1. Introduction
1.1. Why this brief?
There has been much interest in assessing health systems performance in recent years, resulting in a wide spectrum of approaches, frameworks, and nomenclature
The global COVID-19 pandemic serves as a stark reminder that a robust and resilient health system is one of the best defences against health threats. Yet, in practice, ensuring a strong system involves a number of policy actions that need to be prioritized and resourced based on the best available evidence. The latter requires health systems to be monitored, and regularly assessed, in order to build on its strengths and overcome its shortcomings (Witter et al., 2019).
The collection of information for purposes of a system-wide assessment has therefore attracted renewed interest in recent years, reflected in a variety of data collection tools and health system frameworks. Unfortunately, considerable variation in those tools and frameworks has led to inconsistencies and even confusion as to what exactly is being measured and for what purpose (Bennet & Peters, 2015). The varying objectives and approaches taken by different actors in different contexts have also led to different labels used for the wide spectrum of assessment exercises, including health system assessment, health system performance assessment and health system situation analysis. Table 1 elaborates on this point, laying out the principal assessment tools, with their title and objectives, developed for this area.
Table 1
Selection of tools that aid data/information collection for assessment purposes.
Besides the tools indicated in Table 1, which principally accompany the user through the data and information collection process, the health system assessment landscape is further populated with varying health system frameworks, which are conceptual in nature. These frameworks aim to promote a more theoretical understanding of the health system (Aday et al., 1999; WHO, 2000; Commonwealth Fund, 2006; Atun, 2010; Roberts et al., 2008; Kruk et al., 2018). HSA tools especially draw from two conceptual frameworks published by WHO in 2000 and 2007 (Murray & Frenk, 2000; WHO, 2007), further detailed in Section 2.2. Several tools and frameworks have also served as a basis for measuring health system performance.
Current tools and frameworks range from those focusing on descriptive evaluations of health systems’ structures and features to those centred on more quantitative assessments of how well the goals of health systems are attained
In a sense, a rough continuum can be observed across the range of tools and frameworks that guide health system-wide assessment exercises. At one end, a focus is placed on evaluating the current structure of the health system, often through the conceptual framework of health system functions or building blocks (Murray & Frenk, 2000; WHO, 2007). At the other end, an emphasis is given to evaluating how well the system is performing overall, by examining the extent to which health systems are meeting a set of defined health system goals. The latter usually draws more on quantitative measures and analytic methods, often referred to as HSPA. The former tends to be pre-occupied with an in-depth description of the system’s structures and features in an attempt at comprehending the system’s strengths and failures.
Ultimately, however, the business of strengthening health systems relies on firmly hooking up both ends of the continuum, and offering a comprehensive understanding of what systems look like, how they perform and what structures work (or do not) to attain their performance level. Such an approach can help to clarify the relationship between what health system actors do and which goals those actors wish to achieve with their actions. It would also shed light on the connection between health system inputs, outputs and outcomes. Put differently, an elucidation of the crucial link between the performance of individual health system functions and the performance of the health system overall is needed.
The HSPA Framework for UHC attempts to unify the existing tools' content into one framework
Sifting through the details of those tools was the starting point for developing a harmonized conceptualization of the entire health system for assessment; this was undertaken by the UHC2030 Technical Working Group (TWG) on Health System Assessments (HSA) (see Box 1), a group that included the developers and implementers of the tools listed in Table 1. The TWG further delved into fundamental questions regarding the system’s boundaries, component elements and goals. The resultant HSPA Framework for UHC represents a comprehensive attempt to address those questions with the underlying understanding that, in many cases, there is no right or wrong answer. The aim was to find the optimal, harmonized solution, given the perspective taken, available evidence and expert appraisal. In early 2022, this work resulted in the publication of Health System Performance Assessment: A Framework for Policy Analysis (Papanicolas et al., 2022), which elaborates on the development process and rationale for the HSPA Framework for UHC.
Box 1
The UHC2030 Technical Working Group on Health Systems Assessment.
Despite the great deal of overlap across these efforts, a consensus on the basics of health system design is clear (see Table 1). Differences tend to play out in the level of prominence accorded to different health system areas, and importantly for purposes of the HSPA Framework for UHC, in the extent to which health system goals are explicitly emphasized.
The proposed framework builds on existing tools and frameworks to unpack how policy-makers can assess the performance of health system structures and inputs, as well as outputs and outcomes, the latter being essentially what those structures and inputs aspire to feed into.
This policy brief summarizes the above-mentioned study and the core of the HSPA Framework for UHC by providing a concise overview of terms, concepts, measures and approaches that are necessary to foster a common understanding of performance assessment among policy-makers who are looking to strengthen health systems and make progress towards universal health coverage.
