Health System Performance Assessment Framework for Luxembourg

2. Luxembourg’s HSPA framework

Abstract

Luxembourg’s HSPA defines its purpose as a tool to support evidence‑based policymaking, monitoring population health and healthcare system performance, and promoting person-centredness. Its scope is comprehensive and includes broader determinants of health and cross-border populations. An inclusive process led to the HSPA purpose and scope recognition among national health system stakeholders.

Luxembourg’s HSPA framework has 12 domains and 30 subdomains, comprehensively covering all aspects of health, healthcare, and health system outcomes, processes, inputs, and cross-cutting topics. The chapter provides a description of these domains and subdomains and takes note of the framework’s participatory development process.

2.1. The purpose and scope of Luxembourg’s HSPA

Defining a purpose and a scope of the HSPA is an initial step to guide a national HSPA framework development process and to align parties around a common idea of its use. Defining the HSPA purpose properly is key to drawing a boundary to the HSPA scope, for which the HSPA framework then provides a structure. Likewise, criteria to select HSPA indicators depend on the definition of purpose and scope of the national HSPA. While countries use their HSPAs for various reasons and their frameworks may employ different shapes and colours, the international dynamics over the past two decades highlight the importance of developing a country-tailored framework in collaboration with national health system stakeholders, through an engaging and participatory process.

The purpose and scope of Luxembourg’s HSPA was developed through consultations with the members of the Principal Working Group (PWG) and the High Level Advisory Board (HLAB). Firstly, the topic was addressed by a dedicated workshop of the PWG in September 2024, and during the first meeting of the HLAB in the same month. Based on these initial consultations, the draft purpose and scope of Luxembourg’s HSPA was acknowledged and further discussed by the PWG members during their workshops 3, 4 and 5 in November 2024 and January 2025, and subsequently discussed and consented by the HLAB during their January 2025 and July 2025 meetings. Annex A provides an overview of key discussions, meetings and activities conducted during the project of developing the HSPA framework for Luxembourg.

From the very beginning, the HLAB members emphasised the importance of developing the HSPA as a tool to support policymaking in Luxembourg. The ObSanté viewed it as important collaboration to help frame its health system assessment work to provide meaningful and valuable information for Luxembourg’s policymakers; the framework would become a key tool in the implementation of the ObSanté’s legal mandate to produce, every three years, a national report on the health status of the population, the determinants of health and the health system, including its findings and proposals (Art. 8, Alinea 2 of the Loi du 2 mars 2021 (2021[1])). Likewise, strengthening public accountability through improved public reporting was marked as a potential valuable purpose of the HSPA in Luxembourg, emphasising the importance of international comparison where data feasible. Additional suggestions for HSPA purpose for Luxembourg included supporting improvements in accountability of the various health system stakeholders and targeting sectorial thinking and actions, as well as bringing forward the patient perspective. Additionally, the HSPA project was viewed by many co‑operating stakeholders as a useful means to embrace differences in perspectives and stances of the variety of stakeholders who were actively involved in the project, thus helping to avoid organisational biases influencing the final framework.

Based on stakeholder consultation and consent, Luxembourg’s HSPA purpose thus includes monitoring of population health to target its improvements and address inequalities; monitoring of healthcare system performance to enhance accountability and transparency; increasing public awareness and health literacy; and supporting evidence‑based policy planning and decision making, including for promotion of patient-centred approach (Figure 2.1). In addition, the scope of Luxembourg’s HSPA includes broader determinants of health, goes beyond Luxembourg’s residing nationals, and takes a holistic view of the health system through a comprehensive approach (Figure 2.2).

Figure 2.1. The purpose of Luxembourg’s HSPA framework

Source: Developing the HSPA framework for Luxembourg project, HLAB meeting in January 2025.

Figure 2.2. The scope of Luxembourg’s HSPA framework

Source: Developing the HSPA framework for Luxembourg project, HLAB meeting in January 2025.

2.2. Luxembourg’s HSPA framework domains and subdomains

Luxembourg’s HSPA framework is composed of 12 domains (Box 2.1), grouped into 4 blocks: outcomes, processes, inputs, and cross-cutting topics. These domains are further detailed out by 30 subdomains, comprehensively covering all aspects of Luxembourgish population health, healthcare, and health system and reflecting the defined HSPA purpose and scope as presented in the Section 2.1.

Box 2.1. What is an HSPA framework domain?

