Health System Performance Assessment Framework for Luxembourg

1. Introduction: Health System Performance Assessment as a policy tool

Abstract

Health System Performance Assessment (HSPA) is a comprehensive evaluation of how a health system meets population needs, allocates resources, and achieves policy goals. In this regard, national HSPA frameworks structure available health data information for shared and informed policy and decision making.

The National Health Observatory (ObSanté) played a pivotal role in initiating the process of setting up a national HSPA framework for Luxembourg. The process was stakeholder-inclusive: the broad stakeholder participation in formulating the framework and selecting HSPA indicators ensured that the resulting HSPA framework is nationally relevant and enjoys shared ownership. The purpose of this report is to provide a groundwork for a transparent and accountable process of HSPA implementation in Luxembourg. It aims to foster greater awareness of and engagement in HSPA across its health system stakeholders and the public.

1.1. Structuring health data information for shared and informed decision making

1.1.1. Health System Performance Assessment is a comprehensive evaluation of how a health system meets population needs, allocates resources and achieves policy goals

Health systems across OECD Member countries have become increasingly data-rich environments, yet many still struggle to turn this wealth of information into useful insights for policy decisions. While available health data provide a means to manage and improve health system performance and healthcare quality, health data also helps respond to major public health challenges and advance scientific discoveries. With advances in digitalisation and health data infrastructure, the question turns from whether an information exists to whether it is used for the benefit of societies, and which information is the most relevant. This has been among the driving factors for Luxembourg’s decision to develop a national health system performance assessment framework (see Section 1.2).

Health system performance assessment (HSPA) plays an integral role in ensuring that health systems are delivering quality health services and population needs are being met (Box 1.1). An HSPA involves a comprehensive evaluation that examines the effectiveness, efficiency, equity, and responsiveness of a health system. Through routine systematic assessment of the performance of the health system – by looking at the health outcomes, processes, and structures – HSPA acts as a tool for policy and decision makers to identify areas that need further improvement, supporting efficient resource allocation and evaluation of attainment of policy objectives.

Box 1.1. What is a Health System Performance Assessment (HSPA)?

HSPA is a systematic approach to comprehensively evaluating a health system and its performance. An HSPA framework creates a structure for assessment that aligns with country health system context, specific objectives and assessment purposes. At the country level, an HSPA framework is a tool that helps to mobilise evidence to ensure that services are meeting the needs of the general population, patients and healthcare providers, while respecting the financial constraints.

An HSPA involves a routine assessment of performance of the health system overall to identify areas that need improvement or changes in direction, where resources can be allocated more efficiently, and whether policy objectives are being met.

Source: OECD (2026[1]), Learning through National Health System Performance Assessment (HSPA), https://doi.org/10.1787/2fa1314a-en.

1.1.2. National HSPA frameworks are strategic tools that build on international learning and benchmarking

Over the past decades, country-specific HSPA frameworks have been developed and used increasingly across OECD countries and regions to structure health data information for shared and informed policy and decision making. At the national level, HSPA frameworks most commonly serve as strategic tools to monitor performance, ensure accountability, and guide policy, while addressing challenges such as rising costs, ageing populations, and the need for stronger system resilience (OECD, 2026[1]).

The development and implementation of national HSPAs goes hand in hand with international learning and benchmarking. The role of international organisations in supporting HSPA frameworks’ development has been significant: In 2018, Fekri et al. (2018[2]) found that 17 of the 30 countries they examined acknowledged assistance from organisations such as the EU, OECD, World Health Organization and World Bank in their national reports. The OECD has been committed to help countries identify key principles of high-performing health systems and to assess health system performance based on internationally comparable health indicators. The renewed OECD HSPA framework, endorsed by the OECD Health Ministers in 2024, guides the organisation’s focus on further development of internationally comparable measurements, including a strong emphasis on measuring new dimensions of people‑centredness, health system resilience, and environmental sustainability (OECD, 2024[3]). Beyond developing metrics, the OECD has been providing direct technical assistance to its member countries to help design their national HSPA frameworks through participatory and inclusive processes; the technical support provided to Luxembourg and this report are direct outcomes of such bilateral co‑operation with Luxembourg’s authorities and stakeholders.

