NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
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.)
Revising the OECD’s HSPA framework
Measures of health system performance have evolved as new evidence from health sector policy and experiences emerged since the OECD first published comparative reviews of health system reforms in 1992. For decades, the OECD has helped countries to identify the key principles of high-performing health systems and to assess health system performance based on internationally comparable health indicators. The pinnacle of these efforts is represented by the OECD’s long-running flagship publication, Health at a Glance (OECD, 2023a). This work has contributed to, and been guided by, the development of conceptual frameworks for health system performance developed by the OECD over time (Hurst & Jee-Hughes, 2001; Kelley & Hurst, 2006; Carinci et al., 2015), as well as more recent and focused developments that zoom-in on two specific angles: people-centredness (OECD, 2021) and resilience (OECD, 2020).
Health systems are today under intense pressure to adapt to evolving needs and megatrends driven by population ageing, digitalization, and climate change, as well as to be better prepared to withstand sudden, large-scale natural or man-made shocks such as pandemics, natural and environmental disasters, biological, chemical, cyber, financial and nuclear threats, and social unrest. Additionally, patients’ expectations for health systems have evolved considerably to a view of integrated and people-centred systems in which access to and quality of care are crucial features.
This evolving policy context calls for a new vision of performance assessment that integrates new dimensions of performance, such as resilience, people-centredness, and environmental sustainability. The renewed framework developed by the OECD Secretariat with the support of the OECD’s expert groups and working parties reflects the changing landscape of health systems today and combines several components of other frameworks currently in use.
The OECD’s renewed HSPA framework
The renewed OECD framework builds on existing frameworks that guide the OECD’s work on health, including the 2015 revision of the HSPA framework (Carinci et al., 2015), the People-Centred Health System Framework System (OECD, 2021), and the Resilience Shock-Cycle Framework (OECD, 2020).
The “classic trio” at the basis of most HSPA frameworks – input, process, and outcomes – is visible in the framework (Donabedian, 2005). Figure A2.1 shows that resources and policy are fed into health services and interventions, which in turn produce outcomes.
The renewed framework places people’s health needs and preferences at the core of the health system, reflecting the directions from the 2017 OECD meeting of Health Ministers to make health system more people-centred (OECD, 2017). As such, people-centredness is regarded both as an objective of health systems, and instrumental to achieving other policy objectives. Incorporating the elements of the People-Centred Health Systems framework, people-centredness can be expressed through its five subdomains: voice, choice, co-production, respectfulness, and integration. This change implies a ramp-up of efforts in the collection and reporting of relevant indicators, already under way with the OECD’s Patient-Reported Indicator Surveys initiative (PaRIS) (de Boer et al., 2022).
Health systems resources and characteristics’ six building blocks (workforce; expenditure and financing, technologies and pharmaceuticals; governance; data and digital; knowledge and innovation) sustain access and coverage of quality healthcare services and public health interventions, in order to achieve the outcome of better individual and population health.
The socioeconomic, demographic, and environmental context refers to the broader conditions that influence and interact with the health system. The renewed framework stresses its role as a health determinant while acknowledging that health system actions impact the environmental, economic, commercial, and social contexts, thereby presenting a circular interaction model.
The framework also includes four “cross-cutting” dimensions of health system performance, namely efficiency and equity on one side, and sustainability and resilience on the other. The reason why these are cross-cutting is that they do not belong to one particular block in the framework but relate to them all.
The concepts used in the framework are not necessarily mutually exclusive, and therefore they may overlap. Some relations between concepts are explicitly acknowledged, for instance Donabedian’s model of structure, process, and outcomes remains visible. Yet the framework remains high level. It shows the main elements in relation to one another at a higher level and is not intended to detail all possible conceptual relationships. This high-level approach makes it suitable for application to a range of countries with very different geographical sizes, economies and health systems. The various impacts of the health system are also interrelated: individual and public health can affect people’s wealth and vice versa; health inequalities can foster other socioeconomic inequalities; health systems have an impact on the environment, for example, through emissions and waste, while the environment also affects people’s health.
Endorsing a high-level framework allows for the possibility to “zoom in”, unpack, and elaborate dimensions of the framework in more detail, for example, via subdimensions, complemented by a series of accompanying measures and linked indicator portfolios at working level, which can be used to facilitate cross-country analysis and comparisons.
To put the framework into practice, its various concepts need to be broken down into more specific and measurable elements and then populated with indicators. Since various components of the framework draw from existing frameworks, the OECD has already developed many such indicators. Consequently, several dimensions of the renewed framework can already boast a robust collection of indicators. Nevertheless, the HSPA framework revision also presents opportunities for introducing fresh indicators and enhancing the quality of existing ones.
A zoom on workforce, digitalization, people centredness, and quality and access
As for the WHO framework, all the areas explored in this brief are also covered by the OECD’s renewed framework.
