Learning through national Health System Performance Assessment (HSPA)

2. Countries use national HSPA frameworks to drive evidence‑based and targeted health system improvements

2.1. National HSPA frameworks are primarily used to monitor performance, ensure accountability, and inform policy decisions

OECD Member countries deploy national HSPAs as strategic instruments to generate evidence‑based health system improvements. Each framework is tailored to country-specific contexts – including health system architecture, demographic profiles, care delivery infrastructure, epidemiological projections and national policy priorities. HSPAs enable policymakers to make data-driven decisions by systematically identifying performance gaps requiring intervention. Through longitudinal analysis of key performance indicators, countries can build comprehensive intelligence on system strengths and vulnerabilities, facilitating targeted policy responses to emerging challenges and performance deficits.

The analysis of national HSPAs identified seven distinct purposes for these frameworks, with varying prevalence reflecting differences in national priorities and implementation approaches (Figure 1). The three most common applications are performance monitoring, public accountability reporting and informing system-wide reforms, while other purposes vary according to each country’s specific health system needs and national policy context.

Figure 1. Selected reasons countries use HSPA frameworks

2.1.1. Monitoring and public reporting are key functions of HSPAs

National HSPA frameworks help organise evidence on health system performance, turning data into insights and supporting analysis. Many OECD Member countries with HSPAs incorporate the monitoring function to their frameworks, which are designed to capture developments in health system components or outcomes in a timely manner. This can include monitoring of desired developments, as well as capturing unexpected changes. HSPA frameworks aim to structure the assessment in an accessible way (hence including a limited set of carefully selected indicators) that is easy to understand for policymakers and decision makers and for the general public, allowing a quick publicly available and accessible overview of the situation within the health system. To increase the accessibility of health data for the public and all health system stakeholders, most countries publish reports that analyse the HSPA indicators via figures and text to provide context for the reader.

Ireland’s Sláintecare reform programme emphasises comprehensive health system strengthening, encompassing governance, funding mechanisms and financial management, workforce planning, eHealth and other knowledge‑based technologies, quality and performance management, and procurement. Ireland recognised a need to develop an outcome‑oriented HSPA framework which reflects the priorities of multiple stakeholders, including citizens, aligns stakeholder interests and contributes to realising people‑centred, value‑based health systems. This led to a HSPA design strategy with emphasis on citizen participation through a citizen panel (Brito Fernandes et al., 2021[15]) and eventual development of an interactive website that displays the indicators included in the HSPA (see www.hspa.gov.ie).

Other countries, including Belgium, Canada and Italy, also maintain online portals where data are disseminated through dashboards; a similar system is planned in Czechia, Estonia and Luxembourg and under consideration in Latvia and Australia, pending resources to develop it. Online tools also facilitate more frequent and reliable updates to HSPA data between full report publications and can be automated to allow for more regular updates.

2.1.2. HSPA frameworks help strengthen transparency and accountability

Transparency and accountability emerge as explicit purposes of some countries’ HSPA frameworks, often seen as an outcome of monitoring and reporting activities. Slovenia positions these goals prominently in development of its HSPA, using performance assessment to increase system openness and stakeholder accountability. The public reporting of performance data creates incentives for improvements by stakeholders, while enabling citizens to understand how their health system performs and where resources are being allocated. The listed objectives of the Belgian HSPA also clearly reference this transparency dimension, with a goal to: “provide a transparent and accountable view of the health system performance, in accordance with the commitment made in the Tallinn Charter” (Gerkens et al., 2023[10]). Estonia’s HSPA purpose of accountability is articulated through fostering of stakeholders’ engagement and ownership across the health system (OECD, 2023[16]), and exemplified through a stakeholder meeting taking place to discuss the draft HSPA results prior to publication. The framework explicitly targets public awareness and stakeholders’ accountability among its key aims.

2.1.3. HSPA frameworks support evidence‑informed decision making

Evidence‑informed decision making is an increasingly common core function of many national HSPAs, as objective data placed in context support policymakers in targeting resources effectively to address specific challenges. This requires embedding of long-term health system goals in short-term decision cycles through performance assessment and creating synergy between macro-level system assessment and meso/micro performance management.