1.1.3. A systematised approach is needed to make an HSPA operational and sustainable

According to a recent analysis by the OECD (2026[1]), countries use national HSPA frameworks most commonly for performance monitoring, public accountability, and policy development, but also for other purposes. Setting a clear purpose and scope for a national HSPA has been identified as key to sustained implementation, and to the development of a national HSPA framework that would be adapted to the national context and health system and population needs. Stakeholder inclusion and their co-development are essential when setting up an HSPA framework to ensure the framework remains nationally relevant, while enabling international comparison and supporting evidence‑based improvements in health system performance – an approach undertaken also in Luxembourg for setting up its national HSPA (see Section 1.2.2).

Box 1.2. provides concepts behind national HSPA framework developments and international practice on defining scope, purpose and structure of a national HSPA. The Donabedian model (Donabedian, 1972[4]) – developed in the 1970s to assess healthcare quality – has remained a foundational approach to most national HSPA frameworks, though international developments led to distinguishing outputs of the health system from outcomes in some contexts alongside its three original components of structure, process, and outcomes. Luxembourg’s HSPA framework, presented in Chapter 2, has been developed along the same logic (Section 2.3).

Box 1.2. Concepts behind national HSPA frameworks development and international practice

Several steps need to be undertaken to develop an operational HSPA framework. The process needs (1) to set objectives for the HSPA, (2) to set a scope of Health, System, Performance analysis unit and tools, and Assessment functions, and (3) to develop a framework and (4) populate it with indicators. Then, (5) the HSPA needs to be substantiated by regularly updated data and reported in a timely manner.

First, clear objectives for the HSPA need to be set. These objectives are set and shared among stakeholders involved – particularly those whose performance will be assessed through the HSPA. For each HSPA, relevant stakeholders may vary depending on the scope and purpose of the HSPA. Meetings represented by relevant stakeholders are usually held to set and share objectives and provide input. In an increasing number of countries, citizens and patient groups/representatives have also been involved in setting HSPA objectives as efforts are made to transform health systems towards being more people centred.

Second, the scope of the HSPA needs to be set and it needs to clarify each of the following areas:

• Health (i.e. whether to refer to poor health outcomes, disease prevalence, and mortality, or will include disabilities and well-being)

• Systems (i.e. whether to refer to health system, healthcare systems and/or social care)

• Performance of overarching system, specific services and/or delivery systems

• Assessment functions such as management, policymaking, accountability, and/or improvement.

Like objective setting, the scope of the HSPA needs to be identified collectively by relevant stakeholders. A multi-stakeholder consultation process is particularly important for the level of performance assessment and assessment functions because buy-ins and engagement from relevant stakeholders bring successful operationalisation of the HSPA and subsequently lead to health system strengthening.

Third, a national HSPA framework needs to reflect objectives and scope set and needs to lay out key domains for health systems assessment. National HSPAs usually have a framework, which often uses structures/inputs, processes, outputs, and outcomes as key dimensions, and in each dimension, key domains that reflect health policy priorities are identified. In some countries’ HSPA frameworks, crosscutting themes such as equity, efficiency and/or sustainability are highlighted as dedicated domains (OECD, 2026[1]).

Fourth, the assessment framework needs to be populated with indicators, which are substantiated by data that are updated regularly to capture changes in health system performance in a timely manner. Indicators can be drawn from existing health statistics and/or newly developed, for instance by administering surveys or by allowing secondary use of health data and linking data sources. For national and international benchmarking, use of international indicators such as those developed at the OECD covering all spectrum of healthcare can be used (OECD, 2025[5]). Depending on the objectives and scope of the HSPA, newly developed indicators including people ‑centredness, patient safety culture, patient-reported experience measures for specific conditions and on patient safety, integrated care, and end-of-life care can be also considered for measurement.

Different types of measurements can be used to communicate health system performance. An HSPA framework can have a number of indicators, dashboards with key indicators or a compound index, which summarises health system performance. A decision on the type of measurements depends on the objectives as well as functions of the HSPA. If the HSPA is meant to signal overall performance to policymakers or for health system management, a summarised tool such as dashboards or compound indices may communicate the message better. But if the HSPA is meant to serve many stakeholders, for example, to change practices, more detailed data catered to each stakeholder may be useful. A mix of measurement types can be used since HSPAs often have a mix of objectives and functions.

Source: Adapted from OECD (2023[6]), Health System Performance Assessment Framework for the Czech Republic, Annex A, https://doi.org/10.1787/5d59b667-en.

