Introduction Many different indicators can be used for health system effectiveness. Therefore, using composite indicators is a good way to summarize them all. One example of such efforts is the Healthcare Access and Quality Index (HAQI) from the Global Burden of Diseases study, for which different causes of mortality amenable to health care are summarized in this index through principal component analysis and exploratory factor analysis. While these approaches use the variance of the indicators, they do not consider room for improvement, i.e. distance to the frontier. Thus, in this study we present the Benefit-of-Doubt (BoD) approach as a solution for combining frontier analysis and composite indicators, using amenable mortality estimates for 189 countries.

Methods We performed a retrospective observational and methodological study, using data on 32 causes of mortality amenable to health care for 189 countries in 2015. As these indicators can be summed up (they all have the same units), there is a gold-standard to compare with. However, this is not the case for most of the health system effectiveness indicators or other analyses. For analyzing effectiveness through the BoD approach, countries were divided by regions, either by WHO regions and by socio-demographic index (SDI).

Results We have found important differences, highlighting those causes of death that contributed more to effectiveness by WHO and SDI region. There were wide heterogeneities across causes of death. Additionally, overall analysis showed that the composite indicators were correlated but with some specific important differences.

Discussion We show that the BoD approach is a good option for computing composite indicators, also when using information on ‘room for improvement’, i.e. distance to the frontier. The use of BoD in health systems performance assessment, specifically in effectiveness and efficiency dimensions, can be an interesting step towards priority setting.