Identifying Major Health-System Challenges in Developing Countries Using PERs: Equity is the Elephant in the Room.

Despite an unprecedented increase in official development assistance to health in the last 25 years, there is no systematic way to assess dominant patterns in health-system challenges and opportunities in developing countries. Developing a new global instrument for and by donors and development partners would be resource-intensive and cumbersome. In this article, we demonstrate that Public Expenditure Reviews (PERs) can be used to reveal such patterns. PERs are analytical reports financed and conducted by the World Bank that have been used for years to identify and prioritize country-specific health sector reform needs. In order to extend their use beyond the country level, a reading instrument is developed in the form of a questionnaire to systematically identify the different themes addressed in each PER. All PERs published over a period of ten years are reviewed for health sector content. A new database is created with data on 70 PERs, spanning 61 countries. Analysis of the data reveals dominant themes globally, patterns across development levels, and some regional variations. Our main finding is that issues related to equity strongly dominate and are relevant across all regions and income groups. In addition, the article highlights the usefulness of PERs beyond providing country-specific information. Without losing the country-focus and flexibility of PERs, thoughtful and minor investments in how Health PERs are conducted can create a relatively cheap and strongly operational instrument for building global knowledge bases on health sector needs and challenges.