Health System Performance Assessment Framework for the Slovak Republic

2. The Slovak HSPA framework

Abstract

The health system performance assessment (HSPA) framework for the Slovak Republic is a tool for monitoring the Slovak health system and healthcare performance, designed to improve public reporting and to inform policy and decision making. It particularly focusses on monitoring regional differences, time trends and international comparisons, as well as healthcare quality.

The Slovak HSPA framework has 18 domains grouped in 5 areas, comprehensively covering all aspects of the Slovak population health, healthcare, and its health system. Aligned with the commonly used HSPA domains internationally, extra emphasis is placed on prevention and risk factors, as well as efficiency. The chapter provides a description of Slovak framework domains and summarises the participatory framework development process.

2.1. The purpose and scope of the Slovak 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 the Slovak HSPA was developed through consultations with members of the PWG and the 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 the Slovak HSPA was acknowledged and further discussed by the PWG members during their workshops 3, 4 and 5 in December 2024 and January 2025, and subsequently discussed and consented by the HLAB during their January 2025 and September 2025 meetings. Annex A provides an overview of key discussions, meetings and activities conducted during the project of developing the HSPA framework for the Slovak Republic.

From the beginning of the HSPA framework project, the Slovak stakeholders had emphasised to include in the national HSPA, conditional on data availability, a focus on marginalised, disadvantaged and/or national minorities wherever data allows for a higher granularity of indicator information. Slovak stakeholders also highlighted their HSPA should focus on issues that are of particular concern in the Slovak Republic, such as prevention, beyond providing a comprehensive overview of performance of their health system and offering relevant international comparison. In addition, in line with other country HSPA experience, stakeholders had acknowledged the role of comparator data for HSPA indicators, including international benchmarks and time trends. Lastly, stakeholders emphasised the preference to use existing indicators, building on already collected data, to populate the HSPA framework; it was also acknowledged that the HSPA project offers opportunities to strengthen stakeholder collaboration to improve data collection and international data reporting where international methodology had not yet been applied to Slovak datasets to produce specific indicators.

As the project progressed, mutual agreement among the Slovak stakeholders has gradually developed on the understanding the national HSPA as a tool to inform evidence‑based policymaking, as opposed to health policy strategies which define policy objectives and policy measures. However, a national HSPA is often linked to a national health strategy through its focus on the same or related priority areas and topics, and the HSPA can be helpful in supporting the policy developments further (see Section 5.2 on how the Slovak HSPA supports evidence‑informed policymaking and the synergies between the Slovak HSPA and the Strategic Framework for Healthcare for the years 2014-2030).

Based on stakeholder consultation and consent, the Slovak HSPA purpose includes monitoring of Slovak health system and healthcare performance to improve public reporting and to inform policy and decision making. By these three main purposes, it also seeks to improve accountability, engage cross-sectoral stakeholders, and improve health system transparency for public. By design, the Slovak HSPA aims to monitor regional differences, time trends, international comparisons, and healthcare quality (Figure 2.1). The Slovak HSPA understands the monitoring of healthcare quality in a broad sense of including any services which contribute to improved health outcomes and are (co)funded by public resources, including, but not limited to, prevention, health literacy campaigns, and healthcare provision.

In addition, the scope of the Slovak HSPA targets the whole Slovak population with an indirect emphasis on marginalised and disadvantaged communities; and extends, to a certain degree, beyond the healthcare system by making some connections to education and environmental and socio-economic factors (Figure 2.2).

Figure 2.1. The purpose of the Slovak HSPA

Source: Developing HSPA Framework for the Slovak Republic project.

Figure 2.2. The scope of the Slovak HSPA

Source: Developing HSPA Framework for the Slovak Republic project.

2.2. The Slovak HSPA framework domains

The Slovak HSPA framework is composed of 18 domains (Box 2.1), grouped into 5 areas: resources, prevention and risk factors, healthcare services, outcomes, and efficiency. The domains are described by the total of 110 indicators, which are presented in detail in chapter 3. Together, the framework domains comprehensively cover all aspects of the Slovak population health, healthcare and its health system, in line with the defined purpose and scope of the Slovak HSPA as presented in 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, each of them being populated by several indicators. Framework domains can be grouped into bigger domain areas or framework building blocks, while they can, but need not, be as well divided into smaller subdomains. 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[1]), Learning through national Health System Performance Assessment (HSPA), https://doi.org/10.1787/2fa1314a-en.