A domain in an HSPA framework usually refers to an area of a health system which is assessed to evaluate a health system’s performance and to understand specific aspects of the system and its outcomes. An HSPA framework has multiple domains, and each domain can include several subdomains and indicators. In this regard, domains provide a structure to comprehensively analyse aspects of a health system’s performance. Selection of domains for a national HSPA framework depends on the specific purpose and objectives of the given national HSPA, and the context of a country’s health system.

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

In Luxembourg’s HSPA framework visual (Figure 2.3), blocks of domains are depicted by four distinct colours: the emphasis is placed on Outcomes, aligning it to the national HSPA purpose to improve population health. Domains marked in the blocks of Processes and Inputs focus on healthcare services and their provision and feed into the Outcomes. The cross-cutting themes surround the other three building blocks, and influence jointly the healthcare provision and outcome elements. The overall logic of the framework aligns with the Donabedian (1972[3]) approach to structuring a health system performance assessment (see Box 2.2 in the next section). Figure 2.3 shows the HSPA framework for Luxembourg in English language, while the French translation is provided in Annex E, Figure A.E.1.

Figure 2.3. Luxembourg’s HSPA framework has 12 domains and 30 subdomains

Source: Developing the HSPA framework for Luxembourg project, HLAB meeting in November 2025

While national HSPA frameworks across OECD countries share core structural features, countries vary in how they organise domains, handle disaggregation, and use indicators (OECD, 2026[2]). Stakeholders in different countries emphasise different themes, tailoring their frameworks to their country’s needs and reflecting national health priorities. During the HSPA framework development project in Luxembourg (see section 2.3 for the process), stakeholders placed emphasis on topics of mental health and integrated care, while also indicating several themes classified as cross-cutting topics, compared to what may be the situation in other countries. In particular, the Luxembourgish stakeholders highlighted the themes of integrated care, access and equity, health system governance, mental health, prevention, and health workforce education and training (formation). These areas of interest are reflected in Luxembourg’s HSPA framework.

Luxembourg’s framework covers the commonly used domains such as population health outcomes, access to care, patient safety and workforce, but also includes domains that are classified as new or emerging – in the sense that countries’ interests in these themes have developed only recently, and metrics for measuring some key elements of these themes have often not yet been fully developed.

Compared to the commonly used HSPA framework structures, the topic of mental health features prominently in the Luxembourg’s HSPA framework, having its own subdomain. While mental health is an integral part of population health outcomes, it is recognised as a dedicated subdomain within the framework to provide a special emphasis on the topic in the HSPA in Luxembourg. Alongside the mental health subdomain, mental healthcare indicators received priority from stakeholders across various other domains, from access to infrastructure. Section 3.3 provides a use case example of the mental health topic to show how a specific policy-relevant theme can be analysed across framework domains, identifying in total nine subdomains in addition to the Mental health outcomes.

Some of the descriptions of the subdomains may be more forward-looking, not necessarily fully aligned to the selection of indicators presented in section 3.2. This may happen due to two reasons. First, because stakeholders may have prioritised, during the indicator selection process, some particular topics over others within a broader subdomain’s theme – this is for instance the case of Co‑ordination of Care subdomain in Integrated Care domain, where indicators on measurement of the consequences of insufficient care co‑ordination were not prioritised for the first HSPA cycle. Second reason stems from the emerging nature of some subdomains with limited metrics available to capture a subdomain’s theme in its entirety. This is for instance the case of the subdomain Non-behavioural Determinants of health, and the Climate Change subdomain in Sustainability. Especially for the latter, Luxembourg’s authorities may wish to reassess measurement options in the future, to capture more comprehensively the substance of this subdomain by adding or replacing some indicators. A suitable time to do so may for instance be when launching a second or subsequent HSPA cycles (see section 4.3.1). Table 2.1 describes Luxembourg’s HSPA domains and subdomains in detail.