2. Understand the core elements of the HSPA Framework for UHC
2.1. Delineating health system boundaries
Delineating the perimeters of the health system boundaries affects the content of performance assessment and the actionability and accountability of policy actions identified therein
In order to measure health system performance, the health system must be defined and given clear confines.
Delineating health system boundaries for the particular purpose of performance assessment is intricately linked with actionability and accountability. Most assessments are largely meant to trigger policy action, so its focus requires a realistic sense of what health system actors can be held accountable for in terms of influencing final health system goals.
Where exactly the perimeters of the health system lie therefore has important implications for HSPA content. A broad health system boundary, encompassing public health, health promotion, social and other determinants of health, provides a more comprehensive representation of all factors affecting health system outcomes. But its significant drawback is the potential to limit the framework’s ability to identify performance-improving interventions within the authority of those who generally work in or close to the health system. Yet reducing the health system boundaries to health care alone runs the risk of overlooking some crucial factors that impact on health – such as education or employment. Examples of health system definitions can be found in Annex 1.
The HSPA Framework for UHC focuses on curative health services as well as health promotion and disease prevention, but interactions with other sectors are also acknowledged
For the HSPA Framework for UHC, the health system scope as per the Murray & Frenk (2000) definition of the health system: “health actions…whose primary intent is to improve or maintain health” was adopted, largely but not entirely staying within the traditional health care remit. “Improving and maintaining health” is seen as being inclusive of many public health and health promotion activities, expounded further in Section 3. Crucially, the health system governance function is leveraged to demonstrate what can be done within the health system to shape other sectors’ actions impacting on health. The framework, therefore, guides the assessment of those actions that health system actors can feasibly undertake, while explicitly acknowledging (but not necessarily directly assessing) the substantial impact on health of a range of socioeconomic determinants that lie outside the boundaries of the health system.
2.2. Identifying health system components
Many frameworks focus on assessing health systems building blocks, i.e., what the system is, whereas functions focus more on actions health system can undertake to perform well
Identifying and describing the structures and organizations that make up the health system is one of the key roles of health system frameworks (see Annex 2), two of which have been widely used to structure information collected for health system assessments. The four functions were introduced in the World Health Report 2000 (WHO, 2000), later followed by the six health system building blocks in WHO’s 2007 framework for health system strengthening (WHO, 2007). Both break down the health system into its core elements but do so in slightly different ways, albeit with large overlap. For instance, the building blocks of leadership and governance, financing and service delivery reflect the core functions of stewardship, financing and provision of health services. Similarly, the building blocks of health workforce and medical products and technologies are core to the resource generation function. The health information building block arguably spans all health system functions. Although the building blocks’ emphasis is on the description of what the system is, the functions are by definition more dynamic because they highlight what the system does, thus emphasizing the actions for the health system to undertake in order to perform well.
The HSPA Framework for UHC takes the more dynamic approach and focuses on health systems functions, additionally disaggregating them into sub-functions and linking those to their respective assessment areas
For purposes of the HSPA Framework for UHC, the functions (governance, resource generation, financing and service delivery) were an obvious entry point for identifying the factors that influence performance (defined in terms of the intermediate objectives and final goals of the health system). The focus on functionality rather than structure or input provided a clear conceptualization of how actions taken within the health system can influence performance of the health system itself.
In the framework, each of the functions is further disaggregated into sub-functions (see Section 3). The sub-functions aim to pinpoint more specific areas of action within a health system (see Box 2). Crucially, functions and sub-functions are linked to assessment areas – the key novel element that helps to outline and identify what can be done within a health system to improve its performance. Where possible, assessment areas include a selection of indicative measures – non-exhaustive examples of high-level quantitative and/or qualitative indicators – which reflect the performance of that function or sub-function. The process of selecting sub-functions, assessment areas and indicative measures for each of the functions included literature reviews, TWG exchanges and expert consensus, further detailed in Papanicolas et al. (2022).
Box 2
What is meant by sub-functions, assessment areas and indicative measures?
2.3. Defining health system goals
The HSPA Framework for UHC looks at both health systems inputs and outputs, focusing on understanding how the former generate the latter
Health systems aim to fulfil certain objectives, such as health improvement, people centredness and financial protection among others (see Table 2). Most frameworks also distinguish between intermediate objectives and final health system goals. Outcome-focused assessments therefore emphasize the monitoring, evaluation and communication of the extent to which the health system meets those objectives (Smith et al., 2009). By contrast, input-focused assessments of the health system tend to focus on describing the structures that make up the system. The HSPA Framework for UHC promotes a comprehensive examination of both inputs and outcomes, with a particular emphasis on how the two are linked, that is, how the inputs are used to generate outcomes.
