Health system performance assessment : synthesis report, Belgium, 19-20 May 2014.
Date: 2015-03-09
Institutions: Directorate-General for Employment, Social Affairs and Inclusion
Subjects: EU Member State, cost-effectiveness analysis, health care system, organisation of health care, public health

ISSN 1977-7973

Peer Review  

in Social Protection  

and Social Inclusion  

Health System Performance 
Assessment 

Synthesis Report

Belgium, 19-20 May 2014

Social Europe

 
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Health System 
Performance Assessment

PETER SMITH
Imperial College Business School

Synthesis Report

ACKNOWLEDGEMENT

The author would like to thank the Belgian HSPA team for the clear 
presentations of their work, all participants in the Peer Review process 
for their helpful and perceptive contributions, and Renate Haupfleisch and 
Monika Natter at ÖSB for their helpful guidance throughout. Any errors or 
misrepresentations in this report nevertheless remain the responsibility of 
the author.

European Commission

Directorate-General for Employment, Social Affairs and Inclusion
Manuscript completed in July 2014

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ISBN 978-92-79-39636-6 
ISSN 1977-7973 
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Table of contents

Executive Summary  

A. 

Policy context at the European level  

B. 

The Belgian good practice under review  

C. 

Policies and experiences in peer countries  

D.  Main issues discussed during the meeting  

E. 

Conclusions and lessons learned  

References  

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Executive Summary 

The World Health Organisation (WHO) defines health system performance assessment (HSPA) 
as “a country-specific process of monitoring, evaluating, communicating and reviewing the 
achievement  of  high-level  health  system  goals  based  on  health  system  strategies”.  The 
broad aim of HSPA is to promote strategic accountability for health system actions. Specific 
objectives  might  include:  setting  out  the  goals  and  priorities  for  a  health  system;  acting 
as a focus for policymaking and coordinating actions within the health system; measuring 
progress  towards  achievement  of  goals;  informing  public  debate  on  the  health  system 
amongst  stakeholders  and  citizens.  Countries  in  the  WHO  European  Region  signed  up  to 
the  2008  “Tallinn  Charter”,  which  included  a  commitment  to  promote  transparency  and 
accountability to citizens and other legitimate stakeholders for the way that health system 
money has been spent.

Many Member States have started to introduce HSPA initiatives. These have taken a variety 
of  forms,  and  been  undertaken  for  a  variety  of  purposes.  The  common  theme  features 
are that HSPA should focus on the health system as a whole, and not just health services; 
that performance should be expressed in terms of outcomes such as improved health and 
reduced exposure to financial risk, rather than processes such as workforce size or numbers 
of treatments; and that progress should be quantified using reliable metrics and associated 
analytic techniques. There is nevertheless a widespread belief that the exact form of HSPA 
should be a matter of choice for individual countries.

The  Belgian  HSPA  initiative  was  the  subject  of  this  Peer  Review.  It  was  commended  by 
participants  as  being  a  good  model  for  other  countries  seeking  to  introduce  or  enhance 
a HSPA process. Particularly noteworthy are the clarity of objectives, the clear conceptual 
framework,  the  independent  rigour  of  the  analysis,  the  emphasis  on  equity,  and  the 
commitment to a continuing HSPA process. Work is continuing to identify the appropriate 
way of linking the Belgian HSPA with policy processes. This aspect of HSPA is underdeveloped 
in most countries and likely to vary depending on institutional arrangements.

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Peer  Review  participants  discussed  a  wide  range  of  institutional  and  technical  issues 
associated with HSPA, summarized in this report, under the broad headings of institutional 
arrangements for HSPA; objectives; data sources; methodology; dissemination; the role of 
HSPA in the policy process; and the role of action on HSPA at the European level. Particular 
unresolved issues include:

 • The processes for setting HSPA goals and methods;

 • What should be the basis of comparison in HSPA (international; regional; trends over 

time);

 • How to choose performance indicators;

 • The treatment of health system efficiency within HSPA;

 • The treatment of equity (fairness);

 • Data gaps and inconsistencies; 

 • How to disseminate HSPA

 • How to integrate HSPA into the policy process.

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Existing  action  at  the  international  level  includes  the  preparation  of  long-running  data 
series  by  the  Organisation  for  Economic  Cooperation  and  Development  (OECD),  and  the 
compilation  of  comprehensive  descriptions  of  health  systems  (including  some  outside 
Europe)  according  to  a  standardized  template  by  the  European  Observatory  for  Health 
Systems and Policy. The World Health Organisation (WHO) European Region has undertaken 
several HSPA initiatives at the invitation of member countries. All three organisations also 
publish widely on general policy issues relevant to HSPA.

At the EU-level, the European Commission has created the European Core Health Indicators 
(ECHI) initiative, which assembles 88 indicators relevant to HSPA. In 2011 the Council of the 
European Union set up a reflection process to identify effective ways of investing in health 
which concluded that Member States should use HSPA for policymaking, accountability and 
transparency. Social Protection Committee (SPC) and its Indicators Subgroup are exploring 
the feasibility of adapting the Joint Assessment Framework (JAF) methodology to the area 
of health systems as a “first-step screening device to detect possible challenges in health 
systems, with a specific focus on issues related to access, quality and equity”.

Peer  Review  participants  identified  strong  arguments  for  action  at  a  European  level  to 
nurture and sustain HSPA, for example in securing international agreement on the scope of 
data collection efforts, the specification of data definitions and standards, the promotion of 
data collection and dissemination by international agencies, and sharing best practice on 
the use of the information. It was also pointed out that HSPA should generally be a national 
undertaking, tailored to local needs.

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A.  Policy context at the European level 

Health  system  performance  assessment  (HSPA)  is  becoming  a  central  instrument  in  the 
governance  of  modern  health  systems.  The  notion  of  the  health  system  was  first  given 
concerted attention in the World Health Report 2000 (WHO, 2000), and further developed 
in the WHO  report Everybody’s business: strengthening health systems to improve health 
outcomes (WHO, 2007). It defined the health system as “… all the activities whose primary 
purpose  is  to  promote,  restore  or  maintain  health.”  The  World  Health  Organisation  then 
defines HSPA as “a country-specific process of monitoring, evaluating, communicating and 
reviewing  the  achievement  of  high-level  health  system  goals  based  on  health  system 
strategies” (WHO, 2012). The prime objectives of HSPA are:

 • To set out the goals and priorities for a health system;

 • To act as a focus for policymaking and coordinating actions within the health system;

 • To measure progress towards achievement of goals;

 • To act as a basis for comparison with other health systems;

 • To  promote  transparency  and  accountability  to  citizens  and  other  legitimate 

stakeholders for the way that money has been spent.

