each of the 14 subregions. This system of model life tables has been used extensively in the development of life tables for each Member State and in projecting life tables to 1999 when the most recent data avail able are from earlier years. Details on the data, methods and results by country of this life table analysis are available in the corresponding technical paper. A major innovation that WHO is introducing this year to demographic and other analy- ses is the reporting of uncertainty intervals To capture the uncertainty due to sampling indirect estimation technique or projection to 1999, 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 10th percentile and the 90th percentile. This uncertainty analysis was facilitated by the development of new methods and software tools. In coun tries with a substantial HIV epidemic, recent estimates of the level and uncertainty range of the magnitude of the HiV epidemic have been incorporated into the life table uncertainty ANNEX TABLES 3 AND 4 Causes of death for the 14 subregions and the world have been estimated based on data from national vital registration systems that capture 16.7 million deaths annually. In addi tion, information from sample registration systems, population laboratories and epidemic logical analyses of specific conditions have been used to produce better estimates of the cause of death pattems Cause of death data have been carefully analysed to take into account incomplete cov- erage of vital registration in countries and the likely differences in cause of death pattens that would be expected in the uncovered and often poorer sub-populations. Techniques to undertake this analysis have been developed based on the global burden of disease study? nd further refined using a much more extensive database and more robust modelling techniques Special attention has been paid to problems of misattribution or miscoding of causes of death in cardiovascular diseases, cancer, injuries and general ill-defined categories. A cor- rection algorithm for reclassifying ill-defined cardiovascular codes has been developed Cancer mortality by site has been evaluated using both vital registration data and popula tion based cancer incidence registries. The latter have been analysed using a complete age, period cohort model of cancer survival in each region. 2
Statistical Annex 145 ANNEX TABLE 2 To assess the performance of health systems in terms of health achievement, it was crucial to develop the best possible assessment of the life table for each country. New life tables have been developed for all 191 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. This review benefited greatly from the work undertaken on child mortality by UNICEF3 and the UN Population Division 1998 demographic assessment.4 To aid in demographic, cause of death and burden of disease analysis, the 191 Member States have been divided into 5 mortality strata on the basis of their level of child (5q0) and adult male mortality (45q15). The matrix defined by the six WHO Regions and the 5 mortality strata leads to 14 subregions, since not every mortality stratum is represented in every Region. These subregions are used in Tables 3 and 4 for presentation of results. Because of increasing heterogeneity of patterns of adult and child mortality, WHO has developed a system of two-parameter logit life tables for each of the 14 subregions.5 This system of model life tables has been used extensively in the development of life tables for each Member State and in projecting life tables to 1999 when the most recent data available are from earlier years. Details on the data, methods and results by country of this life table analysis are available in the corresponding technical paper.6 A major innovation that WHO is introducing this year to demographic and other analyses is the reporting of uncertainty intervals. To capture the uncertainty due to sampling, indirect estimation technique or projection to 1999, 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 10th percentile and the 90th percentile. This uncertainty analysis was facilitated by the development of new methods and software tools.7 In countries with a substantial HIV epidemic, recent estimates of the level and uncertainty range of the magnitude of the HIV epidemic have been incorporated into the life table uncertainty analysis.8 ANNEX TABLES 3 AND 4 Causes of death for the 14 subregions and the world have been estimated based on data from national vital registration systems that capture 16.7 million deaths annually. In addition, information from sample registration systems, population laboratories and epidemiological analyses of specific conditions have been used to produce better estimates of the cause of death patterns. 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 the uncovered and often poorer sub-populations. Techniques to undertake this analysis have been developed based on the global burden of disease study9 and further refined using a much more extensive database and more robust modelling techniques.10 Special attention has been paid to problems of misattribution or miscoding of causes of death in cardiovascular diseases, cancer, injuries and general ill-defined categories. A correction algorithm for reclassifying ill-defined cardiovascular codes has been developed.11 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.12
The World Health Report 2000 Annex Table 4 provides estimates of the burden of disease using disability-adjusted life years (DALYs)as a measure of the health gap in the world in 1999. DALYs along with disability-adjusted life expectancy are summary measures of population health. DALYS are a type of health gap that measures the difference between a populations health and normative goal of living in full health. For a review of the development of DALYs and recent advances in the measurement of the burden of disease see murray lopez. DALYs have been estimated based on cause of death information for each Region and regional assess ments of the ep ology of major disabling conditions ANNEX TABLE 5 Annex Table 5 provides measurements of health attainment in terms of the average level of population health and the distribution of population health or health equality. iwo meas- ures are reported by WHo for the first time at the country level: disability-adjusted life expectancy and the index of equality of child survival Achievement of the average level of population health is reported in terms of disability. djusted life expectancy (DALE). daLE is most easily understood as the expectation of life lived in equivalent full health. As a summary measure of the burden of disability from all causes in a population, DALE has two advantages over other summary measures. The first that it is relatively easy to explain the concept of a lifespan without disability to a non- technical audience. The second is that it is easy to calculate DALE using the Sullivan method based on age-specific information on the prevalence of non-fatal health outcomes. In the global burden of disease study, dale was estimated at the regional level, based on the estimates of all disabling sequelae included in the study. Disability weights were measured for each of these sequelae for five standard age groups, sex and eight regions. National estimates of dale are based on the life tables for each member state summa rized in Annex Table 2, population representative sample surveys assessing physical and cognitive disability and general health status, and detailed information on the epidemiol ogy of major disabling conditions in each country. Use of household surveys is complicated by the variation in self-assessed health for a given level of observed health as a function of ex, age, socioeconomic status, exposure to health services, and culture. 5, I6 The methodo- logical details for national estimates of dale and the uncertainty in these estimates are provided elsewhere.17 Measurement of achievement in the distribution of health is based on the who frame work for measuring health inequality. s The intention is ultimately to measure the distribu tion of health using the distribution of DALe across individuals. However, the analysis of the distribution of DALE in each country has not yet been completed For selected coun- ies, the distribution of life expectancy across small areas has been completed and reveals lat there is often much greater variation in life expectancy and probably in DALE than expected. 9 In this World health report, the analysis of achievement in the distribution of health, presented in Annex Table 5, is the index of equality of child survival. It is based on the distribution of child survival across countries, and takes advantage of the widely ava able and extensive information on complete birth histories in the demographic and health surveys and small area vital registration data on child mortality Statistical methods based on maximum likelihood estimation of the extended beta binomial distribution have been developed to distinguish between variation across moth ers in the number of children who have died due to chance and that due to differences in the underlying risks of death. 2 This statistical method has been applied to demographic and health survey data and small area data from more than 60 countries to estimate the
146 The World Health Report 2000 Annex Table 4 provides estimates of the burden of disease using disability-adjusted life years (DALYs) as a measure of the health gap in the world in 1999. DALYs along with disability-adjusted life expectancy are summary measures of population health.13 DALYs are a type of health gap that measures the difference between a population’s health and a normative goal of living in full health. For a review of the development of DALYs and recent advances in the measurement of the burden of disease see Murray & Lopez.14 DALYs have been estimated based on cause of death information for each Region and regional assessments of the epidemiology of major disabling conditions. ANNEX TABLE 5 Annex Table 5 provides measurements of health attainment in terms of the average level of population health and the distribution of population health or health equality. Two measures are reported by WHO for the first time at the country level: disability-adjusted life expectancy and the index of equality of child survival. Achievement of the average level of population health is reported in terms of disabilityadjusted life expectancy (DALE). DALE is most easily understood as the expectation of life lived in equivalent full health. As a summary measure of the burden of disability from all causes in a population, DALE has two advantages over other summary measures. The first is that it is relatively easy to explain the concept of a lifespan without disability to a nontechnical audience. The second is that it is easy to calculate DALE using the Sullivan method based on age-specific information on the prevalence of non-fatal health outcomes. In the global burden of disease study, DALE was estimated at the regional level, based on the estimates of all disabling sequelae included in the study. Disability weights were measured for each of these sequelae for five standard age groups, sex and eight regions. National estimates of DALE are based on the life tables for each Member State summarized in Annex Table 2, population representative sample surveys assessing physical and cognitive disability and general health status, and detailed information on the epidemiology of major disabling conditions in each country. Use of household surveys is complicated by the variation in self-assessed health for a given level of observed health as a function of sex, age, socioeconomic status, exposure to health services, and culture.15, 16 The methodological details for national estimates of DALE and the uncertainty in these estimates are provided elsewhere.17 Measurement of achievement in the distribution of health is based on the WHO framework for measuring health inequality.18 The intention is ultimately to measure the distribution of health using the distribution of DALE across individuals. However, the analysis of the distribution of DALE in each country has not yet been completed. For selected countries, the distribution of life expectancy across small areas has been completed and reveals that there is often much greater variation in life expectancy and probably in DALE than expected.19 In this World health report, the analysis of achievement in the distribution of health, presented in Annex Table 5, is the index of equality of child survival. It is based on the distribution of child survival across countries, and takes advantage of the widely available and extensive information on complete birth histories in the demographic and health surveys and small area vital registration data on child mortality. Statistical methods based on maximum likelihood estimation of the extended betabinomial distribution have been developed to distinguish between variation across mothers in the number of children who have died due to chance and that due to differences in the underlying risks of death.20 This statistical method has been applied to demographic and health survey data and small area data from more than 60 countries to estimate the