Table 2
What are the key intermediate and final health systems goals in the existing assessment frameworks and tools?
Health improvement is one of the principal goals in the HSPA Framework for UHC; this goal as well as other final health system goals such as people-centredness, financial protection, efficiency, and equity, are all embedded in the understanding of UHC
Across all frameworks and health system assessment tools, health improvement features as one of the key objectives. Some measure of the system’s responsiveness to people’s non-medical needs in their interaction with the health system is also frequently identified as a final goal, conceptualized either to consider patients specifically (satisfaction with health care services) or with a focus on the broader population (people-centredness and/or human rights and confidence in the system). Efficiency and equity are also identified as crucial objectives in almost all tools and frameworks. However, it is not always clear from the frameworks and tools whether efficiency and equity are applied to either the entire system or to a particular sub-unit within the system (for example, a hospital, district, group of services, population group). Another health system goal that is frequently cited is the health system’s role in protecting the population against risk. The nature of this risk may vary, although most assessment tools single out financial risk protection from health costs specifically. Access and quality also feature prominently across frameworks and tools, often as intermediate objectives of the system.
In the HSPA Framework for UHC, these principal goals are closely adhered to at the health system level. They are identified as: health improvement, people-centredness, financial protection, accompanied by the cross-cutting goals of health system efficiency (how much outcome is attained given the health system inputs) and equity (distribution of outcomes across the population). Quality and access are distinguished as intermediate objectives, with quality broken down into effectiveness, safety and user experience. Health service efficiency and health service equity are also emphasized as intermediate objectives.
The framework is entitled HSPA Framework for UHC, purposefully containing the add-on “for UHC” for two reasons: first, health system strengthening through improving performance is the principal means to move towards universal health coverage, and second, all of the final goals of the framework measure factors necessary to attaining UHC as included in the definition widely used by health stakeholders, and which has been reinforced by the world’s broad and repeated commitments to the UHC target at various global forums (UN, 2015, 2019), namely:
“UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course,” (WHO, 2010a).
3. Bringing all the elements together into the HSPA Framework for UHC
3.1. Linking functions to goals
The HSPA Framework for UHC links the four functions and their sub-functions with intermediate objectives and final goals, highlighting the various interlinkages between them and placing everything within the wider socioeconomic context
This section introduces the HSPA Framework for UHC (Figure 1). It brings together the four functions, intermediate objectives and final goals, while placing the health system within a wider socioeconomic context.
Figure 1
HSPA Framework for UHC – an overview. Note: HSPA, Health System Performance Assessment. Source: Papanicolas et al. (2022).
In the framework, the sub-functions are laid out and indicated for each function (see Annex 3). As discussed, sub-functions represent key topical areas, which matter most for function-level performance and for the function’s contribution to overall system performance. In addition, assessment areas linked to the (sub-) functions are construed – these are areas, the appraisal of which is needed to grasp function-level performance (see Box 2).
Colour-coded links between different functions, and functions and outcomes, enable a visual association of the interlinkages within the health system. Further explanations for Figure 1 are given below and in Section 4. Any whole-of-sector assessment exercise should collect information on, and examine the performance of, both the functions and the extent to which system goals are achieved. Linking the two in practice rests on a solid understanding that high-performing functions are the basis for high-performing health systems.
3.2. Understanding the governance function
The governance function is a systemic enabler for all other health system functions
The WHO (2007) definition for governance is: “ensuring [that] strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design and accountability”. The governance function is strategically placed at the very left of the framework as a systemic enabler for all other health system functions.
The framework thus differentiates overall health system governance from governance actions that are specifically linked to the governance of the other three functions. For example, the “governance of financing” includes specific governance actions relating to financing activities, such as public financial management and decisions linked to benefit package coverage. The “governance of resource generation” would include activities such as health workforce planning and management of procurement systems. The “governance of service delivery” relates to management and decision-making within units of service delivery (health centre, district, primary health care service network), service integration and quality assurance mechanisms. In this brief, governance-related assessment areas are described here, not only under the system-level governance function, but also under each of the other three system-level functions.
The salient point here is that when assessing the governance function (see Figure 2), both overall system-wide governance, as well as the governance issues relating to the other three functions (financing, resource generation and service delivery), need to be examined to comprehend whether the governance function is performing well and is also enabling the system to perform well.
Figure 2
Assessing governance in the HSPA Framework for UHC. Source: Papanicolas et al. (2022).
