Health System Performance Assessment Framework for Luxembourg

3. Indicators to assess the performance of Luxembourg’s health system

Abstract

An inclusive stepwise process was undertaken to select indicators for Luxembourg’s HSPA, engaging health system stakeholders in several discussions and an indicator prioritisation activity, and gaining their approval for the final set of indicators in November 2025. Luxembourg’s HSPA framework is populated by 105 indicators, which are distributed across the framework’s 12 domains and 30 subdomains. The largest number of indicators reflects health system inputs (35), followed by indicators reflecting processes (33), while there is a lower number of outcome indicators (18) and indicators in the cross-cutting domains (19).

The chapter describes the comprehensive HSPA indicator selection process, which included 22 organisations, associations and governmental bodies, and provides an overview of indicators selected in each subdomain, expanding detailed concepts where relevant. Finally, the chapter provides a use case example for HSPA indicators on a specific topic, illustrating how indicators can be connected throughout the HSPA framework.

3.1. Indicator selection methodology and process

The process of selecting indicators for Luxembourg’s HSPA was designed to be thorough, transparent, and grounded in international best practice. Drawing on the OECD’s extensive experience supporting national HSPA framework development, including in Estonia (OECD, 2023[1]) and Czechia (OECD, 2023[2]), the overall approach in Luxembourg combined technical rigor with a strong emphasis on stakeholder engagement. Figure 3.1 outlines key activities undertaken to reach the final set of indicators selected for the HSPA framework in Luxembourg, described through seven distinct but partially overlapping activities undertaken by the Luxembourgish Project Management Team (PMT), the Luxembourgish health system stakeholders, and the OECD team between May 2025 and January 2026.

Figure 3.1. Overview of the HSPA indicator selection process in Luxembourg

Source: Developing the HSPA framework for Luxembourg project.

3.1.1. From a comprehensive indicator repository to a pre‑selected indicator set

Activities 1‑4 in Figure 3.1 outline the initial steps in indicator selection undertaken by the Luxembourgish Project Management Team (PMT) and the OECD team with input from Luxembourg’s health system stakeholders.

a) Firstly, a comprehensive indicator repository was compiled by the OECD team. This comprised a comprehensive set of existing and potential indicators from multiple sources, including 1 295 indicators from datasets and publications managed by national health system and data organisations in Luxembourg (OECD (2025[3]) and Annex B), and 3 931 from international databases from the OECD, Eurostat, European Centres for Disease Control (ECDC) and the WHO. For each indicator, the OECD documented initial metadata: indicator source and custodian, type, availability, available disaggregation, and other relevant characteristics. For inspiration and reference purposes, 1 611 indicators used in HSPAs in other countries or compiled by the European Commission’s Expert Group on HSPA1 were listed without accompanying metadata. This resulted in a large repository of 6 837 potential indicators to consider for Luxembourg’s HSPA.

b) Secondly, the OECD and the PMT organised four Technical Focus Group meetings with national experts from different organisations between May-July 2025 (Annex A). The purpose of the meetings was to discuss themes selected based on high prioritisation by stakeholders in Principle Working Group meetings in January 2024 (See Chapter 2, Figure 2.4) or where it was not clear what indicators or measurement approaches would be best suited to capture the theme in Luxembourg’s HSPA. The meetings focussed on: (1) patient-centredness and empowerment, (2) integrated care, (3) value‑based care, and (4) mental health. These exchanges generated new ideas for indicators or highlighted relevant existing metrics or datasets, with 107 additional indicators added to Luxembourg’s indicator repository.

c) Thirdly, the PMT and the OECD mapped indicators in the repository onto the domains and subdomains specified in the first HSPA draft framework (Section 2.3) and consolidated the lists per domains and subdomains between July-August 2025. The purpose of the step was to (a) align indicators from the repository to the emerging structure of domains and subdomains via mapping each metrics to a suitable subdomain based on the metrics’ measurement substance; and (b) to identify and remove duplicates, redundancies, and inconsistencies from the repository. As part of this review, duplicated repository indicators, e.g. metrics which featured more than once in the repository due to their existence in multiple source databases (such as for international data questionnaires and original national data, or international joint data questionnaires), were consolidated, and the teams examined the extent to which each domain and subdomain was supported by available data. During this stage, indicators that did not correspond to any of the framework subdomain descriptions (see Section 2.2), or that did not match the overall purpose and scope of the HSPA framework (see Section 2.1), were excluded to ensure the set of framework-mapped indicators would be coherent, meaningful, and aligned with the framework’s structure. This step resulted in a consolidated list of 1 315 indicators.

d) Fourth, a rigorous pre‑selection process was carried out by the PMT with the support of the OECD team. The objective of the pre‑selection was to identify, from the consolidated list of indicators mapped to the framework structure, those indicators that were most relevant and useful for each Luxembourg’s HSPA subdomain based on their description. The criteria of indicator availability and benchmarking possibilities were also considered during the pre‑selection process. This process resulted in a shortlist of 282 pre‑selected indicators, organised by HSPA framework sub-domains. The non-pre‑selected indicators were kept in the documentation of each subdomain, to support stakeholder discussions in their prioritisation (see next step in section 3.1.2) and to allow stakeholders to indicate if they considered any alternative indicator to be more appropriate. At this step, an approximate target number of indicators for each subdomain was defined, to sum up to a total of 100 across the whole HSPA framework.

Through this multi-stage process, starting from an extensive indicator repository and gradually narrowing the list of possible metrics down, the initial pool of 6 837 indicators was reduced to 282 candidate indicators for scoring and prioritisation by Luxembourg’s health system stakeholders in the next step.

3.1.2. Stakeholder scoring and prioritisation for the first draft list of indicators for the HSPA

Activity 5 in Figure 3.1 comprises the scoring process undertaken by health system stakeholders in Luxembourg.

e) The list of 282 pre‑selected indicators, distributed across 31 subdomains of the draft HSPA framework (prior to combining Demographic and Socio‑economic equity subdomains, see section 2.3.2), was shared with members of the PWG for a scoring and prioritisation in September 2025. The PWG stakeholders received an Excel file to fill their answers and were asked to score each indicator based on two criteria using a four‑point scale: the significance of the indicator to understand health system performance, and relevance of the indicator for the specific subdomain in which it was placed (Table 3.1). This scoring and prioritisation process was not limited to nominated PWG members – instead, PWG members could opt to extend the invitation to fill the prioritisation file to their colleagues, member organisations, or collaborating partners. Additionally, stakeholders were offered flexible options for submitting their scoring: they could work together as a group and submit a joint score on behalf of the same organisation (or two), or complete the scoring individually and submit several separate responses on behalf of one stakeholder. A total of 40 individuals participated in this exercise, representing 22 organisations, associations and governmental bodies in the Luxembourgish health system.

Table 3.1. PWG members were asked to evaluate each indicator using two core criteria: significance for health system performance and relevance for framework’s subdomains

Criterion	Description	Scoring scale
Significance for health system performance	This criterion captures how important an indicator is for understanding and improving the health system’s performance. When scoring significance, members were asked to consider whether the indicator: (1) Reflects an important health condition, service, or policy area; (2) Provides insights that can meaningfully inform decision making; (3) Supports monitoring of service quality, resource allocation, equity, or efficiency	1=Low significance 2=Moderate significance 3=High significance 4=Critical significance
Relevance to the sub-domain	This criterion assesses how well an indicator fits the specific subdomain in which it is placed. The question is not whether the indicator is useful in general, but whether it meaningfully captures an aspect of the subdomain’s definition and purpose.	1=Irrelevant 2=Somewhat relevant 3=Relevant 4=Highly relevant

Source: Developing the HSPA framework for Luxembourg project.

Standardising and interpreting stakeholder scoring results

The results of submitted stakeholders’ scorings were standardised through a multi-step procedure. This ensured that each organisation’s contribution was reflected proportionately, producing a single metric that allowed for quantitative benchmarking based on the criteria in Table 3.1. For each indicator, a composite score was calculated as follows:

a) Individual scores were weighted by organisation (e.g. four separate responses for one organisation would result in 0.25 weights for each)

b) Weighted average relevance and significance scores were calculated for each indicator:

Equation 3.1.

$\frac{\sum _{i=1}^n\left({score}_i\mathrm{*}{weight}_i\right)}{\sum _{i=1}^n\left({weight}_i\right)}$

c) A composite score was calculated for each indicator:

Equation 3.2.

$\frac{avg.\mathrm{ }significance+avg.\mathrm{ }relevance}{2}$

d) Indicators were ranked within each subdomain by their composite scores.

Using the pre‑defined target number of HSPA indicators for each subdomain, top-scoring candidate indicators were reviewed and proposed for inclusion in the HSPA by the PMT and the OECD, to be then discussed with the PWG members in the next step of the indicator selection process. In preparation of the proposal to the PWG, each subdomain indicator set was reviewed, and, where relevant, some lower-scoring indicators were retained for discussion and proposed for inclusion among the higher-scored ones when justified by high policy relevance, importance for the Luxembourg context, international benchmarking value, to complement higher-scoring indicators, or to enhance interpretation. In some cases, additional indicators were proposed as contextualising indicators to provide context to another indicator(s) (the final list of identified and selected contextualising indicators can be found in Annex D. Results of the stakeholder scoring and prioritisation, with indication of the top-scoring candidate indicators, was then shared with the PWG members ahead of the PWG meetings in which indicators were reviewed and discussed by subdomains in detail (see next section).

3.1.3. Finalisation of the list of indicators for the HSPA

Activities 6 and 7 in Figure 3.1 focussed on finalisation of the list of indicators to populate Luxembourg’s HSPA framework, including reaching a common agreement across stakeholder representatives (see Box 3.1).

6. Two PWG meetings were held in October 2025 to discuss scoring results, validate indicator selection, and reach agreements on the final set of indicators in the HSPA that reflect diverse perspectives across PWG members. Based on stakeholders’ scoring and prioritisation of candidate indicators, the PMT and OECD provided an overview of the set of top-candidate indicators within each subdomain. Each subdomain presentation was followed by a brief discussion allowing stakeholders to provide feedback, clarify or suggest further considerations on the proposed indicator selection. The two PWG meetings resulted in an agreed set of indicators covering 10 domains of the LUX HSPA framework (see Section 2.2). The two remaining domains (“Determinants of health” and “Equity”) were shared for written feedback due to time constraints. At this stage, further agreement was sought from the PWG to merge “Geographic equity” and “Demographic equity” subdomains into a single subdomain in Luxembourg’s framework (see Section 2.3).

The set of indicators consented by the PWG was presented at the HLAB meeting in November 2025, where an addition of two indicators was made to the “Fiscal Sustainability” subdomain (within the “Finances” domain), following suggestions from the IGSS. These indicators provide further insight into the financial position of the insurance system: reserves-to‑expenditure for sickness insurance and for long-term care insurance (see Section 3.2.9).

The list of Luxembourg’s HSPA indicators was consented by the HLAB to comprise a total of 105 indicators across 12 domains and 30 subdomains.

7. In the first quarter of 2026, the PMT further consulted the final set of Luxembourg’s HSPA indicators in bilateral meetings with stakeholders and data custodians to complement indicator specifications and refine indicator technical details such as data availability, collection source, and collection frequency; this information would feed into the development of indicator technical sheets during the HSPA implementation process in 2026. These consultations also confirmed the HSPA indicator custodianship for the final list of indicators (see Section 4.1).

In addition, an internal review by the PMT on indicator availability (including data and/or methodology availability) identified a set of 14 HSPA indicators which were marked as placeholder indicators (see Box 3.2 for the definition of an HSPA placeholder indicator). This was down from previously 26 placeholder indicators, as some indicators, earlier marked as placeholders, were identified as existent and available through the data custodian consultations.

Luxembourg’s stakeholders have been actively involved throughout the indicator selection and prioritisation process and the final list of indicators that populate Luxembourg’s HSPA framework reflects their diverse perspectives. Box 3.1 summarises the steps and inputs received from broad stakeholder representation throughout the HSPA indicator selection process.

Box 3.1. Stakeholders in Luxembourg’s health system contributed actively to the HSPA indicator selection process

Stakeholders across Luxembourg’s health system were engaged at steps two, five, six and seven of the HSPA indicator selection process (see Figure 3.1).

The four Technical Focus Groups (TFC) described in activity two, held between May and July 2025, were each attended by representatives from six to ten organisations relevant to the specific topic of the TFC, who contributed their insights to identify relevant indicators and priorities.