The five main domain areas in the Slovak HSPA framework (Figure 2.3) are interlinked: Resources cover domains related to structural and system-level inputs. Domains in Prevention and Risk Factors directly influence population and individual health status, which is then captured by the domains in the Outcomes area, focussing on general population health outcomes and on disease‑specific health outcomes. Healthcare Services area focusses on provision and delivery of healthcare, while Efficiency is a cross-cutting area focussing explicitly on cost efficiency and on care provision efficiency. All five domain areas are interlinked, which is highlighted by arrows surrounding the core of the Slovak HSPA framework.

Figure 2.3 shows the Slovak HSPA framework in English language while the Slovak translation is provided in Annex E, Figure A.E.1.

Figure 2.3. The Slovak HSPA framework has 18 domains organised in five areas

Source: Developing HSPA Framework for the Slovak Republic project.

The colours in the Slovak framework align with the logic of the Donabedian approach to health system performances assessment (Donabedian, 1972[2]), which identifies three interconnected categories influencing quality of care: structure, processes and outcomes (see also Box 2.2 in the next section). In the Slovak HSPA, the processes are depicted as two separate domain areas which however have the same colour: the area of Prevention and Risk Factors, and the Healthcare Services area. This structure highlights that both areas equally belong into health system processes that influence health outcomes, while at the same time reflect a specific emphasis of the Slovak national health policymakers and stakeholders on prevention and public health. This is also partly due to the lower-than-desired performance of the Slovak system in these issues, as viewed by national authorities and stakeholders.

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[1]). Stakeholders in different countries emphasise different themes, adapting their frameworks to their country’s needs and reflecting national priorities. During the HSPA framework development project in the Slovak Republic, stakeholders placed emphasis on cost monitoring, access, health data and digital, health sector governance, prevention, care quality, and workforce, and more broadly on issues connected with efficiency and equity (see Section 2.3). These topics of interest are reflected in the Slovak HSPA framework either through domains or through the selection of HSPA indicators.

The emphasis that the Slovak health system stakeholders have put on the themes of prevention (including explicitly health literacy, vaccination and secondary prevention), efficiency, and equity resulted in these areas featuring more prominently within and across the Slovak HSPA framework. While Prevention and risk factors and Efficiency became two dedicated domain areas of the national framework, the equity has been dismantled as a separate domain area during the framework refinement process (see Box 2.2 in Section 2.3.2). Instead, equity issues, including equity in prevention, equity in access to healthcare, and equity in health status, have been highlighted through the choice of indicators that populate the Slovak framework, bringing the equity perspective to as many domains as possible, conditional on data feasibility. This equity-sensitive perspective of the Slovak framework is illustrated in Chapter 4, for which equity has been chosen as a use case example for the Slovak HSPA framework, to illustrate how indicators can be linked across framework domains to uncover a policy topic.

Some national HSPA frameworks have a three‑level structure, employing also subdomains to framework domains. In the case of the Slovak Republic, a decision was taken during the HSPA framework development process to move forward with a higher number of domains while not employing an additional subdomain level. This decision provided for a greater flexibility in indicator selection.

Table 2.1 describes the Slovak HSPA framework domains in detail. Some of the domain descriptions may be forward-looking, not necessarily fully aligned to the selection of indicators presented in Section 3.2. This is mainly due to two reasons: First, because stakeholders have prioritised, during the indicator selection process, some topics over others within a broader theme of the domain. Second, some domains may have currently only a limited scope of metrics available to capture the domain’s theme in its entirety. For the latter, Slovak authorities may wish to reassess measurement options in the future, to capture more comprehensively the substance of selected domains by adding or replacing some indicators when these become available.