HSPA was given a further stimulus in the WHO European Region by the signing of the “Tallinn 
Charter on Health Systems for Health and Wealth” in 2008. The 53 Ministers of Health from 
the European region made a commitment “to promote transparency and be accountable for 
health systems performance to achieve measurable results”. HSPA is seen as an important 
mechanism for fulfilling that commitment. As envisaged by WHO, it is primarily a country-
specific process for which there is no single accepted template, although there are many 
generally accepted principles of best practice in developing a specific HSPA (WHO, 2012). 
Some of these include:

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 • HSPA should focus on the health system as a whole, including health promotion and 

public health as well as health services;

 • Health systems goals should be expressed in terms of outcomes such as improved 
health and reduced exposure to financial risk, rather than processes such as workforce 
size or numbers of treatments;

 • Wherever feasible, progress should be quantified using reliable metrics and associated 

analytic techniques;

 • HSPA should be a regular process, embedded in all aspects of health policymaking;

 • The exact form of HSPA should be a matter of choice for individual systems, although 
its effectiveness is likely to be maximized by the adoption of metrics and methods 
that enjoy widespread international use. 

Despite differences in how objectives are expressed and measured, there is almost universal 
agreement that any HSPA should reflect health system goals related to the following:

 • The improvement in health that can be attributed to the health system as a whole;

 • The health system’s responsiveness to citizens’ preferences;

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 • The financial protection offered by the health system;

 • The productivity, or value-for-money, of the health system.

Furthermore, many formulations of HSPA make reference to the issue of fairness, or equity, 
in how attainment of its goals is distributed across different population groups. 

There is less consensus on how to incorporate health system functions into HSPA. These 
might include: service delivery; workforce; information resources; medical products, vaccines 
and technologies; financing; and stewardship. Such functions are the fundamental building 
blocks of any health system, and how they are deployed can have a major influence on 
health  system  outcomes.  However,  they  are  often  difficult  to  compare  across  different 
types of health system, and a focus on functions can sometimes inhibit progress towards 
new  ways  of  promoting  the  ultimate  goals  of  the  health  system,  such  as  a  shift  away 
from treatment towards prevention of disease. It is for this reason that HSPA should focus 
primarily on outcomes. Assessment of functions may be an important diagnostic tool for 
understanding reasons for progress (or lack of progress) towards health system goals, but 
should not be the prime focus of HSPA. Box 1 summarizes the key features of HSPA, as 
envisaged by the WHO (WHO 2009).

Box 1: Key features of HSPA (WHO 2009, p141)

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HSPA is regular, systematic and transparent. Reporting mechanisms are defined beforehand 
and cover the whole assessment. It is not bound in time by a reform agenda or national 
health plan end-point, although it might be revised at regular intervals better to reflect 
emerging priorities and to revise targets with the aim of achieving them.

HSPA is comprehensive and balanced in scope, covers the whole health system and is not 
limited to specific programmes, objectives or levels of care. The performance of the system 
as a whole is more than the sum of the performance of each of its constituents.

HSPA is analytical and uses complementary sources of information to assess performance. 
Performance indicators are supported in their interpretation by policy analysis, 
complementary information (qualitative assessments) and reference points: trends over 
time, local, regional or international comparisons or comparisons to standards, targets or 
benchmarks.

In meeting these criteria, health system performance assessment needs to be transparent 
and promote the accountability of the health system steward. 

A  cornerstone  of  HSPA  is  comparison  with  other  systems,  either  through  the  use  of 
quantitative indicators or using more qualitative descriptions. In some circumstances the 
focus can be on a system’s trends over time (comparison with itself), or comparisons of 
regions or other subsystems within the overall system (comparison within itself). However, 
the principal analytic focus of many HSPA initiatives has been comparison with other health 
systems. If undertaken persuasively, such comparisons can be one of the most powerful 
instruments for securing media interest, engaging policymakers, and encouraging reform. 
However, such comparison can be contentious and analytically complex for a number of 
reasons. These include: non-comparability of concepts (e.g. different definitions of disability), 

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different data collection mechanisms, and the need to adjust for different contextual factors 
(e.g. the age distribution of the populations).

A  variety  of  resources  have  been  developed  to  facilitate  comparison  and  support  HSPA, 
in  the  form  of  information  systems  and  descriptions  of  health  systems.  The  longest 
established  dataset  for  high  income  countries  is  the  OECD  Health  Data,  which  includes 
data series from 1961 covering health outcomes, health service resources, utilization, and 
workforce (OECD 2013a). More recently, the OECD has established a Health Care Quality 
Indicator (HCQI) project that is identifying and collecting a series of comparable indicators 
of the quality of specific aspects of health services (OECD 2014). The OECD has also been 
instrumental in developing the System of Health Accounts (SHA), the standard framework 
for producing consistent and internationally comparable financial data on health systems. 
Various  perspectives  on  the  OECD  data  sources  are  presented  in  the  OECD  “Health  at  a 
Glance”  publications,  which  include  a  publication  dedicated  to  the  situation  in  all  the  EU 
Member States (OECD 2013b, OECD 2012). 

The European Commission has created the European Core Health Indicators (ECHI) initiative, 
which  assembles  88  indicators  relevant  to  HSPA,  for  over  50  of  which  data  are  readily 
available  and  reasonably  comparable.  The  indicators  are  grouped  into  five  broad  areas: 
demographic  and  socio-economic  factors,  health  status,  determinants  of  health,  health 
services, and health promotion. The ECHI indicators can be analysed using the web-based 
HEIDI tool (European Commission 2014). This prepares graphs, maps or bar charts, showing 
trends in indicators, or allowing comparison between chosen countries or groups of countries. 

At  a  global  level,  other  data  repositories  include  the  World  Bank’s  World  Development 
Indicators,  the  World  Health  Organisation’s  Global  Health  Observatory,  and  Institute  of 
Health Metrics and Evaluation’s Global Health Data Exchange. The coverage, completeness 
and reliability of these series is highly variable. The European Commission has also funded 
several projects under its FP7 programme that identify and analyse health data from the 
perspective of cross-country comparisons. These include EuroREACH, EuroHOPE and ECHO. 
EuroREACH developed a “Health Data Navigator” that helps potential users to secure access 
to and analyse comparable data sources across Europe (Hofmarcher 2013). 

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There are a number of other potential resources for quantitative comparison. These include 
the annual surveys of the Commonwealth Fund, a New York based charitable foundation, 
and  the  private  Swedish  organisation  Health  Consumer  Powerhouse,  which    produces  a 
‘EuroHealth Consumer Index’.

The  prime  source  for  informed  and  comparable  descriptions  of  health  systems  is  the 
European Observatory on Health Systems and Policies, a partnership between the European 
Commission, the World Bank, the WHO, and certain Member States (European Observatory 
on Health Systems and Policies 2014). Its Health Systems in Transition (HiT) series offers 
comprehensive descriptions of health systems (including some outside Europe) according 
to  a  standardized  template.  The  Observatory  also  publishes  books  on  important  policy 
issues, including a volume on the principles and practice of performance measurement in 
health (Smith 2010) and a volume specifically examining the issues associated with health 
system performance comparison (Papanicolas 2013). 