Workforce
Over the past two decades, the health workforce has been under considerable strain, both in terms of numbers and the skills needed to work with new technologies and adapt to new roles. In this renewed framework, the workforce domain includes three dimensions:
- Availability and quantities of health workers;
- Skills of health workers; and
- Health workers’ safety and well-being.
The availability and quantities of health workers is a “classic” category on which the OECD has built long-time trends data. Typical indicators are numbers of doctors and nurses, but more granular data (i.e., at specialty level) should be considered for future rounds of data collection.
The focus on skills is from a more recent date. However, skill shortages are a global issue. The COVID-19 pandemic has further aggravated these shortages and emphasized the importance of resilient and well skilled healthcare workforces. Equipping health workforces with the right skills is essential to responding to future health crises, and to preparing for the increasing use of digital technologies and demographic change, among other trends (OECD/ILO, 2022).
The safety and well-being of health workers is a relevant element of the workforce domain, and OECD work on this topic has recently begun. The COVID-19 pandemic has highlighted this issue. Particularly in times of crisis, it is clear that shortages, skills, and staff well-being are interlinked. Addressing health workforce shortages requires increased investment in education and training, increased recruitment to reduce workload and pressure on existing staff, and improved retention by improving working conditions and pay rates for traditionally undervalued categories of workers (OECD, 2023b). Possible new indicators on health workforce retention will be given great attention in the renewed framework.
Digitalization
The data and digital dimension covers health data infrastructure, security, and management. The OECD collects several indicators related to digitalization in health. A few examples are the adoption of electronic medical records and the use of telemedicine and teleconsultations, but perhaps the most structured data collection related to health data digitalization is based on monitoring of the OECD Health Data Governance Recommendation, adopted in 2016 in recognition of a growing need for an international standard to harmonize approaches to health data governance. Some of the indicators on health data governance include:
- Timeliness of key national health datasets;
- Key datasets linked on a regular basis; and
- Record linkage projects used to regularly monitor healthcare quality or health system performance.
More recently, the OECD has been reflecting on the concept of digital health readiness (OECD, 2023a), which is a comprehensive measure of a health system’s capacity to effectively utilize analytics, data, and technology to improve individual, community, and public health outcomes. It encompasses various aspects (see below), each essential for a well functioning digital health ecosystem, and that could each be populated with new indicators.
People-centredness
In the renewed OECD HSPA framework, indicators to reflect the people-centredness of health systems sit at the centre of Figure A2.1, overlapping the resources and services sections. This has important implications for the revision of the framework, as more data collection and analysis efforts are needed. While some indicators for people-centredness are included in the regular HCQO data collection, and also reported in Health at a Glance, such as doctors spending enough time with patient, providing easy-to-understand explanations, and involving patients’ in decisions about care and treatment, good data to assess people-centred health systems remains the exception rather than the rule and more effort is needed in the collection and reporting of indicators related to people-centredness (OECD, 2021).
The OECD’s Patient-Reported Indicator Surveys initiative (PaRIS)5 will further refine and improve the indicators for people-centredness, as well as improve their availability across countries participating in the survey. Examples are PaRIS survey items on co-production of care that are currently being measured in twenty countries:
I have difficulty understanding a lot of the health information that I read;
- My health professionals and I work together to manage my health;
- I leave it to health professionals to make the right decisions about my health;
- Are you involved as much as you want to be in decisions about your care?
- Do you discuss with the health professionals involved in your care what is most important for you in managing your own health and well-being?
- Do you have enough support from the healthcare professionals to help you to manage your own health and well-being?
Health literacy is another major dimension of people centredness that is embedded in the OECD’s renewed framework. Health literacy encompasses the knowledge, motivation, and skills required to access, comprehend, assess, and apply information to make informed decisions regarding healthcare, disease prevention, and the enhancement of overall well-being over the life-course. It has far-reaching consequences for individuals’ ability to manage their health, use preventative services, and take part in decision-making regarding their health and well-being. At the societal level, health literacy impacts healthcare use, prevention and health promotion programmes, equity and social justice, as well as productivity.
Quality and access
The framework, in its assessment of healthcare services and public health interventions (ranging from preventive to palliative care), specifically accounts for two fundamental elements: “quality”, and “access and coverage”.
Quality is a long-standing focus of OECD work with its HCQO indicator set containing 64 indicators that focus on the standards and effectiveness of healthcare services, safeguarding patient safety, and ensuring that care is evidence-based and meets established and validated practices. A key subdimension of quality is effectiveness, which is the degree of achieving desirable outcomes, given the correct provision of healthcare services to all who could benefit, but not to those who would not benefit (Kelley & Hurst, 2006). The second subdimension of quality is safety. Patient safety is the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum, while an acceptable minimum refers to the collective notions of current knowledge, resources available, and the context in which care was delivered and weighed against the risk of non-treatment or alternative treatment (Slawomirski & Klazinga, 2022).