The stakeholder scoring and prioritisation (activity 5) in September 2025 included active participation (scoring) of 40 individuals representing 22 organisations in the Luxembourgish health system.

The methodology for activity 5 was introduced to the PWG in its meeting in July 2025, attended by 35 participants, representing 21 health sector organisations and governmental bodies.

Activity 6 to reach agreements on the final indicator set included two meetings of the PWG and one meeting of the HLAB. Two PWG meetings on consecutive days in October 2025 were attended by around 40 participants, representing some 25 organisations and governmental bodies across Luxembourg’s health system.

Activity 7 comprised several bilateral meetings between the PMT and Luxembourg’s health system stakeholders to refine indicator details and agree on HSPA indicator custodianship.

Annex A provides an overview of the main stakeholder meetings throughout the project.

3.2. Indicators populating Luxembourg’s HSPA framework

Luxembourg’s HSPA framework includes 105 indicators, distributed across 12 domains and 30 subdomains of the framework (Section 2.2) (Figure 3.2). The number and distribution of indicators across subdomains, selected through a rigorous multi-stage process (Section 3.1), seeks to balance practical feasibility with measurement depth to meet the objectives of the HSPA.

Figure 3.2. Luxembourg’s HSPA indicators are distributed across framework subdomains, which are grouped into domains and theme blocks

Number of indicators in Luxembourg’s HSPA by blocks, domains and subdomains

Source: Developing the HSPA framework for Luxembourg project.

While the majority of the 105 indicators come from data and indicator sources that are already available, 14 are placeholder indicators where further development is needed (either in data collection or in indicator methodology, see Box 3.2). In addition, 12 contextualising indicators were identified (Annex D) to complement the information of the main HSPA indicator set. Looking at the Luxembourg’s HSPA indicator set from the perspective of international comparability, 78 indicators are derived from international data collections and databases, allowing for benchmarking with other countries (see Annex B for more information on Luxembourg’s health data landscape).

Sections 3.2.1 – 3.2.12 provide an outline of indicators in each domain, starting with a definition of the domain, and are accompanied by tables summarising selected technical details on the indicators. Box 3.2 explains indicator technical details which feature in the indicator summary tables throughout this subchapter. More information on indicator technical sheets is then provided in Annex C, Table C.1. Where relevant, the following subsections highlight information and topics considered particularly important by Luxembourg health system stakeholders during the selection process discussions and in the subsequent bilateral consultations.

Box 3.2. Explanations of technical information included in indicator tables within Section 3.2

Placeholder indicator – an HSPA indicator is not readily available for analysis because (a) indicator methodology and data have not been defined, (b) methodology exists, but primary data is not collected in Luxembourg, or does not meet criteria required for calculations, or (c) primary data exists but methodology needs further refinement.

Contextualising indicator – an indicator outside of the main HSPA indicator set that can be used to contextualise or complement the analyses of a selected HSPA indicator.

Indicator breakdown – possible disaggregations of the indicator into subgroups for analysis (e.g. by age, sex, region, socio-economic status). The description of available breakdowns may vary by indicator source, e.g. the variable sex is reported in EHIS and EU-SILC surveys, but gender variable is used in PaRIS and HBSC surveys.

HSPA Indicator custodian – the organisation or governmental body responsible for the analysis of the indicator for the purposes of the HSPA in Luxembourg. Section 4.2.3 summarises the custodianship of HSPA indicators in the context of governance of the HSPA in Luxembourg.

Indicator source for HSPA – organisation or governmental body publishing or disseminating the original indicator, serving as the source for the purposes of the HSPA indicator. This entity can also be responsible for defining or producing the indicator.

Data custodian – organisation(s) managing or responsible for the dataset(s) used to obtain the indicator. Section 4.2.3 summarises the custodianship of the data in the context of governance of the HSPA in Luxembourg. Data infrastructure, including responsibilities and datasets managed by health data stakeholders in Luxembourg, is further described in Annex B.

Data source for HSPA – survey or dataset to based on which an indicator is generated; this generally also includes the name of data collection questionnaire or survey. Further information on many of the data sources is provided in Annex B.

Data collection frequency – frequency of data collection or calculation to generate updates to the original indicator, i.e. to the Indicator source for HSPA.

Note: Further explanations of the technical information categories are provided in Annex C.

3.2.1. Outcomes: Health status domain

The Health status domain is captured by nine indicators. Its two subdomains, Population outcomes and Mental health have six and three indicators, respectively.

Population outcomes

The Population outcomes subdomain describes the state of health of a population assessed by subjective or objective indicators – healthy life expectancy, life expectancy, and self-reported health status (Table 3.2). The selected six indicators provide an assessment across mortality and disability and include objective measures and subjective perceptions of individuals’ health status.

Table 3.2. Population outcomes indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Life expectancy at birth	By sex	ObSanté	EUROSTAT	STATEC	Cause of death Registry, DiSa	Available, updated annual
Life expectancy and healthy life years at age 65	By sex	ObSanté	EUROSTAT	STATEC	Cause of death Registry, DiSa and EU-SILC1 survey	Available, updated annually
Standardised mortality rates	By sex, age, cause	ObSanté	EUROSTAT	DiSa (Epistat)	Causes of deaths registry	Available, updated annually
Self-perceived health	By sex, age, activity limitation (none, some, severe)	ObSanté	EUROSTAT	STATEC	EU-SILC survey	Available, updated annually
Distribution of beneficiaries of LTC by main cause of dependency (e.g. mental health, rare diseases)	By cause of dependency	IGSS	IGSS	IGSS	Rapport général sur la sécurité sociale	Available, updated annually
Cancer incidence	By cancer site	RNC	RNC	RNC	RNC Rapport Cancer au Luxembourg	Available

1. EU statistics on income and living conditions.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on Life expectancy at birth provides a fundamental measure of population health, capturing longevity among the population. In addition, Life expectancy and healthy life years at age 65 captures the longevity among older populations, however comprising a measure of morbidity examining the state of health the years are spent in. This part of information is retrieved from the EU-SILC survey by the EUROSTAT. The indicator on Standardised mortality rate monitors general mortality patterns, with breakdowns by sex and age providing an overview when people are dying, and the underlying causes driving these deaths. Breakdowns by major disease areas, such as cancer and cardiovascular disease, are included.

Morbidity and disability are further captured by the indicator Self-perceived health, providing a measure of how the population’s subjective perception of their health status. This indicator can be broken down by activity limitation, sex, and age, which help better understand health status by population group and disability. Distribution of beneficiaries of long-term care by main cause of dependency (e.g. mental health, rare diseases) provides insight from administrative sources into the number of people living with disabilities, including mental health disorders. Finally, the indicator on Cancer incidence provides a disease‑specific morbidity measure with breakdowns by cancer site, representing a leading cause of death in European countries. It is possible to compare all indicators internationally except for Distribution of beneficiaries of LTC and Cancer incidence, allowing to benchmark Luxembourg’s performance.

Mental health

The Mental health subdomain describes the mental health status of the population. Three indicators were selected to assess mental health using both self-reported symptoms among the population and patient-reported outcomes, covering both adolescence and adulthood (Table 3.3).

Table 3.3. Mental health indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Proportion (%) of adolescents reporting multiple health complaints	By gender, by perceived wealth (afflucence)	ObSanté	WHO	University of Luxembourg	HBSC1	Available, updated every 4 years
Current depressive symptoms	By sex, age, country of birth	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH2 (data producer)	EHIS3	Available, updated every 6 years
Emotional distress (feeling anxious, depressed or irritable)	By gender, age, education, income	ObSanté	OECD	DiSa (DMC-CQS4) (data owner) / LIH (data producer)	PaRIS survey (microdata)	Available, updated every 4 years

1. Health Behaviour in School-aged Children Study

2. Luxembourg Institute of Health

3. European Health Interview Survey

4. Division de la Médecine Curative et de la Qualité en Santé

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on Proportion of adolescents reporting multiple health complaints captures mental and psychosomatic distress in young people. Adolescents were asked how often they experienced the following health complaints in the last 6 months: headache, stomachache, backache, feeling low, irritability or bad temper, feeling nervous, difficulties in getting to sleep, and feeling dizzy. Stakeholders considered this measure valid for the Mental health domain as it combines psychological and somatic symptoms that tend to co‑occur and are widely recognised as markers of stress, low emotional well-being, or emerging mental health disorders. 

Adults’ mental health is captured with the indicator on Current depressive symptoms with breakdowns by country of birth, sex, and age measures the self-reported prevalence of depression, while the breakdowns provide further information on populations at risk. Analyses of this indicator will be complemented with the contextualising indicator on Antidepressants consumption (Annex D). This provides a further perspective on mental health. On balance with the Current depressive symptoms indicator, a high consumption could reflect over-treatment, while low rates may show barriers to access or underdiagnosis. The Emotional distress (feeling anxious, depressed or irritable) from the OECD’s Patient Reported Indicators Survey (PaRIS) measures the self-reported frequency of distress among primary care patients aged over 45 with chronic conditions. This indicator captures an at-risk population and allows for various breakdowns, including by sociodemographic factors and number of chronic conditions. It can be captured either by self-reported frequency, or as a proportion of people reporting frequent distress.

As data sources of all three indicators are internationally conducted surveys, international comparisons can be made for all of them. The frequency of update varies, depending on the frequency in which the different surveys are conducted.

3.2.2. Outcomes: Person centredness domain

The Person centredness domain is captured by nine indicators. Its three subdomains, Patient-centred care, Health literacy and Patient experience have three, two and four indicators, respectively.

Patient-centred care

The Patient-centred care subdomain describes the extent to which care is delivered in a holistic and collaborative manner, treating individuals as equal partners and considering their preferences and cultural, social, and linguistic backgrounds in maintaining health, managing illness, and finding suitable solutions. The selected indicators assess patient-centred care from the patient perspective, through general and specific measures (Table 3.4).

Table 3.4. Patient-centred care indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Person-centred care (composite indicator)	By gender, age, education, income	ObSanté	OECD	DiSa (DMC-QS1) (data owner) / LIH2 (data producer)	PaRIS3 survey	Available, updated every 4 years
Doctor involving patients in decisions about care or treatment during the last visit	By gender, age, education, income	ObSanté	OECD	DiSa (Epistat) (data owner) / LIH (data producer)	HCQO4	Available, updated every 6 years
Doctor providing easy-to‑understand explanations during the last visit	By gender, age, education, income	ObSanté	OECD	DiSa (Epistat) (data owner) / LIH (data producer)	HCQO	Available, updated every 6 years

1. Division de la Médecine Curative et de la Qualité en Santé

2. Luxembourg Institute of Health

3. Patient-Reported Indicator Surveys

4. Healthcare quality and outcomes.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The composite indicator on Person-centred care constitutes a combined measure of eight dimensions that capture whether care is perceived as person-centred, reflecting views among primary care users with chronic conditions aged 45 and over, derived from the OECD’s Patient Reported Indicator Surveys (PaRIS). Dimensions include whether patients reported discussing what is important to them with their attending health professional, whether they felt involved in their care decisions, were considered as a “whole person”, did not need to repeat information, experienced joined-up care, and received support, information, and confidence to self-manage their health condition. The indicator offers multiple data breakdowns (by education, income, age, sex, etc).

In addition, the indicators Doctor involving patients in decisions about care or treatment during the last visit and Doctor providing easy-to‑understand explanations during the last visit are both reported by patients about their last physician contact, and complement the focus on specific aspects of person-centred care, such as shared decision making and communication quality. Among patient experience measures prioritised for voting, these two were highlighted as particularly essential to capture separately under this domain. In 2019, the two indicators were included by Luxembourg in its national version of the EHIS survey questionnaire, and the data for these questions is collected internationally through the OECD Healthcare Quality and Outcomes (HCQO) data collection. International comparisons are available for all three indicators through international surveys or the OECD Health Statistics database (OECD, 2025[4]). As the indicators are based on survey data, breakdowns by socio-economic variables are possible, creating a link to the Equity domain (Section 3.2.12) and reflecting priorities identified by Luxembourg’s stakeholders during the HSPA framework development.

Health literacy

The Health literacy subdomain relates to people’s knowledge, motivation, and skills to seek, understand, evaluate and use health information to make decisions related to health promotion, prevention and use of healthcare services. Two indicators were selected to cover both general health literacy and mental health-specific literacy (Table 3.5).