Finally, OECD countries have diverse experience in implementing their national HSPAs successfully and sustainably. Though country situations differ, three enabling conditions have been identified to foster sustained HSPA implementation (OECD, 2026[1]):

• Robust health data infrastructure, which both supports HSPA and can be strengthened through it;

• Broad stakeholder engagement, ensuring ownership and co‑ordination across institutions;

• Alignment with national health policy priorities, facilitating long-term implementation and collaboration.

Luxembourg’s HSPA project has taken account of the international experience and followed good practice examples of countries that have a long history of national HSPA and those that are in the process of its implementation. This report takes stock of Luxembourg’s HSPA development as of January 2026, elaborating on the three enablers throughout its chapters.

1.2. Towards a commonly shared HSPA framework in Luxembourg

The National Health Observatory (Observatoire national de la santé, ObSanté) played a key role in initiating the process of setting up a national HSPA framework for Luxembourg, with the support of national authorities. The ObSanté, established in 2022, has a legal mandate to assess and report on the health status of the population, health determinants and the Luxembourgish healthcare system (The Government of the Grand-Duché of Luxembourg, 2021[7]). In fulfilling its role, it has sought to follow the best international practice and provide Luxembourg’s policy and decision makers with the most suitable tools. Likewise, any assessment and reporting are influenced by the national context and specificities, such as for instance the cross-border characteristics of Luxembourg’s health system and its strong reliance on health professionals trained and/or living abroad. In addition, strategic planning has been seen as necessary to cope with the health system sustainability issues stemming from the demographic pressure, financial constraints, health workforce availability issues, and health system’s environmental footprint. Therefore, in 2024, the ObSanté initiated Luxembourg authorities’ request for technical assistance from the European Commission and consequently from the OECD to support the process of developing a national HSPA framework, aiming to set up a tool that would enable monitoring of its health system and reforms and support evidence‑based health policy- and decision making.

The recognition of a lack of evidence‑based information that would be contextualised to the national health system has been long-lasting and broadly shared across Luxembourg’s stakeholders. While the mutual recognition of a need to assess the health and care system has been exercised by the national authorities and policymakers through the foundation of the ObSanté and its legal mandate, a common agreement on a tool to enable strategic planning, policy development, and monitoring of the functioning of Luxembourg’s health system and reforms was missing in 2024. The ObSanté aimed for a participatory process to develop a suitable framework to run such an assessment, and this approach has been followed throughout the framework development process.

1.2.1. Objectives and scope of this report

The purpose of the present report is to provide a groundwork for a transparent and accountable process of HSPA implementation in Luxembourg, based on commonly shared HSPA purpose, scope and framework. By making this information public, it aims to foster greater awareness of and engagement in HSPA across health system stakeholders and the public.

The present report is a key output of the project “Developing Health System Performance Assessment Frameworks for Luxembourg and Slovakia”. Funded by the European Union via the Technical Support Instrument, and implemented by the OECD, in co‑operation with the European Commission, the project has aimed at supporting the Slovak Republic and Luxembourg in setting up their national HSPAs, building in-house national capacities enabling production of regular HSPA reports, and supporting the production of their first national HSPA reports. The project has been designed as multi-country to enhance cross-country learning and mutual experience sharing on HSPA development. Therefore, the two countries involved, Luxembourg and the Slovak Republic, have been setting up their national HSPAs along the same timeline which allowed them to maximise learning experience and synergies during the development process, and participate in some project activities jointly.

This report takes stock of outcomes and activities convened by the OECD in co‑operation with the ObSanté and the European Commission SG REFORM within the project’s Luxembourgish workstream. Earlier in the project, the OECD, in collaboration with national authorities and the European Commission SG Reform, prepared Situational Analysis of Luxembourg’s Health Data Infrastructure for HSPA Purposes, which provided an overview of the Luxembourgish health data landscape for the purposes of developing Luxembourg’s national HSPA (OECD, 2025[8]).

In the next chapters, the report describes in detail the final version of Luxembourg’s HSPA framework (Chapter 2), its purpose and scope (Section 2.1) and domains and subdomains (Section 2.2), and outlines processes and considerations that accompanied framework development (Section 2.3), including methodology. Chapter 3 elaborates on the indicators that were selected to populate the HSPA framework, outlining the indicator selection process and methodology (Section 3.1), providing HSPA indicator details (Section 3.2), and displaying a use case example for HSPA indicators on mental health and care (Section 3.3). In addition, the report outlines the HSPA governance structure for Luxembourg, agreed on by the main stakeholders and data custodians (Chapter 4). The main text of this methodological report is complemented by a series of Annexes, summarising key project meetings, discussions and capacity building activities (Annex A), providing an overview of health data landscape in Luxembourg for the purposes of the HSPA (Annex B), outlining technical details for HSPA indicator sheets (Annex C), complementing the list of HSPA indicators by some contextualising indicators (Annex D), and displaying the HSPA framework for Luxembourg in French (Annex E).