The HSPA Framework for UHC outlines four sub-functions for the assessment of the overall governance function: policy and vision, stakeholder voice, information and intelligence, and legislation and regulation
Policy and vision sub-function
The policy and vision sub-function centres on having the capability and resourced capacity to provide a clearly articulated strategic vision for the health sector. Assessment seeks to identify whether this is available in a written and traceable form, such as a single document, a set of policies, laws and/or guidelines to which governments can be held accountable.
At the core of shaping health policy and providing a vision for the health sector is intersectoral collaboration; hence, the existence and quality of multisectoral collaboration will be a key focus of assessment.
Stakeholder voice sub-function
The stakeholder voice sub-function revolves around the real possibility for key stakeholders – such as civil society organizations, vulnerable and marginalized communities, the public, academia, provider associations – to contribute meaningfully to health policy decisions (assessment area “stakeholder participation in policy-making”). This sub-function therefore requires solid government capacity to initiate, steer and sustain long-term participatory processes for purposes of capturing the stakeholder voice as part of the regular health sector modus operandi (assessment area “stakeholder participation as a government priority”).
Information and intelligence sub-function
The information and intelligence sub-function is essentially about data governance. It involves the managerial culture and political will needed to support an environment where evidence generation and use are the norm, where changes within the health system and their effects on systems performance are constantly monitored, learned from and acted upon (assessment area “collection of relevant data”). A well-functioning information system that is accessible for a wide range of health system stakeholders is therefore crucial for data-driven decision-making (assessment area “evidence-driven decision-making”).
Legislation and regulation sub-function
Legislation and regulation are powerful levers for the achievement of health system goals. For example, rights-based health laws or regulatory frameworks for private sector service provision can have a profound enabling effect on the performance of further health system functions, and subsequently on health system outcomes. Assessment areas here are “capacity to legislate” and “ensuring compliance with legislation”.
3.3. Understanding the resource generation function
Resource generation ensures that the health system has the necessary human and physical resources
Resource generation is the function that ensures that a health system has all the inputs it needs to operate. These inputs include health workers, medical devices, medical equipment, infrastructure, pharmaceuticals, vaccines, consumables and medical supplies. This function describes how inputs are produced, procured, made available or maintained nationally. The way the resources are brought together and used would be reflected in the service delivery function.
Resource generation is carefully placed in the HSPA Framework for UHC between governance and service delivery (see Figure 3), indicating that the governance function enables the resource generation function, and resource generation feeds into, and enables, the service delivery function. Ultimately, the influence of resource generation on the intermediate and final health system goals works through service delivery, that is, its impacts on health system performance hinge on providing the right resources at the right time for use within the service delivery function.
Figure 3
Assessing resource generation in the HSPA Framework for UHC. Source: Papanicolas et al. (2022).
Table 3
Functions, sub-functions and assessment areas: governance.
That crucial role is reflected in the resource generation sub-functions, and their assessment areas.
The HSPA Framework for UHC distinguishes three sub-functions of the resource generation function: health workforce, infrastructure and medical equipment, and pharmaceuticals and other consumables. Governance of resource generation is an additional sub-function through which resource generation can be assessed
Health workforce
For the HSPA Framework for UHC, the broad 2009 definition by WHO of the health workforce: “all persons engaged in actions whose primary intent is to enhance health” (WHO, 2006) is used. This interpretation explicitly values both formal and informal activities undertaken in the health sector, and expands on the World Health Report 2000 definition, which focused more on formally contracted health workers (WHO, 2000). This sub-function therefore explicitly includes informal care as a critical aspect of its impact on performance.
The assessment areas are similar across the resource generation sub-functions: availability, mix/distribution and a measure of upkeep, that is, education in the case of the health workforce. Availability and mix/distribution are essentially about human resources who are made available at the right place and right time, thereby enabling the service delivery function.
Infrastructure and medical equipment
Infrastructure and medical equipment are physical resources that give health providers, and users, the tools needed to provide effective and efficient health services. Resource generation achieves its maximum performance through the interplay of a large, qualified health workforce, equipped with drugs and consumables, working in adequately built and equipped health facilities.
The World Health Report 2000 refers to infrastructure and medical equipment as “physical capital”, one of the two health system inputs that define physical resources (WHO, 2000). Rather than adopting terminology that emphasizes the economic value of assets, the perspective of functionality and systems performance is taken, and this sub-function is renamed: infrastructure and medical equipment.