Table 2.1. Description of the Slovak HSPA framework domains

Area	Domain	Description of a domain
Resources	Workforce	Human resources is key part of healthcare provision structures. This workforce domain includes monitoring of health workforce stock, including its structure, and health workforce inflow and outflow
	Financing	The Financing domain addresses health system and care expenditures and its structure. The domain also looks forward to sustainability of financial resources of the Slovak health system
	Infrastructure	The domain of Infrastructure providers an overview of current state of healthcare facilities
	Digitalisation and data	The Digitalisation and data domain reviews progress in adopting digital tools within healthcare delivery and information sharing. The domain supports discussions on how digitalisation may influence access, care continuity and care provision efficiency
	Governance	The Governance domain aims to focus on factors that influence overall stability and predictability of the system, such as involvement of stakeholders, trust and transparency. It looks at population’s overall perception of the health and care system
	Research and innovation	The Research and innovation domain monitors Slovak capacity and involvement in healthcare research and development activities, such as clinical trials and strategic partnerships. The domain provides insight into the innovation ecosystem, research capacity and the country’s integration into international research networks.
Prevention and risk factors	Health literacy	The Health literacy domain looks at population’s ability to access, understand and use health information. The domain supports identification of vulnerable groups and can help inform targeted literacy and communication strategies.
	Prevention	Prevention domain focusses on healthcare services that can prevent a disease onset or development, or focus on early disease detection. In this regard, prevention decreases healthcare needs and leads to better expected health outcomes.
	Behavioural determinants	The Behavioural determinants domain focusses on modifiable lifestyle and behavioural risk factors linked to non-communicable disease burden
	Environment and AMR	Environmental risk factors are external determinants of health that affect all individuals, including, but not limited to, air quality. The domain focusses on environmental health determinants and antimicrobial resistance as systemic risks.
Healthcare Services	Access to services	The Access domain focusses on barriers to accessing healthcare, whether financial, geographic or time‑related. The domain combines demand-side (patient reported), supply-side (provider network coverage) and system-level (financial protection, emergency response) perspectives on access.
	Quality and safety	The Quality and safety domain describes outputs of healthcare delivery process, focussing on clinical outcomes, patient safety and infection control. The domain indicators span effectiveness, safety and workforce strain dimensions of quality of care.
	Care co‑ordination	The Care co‑ordination domain looks at how effectively care is managed across providers, settings and time. The domain focusses on outcomes sensitive to continuity and integration of care rather than acute events alone.
	People centredness	The domain of People centredness reviews people’s experience with the health system and healthcare delivery, focussing on patient-doctor relationship and system responsiveness
Outcomes	General health outcomes	The General health outcomes domain focusses on population health through mortality, morbidity and self-reported measures, providing an overview of the health status of the Slovak population. The domain combines objective mortality information with subjective health assessments.
	Disease‑specific health outcomes	The domain of Disease‑specific health outcomes provides insights on selected diseases and chronic conditions, including their incidence, prevalence, and burden.
Efficiency	Cost efficiency	The Cost efficiency domain reviews healthcare cost efficiency with a specific focus on hospitals and pharmaceuticals, including for review of cost structures and cost-efficient prescription.
	Care provision efficiency	The Care provision efficiency domain reviews operational performance and service utilisation patterns, focussing on efficient provision of care. The domain provides an overview of inpatient and outpatient throughput, including bed utilisation and systemic use of antibacterials

Source: Developing HSPA Framework for the Slovak Republic project, January 2026.

2.3. Designing the Slovak HSPA framework with stakeholder ownership

A consultative process for developing a shared HSPA framework was used in the Slovak Republic. The process of setting up the Slovak HSPA framework 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.

While the process was complex by design, stakeholder input was invaluable. In addition, some of the PWG members also highlighted the value added of the Developing the Slovak HSPA Framework project for their other data-related projects, such as redesigning their data collecting mechanisms.

2.3.1. Building consensus to develop the first framework draft

The first draft of the Slovak HSPA framework was developed using interactive techniques of stakeholder engagement. Authorities and stakeholders from across the Slovak 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 195 ideas were generated by the Slovak stakeholders, which were initially clustered into 31 domain themes, out of which 18 received priority votes from the stakeholder discussion groups (Figure 2.4). These results were considered when constructing the first proposal for the draft HSPA framework for the Slovak Republic. Box 2.2 describes the process and methodology of the development of the first framework draft proposal.

Figure 2.4. A total of 195 ideas were identified, clustered into 31 possible framework domain themes, out of which 18 received stakeholder priority votes

Among the initial 31 domain themes, cost monitoring, access, data and digital (health), governance, prevention, care quality, and workforce received the most priority votes by stakeholders

Note: The colours to the right side of the bars refer to the prioritisation votes given by stakeholder groups.

Source: Developing HSPA Framework for the Slovak Republic project.