For countries with decentralised health systems, a national HSPA can serve as a co‑ordination mechanism tool. Czechia prioritises inclusive HSPA governance arrangements with shared framework ownership across stakeholders precisely because of its decentralised health insurance system and overlapping institutional responsibilities. Such an approach enables more effective monitoring and informed decision making, despite system fragmentation. In Australia, the update of its Health System Performance conceptual framework will support “evidence-based decision making to drive continuous improvement and innovation on priorities that require joint action across sectors and jurisdictions” (AIHW/ACSQHC, forthcoming[17]).

2.1.4. HSPA frameworks contribute to strengthening strategic planning and target setting

Use of HSPA information to improve health system planning is articulated by several countries, including Australia, Czechia and Luxembourg, while others focus on monitoring of planned changes. Australia is undertaking a revision of its framework, to reconceptualise the purpose of its national HSPA to provide a whole of health system perspective, to integrate the efforts of national and regional governments. While the 2017 framework primarily served as a broad data categorisation tool, the new framework is being deliberately designed as a decision support tool for health leaders and as a mechanism for supporting shared stewardship and evidence-based decision-making to drive continuous improvement and innovation on whole-of-system priorities that require joint action across sectors and jurisdictions (AIHW/ACSQHC, forthcoming[17]). HSPA frameworks additionally structure evidence and provide context to help assess progress against nationally relevant targets, creating clear lines of accountability for health system performance (see Section 2.2).

2.1.5. HSPA frameworks also support monitoring of system reforms and change management

Some countries have deployed HSPA as a reform implementation tool. Ireland initially implemented HSPA in alignment with the Sláintecare, its 10‑year reform programme launched in 2017, aiming to use the framework to measure, monitor and evaluate priority areas of the reform and to inform policy cycles. As the HSPA has evolved, additional priority goals of the Programme for Government, the Health Service Executive Corporate Plan as well as Ministerial priorities have been incorporated. Similarly, Estonia prioritises HSPA for strategic planning and policy monitoring, aligning purpose and scope of the HSPA with key policy priorities. By developing a systematised list of monitoring indicators within its HSPA framework, the country explicitly aimed to strengthen health information system governance and include indicators that evaluate national plans, including monitoring of progress towards the goals of its National Health Plan 2020-2030 (OECD, 2023[16]). Slovenia’s HSPA is linked to its National Healthcare Plan 2016-2025, with the aim to assess critical system aspects and monitor progress towards targets within the plan (Perko et al., 2019[18]) while Latvia’s framework provides benchmarking assessments at international, regional, municipal and even health service provider level, depending on the indicator (Latvian Centres for Disease Prevention and Control, 2024[19]).

2.1.6. Aligning stakeholders around common objectives is another key outcome of HSPA frameworks

Several countries highlight HSPA’s role in creating alignment among their system stakeholders. Czechia emphasises shared ownership in the HSPA development process to align activities and expectations across stakeholder groups. This alignment function is particularly valuable in complex health systems with multiple actors, helping to create a shared vision and a co‑ordinated approach to health system improvement. Supporting shared stewardship is one of the aims of the Australian HSPA, while Estonia similarly emphasises common objectives for stakeholders to improve the health of the population. These objectives are reflected in the highly consultative stakeholder-oriented HSPA development process in most countries that ensures fit to national context, and sustainable adoption and implementation of the HSPA (see Section 3.2).

By reinforcing quality review processes and targeted data use, HSPA frameworks make international comparisons more consistent. Quality monitoring and improvement represent a central purpose for HSPA adoption in many countries. Croatia’s Ministry of Health developed an HSPA framework primarily to enhance quality of care monitoring, validate existing indicators and develop new ones – deliberately broadening assessment beyond the previously hospital-focussed analyses. Latvia also emphasises quality along with equity and financial sustainability as the three main purposes guiding its HSPA implementation. Additionally, targeted use of health data is explicitly articulated as one of the purposes of the HSPA in Estonia.