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The  Directive  on  the  application  of  patients’  rights  in  cross-border  care1  set  a  further 
basis for the assessment of health systems in the EU, in that it requires Member States 
to cooperate on standards and guidelines on quality and safety, and to exchange relevant 
information.  According  to  the  Directive,  national  contact  points  should  be  in  charge  of 
information exchange. 

In 2011 the Council of the European Union set up “a reflection process ... to identify effective 
ways  of  investing  in  health,  so  as  to  pursue  modern,  responsive  and  sustainable  health 
systems”. The Working Party on Public Health at Senior Level led this process and reported 
in  2013.  Five  subgroups  were  established,  of  which  the  fifth  examined  “measuring  and 
monitoring  the  effectiveness  of  health  investments”.  It  focused  on  the  role  of  Member 
States and the Commission in promoting HSPA. As part of its work, the subgroup undertook 
a survey of the use of HSPA by Member States. Of 17 respondents, 13 reported having 
some sort of HSPA in place at national or regional level (Belgium, Croatia, Sweden, England, 
Finland, Greece, Lithuania, Portugal, Slovakia, Slovenia, Spain, Austria, Denmark). 

In its conclusions on this reflection process, the Council included a recommendation that 
Member States should “use health system performance assessment (HSPA) for policymaking, 
accountability and transparency” and that the Commission should support Member States 
in that endeavour.  It further urged improvement in the coordination of HSPA by Member 
States and the Commission by:

 • streamlining  the  debate  on  the  theoretical  HSPA  framework  and  identifying  useful 

methodologies and tools to support policy maker in taking decisions;

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 • defining criteria for selecting priority areas for HSPA at EU level and improving the 
availability and quality of relevant data and information. (Council Conclusions adopted 
10 December 2013.)

The Union’s Expert Panel on effective ways of investing in Health (EXPH) has prepared a 
commentary on the subgroup’s proposals that raises some key technical and implementation 
issues (EXPH 2014). It recommends the development of a clear conceptual framework that 
defines  the  scope  of  the  health  system  to  be  assessed.  This  would  facilitate  a  stepped 
approach  to  the  model  development  and  testing.  The  EXPH  highlights  a  number  of 
methodological and practical considerations that have been identified in the international 
literature that should be taken into account, and outlines a number of practical possibilities.

In  April  2014  the  Commission  published  a  Communication  on  effective,  accessible  and 
resilient  health  systems,  in  which  it  proposed  a  EU  agenda  to  strengthen  effectiveness, 
increase accessibility and improve the resilience of health systems in EU Member States2. 
HSPA  is  seen  as  an  essential  tool  to  strengthen  the  resilience  of  health  systems,  and  a 
proper health information system is identified as an important element of resilience. 

Lastly,  the  Social  Protection  Committee  (SPC)  and  its  Indicators  Subgroup  explored  the 
feasibility of adapting the Joint Assessment Framework (JAF) methodology3  to the area of 

1  Directive 2011/24/EU of the European Parliament and of the Council, of 9 March 2011.
2 
  Communication from the Commission on effective, accessible and resilient health systems, 
4.4.2014, COM(2014) 215: http://ec.europa.eu/health/healthcare/docs/com2014_215_final_en.pdf 
3   Joint assessment framework is a methodology agreed by Employment Committee, Social Protec-

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health systems (Social Protection Committee Indicators Sub-group 2013). This quantitative 
methodology is seen as a “first-step screening device to detect possible challenges in MS’s 
health systems, with a specific focus on issues related to access, quality and equity”. It is 
intended that this should be followed up with a more qualitative assessment intended to 
“verify and deepen the understanding of the challenges identified by this first screening”. 
The proposed model is illustrated in Figure 1. The distinctive features are:

 • a strong focus on equity

 • measuring overall health outcomes (including mental health)

 • a focus on the performance of health care services (access, quality and resources)

as  well  as  contextual  factors.  As  acknowledged  in  the  sub-group’s  report,  the  area  of 
efficiency is the least well developed. The approach is being tested during 2014.

Figure 1: Proposed model of the JAF framework in the area of health

Overall Health Outcomes

How healthy are citizens of MS and what are their health outcomes? 

Determinants of the health care 
performance

Do all people in need of health care 
get access to quality health care?

Non-health care determinants

What is the general profile in terms 
of non-healthcare factors?

E
q
u
i
t
y

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y
c
n
e
i
c
ffi
E

 Access

Quality 

 Resources

Health  
behaviour  
Lifestyle

External factors 
not related to 
lifestyle

Context information

Demographics, Poverty and social exclusion, GDP per capita, Educational status, 
Spending on Health

In order to develop methodology to assess health systems’ efficiency, the Commission will 
undertake a joint project with OECD on this issue. This will complement the ongoing study “A 
Life Table Analysis: health system cost-effectiveness assessments across Europe”4, funded 
by the Commission and carried out by the Dutch National Institute for Public Health and the 
Environment (RIVM).

tion Committee and Commission to monitor progress on Europe 2020. It is also applied to the areas 
of employment, social inclusion, education. More information available at: http://ec.europa.eu/social/
main.jsp?langId=en&catId=89&newsId=972&furtherNews=yes
4 
  The study is expected to be finalised by the end of 2014, for more information see:  
http://ec.europa.eu/eahc/documents/health/tenders/2013/EN/EAHC_2013_05_Specifications.pdf

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B.  The Belgian good practice under review 

The  adoption  in  2008  of  the  Tallinn  Charter  by  all  countries  in  the  WHO  European 
Region  was  an  important  milestone  in  the  move  towards  HSPA  in  Belgium.  The  Charter 
underlines the importance of health as an investment to promote economic development 
and solidarity, and signatories committed to the adoption of health system performance 
assessment.  On 18 March 2008, following a recommendation of the Tallinn Charter (WHO) 
the Belgian governmental agreement on public health formulated an agreement that: “The 
performances of our health system (including quality), are to be assessed on the basis of 
measurable objectives.” 

Belgian health authorities asked their health administration - scientifically supported by the 
Health Care Knowledge Centre (KCE), the Institute of Public Health (IPH) and the National 
Institute  for  Health  and  Disability  Insurance  (NIHDI)  –  to  test  the  feasibility  of  a  Health 
System Performance Assessment report (HSPA) in Belgium. Since then the following reports 
have been published:

 • two full HSPA reports (2009, 2012) ;

 • an intermediate report assessing the evolution of HSPA in Belgium (2014);

 • a thematic report on general practice (2010). 

In the future, Belgium will publish HSPA every four years with intermediate reports every 
two years. The next report is expected to be published in December 2015. 

