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Dionne Kringos, Damir Ivanković, Erica Barbazza, Niek Klazinga, Óscar Brito Fernandes, Health system performance assessment: embedding resilience through performance intelligence, International Journal for Quality in Health Care, Volume 36, Issue 1, 2024, mzae010, https://doi.org/10.1093/intqhc/mzae010
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Abstract
Health systems around the world are facing challenges in achieving their goals. In the wake of the coronavirus disease pandemic, the need for resilient health systems has become even more apparent. This article argues that embedding resilience into health system performance assessment (HSPA) frameworks can be a valuable approach for improving health system performance. This perspective examines key challenges threatening health systems and makes a case for the continued relevance of HSPA by embedding resilience-related performance intelligence.
Introduction
Fifteen years after the Tallinn Charter, European countries and international organizations, including the World Health Organization, European Union (EU), and Organisation for Economic Co-operation and Development (OECD), remain committed to strengthening health systems through Health System Performance Assessment (HSPA) [1]. Recently launched HSPA frameworks in Croatia [2], Czechia [3], Estonia [4], Ireland [5], and Lithuania [2] serve to demonstrate the continued relevance of HSPA as a tool to evaluate and measure the extent to which health systems achieve their goals and objectives [6]. As healthcare performance intelligence researchers, we have worked closely with many of these countries, and others, from inception to the roll-out of their HSPA frameworks.
Alongside HSPA, the notion of health system resilience has gained importance in the post-coronavirus disease (COVID-19) era, introducing an important shift to prioritize the adaptive capacities of health systems across health system functions [7]. Resilience refers to the ability of health systems to absorb shocks, adapt to changes, and maintain essential functions during crises [8, 9]. Health system resilience relies on proactive planning, resource allocation, policy reforms, and collaboration among stakeholders at global, national, and subnational levels to leverage available resources and drive health systems to perform more effectively. Embedding the assessment of resilience in HSPA seems opportune. However, before COVID-19, resilience was not mentioned in HSPA frameworks and embedding is currently explored [10]. For this, alignment with the varied conventional uses of HSPA is key (Table 1). This perspective examines key challenges threatening health systems and makes a case for the continued relevance of HSPA by embedding resilience-related performance intelligence.
| Uses . | Description . |
|---|---|
| Identifying areas of improvement | Providing a systematic evaluation of system strengths and weaknesses helps highlight areas for improvement and specific challenges to be addressed. |
| Monitoring progress | Continuously tracking key indicators and metrics over time helps ensure that progress is being made and allows for timely adjustments if needed. |
| Evidence-informed decision-making | Objective data and evidence support decision-makers to make informed choices that target efforts and resources to address the specific challenges faced. |
| Increasing accountability and transparency | Publicly reporting performance data and outcomes ensures systems are held accountable for their performance, while also fostering public trust and encouraging continuous improvement. |
| Benchmarking and learning from good practices | Comparing performance indicators and outcomes with other contexts helps to identify and exchange successful strategies and interventions. |
| Targeting resource allocation | The information generated supports decision-makers to allocate resources strategically to address the specific challenges identified, such as workforce shortages, access disparities, or infrastructure gaps. |
| Evaluating interventions | Assessing the impact and effectiveness of specific interventions allows a health system to learn from successes and failures and identify areas for the further refinement of interventions to best align with the desired outcomes. |
| Engaging stakeholders and advocacy | Engagement of key stakeholders in HSPA raises awareness about the challenges faced by a health system and can facilitate collaboration and collective action to address the challenges identified. |
| Uses . | Description . |
|---|---|
| Identifying areas of improvement | Providing a systematic evaluation of system strengths and weaknesses helps highlight areas for improvement and specific challenges to be addressed. |
| Monitoring progress | Continuously tracking key indicators and metrics over time helps ensure that progress is being made and allows for timely adjustments if needed. |
| Evidence-informed decision-making | Objective data and evidence support decision-makers to make informed choices that target efforts and resources to address the specific challenges faced. |
| Increasing accountability and transparency | Publicly reporting performance data and outcomes ensures systems are held accountable for their performance, while also fostering public trust and encouraging continuous improvement. |
| Benchmarking and learning from good practices | Comparing performance indicators and outcomes with other contexts helps to identify and exchange successful strategies and interventions. |
| Targeting resource allocation | The information generated supports decision-makers to allocate resources strategically to address the specific challenges identified, such as workforce shortages, access disparities, or infrastructure gaps. |
| Evaluating interventions | Assessing the impact and effectiveness of specific interventions allows a health system to learn from successes and failures and identify areas for the further refinement of interventions to best align with the desired outcomes. |
| Engaging stakeholders and advocacy | Engagement of key stakeholders in HSPA raises awareness about the challenges faced by a health system and can facilitate collaboration and collective action to address the challenges identified. |
| Uses . | Description . |