International benchmarking is another significant application of national HSPAs, and is an explicit HSPA purpose in several countries, including Czechia and the Slovak Republic. Countries benchmark many of their indicators against international standards, allowing them to identify relative strengths and weaknesses. By comparing their performance indicators and outcomes with those of other OECD Member countries, policymakers can identify good country examples and explore strategies and interventions that could be adapted and implemented in their own contexts.

2.2. Countries adapt HSPA domains to national contexts and priorities

This section provides a comparative review of commonalities and differences across OECD Member countries’ national HSPA frameworks, firstly in terms of structure of the frameworks, and secondly comparing content by examining domain choices and indicators selected. This exploratory work is non-exhaustive and mostly relies on the national HSPA activities undertaken in Australia, Belgium, Canada, Czechia, Estonia, Ireland, Italy, Latvia, Luxembourg, the Slovak Republic and Slovenia.

The analysis first examines four key structural elements of national HSPA frameworks: domain organisation, indicator disaggregation approaches, placeholder indicator usage and alignment of framework structure with national policy contexts (Table 1). All countries in the sample base their national HSPA domains on international measurement approaches, structuring them around system structures, processes, and outcomes (see Annex A). Yet each country adapts these principles differently. One key difference is disaggregation strategies, which reveal how country size and health system organisation shape national HSPA design. Federal systems with decentralised responsibilities such as Australia, Canada and Italy disaggregate most HSPA indicators by region to reflect jurisdictional accountabilities. Belgium disaggregates by language regions. In contrast, Estonia’s and Latvia’s smaller size, centralised system and low population density in some regions mean that for a subset of indicators, regional benchmarking offers limited value and international comparisons are prioritised.

Countries also differ in the number of indicators included in the framework, and how they use placeholder indicators strategically to balance comprehensiveness with current measurement capacity. The number of indicators included in a national HSPA framework may vary according to its purpose and the process used for its development. Countries aim to strike a balance between feasibility, the frequency of monitoring, and the comprehensiveness of performance assessment. For instance, Italy’s NGS framework includes 88 key indicators (with some currently defined as yearly placeholder indicators), while Czechia, Luxembourg, and the Slovak Republic each fall within the range of 100 to 150 indicators. Estonia and Ireland, by contrast, include more than 200 indicators. Placeholder indicators serve as markers where additional data development is desired. In Estonia’s HSPA framework, 38% of indicators are placeholders, compared to around 25% in Czechia and Ireland. This demonstrates how countries establish ambitious frameworks while acknowledging data infrastructure limitations. It enables countries to signal policy priorities and create incentives for data development rather than limiting frameworks to currently available metrics.

Another difference concerns the linkage between HSPA indicators and national health strategies. Estonia demonstrates comprehensive integration, connecting its HSPA framework to multiple strategic documents including the National Health Plan 2020-2030, the Cancer Control Plan, the Mental Health Action Plan and the Health Information System Strategy. This can be the reason for the large number of placeholder indicators included in that framework. Belgium is undertaking work to define Belgian health and healthcare priorities and targets, under which indicators in its HSPA and other assessment reports (Health Status Report, medical practice variations) will be used to monitor inter-federal health objectives (Gerkens et al., 2023[10]). In Italy, the NGS evaluation framework computes composite performance scores against minimum performance standards set ex ante across specific areas: collective prevention and public health, primary care and hospital care, complemented by context indicators to estimate healthcare need, a social equity indicator and Clinical Pathways monitoring and evaluation indicators. These scores are used to ensure that essential levels of service are met in all regions (Box 2). This variation reflects different political contexts and HSPA purposes, with countries using HSPAs primarily for monitoring, while others embed them deeply into policy implementation cycles (see Section 2.1).

