Learning through national Health System Performance Assessment (HSPA)

1. Assessment of health system performance through comparable metrics is gaining prominence

1.1. The OECD has been playing a major role in defining key principles for assessing health systems’ performance

For decades, the OECD has helped countries to identify the key principles of high-performing health systems and to assess health system performance (Box 1) based on internationally comparable health indicators. This work has contributed to, and been guided by, the development of conceptual frameworks for health system performance developed by the OECD over time (Hurst and Jee-Hughes, 2001[1]; Kelley and Hurst, 2006[2]; Carinci, F et al., 2015[3]).

The 2002 report Measuring Up: Improving Health System Performance in OECD Countries, a collaboration between the OECD and Health Canada (OECD, 2002[4]), marked a pivotal evolution in health system performance assessment (HSPA) methodology. Moving away from a view of health system performance as a singular international process of comparison, the methodology shifted towards generating and capturing a more diverse range of data to contribute to national measurement processes. The report created a blueprint for today’s multidimensional HSPA practices through its comprehensive measurement framework, which spanned inputs, processes, outputs and outcomes. As data availability expanded, the report’s organisational structure provided a flexible yet standardised approach that continues to guide how health systems collect, analyse and apply performance data to meet diverse national health system needs. Following nearly a decade of healthcare quality indicator development, the 2015 revision of the OECD’s HSPA framework shifted attention to the actionability of international comparisons of healthcare quality, validating the reliability of indicators as decision support tools (Carinci, F et al., 2015[3]).

At the OECD Health Ministerial Meeting in January 2024, the Ministers welcomed the renewed HSPA framework, which incorporates new performance dimensions – notably people‑centredness, resilience and environmental sustainability – and places increased emphasis on addressing inequalities (OECD, 2024[5]). The framework expands on existing OECD efforts in these domains, including focussed developments that zoomed in on people‑centredness (OECD, 2021[6]) and resilience (OECD, 2023[7]). By offering common definitions and fostering a shared understanding among policymakers, stakeholders and organisations, the renewed HSPA framework enhances international collaboration and lays the foundation for developing future internationally comparable indicators, facilitating data collection, policy analysis and integration of knowledge.

Box 1. HSPA frameworks are used for comprehensive assessments of health systems’ performance

HSPA is a systematic approach to comprehensively evaluating a health system. 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.

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.

1.2. Countries adopt national frameworks for context-specific evaluations of their health system performance

Beyond international developments in HSPA, evaluation of health system performance at a national level has gained increasing prominence on the global health agenda. This growing focus stems from a confluence of factors, including the escalating costs of healthcare, the demographic shift towards ageing populations, the rapid advancements in medical technology, and the fundamental need for health systems to prepare for major acute or enduring challenges such as health emergencies and climate change (OECD, 2024[5]). Furthermore, countries’ enhanced health data infrastructures have significantly expanded the available information, which has leveraged interest in using these resources in a structured way for policy-relevant insights and system improvement.

Over the last decades, many OECD Member countries have successfully designed and implemented national HSPA frameworks (see Box 2 and Annex A). A national HSPA delivers an overview of a health system and its performance, providing unique opportunities to understand the health system as a whole and harness the efforts across health system stakeholders to achieve shared goals. HSPA can facilitate evidence‑based priority setting and resource allocation through the identification of strengths and weaknesses within a health system. Further, HSPA enables valuable cross-country learning and benchmarking, as countries with diverse systems can explore new effective health policies through targeted comparison with others. The high uptake of HSPAs across OECD Member countries creates opportunities for sharing experiences in embedding evidence in policymaking, communicating HSPA results to the public, and building capacities to measure and analyse complex aspects of national health systems and their governance.

Box 2. OECD Member countries have made progress in implementing national HSPA frameworks in previous decades

Among the pioneers of national HSPAs are Canada (1999), which in 2002 partnered with the OECD the Measuring Up report (OECD, 2002[4]) that intended to standardise the collection and use of indicators across levels of health service organisation and delivery, Italy (2001), Spain (2003), Sweden and the Netherlands (2006). Further international activities, such as the OECD’s continued measurement work of the Healthcare Quality Indicators Project (Kelley and Hurst, 2006[2]) or the Tallinn Charter (WHO, 2008[8]), which established a commitment to health system performance measurement in Europe, further accelerated national HSPA activities, including those in Estonia (2009) and Belgium (2010).

Some countries have updated their HSPA frameworks since their introduction to respond to evolving needs and external contexts. Canada’s Health Indicator Framework was renewed in 2013, building on the 1999 one (Canadian Institute for Health Information, 2013[9]). Belgium published a revision of its HSPA framework in 2023, though minor changes have been implemented throughout in successive reports since its introduction in 2010 (Gerkens et al., 2023[10]). The Australian Health Performance Framework was published in 2017 (The National Health Information and Performance Principal Committee, 2017[11]), and in 2024-2026 its Health System Performance conceptual model is undergoing a reassessment of its purpose and scope and update to its structure. Italy uses the New Guarantee System (NGS) from 2019 to assess the provision of essential levels of service at the regional level (Ministero della Salute, 2025[12]). Additionally, some Italian regions use the voluntary academia-developed Interregional Performance Evaluation System (IRPES) set of indicators, established in 2008, to support local healthcare management (Vola et al., 2022[13]).

Between 2017 and 2024, many European countries asked the European Commission for technical support to set up national HSPA frameworks, tools and methodologies. These include Croatia, Czechia, Estonia (to relaunch national HSPA activities after the 2009 framework was abandoned), Ireland, Latvia, Lithuania, Luxembourg, the Slovak Republic and Slovenia (Albreht et al., forthcoming[14]). The Expert Group on HSPA,1 established at the EU level, exemplifies the critical role of collaborative communities of practice in health system improvements.

1. Comprising EU Member States, with Norway, the OECD, the WHO Regional Office for Europe, and the European Observatory on Health Systems and Policies participate as observers, the EU Expert Group on HSPA identifies policy priorities and methodologies for quality assessment, integrated care and health system resilience. This collaborative approach is complemented by the European Commission’s technical support structures (initially the Structural Reform Support Service, later the Directorate‑General for Structural Reform Support, now the Reform and Investment Task Force), which provide tailored assistance to Member States implementing health reforms through programmes like the Structural Reform Support Programme and Technical Support Instrument.

This policy paper examines key patterns and variations in national approaches to HSPA. This exploratory work is non-exhaustive and mostly relies on national HSPA activities undertaken in Australia, Belgium, Canada, Czechia, Estonia, Ireland, Italy, Latvia, Luxembourg, the Slovak Republic and Slovenia. It has been developed based on desk research and the OECD Secretariat’s experience while working with several countries on developing their HSPA activities, as well as on information shared by countries through the meetings of the Healthcare Quality and Outcomes Working Party.

Section 2 analyses the variations in national HSPA purposes, governance arrangements and substantive focus areas, while identifying important commonalities that have emerged across diverse national HSPAs. Section 3 explores three critical enabling conditions that form the foundation for a successful HSPA implementation: robust data infrastructure, inclusive stakeholder engagement and integration with broader policy processes. Finally, Section 4 outlines the OECD’s contributions to advancing HSPA methodology and practice, including through direct technical assistance to Member countries pursuing their own national HSPA journey.