Table 2.1. Description of Luxembourg’s HSPA framework domains and subdomains

Area	Domain	Subdomain	Description of subdomains
Outcomes	Health status	Population outcomes	Describes the state of health of a population assessed by subjective or objective indicators – healthy life expectancy, life expectancy and self-reported health status.
		Mental health	Describes the mental health status of the population.
	Person centredness	Patient-centred care	A holistic and collaborative approach that treats the person as an equal partner, considering their preferences and cultural, social, and linguistic background in maintaining health, managing illness, and finding suitable solutions.
		Health literacy	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.
		Patient experience	A patient experience encompasses the aspects of their care journey that patients consider most important.
Processes	Access to care	Financial protection	Describes the different dimensions of health insurance coverage, including population coverage (who and who is not covered), the covered services and the extend of service coverage, as well as monitoring the level of financial hardship in accessing healthcare.
		Operational access	Monitors timeliness of access and geographical accessibility to appropriate care, medicines and medical equipment, in Luxembourg and abroad.
	Value‑based care	Patient safety	Refers to monitoring unnecessary harm associated with the provision of healthcare services.
		Guidelines compliance	Describes the adoption of an evidence‑based approach to the effective delivery of healthcare services to patients.
		Quality of care	Clinical effectiveness and health intervention outcomes, including the quality of primary and inpatient care and long-term care and patient reported outcome measures (PROMs).
		Cost efficiency	Describes the extent to which best possible value has been achieved in the use of health services and available resources (incl. financial resources).
	Integrated care	Prevention	The health system’s ability to prevent disease through primary prevention or timely detection through secondary prevention.
		Coordination of care	Reviews an 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.
		Continuity of care	Measures the patient’s journey through the system (patient pathway) and the continuity of patient care between individual providers for a specific diagnosis.
Inputs	Governance	Leadership	Refers to the capacity of making, changing, monitoring and enforcing the rules that govern the demand and supply of health services.
		Transparency & accountability	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.
	Infrastructure	Physical resources	Availability of facilities and equipment to provide health services according to population needs.
		Pharmaceuticals	Availability of and access to essential and innovative medicinal products.
		Digital health	Refers to 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 the actual use of digital health and information.
		Research & development	The level of Luxembourg’s involvement in medical research and innovative activities, creating carrier development opportunities for health workforce.
	Workforce	Training	The provision of training of medical professionals.
		Workforce capacity	Describes the number, availability, migration and skill mix of healthcare service providers.
	Finances	Fiscal sustainability	Describes the system’s revenue sources, the availability and stability of financial resources over time, and evaluating their adequacy to sustainably cover the system’s expenditures.
		Financial allocation	Distribution of funds and budgetary allocation across the health sector.
Cross-cutting	Sustainability	Resilience	Resilience is the proactive capacity of health system organisations, units, teams, and individuals to anticipate, adapt to, and respond swiftly to changes and challenges – ensuring continuity, quality of care without merely resisting disruption.
		Climate change	Refers to the health system ability to adapt, respond, and remain resilient to climate‑related health threats while minimising its own environmental impact.
	Equity	Demographic and geographic	Demographic and geographic factors that can affect or determine access to health services or exposure to health risks.
		Socio‑economic	The influence of socio‑economic factors (e.g. income, education) on health and health behaviour.
	Determinants of health	Behavioural risk factors	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.
		Non-behavioural determinants	Focuses on the 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.

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

2.3. Stakeholder ownership of the HSPA framework in Luxembourg

A consultative process for developing a shared HSPA framework was used in Luxembourg. The process of setting up the HSPA framework for Luxembourg had two main phases. First, the draft framework was developed through a participatory consensus building on HSPA themes among health sector stakeholders, and, second, the framework was improved for its structural coherence based on expert consultations, technical focus groups and initial indicator repository mapping.

2.3.1. Building consensus among stakeholders to develop the first framework draft

The first draft of the HSPA framework for Luxembourg was developed by using interactive techniques of stakeholder engagement. Authorities and stakeholders from across Luxembourg’s health system gathered for two in-person workshops to identify possible domain themes for their national HSPA, to prioritise them, and to discuss potential metrics to evaluate elements of performance. A total of 331 domain theme ideas were generated by the Luxembourgish stakeholders, which were initially clustered into 38 domain themes, out of which 20 received prioritisation votes from the stakeholder discussion groups (Figure 2.4). These results were considered when constructing the first proposal for a draft HSPA framework for Luxembourg. Box 2.2 describes the process and methodology of the development of the first framework draft proposal.

Figure 2.4. A total of 331 possible domain themes were identified, clustered into 38 domain themes, out of which 20 received stakeholder priority votes

Among the initial 38 possible domain themes, identified by stakeholders through an interactive process, integrated care, workforce formation, mental health, prevention, access, and system governance received the highest priority votes

Source: Developing the HSPA framework for Luxembourg project, January 2025 Principal Working Group meeting.

Box 2.2. The process and methodology of the development of the first HSPA framework draft proposal for Luxembourg

Interactive workshops help gather and learn about stakeholder insights on HSPA for the development of the first framework proposal. About 45 stakeholders, members of the Principal Working Group (PWG), representing broadly Luxembourg’s health system organisations and including key governmental authorities, agencies, patients and provider representatives, participated in two framework development workshops held in-person in Luxembourg on 20 January‑21, 2025.

