Maximizing Health Impact: World Bank’s Guide to Public Expenditure Reviews

The "Health Public Expenditure Reviews: A How-to Guide" is a pivotal update from the World Bank, crafted with support from its Health, Nutrition, and Population (HNP) Global Practice and enriched by research from global institutions including the World Health Organization, OECD, and the Joint Learning Network for Universal Health Coverage. Building on nearly three decades of public expenditure review guidance, the document reflects both the enduring challenges and emerging complexities of global health financing. It answers the call for more accountable, equitable, and efficient public spending, particularly as countries aim to achieve universal health coverage (UHC) and navigate aging populations, changing disease burdens, and constrained budgets. Rooted in the World Bank’s Human Capital Project, the guide supports its broader goal of enabling 1.5 billion people to access quality healthcare by 2030.

This new edition doesn’t offer a one-size-fits-all prescription. Instead, it provides a versatile, modular toolkit designed for flexibility. Each section or module can be tailored to a country’s needs, timeframe, and available data. A Health PER, as defined in this guide, is not merely a budgetary audit; it is a strategic evaluation of how well public funds are supporting health outcomes. The guide asserts that effective reviews go beyond numbers, helping countries trace the flow of resources through their health systems and identify where inefficiencies, inequities, or weak governance are holding them back.

From Data to Diagnosis: The Results Chain Framework

Central to the guide is its results chain framework, which maps the journey of financial resources through stages of mobilization, pooling, and allocation, then through inputs like staff and infrastructure, service delivery, and ultimately to health outcomes. Each link in this chain offers opportunities for scrutiny. Are funds pooled in a way that reduces administrative waste? Are medicines being procured at the best prices? Is the health workforce equitably distributed? Are service outcomes, such as immunization or maternal care, reaching the most vulnerable?

To answer such questions, the guide provides 15 topic-specific modules covering everything from infrastructure and pharmaceuticals to risk protection and primary care. These are complemented by cross-cutting technical notes that allow for high-level efficiency and equity assessments. Each component comes equipped with indicators, data sources, benchmarking strategies, and recommended analytic methods. Data are drawn from national systems, such as Ministries of Health and Finance, health insurance reports, and household surveys, as well as international databases like the WHO Global Health Expenditure Database and the World Bank’s World Development Indicators.

A Structured, Participatory Process

The guide structures the Health PER process into five key steps. It begins with defining the scope, ensuring that the exercise aligns with the country's policy priorities and available resources. Then, it identifies key questions, whether concerning fiscal sustainability, inefficiencies in pharmaceutical spending, or inequities in access. Next comes rigorous data collection from both primary and secondary sources, followed by in-depth analysis using either the broader cross-cutting tools or more granular topic modules. The process culminates in stakeholder engagement, where findings are validated, and actionable recommendations are co-developed with government counterparts.

Government engagement is not a footnote in this guide, it is a pillar. The World Bank urges PER teams to work closely with Ministries of Health and Finance, local policymakers, and development partners. Regular workshops, collaborative data analysis, and joint validation sessions are critical not just for accuracy, but for building ownership and ensuring recommendations translate into reform.

Turning Evidence Into Action

A standout feature of this guide is its insistence on specificity. Too often, fiscal reviews conclude with vague platitudes like “improve primary care” or “reduce waste.” This guide warns against such generalities. Instead, it advocates for precise, context-sensitive recommendations: for example, revising procurement procedures to lower drug costs, or reallocating underused infrastructure funding toward workforce training. It also encourages authors to highlight trade-offs, such as when improving efficiency may inadvertently affect equity, and to suggest mitigation strategies.

To help prioritize reforms, the guide recommends tools like multicriteria analysis, which scores proposed policy actions on relevance, technical and political feasibility, and the strength of the underlying evidence. These tools enable decision-makers to focus on a manageable number of high-impact interventions. Importantly, the guide emphasizes that even in efficient systems, waste and inefficiency persist. Efficiency gains rarely yield immediate cash savings but often allow systems to do more with the same resources, especially when enabled by better public financial management systems.

A Living Document for a Changing World

Ultimately, the guide is designed as a living resource, dynamic and adaptable. Future updates are expected to cover emerging areas such as pandemic preparedness spending, digital health systems, and climate-related health financing. As health challenges grow more complex, so too must the tools to evaluate and address them.

The World Bank’s report is more than just a manual. It is a strategic platform for countries to critically examine how their health systems are funded, where resources are most needed, and how policies can be realigned to achieve better outcomes. At a time when every dollar must count, this guide offers both the compass and the roadmap to navigate the path toward healthier, more resilient populations.