Infrastructure and medical equipment are characterized by the large capital investments required to build health infrastructure, such as health facilities, and to equip health facilities with medical equipment, such as magnetic resonance imaging scanners. Another common characteristic is the recurrent costs for maintenance until depreciation reaches an obsolete, or non-functional, status. These two characteristics differentiate the infrastructure and medical equipment sub-function from the consumables and pharmaceuticals sub-function – because the latter does not require a large initial investment or ongoing maintenance because these are one-off or disposable items.
The assessment areas for infrastructure and medical equipment are, again, availability and mix/distribution. In addition, the measure of upkeep is “maintenance”, a pivotal area in terms of impact on function performance.
Pharmaceuticals and other consumables
WHO defines the characteristics of pharmaceuticals as products that should be “safe, effective, and of good quality” as well as “prescribed and used rationally” (WHO, 2021). Consumables are described in the World Health Report 2000 as an umbrella term that includes pharmaceutical products (WHO, 2000).
In line with the WHO approach, pharmaceuticals and consumables are treated in the same way, as both are used and consumed once – or when used more than once, they are disposable – and neither requires capital investment or maintenance. Single-use medical devices are considered to be consumables, because they are also intended for one-time, or temporary, use. For the same reason, vaccines would also fall under this category.
In the literature, policy documents and HSA tools, terms such as pharmaceutical system, pharmaceutical management system, pharmaceutical supply system and pharmaceutical sector are used interchangeably. All of these labels suggest that pharmaceuticals are part of an ecosystem that ensures safety, efficacy and quality. This spectrum includes medicines research and development, management, manufacturing, procurement, supply and use. Many of these actions are, for the purposes of the HSPA Framework for UHC, part of other health system functions or sub-functions. For instance, pharmaceutical management would be governance of resource generation; pharmaceutical use would be part of service delivery; and domestic manufacturing would be part of the pharmaceuticals sub-function of resource generation because it involves making drugs available for use in the country at a very macro level.
In short, the sub-function labelled pharmaceuticals and consumables focuses on the manufacturing and procurement processes needed to ensure that these products are available where and when they are needed.
Procurement can be differentiated from purchasing, which is a sub-function of financing and focuses on purchasing services. A health service brings together several inputs, including pharmaceuticals, whereas procurement is concerned with procuring a good input into the health service.
Table 4
Functions, sub-functions and assessment areas: resource generation.
The assessment areas are only availability and mix/distribution as there is no upkeep for one-off use or disposable items.
Governance of resource generation
The point of intersection between governance and resource generation is called the governance of resource generation. This intersection includes governance matters that are specific to resource generation, as opposed to those involved with the overall system governance functions. The governance-of elements of resource generation centre on a wide range of tasks associated with planning for resources. These include health workforce planning and forecasting; setting quality standards, such as self-regulation of health providers by professional associations; and monitoring those standards, through regular inventory management of large medical equipment, for example. This sub-function is complex and far-reaching in terms of the performance of the resource generation function because it involves many parties, including patients, health providers, manufacturers and salespeople; can have serious consequences, at worst death, if not done well; and requires more than informal controls to be effective (Management Sciences for Health, 2012).
3.4. Understanding the financing function
Financing is about raising and spending money where it is needed and creating appropriate incentives for service delivery
Financing constitutes an integral function of a health system: raising and spending money on health care. However, its remit is also in making funding available where needed and creating appropriate financial incentives for providers to deliver accessible and effective health services.
Financing is closely linked to other main functions, including through providing monetary resources for operational aspects of governance, resource generation and service delivery (Figure 4). It is also instrumental in achieving health system goals, and is particularly closely linked to ensuring efficiency of health systems and (through service delivery) financial protection.
Figure 4
Assessing financing in the HSPA Framework for UHC. Source: Papanicolas et al. (2022).
Table 5
Functions, sub-functions and assessment areas: financing.
The HSPA Framework for UHC identifies three financing sub-functions (revenue raising, pooling and purchasing), as well as governance of financing, as the key components through which financing can be assessed (Cylus et al., 2022)
Revenue raising
Revenue raising refers to the ways in which money is brought into the health system. A well-performing revenue raising sub-function should ensure that the health system has sufficient resources to meet the health care needs of the population; that those resources are stable, predictable and able to cope with shocks; and that they are collected in an equitable manner to ensure the burden of health system financing does not fall on the poor or sick.
Pooling
Pooling refers to the accumulation of prepaid funds, which can be used to purchase goods and services on behalf of a population. The pooling function is largely intended to ensure that resources are distributed in an equitable way and also to enable efficiency through economies of scale.