Table 1. While national HSPA frameworks share core structural features, countries vary in how they organise domains, handle disaggregation, and use indicators

Structural element	Observations on commonalities and differences	Examples or distinctive features reported in countries’ HSPA frameworks
Structuring of domains	Countries align their HSPA frameworks with international approaches to measuring structures, processes, outcomes and outputs1 of health systems.	See Annex A for examples of selected countries’ HSPA frameworks.
Within-country disaggregation	Feasibility, choice and level of disaggregation of indicators depends on the size of the country, organisation of the health system, maturity of its health data infrastructure, national priorities and purpose of its national HSPA.	Larger countries with decentralised health system responsibilities such as Australia, Canada and Italy disaggregate all or most indicators by region. Belgium disaggregates by the three language regions. Estonia and Latvia, owing to smaller size, centralised health system organisation and low population density in some regions, some indicators are not considered suitable for regional benchmarking.
Placeholder indicators	Decisions about including placeholder indicators vary depending on the purpose of the HSPA, data availability and indicator needs for national purposes. An indicator may be considered a placeholder for several reasons, such as a lack of availability of relevant data, the need to develop and reach consensus on its methodology, or the requirement to adapt an existing methodology from another country to the national context.	Close to two in five (38%) of Estonia’s HSPA indicators are placeholders, included to enable closer alignment with several national plans. Nearly one in three (31%) of indicators in Italy’s NGS are placeholders. Czechia and Ireland included around a quarter (25‑26%) of placeholder indicators in their HSPAs.
Indicators’ linkage to national plans and use of established targets	Countries’ alignment of HSPAs with national plans varies, depending on the (political) context and purpose of their HSPA. Selection and inclusion of targets for indicators is a complex process involving statistics, policy and politics. Specific targets for all indicators are usually not in place at the time of publication of the first HSPA reports and, depending on the HSPA purpose, may not be needed.	Belgium has developed targets for several key policy areas. Ireland has been working on operationalising its HSPA indicator targets to Sláintecare programme objectives.

1. The Donabedian model is a foundational approach to healthcare quality developed in the 1970s that focusses on three main components: structure, process, and outcomes (Donabedian, 1972[20]), while international developments led to later distinguishing outputs of the system from outcomes in some contexts.

Note: Observations and general tendencies are reported, without a systematic comprehensive analysis. In addition, many other observations – for example, where countries’ approaches tend to follow more similar established patterns – were not selected for inclusion in this table owing to its length.

Source: Authors’ analysis and Noto et al. (2019[21]), Health system performance assessment in small countries: the case study of Latvia; Gerkens et al. (2023[10]), Performance of the Belgian health system: Revision of the conceptual framework and indicators set; The National Health Information and Performance Principal Committee (2017[11]), The Australian Health Performance Framework; OECD (2023[16]), Health System Performance Assessment Framework for Estonia; OECD (2023[22]), Health System Performance Assessment Framework for Czechia; Department of Health Ireland (2025[23]), Health System Performance Assessment (HSPA) Platform; Canadian Institute for Health Information (2013[9]), A Performance Measurement Framework for the Canadian Health System. Technical Report; Ministero della Salute (2025[12]), The New Guarantee System [Il Nuovo Sistema di Garanzia (NSG)].

Table 2 outlines key observations on the topics and themes included in HSPA frameworks, revealing both established and emerging priorities in health system performance measurement. Traditional domains form the foundation of all national frameworks. Workforce measurement appears universally, although it varies in scope across countries, as illustrated by Ireland’s inclusion of community health workers and measurement in full-time equivalents rather than headcounts. Quality and safety indicators follow similar patterns across countries, measuring clinical effectiveness through treatable mortality for instance, and incorporation of key OECD Healthcare Quality metrics such as the rate of avoidable hospital admissions. Patient safety frequently measured through healthcare‑associated infections, although international comparisons remain challenging. Financial domains often contain the highest numbers of indicators in national frameworks, with countries aligning metrics to the OECD-defined System of Health Accounts (SHA) terminology. Efficiency measurement frequently overlaps with financial sustainability – tracking, for instance, length of hospital stay, day surgery rates and generic prescriptions. Some countries demonstrate specific approaches though: Slovenia breaks down emergency visits by month and severity, while Ireland separates efficiency into short-, medium- and long-term measures. Newer conceptualisations of efficiency in healthcare focus explicitly on highest possible value delivered relative to resource, with the draft HSPA framework in Australia defining this domain through assessment of whether care is delivered in the lowest acuity setting that is appropriate to need and if the health system is set up in a way to support this. It also includes consideration of appropriate preventative and early intervention care.

