International frameworks

Whilst, at the turn of the millennium, the UK, USA, Australia and Canada led the way for the development of country specific frameworks, it was the work of OECD and WHO that really placed HSPA frameworks on the international map. This work was then followed, many years later, by the European Commission (CION). This section outlines the development of these international frameworks. The catalyst for these new developments was the increasing concern on the sustainability of health care, as well as the drive to improve quality of care and health outcomes. Jee and Or (1999) were commissioned by OECD to draw up a paper which served as the basis for OECD’s work in this area for the years to follow. This was the first time that health outcomes, using the Donabedian model (Donabedian, 1980a), were linked to health policy development.

2.4.2.1 World Health Organisation

In 2000, WHO launched its first World Health Report (World Health Organisation, 2000), which had a major impact on performance assessment for two main reasons. To begin with, it was the first time that an international health organisation developed and measured performance indicators within a performance framework and secondly it was the first attempt at classifying the performance of WHO member states using a performance metric (Murray & Frenk, 2000). Whilst the former development was welcomed and hailed as a breakthrough, the latter was mired in controversy and lacked consensus, since it was argued that producing a performance league of countries was neither scientifically sound, nor did it reflect reality on the ground (Navarro, 2000).

In this report, WHO (World Health Organisation, 2000, p. xii) defined the boundaries of health systems and created a conceptual framework ‘to help Member States measure their own performance, understand the factors that contribute to it, improve it, and respond better to the needs and expectations of the people they serve and represent’ and thus allow individual member states to mould their own national HSPA framework from this WHO conceptual model. The WHO framework was built on the premise of a health system whose primary objective is the improvement of health. It therefore put forward, for the first time, the belief that the health system of a country or region should be planned for the attainment of better health, through a number of

dimensions. In this innovative report, WHO subscribed to determining the health status of a population through population based, efficiency and effectiveness measures. Contrary to the OECD work carried out a few years later, it did not focus upon quality indicators per se but supplants quality with overall indicators of effectiveness and performance. However, it created a new measure of overall population health, something of a ‘sum of all measures of burden of disease,’ or more precisely the numbers of disability-adjusted life years (DALYs) lost. This summative type indicator paved the way for many other similar indicators that now attempt to measure population health or lack of health thereof.

2.4.2.2 OECD

In 2006, OECD commissioned a number of expert groups to draw up various performance assessment frameworks. The work by Arah and his colleagues in the Netherlands (Arah, et al., 2006) led the process which took some years to complete. The impetus for this work arose from the increasing burden placed upon health systems to deliver with fewer resources, in a climate of increasing expectations, ageing populations and advances in medical technologies. This prompted many OECD member states to develop performance measurement and management frameworks that capture equity, quality and efficiency goals within their health systems (Hurst, 2000), (Hurst & Jee-Hughes, 2001), (Hurst, 2002).

OECD’s Health Care Quality Indicator (HCQI) Project was an international effort utilising the expertise of OECD member states to develop a common set of indicators, primarily linked to quality of health care. The OECD health system performance framework contained three main goals, namely health improvement and outcomes, responsiveness and access and financial contribution and health expenditure. Following this project, 5 separate panels were set up to develop indicators for specific disease groups or areas, namely CardiacIndicators (Ulla, et al., 2006), (17 indicators); Diabetes (Nicollucci, et al., 2006), (12 indicators); Primary Care (Marshall, et al., 2006), (27 indicators); Mental Health (Hermann, et al., 2006), (12 indicators); and Patient Safety (Mcloughlin, et al., 2006), (21 indicators).

2.4.2.3 European core health indicators

The European Core Health Indicators (ECHI) project was devised by the Network of Competent Authorities on Health Information in 2004 (Network of Competent Authorities on Health Information, 2004). This was preceded by work on the development of a list of around 400 indicators as part the ECHI-1 and ECHI-2 projects under the Health Monitoring Programme, a sub-set of the Public Health Programme (1996-2003). One of the objectives of the Public Health Programme was to develop comparable information on the health of the population, health behaviours and lifestyles, disease incidence, and on health systems, including data on access to care, quality of care, human resources, and on financial viability of health care systems.

DG SANCO (now Sante) continued to refine the data collection and analysis methodology and almost 10 years later, commissioned a study to evaluate the use and impact of the ECHI project by the Member States (DG SANCO, EU Commission, 2013). The outcome was the development of the European Core Health Indicators, with 88 indicators covering 17 policy areas. The indicators fall under one of five categories – demography and socio-economic measures, health status, indicators on health determinants of health, health services and health promotion. The resultant set of 88 core indicators is now used as a framework for EU member states to align their data collection and analytical methodologies with this core list (European Commission, 2013).

The three frameworks outlined above now overlap considerably in terms of policy areas and indicators used. There is, thankfully one may add, a growing momentum of sharing data sets and other information between WHO, OECD and the EU, moving towards greater convergence possibly creating an agreed list of core and supplementary indicators for all member states. This will certainly go a long way in reducing duplication of effort and data as well as streamline methodologies. This has resulted in the publication of OECD’s ‘Health at a Glance’ as a collaborative effort between OECD, WHO and EU.1