Learning through national Health System Performance Assessment (HSPA)

4. The OECD supports countries in developing tailored HSPA frameworks

The role of international organisations in supporting HSPA frameworks’ development has been significant. In 2018, Fekri et al. (2018[32]) found that 17 of the 30 countries they examined acknowledged assistance from organisations such as the EU, OECD, World Health Organization and World Bank in their national reports. The OECD Secretariat has long been committed to assisting countries in developing their HSPAs, providing guidance on methodologies, frameworks, and indicators, and facilitating cross-country learning.

4.1. The OECD’s renewed HSPA framework guides indicator development for health system assessments and fosters international collaboration

For the past three decades, the OECD has helped countries to identify the key principles of high-performing health systems and to assess health system performance 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 Secretariat over time. More particularly, in the early 2000s, the development of the OECD Healthcare Quality and Outcomes framework was a hallmark initiative that pushed forward the agenda of using administrative data in the measurement of healthcare quality. In the following years, additional frameworks have contributed to guide OECD’s work on health, including the 2015 revision of the HSPA framework, the Framework for People‑Centred Health Systems, and the Resilience Shock-Cycle Framework.

The OECD’s commitment to HSPA has evolved over time, adapting to the changing landscape of healthcare and emerging global challenges. Recognising the need to address contemporary issues such as population ageing, the increasing impact of digitalisation and the growing threat of climate change, the OECD recently renewed its HSPA framework, which was adopted by the Health Committee in 2023 and endorsed during the 2024 OECD Health Ministerial Meeting (OECD, 2024[33]). This revised framework builds upon earlier versions and incorporates crucial new dimensions, including a stronger emphasis on people‑centredness, the critical aspect of health system resilience and the growing importance of environmental sustainability.

A central aim of the OECD’s renewed HSPA framework is to provide strategic guidance for the Organisation’s own work on health systems performance measurement and international comparisons. It achieves this by providing a common language, a set of shared definitions, and a mutual understanding of the key concepts and principles underpinning HSPA. The 2025 edition of Health at a Glance presented indicators in alignment with the renewed OECD HSPA framework (OECD, 2025[34]).

Finally, the OECD’s framework plays a vital role in guiding the development of new health indicators and data collection methodologies that are essential for measuring the performance of health systems in the 21st century. Following the framework’s adoption, ongoing discussions with countries and relevant working parties have focussed on identifying possible new indicators. Some of the progress made is described below.

4.1.1. The OECD Secretariat is developing a new set of digital health indicators

To populate the “data and digital” component of the renewed HSPA framework, the OECD Secretariat is developing new digital health indicators to support healthcare system digitalisation. This work delivers two key outputs: a concise set of indicators assessing readiness, usage and impact of digital technologies; and a country-level toolbox with complementary indicators to help measure progress within national digital health ecosystems.

The first output measures international/regional progress and promotes a common language for digital health metrics. It covers readiness (capacity in technology, people and governance), usage (adoption of digital tools) and impact (both short-term effects like PROMs and PREMs, and long-term system-wide economic benefits). Building on the 2019‑2020 OECD survey of health data development (Oderkirk, 2021[28]), data on eight core readiness indicators were collected through the 2025 OECD Health Data Governance, AI and Health Workforce, and Interoperability Survey. These responses are under review. Pilot data collection for the four usage indicators will soon launch across selected countries. Impact indicators will follow later, as they depend on foundational data from the readiness and usage dimensions.

4.1.2. Measuring resilience and sustainability dimensions

A key lesson from the recent COVID‑19 health emergency was the need for health systems to be resilient and sustainable – now reflected as transversal dimensions in the renewed OECD HSPA framework. These two dimensions can also be very relevant when analysed in the context of climate change. Ongoing work co‑ordinated by the Working Party on Health Statistics estimates GHG emissions of the health sector – one component in assessing whether the impact of health systems is environmentally sustainable. In this work, overall GHG emissions related to the final demand of healthcare are measured, as are those of identified subsectors such as hospitals or medical goods. The origins of emissions are also identified; this could potentially help developing strategies to decarbonise health systems.

In addition, a data collection on emergency visits and hospitalisations due to climate change‑sensitive conditions has been piloted to quantify the health impact of climate change – in particular, extreme temperatures. This picture can be complemented with existing indicators such as all-cause mortality (which can be monitored during heatwaves, for example) and incidence of vector-borne diseases. This set of indicators can be considered as a first step to monitor the resilience of population health in the face of a changing climate.

4.1.3. Expanding the scope of access and workforce dimensions

A critical objective of high-performing health systems is to ensure adequate access to quality healthcare. As part of this, there is a need to monitor information on frontline healthcare services, such as emergency medical care. However, indicators related to the delivery of emergency care have not been developed and collected on a regular basis. This information gap has received increased attention as countries strive to develop more resilient health systems. In addition, information on the use of emergency services can provide an insight into the efficiency of primary care services. Following an initial feasibility study, variables covering the use of hospital emergency department services – disaggregated by mode of arrival and result of visit – have been integrated into the annual data collection. In parallel, granular high-frequency data on emergency department visits by age, sex, subnational region and selected diagnostic categories have been collected to support a number of ongoing projects.