Statistical annex underlying distribution of the risk of child death. For the purposes of calculating the index of equality of child survival, child mortality distributions have been transformed into distri- butions of expected survival time under age 5 years. The resulting distributions of survival time have been summarized for the creation of a composite index using the following Equality of child survival 1-isl j-l here x is the survival time of a given child and x is the mean survival time across children The particular form of this summary measure of inequality has been selected on the basis of a survey of preferences for measuring health inequality of over one thousand re- spondents. 22 Because all measures of goal achievement are intended to be positive meas- ures, the inequality index has been transformed into an index of equality by calculating one minus child survival inequality, as shown above. As the measure of inequality has a maxi mum value that can be greater than 1, in theory this transformed measure of equality of child survival could be negative. However, across the range of countries, no country has a egree of inequality that would lead to a measurement of equality less than zero. The value of 1 can be interpreted as complete equality and zero can be interpreted as a degree of inequality that is worse than has been seen in any country measured directly or estimated indirectly to date For countries without a demographic and health survey or small area data, the index of the distribution of health for child survival has been estimated using indirect techniques and information on important covariates of health inequality such as poverty, educational attainment and the level of child mortality. ANNEX TABLE 6 The measurement of achievement in the level of responsiveness was based on a survey of nearly two thousand key informants in selected countries. Key informants were aske to evaluate the performance of their health system regarding seven elements of respon siveness: dignity, autonomy and confidentiality jointly termed respect of persons); and ompt attention, quality of basic amenities, access to social support networks during care nd choice of care provider(encompassed by the term client orientation). The elements were scored from 0 to 10. Scores on each component were combined into a composite score for responsiveness based on results of the survey on preferences for health system performance assessment. For other countries, achievement in the level of responsivenes has been estimated using indirect techniques and information on important covariates of responsiveness. To enhance the measurement of responsiveness, WHO is actively devel oping and field testing instruments to measure responsiveness from household respond ents. This strategy of using household surveys will be supplemented with facility surveys to re directly some components of responsiveness he measurement of achievement in the distribution of responsiveness reflected in Annex 6 is based on a very simple approach. Respondents in the key informants survey were asked to identify groups who were disadvantaged with regard to responsiveness.The number of times a particular group was identified as disadvantaged was used to calculate a key informant intensity score. Four groups had high key informant intensity scores: poor peo- ple, women, old people, and indigenous groups or racially disadvantaged groups (in most stances minorities). The key informant intensity scores for these four groups were multi
Statistical Annex 147 underlying distribution of the risk of child death.21 For the purposes of calculating the index of equality of child survival, child mortality distributions have been transformed into distributions of expected survival time under age 5 years. The resulting distributions of survival time have been summarized for the creation of a composite index using the following formula: where x is the survival time of a given child and x is the mean survival time across children. The particular form of this summary measure of inequality has been selected on the basis of a survey of preferences for measuring health inequality of over one thousand respondents.22 Because all measures of goal achievement are intended to be positive measures, the inequality index has been transformed into an index of equality by calculating one minus child survival inequality, as shown above. As the measure of inequality has a maximum value that can be greater than 1, in theory this transformed measure of equality of child survival could be negative. However, across the range of countries, no country has a degree of inequality that would lead to a measurement of equality less than zero. The value of 1 can be interpreted as complete equality and zero can be interpreted as a degree of inequality that is worse than has been seen in any country measured directly or estimated indirectly to date. For countries without a demographic and health survey or small area data, the index of the distribution of health for child survival has been estimated using indirect techniques and information on important covariates of health inequality such as poverty, educational attainment and the level of child mortality. ANNEX TABLE 6 The measurement of achievement in the level of responsiveness was based on a survey of nearly two thousand key informants in selected countries.23 Key informants were asked to evaluate the performance of their health system regarding seven elements of responsiveness: dignity, autonomy and confidentiality (jointly termed respect of persons); and prompt attention, quality of basic amenities, access to social support networks during care and choice of care provider (encompassed by the term client orientation). The elements were scored from 0 to 10. Scores on each component were combined into a composite score for responsiveness based on results of the survey on preferences for health system performance assessment. For other countries, achievement in the level of responsiveness has been estimated using indirect techniques and information on important covariates of responsiveness.24 To enhance the measurement of responsiveness, WHO is actively developing and field testing instruments to measure responsiveness from household respondents. This strategy of using household surveys will be supplemented with facility surveys to observe directly some components of responsiveness.25 The measurement of achievement in the distribution of responsiveness reflected in Annex Table 6 is based on a very simple approach. Respondents in the key informants survey were asked to identify groups who were disadvantaged with regard to responsiveness. The number of times a particular group was identified as disadvantaged was used to calculate a key informant intensity score. Four groups had high key informant intensity scores: poor people, women, old people, and indigenous groups or racially disadvantaged groups (in most instances minorities). The key informant intensity scores for these four groups were multi- ΣΣ 1 – n i=1 j=1 xi – xj 3 2 –– 0.5 Equality of child survival = n 2n x