|---|---|
| Identifying areas of improvement | Providing a systematic evaluation of system strengths and weaknesses helps highlight areas for improvement and specific challenges to be addressed. |
| Monitoring progress | Continuously tracking key indicators and metrics over time helps ensure that progress is being made and allows for timely adjustments if needed. |
| Evidence-informed decision-making | Objective data and evidence support decision-makers to make informed choices that target efforts and resources to address the specific challenges faced. |
| Increasing accountability and transparency | Publicly reporting performance data and outcomes ensures systems are held accountable for their performance, while also fostering public trust and encouraging continuous improvement. |
| Benchmarking and learning from good practices | Comparing performance indicators and outcomes with other contexts helps to identify and exchange successful strategies and interventions. |
| Targeting resource allocation | The information generated supports decision-makers to allocate resources strategically to address the specific challenges identified, such as workforce shortages, access disparities, or infrastructure gaps. |
| Evaluating interventions | Assessing the impact and effectiveness of specific interventions allows a health system to learn from successes and failures and identify areas for the further refinement of interventions to best align with the desired outcomes. |
| Engaging stakeholders and advocacy | Engagement of key stakeholders in HSPA raises awareness about the challenges faced by a health system and can facilitate collaboration and collective action to address the challenges identified. |
| Uses . | Description . |
|---|---|
| Identifying areas of improvement | Providing a systematic evaluation of system strengths and weaknesses helps highlight areas for improvement and specific challenges to be addressed. |
| Monitoring progress | Continuously tracking key indicators and metrics over time helps ensure that progress is being made and allows for timely adjustments if needed. |
| Evidence-informed decision-making | Objective data and evidence support decision-makers to make informed choices that target efforts and resources to address the specific challenges faced. |
| Increasing accountability and transparency | Publicly reporting performance data and outcomes ensures systems are held accountable for their performance, while also fostering public trust and encouraging continuous improvement. |
| Benchmarking and learning from good practices | Comparing performance indicators and outcomes with other contexts helps to identify and exchange successful strategies and interventions. |
| Targeting resource allocation | The information generated supports decision-makers to allocate resources strategically to address the specific challenges identified, such as workforce shortages, access disparities, or infrastructure gaps. |
| Evaluating interventions | Assessing the impact and effectiveness of specific interventions allows a health system to learn from successes and failures and identify areas for the further refinement of interventions to best align with the desired outcomes. |
| Engaging stakeholders and advocacy | Engagement of key stakeholders in HSPA raises awareness about the challenges faced by a health system and can facilitate collaboration and collective action to address the challenges identified. |
Challenges impacting health system resilience
Current and future challenges impacting the resilience of health systems can vary across regions, but many prominent ones are common. We highlighted six nearly universal challenges influencing the resilience of health systems and examples of performance information needed to govern each challenge. First, and most urgently, countries are experiencing ‘shortages and maldistribution of healthcare professionals’, which impact the capacity to respond timely to health crises and deliver quality services. For instance, measuring the availability and distribution of healthcare professionals helps identify areas facing shortages and inform recruitment and retention strategies to enhance workforce capacity. Second, ‘patient safety management’ in many systems remains focused on reacting to errors rather than co-developing mechanisms for continuously learning from these incidents and building resilience in complex care processes and pathways. For example, measuring people-reported experiences of safety could inform insights on how to assure safe care, prevent unsafe care, and manage patient safety incidents in a people-centred manner. Third, the ‘climate crisis’ poses substantial threats to the capacity of health systems to manage and protect population health during shocks including the uprising of vector-borne diseases, air pollution, and food security issues. For instance, measuring health indicators affected by climate change, such as heat-related illnesses, respiratory diseases, and vector-borne infections, helps assess health risks and inform adaptation strategies. Fourth, health crisis exacerbates existing inequalities even further; thus, resilient health systems must ensure ‘equitable access’ when planning resource allocation to address the health needs of all people. For example, monitoring the proportion of care costs paid directly by individuals can guide policies to enhance affordability and protect people at higher risk of experiencing vulnerability. Fifth, the underdevelopment of ‘integrated and interoperable health information systems’ underpinned by appropriate data privacy and security regulations compromises timely data-driven decision-making during a crisis. For example, the measurement of data exchanges at the individual (e.g. between service users and providers) and the population levels (e.g. between registries and administrative databases) and the timing of these interactions can inform about interoperability maturity. Lastly, ‘financial challenges’ driven by rising healthcare costs, funding gaps, and low-value care hamper achieving financial sustainability, which limits the power of health systems in strengthening resilience. For instance, analysing the balance between public and private funding sources helps evaluate the sustainability and equity of financing arrangements.