Moving beyond these established domains, newer themes reflect evolving health system priorities, while variations in what is captured reflect national priorities or areas perceived to be problematic. Resilience gained prominence in the aftermath of COVID‑19, as countries adopted diverse strategies shaped by variations in indicators and policy responses. While some concentrated on sustaining essential healthcare services and safeguarding vulnerable populations, others put more emphasis on enhancing management capacity, staff readiness, digital health adoption and reinforcement of primary healthcare. A content analysis of six countries identified six distinct definitions of resilience based on key performance indicators: meeting unmet needs and preserving outcomes, protecting vulnerable groups, securing and deploying resources, ensuring trained and prepared staff, leveraging digital health, and strengthening primary healthcare (Vainieri, Caputo and Vinci, 2024[24]). Belgium added resilience as a transversal domain in its HSPA framework in 2023. Ireland measures workforce motivation through staff surveys and absences, and plans to define surge capacity indicators. Canada offers yet another perspective, grouping indicators under resilience that reflect “adjustment to population health needs” to emphasise system adaptability. Environmental sustainability represents another emerging priority, exemplified by Ireland’s direct measurement of greenhouse gas (GHG) and carbon dioxide (CO₂) emissions in its HSPA, but this domain is still not well covered by most countries’ frameworks.

At the frontier of HSPA development, person-centredness and integrated care showcase diverse implementation strategies. Countries’ approaches to capturing patient voice vary considerably. Latvia’s experience demonstrates how making patient experience a core building block can drive data development in that domain, making use of placeholder indicators for new data collection needs. Ireland exemplifies comprehensive implementation, including indicators of patient-reported experience measurements (PREMs), patient-reported outcome measurements (PROMs), carer experiences and staff experiences. In contrast, Czechia shows how these measures can be embedded throughout other existing domains, placing PROMs within the health status domain and PREMs within the domain of quality of care, for instance.

Table 2. HSPA frameworks across countries reflect shared core domains, implemented with varying scope, depth and types of indicators