The World Health Report 2000 olied by the actual percentage of the population within these vulnerable groups in a coun- try to calculate a simple measure of responsiveness inequality ranging from 0 to 1.The total score was calculated taking into account the fact that some individuals belong to more than one disadvantaged group. Annex Table 6 provides a measure of the equality of responsive- ness, scaled such that 1 is complete equality and 0 is complete inequality. For other coun- ies, achievement on the distribution of responsiveness has been estimated using indirect techniques and information on important covariates of the distribution of responsiveness including absolute poverty and access to health care ANNEX TABLE 7 The index presented in this table is meant to measure both fairness of financial contri bution and financial risk protection; the basic concepts and principles are outlined in detail elsewhere 26 The measurement of achievement in fairness of financial contribution starts with the concept of a household s contribution to the financing of the health system. The health financing contribution of a household is defined as the ratio of total household spending on health to its permanent income above subsistence. Total household spending on health includes payments towards the financing of the health system through income taxes, value-added tax, excise tax, social security contributions, private voluntary insurance, and out-of-pocket payments. Permanent income above subsistence is estimated for a house- hold as total expenditure plus tax payments not included in total expenditure minus ex- penditure on food The distribution of households'financial contribution is calculated using household sur- vey data which includes information on income(individual level)and household expend ture(by goods and services including health). In addition, the calculations require govemment tax documents(including information on income tax, sales tax, and property tax), national health accounts, national accounts, and government budgets. Such in-depth analysis has been completed for selected countries where such information is available. For other coun tries, the distribution of health financing contribution has been estimated using indirect methods and information on important covariates. 2 To allow for comparisons of the faimess of financial contribution, the distribution of health financing contribution across households has been summarized using an index. This index is designed to weight highly households that have spent a very large share of their income beyond subsistence on health. The index therefore reflects inequality in house hold financial contribution but particularly reflects those households at risk of impoverish ment from high levels of health expenditure. The index is of the form HFC:-HFC Fairness of financial contribution=1-4 ial 0.125n where HFC is the financial contribution of a given household and HFC is the average finan cial contribution across households The index is designed so that complete equality of household contributions is 1 and O is below the largest degree of inequality observed across countries
148 The World Health Report 2000 plied by the actual percentage of the population within these vulnerable groups in a country to calculate a simple measure of responsiveness inequality ranging from 0 to 1. The total score was calculated taking into account the fact that some individuals belong to more than one disadvantaged group. Annex Table 6 provides a measure of the equality of responsiveness, scaled such that 1 is complete equality and 0 is complete inequality. For other countries, achievement on the distribution of responsiveness has been estimated using indirect techniques and information on important covariates of the distribution of responsiveness including absolute poverty and access to health care. ANNEX TABLE 7 The index presented in this table is meant to measure both fairness of financial contribution and financial risk protection;1 the basic concepts and principles are outlined in detail elsewhere.26 The measurement of achievement in fairness of financial contribution starts with the concept of a household’s contribution to the financing of the health system. The health financing contribution of a household is defined as the ratio of total household spending on health to its permanent income above subsistence. Total household spending on health includes payments towards the financing of the health system through income taxes, value-added tax, excise tax, social security contributions, private voluntary insurance, and out-of-pocket payments. Permanent income above subsistence is estimated for a household as total expenditure plus tax payments not included in total expenditure minus expenditure on food. The distribution of households’ financial contribution is calculated using household survey data which includes information on income (individual level) and household expenditure (by goods and services including health). In addition, the calculations require government tax documents (including information on income tax, sales tax, and property tax), national health accounts, national accounts, and government budgets. Such in-depth analysis has been completed for selected countries where such information is available.27 For other countries, the distribution of health financing contribution has been estimated using indirect methods and information on important covariates.28 To allow for comparisons of the fairness of financial contribution, the distribution of health financing contribution across households has been summarized using an index. This index is designed to weight highly households that have spent a very large share of their income beyond subsistence on health. The index therefore reflects inequality in household financial contribution but particularly reflects those households at risk of impoverishment from high levels of health expenditure. The index is of the form: where HFC is the financial contribution of a given household and HFC is the average financial contribution across households. The index is designed so that complete equality of household contributions is 1 and 0 is below the largest degree of inequality observed across countries. Σ 1 – 4 n i=1 HFCi – HFC 3 Fairness of financial contribution = 0.125n