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The Belgian HSPA report explicitly pursues two strategic objectives (Gerkens 2010): 

 • To  provide  a  transparent  and  accountable  view  of  the  Belgian  health  system 

performance, in accordance with the commitment made in the Tallinn Charter; 

 • To inform health authorities of the performance of the health system and to support 
policy planning; and in the long-term, to monitor the health system performance over 
time. 

A further implicit yet concrete reason to prepare an HSPA report was to answer the question 
posed by the National Insurance Institute, namely “Can we objectively say that expenses in 
the Belgian health system are correctly spent (value for money)?” There was also a desire to 
collect and compare data on quality of care, inequities and unmet needs. Supporting policy 
was not an objective of HSPA at the outset, but following the publication of several reports, 
it is progressively becoming an issue.

Alongside  HSPA,  there  has  been  in  Belgium  increased  interest  in  the  development  of 
performance  measurement  based  on  a  more  thematic  issue  (e.g.  general  medicine). 
This kind of initiative, designed in cooperation with field experts, was used to define and 
share  priorities  between  the  practitioners  and  the  authorities,  to  compare  organisations 
(benchmarking),  to  improve  quality  of  care  and  encourage  continuous  professional 
development, innovation and to inform incentives. 

Internationally,  several  organisations  provide  resources  to  benchmark  Belgium  against 
other  European  countries  on  health  status  and  healthcare  indicators,  including  the  WHO 

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“World Health Report 2000”, the biannual report “Health at a glance Europe” resulting from 
a  collaboration  of  OECD  and  the  European  Union,  the  EU  website  of  the  ECHI  indicators 
and the Euro Health Consumer Index. One perspective on the Belgian HSPA initiative is that 
it acts as a means of seeking to interpret those reports, helping Belgium to fill gaps and 
shorten the delays in data collection associated with international comparisons. Belgium is 
also interested in building an international network to share best practices with countries 
with comparable health system design.

Belgium has a holistic approach to the assessment of the health system performance that 
is similar to the proposed JAF approach, according to a conceptual framework embracing 
five dimensions of performance: quality; accessibility; efficiency; sustainability; and equity. 
The 2012 report uses a total of 74 indicators chosen to assess levels of performance at 
the national level. Considerable attention is paid to accessible presentation of the results, 
and Belgian attainment is assessed in relation to the other EU-15 countries. Many of the 
indicators are disaggregated according to factors such as gender, region, socio-economic 
status. Where they exist, data gaps and weaknesses are acknowledged. The presentation of 
data concludes with an overall assessment of the strengths and weakness of the Belgian 
health system based on the reported indicators.

The specific operational objectives of the 2012 report were:

 • To review the core set of 55 indicators of the previous report, with a special focus on 

the 11 indicators for which there were no data in 2010;

 • To enrich the core set with indicators from the following domains: health promotion, 
general medicine, mental health, long-term care, end-of-life care; to add indicators 
on patient-centeredness and continuity of care (two sub-dimensions of quality); and, 
finally, to propose indicators on equity in the health system;

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 • To measure the selected indicators, when possible, or to identify gaps in the availability 

of data; 

 • To  interpret  the  results  in  order  to  provide  a  global  evaluation  of  the  performance 
of  the  Belgian  health  system  by  means  of  several  criteria,  including  international 
benchmarking when appropriate.

The  Belgian  HSPA  experience  has  prompted  a  number  of  important  debates  that  are  of 
general  relevance  in  the  development  of  a  country’s  HSPA.  A  first  point  of  discussion  in 
Belgium was whether to include “health status” to measure the outcomes of the system, 
in  contrast  to  physical  health  system  outputs.  However  it  was  considered  that  the  link 
between health status as an outcome and the performance of the health system remains 
unclear, and more evidence will be needed before it can be used reliably. 

Another point of discussion was the treatment of “non-medical determinants of health”. 
Belgium’s choice was not to include these in the framework, as the scope of the HSPA is 
the “health system”. However, it remains unclear where to draw the boundary. For example, 
health promotion belongs definitively to health systems and interacts with health behaviour 
and life style. The discussion remains open, and is related to the debate on “health in all 
policies”, which implies looking outside the health sector for cost-effective policies that can 
generate better health and reduce the demand for health services. 

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Belgium  went  a  step  further  than  the  SPC  recommendations  by  adopting  a  specific 
approach that encompasses the different aspects of the health system (and not only acute 
care), namely: health promotion, preventive care, curative care, long-term care and end-
of-life care. This was found to be helpful, although of course the details of the approach 
are likely to be different from country to country depending on the health system design 
(degree of specialisation of health services), country organisation (centralisation/regional), 
and governance (Ministry of Health including – or not – social affairs). It is nevertheless 
recognised that the design of the framework should in no way be driven by existing data 
(international  data  are  mainly  based  on  hospital  acute  care)  and  a  broader  approach  – 
including social affairs and insurance data as in Belgium – can inform a better understanding 
of inequalities issues.

The final section of the 2012 report reflects on the contribution of the 2012 report itself. 
It considers that the major contributions relative to 2010 are: improved data availability; a 
more comprehensive set of indicators offering a more comprehensive view of the system; 
simplification  of  the  structure  of  the  set  of  indicators  to  facilitate  easier  understanding; 
more  systematic  analysis  of  the  data;  better  use  of  existing  information;  and  improved 
communication  of  results.  The  acknowledged  weaknesses  relate  principally  to  continued 
data shortcomings, including data coverage, timeliness and reliability.

Like all countries, Belgium has struggled with an absence of good definitions and a good 
framework for analysing “efficiency” and “equity”. The interconnection between effectiveness, 
appropriateness and efficiency also requires clarification. The role of health promotion and 
non-health determinants must also be further explored in the context of HSPA. 

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14

Comparison with international experience suggests that Belgium’s HSPA can be improved 
in several aspects: 

 • Health  insurance  coverage  is  not  enough  to  analyse  financial  accessibility.  Some 
aspects of the depth of coverage should be included, and it is essential to analyse the 
issues of both equity and inequalities. 

 • Efficiency needs to be analysed in depth especially when the economic situation is 

problematic. 

 • From the resilience point of view5, “good governance” and “adequate costing” are also 

issues that should be strengthened in Belgium’s HSPA. 

 • The appropriate analysis of quality is also a point of discussion since some aspects 

are sometimes too detailed. 

The  Belgium  HSPA  has  hitherto  been  used  mainly  for  accountability.  However,  the  belief 
is  that  it  can  contribute  to  a  rapid  improvement  of  the  health  system.  Those  charged 
with developing the Belgian initiative offer the following observations, in the light of their 
experience: 

5  According to the resilience factors identified in the Communication from the Commission on effec-
tive, accessible and resilient health systems, 4 April 2014, COM(2014) 215 

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1. HSPA should provide a global balanced overview which enables aligning views between 

 • health, social affairs and economic affairs; 

 • the field and decision makers. 