1.2.2. Setting up the HSPA in Luxembourg: a stakeholder-inclusive process

Luxembourg’s HSPA, including its framework and HSPA indicators, has been developed through an engaging and consultative process ensuring relevance and actionability, building on international expertise. The participatory initiative allowed to bring together stakeholders in the health sector to share common health system objectives and to support their work towards better health system performance. National authorities and stakeholders were involved throughout the project in three dedicated project groups and teams (Figure 1.1).

Figure 1.1. Organisation of project teams and groups to set up HSPA in Luxembourg

Source: Developing the HSPA framework for Luxembourg project.

The project to develop Luxembourg’s HSPA was steered by the High Level Advisory Board (HLAB). Its members included senior representatives of key national health system and data stakeholders in Luxembourg: Ministry of Health and Social Security; Ministry of Finance; Ministry of Family Affairs, Solidarity, Living Together and Reception of Refugees; Health Directorate (DiSa); General Inspectorate of Social Security (IGSS), National Institute for Statistics and Economic Studies (STATEC); National Health Insurance Fund (CNS); and the National Health Observatory (ObSanté). In addition, two international members of the ObSanté’s Council of Observers joined the Luxembourg project’s HLAB to provide further international perspective. The HLAB overviewed the whole project and oversighted its development, it also consented to the final list of HSPA indicators and discussed the HSPA governance proposal.

The Project Management Team (PMT) was key to the smooth running of the project and HSPA development. It was composed of representatives of the ObSanté, IGSS, and DiSa and met regularly during the whole project. Together with the OECD team and the European Commission’s SG Reform representative it prepared meeting agendas and meeting documents and formulated proposals to be discussed by the other project groups. The OECD team provided international expertise and knowledge, steered and moderated stakeholder discussions, conducted a review of Luxembourg’s health data availability, provided expert input for indicator selection, and technically supported the national HSPA team throughout the whole process.

The Principal Working Group (PWG) was composed of a broad range of Luxembourg’s health system stakeholders (see Box 1.3) and was instrumental to the development of Luxembourg’s HSPA framework and the HSPA indicator list. Through a series of dedicated workshops and technical focus groups, the PWG members helped define the scope and purpose of Luxembourg’s HSPA, provided invaluable insights into the health data landscape, identified HSPA framework domains, and prioritised indicators to populate the framework. Some of the PWG members also participated in international study visits to the OECD and to Estonia in March and May 2025, which aimed to further support HSPA capacity building at Luxembourg’s authorities and agencies (see Annex A for details on the capacity building and study visits).

Box 1.3. Luxembourg’s stakeholders participating in the project and actively involved in the development of Luxembourg’s HSPA – members of the Principal Working Group for Luxembourg

• AEC – Administration d’évaluation et de contrôle de l’assurance dépendance

• Agence eSanté

• AMMD – Association des Médecins et Médecins-Dentistes

• ANIL – Association Nationale des Infirmières et Infirmiers du Luxembourg

• CNS – Caisse nationale de santé

• CEM – Cellule d’expertise médicale

• Cellule scientifique de la Chambre des Députés

• CAPAT – Cercle des Associations de Patients

• Cercle des Médecins Généralistes

• Collège médical

• Commission de la Santé et de la Sécurité sociale (Chambre des Députés)

• Conseil Scientifique du domaine de la santé

• CSCPS – Conseil Supérieur de Certaines Professions de Santé

• CSMI – Conseil supérieur des maladies infectieuses

• CMSS – Contrôle médical de la Sécurité sociale

• COPAS – Confédération luxembourgeoise des prestataires et ententes dans les domaines de prévention, d’aides et de soins aux personnes dépendantes

• Croix-Rouge luxembourgeoise

• DiSa – Direction de la santé

• FLLAM – Fédération Luxembourgeoise des Laboratoires d’Analyses Médicales

• FHL – Fédération des Hôpitaux Luxembourgeois

• IGSS – Inspection générale de la sécurité sociale

• INC – Institut National du Cancer

• La Ligue Luxembourgeoise d’Hygiène Mentale La Ligue luxembourgeoise de prévention et d’action médico-sociales