Statistical annex ANNEX TaBLE 8 National health accounts are designed to be a policy relevant, comprehensive, consis tent, timely and standardized instrument that traces the levels and trends of consumption of medical goods and services( the expenditure approach), the value-added created by service nd manufacturing industries producing these commodities(the production approach) and the incomes generated by this process as well as the taxes, mandatory contributions premiums and direct payments that fund the system(the financial approach). The current developmental stage of WHO national health accounts leans more towards a measure- hent of the financing flows Health care finance is divided into public and private flows. For public expenditure, the source most frequently used was Table B on expenditure by function published by the IMF in Government finance statistics yearbook. This rests on a body of exacting rules (not always strictly applied by the respondent countries) and deals in most cases only with central government expenditure. IMF and national sources have been used as far as possible to complement the central government data. United Nations National accounts (Tables 2.1 and 2.3 )and consistent domestic sources have also been used. OECD Health data has sup plied much of the information for the 29 OECD Member countries. Private expenditure on health has been estimated from United Nations and OECD National accounts ( Tables 2.3 and 2.1, respectively) and from the ratio of medical care to total consumption as derived from household surveys, that ratio being applied to total private consumption. This con- cerns mainly out-of-pocket spending. Private insurance premiums, mandated employer health programmes, expenditure by non-profit institutions serving mainly households and less frequently, private investment have been obtained from national sources. National health accounts prepared by a number of countries have been used to the extent that they were accessible. The plausibility of the estimates has been tested against financial and other analyses conducted in some countries or involving a group of countries A first complete table was reviewed by a large number of experts on individual countries and by policy analysts and statisticians of WHO Member States. Their observations led toa reassessment of certain sub-aggregate ANNEX TABLE 9 Overall health system attainment is presented in Annex Table 9. This composite meas- are of achievement in the level of health, the distribution of health, the level of responsive ness, the distribution of responsiveness and faimess of financial contribution has been constructed based on weights derived from the survey of over one thousand public health practitioners from over 100 countries. The composite is constructed on a scale from 0 to 100, the maximum value. As explained in Box 2.4, the weights on the five components are 25%level of health, 25% distribution of health, 12.5% level of responsiveness, 12.5% distr bution of responsiveness and 25% fairness of financial contribution. The mean value and uncertainty intervals have been estimated for overall health system achievement using the uncertainty intervals for each of the five components. In addition, the table provides un- certainty intervals for the ranks as well as the value of overall health system achievement Rank uncertainty is not only a function of the uncertainty of the measurement for each country but also the uncertainty of the measurement of adjacent countries in the league
Statistical Annex 149 ANNEX TABLE 8 National health accounts are designed to be a policy relevant, comprehensive, consistent, timely and standardized instrument that traces the levels and trends of consumption of medical goods and services (the expenditure approach), the value-added created by service and manufacturing industries producing these commodities (the production approach) and the incomes generated by this process as well as the taxes, mandatory contributions, premiums and direct payments that fund the system (the financial approach). The current developmental stage of WHO national health accounts leans more towards a measurement of the financing flows.29 Health care finance is divided into public and private flows. For public expenditure, the source most frequently used was Table B on expenditure by function published by the IMF in Government finance statistics yearbook. This rests on a body of exacting rules (not always strictly applied by the respondent countries) and deals in most cases only with central government expenditure. IMF and national sources have been used as far as possible to complement the central government data. United Nations National accounts (Tables 2.1 and 2.3) and consistent domestic sources have also been used. OECD Health data has supplied much of the information for the 29 OECD Member countries. Private expenditure on health has been estimated from United Nations and OECD National accounts (Tables 2.5 and 2.1, respectively) and from the ratio of medical care to total consumption as derived from household surveys, that ratio being applied to total private consumption. This concerns mainly out-of-pocket spending. Private insurance premiums, mandated employer health programmes, expenditure by non-profit institutions serving mainly households and, less frequently, private investment have been obtained from national sources. National health accounts prepared by a number of countries have been used to the extent that they were accessible. The plausibility of the estimates has been tested against financial and other analyses conducted in some countries or involving a group of countries. A first complete table was reviewed by a large number of experts on individual countries and by policy analysts and statisticians of WHO Member States. Their observations