2. It is essential that values – like quality, access, equity, on the one hand, and sustainability 
and efficiency, on the other hand – are shared between stakeholders. 

3. It’s also essential to analyse the health system as a whole encompassing 

 • acute, and also chronic and mental care; 

 • hospital (residential) care and also primary care; 

 • health system and also health promotion and health in all policies. 

4. The set of indicators should remain comprehensive and elaborated enough to assess the 
system as a whole. 

5.  The  report  must  lead  to  concrete  recommendations  which  should  be  translated  into 
action(s). 

6. Many aspects still need further development, like 

 • dimension analysis (outcome of the health system , efficiency, inequalities, …); 

 • ways to improve data collection ( upi, electronic data , linking data); 

 • elaborate good indicators for primary care, mental care, chronic care , end of life; 

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15

 • improve international benchmarking; 

 • improve data reporting; 

 • ways to improve health systems (prioritise, targets, incentives). 

7. There is a need to develop a European network on HSPA.

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C.  Policies and experiences in peer countries 

As part of the Peer Review process, a questionnaire was circulated to participating countries 
requesting the following information:

1.  A brief description of the country’s approach to HSPA. 

2.  The thematic priorities that have been selected

3.  How benchmarks are chosen (for assessing what is good and what could be improved), 

and how the main indicators for drawing key conclusions are selected.

4.  What targets are used for measuring improvement, and whether progress is quantified 

using reliable metrics and associated analytic techniques.

5.  Whether and how HSPA influences national policy making. How the main results of the 
report are communicated to the general public, and whether HSPA is used to change 
policy.

6.  An assessment of the strengths and weaknesses of the country’s HSPA: the challenges 

that are faced and the priorities for improving the HSPA system.

7.  What kind of EU level support would be needed to support national level HSPA.

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16

Completed  questionnaires  were  received  from  six  Member  States:  Austria,  Malta, 
Netherlands,  Portugal,  Sweden  and  the  United  Kingdom  (England).  In  addition,  although 
it  does  not  formally  undertake  HSPA  at  the  national  level,  Germany  responded  with  a 
description of activities in Germany related to HSPA processes.

Where  appropriate,  responses  for  certain  headings  are  summarized  in  Table  Annex  1 
(appended).  The  broad  conclusions  drawn  from  the  questionnaire  responses  can  be 
summarized as follows:

1.  There is a general commitment to HSPA amongst all the responding countries.

2.  Countries are at different stages of development in their HSPA systems.

3.  The aims of HSPA vary between countries, reflecting different emphases towards (a) 
promoting the accountability of national institutions (b) informing policy (c) improving 
transparency and understanding and (d) holding devolved entities to account.

4.  The processes of HSPA vary between countries, for example in terms of 

 • Who instigates and drives forward the demand for HSPA
 • How stakeholders’ differing priorities are resolved
 • Who funds HSPA
 • Who undertakes HSPA
 • The format and contents of HSPA
 • Whether HSPA is a continuing and sustained process.

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5.  All  systems  have  adopted  some  sort  of  analytic  framework  for  undertaking  HSPA, 
although these differ somewhat, mainly in details. The major differences relate to the 
assumed scope of the health system, principally the extent to which the HSPA focuses 
solely on health services or takes a broader societal perspective.

6.  The  basis  for  comparison  varies  between  countries,  but  there  is  heavy  reliance  on 
international comparison, as well as some consideration of national trends over time 
and regional comparisons within the country.

7.  The extent and nature of HSPA influence over health policy differs between countries. 
In some it has directly fed into governmental decision-making, whilst in others it has 
a less direct influence through informing political debate. 

8.  Most  HSPA  efforts  are  at  an  early  stage  of  development.  Achievements  include 
acting as a framework for reporting progress, identifying key data weaknesses, and 
identifying  priorities  for  health  system  action.  Principal  challenges  relate  to  data 
weaknesses  and  identifying  the  most  appropriate  means  of  transmitting  results  to 
relevant stakeholders, including the public.

9.  There is an important role at the European level for nurturing exchange of ideas and 

promoting the availability and comparability of relevant data.

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D.  Main issues discussed during the meeting 

These  and  other  issues  were  elaborated  on  by  country  representatives  and  other 
stakeholders at the Peer Review meeting. The meeting included presentations examining 
the  international  HSPA  context  and  giving  details  of  the  specific  Belgian  initiative  under 
scrutiny.  These  were  followed  by  general  discussions  of  all  participants  on  the  goals  of 
HSPA; methodology; impact and monitoring; governance of HSPA; and the role of support 
at the European level. 

There were presentations on activities and policy needs relevant to HSPA from representatives 
from  the  European  Commission  in  DG  EMPL,  DG  SANCO  and  DG  ECFIN,  reflecting  the 
importance  of  HSPA  across  policy  domains.  Representatives  from  the  Organisation  for 
Economic Cooperation and Development (OECD) and the European Observatory on Health 
Systems and Policy described their relevant activity at the European level, and their joint 
working with the Commission.

The meeting did not seek a consensus, and there was not unanimity on all issues. However, 
the following summarizes some of the issues raised at the meeting.

1.  HSPA can help to frame our thinking about health systems, which are highly complex 
structures. Internationally consistent data sources are a crucial resource for any HSPA.

2.  The precise format for HSPA is essentially a matter for individual countries, as there 
are legitimate variations in the perspective to be adopted and the goals of the HSPA. 

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3.  The demand for HSPA comes from a variety of sources. Government may be the main 
drivers,  but  stakeholders  with  a  range  of  different  interests  may  also  be  involved. 
Consensus on the aims of HSPA is easier to achieve in some countries than in others.

4.  The funding of HSPA can raise issues concerning its independence.

5.  HSPA should be descriptive rather than prescriptive. Although its findings may lead 
to recommendations for improving a health system, these should best be formulated 
outside the direct HSPA process.

6.  Comparisons are fundamental to all HSPA exercises. These may look at international 
or regional differences. Such comparisons can help identify problems and inefficiencies 
within national or local healthcare provision. Comparison of trends over time can also 
help to identify the impacts of reforms. 

7.  The selection of indicators used in HSPA will affect its outcome. While some selection 
is inevitable, concerns were expressed about approaches that strongly compress the 
number of indicators. 

8.  Data  weaknesses  are  a  common  constraint,  with  information  on  certain  areas  of 
activity either absent, weak, unreliable or out-of-date. Certain thematic areas such as 
mental illness present special difficulties. 

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9.  HSPA  exercises  are  in  themselves  a  means  of  improving  the  quality  and  scope  of 
data. In a number of countries, HSPA has stimulated new data collection efforts. In 
particular, use of international datasets may draw attention to gaps in national data.

10.  There  is  a  particular  concern  about  the  absence  of  useful  indicators  of  system 

efficiency. 