How can we make HSPA frameworks fit for the future?
We proposed that the integration of resilience underpinned by efficient governance mechanisms and digitalization can significantly enhance the effectiveness of HSPA and better support decision-making processes in the following ways.
Holistically incorporate indicators to capture resilience across HSPA frameworks
Indicator selection should always be anchored in fitness for purpose (ensuring purpose-driven measurements is linked to strategic functions) and use (the right information is available to those who need it when they need it) considerations. Incorporating indicators that measure the impact of challenges like those described earlier is needed across HSPA frameworks to ensure that the perspective of health system resilience is meaningfully captured. These indicators should be able to address the urgency of the challenges and hence reflect relevant parts of the resilience of systems. Caution is needed to avoid the tokenistic inclusion of resilience as a sole domain or indicator.
Ensure broad and continuous stakeholder participation to promote trust and accountability
HSPA frameworks should involve a wide range of stakeholders (including health professionals, patients and their advocates, and citizens) through inclusive governance mechanisms. Engaging stakeholders in the design, implementation, and evaluation of HSPA frameworks can ensure that they capture diverse perspectives, priorities, and emerging challenges. Participatory processes contribute to empower communities, build trust in the assessment process, and nurture accountability of actors in the system in developing whole-of-society responses to health system challenges.
Instil flexibility to nurture evolution through continuous review
HSPA frameworks should be designed with built-in flexibility and agility and undergo continuous review and iteration to accommodate emerging challenges and evolving knowledge. This requires a shift from rigid frameworks that focus mainly on existing structures and indicators to more dynamic frameworks that can better support decision-making processes by incorporating new dimensions of performance and indicators that reflect emerging challenges and trends in health care.
Unleash the power of data by leveraging technological advancements
Health-related data from existing sources (e.g. census and mortality statistics, registries, surveys, and electronic health records), or repurposing data from alternative sources (e.g. social media), allows HSPA to further the public good and be a source of insights into the resilience of health systems. Harnessing big data, artificial intelligence, and analytics in HSPA underpinned by a sustainable implementation of (near) real-time data collection through optimal data linkages can enhance the timeliness and relevance of HSPA. This evolution offers several benefits, such as providing a comprehensive view of resources utilization and health outcomes, improving the people-centredness feature of HSPA with insights into outcomes and thus improving care delivery and personalization, and enhancing a culture of research and innovation.
Promote international cooperation
The challenges described go beyond borders and require international cooperation. By working together, countries can share knowledge, resources, and expertise, leading to more robust and informed decision-making. International cooperation in HSPA, such as the HSPA community of practice in the EU and the HSPA work conducted by the OECD, allows for the exchange of good practices, lessons learned, and innovations, which can improve the effectiveness and efficiency of health systems worldwide underpinned by notions of solidarity among nations by fostering a global response that addresses health inequalities and improves health outcomes for all.
Conclusion
By implementing these changes, HSPA frameworks can become more adaptive, inclusive, and responsive to emerging challenges with the ambition of further enhancing the resilience of health systems. This, in turn, enables decision-makers to make informed decisions, allocate resources effectively, and drive improvements in health system performance which translate to better health outcomes.
Conflict of interest
No new data were generated or analysed in support of this research.
References
Author notes
Handling Editor: Prof. Rosa Sunol