In addition, in the context of health system resources, work on improving the availability, quality and comparability of key data on the health and care workforce is continuing. Developmental work has focussed on key aspects of the working conditions of health workers, including monetary aspects (remuneration) and non-monetary aspects (working hours and the quality of the work environment).

4.1.4. The PaRIS survey provides a unique opportunity to collect indicators on people‑centredness

The OECD’s Patient Reported Indicators Survey (PaRIS) initiative provides a unique and valuable resource for countries’ HSPA frameworks. It fills a critical gap by systematically capturing the outcomes and experiences of healthcare that matter most to people – especially those living with chronic conditions. This complements traditional metrics that typically focus on inputs, processes and outputs such as spending or mortality rates. Additionally, the PaRIS survey represents the largest international patients’ survey to date, offering valuable cross-country information on patient perspectives.

As in a lot of recent national HSPA frameworks, people’s needs and preferences are a central focus of the OECD’s approach. By linking PROMs and PREMs with the characteristics of primary care practices and broader health system features, PaRIS helps policymakers understand how well their systems are meeting people’s needs and where to focus efforts to improve quality and performance in primary care. PaRIS will include repeated waves of data collection, enabling countries to monitor developments over time. Such repeated measures are essential for tracking progress, identifying trends and supporting continuous improvement in HSPA. Ultimately, PaRIS supports the reorganisation of healthcare around what matters most to people: their experiences and health outcomes. It shows that care is better tailored to individuals when it is more person-centred, leading to improved health outcomes, stronger trust in the healthcare system and more responsive care. By integrating PaRIS into national quality improvement strategies, countries can build their capacity to measure this critical dimension and apply it for ongoing learning and system improvement.

4.2. The OECD also supports country-specific HSPA framework development

The OECD’s approach to HSPA extends beyond providing a framework that guides development work on international comparisons and policy analysis. The Organisation also actively supports Member countries in the development of their own national HSPA frameworks, tailored to their unique local contexts and specific needs. Recent collaborations with Czechia and Estonia in 2021‑2023 exemplify this approach, and have resulted in comprehensive HSPA frameworks that are now being implemented, demonstrating the practical impact of the OECD’s technical support.

The OECD’s methodology for HSPA framework development follows a systematic, highly consultative and collaborative process designed to ensure sustainability and stakeholder buy-in. This approach includes several key phases:

• First, the OECD facilitates the definition of a clear purpose and scope for the HSPA framework through stakeholder workshops and consultations to ensure alignment with national priorities (see Section 2.1). For instance, Estonia’s HSPA framework aimed to establish common objectives among stakeholders, manage health system changes, increase public awareness, improve transparency and enhance targeted data use, while Czechia emphasised increased accountability and stakeholder involvement, alongside improving policy planning, monitoring and decision making in its decentralised health system.

• Subsequently, the OECD guides countries through framework development using a participatory approach (see Section 3.2). This involves the establishment of governance structures including high-level advisory boards, principal working groups and project management teams comprising representatives from key national health authorities. Technical focus groups help to identify relevant available data that reflect national priorities while remaining internationally comparable, while broad stakeholder groups participate in the final indicator selection process.

• For indicator selection, the OECD supports countries in achieving a balance between conceptual relevance and practical feasibility (see Section 2.2). The process typically includes a comprehensive overview of the country’s health data infrastructure baseline, preparation of a list of possible indicators, stakeholder scoring exercises based on predefined criteria, and multiple rounds of consultations through focus groups and bilateral meetings. This results in a wide‑ranging set of indicators, including both readily available metrics and aspirational placeholder indicators for future development, creating both a practical starting point and an agenda for strengthening measurement capacity.

A distinctive feature of the OECD’s support is its focus on capacity building to ensure HSPA sustainability. Estonia envisages integrating HSPA concepts into university curricula, developing study guides and proposing future activities to enhance analytical capacity across the health system. In this context, the University of Tartu is considering incorporating HSPA modules into its Master of Public Health programme.

Throughout the process, the OECD promotes international best practices while adapting them to each country’s specific context. To build lasting institutional HSPA capacity at key national organisations, the OECD’s support includes interactive activities such as study visits, focussed knowledge exchanges, and sharing OECD practices in data handling, policy analysis and modelling. Currently, the OECD is engaged in similar collaborative projects with Luxembourg and the Slovak Republic (see Box 3), applying lessons learned from earlier engagements while respecting the unique characteristics of these health systems. This approach ensures that the countries’ national HSPA frameworks will capitalise on internationally comparisons and benchmarking, while providing valuable insights in the national context.

Box 3. The OECD provides technical support to Luxembourg and the Slovak Republic

Starting in 2024, the OECD is providing support to national authorities in Luxembourg and the Slovak Republic in the development and implementation of their national HSPA frameworks. Both countries reported a missing tool to enable evidence‑informed health policymaking and decision making, prompting the national governments to request technical support through the European Commission’s Technical Support Instrument. The OECD was selected as the counterpart to support the countries through methodology, and HSPA and knowledge‑building activities. As of May 2025, the projects have progressed through a series of meetings to develop a consensus on the national HSPA frameworks’ purpose and identification of priority themes for initial drafts. Health data infrastructure baseline reports were drafted by the OECD based on significant stakeholder input through bilateral consultations, describing current health data landscape and data availability. Activities to support selection of indicators are ongoing.