11.  The technical difficulty of developing appropriate indicators of equity of health and 

access to health services between social groups was also noted.

12.   “Patient vignettes” (describing how an otherwise identical case is treated in different 
systems) may be another possible means of comparison, but they are currently little 
used.

13.  Some constraints on access to data exist. Real or perceived threats to privacy have 
become a major issue in some countries, and health data are particularly sensitive 
in this regard. Various anonymisation techniques may help to overcome resistance to 
data collection for legitimate research purposes. 

14.  A number of technical challenges remain. The concept of equity in health provision 
is difficult to capture in metrics. Access to care is an important concern here, notably 
the  coverage  of  health  insurance  systems  and  whether  or  not  co-payments  are 
required from patients. The measurement of efficiency also raises some questions. 
Should inefficiencies be treated simply as money badly spent, or should an effort be 
made to measure bad outputs? Nor is it always easy to determine whether health 
outcomes, such as life expectancy, are attributable to the health system or to other 
causes. However, some progress is being made on this, through the development of 
concepts such as “avoidable mortality” and “avoidable [hospital] admissions”. Patient-
reported  outcome  measures6  (PROMs)  can  assist  the  reporting  of  outcomes  other 
than  mortality.  The  generic  EQ-5D  outcome  measure,  developed  with  EU  funding, 
could be used to check if people with chronic long-term conditions, such as diabetes, 
enjoy a different quality of life in different countries. 

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19

15.  Accountability is key to the success of HSPA. But of whom to whom? And how? Is it the 
accountability of governments to parliaments? Or of governments to citizens? Or of 
healthcare providers to patients? This needs further consideration, as it will determine 
the nature and content of HSPA.

16.  Are  targets  and  rankings  legitimate  aims  of  HSPA?  They  are  likely  to  draw  more 
attention, but will this be productive attention? It was agreed that any cross-border 
benchmarking should maintain maximum flexibility. 

6  Patient reported outcomes are standardised questionnaires that ask patients about their health-
related quality of life before, during, or after treatment (Smith 2013). They can be either disease-
specific or generic (applicable across a wide range of disease areas). The EQ5D is a generic PROM 
instrument that has been developed by the EuroQol group and applied in a wide range of settings. 
It can be used either to assess improvements in quality of life following treatment, or to monitor 
ongoing health-related quality of life. www.euroqol.org/ 

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17. Dissemination of HSPA findings is important, and research may be needed to identify 
the  best  methods.  Full  HSPA  reports  are  unlikely  to  appeal  to  a  non-specialist 
readership. Peer reviewers noted the Belgian practice of publishing a summary report 
for a wider public. They particularly praised Belgium’s use of tables with “smileys” to 
present the results in an easily understandable way. 

18. The meeting considered some key criteria for assessing a HSPA initiative: 

 • Does  it  have  clear  objectives  that  guide  those  charged  with  undertaking  the 

analysis and organising dissemination? 

 • Is  there  a  clear  process  for  commissioning  the  HSPA,  with  guidance  on  who  is 

accountable for each stage of preparation? 

 • Is there a clear conceptual framework for the HSPA? 
 • Does it focus on the health system as a whole, including health promotion and 

public health as well as health services? 

 • Are system goals expressed in terms of outcomes (such as improved health and 
reduced exposure to financial risk) rather than processes (such as workforce size 
or numbers of treatments)? 

 • Is progress quantified using reliable metrics and associated analytic techniques? 

Are the chosen international benchmarks appropriate? 
 • Is the HSPA adequately disseminated and promoted? 
 • Is it a regular, sustainable process, with suitable arrangements for reviewing and 

updating? 

 • Is HSPA fully embedded within health policy-making?

19. European and international action to promote HSPA is desirable. However, participants 
voiced  the  opinion  that  creating  a  European  HSPA  would  be  challenging,  notably 
because  health  systems  are  a  national  competence  and  are  structured  differently 
in each country and thus could be difficult to compare. So the focus of HSPA in each 
Member  State  will  not  necessarily  be  the  same,  although  there  may  be  scope  at 
some stage in the future for developing a more standardised format. Bilateral and 
multilateral cooperation between countries can also provide important HSPA resources.

20. A joint review of health-related, country-specific recommendations will be carried out 
in 2014 by the EU Social Protection Committee (SPC). A public consultation on the EU’s 
2020 strategy is underway and will remain open until October. This is an opportunity 
to provide reflections on the role of health systems in that strategy. 

21. The EU is encouraging all Member States to report health expenditure through the 
system  of  health  accounts  (SHA),  in  order  to  improve  the  data  and  make  them 
comparable.  A  number  of  countries  are  now  using  the  SHA.  The  Commission  also 
monitors the financial sustainability of healthcare expenditure items.  

22. The EU is already providing forums for sharing experience on HSPA, and a number of 
European  and  international  indicator,  data  and  methodology  sources  are  available 
or  in  preparation,  as  discussed  in  Part  A  above.  The  sub-group  of  the  reflection 
process in charge of HSPA suggested setting up an expert group to identify tools and 
methodologies for HSPA in support of national policy-makers.

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E.  Conclusions and lessons learned 

HSPA is an important undertaking that should provide a framework for assessing how a 
health system is performing, improving transparency, providing accountability for the money 
spent, and identifying priorities for action. It is difficult to see how publicly funded health 
systems  can  justify  their  expenditure  to  finance  ministries,  parliaments  and  the  general 
public without seeking to demonstrate that the money for which they are responsible is 
well spent. This principle was articulated in the 2008 Tallinn Charter, to which all European 
Member States are signatories, and has become even more important in the light of the 
financial challenges currently faced by many countries.

However, HSPA is also a complex undertaking. Modern health systems represent one of the 
most complex sectors of the economy, seeking to address a huge diversity of health needs 
using  many  types  of  interventions.  Furthermore,  although  improved  health  and  reduced 
inequalities are a prime objective of all health systems, there is a continuing debate about 
the  extent  to  which  health  outcomes  can  be  attributed  to  health  system  actions.  This 
uncertainty has led to some debate about the correct definition of the health system, and 
the extent to which it should embrace broad social determinants of health such as diet and 
other health-related behaviour.

There  was  a  widespread  sentiment  amongst  participants  (previously  also  expressed  by 
the  World  Health  Organisation)  that  the  form  of  HSPA  is  fundamentally  a  matter  for 
national governments. This is both for practical reasons (institutional arrangements differ 
substantially between countries) but also due to the need to respect local autonomy. Similar 
arguments apply within countries, often making it harder to implement national HSPA in a 
federal state than a unitary state.  