Table 3.5. Health literacy indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Self-reported understanding of health issues and information	By gender, age, education, income	ObSanté	OECD	DiSa (DMC-QS1) (data owner) / LIH2(data producer)	PaRIS	Available, updated every 4 years
Mental health literacy						Placeholder

1. Division de la Médecine Curative et de la Qualité en Santé

2. Luxembourg Institute of Health.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on Self-reported understanding of health issues and information is a composite of responses to two questions: “Most health issues are too complex for me to understand” and “I have difficulty understanding a lot of the health information I read.” Collected as part of the PaRIS survey among primary care users aged over 45 with chronic condition, it includes multiple data breakdowns (by education, income, age, sex, etc).

The indicator on Mental health literacy is currently a placeholder pending development. The need for metrics on people‑centredness in mental healthcare was particularly emphasised by experts in the Technical Focus Group on people‑centredness, leading to the inclusion of an indicator as a placeholder in the absence of data and methodology.

Patient experience

The Patient experience subdomain encompasses the aspects of the care journey that patients consider most important. Four indicators were selected to cover patient experience in different care settings (hospital, primary care settings and long-term care) and monitor the satisfaction of patients with integrated care networks (“réseaux de compétences”), a Luxembourgish initiative to improve co‑ordination and continuity of care (Table 3.6).

Table 3.6. Patient experience indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Patient-Reported Hospital Stay Satisfaction		FHL1	FHL	FHL		Placeholder
Patient satisfaction with co‑ordination and continuity of care		DiSa (DMC-QS2)	DiSa (DMC-QS)	DiSa (DMC-QS)	Réseaux de compétences	Placeholder
Patients reporting having experienced an adverse event (negative experience)	By gender, age, education, income	ObSanté	OECD	DiSa (DMC-QS) (data owner) / LIH3 (data producer)	PaRIS4	Available, updated every 4 years
Long-term care beneficiary satisfaction		MiFa5	MiFa	MiFa	Long term care evaluation	Available (not publicly), updated every 3 years

1. Fédération des Hôpitaux Luxembourgeois

2. Division de la médecine curative et de la qualité en santé

3. Luxembourg Institute of Health

4. Patient-Reported Indicator Surveys

5. Ministère de la Famille, des Solidarités, du Vivre ensemble et de l’Accueil.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Patient-reported hospital stay satisfaction measures experiences in inpatient care. This is a placeholder indicator, with data expected from hospital satisfaction surveys by the time of publication of the first Luxembourg’s HSPA report. The indicator Patient satisfaction with co‑ordination and continuity of care focusses on patient experience in the context of integrated care networks for specific diseases. This is currently a placeholder that aims to provide a complementary perspective more oriented on specific diseases.

The indicator Patients reporting having experienced an adverse event captures harmful or problematic patient experiences with the healthcare system. Examples of adverse events captured include not getting an appointment when needed, receiving a wrong or delayed diagnosis or treatment, or experiencing problems with communications between healthcare professionals. Data comes from the OECD PaRIS survey, making international comparison and benchmarking possible.

The indicator on Long-term care beneficiary satisfaction captures perceptions among recipients of long-term care. The indicator is reported by the Ministry of Family, Solidarity, Living together and Reception of Refugees, with data expected to become available by the end of 2027 when the first round of evaluation will be completed. Stakeholders highlighted the importance of addressing measurement gaps in satisfaction with long-term care.

3.2.3. Processes: Access to care domain

The Access to care domain includes five indicators. There are two subdomains: Financial protection includes two indicators, while Operational access is captured in three indicators.

Financial protection

The Financial protection subdomain describes the different dimensions of health insurance coverage, including population coverage (who is and who is not covered), the covered services and the extent of service coverage, as well as monitoring the level of financial hardship in accessing healthcare. The two indicators capture expenditure patterns and perceived barriers to accessing mental healthcare, an essential but often under-resourced area of care (Table 3.7).

Table 3.7. Financial protection indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Out-of-pocket spending by type of service	By type of service (medical goods, outpatient, dental, inpatient, LTC, etc)	ObSanté	OECD	IGSS	JHAQ1	Available, updated annually
Unmet need for mental healthcare due to financial reasons	By sex, age, income quintile and level of disability	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS2	Available, updated every 6 years

1. Joint Health Accounts questionnaire.

2. European Health Interview Survey.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

Out-of-pocket spending by type of service measures direct payments made by households, with breakdowns by medical goods, outpatient care, dental care, inpatient care, long-term care, and other services. This shows which services have the greatest financial burden on patients. The indicator Unmet need for mental healthcare due to financial reasons refers to the proportion of people who self-reported unmet mental health needs due to financial reasons in the past 12 months. The indicator was prioritised due to particular attention to inclusion of the mental health topic in Luxembourg throughout the HSPA, incorporating stakeholders’ priorities. Both indicators can be compared and benchmarked internationally.

Operational access

The Operational access subdomain monitors timeliness of access and geographical accessibility to appropriate care, medicines and medical equipment, in Luxembourg and abroad. Three indicators were chosen to capture both perceived and objective barriers to timely access (Table 3.8). Discussion among stakeholders highlighted the need to have a particular attention to vulnerable populations when analysing these indicators.

Table 3.8. Operational access indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Self-reported unmet needs for medical examination or treatment	By sex, age, education, income, main reason declared (distance to travel, waiting times, financial reasons)	ObSanté	EUROSTAT	STATEC1	EU-SILC2	Available, updated annually
Waiting times for health services	By type of service (e.g. diagnostic exams)	ObSanté	ObSanté	FHL3	Carte sanitaire	Available, updated every 2 years
Median time in days from tissue diagnosis of cancer to treatment initiation	By sex, cancer type	ObSanté	OECD	DiSa (Epistat) /RNC4	RNC	Available, updated every 2 years

1. National Institute for Statistics and Economic Studies of Luxembourg

2. EU statistics on income and living conditions

3. Fédération des Hôpitaux Luxembourgeois

4. Registre National du Cancer.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Self-reported unmet needs for medical examination or treatment captures access barriers, via a self-reported measure of not seeking care despite needing it, due to distance to travel, waiting times, and financial reasons. Breakdowns by education, income, sex, age, and main reason for not seeking care are available.

Waiting times for appointments and treatments by type of appointment provides an objective measure of care timeliness for diagnostic exams and other services. With introduction and measurement activities ongoing, it is due to be introduced first for a subset on diagnostic imaging exams. In addition, the indicator Median time in days from tissue diagnosis of cancer to treatment initiation measures a step in a critical care pathway where timely intervention can affect survival, introduced as part of a 2025 pilot data collection by the OECD. International comparisons are available for the indicators on Self-perceived unmet needs and Median time from tissue diagnosis of cancer to treatment.

3.2.4. Processes: Value‑based care domain

The Value‑based care domain includes 16 indicators in four subdomains, including five indicators under the Patient safety subdomain, two under Guidelines compliance, five under Quality of care, and four under Cost-efficiency.

Patient safety

The Patient safety subdomain refers to monitoring unnecessary harm associated with the provision of healthcare services. Five indicators were selected that reflect safety in various settings, including hospital, long-term care and community settings (Table 3.9). These capture key patient safety areas, including infections, medication safety, and preventable adverse events that can impact patient outcomes.

Table 3.9. Patient safety indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
ICU-acquired bloodstream infection rates	ObSanté	ECDC1	DiSa (DMC-QS)	DiSa (DMC-QS)	Available (not publicly), updated annually
Proportion of bloodstream infection due to methicillin-resistant Staphylococcus aureus (MRSA) (%)	ObSanté	WHO (Global Health Observatory)	LNS	Rapport surveillance PNA2	Available, updated annually
Patients who developed a stage 2 or higher pressure ulcer during hospitalisation	FHL/CNS3	FHL/CNS	FHL/CNS	Incitants qualité	Available, updated annually
Hospital admissions due to falls among people in long-term care	ObSanté	OECD	IGSS	OECD Long-Term Care Quality Pilot 2025	Available (not publicly)
Proportion of 75‑year‑olds and over who are taking more than 5 medications concurrently	ObSanté	OECD	IGSS	HCQO4	Available, updated every 2 years.

Note: No breakdowns specified.

1. European Centre for Disease Prevention and Control 

2. Plan national antibiotiques

3. Fédération des Hôpitaux Luxembourgeois/Caisse nationale de santé

4. Healthcare quality and outcomes.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator ICU-acquired bloodstream infection rates relates to infection prevention and control in intensive care settings. As antimicrobial resistance is a growing threat to treating infections, the indicator on Proportion of bloodstream infection due to methicillin-resistant Staphylococcus aureus (MRSA) monitors resistance to antibiotics, reflecting blood samples from any setting in participating laboratories. However, as MRSA is often transmitted in hospitals, it is relevant to characterising hospital-acquired infections.

The indicator Hospital admissions due to falls among people in long-term care captures preventable injuries with breakdowns by setting available (whether people come from long-term facilities or home). The methodology was piloted for the first time in 2025 as part of the OECD Long-Term Care Quality Pilot data collection, and Luxembourg submitted data for this indicator. Research and development on the indicator are planned in the coming years to establish it for reliable international comparisons, but the methodology can already be used to monitor national trends. The indicator Incidence of patients who developed a stage 2 or higher pressure ulcer acquired during hospitalisation will also track a preventable complication indicative of care quality. This indicator is complemented by a contextualising indicator Pressure ulcers among people receiving long-term care – a national indicator, which provides additional insight into preventable adverse events in a high-risk setting (see Annex D for contextualising indicators).

The indicator on Proportion of 75‑year‑olds and over who are taking more than 5 medications concurrently measures polypharmacy in older people.

All indicators except Pressure ulcer incidence can be compared internationally.

Guidelines compliance

The Guidelines compliance subdomain describes the adoption of an evidence‑based approach to the effective delivery of healthcare services to patients. Two indicators were chosen to balance breadth and applicability: one tracks cancer care pathways, while the other provides an available measure of guideline compliance in prescribing (Table 3.10).

Table 3.10. Guidelines compliance indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Patient pathway compliance with established protocols – cancer care	INC1	INC			Placeholder
Elderly patients with prescription of long-acting benzodiazepines or related medications per 1 000 patients aged 65 or over	ObSanté	OECD	IGSS	HCQO2	Available, updated every 2 years

Note: No breakdowns specified.

1. Institut National du Cancer 

2. Healthcare quality and outcomes.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Patient pathway compliance with established protocols – cancer care looks at whether cancer patients receive care consistent with evidence‑based treatment pathways, currently a placeholder indicator. The indicator Elderly patients with prescription of long-acting benzodiazepines or related medications measures potentially inappropriate prescribing, expressed per 1 000 patients aged 65 or over. While these medications are typically prescribed for anxiety and sleep disorders, in older people they are also used to control agitation. However, they could increase the risk of adverse outcomes, such as falls, delirium, and low blood pressure, and can be considered inappropriate in older adults. This indicator is accompanied by a contextualising indicator on Long-term prescribing of benzodiazepines in this population, used to further examine prescribing patterns and capturing frequent use of other benzodiazepines (Annex D). The indicators on prescribing patterns can be compared internationally.

Quality of care

This subdomain covers quality and outcomes of care, including clinical effectiveness and outcomes of health interventions. Five indicators were selected to cover care quality across different settings (hospital, long-term and community-based care), comprising condition-specific measures on cancer and cardiovascular care quality, as well as capturing acute and long-term care quality (Table 3.11). While four of the indicators are derived from administrative sources, a patient-reported outcome indicator is included, aligned with stakeholder emphasis on the importance of capturing patient perceptions, expressed during the selection process.

Table 3.11. Quality of care indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Ischaemic stroke 30‑day mortality following a hospital admission	Unlinked data (During same admission), Linked data (all cases)	ObSanté	OECD	DiSa (Epistat)	HCQO1	Available, updated every 2 years
Rate of rehospitalisation within 1 to 30 days		FHL/CNS2	FHL/CNS	FHL/CNS	Incitants qualité	Available (not publicly), updated annually
Share of people with chemical restraints in long-term care	By setting: long term care facilities, at home	ObSanté	OECD	IGSS	OECD Long-Term Care Quality Pilot 2025	Available (not publicly), updated annually
Five‑year net cancer survival rate by cancer site	By cancer site	ObSanté	CONCORD3	RNC4	RNC	Available (not publicly), updated every 5 years
Breast cancer PROMs – Pre‑operative and post-operative health status scale measured by the EORTC QLQ-C30 questionnaire			OECD		PaRIS Breast Cancer PROMs	Placeholder

1. Healthcare quality and outcomes

2. Fédération des Hôpitaux Luxembourgeois/Caisse nationale de santé

3. Global research programme led by the London School of Hygiene & Tropical Medicine (LSHTM) that tracks cancer survival rates worldwide, endorsed by WHO.