The workshops had interactive sessions to gain input for the draft HSPA framework for Luxembourg. Using the OECD methodology developed and tested with Estonia and Czechia, the Luxembourgish health system stakeholders engaged in generating ideas for HSPA domain themes (using the question “What domain themes should be covered in your national HSPA framework?”). Ideas for themes were collected from individual participants and through their discussions, and then clustered into emerging domain themes.

Four discussion groups of participants, divided by their organisations’ perspective and role in Luxembourg’s health system (supporting state organisations, system governance organisations, consumers, providers) then prioritised the emerging domain themes for inclusion in the framework. Using the question “From the identified domain themes, which ones are the most important?”, each group could cast up to 10 votes. The interactive discussions considered factors discussed in the previous PWG meetings, the draft scope and purpose of Luxembourg’s HSPA, health data infrastructure available in Luxembourg, and good practices from other countries. Figure 2.4 depicts the clustering of domain themes and results of stakeholder prioritisation.

Following the theme generating and the prioritisation, emerging domains were organised by Luxembourg’s PMT and the OECD team, grouping related themes into common domains and subdomains. The draft framework was then presented to workshop participants for validation and feedback.

The first proposal for the draft framework had initially 5 building blocks. Three of them (Inputs, Throughputs, Outcomes) related to health services and healthcare provision, in line with the Donabedian conceptual approach for examining health services and evaluating quality of health service delivery, which presents three interconnected categories that influence quality of care: structure, process and outcomes (Donabedian, 1972[3]). The fourth building block, labelled as Transversal, included domain themes, which might get re‑grouped into a more complex domain-subdomain structure, and included themes running across the health service domains, such as various dimensions of equity, resilience, research and development, and information. The last building block of the first draft framework proposal included domain themes that represented grounding elements for a health system, such as environmental and health behavioural risk factors, climate, prevention, health literacy, and system governance.

Creation of the first draft HSPA framework for Luxembourg was complemented by a discussion on potential indicators and indicator themes that might be used to evaluate domains of performance. These domain theme specifications were then used later in the project to support definition of indicators to populate Luxembourg’s HSPA framework.

Source: OECD (2025), Developing Health System Performance Assessment framework for Luxembourg, Output 3: First draft of the HSPA framework proposal for Luxembourg, March 2025.

2.3.2. Improving the framework draft for structural coherence based on expert inputs

The first draft proposal for the HSPA framework for Luxembourg reflected the outcomes of the interactive stakeholder workshops. It was shared with the Principal Working Group (PWG) members, and the HLAB for their reflection, and further elaborated on based on outcomes of the Technical Focus Groups (see Annex A) and during the indicator selection process (described in section 3.1). It also served as a guiding tool for stakeholders’ selection of HSPA indicators to populate the domains and subdomains of Luxembourg’s finalised HSPA framework.

The refinements focussed on improving the framework’s structural coherence, developing clear domain definitions, and enhancing the framework’s usability and strategic alignment. In this process, the original five framework building blocks were consolidated into four, by dissolving the grounding elements block into relevant domains. To avoid duplications of topics and enhance the framework Donabedian structural coherence, the domain themes of risk factors, climate, prevention, health literacy and system governance were redistributed into relevant domains in the other four blocks of Outcomes, Processes, Inputs and Cross-cutting.

Based on feedback from experts, Technical Focus Group discussions, and initial indicator repository mapping (see section 3.1), and considering domain ideas generated by stakeholders during the development workshops, the PMT team proposed a revised domain structure. This included an introduction of subdomains to each domain, i.e. creating a three‑level structure of the framework. Such change streamlined the framework structure by reducing the number of domains. Further, some topics were merged into common domains and subdomains based on their thematic fit. In addition, a new domain of Finances was introduced to better capture underrepresented financing topics and the emerging theme of fiscal sustainability. Based on this refined version of the draft HSPA framework for Luxembourg, a description of all domains and subdomains was developed (Table 2.1 in section 2.2), which was then used during the process of stakeholder prioritisation of possible HSPA indicators. Last edits to the draft framework were introduced after the indicator selection process, merging demographic and geographic subdomains of Equity into a single subdomain due to the low number of selected indicators. The final version of Luxembourg’s HSPA framework thus has 12 domains and 30 subdomains divided into four blocks or areas (see Figure 2.3 above).

References

[3] 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] 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.

[1] 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.