Domain or theme	Observations on commonalities and differences	Examples or distinctive features reported in countries’ HSPA frameworks
Health system resources, characteristics and policies
Financing, financial sustainability	Financing is one of the foundational indicator domains in European countries, usually drawing on internationally comparable indicators aligned with SHA terminology.	Czechia covers financial stability through health system revenues and expenditures, funding availability over time, and ratio of insurance system reserves to current expenditure. Ireland includes a (placeholder) indicator on research and development funding and investment in medical technologies.
Workforce	Workforce is included in most countries’ HSPA frameworks. This dimension commonly contains the numbers of workers, although inclusion of allied health professionals is less widespread. Depending on priorities within a country, further focus can be placed on education and training.	Ireland includes community health workers, and measures workforce numbers in full-time equivalents. Czechia makes a distinction between current and the future health workforce capacities. The draft Australian framework captures current volume, availability, capacity, workload and distribution of doctors, nurses, Aboriginal health workers and other healthcare workers, and the ability to maintain an adequate workforce into the future.
Data and digitalisation	Data and digitalisation is increasingly included as a separate structural domain by many countries.	Estonia includes placeholder indicators aligned with the Health Information System Strategy on patient portal usability, Electronic Health Records interoperability, health information exchange, secondary use of data, telemedicine and security. The draft Australian framework assesses technology that enables connected care across the health system (e.g. EHRs, telehealth and electronic prescriptions) and data systems that support system improvement and evidence generation.
Innovation	While some countries measure innovation through digitalisation, others focus on aspects such as clinical processes or research/trial activity.	Canada includes innovation and learning capacity as a dimension focussing on implementation of internally generated or borrowed ideas – noting, for instance, adoption of surgical checklists and clinical guidelines.
Governance	Many countries perceive the governance domain as important for an HSPA, but few have indicators and data available to measure this.	Ireland measures implementation of hospital guidelines and warning systems under a “processes” dimension. The draft Australian framework measures shared stewardship, stakeholder voice, policy and information making. Estonia includes four placeholder indicators on broad governance topics, without specific methodology available.
Healthcare services and public health interventions
Access	In the access domain, most countries include indicators on waiting times, geographical availability, financial protection and unmet needs.	Ireland includes a dimension of “geographic equity”. Belgium assesses accessibility in terms of financial accessibility, health workforce distribution and health services distribution. Czechia uses specific unmet needs for financial affordability, in addition to nine other indicators. Latvia’s HSPA framework measures general practitioner (GP) and specialist visits specifically among people aged 45‑64, reflecting access at an age when chronic conditions often start.
Quality and safety	Healthcare quality is commonly included via clinical effectiveness (e.g. mortality from treatable conditions), patient safety (e.g. healthcare‑associated infections) and appropriateness of care (e.g. avoidable hospital admissions). Some reconceptualise safety by including process indicators of safety culture while data comparability for administrative safety metrics is low.	Most countries include key established indicators from OECD foundational work on healthcare quality, with those requiring basic health data infrastructure near-universally included. While many countries include cancer survival metrics based on national monitoring, international comparisons remain reliant on CONCORD data, which are available with a time delay. Belgium’s HSPA framework measures safety of care through point-prevalence surveys of infections in healthcare. As of 2024, the measurement has been broadened to health worker-reported safety culture.
Integrated care	Integrated care is an increasingly common domain allowing to follow the patient past acute events through the care pathways, with many countries undertaking activities to increase the availability of indicators to measure it through data linkages.	Several countries have adopted OECD’s integrated care indicators that measure 1‑year outcomes after a cardiovascular event. Ireland includes informational (documentation) and relational (turnover rates) continuity, co‑ordination and integration (care delivery and readmissions), using many placeholder indicators. The draft Australian framework includes a dimension co‑ordinated and continuous within and between all parts of the health system and care settings throughout the person’s healthcare journey. “Other care settings” capture settings that interface with healthcare, such as aged care, disability and community services. Italy uses 10 indicators to monitor and evaluate Clinical Pathways, covering COPD, heart failure, diabetes, breast cancer in women, colon cancer, and rectal cancer.
Person-centredness
Person-centredness	Country approaches to measuring person-centredness vary depending on the availability of data on PROMs and PREMs. Some HSPAs focus specifically on patient centredness. Patient voice can be captured either through a dedicated domain or across several domains across process, outcomes and outputs.	Ireland includes PREMs, PROMs, carer experiences and staff experiences in its HSPA framework. Czechia uses PROMs within the “experienced health” subdomain of health status, and PREMs as part of “people‑centredness” in the quality domain. Estonia includes a domain with six placeholder indicators on PREMs, PROMs and employment rate among people with chronic diseases, signalling priority. OECD Patient-Reported Indicator Surveys (PaRIS) indicators provide new internationally comparable patient-reported data (see Section 4.1).
Health literacy	Countries are increasingly recognising the importance of health literacy, bringing it out as a specific domain or including measurement of related indicators in other subdomains.	The OECD PaRIS and other international initiatives offer opportunities to measure health literacy through self-reported or structured assessments. With a priority of improving people’s engagement in their own health, Estonia includes a domain of health literacy in its HSPA framework, measuring it through administrative data on patterns of appropriate healthcare use.
Individual and population health
Health status	All countries monitor this dimension using indicators such as life expectancy or healthy life expectancy and sometimes prevalence of specific diseases.	As of 2019, Belgium separates health status into a distinct publication, with Sciensano as the lead (as opposed to the Belgian Healthcare Knowledge Centre for the HSPA), and close collaboration between responsible organisations. Latvia separates long- and short-term outcomes, with all indicators capturing general and cause‑specific mortality overall or in specific population groups. Estonia uses six indicators in the central health status domain (including life expectancy, healthy life expectancy and self-rated health), while a separate outcomes section captures cause‑specific morbidity and mortality.
Cross-cutting dimensions
Efficiency	Common efficiency measures include length of hospital stay, day surgery rates, generic prescriptions and various cost – effectiveness indicators. Some countries combine this topic with financial sustainability or appropriateness of care. A newer conceptualisation captures efficiency through a focus on value delivered to the population.	Slovenia disaggregates emergency department visits by month and severity in order to signal inefficient service use. Ireland separates measurement into short-term (e.g. inpatient/day case waiting times and emergency department performance), mid-term (e.g. total number of out-of-hours GP contacts) and long-term efficiency measures. The draft Australian framework places focus on assessing whether care is delivered in the lowest acuity setting that is appropriate to need and if the health system is set up in a way to support this. It also includes consideration of appropriate preventative and early intervention care.
Equity	There is variation across countries in whether equity is included explicitly as a domain with dedicated indicators to measure it, or embedded throughout other domains via indicator disaggregation.	Ireland looks at self-reported health and GP visits by sex, gender and country of birth. Czechia does not use an equity domain but prioritises disaggregation of indicators throughout its HSPA framework. The draft Australian framework includes Aboriginal and Torres Strait Islanders’ health as a core element, establishing culturally safe care as a domain.
Resilience	Resilience presents a newer emerging focus for OECD Member countries, building on lessons learned from the COVID‑19 pandemic. Examples can include metrics on surge capacity, workforce flexibility, stockpile management and institutional adaptability during crises.	Belgium’s 2023 revised HSPA framework introduces resilience as a transversal domain capturing variation as a response to shock, with indicators on adequate workforce, maintaining essential health services and ability to scale up capacity. Ireland uses workforce motivation and support (via staff survey and absence information), surge capacity and capacity to scale up/down (placeholders). Canada uses the domain of adjustment to population health needs, referring to the system’s ability to adapt. Italy’s new HSPA will include standard indicators to assess resilience capacity, capturing not only response capabilities but also the foundational components of resilience. Italy’s voluntary IRPES framework was expanded by 63 novel resilience indicators in 2020 to support regional monitoring.
Sustainability and environment	For some countries, environment is out of the scope of the framework while others measure environmental characteristics relevant to health. Aligned with emerging priorities, a few countries have started to include the impact of the healthcare system on the environment as an outcome.	Ireland measures overall GHG and CO2 emissions in its HSPA framework. Estonia includes indicators on air, water and noise exposure, as well as climate change (seasonal mortality). Belgium’s HSPA includes the domain of environmental sustainability as the system’s capacity to minimise negative impacts on the environment and leverage opportunities to restore and improve it for health, although the dimension is not yet formally integrated owing to a lack of data availability.