4. Registre National du Cancer.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Ischaemic stroke 30‑day mortality following an admission assesses acute care quality, reflecting outcomes after ischaemic stroke, which is a major cause of death. The indicator is measured among patient admitted to a hospital with a diagnosis of stroke, and can either capture only deaths during the hospitalisation or follow the patient across settings to capture deaths after a hospital discharge to provide a comprehensive picture of mortality outcomes. In addition, the indicator Rate of rehospitalisation within 1 to 30 days assesses care outcomes across hospitals and community care, incorporating a link with continuity of care (Section 3.2.5). The data to calculate the indicator is available, though the indicator has not yet been published in Luxembourg.

Aligned with comments from many stakeholders that quality should be better monitored in long-term care, the indicator on Share of people with physical or chemical restraints serves as a proxy of person-centred care practices. High levels of restraint use may indicate gaps in staff capacity, training, care organisation, or access to appropriate non‑pharmacological support. Breakdowns by long-term care setting are available (LTC facilities and at home). The methodology was piloted for the first time in 2025 as part of the OECD Long-Term Care Quality Pilot data collection, and data for Luxembourg has not yet been made publicly available. The methodology can be used to monitor national trends. However, stakeholder discussions underlined the importance of monitoring long-term care quality, leading to the inclusion of a dedicated indicator with methodology available in the Luxembourg’s HSPA.

The indicator Five‑year net cancer survival rate with breakdowns by cancer site monitors clinical outcomes after diagnosis of cancer. This is currently not publicly available, with data release for breast cancer survival expected in 2026. Estimations of five‑year survival for other cancer sites, such as colorectal, lung, prostate and blood cancers, will be available at a later date. Capturing patient perceptions, Breast cancer patient-reported outcome measures – pre‑operative and post-operative health status scale measured by the EORTC QLQ-C30 questionnaire. This indicator is currently a placeholder, as a programme to measure these outcomes has not yet started.

International comparison is possible for indicators for Ischaemic stroke 30‑day mortality, Share of people with restraints in LTC and Five‑year cancer survival.

Cost-efficiency

The Cost-efficiency subdomain describes the extent to which best possible value has been achieved in the use of health services and available resources. Four indicators were selected to monitor resource utilisation efficiency in hospitals and emergency care, and the efficient use of pharmaceuticals (Table 3.12).

Table 3.12. Cost-efficiency indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
In-patient average length of stay	By sex, age, and cause of stay (ICD‑10 diagnoses)	ObSanté	EUROSTAT	DiSa (Epistat)	JQNMHCS1	Available, updated annually
Proportion of day care cases for selected surgeries	By procedure type (e.g. cataract, tonsillectomy, inguinal hermia repair, circumcision)	ObSanté	OECD	IGSS	JQNMHCS	Available, updated annually
Share of emergency room visits classified as non-urgent	By demography, geography, (non)residency	IGSS	IGSS	IGSS	Rapport général sur la sécurité sociale	Available, updated annually
Share of generics in respective pharmaceutical market	By type of market (hospital, commuity, third-party)	ObSanté	OECD	IGSS	Health Data Questionnaire	Available, updated annually

1. Joint Questionnaire on Non-Monetary Healthcare Statistics.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

To capture efficiency of hospital care, the indicator on In-patient average length of stay serves as a proxy for overall hospital resource utilisation. Share of one‑day surgery in all surgery for selected procedures measures use of less resource‑intensive care delivery, with breakdowns by procedure type (e.g. cataracts, tonsillectomies, etc). The indicator on Share of emergency room visits classified as non-urgent puts the focus on potentially avoidable emergency department use, reflecting inefficient use of care resources.

The indicator Share of generics in respective pharmaceutical market measures cost-effective prescribing practices, reliance on generics over more expensive proprietary drugs. The indicator is available by type of market (hospital, community, third-party) and expressed as percentage of sales value and sales volume in the same market. Substitution with generics is currently restricted in Luxembourg (with exceptions). Analyses of this indicator are complemented with the contextualising indicator Share of biosimilars (DDDs) among all biologicals, which adds an additional information on value‑based care in use of pharmaceuticals (Annex D). International comparisons are available for all indicators, except the Share of non-urgent emergency room visits.

3.2.5. Processes: Integrated care domain

The Integrated care domain includes 12 indicators, covering three subdomains. The Prevention subdomain includes five indicators; Co‑ordination of care captures four and Continuity of care three indicators.

Prevention

The Prevention subdomain addresses the health system’s ability to prevent disease through primary prevention or timely detection through secondary prevention. Five indicators were therefore selected to assess overall prevention efforts and secondary prevention (Table 3.13). Following discussion among stakeholders, it was decided this subdomain would not include indicators on risk factors, which are captured in the subdomain on Behavioural determinants of health.

Table 3.13. Prevention indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Health expenditure on prevention	By type of provider	ObSanté	OECD	IGSS	System of health accounts	Available, updated annually
Causes of preventable mortality	By sex	ObSanté	EUROSTAT	DiSa, Epistat	Causes of deaths registry	Available, updated annually
Proportion (%) of children aged 25‑30 months old with complete vaccination as per the national vaccination schedule for children by age 2 years		DiSa (Epistat)	DiSa (Epistat)	DiSa (Epistat)	Children vaccination survey	Available, updated every 5 years
Self-reported screening of cardiovascular diseases and diabetes risks: blood pressure, cholesterol, blood sugar	By sex, age, education, income quintile, urbanisation	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS1	Available, updated every 6 years
Breast Cancer Screening population coverage		ObSanté	OECD	DiSa (Service de co‑ordination des depistages)	Programme mammographie	Available, updated annually

1. European Health Interview Survey.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Health expenditure on prevention measures financial investment in organised preventive services. This indicator also relates to the subdomain on Financial allocation, in the domain on Finances. The indicator Causes of preventable mortality measures outcomes of prevention efforts across the health system.

The indicator Proportion of children aged 25‑30 months old with complete vaccination as per the national vaccination schedule for children by age 2 years looks at primary prevention through childhood vaccination coverage. Self-reported screening of cardiovascular diseases and diabetes risks captures population-level coverage with a programme aiming to identify and reduce disease risk, with breakdowns by education, age, and degree of urbanisation. Secondary prevention is captured via Cancer screening for malignant neoplasms of female breast, focussing on organised screening programme coverage. A contextualising indicator on Colorectal cancer screening can be used to supplement analyses on screening coverage (Annex D).

International comparisons can be used for indicators derived from cross-country collections, including Health expenditure on prevention, Causes of preventable mortality and Breast cancer screening.

Co‑ordination of care

The Co‑ordination of care subdomain reviews the ongoing co‑ordination of multiple providers in the care of chronically ill patients, including measurement of the consequences of insufficient co‑ordination and the support of their long-term health needs. The selected four indicators capture organisational care co‑ordination activities as well as patient-reported experience of co‑ordination (Table 3.14). As all aspects of the subdomain definition are not covered with the selected set of indicators, future updates may consider an extension when relevant data is available.

Table 3.14. Co‑ordination of care indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Cancer patients discussed by multidisciplinary diagnostic teams		INC/RNC1	INC/RNC	INC/RNC	INC/RNC	Placeholder
Number of patients enrolled in the Réseaux de compétence (RdC)		DiSa (DMC-QS2)	DiSa (DMC-QS)	DiSa (DMC-QS)	Réseaux de compétences	Available (not publicly)
Experienced co‑ordination: patients with chronic conditions who report having a care plan available to them	By gender, age education, income	ObSanté	OECD	DiSa (DMC-QS) (data owner) / LIH (data producer)	PaRIS3 survey	Available, updated every 4 years
Experienced co‑ordination: patients with chronic conditions who report professionals in their care appear to be following the same care plan	By gender, age education, income	ObSanté	OECD	DiSa (DMC-QS) (data owner) / LIH (data producer)	PaRIS survey	Available, updated every 4 years

1. Institut National du Cancer/Registre National du Cancer

2. La division de la médecine curative et de la qualité en santé

3. Patient-Reported Indicator Surveys.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Cancer patients discussed by multidisciplinary diagnostic teams looks at collaborative care planning, enabling care co‑ordination. The indicator is a placeholder, pending reviews of data completeness and assessment of data sources. To reflect care co‑ordination beyond cancer, the indicator on Number of patients enrolled in the Réseaux de compétence (RdC) will measure the enrolment of patients in specialised care networks that offer structured co‑ordination support. Data are currently available (though not yet published) to capture participation in the Parkinson care network. In the future these data are expected to reflect the registration of patients in the other Réseaux de compétence operating in Luxembourg. These indicators were selected with input from health system stakeholders, who emphasised the importance of leveraging existing Réseaux de compétence frameworks as models for measuring integrated care, and expanding care co‑ordination indicators.

Two indicators from the OECD PaRIS survey capture patient-reported co‑ordination experiences among patients aged over 45 with chronic conditions. These indicators are Experienced co‑ordination: patients with chronic conditions who report having a care plan available to them and Experienced co‑ordination: patients with chronic conditions who report professionals in their care appear to be following the same care plan, both measured as a proportion of respondents. Breakdowns by age, gender, education and income are available from the survey microdata, which allow to capture socio-economic and demographic differences, in line with priorities identified by stakeholders. International comparisons are available for the patient-reported indicators.

Continuity of care

The Continuity of care subdomain measures the patient’s journey through the system (patient pathway) and the continuity of patient care between individual providers for a specific diagnosis. Three indicators were selected to assess care continuity, one in primary care and two during care transitions when patients are particularly vulnerable (Table 3.15).

Table 3.15. Continuity of care indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Percentage of patients that have been visiting the same primary care professional for more than five years	By gender, age education, income	ObSanté	OECD	DiSa, (DMC-QS1) (data owner) / LIH (data producer)	PaRIS2	Available, updated every 4 years
Unplanned/urgent inpatient admissions during the last days of life (end-of-life care)	By cause of death3; time period (last 30 or 180 days of life)	ObSanté	OECD	DiSa/IGSS	HCQO4	Available (not publicly), updated every 2 years
Suicide within 1 year after discharge among patients diagnosed with a mental disorder		ObSanté	OECD	DiSa/IGSS	HCQO4	Available (not publicly), updated every 2 years

1. La division de la médecine curative et de la qualité en santé

2. Patient-Reported Indicator Surveys

3. Causes include: all causes of death, Alzheimer’s and other dementias, cancer, cardiovascular diseases, chronic respiratory diseases. 4. Healthcare Quality and Outcomes. The indicators included in the HCQO Data Collection data source can be calculated by Luxembourg from existing data sources, and are planned to be provided in upcoming data collections. They are marked as not publicly available as despite underlying data and methodology availability, they have not yet been calculated.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on Percentage of patients that have been visiting the same primary care professional for more than five years from the OECD PaRIS survey focusses on the long-term relationships between patients and their primary care professionals, a key enabler of continuity of care and associated with positive patient experiences (OECD, 2025[5]). The survey data can be used to capture inequalities, consistent with stakeholder priorities. Analyses of this indicator are complemented with a contextual indicator on the Proportion of general practitioner (GP) consultations with the same physician per patient, which uses administrative data to provide a complementary measure of doctor-patient relationships (Annex D). This indicator has not been previously published, though data is available.

The indicator Unplanned/urgent inpatient admissions during the last days of life focusses on end-of-life care, capturing continuity by proxy of potentially avoidable hospitalisations had care been continuous and co‑ordinated across multiple providers, and aligned with patient preferences which are often to receive it at their home. A breakdown by cause of death and by time period (last 30 or 180 days of life) is available. Stakeholders identified indicators on avoidable healthcare utilisation as important to include, and, at the same time, wished to cover adequately long-term care and end-of-life care in the HSPA framework. In addition, the indicator on Suicide within 1 year after discharge among patients diagnosed with a mental disorder reflects continuity of care in follow-up to transitions to community care. The indicator was selected due to the identification of mental health as a high-priority focus area in Luxembourg (Section 2.3). Both of these indicators are included in the HCQO Data Collection, can be calculated by Luxembourg from existing data sources and are planned to be provided in upcoming data collections. However, for the moment, they have not yet been calculated. International comparisons are available for all indicators in this subdomain.

