Learning through national Health System Performance Assessment (HSPA)

3. Three enabling conditions drive HSPA sustainability

The design, implementation and utilisation of HSPA frameworks at the national level thrive on a set of enabling conditions that support a robust, impactful and sustainable assessment process. While dedicated personnel, a defined budget and clear institutional responsibility constitute foundational prerequisites for HSPA development, this section focusses on three specific enabling factors for successful and lasting implementation: robust health data infrastructure, broad stakeholder engagement ensuring ownership of the national framework, and integration into the wider health policy agenda. These factors were identified based on countries’ insights shared with the OECD Secretariat and its experience in supporting the development of national HSPA processes.

3.1. Health data infrastructure serves as a foundation for HSPA and benefits from its implementation

The national health data infrastructure serves as a basis for any HSPA activity. It must be capable of effectively collecting, managing and analysing the data needed to generate meaningful performance intelligence, providing a comprehensive measurement approach able to integrate administrative and survey-based indicators. Key aspects of this include ensuring data quality, maintaining the timeliness of data collection and reporting, promoting interoperability between different data systems, and building responsive delivery outputs. A reliable and wide‑ranging data foundation enhances the ability to assess health system performance accurately and comprehensively. The OECD Council Recommendation on Health Data Governance, adopted in 2016, supports countries in their efforts to improve access to, and processing of, personal health data for health-related public interest purposes (OECD, 2016[27]). While implementation of the Recommendation varies across OECD Member countries (Oderkirk, 2021[28]), secondary use of health data is at the core of HSPA national activities.

Activities on HSPA framework development and implementation also provide countries with an opportunity to strengthen their health data infrastructure. The process of identifying available data promotes secondary use of data originally collected for administrative or clinical purposes, and linking and sharing datasets across national data custodians. In some cases, countries may realise duplication of efforts to collect similar information, identifying an opportunity for harmonisation of fragmented data sources and avoiding information silos that may exist between different government agencies and healthcare providers. The HSPA framework development process often necessitates explicit conversations about metadata standards, coding systems and methodological alignments that might otherwise remain fragmented across different institutions.

In Estonia, the HSPA framework development process catalysed a comprehensive mapping of data flows between institutions, revealing both duplications and gaps in data collection that could be addressed systematically. Czechia’s HSPA framework implementation leveraged the previous long-lasting efforts for more co‑ordinated data sharing between the Ministry of Health, health insurance funds and the Institute of Health Information and Statistics, aligning the HSPA activities with new legislative amendments on reporting key health sector statistics.

Improvements in data infrastructure may also be related to identification of needs for enhancement of the evidence base for health policy decisions. As data infrastructures and indicator methodologies mature in their ability to measure performance based on outcomes – such as targeted improvements in health status and care quality as experienced by patients – this information crucially complements the use of process indicators like the number of consultations or size of the workforce. This outcome‑oriented approach assesses the primary goal of health systems – improving population health – by providing an indication of overall health and well-being, while process and infrastructure indicators remain important for broader interpretation and analysis.

As an example, Ireland’s HSPA framework development process aided a discussion about the lack of a patient identifier in the data infrastructure that could support data linkage, which culminated in the acceleration of the rollout of an individual health identifier across national datasets during the COVID‑19 pandemic (Ivanković et al., 2022[29]). Latvia is another example where authorities initiated a PREMs workstream when the patient-centredness dimension was included in the HSPA framework and no indicator was attached to it. This led to the development of national patient experience surveys to provide regular data on an aspect of care quality that was previously unmeasured.

Lastly, a recurring challenge encountered by many OECD Member countries in developing their HSPA frameworks is the presence of data gaps and inconsistencies. Engaging in HSPA activities provides countries with an opportunity to address these challenges through improvements in data collection methods, data quality enhancement and greater comparability across data sources. For example, Belgium’s HSPA process identified significant variations in data quality across regions, prompting targeted efforts to standardise collection methods and validation procedures. As such, developing national frameworks offers opportunities to strengthen the health system data infrastructures from the very early stages.

3.2. Broad stakeholder engagement ensures ownership of HSPA, while HSPA implementation promotes co‑ordination across organisations

As all countries have multiple organisations involved in health system data management and policy implementation, engagement in HSPA across the entire system is crucial. Broad participation leads to ownership and buy-in, and ensures that frameworks are relevant, credible and influential in policy development. Engaging diverse stakeholders – including state and regional health and finance authorities, healthcare providers, health professionals, policymakers, patients, advocacy groups and the wider public – allows HSPA to have a deeper impact. This engagement creates opportunities for various voices to be heard in health system governance while increasing accountability and transparency. This is at the heart of the OECD’s support to national HSPA developments (see Section 4).