led to a reassessment of certain sub-aggregates. ANNEX TABLE 9 Overall health system attainment is presented in Annex Table 9. This composite measure of achievement in the level of health, the distribution of health, the level of responsiveness, the distribution of responsiveness and fairness of financial contribution has been constructed based on weights derived from the survey of over one thousand public health practitioners from over 100 countries.22 The composite is constructed on a scale from 0 to 100, the maximum value. As explained in Box 2.4, the weights on the five components are 25% level of health, 25% distribution of health, 12.5% level of responsiveness, 12.5% distribution of responsiveness and 25% fairness of financial contribution. The mean value and uncertainty intervals have been estimated for overall health system achievement using the uncertainty intervals for each of the five components.30 In addition, the table provides uncertainty intervals for the ranks as well as the value of overall health system achievement. Rank uncertainty is not only a function of the uncertainty of the measurement for each country but also the uncertainty of the measurement of adjacent countries in the league table
The World Health Report 2000 ANNEX TABLE 10 The index of performance on the level of health reports how efficiently health systems translate expenditure into health as measured by disability-adjusted life expectancy ALE) Performance on the level of health is defined as the ratio between achieved levels of health and the levels of health that could be achieved by the most efficient health system. More specifically, the numerator of the ratio is the difference between observed DALE in a coun try and the dale that would be observed in the absence of a functioning modern health system given the other non-health system determinants that influence health, which are represented by education. The denominator of the ratio is the difference between the maxi- mum possible dALE that could have been achieved for the observed levels of health ex- penditure per capita in each country and the daLE in the absence of a functioning health system Econometric methods have been used to estimate the maximum DALE for a given level of health expenditure and other non-health system factors using frontier production alysis. The relationship between life expectancy and human capital at the turn of the ntury was used to estimate the minimum dale that would have been expected in each country(at current levels of educational attainment) in the absence of an effective health system The details of the data, methods and results are provided elsewhere. 3 Annex Table 10 provides uncertainty intervals for both the absolute value of performance and the rank of each country Overall performance of health systems was measured using a similar process relating overall health system achievement to health system expenditure. Maximum attainable com posite goal achievement was estimated using a frontier production model relating overall health system achievement to health expenditure and other non-health system determi- nants represented by educational attainment. Results of this analysis were largely invariant to model specification. More detail is provided in the corresponding technical paper. 2 1 Murray CJL, Frenk. A WHO framework for health system perfor assessment. Bulletin of the World Health Organization, 2000, 78(6)(in press) 2 Evans DE, Bendib L, Tandon A, Lauer J, Ebener S, Hutubessy R, AsadaY, Murray CJL. Estimates of incon er capita, literacy, educational attainment, absolute poverty, and Report 2000. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 7). 3 Hill K, Rohini PO, Mahy M, Jones G. Trends in child mortality in the developing world: 1960 to 1996. New York, UNICEF 1999 World population prospects: the 1998 revision. New York, United Nations, 1999 s Murray CJL, Lopez AD, Ahmad O, Salomon J WHO system of model life tables. Geneva, World Health Organization, 2000(GPE Discussion Paper No 8) Lopez AD, Salomon J, Ahmad O, Murray CL Life tables for 191 countries: data, methods and results. Ge neva, World Health Organization, 2000(GPE Discussion Paper No 9) sis. Geneva, World Health Organizaton, 20o naya Salomon J, Murray CJL. Methods for life exp 0(G 8 Salomon J, Gakidou EE, Murray C]L Methads for modelling the HIVIAIDS epidemic in sub-Saharan Africa Geneva, World Health Organization, 2000( GPE Discussion Paper No. 3). 9 Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensice assessment of mortality and di ability from diseases 1990 and projected to 2020. Cambridge, MA, Harvard Schoo of Public Health on behalf of the World Health Organization and the World Bank, 1996( Global Burden of Disease and Injury Series, Vol. 1). Salomon J, Murray CJL. Compositional models for mortality by age, ser and cause. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 11)
150 The World Health Report 2000 ANNEX TABLE 10 The index of performance on the level of health reports how efficiently health systems translate expenditure into health as measured by disability-adjusted life expectancy (DALE). Performance on the level of health is defined as the ratio between achieved levels of health and the levels of health that could be achieved by the most efficient health system. More specifically, the numerator of the ratio is the difference between observed DALE in a country and the DALE that would be observed in the absence of a functioning modern health system given the other non-health system determinants that influence health, which are represented by education. The denominator of the ratio is the difference between the maximum possible DALE that could have been achieved for the observed levels of health expenditure per capita in each country and the DALE in the absence of a functioning health system. Econometric methods have been used to estimate the maximum DALE for a given level of health expenditure and other non-health system factors using frontier production analysis. The relationship between life expectancy and human capital at the turn of the century was used to estimate the minimum DALE that would have been expected in each country (at current levels of educational attainment) in the absence of an effective health system The details of the data, methods and results are provided elsewhere.31 Annex Table 10 provides uncertainty intervals for both the absolute value of performance and the rank of each country. Overall performance of health systems was measured using a similar process relating overall health system achievement to health system expenditure. Maximum attainable composite goal achievement was estimated using a frontier production model relating overall health system achievement to health expenditure and other non-health system determinants represented by educational attainment. Results of this analysis were largely invariant to model specification. More detail is provided in the corresponding technical paper.32 1 Murray CJL, Frenk J. A WHO framework for health system performance assessment. Bulletin of the World Health Organization, 2000, 78(6) (in press). 