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The Belgian HSPA initiative was nevertheless commended by the Peer Review participants 
as being a good model for other countries seeking to introduce or enhance a HSPA process. 
Particularly  noteworthy  are  the  clarity  of  objectives,  the  clear  conceptual  framework, 
the independent rigour of the analysis,  the emphasis on  equity, and the  commitment  to 
a  continuing  HSPA  process.  Work  is  continuing  to  identify  the  appropriate  way  of  linking 
the  Belgian  HSPA  with  policy  processes.  This  aspect  of  HSPA  is  underdeveloped  in  most 
countries and likely to vary depending on institutional arrangements. 

There  are  strong  arguments,  as  expressed  amongst  Peer  Review  participants,  for  action 
at a European level to nurture and sustain HSPA. The feasibility and effectiveness of HSPA 
depends  crucially  on  the  existence  of  extensive  comparable  and  reliable  data  sources, 
collected on a consistent basis from as many countries as possible. A crucial role at the 
international  level  is  to  secure  international  agreement  on  the  scope  of  data  collection 
efforts, the specification of data definitions and standards, the promotion of data collection 
and dissemination by international agencies, and sharing best practice on the use of the 
information.

The technical work of the Social Protection Committee in developing a health policy area 
within  the  Joint  Assessment  Framework  appears  to  be  aligned  with  the  HSPA  initiatives 
being developed by individual Member States. The proposed framework is consistent with 
many of the frameworks already adopted by Member States, and has a strong focus on 

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equity, a persistent concern within many HSPA initiatives. As with all HSPA efforts to date, 
the SPC has not developed the efficiency aspect of the framework in any detail, and this 
would appear to be a priority. It is important to underline that identification of inefficiency is 
important not just because it represents a poor use of resources. A failure to use resources 
efficiently may often result in denial of treatment for some patients because the resources 
they need are wasted elsewhere, leading directly to a loss of health caused by inefficiency.

The  Peer  Review  nevertheless  highlighted  concerns  that  HSPA  should  be  a  national 
undertaking, tailored to local needs, and therefore the context in which JAF Health is used 
should be clearly stated and explained carefully. There are coherent arguments for adopting 
consistent  reporting  practices  across  countries  (particularly  if  those  countries  actively 
agree to participate). However, the history of HSPA (notably the World Health Report 2000) 
illustrates the risks of seeking to assess health systems according to a single template, and 
the associated potential for undermining the commitment to HSPA.

Ultimately, failure of health systems to be properly accountable for the use of their resources 
may lead to a reluctance on the part of governments and citizens to continue to support 
publicly  funded  health  services.  The  breakdown  of  solidarity  in  the  health  domain  could 
lead  to  many  adverse  consequences,  in  the  form  of  reduced  health,  increased  exposure 
to financial risk, and diminished equity. Undertaken effectively, HSPA has the potential to 
contribute significantly to that need for accountability, and there is a compelling argument 
to promote the principles of HSPA and support best practice. 

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References 

European  Commission.  European  Core  Health  Indicators  (ECHI).  2014    4  March  2014]; 
Available from: http://ec.europa.eu/health/indicators/echi/index_en.htm.

European  Observatory  on  Health  Systems  and  Policies.  European  Observatory  on  Health 
Systems  and  Policies.  2014    4  March  2014];  Available  from:  http://www.euro.who.int/en/
about-us/partners/observatory.

EXPH (EXpert Panel on effective ways of investing in Health), Definition and Endorsement 
of Criteria to Identify Priority Areas When Assessing the Performance of Health Systems, 
2014, Brussels: European Union.

Gerkens, S. and S. Merkur, Belgium: Health system review, 2010, Copenhagen: World Health 
Organization, on behalf of the European Observatory on Health Systems and Policies.

Hofmarcher, M.M. and P. Smith, eds. The Health Data Navigator. A toolkit for comparative 
performance  analysis.  A  EuroREACH  product.  2013,  European  Centre  for  Social  Welfare 
Policy and Research: Vienna.

Organization for Economic Cooperation and Development, Health at a Glance: Europe 2012, 
2012, OECD: Paris.

Organization for Economic Cooperation and Development, OECD Health Data 2013, 2013a, 
Paris: OECD.

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23

Organization for Economic Cooperation and Development, Health at a glance 2013b: OECD 
indicators, 2013, OECD: Paris.

Organization  for  Economic  Cooperation  and  Development.  OECD  Health  Care  Quality 
Indicators.  2014    4  March  2014];  Available  from:  http://www.oecd.org/health/health-
systems/healthcarequalityindicators.htm.

Papanicolas, I. and P. Smith, eds. Health system performance comparison: an agenda for 
policy, information and research. 2013, Open University Press: Maidenhead.

Smith, P., et al., eds. Performance measurement for health system improvement: experiences, 
challenges and prospects. 2010, Cambridge University Press: Cambridge.

Smith, P. and A. Street, On the uses of routine patient reported health outcome data. Health 
Economics, 2013. 22(2): p. 119-131.

Social Protection Committee Indicators Sub-group, Developing an assessment framework in 
the area of health based on the Joint Assessment Framework methodology: final report to 
the SPC on the first stage of implementation, 2013, Brussels: European Commission Social 
Protection Committee.

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World  Health  Organization,  The  World  Health  Report  2000.    Health  systems:  improving 
performance, 2000, Geneva: World Health Organization.

World Health Organization, Everybody’s business: strengthening health systems to improve 
health outcomes 2007, Geneva: World Health Organization.

World Health Organization, The European health report 2009. Health and health systems, 
2009, Copenhagen: World Health Organization Regional Office for Europe.

World Health Organization, Pathways to health system performance assessment: a manual 
to  conducting  health  system  performance  assessment  at  national  or  sub-national  level, 
2012, Copenhagen: World Health Organization Regional Office for Europe.

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Country

Austria

Malta

Broad aims

Improving 
understanding of 
performance for 
politicians and 
representatives 

Timely publication of 
performance data.

To continually assess 
the nation’s health 
needs and associated 
health policy. 

To enhance 
accountability, 
transparency and 
sustainability of the 
health care system.

Basis of 
comparison
Comparison with EU-15 
average

Integration into 
policy
Identifying areas of 
actions to be taken by 
policy makers. 

Part of a wider 
evaluation framework 
(for the future).

Achievements and 
challenges
Integrating the current 
framework into a wider 
evaluation framework 
also encompassing 
public health;

Embedding HSPA more 
deeply in the policy 
making process.

Priorities for EU

A set of current, 
homogenous 
performance indicators, 
which are also provided 
on a regional level could 
support the national 
efforts.

WHO Euro Region and 
the European Union 
Member States.

EU-15 average

Yet to be established, 
but likely: 

•	 To monitor the health 
system’s ability to 
cater for the nation’s 
health needs;

Creating an indicator set 
within the HSPA which 
mirrors the performance 
of the health system as 
a whole and not only its 
component parts

Developing an 
appropriate IT 
infrastructure.

•	 To increase 

accountability, 
transparency and 
sustainability of the 
health care system; 

•	 Gauge future policy 

directions. 

