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Karanikolos M, Adib K, Azzopardi Muscat Net al., authors; Figueras J, Karanikolos M, Guanais F, et al., editors. Assessing health system performance: Proof of concept for a HSPA dashboard of key indicators [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2023. (Policy Brief, No. 60.)
Assessing health system performance: Proof of concept for a HSPA dashboard of key indicators [Internet].
Show detailsWhat is new in the WHO-Observatory global HSPA framework?
The global COVID-19 pandemic serves as a stark reminder that a robust and resilient health system is one of the best defences against health threats. However, ensuring a strong system that can build on its strengths and overcome its shortcomings is complex. It involves prioritizing and resourcing policy actions, drawing on the best available evidence, which in turn requires monitoring and regular assessment. The WHO-Observatory global HSPA framework is a policy tool that enables policy-makers to organize and make sense of HSPA. It was the result of international effort and consensus and has been updated to capture the experience of the pandemic and to support policy-makers in a post-COVID world.
The updated HSPA framework (see Rajan et al., 2023)3 recognizes that performance assessment is ultimately about understanding what drives and shapes the health system and its outcomes so that policy-makers can make informed choices about change. It also understands the challenges around how to adequately interpret country health data to pinpoint the root causes of a health system bottleneck or clearly discern a policy intervention’s impact. It provides a clear anchoring structure and evidence-informed and plausible pathways of association that enable decision-makers to take the right policy actions.
The framework in this brief is the version updated in light of the “perma-crisis” which sees health policy-makers steering their national health system while dealing with inflation, regional wars, large refugee influxes, climate change, loss of population trust, more frequent changes in government, and myriad other challenges.
The framework captures more clearly those policy areas that can strengthen health systems resilience
The WHO-Observatory global HSPA framework gives a structured and comprehensive overview of a health system and how it works. It links the four functions and their subfunctions with intermediate objectives and final goals, highlighting the various interlinkages between them and placing everything within the wider socioeconomic and societal context.
- Governance and multisectoral action
The governance function has been adapted to better reflect its essence – multisectoral collaboration, i.e., how to ensure that all stakeholders, including the population, engage constructively with one another to steer the sector towards its stated and shared goals. This also captures the heightened need for collaboration across sectors to respond to today’s pressing health system challenges – antimicrobial resistance, emergency preparedness, and food security, to name but a few.
- Digital health
The realm of digital health has also been boosted and is explicitly shown in the renewed framework, appearing in governance, resource generation, and service delivery as a subfunction because digital health is pivotal in enhancing access and efficiency, catalysing patient-centred approaches, and promoting timely and data-driven decision-making.
- Environmental considerations
Environmental health is also emphasized, particularly in societal goals, but also in service delivery. The framework now incorporates the adaptation of health services to climate change and highlights the efforts needed by health system actors to reduce the environmental impact of delivering health services.
- Health security and resilienceHealth security encompasses all the final goals of the health system, so achieving the health system’s overarching goals and having a high-performing system will ensure effective protection against health threats, and achieve health security. Much of health security comes from the intricate network of linkages between the functions, and between the functions and goals, as captured by (and throughout) the framework. These vital interconnections define the essence of the health system and are termed “performance and resilience links” – they are depicted in Fig. 1.24 and in appendix figures A1.1 and A1.2 connecting all the elements of the framework. Resilience is thus the system’s ability to withstand challenges and rebound, relying on the quality of the connections between different functions, subfunctions, assessment areas, and goals (performance) but applied to health system specific shocks, strains, and challenges, and taking into account the temporal dimension (stages of the shock cycle).
The renewed HSPA framework better understands the health system’s contributions to broader societal goals
The renewed global HSPA framework recognizes the significant role of the health system in contributing to larger societal objectives. They are not directly evaluated within the framework, but they need to be considered as the contribution of the health system to societal well-being, through economic development, environmental sustainability, and societal cohesion. The renewed HSPA framework reminds policy-makers of precisely how critical the health system is in advancing the broader societal goals, although the framework also acknowledges boundaries of accountability between the health system and larger societal objectives.
This brief builds on the HSPA framework to present the proof of concept for tracer indicators and a performance dashboard
The framework can be used as a blueprint to explore health system performance assessment. Users can start either from examining how performance of the functions affects health system goals, or from exploring how health system goals can lead to understanding of performance of specific health system functions. One example of the use of the framework is elaborated below.
How do health workforce, digital health, people-centredness, and access and effectiveness fit within the WHO-Observatory global HSPA framework?
All the areas explored in this brief are explicitly covered by the framework.
Health workforce is a subfunction of resource generation. The framework allows users to identify the immediate assessment areas for the health workforce: availability, mix and distribution, and health workforce education, as well as the planning of human resources for health (see Fig. 1.2). The workforce is also enabled by the existing health system infrastructure (also part of resource generation) and other functions. For example, in health system governance, the quality of strategic direction determines whether the workforce is a strategic priority; participation in policy-making ensures policies incorporate the voices of healthcare workers; and capacity to legislate addresses the system’s ability to regulate the workforce. These are among the most important elements in ensuring good workforce performance. At the same time, the financing function provides monetary resources through revenue raising (by ensuring there are sufficient funds in the system to invest in the workforce), and through purchasing (paying healthcare workers, ensuring efficient purchasing, and allocating funds according to need). The health workforce underpins the delivery of all healthcare services, and thus the achievement of health system goals.