2 Evans DE, Bendib L, Tandon A, Lauer J, Ebener S, Hutubessy R, Asada Y, Murray CJL. Estimates of income per capita, literacy, educational attainment, absolute poverty, and income Gini coefficients for The World Health Report 2000. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 7). 3 Hill K, Rohini PO, Mahy M, Jones G. Trends in child mortality in the developing world: 1960 to 1996. New York, UNICEF, 1999. 4 World population prospects: the 1998 revision. New York, United Nations, 1999. 5 Murray CJL, Lopez AD, Ahmad O, Salomon J. WHO system of model life tables. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 8). 6 Lopez AD, Salomon J, Ahmad O, Murray CJL. Life tables for 191 countries: data, methods and results. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 9). 7 Salomon J, Murray CJL. Methods for life expectancy and disability-adjusted life expectancy uncertainty analysis. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 10). 8 Salomon J, Gakidou EE, Murray CJL. Methods for modelling the HIV/AIDS epidemic in sub-Saharan Africa. Geneva,World Health Organization, 2000 (GPE Discussion Paper No. 3). 9 Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. 1). 10 Salomon J, Murray CJL. Compositional models for mortality by age, sex and cause. Geneva,World Health Organization, 2000 (GPE Discussion Paper No. 11)
Statistical annex 1 Lozano R, Murray C L, Lopez AD, Satoh T Miscoding and misclassification of ischaemic heart disease mor- tality. Geneva, World Health Organization, 2000(GPE Discussion Paper No 12) Boschi-Pinto C, Murray CJL, Lopez AD, Lozano R Cancer survival by site for 14 regions of the woord Geneva, World Health Organization, 2000( GPE Discussion Paper No 13) alth. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 2) u Murray CL, Lopez AD. Progress and directions in refining the global burden of disease approach: re- Rs Sponse to Williams. Health Economics, 2000,9: 69-82. I Moesgaard-Iburg K, Murray CL, Salomon J. Expectations for health distorts: self-reported and ph assessed health status compared to observed health status. Geneva, World Health Organization, 2000(GP Discussion Paper No 14) 16 Sadana R, Mathers C, Lopez A, Murray CJL. Comparative analysis of more than 50 household surveys on health staties. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 15) Mathers C, Sadana r, Salomon J, Murray CL, Lopez AD of DALE for 191 countries: methods and results. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 16). 1s Gakidou EE, Murray CJL, FrenkJ Measuring health inequality: an approach based on the distribution of health expectancy. Bulletin of the World Health Organization, 2000, 78(1): 42-54 Lopez AD, Murray CJL, Ferguson B, Tamaskovic L. Life expectancy for small areas in selected countries Geneva, World Health Organization, 2000(GPE Discussion Paper No. 17) Gakidou EE, King G. Using an extended beta-binomial model to estimate the distribution of child mortality risk. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 18) 2 Gakidou EE, Murray C]L. Estimates of the distribution of child survival in 191 countries. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 19) World Health Organization, 2000( GPE Discussion Paper No 20) 2 de Silva A, Valentine N Measuring resp ss: results of a key informants survey in 35 countries. Geneva, World Health Organization, 2000(GPE Discussion Paper No 21) Valentine N, de Silva A, Murray CJL. Estimates of responsiveness level and distribution for 191 countries methods and results. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 22) 2 Darby C, Valentine N, Murray CJL. WHO strategy on measuring responsiveness. Geneva, World Health Organization, 2000( GPE Discussion Paper No 23) Murray CJL, Knaul E, Musgrove P, Xu K, Kawabata K Defining and measuring faimess of financial contribu tion. Geneva, World Health Organization, 2000(GPE Discussion Paper No 24) Xu K, Lydon P Ortiz de Iturbide J, Musgrove P, Knaul E, Kawabata K, Florez Ce, John J, Wibulpolpras S, Waters H, Tansel A Analysis of the faimess of financial contribution in 21 countries. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 25) Xu K, Murray CL, Lydon P, Ortiz de Iturbide J. Estimates of the fairness of financial contribution for 191 countries. Geneva, World Health Organization, 2000(GPE Discussion Paper No. 26) 2 Poullier JP, Hernandez P. Estimates of national health accounts. Aggregates for for 191 countries in 1997. Geneva, World Health Organization, 2000( GPE Discussion Paper No. 27) Tay CJL, Frenk J, Tandon A, Lauer J. Overall health system achievement for 191 countries. Geneva, World ath Organization, 2000( GPE Discussion Paper No. 28) Evans D, Tandon A, Murray CJL, LauerJ The comparative eficiency of national health systems in producing health: an analysis of 191 countries. Geneva, World Health Organization, 2000(GPE Discussion Paper No
Statistical Annex 151 11 Lozano R, Murray CJL, Lopez AD, Satoh T. Miscoding and misclassification of ischaemic heart disease mortality. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 12). 12 Boschi-Pinto C, Murray CJL, Lopez AD, Lozano R. Cancer survival by site for 14 regions of the world. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 13). 13 Murray CJL, Salomon J, Mathers C. A critical review of summary measures of population health. Geneva,World Health Organization, 2000 (GPE Discussion Paper No. 2). 14 Murray CJL, Lopez AD. Progress and directions in refining the global burden of disease approach: response to Williams. Health Economics, 2000, 9: 69-82. 15 Moesgaard-Iburg K, Murray CJL, Salomon J. Expectations for health distorts: self-reported and physicianassessed health status compared to observed health status. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 14). 16 Sadana R, Mathers C, Lopez A, Murray CJL. Comparative analysis of more than 50 household surveys on health status. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 15). 