3.2.6. Inputs: Governance domain

The Governance domain includes five indicators, with two included in the Leadership subdomain and three in the Transparency and accountability subdomain.

Leadership

The Leadership subdomain refers to the capacity of making, changing, monitoring and enforcing the rules that govern the demand and supply of health services. The two selected indicators capture emergency and crisis preparedness capacity, and citizen engagement in health-system decision making (Table 3.16).

Table 3.16. Leadership indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
International Health Regulations (IHR) capacity score	ObSanté	WHO			Available, updated annually
Patients having a formal participatory role in health policy	ObSanté	OECD	ObSanté	OECD Health System Characteristics Survey	Available (not publicly)

Note: No breakdowns specified.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The International Health Regulations capacity score is a composite score of nationally self-assessed indicators for each of the 15 core capacities2 to detect, assess, notify and respond to potential public health events of international concern. Derived from an international questionnaire, benchmarking with other countries is possible.

The indicator on Patients having a formal participatory role in health policy is a composite indicator to evaluate the institutionalisation of patient voice in health policymaking. This indicator assesses whether patients have a formal role in five different health policy areas: (1) licensing of pharmaceuticals, (2) coverage or reimbursement, (3) health technology assessment, (4) decisions related to service planning, and (5) definition of public health objectives. The indicator methodology3 was developed by Belgium for the Belgian HSPA framework (Belgian Healthcare Knowledge Centre, 2024[6]), and the data is available for Luxembourg through the OECD Health Systems Characteristics Survey (OECD/The Health Foundation, 2025[7]).

Transparency & accountability

The Transparency and accountability subdomain describes the level of trustworthiness and responsiveness of the health system to the public, including making actions and decisions of health system actors visible, transparent, and subject to oversight. The three selected indicators reflect the outcomes of health governance, captured through trust clarity and actionability in set objectives and satisfaction with the health system (Table 3.17).

Table 3.17. Transparency & accountability indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Percentage of Objectives in National Action Plans or Programmes formulated according to SMART Criteria						Placeholder
Proportion of respondents expressing high satisfaction with the healthcare system	By level of trust (high, neutral, or low satisfaction)	ObSanté	OECD	OECD	OECD Trust Survey	Available, updated every 2 years
Trust in healthcare system	By gender, age education, income	ObSanté	OECD	DiSa (DMC-QS1) (data owner) / LIH (data producer)	PaRIS2	Available, updated every 4 years

1. La division de la médecine curative et de la qualité en santé

2. Patient-Reported Indicator Surveys.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Percentage of national action plans with measurable objectives measures the proportion of national strategic or action plans and programmes that include objectives meeting SMART criteria (Specific, Measurable, Achievable, Relevant, Time‑bound). It acts as a proxy for planning and monitoring quality and accountability in health governance. The indicator is a placeholder indicator, as the exact methodology and underlying data have not been defined.

The indicator on Trust in healthcare system refers to the percentage of primary care users with chronic conditions aged 45 and over who report trust in their healthcare system. The data are sourced from the OECD’s PaRIS survey, which enables international comparisons across participating countries with breakdowns available by age, gender, education and other characteristics through the survey microdata. During the indicator selection, stakeholder discussions noted that, in the event this indicator is unavailable in future cycles, an alternative indicator could be used to capture trust in the healthcare system among the overall adult population, derived from Eurofound’s annual Living and Working in the EU e‑survey.

The last indicator selected for this subdomain, Satisfaction with the healthcare system, captures an assessment of the system among the adult population. It comes from the OECD Trust Survey (OECD, 2024[8]), which allows for international comparisons.

3.2.7. Inputs: Infrastructure domain

The Infrastructure domain includes a total of 13 indicators under four subdomains: Physical resources includes four indicators, Pharmaceuticals has two, Digital health five and Research and development (R&D) has two indicators.

Physical resources

The Physical resources subdomain addresses the availability of facilities and equipment to provide health services according to population needs. The four selected indicators cover physical healthcare infrastructure across the care continuum (hospital, intensive and long-term care) and essential medical technology (Table 3.18). The availability of international benchmarks for all indicators facilitates identification of gaps and opportunities for improvement in Luxembourg’s health sector physical resources.

Table 3.18. Physical resources indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Hospital beds	By ownership status, healthcare function, care type	ObSanté	OECD	ObSanté	JQNMHCS1	Available, updated annually
Beds in residential long-term care (LTC) facilities		ObSanté	OECD	MiFa2	JQNMHCS	Available, updated annually
Adult intensive care unit (ICU) hospital beds		ObSanté	OECD	ObSanté	JQNMHCS	Available, updated annually
Medical technology availability (mammographs, Computed Tomography (CT) scanners, MRI units, PET scanners)	By healthcare provider	ObSanté	OECD	DiSa (Division de la Radio-protection)	JQNMHCS	Available, updated annually

1. Joint Questionnaire on Non-Monetary Healthcare Statistics

2. Ministère de la Famille, des Solidarités, du Vivre ensemble et de l’Accueil.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Hospital beds captures bed capacity across settings, and can be examined by hospital ownership status (e.g. public, private), healthcare function (e.g. curative, rehabilitative), and care type (e.g. day care, inpatient care) to provide a more detailed overview. Discussions among stakeholders during the indicator selection process highlighted a distinction could be made in the future between adult and paediatric beds to reflect health system restructuring in Luxembourg.

The Beds in residential long-term care indicator captures the capacity of residential long-term care facilities in Luxembourg and reflects availability of institutional care for individuals with ongoing care needs. In addition, the Adult intensive care unit hospital beds indicator looks at critical care bed capacity.

The indicator on Medical technology availability measures the number and the density of key diagnostic equipment (mammographs, Computed Tomography (CT) scanners, MRI units, and PET scanners), providing insight to the availability and distribution by type of healthcare provider.

Pharmaceuticals

The Pharmaceuticals subdomain refers to the availability of and access to essential and innovative medicinal products. The two selected indicators provide insight into guidelines-based prescribing practises and supply chain security (Table 3.19).

Table 3.19. Pharmaceuticals indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Use of targeted treatment for Human Epidermal growth factor Receptor 2 (HER) in breast cancer	ObSanté	OECD	DiSa (Epistat) /RNC1	HCQO2	Available, updated every 2 years
Drug shortages or supply constraints	DiSa/CNAL3	DiSa/CNAL	DiSa/CNAL		Placeholder

Note: No breakdowns specified.

1. Registre National du Cancer.

2. Healthcare Quality and Outcomes data collection.

3. Centrale nationale d’achat et de logistique.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on the Use of targeted treatment for Human Epidermal growth factor Receptor 2 (HER2) in breast cancer measures use of pharmaceuticals according to well-established guidelines for the treatment of HER2+ breast cancer. The indicator was first measured in 2025 as part of OECD work to develop cancer care quality indicators, and international comparisons are available. Luxembourg contributed data to the pilot data collection.

The Drug shortages or supply constraints indicator aims to capture the availability of medicines and security of supply chains – a topic prioritised as a result of input from stakeholders. This indicator is a placeholder indicator for the moment.

Digital health

The Digital health subdomain describes the integration of advanced technologies and digital innovations in healthcare to improve the accessibility, efficiency, and quality of health services. It involves making health information readily accessible to users of the health system and relevant providers, as well as the level of actual use of digital health and information. Five indicators selected cover digital health enabling conditions (such as investment and interoperability) and monitor implementation of digital solutions (Table 3.20).

Table 3.20. Digital health indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Investment in health Information and Communication Technology (ICT)		ObSanté	EUROSTAT	STATEC1	STATEC	Available, updated annually
Availability index score for electronic health records		ObSanté	European Commission5	Agence eSanté	Electronic health record	Available, updated annually
Practices that can exchange information with other practices		ObSanté	OECD	DiSa (DMC-QS2) (data owner) / LIH (data producer)	PaRIS3	Available, updated every 4 years
Proportion (%) of population having an electronic vaccination record (CVE)		Agence eSanté	Agence eSanté	Agence eSanté	Electronic vaccination records	Available, updated annually
Proportion (%) of ePrescriptions	By category (e.g. pharmaceutical, laboratory services)	CNS4	CNS	CNS	ePrescriptions	Placeholder

1. National Institute for Statistics and Economic Studies of Luxembourg.

2. La division de la médecine curative et de la qualité en santé

3. Patient-Reported Indicator Surveys

4. Caisse nationale de santé

5. Indicator available through European Commission (2024[9]), Report on the State of the Digital Decade 2024, Annex 2.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

Capturing an enabling condition for health system digitalisation, the indicator on Investment in health Information and Communication Technology gauges the financial commitment to digital health infrastructure development. The indicator on Availability index score for electronic health records (EHR) provides an assessment of electronic health data availability via four layers: (1) implementation of online access services for citizens, (2) categories of health data accessible (e.g. prescriptions, results, imaging, summaries), (3) access technology and coverage, (4) equitable access opportunities (e.g. access for guardians/authorised persons, support for disadvantaged groups). The indicator is defined in Annex 2 of European Commission Report on the State of the Digital Decade 2024 (European Commission, 2024[9]).

Monitoring operational implementation, the indicator on Practices that can exchange information with other practices captures information-exchange capabilities across primary care settings, derived from the provider questionnaire of the OECD PaRIS survey.

International comparisons are possible for these three indicators, while the below two indicators are built on national data only.

The indicator on the Proportion of the population with an electronic vaccination record (CVE) captures the implementation of digital vaccination records in Luxembourg. Given the recency of the implementation, the analysis would be accompanied by the contextual indicator The proportion of resident children aged 0‑14 years with an electronic vaccination record (CVE) to capture prevalence of the record among population who have more recently been included in the childhood vaccination schedule (Annex D). The Proportion of ePrescriptions indicator captures the rollout of electronic prescribing in Luxembourg. This indicator is currently retained as a placeholder, as the ePrescription system rollout is expected in 2026, after which the indicator will be monitored annually. Once the e‑vaccination and e‑prescription systems are fully implemented and achieve sufficiently broad population coverage, the corresponding indicators may be replaced in the HSPA framework with those capturing evolving digitalisation priorities.

Research and development

The Research and development subdomain addresses the level of Luxembourg’s involvement in medical research and innovative activities, creating carrier development opportunities for health workforce. The indicators were chosen to reflect the financial investment in R&D and Luxembourg’s involvement in international research activity (Table 3.21).

Table 3.21. Research and development indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Government budget allocations for R&D in health	ObSanté	EUROSTAT	STATEC/IGF1	Government budget	Available, updated annually
Clinical trials started per year with Luxembourg’s participation and number of active sites in Luxembourg		European Medicines Agency (Clinical Trials Information System)			Placeholder

Note: No breakdowns specified.

1. National Institute for Statistics and Economic Studies of Luxembourg/Inspection générale des finances.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator government budget allocations for R&D in health captures public financial commitment to enabling health research and innovation. The indicator Clinical trials started per year with Luxembourg’s participation and the number of active sites in Luxembourg reflects the country’s engagement in clinical research and its attractiveness as a research location. While a methodology and underlying data for this indicator are available, data for Luxembourg are not regularly reported. International comparisons for both indicators are available. Analyses on clinical trials would be complemented with contextual indicators on the Share of early-phase (Phase I and II) clinical trials among total new clinical trials and the Share of total new clinical trials conducted in the EU (Annex D). During indicator selection, stakeholders noted their value for a more comprehensive assessment of the clinical research landscape.

3.2.8. Inputs: Workforce domain

The Workforce domain includes a total of seven indicators under two subdomains. The Training subdomain has four indicators, while the Workforce capacity subdomain has three.

Training

The Training subdomain relates to the provision of training of medical professionals. The indicators were selected to cover training across the professional lifecycle, including initial education (medical and nursing graduates), entry into practice (licensing), and continuous learning and training (Table 3.22). Together, they assess Luxembourg’s support to its health workforce capacity to meet the needs of its population.