Purchasing
Purchasing refers to payers using funds to pay for health care on behalf of a population. It is mainly concerned with getting resources to those who need them most and doing this efficiently by minimizing costs. As a result, purchasing can have a major impact on intermediate objectives such as quality and, ultimately, health outcomes.
Governance of financing
The governance of financing sub-function covers choices and factors that determine if the flow of funds in the health system is fit for purpose and performs adequately. The key aspects of governance of financing are policies relating to benefits design and service coverage, as well as Public Financial Management.
Benefit design and coverage policies determine who is covered, what services are covered, and any restrictions or conditions of access. Public Financial Management is the set of rules that govern the allocation, use and accountability of public funds. In a health system, Public Financial Management plays a key role in the budgetary formulations that determine the level and allocation of public funding for health; the execution of that budget in terms of effectiveness and targeting of spending; and financial monitoring and transparency.
3.5. Understanding the service delivery function
Service delivery function is the most proximal function to health systems intermediate objectives
Delivering services is a core function of the health system. This is influenced by the other functions (governance, financing and resource generation). Therefore, on the HSPA Framework for UHC, it is placed closest to the intermediate objectives (Figure 5). Service delivery is conceptualized through an evolution of existing definitions, that is, the combination of inputs into a production process that leads to the delivery of a series of interventions (Murray & Frenk, 2000), but also acknowledging the performance aspect through highlighting the need to ensure access, quality, safety and continuity of care in the process (WHO, 2007). Service delivery directly impacts on intermediate health system objectives and, ultimately, the achievement of the final health system goals.
Figure 5
Assessing service delivery in the HSPA Framework for UHC. Source: Papanicolas et al. (2022).
Service delivery is therefore a broad concept and difficult to separate into discrete sub-functions that match organizational structures (for example, levels – primary, secondary, tertiary; purpose – preventive, curative, rehabilitative, long-term care; platforms – primary care centre, hospital, etc; modes – outpatient, inpatient, day care, home care) of health systems globally. Instead, the framework broadly distinguishes the sub-functions of public health, primary care and specialist care, allowing specific services to be attributed to those sub-functions according to a specific country context (Nolte et al., 2022). Assessment areas of all service delivery sub-functions coincide with intermediate health system objectives and include aspects of quality (effectiveness, safety, user experience, as well as efficiency and equity of service delivery) and access to services. As with other functions, governance of service delivery also plays an important role across the three sub-functions, providing service delivery with the basis to operate.
The HSPA Framework for UHC identifies three sub-functions of the service delivery function: public health, primary care and specialist care, in addition to the governance of service delivery
Public health
The public health sub-function aims to fulfil the preventive care needs of the population, although where the boundaries lie between prevention and care is often blurred. Considerable variation can be seen in this sub-function in terms of the operational areas and activities covered, ranging from disease prevention, health care, emergency preparedness, social participation and communication. This may reflect differences in perspectives on what constitutes public health, particularly in relation to universal health coverage and to what degree health care should be considered a public health operation.
Primary care
Primary care represents the first point of contact for unspecified and common health problems. Here also, however, boundaries can vary widely between the other service delivery sub-functions, depending on setting, organizational history and approach. For example, services that fulfil a wider public health function are often provided in primary care settings (for example, vaccination, family planning), whereas in some countries primary care entities may host specialized care practitioners.
Specialist care
Specialist care is care that is provided beyond the first contact triage and generally requires specialist skills. In many countries, specialist care may be distinguished into secondary care (often provided in local hospitals) and tertiary care (often provided in highly specialized centres). The expansion of medical technologies and e-health solutions has blurred the boundaries between the service delivery sub-functions further, bringing specialized diagnostic and therapeutic interventions closer to patients into ambulatory settings or even people’s homes. The rising burden of chronic disease has also led to models of care with some specialist care in the community, leading the way to achieving many health system objectives such as increased accessibility of services, enhanced continuity of care and improved service responsiveness (WHO, 2016).
Governance of service delivery
Governance of service delivery relates to planning and decision-making for health services, including ensuring health service integration and quality assurance mechanisms in service provision. The delineation towards overall systems governance lies in the specificity of the decision-making – when it is for the delivery of health services, and not for the system as a whole, then it would be part of the governance of service delivery.
Table 6
Functions, sub-functions and assessment areas: service delivery.
3.6. The full HSPA Framework for UHC
Most of the time, health system functions impact on health system goals indirectly, through service delivery
Figure 6 shows the full HSPA Framework for UHC.
Figure 6
HSPA Framework for UHC. Source: Papanicolas et al. (2022).