Digital health is situated in multiple health system functions (see Fig. 1.2), because it covers governance areas (information and digital knowledge collection and use for policy-making) and physical and digital infrastructure (availability, distribution, and maintenance), as well as the way services are delivered (for example, e-health), and integrated and coordinated care. Delivery of digital health services, as enabled through other functions, impacts on health system goals, for example, access and equity (the ability to access telemedicine services or booking systems “counts”, albeit there are equity implications as vulnerable groups may not be able to use digital tools in practice), efficiency (where services that do not need physical presence can be delivered remotely), and user experience. In addition, information collected through performance assessment processes should feed back to inform improvement. Differentiating assessment areas for digital health by function is an important addition that the HSPA framework brings to policy-makers, allowing them to assess concrete components of digital health and relate them to the functioning of the entire system.
People-centredness is one of the final health system goals (see Fig. 1.2), with the extent to which people-centredness is achieved reflecting the performance of the entire system and contributing to the achievement of other goals, such as equity and health improvement. User experience is a key intermediate health system objective contributing to the people-centredness of the health system. The HSPA framework also shows how people-centredness directly reflects health system governance and particularly its “population and civil society participation” subfunction. The latter can be assessed through the degree of participation of all stakeholders in policy-making and the political priority placed on enabling participation, as well as the system’s overall transparency and accountability.
Access and effectiveness are the key intermediate health system objectives. In the HSPA framework (Fig. 1.2) quality is a multidimensional construct that includes effectiveness, safety, and user experience. It also includes the cross-cutting areas of efficiency and equity of service delivery. Access in the framework is depicted both inside and outside the quality boundary because the presence of access is a pre-condition to receiving quality services, while lack of access means service delivery cannot be fully assessed in terms of quality. At the same time, access and effectiveness contribute to health system goals, especially to health improvement, while access also contributes to financial protection and equity. The section below uses access and effectiveness as examples to illustrate how the WHO-Observatory global HSPA framework can serve as a blueprint to identify possible performance pathways between different elements of the health system.
How can the WHO-Observatory global HSPA framework be used in practice?
Assessing access and effectiveness is explored in Chapter 5 of this brief. Appendix Figure A1.1 illustrates the possible linkages that reflect how access and effectiveness relate to performance of health system functions. The WHO-Observatory global HSPA framework (see Figure 1.2) has been greyed in order to highlight specific pathways and some of the relevant areas. The following text is the testing ground for the operationalization of the framework; for more examples, please see Rajan et al. (2023).
Figure A1.1
How access and effectiveness can be used to measure performance of the functions. The figure is an illustration of some possible performance linkages (dotted lines). Directions of arrows could go either or both ways, depending on the starting point of (more...)
Figure A1.2
Examples of indicators that can be used as tracers to assess availability, mix, and distribution of the health workforce. Adapted from Rajan et al (2023)
How do access and effectiveness relate to health system functions?
As described above, access and effectiveness are key intermediate health system objectives, and also shape the outcomes of the service delivery function (box 1 in Fig. A1.1), so in this example the pathway arrow goes right to left, towards service delivery. At the same time, access and effectiveness contribute to health system goals, especially to health improvement, with access also contributing to financial protection and equity (boxes 2).
Indicators assessing access and effectiveness are measures of aspects of performance of service delivery (box 3). Tracer indicators, such as preventable and treatable mortality, show performance of service delivery overall (because the indicator combines timely access, effectiveness, and safety of services). Poor performance of service delivery may lie within specific types of care (for example, public health, primary care, specialist care, long-term care, or mental health care). “Poor” tracer indicators could also point to poor governance of service delivery (for example, lack of quality assurance or integration, box 4) or resource generation (setting and assessing quality standards for human and physical resources, box 5). They can also reflect poor performance of other functions, for example, the lack of availability of human and physical resources or of investment in health, or governance failures (boxes 8). In order to better understand the underlying weaknesses of service delivery, more nuanced indicators reflecting specific assessment areas of those functions need to be used (see Figure A1.2 and the example exploring the assessment of selected health workforce areas).
Access also needs to be assessed separately from indicators of quality to ensure that everyone in need of healthcare services can access them. Therefore, there are distinct assessment areas for resource generation (availability and distribution, boxes 6) and financing (allocation according to need and comprehensive coverage, boxes 7), along with a tracer indicator of unmet need for healthcare. The latter allows policy-makers to distinguish whether lack of access to care stems from health system factors (user charges, waiting lists, lack of services in the area), and to identify socioeconomic groups with the highest level of unmet need (highlighting where these lack health coverage).
How do tracer indicators fit within the HSPA framework?
Figure A1.2 shows a more elaborated example for the resource generation function. It also contains tracer indicators related to more than one assessment areas – availability and mix/distribution of the health workforce – to capture one possible driver of challenges for access and effectiveness. The idea here is to illustrate how subfunctions and assessment areas can gradually be populated with tracer indicators that provide crucial information on health system performance.
Footnotes
- 3
For details of the HSPA framework’s functions, sub-functions, assessment areas, and links to intermediate and final objectives, please see Rajan D et al. (2023).
- 4
Figure 1.2 is in the Introduction to this brief. Figures in the appendices are labelled A1.1, A1.2 and A2.1.
- An updated WHO-Observatory global HSPA framework - Assessing health system perfo...An updated WHO-Observatory global HSPA framework - Assessing health system performance
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