Table 3.22. Training indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Number of medical graduates who obtained their degree in Luxembourg		ObSanté	OECD	University of Luxembourg	JQNMHCS1	Placeholder
Number of nursing graduates who obtained their degree in Luxembourg		ObSanté	OECD	ENSA2 / University of Luxembourg	JQNMHCS	Available, updated annually
Newly licensed to practise health professionals in Luxembourg3	By profession	ObSanté	STATEC	M3S4	Healthcare professionals registry	Available, updated annually
Extent to which continuous learning and training for health workers is formalised and implemented		Collège Médical	Collège médical	Collège Médical		Placeholder

1. Joint Questionnaire on Non-Monetary Healthcare Statistics

2. Ecole nationale de santé du Luxembourg.

3. Newly awarded certification in Luxembourg or recognised from abroad.

4. Ministry of Health and Social Security.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

Capturing undergraduate education, the Number of medical graduates who obtained their degree in Luxembourg and the Number of nursing graduates who obtained their degree in Luxembourg approximate the domestic production of physicians and nurses. Luxembourg plans to introduce its first full training programme for physicians in the coming years, meaning the indicator will become applicable once the first cohorts complete their training and obtain a degree in the country. Further, the indicator “The number of current medical students in Luxembourg” may also provide additional contextual information but is retained as a placeholder until the programme becomes fully established (Annex D). Both indicators are part of international OECD data collections, and international comparisons are available.

Regarding entry into practice, the indicator Newly licensed-to-practise health professionals in Luxembourg cover both domestically trained and foreign-trained health professionals who were awarded a licence to practice in Luxembourg (Reconnaissance de diplômes étrangers). A breakdown by profession is available, with published data by STATEC on nurses, midwives and healthcare assistants. The underlying Registry of Healthcare Professionals additionally contains information about physicians, and could be used for cross-country analyses, drawing also from the OECD indicator on Foreign-trained doctors.

The indicator Extent to which continuous learning and training for health workers is formalised and implemented looks at continuing professional development (CPD), capturing systems in place to support skills maintenance and development among health professionals. At present, the indicator is a placeholder, as the methodology can be developed once the Collège Médical starts collecting data on CPD activities. Monitoring of CPD was considered high priority by stakeholders given existing legislation on the topic is not enforced, despite the importance of continuous learning in maintaining professional competence in the health workforce.

Workforce capacity

The Workforce subdomain describes the number, availability, migration, and skill mix of healthcare service providers. The three selected indicators were chosen to cover key health professionals: nurses, doctors and long-term care workers (Table 3.23).

Table 3.23. Workforce capacity indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Practicing nurses	By sex, age, country of birth, country of residence	ObSanté	OECD	IGSS	JQNMHCS1	Available, updated annually
Practicing physicians	By sex, age, specialisation, country of birth, country of residence	ObSanté	OECD	IGSS	JQNMHCS	Available, updated annually
Long-term care workers	By work setting (at home or in institutions)	ObSanté	OECD	IGSS	Health Data Questionnaire	Available, updated annually

1. Joint Questionnaire on Non-Monetary Healthcare Statistics.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The number and density of Practicing nurses, Practicing physicians and Formal long-term care workers look at key workforce stock and availability. These indicators can be disaggregated by age, sex, country of birth, and country of residence, as well as by work setting (for long-term care workers). Further breakdown by specialisation for doctors is available nationally (Inspection générale de la sécurité sociale, 2026[10]). Although the breakdown has not yet become available in international databases, it is expected to be in the future. All indicators in this subdomain are sourced from international data collections by the OECD, and international comparison is possible.

3.2.9. Inputs: Finances domain

The Finances domain includes a total of ten indicators captured in two subdomains. The Fiscal sustainability subdomain includes six indicators, while Financial allocation includes four.

Fiscal sustainability

The Fiscal sustainability subdomain covers the system’s revenue sources, the availability and stability of financial resources over time, and evaluates their adequacy to sustainably cover the system’s expenditures. Six indicators were chosen to enable an overall evaluation of whether the health system has adequate financial resources to meet current and future health needs and monitor the composition of funding schemes, notably from the insurance schemes and public sources (Table 3.24).

Table 3.24. Fiscal sustainability indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Health expenditure by financing type	By financing scheme	ObSanté	OECD	IGSS	JHAQ1	Available, updated annually
Public spending on health	By health function and provider	ObSanté	OECD	IGSS	JHAQ	Available, updated annually
Public spending on healthcare and LTC – forecasts		ObSanté	European Commission	IGSS	2024 Ageing Report2	Available, updated annually
Trend in health and maternity insurance operating balances		IGSS	IGSS	CNS3	Décompte annuel de l’AMM	Available, updated annually
Ratio between the reserve and sickness insurance costs		IGSS	IGSS	CNS	Décompte annuel de l’AMM	Available, updated annually
Ratio between the reserve and LTC insurance costs		IGSS	IGSS	CNS	Décompte annuel de l’AD	Available, updated annually

1. Joint Health Accounts Questionnaire.

2. European Commission, Directorate-General for Economic and Financial Affairs (2024) 2024 Ageing Report: Economic and Budgetary Projections for the EU Member States (2022-2070).

3. Caisse nationale de santé.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The overall composition of spending is captured with the indicator Health expenditure by financing type. This indicator allows disaggregation to assess the respective contributions of government schemes, compulsory health insurance, voluntary health insurance and out-of-pocket spending. The indicator Public spending on health reflects the share of health expenditure within overall government budget allocations and as a share of Gross Domestic Product (GDP), allowing for a breakdown by health function and provider type. The indicator Public spending on healthcare and long-term care – forecasts provides information on the long-term sustainability of public spending, with projections available as a percentage of GDP for the period 2022-2070. The projections build on the work of the Economic Policy Committee’s Ageing Working Group, as part of a mandate by the Economic and Financial Affairs Council of the European Union (European Commission, Directorate-General for Economic and Financial Affairs, 2024[11]). International comparison is available for these indicators through the OECD database and a report by the European Commission.

Capturing the adequacy of overall financial resources to meet needs, the indicator on the Trend in health and maternity insurance operation balances measures the operating balance of Luxembourg’s health and maternity insurance scheme (assurance maladie‑maternité). Two indicators monitor the short-term financial resilience of the insurance funds: Ratio between the reserve and sickness insurance costs and Ratio between the reserve and LTC insurance costs. Luxembourg’s legislation mandates a minimum reserve equal to 10% of annual current expenditures for both funds to ensure their capacity to meet short-term obligations and withstand financial shocks. These two indicators were introduced based on the High-Level Advisory Board’s suggestions during the finalisation of the set of HSPA indicators (see Section 3.1.3).

Financial allocation

The Financial allocation subdomain covers how funds and budgetary allocations are distributed across different providers, services, and functions within the health system. Four indicators were chosen to provide insight to financial resource allocation and areas where investment may be misaligned with population health needs or health priorities (Table 3.25).

Table 3.25. Financial allocation indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Total healthcare expenditure	By location of care1	ObSanté	OECD/ IGSS	IGSS	JHAQ2	Available, updated annually
Health expenditure by provider type	By provider type (hospitals, outpatient providers, LTC facilities, etc.)3	ObSanté	OECD	IGSS	JHAQ	Available, updated annually
Health expenditure by type of service	By type of service (inpatient care, day care, outpatient care, LTC, etc)	ObSanté	OECD	IGSS	JHAQ	Available, updated annually
Health expenditure by function	By function (curative, rehabilitative, long-term, ancillary services, medical goods, preventive care, governance and administration)	ObSanté	OECD	IGSS	JHAQ	Available, updated annually

1. In Luxembourg and abroad (for people insured in Luxembourg).

2. Joint Health Accounts Questionnaire.

3. Including services provided abroad for residents.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The Total health expenditure indicator captures overall health spending, and can be compared internationally at the country level. Luxembourg-specific breakdown by location of care distinguishes between services provided in Luxembourg and those delivered abroad to residents insured in Luxembourg. Relevant to Luxembourg’s context, this indicator provides insights into spending related to cross-border care.

Indicators on Health expenditure by provider type and Health expenditure by type of service capture where and how health spending is incurred. Respectively, they include a breakdown across provider types, such as hospitals, outpatient providers and long-term care facilities, and by type of service, such as inpatient, day care, outpatient and long-term care services. In addition, the indicator on Health expenditure by function measures expenditure by care function, including curative, rehabilitative, long-term and preventive care, medical goods, ancillary services, and health system governance and financing administration. All indicators are expressed as a share of GDP, at purchasing power parity (PPP) per capita, and as a share of total health expenditure.

International comparisons are available for all indicators through the OECD Health Statistics database (2025[4]). However, the breakdown of total health expenditure by care location is specific to Luxembourg and therefore does not allow for international benchmarking.

3.2.10. Cross-cutting: Sustainability domain

The Sustainability domain includes a total of six indicators in two subdomains. The Resilience subdomain includes four indicators, while Climate change subdomain includes two.

Resilience

The Resilience subdomain refers to the proactive capacity of health system organisations, units, teams, and individuals to anticipate, adapt to, and respond swiftly to changes and challenges – ensuring continuity and quality of care without merely resisting disruption. Four indicators were selected to assess the dimensions of antimicrobial resistance, emergency preparedness, and workforce well-being (Table 3.26).

Table 3.26. Resilience indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Preparing for disaster and emergency response programmes – expenditures	ObSanté	OECD		JHAQ1	Placeholder
Quality of Work index for salaried persons working in “Santé humaine et action sociale” (NACE)	CSL2	CSL	CSL/ University of Luxembourg	Survey Quality of Work Index Luxembourg	Available, updated annually
Percentage of antibiotic resistance by antibiotic class	DiSa (DMC-QS3)	ECDC	DiSa (DMC-QS), LNS	EARS-Net4	Available
Concentrations of macrolide antibiotics measured in surface waters	DiSa	DiSa	AGE5		Available

Note: No breakdowns specified.

1. Joint Health Accounts Questionnaire

2. Chambre des salaries

3. Division de la Médecine Curative et de la Qualité en Santé

4. European Antimicrobial Resistance Surveillance Network

5. Administration de la gestion de l’eau.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

Looking at emergency preparedness, the indicator on Expenditures on preparing for disaster and emergency response programmes measures financial investment in readiness and response capacity. It is collected through the Joint Health Accounts Questionnaire, and forms a sub-category under the health functions category of prevention. The indicator is currently a placeholder as data are not available for Luxembourg.

The indicator Quality of work index for salaried persons working in “Santé humaine et action sociale” (NACE category) assesses working conditions and well-being among health and social care workers, recognising workforce as a cornerstone for resilience (CLS, 2025[12]). The underlying Survey Quality of Work Index Luxembourg includes cross-border workers in the sector.

Antimicrobial threats are characterised via two indicators. The Percentage of antibiotic resistance by antibiotic class, which monitors and characterises a critical threat to health. Analyses of this indicator will be complemented by a contextualising indicator on Antimicrobial resistance rates by pathogen – antibiotic combination (Annex D). In addition, the indicator Concentrations of macrolide antibiotics measured in surface waters provides supplementary information on antibiotic presence in the environment, reflecting use of antibiotics and characterising an environmental threat.

Climate change

The Climate change subdomain addresses the health system’s ability to adapt, respond, and remain resilient to climate‑related health threats while minimising its own environmental impact. Two indicators were selected to measure the health system’s environmental footprint as well as the effect on a vulnerable population (Table 3.27). Due to limited metrics available, the subdomain is not captured in full by the current Luxembourg’s HSPA indicators. Luxembourg’s authorities may wish to reassess measurement options in the future by adding or replacing some indicators.

Table 3.27. Climate change indicators

Name of the indicator	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Greenhouse gas emissions related to healthcare demand	ObSanté	OECD	OECD		Available, updated annually
Annual heat-related deaths of adults over 65 years old	ObSanté	The Lancet Countdown on health and climate change			Placeholder

Note: No breakdowns specified. Both indicators refer to estimates. The data for Annual heat-related deaths in adults over 65 years old is sourced from academic articles.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Greenhouse gas emissions related to healthcare demand measures emissions in tonnes of CO₂ equivalent per capita and as a percentage of national emissions. This indicator provides insight into the healthcare sector’s environmental impact and contribution to climate change, and refers to an estimate resulting from a modelling work building on OECD data. International comparisons are available.

The impact on a vulnerable population is captured as the Annual heat-related deaths of adults over 65 years old, which provides incidence estimates of country-level data and a percentage change in heat-related mortality rates between 1990-1999 and 2014-2023. The indicator is marked as a placeholder as the data has been published in two separate articles in the Lancet. Analyses are supplemented by a contextual indicator on Hospitalisations due to heat related conditions (based on emergency department visits) (Annex D).

3.2.11. Cross-cutting: Determinants of health domain

The Determinants of health domain includes a total of eight indicators in two subdomains. The subdomain on Behavioural risk factors captures six indicators, while the Non-behavioural determinants include two.

