Health systems

There is no doubt that, throughout the centuries, health systems have contributed enormously towards improving the health of populations, where health systems have been attributed to increasing life expectancy and quality of life, mostly due to technological advances in medicine and better health care practices (Nolte & McKee, 2004). However, it was not until the seminal, if not controversial, work of the World Health Organisation (WHO) at the turn of the millennium that a comprehensive definition of a health system was proposed in its far-reaching World Health Report. This report defined the health system as ‘… all the activities whose primary purpose

is to promote, restore or maintain health’. Operationally, this definition is further

dissected into comprising ‘the resources, actors and institutions related to the

financing, regulation and provision of health actions,’ where health actions are ‘all

activities whose primary purpose is to promote, restore or maintain health’ (World

Health Organisation, 2000, p. 5).

Most health systems share a common genesis in that they serve to generate health within and improve the health of a population by ensuring equitable access,

a succinct manner by stating that health systems should always strive towards three fundamental goals – ‘improving health, enhancing responsiveness to the expectations

of the population, and assuring fairness of financial contribution’ (Murray & Frenk,

2001). In summary, health systems are in the business of continually improving the health outcomes of the population it serves and all health system performance measures ultimately measure this final objective or goal.

Due to its inclusive nature, the boundaries of a health system are difficult to define. A health system certainly incorporates all ‘health care’ activities but also includes ‘public health’ activities, as well as formal and informal personal care and voluntary care (Canadian Institute for Health Information, 2013). However, since health is determined by many interdependent factors, of which health care is only one, a multi- dimensional approach to health is necessary to understand the complexity of health systems (Arah, et al., 2006). This concept was first introduced by Lalonde in his ‘White Paper’ in Canada in 1974 (Lalonde, 1974), which gave way to many other publications on the subject (Evans & Stoddart, 1990), leading eventually to the ever expanding research on social determinants of health (Marmot & Wilkinson, 2005).

2.2.1 Measuring the performance of health systems

Measurement of performance of health systems has been around for several years (McIntyre, et al., 2001). Initially the performance of health care services and systems was measured through ad hoc, individual and non-related measures and indicators. These pertained, in the main, to general population health, responsiveness of the system to the health care needs of the population, throughput (production) indicators and financial parameters. Other important performance domains were introduced during the eighties and nineties, mostly relating to quality of care, health equity, transparency and accountability, governance and cost-effectiveness or value for money. Quality-adjusted or healthy life measures were later introduced as the focus shifted towards a healthier life rather than a longer life (Kelley & Hurst, 2006).

The breakthrough in health system performance assessment was spurred by the publication of WHO’s World Health report (World Health Organisation, 2010) in 2000, wherein WHO advocated the use of health system performance assessment and

the performance of different health systems was measured and compared in a landmark health system performance assessment (Murray & Evans, 2003). WHO defined health system performance assessment as ‘a country-specific process of monitoring, evaluating, communicating and reviewing the achievement of high-level

health system goals based on health system strategies’ (World Health Organization,

2012, p. ii).

At a European level, the Tallinn Ministerial conference in 2008 and the resulting Tallinn Charter (World Health Organisation, Regional Office for Europe, 2008) committed EU countries, for the first time, albeit rather late in the day, to produce measurable results and to promote transparency and accountability for their health systems. This marked the start of measuring health system performance in Europe, after which several countries took up the challenge (Van Den Berg, et al., 2014).

2.2.2 Health system performance assessment frameworks

Up until the 1990s, although the use of performance indicators was widespread, these indicators were not captured within a conceptual model or framework. One of the first attempts to develop a performance framework at local level was that by van der Bij and Vissers in the Netherlands in 1999 (van der Bij & Vissers, 1999). The seminal work of the WHO, the Organisation for Economic Co-operation and Development (OECD) and the Commonwealth Fund in the United States (Murray & Frenk, 2000), (Arah, et al., 2006), (Commonwealth Fund, Commission on a High Performance Health System, USA, 2006) laid the basis for further frameworks to be developed throughout the world (Department of Health, UK, 1999a), (Canadian Institute for Health Information, 2000), (Queensland Health, National Health Performance Committee, 2001), (Institute of Medicine, 2001a), (Institute of Medicine, 2001b), (Institute of Medicine, 2006).