Note: Observations and general tendencies are reported, without a systematic comprehensive analysis. In addition, many other observations – for example, where countries’ approaches tend to follow more similar established patterns – were not selected for inclusion in this table owing to its length. Categorisation based on OECD (2024[5]) Rethinking Health System Performance Assessment. A Renewed Framework, https://doi.org/10.1787/107182c8‑en.

Source: Authors’ analyses based on The National Health Information and Performance Principal Committee (2017[11]), AIHW and ACSQHC (forthcoming[17]), Australian Health System Performance Assessment Framework 2025: From data to decisions; Gerkens et al. (2023[10]), Performance of the Belgian health system: Revision of the conceptual framework and indicators set; Gerkens et al. (2024[25]), Performance of the Belgian Health System: Report 2024; Canadian Institute for Health Information (2013[9]), A Performance Measurement Framework for the Canadian Health System. Technical Report; OECD (2023[22]), Health System Performance Assessment Framework for Czechia; OECD (2023[16]), Health System Performance Assessment Framework for Estonia; Department of Health Ireland (2025[23]), Health System Performance Assessment (HSPA) Platform; Vola et al. (2022[13]), The Italian interregional performance evaluation system; Ministero della Salute (2025[12]), The New Guarantee System [Il Nuovo Sistema di Garanzia (NSG)]; Noto et al. (2019[21]), Health system performance assessment in small countries: the case study of Latvia; Latvian Centres for Disease Prevention and Control (2024[19]), Assessment of the performance of the health system [Veselības sistēmas darbības snieguma novērtējums]; Perko, D et al., (2019[18]), Health System Performance Assessment for Slovenia.