17 Mathers C, Sadana R, Salomon J, Murray CJL, Lopez AD. Estimates of DALE for 191 countries: methods and results. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 16). 18 Gakidou EE, Murray CJL, Frenk J. Measuring health inequality: an approach based on the distribution of health expectancy. Bulletin of the World Health Organization, 2000, 78(1): 42-54. 19 Lopez AD, Murray CJL, Ferguson B, Tamaskovic L. Life expectancy for small areas in selected countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 17). 20 Gakidou EE, King G. Using an extended beta-binomial model to estimate the distribution of child mortality risk. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 18). 21 Gakidou EE, Murray CJL. Estimates of the distribution of child survival in 191 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 19). 22 Gakidou EE, Frenk J, Murray CJL. Measuring preferences on health system performance assessment. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 20). 23 de Silva A, Valentine N. Measuring responsiveness: results of a key informants survey in 35 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 21). 24 Valentine N, de Silva A, Murray CJL. Estimates of responsiveness level and distribution for 191 countries: methods and results. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 22). 25 Darby C, Valentine N, Murray CJL. WHO strategy on measuring responsiveness. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 23). 26 Murray CJL, Knaul F, Musgrove P, Xu K, Kawabata K. Defining and measuring fairness of financial contribution. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 24). 27 Xu K, Lydon P, Ortiz de Iturbide J, Musgrove P, Knaul F, Kawabata K, Florez CE, John J, Wibulpolprasert S, Waters H, Tansel A. Analysis of the fairness of financial contribution in 21 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 25). 28 Xu K, Murray CJL, Lydon P, Ortiz de Iturbide J. Estimates of the fairness of financial contribution for 191 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 26). 29 Poullier JP, Hernández P. Estimates of national health accounts. Aggregates for for 191 countries in 1997. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 27). 30 Murray CJL, Frenk J, Tandon A, Lauer J. Overall health system achievement for 191 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 28). 31 Evans D, Tandon A, Murray CJL, Lauer J. The comparative efficiency of national health systems in producing health: an analysis of 191 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 29). 32 Tandon A, Murray CJL, Lauer J, Evans D. Measuring overall health system performance for 191 countries. Geneva, World Health Organization, 2000 (GPE Discussion Paper No. 30)
The World Health Report 2000 Annex Table 1 Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997 ATTAINMENT OF GOALS PERFORMANCE Member State Distributi Distribution contribution attainment international 182 181-182172-173103-10418 178 116-120 9427 89-95 92111-112 12-13 Austria 12 199 125116-120 2006818 16260109 roads 53 3-38 45 11672 163137-13889-95144 Bolivia 151-153 101142126 osmia and herzegovina Rm的 111-112 125 Brunei Darussalam 89-95 102 137-138137-138 172164 Canada 154134-135 105-106 仍4 Colombi 157- 153-15579-81 Costa rica Cote d'lvoire 34195 115-11 23-25 131-133 5934 84-86 76-79 128-129
152 The World Health Report 2000 Annex Table 1 Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997 ATTAINMENT OF GOALS PERFORMANCE Member State Health Responsiveness Fairness in Overall On level Overall Level Distribution Level Distribution financial goal of health health (DALE) contribution attainment system performance Afghanistan 168 182 181 – 182 172 – 173 103 – 104 183 184 150 173 Albania 102 129 136 117 173 – 174 86 149 64 55 Algeria 84 110 90 – 91 50 – 52 74 – 75 99 114 45 81 Andorra 10 25 28 39 – 42 33 – 34 17 23 7 4 Angola 165 178 177 188 103 – 104 181 164 165 181 Antigua and Barbuda 48 58 47 – 48 39 – 42 116 – 120 71 43 123 86 Argentina 39 60 40 3 – 38 89 – 95 49 34 71 75 Armenia 41 63 92 111 – 112 181 81 102 56 104 Australia 2 17 12 – 13 3 – 38 26 – 29 12 17 39 32 Austria 17 8 12 – 13 3 – 38 12 – 15 10 6 15 9 Azerbaijan 65 99 130 – 131 125 116 – 120 103 162 60 109 Bahamas 109 67 18 3 – 38 138 – 139 64 22 137 94 Bahrain 61 72 43 – 44 3 – 38 61 58 48 30 42 Bangladesh 140 125 178 181 51 – 52 131 144 103 88 Barbados 53 36 39 3 – 38 107 38 36 87 46 Belarus 83 46 76 – 79 45 – 47 84 – 86 53 74 116 72 Belgium 16 26 16 – 17 3 – 38 3 – 5 13 15 28 21 Belize 94 95 105 – 107 90 146 104 88 34 69 Benin 157 132 175 – 176 160 140 – 141 143 171 136 97 Bhutan 138 158 163 137 – 138 89 – 95 144 135 73 124 Bolivia 133 118 151 – 153 178 68 117 101 142 126 Bosnia and Herzegovina 56 79 108 – 110 124 82 – 83 79 105 70 90 Botswana 187 146 76 – 79 111 – 112 89 – 95 168 85 188 169 Brazil 111 108 130 – 131 84 – 85 189 125 54 78 125 Brunei Darussalam 59 42 24 3 – 38 89 – 95 37 32 76 40 Bulgaria 60 53 161 2 170 74 96 92 102 Burkina Faso 178 137 174 164 173 – 174 159 173 162 132 Burundi 179 154 171 168 114 161 186 171 143 Cambodia 148 150 137 – 138 137 – 138 183 166 140 157 174 Cameroon 156 160 156 183 182 163 131 172 164 Canada 12 18 7 – 8 3 – 38 17 – 19 7 10 35 30 Cape Verde 118 123 154 134 – 135 89 – 95 126 150 55 113 Central African Republic 175 189 183 191 166 190 178 164 189 Chad 161 175 181 – 182 185 58 – 60 177 175 161 178 Chile 32 1 45 103 168 33 44 23 33 China 81 101 88 – 89 105 – 106 188 132 139 61 144 Colombia 74 44 82 93 – 94 1 41 49 51 22 Comoros 146 143 157 – 160 153 – 155 79 – 81 137 165 141 118 Congo 150 142 137 – 138 151 162 155 122 167 166 Cook Islands 67 92 65 89 45 – 47 88 61 95 107 Costa Rica 40 45 68 86 – 87 64 – 65 45 50 25 36 Côte d’Ivoire 155 181 157 – 160 153 – 155 116 – 120 157 153 133 137 Croatia 38 33 76 – 79 83 108 – 111 36 56 57 43 Cuba 33 41 115 – 117 98 – 100 23 – 25 40 118 36 39 Cyprus 25 31 11 44 131 – 133 28 39 22 24 Czech Republic 35 19 47 – 48 45 – 47 71 – 72 30 40 81 48 Democratic People’s Republic of Korea 137 145 139 130 – 131 179 149 172 153 167 Democratic Republic of the Congo 174 174 142 169 – 170 169 179 188 185 188 Denmark 28 21 4 3 – 38 3 – 5 20 8 65 34 Djibouti 166 169 170 140 3 – 5 170 163 163 157 Dominica 26 35 84 – 86 77 – 78 99 – 100 42 70 59 35 Dominican Republic 79 97 95 72 154 66 92 42 51 Ecuador 93 133 76 – 79 182 88 107 97 96 111 Egypt 115 141 102 59 125 – 127 110 115 43 63 El Salvador 87 115 128 128 – 129 176 122 83 37 115 Health expenditure per capita in international dollars