Behavioural risk factors

The Behavioural risk factors subdomain describes people’s actions or habits that are modifiable in order to promote their health, reduce risky behaviour and improve their health. Behavioural risk factors can be affected by individual or population-based prevention efforts. Six indicators were selected to assess key modifiable risk factors across the lifespan, breakdowns of which capture equity dimensions (Table 3.28).

Table 3.28. Behavioural risk factors indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Overweight and obesity in 15‑year‑olds	By gender, perceived wealth (affluence)	ObSanté	WHO	University of Luxembourg	HBSC1	Available, updated every 4 years
Daily smokers of tobacco products	By sex, age, education	ObSanté	EUROSTAT	DiSa (Division de la médecine préventive)	Fondation Cancer (ILRES2 survey)	Available, updated annually
Frequency of alcohol consumption	By sex, age, education, income	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS5	Available, updated every 6 years
Health-enhancing physical activity	By sex, age, education, income	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS	Available, updated every 6 years
Daily consumption of fruit and vegetables	By sex, age, education, income	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS	Available, updated every 6 years
Overweight and obesity in adults	By sex, age, education, income	ObSanté	EUROSTAT	STATEC3	EU-SILC4	Available, updated every 3 years

1. Health Behaviour in School-aged Children

2. Institut luxembourgeois de recherches sociales et d’études de marchés

3. National Institute for Statistics and Economic Studies of Luxembourg

4. European Union Statistics on Income and Living Conditions

5. European Health Interview Survey.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

Regarding behavioural risk factors among adolescents, the indicator 15‑year‑olds who self-reported obesity or overweight has breakdowns by gender and perceived wealth to capture equity. While the Health Behaviour in School-aged Children (HBSC) survey provides measurements at various ages, age 15 is commonly used in international benchmarking of adolescents’ behavioural risk factors.

Among adults, the indicators on Daily smokers of tobacco products, Frequency of alcohol consumption, and Health-enhancing physical activity and Daily consumption of fruit and vegetables capture behavioural health risks, and provide breakdowns by education, income, sex, and age to capture differences. The prevalence of Overweight and obesity in adults reflects an important health risk in adulthood. International comparisons are available for all indicators in this subdomain, as data sources are various international surveys.

Non-behavioural determinants

The Non-behavioural determinants subdomain focusses on conditions surrounding the living environment (home, study, work and leisure environment), including the natural and artificial environment, which affect or can affect population health and well-being. Two indicators selected to capture this domain focus on health impacts of air pollution (Table 3.29).

Table 3.29. Non-behavioural determinants indicators

Name of the indicator	Breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Death rate attributed to household and ambient air pollution	By pollution type (ambient, household)	ObSanté	WHO (Global Health Expenditure Database)			Available
Health impact of air pollution (years of life lost (YLL) and premature deaths) due to exposure to fine particulate matter (PM2.5)		ObSanté	EUROSTAT, calculated by the European Environmental Agency			Available

Note: Both indicators refer to estimates.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on Ambient and household air pollution attributable death rate reflects air pollution-related mortality in the population, including various emission sources like industrial activities, polluting fuel use in households, traffic (i.e. vehicles, trucks, etc.) and others. As household indoor pollution is low in Luxembourg due to low use of polluting cooking sources, a breakdown by pollution type is possible to emphasise the impact of ambient/outdoor sources. The disease burden is based on Global Burden of Disease estimates (IHME, 2025[13]) which for Luxembourg are not based on country data but estimated based on neighbouring and similar countries. The indicator Health impacts of air pollution in terms of years of life lost (YLL) and premature deaths due to exposure to fine particulate matter (PM2.5) measures the mortality burden attributable particulate matter smaller than 2.5 micrometres in diameter, which pose the greatest risk to health among air pollution types. The indicator is calculated as an estimate by the European Environmental Agency, using available air quality and population outcomes data (Soares et al., 2025[14]). International comparisons are available for both indicators. Given that both indicators reflect estimates rather than measured data, complementary or alternative data sources are planned to be evaluated in the future.

3.2.12. Cross-cutting: Equity domain

The Equity domain includes a total of five indicators in two subdomains. The Demographic and geographic equity subdomain includes two indicators, while the Socio‑economic equity subdomain captures three.

Demographic and geographic equity

The Demographic and geographic equity subdomain describes demographic and geographic factors that can affect or determine access to health services or exposure to health risks. Two indicators were selected to assess these dimensions (Table 3.30).

Table 3.30. Demographic and geographic equity indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Self-reported unmet needs for medical examination	By sex, age, degree of urbanisation	ObSanté	EUROSTAT	STATEC2	EU-SILC3	Available, updated annually
Reported victims of domestic violence		MEGA1	MEGA	MEGA	MEGA	Available, updated annually

1. Le ministère de l’Égalité des genres et de la Diversité

2. National Institute for Statistics and Economic Studies of Luxembourg

3. European Union Statistics on Income and Living Conditions.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator on Self-reported unmet needs for medical examination measures perceived access to health services, capturing barriers through reasons declared for unmet need, including distance, waiting times and cost. Breakdowns by degree of urbanisation, sex and age provide insight on the geographic and demographic gradients. International comparisons are available for this indicator.

The indicator Victims of domestic violence captures an important issue disproportionately affecting women. The indicator is compiled by the Ministry of Gender Equality by aggregating use of services aimed at supporting victims.

Additionally, demographic equity measurements by dimensions of sex and age is available through many of the indicators in other domains through data analysis breakdowns.

Socio‑economic equity

The Socio‑economic equity subdomain describes the influence of socio-economic factors (e.g. income, education) on health and health behaviours. Three indicators were selected to assess how income and social benefits relate to general health status, access to healthcare, and utilisation (Table 3.31).

Table 3.31. Socio‑economic equity indicators

Name of the indicator	Indicator breakdown	HSPA Indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA	Indicator availability
Self-perceived health by income and education	By sex, age, education, income, degree of urbanisation	ObSanté	EUROSTAT	STATEC1	EU-SILC2	Available, updated annually
Self-reported unmet needs for medical examination – by main reasons declared	By sex, age, education, income, degree of urbanisation	ObSanté	EUROSTAT	STATEC	EU-SILC	Available, updated annually
Use of hospital emergency care by allocation of vie chère social benefits		IGSS	IGSS	IGSS	Cahier statistique no 15	Available, updated on request

1. National Institute for Statistics and Economic Studies of Luxembourg

2. European Union Statistics on Income and Living Conditions.

Source: Developing the HSPA framework for Luxembourg project, January 2026.

The indicator Self-perceived health by income and education measures subjective health status, with breakdowns relevant to capture individual and intersectional (as a result of multiple factors) risks. Looking at healthcare access, the indicator on Self-reported unmet needs for medical examination and by main reasons declared measures perceived access barriers and their reasons. The indicator includes breakdowns by income, education, sex and age. The main reason declared for the unmet medical needs provides insight into cost, waiting times and distance barriers. International comparisons are available for the self-perceived health and unmet needs indicators via the Eurostat database.

The indicator Rate of use of hospital emergency care by allocation of “vie chère” social benefits assesses healthcare utilisation, looking at whether recipients of a specific social benefit, proxy for socio-economic vulnerability, use emergency care at different rates than the general population. This indicator provides insight into potential gaps in primary care access among vulnerable groups in Luxembourg.

3.3. Use case example: assessing mental healthcare and outcomes through HSPA indicators

This section presents an illustrative example of how Luxembourg’s HSPA framework can be used to analyse a specific policy-relevant theme. The objective is to demonstrate how HSPA indicators can be combined to support a coherent assessment and to illustrate how links across framework domains can be used to better understand health system performance in a given area.

Mental health was selected as a use case due to its high and growing relevance for health policy in Luxembourg, while recognising that it represents only one of several possible themes that could be examined using the HSPA. In the framework, mental health is given particular visibility through a dedicated subdomain, reflecting its importance for the country. At the same time, mental health outcomes are closely linked to the availability of resources and the organisation and quality of care, thus, relevant indicators are also found across other domains and subdomains of the framework. Figure 3.3 shows the localisation of indicators in Luxembourg’s HSPA framework that can be possibly used to examine mental healthcare and outcomes.

The fact that mental health-related indicators are spread across various domains makes this topic particularly well-suited to illustrate the analytical potential of Luxembourg’s HSPA framework. Mental healthcare and outcomes are influenced by factors ranging from prevention and population health to service availability, workforce capacity, care delivery and longer-term support needs. By capitalising on selected indicators from across the framework, this use case example shows how the HSPA can move beyond siloed analysis and support a more integrated assessment of mental health system performance.

Figure 3.3. The location and number of mental health-related indicators in Luxembourg’s HSPA framework

Source: Developing the HSPA framework for Luxembourg project.

3.3.1. Mental health and care‑related input indicators can help assess workforce and physical capacity in mental healthcare delivery

Input indicators capture the structural and workforce resources available to the health system, including mental healthcare. These indicators are best interpreted as enabling conditions that need to be assessed alongside indicators on service delivery, quality and outcomes. Table 3.32 presents two input indicators that are particularly relevant for mental health.

Table 3.32. Input indicators that can be used to capture mental healthcare in Luxembourg’s framework

Domain and subdomain	Name of the indicator	Indicator breakdown	HSPA indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA
Infrastructure/Physical resources	Hospital beds	Ownership status, healthcare function, care type	ObSanté	OECD	ObSanté	JQNMHCS1
Workforce/ Workforce capacity	Practicing physicians	Age, sex, specialisation, country of birth, country of residence	ObSanté	OECD	IGSS	JQNMHCS

1. Joint Questionnaire on Non-Monetary Healthcare Statistics.

The Hospital beds indicator under the Physical resources subdomain can provide information on the number of psychiatric beds in Luxembourg, as a care‑type breakdown is available. This disaggregation makes it possible to assess both the level and trends in inpatient psychiatric capacity, including through international benchmarking (Figure 3.4). However, interpretation of this indicator requires caution: while many countries are deliberately reducing psychiatric bed stocks as part of a shift towards community-based models of mental healthcare, a decline in inpatient psychiatric beds should not be interpreted in isolation as a positive development. Without a parallel strengthening of outpatient mental health services, reductions in inpatient capacity may lead to unintended consequences, such as persistently high occupancy rates, increased pressure on remaining beds, delayed access to care, or unmet needs. Further, a reduction in bed capacity may reflect factors other than shifts towards community-based care, such as the reallocation of beds to other services facing capacity pressures or constraints related to staffing shortages that limit the ability to operate inpatient units. This highlights the importance of analysing mental health system performance in a holistic and cross-cutting manner, rather than drawing conclusions from isolated infrastructure indicators.

Similarly, the Practising physicians indicator, when disaggregated by specialisation, can provide insight into the availability and trends of psychiatrists and psychotherapists in the country (Inspection générale de la sécurité sociale, 2026[10]). These indicators can jointly inform policy discussions on mental health system inputs.

Figure 3.4. Hospital beds in psychiatric care can provide insights on bed capacity and shift towards community-based models of mental healthcare

Note: Data refer to 2023 or nearest year.

Source: OECD Health Statistics 2026.

3.3.2. Process indicators related to mental health and care can capture how mental healthcare is organised, accessed and delivered

Process indicators can capture how mental healthcare is organised, accessed and delivered across the health system. In the context of mental health, relevant process indicators in the HSPA framework can help assess access issues due to financial barriers, quality of care, reliance on tertiary services, and the extent to which the system supports continuity of care beyond inpatient settings. Table 3.33 presents five process indicators relevant to mental health, spanning across Access to care, Value‑based care and Integrated care domains of Luxembourg’s HSPA framework.

Table 3.33. Process indicators that can be used to capture mental healthcare in Luxembourg’s HSPA framework

Domain and subdomain	Name of the indicator	Indicator breakdown	HSPA indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA
Access to care/ Financial protection	Unmet need for mental healthcare due to financial reasons	Sex, age, income quintile and level of disability	ObSsanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS1
Value‑based care/ Cost-efficiency	In-patient average length of stay	Age, sex, cause of disease (ICD‑10)2	ObSanté	EUROSTAT	DiSa (Epistat)	JQNMHCS3
Integrated care/ Co‑ordination of care	Experienced co‑ordination: patients with chronic conditions who report having a care plan available to them	Age, gender, education and more	ObSanté	OECD	DiSa (DMC-QS4) (data owner) / LIH (data producer)	PaRIS
Integrated care/ Co‑ordination of care	Experienced co‑ordination: patients with chronic conditions who report professionals in their care appear to be following the same care plan	Age, gender, education and more	ObSanté	OECD	DiSa (DMC-QS) (data owner) / LIH (data producer)	PaRIS
Integrated care/ Continuity of care	Suicide within 1 year after discharge among patients diagnosed with a mental disorder		ObSanté	OECD	DiSa/IGSS	HCQO5 data collection

1. European Health Interview Survey.

2. 10th revision of the International Classification of Diseases.