Under the PaRIS initiative, the OECD has undertaken the collection of Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) tailored to specific diseases. These encompass PROMs administered both before and after surgeries for conditions like breast cancer and hip and knee replacements, as well as PREMs related to mental health. Furthermore, the OECD is actively gathering data on safety aspects, considering the viewpoints of both healthcare professionals (including safety culture) and patients (involving the occurrence and nature of safety incidents). Additionally, the organization is reporting indicators concerning the quality of end-of-life care, including metrics like unplanned hospital admissions.
Similarly, there is a broad set of indicators on the accessibility of health services (access) and the extent to which public health interventions reach their target population (coverage). These two concepts are related but not interchangeable. Coverage also refers to the proportion of the population that is eligible to receive certain health services, which in turn affects the (financial) accessibility of these services. Collectively, these elements determine the effectiveness and fairness of healthcare delivery.
Using the OECD’s renewed HSPA framework
A fit-for-purpose framework is a tool that will consolidate a collective understanding of high-level policy objectives of health systems and help agree on a common language and terminology. It is not intended to replace national-level HSPA frameworks, but to enable international or regional-level benchmarking and mutual learning.
The renewed OECD HSPA framework will also help in steering indicator development, knowledge integration, international collaboration, and decision-making. It will provide a shared vision of the main elements of health systems that deserve policy attention and will serve the needs of different strands of OECD work on health.
References
- Carinci F, et al. Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators. Int J Qual Health Care. 2015 Available at: https://doi
.org/10.1093/intqhc/mzv004 (accessed 8 December 2023) [PubMed: 25758443] - de Boer D, et al. Assessing the outcomes and experiences of care from the perspective of people living with chronic conditions, to support countries in developing people-centred policies and practices: study protocol of the International Survey of People Living with Chronic Conditions (PaRIS survey). BMJ Open. 2022;12(9):e061424. Available at: https://doi
.org/10.1136 /bmjopen-2022-061424 (accessed 8 December 2023) [PMC free article: PMC9486339] [PubMed: 36123114] - Donabedian A. Evaluating the Quality of Medical Care. Milbank Q. 2005;83(4):691. Available at: https://doi
.org/10.1111/J .1468-0009.2005.00397.X (accessed 8 December 2023) [PMC free article: PMC2690293] [PubMed: 16279964] - Hurst J, Jee-Hughes M. OECD Labour Market and Social Policy Occasional Papers, No. 47. Paris: OECD Publishing; 2001. Performance Measurement and Performance Management in OECD Health Systems. Available at: https://doi
.org/10.1787/788224073713 (accessed 8 December 2023) - Kelley E, Hurst J. OECD Health Working Papers, No. 23. Paris: OECD Publishing; 2006. Health Care Quality Indicators Project: Conceptual Framework Paper. Available at: https://doi
.org/10.1787/440134737301 (accessed 8 December 2023) - OECD. OECD Health Ministerial Meeting. Paris: OECD; 2017. Ministerial Statement – The Next Generation of Health Reforms.
- OECD. OECD Policy Responses to Coronavirus (COVID-19). Paris: OECD Publishing; 2020. A systemic resilience approach to dealing with Covid-19 and future shocks. Available at: https://doi
.org/10.1787/36a5bdfb-en (accessed 8 December 2023) - OECD. OECD Health Policy Studies. Paris: OECD Publishing; 2021. Health for the People, by the People: Building People-centred Health Systems. Available at: https://doi
.org/10.1787/c259e79a-en (accessed 8 December 2023) - OECD. Health at a Glance 2023: OECD Indicators. Paris: OECD Publishing; 2023a. Available at: https://doi
.org/10.1787/7a7afb35-en (accessed 8 December 2023) - OECD. OECD Health Policy Studies. Paris: OECD Publishing; 2023b. Ready for the Next Crisis? Investing in Health System Resilience. Available at: https://doi
.org/10.1787/1e53cf80-en (accessed 8 December 2023) - OECD/ILO. Getting Skills Right. Paris: OECD Publishing; 2022. Equipping Health Workers with the Right Skills: Skills Anticipation in the Health Workforce. Available at: https://doi
.org/10.1787/9b83282e-en (accessed 8 December 2023) - Slawomirski L, Klazinga N. OECD Health Working Papers, No. 145. Paris: OECD Publishing; 2022. The economics of patient safety: From analysis to action. Available at: https://doi
.org/10.1787/761f2da8-en (accessed 8 December 2023)
Footnotes
- 5
The PaRIS International Survey of People Living with Chronic Conditions is the first international survey of patient-reported health outcomes and experiences of adults living with one or more chronic conditions who are managed in primary or other ambulatory care settings. It is the first of its kind to assess the outcomes and experiences of patients managed in primary care across countries.
Figures