Consensus on the need to develop and implement an assessment framework is a necessary first step that typically requires stakeholder engagement from the outset. This initial consensus-building lays the foundation for meaningful participation throughout the setting up of the HSPA framework and the assessment process, and helps to ensure that results will be relevant for the national context and support policy decisions. Stakeholder engagement throughout the HSPA cycle – from design and implementation to evaluation – ensures that frameworks align with health system objectives and user needs. When stakeholders help to define indicators and interpret results, they develop ownership of the process, improving practical application. This collaborative approach creates performance intelligence that is fit for purpose – as measurements address users’ information requirements directly – and ensures that assessments are repeated through embedding in national approaches to health data.

Estonia, for instance, developed its first framework in 2008; this was implemented only once with no follow-up, due to low stakeholder engagement and thus ownership (OECD, 2023[16]). The renewed Estonian HSPA activities since 2021 promise to establish sustainable HSPA as a regular activity, designed with broader stakeholder engagement and co‑ownership from the start. In Italy, the NGS framework is updated annually, supported by strong collaboration with the Regions and other entities. The NGS is closely linked to the Essential Assistance Levels Committee, which includes representatives from the central government (the Ministry of Health, the Ministry of Economy and Finance, and the Presidency of the Council of Ministers) and the Regions. Use and data submission for Italy’s voluntary IRPES framework varies between regions; those with more quality-oriented HSPA governance show higher participation (Vola et al., 2022[13]).

Simultaneously, the process of HSPA development and implementation creates a social dynamic of co‑ordination and collaboration between organisations working on HSPA at the national level. This emerges through enhanced exchanges to calculate specific indicators that require linking of several sources, dialogues on metadata, and discussions on shared goals for the health and health data system. The HSPA development and implementation process typically involves numerous exchanges between statisticians and team leaders of different organisations governing survey and administrative data, as well as organisation leadership, in advisory board meetings. Czechia’s setting up of its HSPA framework involved over 30 workshops and consultation meetings with stakeholders from across the healthcare system; this created strong buy-in for the final framework and strengthened collaboration through meetings of senior leadership following HSPA development (OECD, 2023[22]). Given the purpose of accountability to the public, Ireland conduced a citizens panel for input on vital HSPA dimensions from the people’s perspective (Brito Fernandes et al., 2021[15]).

3.3. Close alignment with health policy priorities supports HSPA use in decision making and helps target interventions effectively

Alignment with overarching national health policy agenda can increase the impact of HSPA. This integration ensures that the assessment process is not an isolated activity but rather a vital component of the health policy cycle, providing relevant insights that directly inform policy decisions and contribute to the achievement of national health objectives. Conducting an HSPA also builds capacity within the system to conceptualise an overview of the health system, improving understanding of information availability and facilitating its use for health system improvement. The value of HSPA extends beyond measurement; it lies in its ability to translate data into actionable insights that drive meaningful changes within the health system.

While only Finland and Italy reported legal obligations for policy decisions to be based on HSPA results in a survey conducted by the Technical University of Berlin, several OECD Member countries (including Belgium and Latvia) reported incorporating performance assessment findings into their decision making processes on a voluntary basis (Blümel et al., forthcoming[26]).

With increasing fiscal constraints, countries have also begun to explore the relationship between performance assessment and financing decisions. Finland’s 2023 health and social services reform demonstrates how HSPA can influence funding decisions directly. The reform shifted responsibility for health and social services to 21 well-being services counties, along with the City of Helsinki, which are financed from the state budget and governed by elected councils, creating a direct link between performance assessment and resource allocation. While most funding is universal and based on service needs and circumstances, a portion is explicitly tied to performance metrics focussed on health and well-being outcomes (OECD/European Observatory on Health Systems and Policies, 2023[30]). Similarly, the Slovak Value for Money division within the Ministry of Finance carries out spending reviews that incorporate health system performance metrics to evaluate the effectiveness of government expenditure in health (OECD/European Observatory on Health Systems and Policies, 2023[31]).

HSPAs may also inform discussions on financing in parliament, including on budget setting, tracking money on activity and flagging sectors where key performance indicators have unwanted variation. In Belgium, HSPA findings are regularly presented to parliamentary committees during budget debates, giving legislators evidence‑based insights into system performance that can inform funding priorities. Finally, Italy’s New Guarantee System (NGS), a tool embedded in its HSPA reporting, affects regional funding and oversight. Additional funding is granted to regions that fully comply with the Essential Levels of Care targets, while low overall performance results in increased national oversight. Persistent low performance can lead to the loss of funding of up to 3% or the use of a Recovery Plan – an instrument designed for such situations. In 2025, seven regions had implemented Recovery Plans.