3. Joint Questionnaire on Non-Monetary Healthcare Statistics.

4. La division de la médecine curative et de la qualité en santé.

5. Healthcare quality and outcomes.

Unmet need for mental healthcare due to financial reasons from the European Health Interview Survey (EHIS) captures self-reported unmet need due to financial costs. It reflects the proportion of respondents among those who reported needing mental healthcare who declared these needs were unmet due to financial reasons. This indicator provides insights to whether financial barriers are a binding constraint to access and whether cost-related unmet need is concentrated in specific population groups (e.g. by income, age or insurance status, where available).

Inpatient average length of stay (ALOS) within the Value‑based care domain has a breakdown available for disease groups including mental and behavioural disorders (Figure 3.5). Therefore, it can help understand how inpatient psychiatric services are used and to signal whether the system relies heavily on hospital-based care. In principle, a sustained shift toward community-based care models may be accompanied by shorter inpatient stays over time, particularly if strengthened outpatient and follow-up services enable earlier discharge and continuity of care. However, ALOS is not a standalone “performance” measure: it is also shaped by the case‑mix and severity of admitted patients, clinical practice patterns, and crucially by capacity constraints (e.g. bed availability and staffing). In systems with high bed occupancy or limited capacity, ALOS may fall because patients are discharged earlier to free beds, potentially increasing the risk of relapse or crisis presentations. To avoid misinterpretation, psychiatric ALOS should be analysed together with other indicators, such as psychiatric bed capacity/occupancy or post-discharge outcomes (including suicide following discharge where available), to assess whether shorter stays reflect better care pathways or simply pressure on inpatient services.

Experienced care co‑ordination indicators from the OECD PaRIS survey under the Integrated care domain add a patient-reported perspective on whether outpatient and primary care services function in a co‑ordinated manner in mental healthcare. Using PaRIS microdata, the indicator can be calculated for mental health-related conditions to assess whether patients have a care plan or whether providers follow the same care plan for their conditions.

Finally, Suicide within one year after discharge under the same domain also provides a critical safety and continuity-of-care signal at the interface between inpatient and community care. It helps assess whether discharge planning, follow-up and community support are adequate to prevent severe adverse outcomes during a high-risk period. However, suicide is a relatively rare event and may be sensitive to small numbers, definitional differences and broader societal factors; it should not be used in isolation to judge service performance. It is most informative when combined with indicators on post-discharge follow-up and care co‑ordination, readmissions, and community service capacity, to assess whether the system provides sustained support after inpatient episodes. While figures for Luxembourg are not yet available for this indicator, the necessary data are available in DiSa and can be used to calculate it for HSPA purposes.

Figure 3.5. Inpatient average length of stay due to mental and behavioural disorders can signal how psychiatric care is used and whether the system relies heavily on inpatient care

Note: Data refer to 2023.

Source: Eurostat 2026.

3.3.3. Mental health and care‑related outcome indicators can capture the effectiveness of the mental health system and long-term consequences of mental health conditions

Outcome indicators related to mental health include indeed all three indicators in the Mental health subdomain, and three additional indicators from other subdomains. They capture the health status, literacy, well-being and longer-term consequences of mental health conditions, reflecting how effectively the health system and broader social environment support mental health needs. Table 3.34 summarises these indicators.

Table 3.34. Outcome indicators that can be used to capture mental healthcare in Luxembourg’s HSPA framework

Domain and subdomain	Name of the indicator	Indicator breakdown	HSPA indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA
Health status/ Mental health	Proportion (%) of adolescents reporting multiple health complaints	Gender, perceived wealth (affluence)	ObSanté	WHO	University of Luxembourg	HBSC1
Health status/ Mental health	Current depressive symptoms	Sex, age, country of birth	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS2
Health status/ Mental health	Emotional distress (feeling anxious, depressed or irritable)	Age, gender, education, income	ObSanté	OECD	DiSa (DMC-QS3) (data owner) / LIH (data producer)	PaRIS survey
Health status/ Population outcomes	Distribution of beneficiaries of LTC	Main cause of dependency (e.g. mental health)	IGSS	IGSS	IGSS	Rapport général sur la sécurité sociale
Person-centredness/ Health literacy	Mental health literacy				Placeholder

1. Health Behaviour in School-aged Children study.

2. European Health Interview Survey.

3. La division de la médecine curative et de la qualité en santé.

Within the Mental health subdomain, the Proportion of adolescents reporting multiple health complaints from the WHO Health Behaviour in School-aged Children study (HBSC) provides an early signal of mental distress by capturing both somatic symptoms (such as headache, stomach ache, backache and dizziness) and psychological symptoms (including feeling low, irritability or bad mood, nervousness and sleep difficulties). Disaggregation by gender and perceived wealth allows the identification of social and gender inequalities in adolescent mental health (Figure 3.6). As for adult population, the Current depressive symptoms indicator from EHIS measures the prevalence of depressive symptomatology, offering a population-level view of mental health burden (Figure 3.6). However, both indicators are based on self-reported symptoms rather than clinical diagnoses and should therefore be interpreted alongside indicators on the availability of, and access to, mental health services. To provide additional context on the mental health burden, the Antidepressant consumption indicator is planned as a contextualising measure (see Annex D). While this can help shed light on overall population mental well-being, it has notable limitations if considered in isolation, as the consumption can be influenced by factors such as access to care, prescribing practices, treatment pathways, and the availability of non-pharmacological interventions (e.g. psychotherapy as a first-line treatment for mild conditions).

Finally, Emotional distress (feeling anxious, depressed or irritable) from the OECD PaRIS survey captures the share of people with chronic conditions who report feeling emotional distress and how common they have these feelings, reflecting emotional well-being from the patient perspective. This indicator adds a person-centred dimension to outcome assessment and helps to link mental health outcomes to experiences of care. A key limitation of this indicator is that it applies only to populations covered by PaRIS and is therefore not representative of the general population; its interpretation should consequently be complemented with population-based mental health indicators.

Under the Population outcomes subdomain, the Distribution of long-term care beneficiaries by main cause of dependency can provide insight into the longer-term consequences of mental health conditions. This indicator highlights the intersection between mental health and long-term care systems and the impact of mental health conditions on functional dependency and care needs.

Mental health literacy, a placeholder indicator under the Person-centredness domain, reflects the population’s ability to recognise mental health problems, seek appropriate help and engage with care. While data and the indicator methodology are not yet available, this indicator is conceptually important for understanding outcomes related to prevention, early intervention and person-centred care.

Figure 3.6. Self-reported multiple health complaints and depressive symptoms can help understand mental health burden among adolescents and adults

 

Note: Unweighted OECD averages. For Panel A: Data refer to 2022. For Panel B: Data refer to 2019.

Source: For Panel A: (WHO, 2022[15]), Health Behaviour in School-aged Children survey. For Panel B: Eurostat (2026).

3.3.4. Cross-cutting indicators related to mental health in the HSPA framework bring a preventive perspective to the mental health system performance assessment

Mental health outcomes are strongly influenced by behavioural risk factors. Indicators capturing these determinants help situate mental health outcomes within a broader prevention efforts and risk-factor context, supporting a more comprehensive assessment of mental health system performance. Table 3.35 presents one such indicator drawn from the Determinants of health domain in Luxembourg’s HSPA framework.

Table 3.35. Cross-cutting indicator that can be used to capture mental healthcare in Luxembourg’s HSPA framework

Domain and subdomain	Name of the indicator	Indicator breakdown	HSPA indicator custodian	Indicator source for HSPA	Data custodian	Data source for HSPA
Determinants of health/ Behavioural risk factors	Frequency of alcohol consumption	Sex, age, education, income	ObSanté	EUROSTAT	DiSa (Epistat) (data owner) / LIH (data producer)	EHIS1

1. European Health Interview Survey.

The Frequency of alcohol consumption from the EHIS survey within the Behavioural risk factors subdomain captures a behavioural risk factor closely linked to mental health outcomes (Figure 3.7). While not a direct mental health outcome, harmful alcohol use both contributes to and results from mental health problems (Puddephatt et al., 2021[16]). In addition, disaggregation by age, sex and education allows identification of high-risk groups.

Figure 3.7. Frequency of alcohol consumption is an important behavioural risk factor affecting mental health and related conditions

Note: Data refer to 2019.

Source: Eurostat (2026).

Taken together, this use case example illustrates how Luxembourg’s HSPA framework can support a structured assessment of mental health in Luxembourg. By combining input, process and outcome indicators, the framework enables an analysis of the performance cutting across the health system. The inclusion of cross-cutting indicators further broadens the perspective by looking at mental health-linked behaviours, thus connecting to prevention efforts. The added value of the HSPA framework lies in moving beyond isolated indicators towards a more coherent understanding of mental health system performance, which can be applied to other areas of health and care for guiding policy recommendations.

References

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[12] CLS (2025), Quality of Work Index 2024: Tendances générales et focus sur la santé mentale et la prévention des addictions chez les salariés], Chambre des salariés du Luxembourg, https://www.csl.lu/app/uploads/2025/02/qow_2024_cnapa_20250212_presentation.pdf.

[9] European Commission (2024), Report on the state of Digital Decade 2024, European Commission, https://digital-strategy.ec.europa.eu/en/library/report-state-digital-decade-2024.

[11] European Commission, Directorate-General for Economic and Financial Affairs (2024), 2024 Ageing Report: Economic and budgetary projections for the EU Member States.

[13] IHME (2025), Global Burden of Disease 2023: Findings from the GBD 2023 Study, Institute for Health Metrics and Evaluation (IHME), https://www.healthdata.org/research-analysis/gbd.

[10] Inspection générale de la sécurité sociale (2026), Rapport général sur la sécurité sociale 2025, https://igss.gouvernement.lu/fr/publications/rg/2025.html.

[5] OECD (2025), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), OECD Publishing, Paris, https://doi.org/10.1787/c8af05a5-en.

[4] OECD (2025), OECD Health Statistics 2025, https://www.oecd.org/en/data/datasets/oecd-health-statistics.html.

[3] OECD (2025), Situational analysis of Luxembourg’s health data infrastructure for HSPA purposes, OECD, Paris, https://www.oecd.org/content/dam/oecd/en/about/projects/the-oecd-technical-support-to-national-hspa-development/Luxembourg-HSPA-Baseline-report.pdf.

[8] OECD (2024), OECD Survey on Drivers of Trust in Public Institutions – 2024 Results: Building Trust in a Complex Policy Environment, OECD Publishing, Paris, https://doi.org/10.1787/9a20554b-en.

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[2] OECD (2023), Health System Performance Assessment Framework for the Czech Republic, OECD Publishing, Paris, https://doi.org/10.1787/5d59b667-en.

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[16] Puddephatt, J. et al. (2021), “Associations of common mental disorder with alcohol use in the adult general population: a systematic review and meta‐analysis”, Addiction, Vol. 117/6, pp. 1543-1572, https://doi.org/10.1111/add.15735.

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[15] WHO (2022), Multiple health complaints, Health Behaviour in School-aged Children survey, https://data-browser.hbsc.org/measure/multiple-health-complaints/.

Notes

← 1.  The European Commission’s HSPA Expert Group provides the EU countries with a forum to exchange experiences on HSPAs at national level.

← 2.  The 15 core capacities are: policy, legal and normative instruments; IHR co‑ordination and National Focal Point functions; financing; laboratory capacity; surveillance; human resources; public health emergency management and preparedness; health service provision; infection prevention and control (IPC); risk communication and community engagement; points of entry such as ports, airports, and ground crossings; zoonotic events; food safety; chemical events; and radiation emergencies.

← 3.  Belgium’s HSPA indicator for “patients having a formal participatory role in health policy” is based on four distinct sub-indicators. These are: the presence of official patient representation in top-level advisory health policy councils; the existence and activity of patient councils or organisations involved in policymaking; legal or regulatory requirements mandating patient participation in health governance; the extent to which patient organisations participate in the design, implementation, or evaluation of health services and policies.