The links depicted in the framework by dotted lines show how each of the functions is connected to the others, and to the intermediate objectives and final health system goals. The functions may affect any one or several of the final goals directly or indirectly. For the most part, as highlighted throughout this brief, the way health system functions impact on goals is largely through the service delivery function with its assessment areas being equal to the intermediate objectives of the system. However, some direct links between the activities within the functions and the attainment of health system outcomes are important for policy-makers to understand in order to fully leverage health system interventions at their disposal. In addition, the interaction between the functions, notably governance’s interplay with all other functions, represents a far-reaching lever to impact on system objectives.
Health system functions can also have a direct impact on specific intermediate objectives and final goals
The HSPA Framework for UHC depicts a small number of direct links between specific functions and specific goals. The governance function has a direct link via a dotted line, which exits the health system and travels through the social and economic determinants of health to impact on health improvement. This direct link acknowledges the potential of the governance function to influence overall population health by collaborating with other sectors and making the case for the co-benefits of addressing health determinants.
A second direct link from the governance function goes to people-centredness. As a goal which captures how far the health system adequately addresses people’s non-medical health needs, it is heavily influenced by the way the health system is designed, a core action within the governance function. This design includes a system that involves people in the decision-making process (stakeholder voice sub-function of governance), thereby being more “people-centred”, that is, responsive to people’s needs (WHO, 2016).
The resource generation function has a single direct link to the final goal of health system efficiency. More specifically, the availability, mix, distribution and quality of inputs, all created by the resource generation function, will directly influence how efficient the overall system is able to be, regardless of whether and how those inputs are used in the service delivery function. The efficiency of the health system refers to maximizing health system objectives given the resources available. In essence, the absolute numbers of the different types of resources available are pre-set in the resource generation function, which can increase or decrease efficiency.
A direct performance link towards health system efficiency can also be seen from the financing function. Financing affects the valuation of the resources available, for example, by determining the cost and prices of inputs, directly influencing the efficiency of the system.
The influence of service delivery on the intermediate objectives of the health system, namely quality and access, can also be seen as a direct link, given that the intermediate objectives and service delivery assessment areas are one and the same. These, in turn, influence all final goals.
The framework acknowledges that broader societal goals should not be ignored when assessing health systems performance
Finally, in Figure 6, the contributions of the health system to broader societal goals are depicted in a linking line but clearly fall outside the boundaries of the main framework, which focuses on what can be assessed within the remit of an HSPA. Nevertheless, although HSPA does not aim to measure the health system’s impact on social, economic, political and cultural factors, their presence in Figure 6 is meant to remind policy analysts and practitioners that broader societal goals should not be ignored when assessing health system performance and drawing policy implications.
4. How to use the framework
The framework is principally a conceptual tool for analysing existing information and data to understand health systems bottlenecks, their origins and impacts on health system performance, as needed
The framework is meant to be applied as a conceptual lens for analysing information and data collected within the context of a system-wide assessment, thereby facilitating a more nuanced understanding of how inputs and structures contribute to system performance, or vice versa, in order to pinpoint areas for improvement.
A health system bottleneck can be traced backwards to explore possible origins (areas to be targeted for improvement), or traced forwards to understand potential influences on health system performance. Doing so may not provide all the answers sought; however, it can serve as a solid basis for in-depth analysis. The framework is designed so that the starting point can be any health system function, sub-function, assessment area, indicative measure, etc. (see Table 3). Importantly, the framework has been designed with existing HSA and HSPA tools in mind, so that performance indicators from other sources that are already collected can be easily mapped onto it.
The framework is therefore meant to be applied as a conceptual lens for analysing information and data collected within the context of a system-wide assessment, thereby facilitating a more nuanced understanding of how inputs and structures contribute to system performance, or vice versa, that is, how system performance has been influenced by inputs and structures.
That being said, three important issues should be considered while applying the framework:
- the framework is meant to be used in conjunction with a whole-of-system appraisal exercise, including both qualitative and quantitative data collection and analysis. Such exercises are usually linked to an in-country process where information is contextualized and interpreted with local knowledge and expertise;
- the assessment areas are not indicators in and of themselves. They simply offer a specifically formulated topical area that needs to be adequately appraised in order to assess function or sub-function performance;
- Indicative measures as displayed in Table 7 are examples for a particular context. Indicators may not necessarily provide the full picture of function or sub-function performance but rather feed into their appraisal when complemented by contextual information normally provided within the health system assessment process.
The framework can be used to study real-life situations and their effects on health system performance
Although it is conceptual, the framework can be used to understand how real-life events affect health system performance. One possible application of the framework is to study how health system performance is affected by various shocks, and how resilient (or not) a health system was in the face of these shocks.
