The Benchmarks of Fairness instrument is a method for evaluating the fairness of health-sector reforms. The concept of fairness in health systems is broad, integrating the goals of equity in access and financing, clinical and administrative efficiency, and accountability. The Benchmarks address the complaint that "it is unfair" when the system treats some patients differently from others with similar needs, when some needs are not met because of administrative inefficiency, or when people have no say in how the system treats them. Fairness involves various claims about what people are owed as a matter of justice (1-3).
The Benchmarks ask by how much reforms improve or worsen aspects of fairness within the health sector nationally or subnationally. They combine an ethical framework with familiar methods from operations research. Using appropriate indicators, changes are measured and evaluated relative to a baseline (the status quo at the time reforms are introduced). This evidence and evaluation enhances deliberations about improving reforms. The Benchmarks serve a different purpose than indices that aggregate all these changes into a single number for ranking health systems comparatively.
The Benchmarks aim to fill two crucial gaps. First, internationally supported reforms over two decades have failed to integrate the key goals of fairness. During the 1980s and early 1990s, international agencies such as the World Bank and International Monetary Fund pushed reforms that involved privatization, user fees, and decentralization, thus sacrificing equity (4-7) and other goals of fairness to the market-oriented pursuit of efficiency. Recently, the World Bank's attention has focused on health inequalities (8, 9) and better governance (10, 11) but has still failed to integrate these goals. Second is the lack of capacity in developing countries to undertake evidence-based policy analysis which is the result of weak information infrastructures and a lack of tools to maximize the use of existing information.
Development and rationale
Teams from Colombia, Mexico, Pakistan and Thailand, using their own recent reforms as case studies, adapted a matrix for assessing the fairness of proposed American health insurance reforms (1, 12, 13) into a generic developing-country framework (14). Despite different cultural and social histories and levels of development in the collaborating sites, teams were able to agree on a generic matrix that included nine main Benchmarks (Box 1). Each Benchmark specifies a key objective of fairness through criteria that capture important elements and means of achieving these objectives (Box 2).
Box 1. The nine main Benchmarks of Fairness and their corresponding
key objective of fairness
Benchmark Objective of
B1 Intersectoral public health Equity
B2 Financial barriers to equitable access
B3 Non-financial barriers to access
B4 Comprehensiveness of benefits and tiering
B5 Equitable financing
B6 Efficacy, efficiency and quality improvement Efficiency
B7 Administrative efficiency
B8 Democratic accountability and empowerment Accountability
B9 Patient and provider autonomy
The nine generic Benchmarks integrate the goals of fairness as follows: Benchmarks 1-5 address equity, 6 and 7 consider efficiency, and 8 and 9 concern accountability (Box 1). Improving clinical and administrative efficiency can make a system fairer by allowing it to meet otherwise unmet needs. Though not all conflicts between efficiency and equity disappear, a fair process (included in Benchmark 8) can resolve disputes about them (15). Accountability is valued both intrinsically, as a matter of fairness in governance, and instrumentally, since it helps achieve efficiency or equity. …