2.3. HSPA governance arrangements depend on purpose and national context

HSPA governance structures have an influence on whether performance assessments translate into policy action. Analysis of OECD country experiences reveals four HSPA governance characteristics that drive HSPA sustainability and policy actionability: institutional and budgetary independence, legal mandates for utilising findings, strategic timing aligned with policy cycles, and systematic stakeholder engagement processes.

2.3.1. Countries structure HSPA through independent or integrated institutional models

Countries structure HSPA governance in two distinct ways, each with specific advantages and trade‑offs. Independent arrangements, where commissioning and performing institutions operate separately, enhance evaluation credibility and reduce potential bias. In Belgium, these institutions are clearly separated organisationally, and HSPA is performed independently of the Federal Ministry of Health. A similar arrangement has been selected for setting up the HSPA framework in Luxembourg. In Canada, the leading HSPA organisation at the federal level is the Canadian Institute for Health Information. However, integrated arrangements, where ministries of health lead both functions (as in Czechia), can streamline co‑ordination and accelerate policy implementation. Countries should weigh evaluation independence against operational efficiency when designing their institutional frameworks.

Evidence suggests that allocating sufficient HSPA resources – for both staffing and funding – is key to the sustainability of a national HSPA. Securing a budget for HSPA activities independently of political decisions on annual budgeting has been reported as facilitating factor for HSPA regularity in Belgium, where the leading HSPA organisation is the Belgian Healthcare Knowledge Centre and its HSPA activities are financed through the national health insurer.

2.3.2. Legal mandates drive HSPA development and use

Legal foundations significantly influence how countries integrate HSPA findings into policy decisions. Finland and Italy report that they have a legal obligation for policy decisions, such as resource allocation, to be based at least partly on HSPA results (Blümel et al., forthcoming[26]). Belgium demonstrates an alternative approach, establishing HSPA through explicit political commitments in governmental agreements rather than legal obligations. This commitment was explicitly formulated in the Belgian Governmental agreement on public health, which states: “The performance of our health system (including quality) is to be assessed on the basis of measurable objectives”. This high-level political commitment has been reinforced through its renewal by successive governments and through consistent support from the leadership of all relevant administrative bodies. It was instrumental in establishing HSPA as a priority on the national health policy agenda and securing its continuity, despite changes in government (Gerkens et al., 2023[10]).

2.3.3. Alignment of HSPA timing with wider policy processes maximises policy influence

Countries that align HSPA cycles with policy planning tend to achieve a greater impact on decision making. Strategic approaches include releasing reports when national health plans are developed, timing assessments to inform budget cycles, and co‑ordinating with electoral timelines. Estonia’s model illustrates sophisticated timing, aligning HSPA cycles with political ones while releasing results sufficiently early to avoid politicisation (2023[16]). Similarly, Australia’s HSPA is planned to support federal, state and territory health ministers in alignment with nationally shared reform commitments (AIHW/ACSQHC, forthcoming[17]). With this in mind, guidance from the ministers is planned to be requested regarding key policy questions to be addressed.

2.3.4. Stakeholder engagement transforms technical analysis into policy action

HSPA governance extends beyond institutional structures to encompass stakeholder engagement processes that determine real-world impact. Belgium, for instance, created a collaborative culture for its HSPA by establishing an inter-administration working group with representatives from ten health administrations at both the federal and regional levels. This working group monitors the HSPA process, ensuring that all relevant authorities contribute to and provide feedback on the reports. This inclusive approach has fostered shared ownership across different levels of government, and has created effective pathways to translate technical findings into policy action (Gerkens et al., 2023[10]). Without such engagement mechanisms, even sophisticated HSPA frameworks risk remaining purely technical exercises with limited policy influence.