Health system resilience is defined as the ability to prepare for, manage (absorb, adapt and transform) and learn from shocks, whereby a shock is defined as a sudden and extreme change that impacts on a health system (Thomas et al., 2020). A quintessential example is the COVID-19 pandemic.
In terms of the HSPA Framework for UHC, a shock causes a sudden and extreme change to the health system context (see blue outer edge in Figure 6). How well health system functions continue to perform, and the extent to which the overall system can continue to meet its intermediate and final goals, is at the heart of health system resilience – a system that can cope with shock-related vulnerabilities. Given the complexity of health systems, there are multiple areas where the COVID-19 pandemic may have impacted the performance of the functions and/or system goals.
Table 8 outlines examples of policy responses to COVID-19 in areas where the pandemic has challenged function-level performance, linking them to the sub-functions and assessment areas identified in the framework. Table 7 examines how the attainment of the final goals can be assessed during the COVID-19 shock.
Table 7
Examples of indicative measures that can be used to assess the attainment of health system goals during COVID-19.
Table 8
Using the HSPA Framework for UHC to study resilience of health system functions during the COVID-19 shock.
5. Policy implications
The HSPA Framework for UHC offers a generic framework for assessing health systems performance that can be applied flexibly in different health system contexts and changing circumstances. It unifies the existing approaches to performance assessment by focusing both on health system functions (inputs) and goals (or outputs). It further adds value by disaggregating the functions into sub-functions, each with their respective assessment areas, and goals into intermediate and final goals, and mapping out the various interlinkages between them. The importance of health systems broader context, while beyond the scope of the framework, is also acknowledged. The Framework’s conceptual nature allows for its use in conjunction with existing data collection tools.
A number of crucial policy implications arise from the conceptual work on health system performance as presented in this brief, as well as from potential applications.
The HSPA Framework for UHC offers a holistic approach to assessing health systems performance and identifying challenges, acknowledging the various interlinkages within health systems functions and goals
Using the framework as an orientation for data and information analysis reminds us that the health system needs to be examined holistically. Policy-makers and practitioners alike can easily become pre-occupied with the details of a particular policy challenge or implementation bottleneck. Yet, long-lasting solutions, rather than stopgap measures, come about when placing the challenge or bottleneck within the context of a larger whole to better understand the upstream influencing factors and downstream impact.
Put differently, the framework strongly orients its user towards in-depth reflection on both what goes into the system and its outcomes; that is, both the means to achieve final system goals as well as the goals themselves. There may be situations where the balance of assessment information collected is skewed towards either the input or the outcome side – applying the HSPA Framework for UHC will nevertheless bring its user back to the reality that system functions shape system performance, and vice versa.
Understanding the linkages between functions and goals also helps to identify those responsible for remedial action, thus promoting accountability
Making such links while analysing health system assessment information not only helps to identify challenges that require remedial action but also assists in pinpointing which person, group or institution should and can take responsibility for that action – thereby promoting accountability and providing a basis to address the health system challenge.
Thinking through health system performance can improve our understanding of resilience and value in health
Finally, thinking through health system performance provides the foundation for understanding resilience as well as value in health, two concepts that have made striking comebacks in the last decade because of contexts such as the global financial crisis as well as the ongoing COVID-19 pandemic. Regarding resilience, the COVID-19 example showed that absorbing the effects of a shock boils down to whether health system functions and sub-functions remain high-performing (resilient) or not, and whether the linkages between the different functions and goals are durable in all types of circumstances.
Value in the health sector is fundamentally about whether a policy intervention explicitly act as levers to catalyse achievement of health system goals. Creating value can therefore be seen as actions that provide the crucial push towards improved system performance. Examples include interventions that make health service purchasing more strategic and less passive; incentives that motivate health workers to provide more patient-centred care; the selection of a health benefit package through a health technology assessment mechanism; and many more (Smith et al., 2020).
Further work on the framework will include testing and validating linkages and assessment areas identified within the framework, including within specific country settings
The next phase of work in this area will clearly focus on testing assessment areas and validating linkages, with the aim of better understanding which quantitative indicators and/or qualitative question sets give users a more accurate sense of sub-function, function, or overall system performance. Verifying how the different assessment areas and sub-functions play out in different national settings is also needed in order to fine-tune framework application and should therefore form an integral part of health system performance research moving forward.
Publication Details
Copyright
Publisher
European Observatory on Health Systems and Policies, Copenhagen (Denmark)
NLM Citation
Rajan D, Papanicolas I, Karanikolos M, et al. Health system performance assessment: A primer for policy-makers [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2022. (Policy Brief, No. 49.) POLICY BRIEF.
