The post-pandemic focus on resilient health systems will require robust health system assessments and performance analysis. The Health System Performance Assessment Framework for Universal Health Coverage offers a conceptual lens for a comprehensive assessment of health system performance

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 ensuring a strong system involves a number of policy actions. These need to be prioritized and resourced based on the best available evidence, which in turn requires a health system to be monitored, and regularly assessed, in order to build on its strengths and overcome its shortcomings.

Assessing health systems means delving into fundamental questions on the system’s boundaries, component elements and goals, and the new Health System Performance Assessment (HSPA) Framework for Universal Health Coverage (UHC) is a tool that will help policy-makers to address those questions. The framework stems from the volume Health System Performance Assessment: A Framework for Policy Analysis, which seeks to find an optimal, harmonized solution to assessment, given the various perspectives including expert appraisal and the evidence available. Both the study and this brief are informed by the underlying understanding that, in many cases, there is no right or wrong answer.

The study and brief draw on a range of tools and frameworks for health system-wide assessment exercises and the efforts of a dedicated technical working group. Tools focused on evaluating the current structure of the health system, often through the conceptual framework of health system functions or building blocks tended to be pre-occupied with in-depth descriptions of system structures and features as a route to identify system strengths and failures. Tools that placed an emphasis on evaluating how well the system is performing overall, by examining the extent to which health systems are meeting health system goals, by contrast tended to draw more on quantitative measures and analytical methods, often referred to as HSPA.

Ultimately, however, the business of strengthening health systems relies on a comprehensive understanding of what systems look like, how they perform and what structures work (or do not) in attaining optimal performance. A cross-cutting approach is needed to clarify the relationship between what health system actors do and the goals those actors wish to achieve, and to identify the connection between health system inputs, outputs and outcomes. This is critical in understanding the link between the performance of individual health system functions and the performance of the health system overall.

This is precisely the intent of the HSPA Framework for UHC, which mobilizes a long tradition of work on performance to help policy-makers assess how health system structures (inputs, outputs and outcomes) can be strengthened to serve people better.

The HSPA Framework for UHC (Figure 1) elaborates on the four health system functions, taken from the World Health Report 2000 – governance, resource generation, financing and service delivery

Figure 1

HSPA Framework for UHC – an overview. Note: HSPA, Health System Performance Assessment. Source: Papanicolas et al. (2022).

The HSPA Framework for UHC focuses on health actions within the traditional health care remit but also includes public health and health promotion activities that contribute to health improvement. While it is beyond the scope of the framework, the influence of the socioeconomic, political and cultural factors on health is explicitly acknowledged by placing the health system within this broader context and by recognizing that the health system is meant to contribute to the wider societal goals. The framework, therefore, acts as a guide to assessing those actions that health system actors can feasibly undertake, while explicitly acknowledging the substantial impact on health of a range of socioeconomic determinants outside the boundaries of the health system.

The framework builds on the four core health system functions, taken from the World Health Report 2000 – governance, resource generation, financing and service delivery – and lays out a set of sub-functions for each of them. Sub-functions represent the key topical areas that matter most for function-level performance and for the function’s contribution to overall system performance.

The HSPA Framework for UHC brings together these four functions, intermediate objectives and the final goals, and places the health system within a wider socioeconomic context

The HSPA Framework for UHC is grounded in the premise that any whole-of-sector 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.

The links depicted in the framework by dotted lines (see Figure 6) 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, the way health system functions impact on goals is through the service delivery function with its assessment areas being captured in the the intermediate objectives of the system. 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.

The framework is principally a conceptual aid to orient the analysis of information collected through health system assessment exercises towards system performance

The framework is a conceptual aid that policy-makers can use to identify areas for health system improvement. It is designed so that the starting point can be any health system function, sub-function, assessment area, indicative measure, etc.

A health system bottleneck can then 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. Importantly, the framework has been designed with existing assessment tools in mind, so that performance indicators from other sources that are already collected can be easily mapped onto it.

The framework’s conceptual lens can therefore help to analyse information and data collected within the context of a system-wide assessment, 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.

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.