Providing expertise and 
know how in specific 
areas of development, 
especially those 
areas that are most 
challenging, such 
as IT systems and 
networking.

Standardising 
approaches to 
information collation 
and comparison 
between Member 
States. 

Promoting best 
practices, sharing of 
national experiences 
and enabling 
the conduct of 
benchmarking exercises.

2
2
5
5

S
y
n
t
h
e
s
i
s

r
e
p
o
r
t

—
B
e

l

g

i

u
m

2014

 
 
 
Netherlands

Somewhere 
between evaluation 
(accountability) and 
agenda-setting (for 
strategic decision 
making).

2014

S
y
n
t
h
e
s
i
s

r
e
p
o
r
t

—
B
e

l

g

i

u
m

2
2
6
6

Trends over time

Selected OECD countries

EU15 average

In health policy making, 
the report is used for 
agenda setting and for 
accountability of the 
ministry to parliament.

The DHCP report is well 
embedded in a network 
of expert researchers 
and health care 
professionals. 

Portugal

Individual EU15 
countries

To support the Ministry 
of Health to improve 
the performance of the 
health system

Contribute to the 
critical evidence base 
necessary to develop 
the National Health Plan

Supporting European 
networks of national 
experts in this area, 
facilitating the 
exchange of methods 
and good practices.

Support for the work of 
international agencies 
such as WHO and OECD, 
particular for ‘poorer’ EU 
countries. 

Supporting sector 
specific capacity 
building (eg long-term 
care, hospital care, 
mental health care, 
primary care, public 
health).

Results are actively 
disseminated among 
policy makers 
and health care 
professionals. In recent 
years, a selection of 
results is presented 
via highly accessible 
information products on 
a dedicated website.

Supports the Ministry 
of Health to improve 
the performance of 
the Portuguese health 
system

The main results 
of the report were 
communicated to the 
general public through 
a media conference and 
press releases.

The major challenge 
is to improve its 
policy impact and 
‘actionability’.

The HSPA introduced 
a health system 
perspective in national 
planning;

Critical gaps in health 
information (eg 
safety and health; 
socioeconomic 
inequalities in health). 

These gaps limit the 
capacity to support 
transparency and 
accountability through 
public reporting.

No decision has 
yet been made 
concerning the future 
institutionalisation of 
HSPA.

 
 
 
Netherlands

Somewhere 

between evaluation 

(accountability) and 

agenda-setting (for 

strategic decision 

making).

Trends over time

In health policy making, 

The DHCP report is well 

Supporting European 

Selected OECD countries

the report is used for 

embedded in a network 

networks of national 

agenda setting and for 

of expert researchers 

experts in this area, 

EU15 average

accountability of the 

and health care 

facilitating the 

ministry to parliament.

professionals. 

Results are actively 

The major challenge 

disseminated among 

is to improve its 

policy makers 

and health care 

policy impact and 

‘actionability’.

Portugal

To support the Ministry 

Individual EU15 

Supports the Ministry 

The HSPA introduced 

of Health to improve 

countries

the performance of the 

health system

Contribute to the 

critical evidence base 

necessary to develop 

the National Health Plan

professionals. In recent 

years, a selection of 

results is presented 

via highly accessible 

information products on 

a dedicated website.

of Health to improve 

the performance of 

the Portuguese health 

system

The main results 

of the report were 

communicated to the 

general public through 

a media conference and 

press releases.

exchange of methods 

and good practices.

Support for the work of 

international agencies 

such as WHO and OECD, 

particular for ‘poorer’ EU 

countries. 

Supporting sector 

specific capacity 

building (eg long-term 

care, hospital care, 

mental health care, 

primary care, public 

health).

More data available 
for international 
comparisons, and 
for more thematic 
approaches for HSPA 
targeting EU countries.

a health system 

perspective in national 

planning;

Critical gaps in health 

information (eg 

safety and health; 

socioeconomic 

inequalities in health). 

These gaps limit the 

capacity to support 

transparency and 

accountability through 

public reporting.

No decision has 

yet been made 

concerning the future 

institutionalisation of 

HSPA.

A large number of 
indicators have been 
developed, with good 
access to data from 
various sources

How to prioritise among 
different measures - 
which are the most 
important indicators? 

How can the 
information be used to 
secure improvement of 
health care?

Action plan to improve 
availability and use 
of data and indicators 
amongst all actors.

Has moved the focus 
away from process, 
concentrating on those 
outcomes that matter 
to people;

It can be difficult 
to establish how 
improvements have 
been arrived at;

Timeliness of data 
can be an issue 
(both availability and 
affordability);

Data is limited in a 
number of areas

Sweden

Mainly within-country; 

Some 

international 
comparisons

To make the publicly 
financed healthcare 
system more 
transparent;

To advance the cause of 
healthcare management 
and control

To promote quality 
and availability of 
data about healthcare 
performance and 
outcomes

Used both in 
decision-making and 
development within the 
county councils

Serve as base to decide 
on national policy 
initiatives. 

Contribute to local 
improvement work

Results are 
communicated to the 
general public.

United Kingdom

Provides a national 
overview of how 
well the system is 
performing

The primary method by 
which NHS England is 
held to account

Leads improvements in 
health outcomes and 
quality of care.

Mainly within-country; 

Trends over time;

Some 

international 
comparisons

Used to hold NHS 
England to account 
for improving health 
outcomes and reducing 
health inequalities;

Data are updated on an 
annual basis using web 
based tools.

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Synthesis report — Belgium

European Commission

Health System Performance Assessment  

2014 — 28 pp. —  17.6×25 cm

ISBN 978-92-79-39636-6 
ISSN 1977-7973 
doi: 10.2767/39073

This publication is available in electronic format in English, French, German and Dutch.

HOW TO OBTAIN EU PUBLICATIONS

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•	 more than one copy or posters/maps:  

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from the delegations in non-EU countries (http://eeas.europa.eu/delegations/index_
en.htm);  
by contacting the Europe Direct service (http://europa.eu/europedirect/index_en.htm) or 
calling 00 800 6 7 8 9 10 11 (freephone number from anywhere in the EU) (*).
(*) The information given is free, as are most calls (though some operators, phone boxes or hotels may charge 

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Priced publications:
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Priced subscriptions 
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Health System Performance Assessment  

Host country: Belgium 

Peer countries: Austria - Estonia - Germany - Luxembourg - Malta - Netherlands - 
Portugal - Sweden - UK 

Health System Performance Assessment (HSPA) allows decision-makers to measure the 
performance of health systems as a whole and to report results regularly to the public 
and relevant stakeholders, but has been developed in relatively few European countries. 
Belgium, which piloted its first HSPA in 2008, hosted a Peer Review which focused on 
the methods and tools needed for further developing HSPA within the EU. This report 
summarises the key issues discussed and the lessons learned.