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

Interactive workshops help gather stakeholder insights on HSPA for the development of the first framework proposal. About 35 stakeholders, members of the Principal Working Group (PWG), broadly representing Slovak health system organisations and including key governmental organisations, patients and provider representatives, participated in two framework development workshops held in-person in Bratislava on 28‑29 January 2025.

The workshops had interactive sessions to gain input for drafting the Slovak HSPA framework. Using the OECD methodology developed and tested with Estonia and Czechia, the Slovak 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.

Then, four discussion groups, divided by participant organisations’ perspective and role in the Slovak health system (state regulating authorities; state supporting organisations; providers, insurers and self-governing regions; and users and population perspective) 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 priority votes. The interactive discussions considered factors discussed in the previous PWG meetings, the draft scope and purpose of the Slovak HSPA, health data infrastructure available in the Slovak Republic, and good practices from other OECD 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 the Slovak project management team (PMT) and the OECD team, grouping related themes into common domains. The draft framework was then presented to workshop participants for validation and feedback.

The first proposal for the draft Slovak HSPA framework had initially six domain areas. At the centre of the draft framework were two domain areas, Prevention and Healthcare Services, reflecting the many identified domain themes associated with healthcare provision and with prevention, including health literacy and health risks. These two “throughput” areas were complemented by the Inputs domain area on one side and Outcomes area on the other. This division has been in line with the Donabedian conceptual approach for examining health systems and evaluating quality of health service delivery using three interconnected categories of structure, processes and outcomes (Donabedian, 1972[2]).

The throughput, or processes domain areas were identified as being influenced by a transversal domain area Efficiency, which could feature a variety of dimensions, including cost efficiency and cost monitoring, efficient use of pharmaceuticals, care provision efficiency, etc. The second transversal domain area Equity was identified to directly affect and be relevant for prevention, healthcare services and outcomes, and could be extended to inputs too. All dimensions within the original Equity domain area reflected the significant emphasis that the Slovak stakeholders put on health and system equity issues, including equity in prevention, equity in healthcare access, and equity in health status. In later adjustments to the Slovak framework draft proposal, the Equity area was abandoned as a separate building block in the framework due to too many overlaps with other domains (see Section 2.3.2).

Creation of the first draft HSPA framework for the Slovak Republic was complemented by a discussion on potential indicators and indicator themes to evaluate domains of performance, an outcome of which later in the project supported definition of indicators to populate the Slovak HSPA framework.

Source: OECD (2025), Developing Health System Performance Assessment framework for the Slovak Republic, Output 3: First draft of the HSPA framework proposal for the Slovak Republic, 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 the Slovak Republic reflected the outcomes of the interactive stakeholder workshops. It was shared with the 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 guided the indicator selection process itself, to populate the domains of the finalised Slovak HSPA framework with indicators.

Some refinements to the Slovak HSPA draft framework were introduced based on expert inputs and clarifications provided during Technical Focus Groups and further PMT and PWG discussions. These focussed on improving framework’s structural coherence by reorganising domain themes and renaming some of them and streamlining the framework’s structure. The initial number of domains was reduced, repetitive topics were redistributed into relevant domains, and domain content and description was refined by merging topics according to their thematic fit (see the final framework in Section 2.2):

• The Input area was renamed to Resources to better reflect its content and the Slovak language translation.

• The Prevention area was renamed to Prevention and Risk Factors to emphasise the importance of lifestyle and environmental factors in primary prevention.

• Topics of primary and secondary prevention and vaccination were all grouped in the Prevention domain.

• On contrary, health risks were made explicitly connected to lifestyle and environment by splitting them into two domains.

• Topics of the original Outputs’ domains were regrouped and streamlined, resulting in two main output domains only.

• People‑centredness was enriched by topics of patient-reported experience and outcome measures (PREMs and PROMs).

• The Efficiency area was streamlined from initially 4 overlapping domains to two distinct categories.

• The Equity area was abandoned, and original domains became content of topically related domains (e.g. Equity of access became part of Access to services domain, and similarly for Equity in prevention and Equity in health status).

Based on the refined version of the draft Slovak HSPA framework, a description of all domains was developed, which was then used during the process of stakeholder voting on HSPA indicators. Last edits to the draft framework were introduced after the indicator selection process, bringing the topic of antimicrobial resistance into the title of the domain on environmental risks. The final version of the Slovak HSPA framework thus has 18 domains distributed across five domain areas (see Figure 2.3 above).

References

[2] 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.

[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.