No explicit or direct definition of a performance assessment framework is evident from the literature. The WHO, through its World Health Report in 2000, describes HSPA as a process carried out at country level which allows the health system to be assessed holistically; a ‘health check’, if you wish, of the entire health system(World

The closest to a definition that the literature provides is that promulgated by the Department of Health in England, as that of a framework which ‘provides a structure and benchmarks for organisations to use to assess its performance. It covers fair access to services, effective delivery of healthcare, efficiency and the patient and carer

experience’ (Department of Health, UK, 2001, p. 6). The World Bank states that a

health system framework is a generic conceptual tool used to describe a health system, termed as follows: ‘It defines, describes and explains the health system, its objectives,

structural and organizational elements, function and processes’ (Shakarishvili, et al.,

2009, p. 4). A HSPA framework is a conceptual model that incorporates the most relevant dimensions that best describe the goals of the health system it promulgates. It depicts the inter-relationships that exist between the different dimensions of a health system and the goals of the health system (Kelley & Hurst, 2006) and therefore a HSPA framework permeates from the strategic objectives of the health system it is supposed to measure.

These frameworks encompass a similar array of indicators organised into different health domains or dimensions, pertaining to effectiveness, quality and safety, responsiveness, access, equity, efficiency, financial mechanisms, determinants of health and more (Canadian Institute for Health Information, 2013). A performance assessment framework typically groups these domains under health inputs, health outputs, health outcomes and health impact, outlining the journey of a health system in providing and improving health.

Within each domain, performance indicators that are relevant to the health system are extracted and so a HSPA framework gives structure and formality to the measurement of the performance of the various components of a health system. A HSPA framework also delineates the method of indicator selection, the data sources that are used for the indicators chosen, its analysis and how results are communicated to stakeholders (World Health Organisation, 2010).

There is no universal template or methodology of developing a HSPA framework. Although WHO believes that each country should devise its own methodological process which is suitable for its circumstances and context, there are a few key

These are:

• HSPA, as the name implies, should focus upon health systems as a whole and not on the components parts of a health system.

• Outcome measures are better placed to mirror performance.

• HSPA should form part of a regular process to measure performance and devise policy as implied within the policy cycle of a HSPA. • Although each country or health system should develop its own HSPA,

its structure and content should be comparable with that of other countries and health systems.

2.2.3 Indicators, the crux of performance assessment

It is important to understand the key role of indicators in measuring performance. The Joint Commission on Accreditation on Healthcare Organisations defined a performance indicator (PI) as a ‘measurement tool used to monitor and evaluate the

quality of important governance, management, clinical and support functions’ (Joint

Commission on Accreditation of Healthcare Organisations, 1990, p. 7). The Health Information and Quality Authority of Ireland sees key performance indicators as measures of performance that are used by organisations to measure how well they are performing against targets or expectations. KPIs measure performance by showing trends to demonstrate that improvements are being made over time (Irish Health Information and Quality Authority, 2013). Performance indicators can be regarded as tools in the hands of policy makers, scientists and health care providers to assess where they are, how they are performing at that point in time or over a period of time (looking at trends) and the direction they are taking. Most of the work around indicators initially revolved around safety and quality of health care provision. Eventually this was expanded to include every facet and aspect of health care, public health and the wider health outcomes. However, Perera, Dowell and Crampton (2012, p. 49) warn that indicators are not always ‘axiomatically good’ since their application in the field depends upon the contextual background in which they are developed. Developing indicators out of context is flawed if not dangerous since they may provide for incorrect and misleading data and information. Perera, Dowell and Crampton. (2012)

are not developed and chosen appropriately for a defined purpose and if the data is misinterpreted. This is especially relevant when PIs are utilised to measure performance by comparing results against standards or with other similar organisations.