• LNS – Laboratoire National de Santé

• Ligue Santé Mentale

• Luxembourg Institute of Health

• Luxembourg Institute of Socio-Economic Research

• MiFa – Ministère de la Famille, des Solidarités, du Vivre ensemble et de l’Accueil

• M3S – Ministère de la Santé et de la Sécurité sociale

• ObSanté – Observatoire national de la santé

• Omega90

• Patiente Vertriedung

• Service national d’information et de médiation dans le domaine de la santé

• Service psychosocial de la Fonction publique

• STATEC – National Institute for Statistics and Economic Studies of Luxembourg

• Syndicat des Pharmaciens du Luxembourg

• Université du Luxembourg

The process of setting up Luxembourg’s HSPA was separated into several steps, in line with international practice, and its methodology is described in greater detail in the following chapters. The PWG meetings (Table 1.1) were closely linked to these project phases, gradually building on the stakeholders’ confidence to conduct an HSPA: It started with first defining the purpose and scope of the HSPA, learning from other countries’ HSPA experience, and reviewing health data availability and health policy priorities’ measurements. Building on the third workshop, findings were summarised in a dedicated baseline report by the OECD (2025[8]), Situational analysis of Luxembourg’s health data infrastructure for HSPA purposes. The following PWG meetings and workshops focussed on developing the HSPA framework, and on the process of populating it with indicators, using an inclusive, consultative, and iterative approach which supported ownership of the HSPA among national authorities and stakeholders. Such an approach ensures that the resulting HSPA framework is nationally relevant, enables international comparison, builds sustainable capacity, and promotes stakeholder ownership – all essential to achieving evidence‑based improvements in health system performance.

Table 1.1. Principal Working Group meetings and workshops in 2024-2025

Date	Topic of the meeting
26 September 2024	The purpose and scope of the HSPA framework for Luxembourg
7 November 2024	Experience with HSPA in other countries (Estonia, Ireland, Belgium)
26 November 2024	Health data infrastructure in Luxembourg
20 January 2025	Draft framework session 1 – Identification and prioritisation of framework domains and domain themes
21 January 2025	Draft framework session 2 – Draft framework and potential indicator themes
10 July 2025	HSPA framework update and next steps – indicator scoring methodology
13 October 2025	Populating the framework – session 1
14 October 2025	Populating the framework – session 2

The project “Developing Health System Performance Assessment Frameworks for Luxembourg and Slovakia” continues beyond the publication of this report. Ultimately, the project aims to support capacity of the two countries to produce their national HSPA reports on regular basis, as a regular activity that would feed into national policy and decision making. In 2025, two study visits were organised to support HSPA capacity building in Luxembourg. Officials from key health authorities and health data custodians participated in a 4‑day capacity building visit to the OECD to learn on data handling, visualisation, and latest health policy analysis trends. Further, Luxembourgish experts participated in a 3‑day study visit to Estonia to learn on its HSPA experience, health data infrastructure, and the Estonian use of data for guiding policy and actions (for more information on both study visits, see Annex A). In 2026, the continued OECD technical support for Luxembourg involves, among others, consultations with the Project Management Team, data custodians, and HSPA indicator custodians on interpretability, comparability and limitations of some HSPA indicators, on the development of indicator sheet templates, indicator sheet piloting, and data analysis result presentation.

References

[4] Donabedian, A. (1972), “Models for Organizing the Delivery of Personal Health Services and Criteria for Evaluating Them”, The Milbank Memorial Fund Quarterly, Vol. 50/4, pp. 103-154.

[2] Fekri, O., E. Macarayan and N. Klazinga (2018), “Health system performance assessment in the WHO European Region: which domains and indicators have been used by Member States for its measurement?”, World Health Organization Regional Office for Europe.

[1] OECD (2026), “Learning through national Health System Performance Assessment (HSPA): Emerging findings from OECD countries”, OECD Publishing, Paris, https://doi.org/10.1787/2fa1314a-en.

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

[8] 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.

[3] OECD (2024), Rethinking Health System Performance Assessment: A Renewed Framework, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/107182c8-en.

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

[7] The Government of the Grand-Duché of Luxembourg (2021), Law of 2 March 2021 on the creation of a National Health Observatory [Loi du 2 mars 2021 portant création d’un Observatoire national de la santé], https://legilux.public.lu/eli/etat/leg/loi/2021/03/02/a168/jo.