Detailing the role of each stakeholder in relation to the HSPA as well as other stakeholders will meet an identified need for governance structures, policies, and processes for health system assessment, and will help to ensure the consistent and systematic generation of health indicators as well as use of the assessment to guide improvements in the Estonian health system. Clearly defined organisational roles facilitate systematic co‑operation between stakeholders across the health system. Section 4.1 provides an overview of the three‑part governance structure of the HSPA reporting process. Section 4.2 specifies responsibilities assigned to stakeholders to meet the objectives of the HSPA throughout the implementation cycle. Finally, Section 4.3 provides overview of proposed distribution of HSPA indicators among indicator custodians.
Health System Performance Assessment Framework for Estonia
4. Governance plan of the Estonian HSPA process
4.1. Governance structure and workflows of the HSPA process
Functions within the HSPA will be organised into three activity groups: HSPA Co‑ordination Board, Advisory Board and Task Force (Figure 4.1). These however slightly differ from the teams defined for the framework development project (described in Section 1.1). The HSPA governance structure was developed as part of the HSPA framework setting project by the core working group and was approved by all stakeholders involved in the project. The final endorsement by the HLAB Board was granted in winter 2023. To become more operational, the composition and working plan of the HSPA governance structure is planned to be confirmed via a decree issued by the Ministry of Social Affairs.
The Advisory Board of the HSPA, led by the Ministry of Social Affairs and involving stakeholders in senior roles across the health system, will take responsibility for ensuring that HSPA meets its purpose and objectives. The Advisory Board will advise on targets set for the HSPA indicators, further develop the HSPA framework, and appoint experts involved in the HSPA reporting and assessment. As such, it will ensure the completion, usability, and consistency of the HSPA reporting. Further, the Advisory Board will provide feedback on the interpretation and dissemination plans for the HSPA results as well as subsequent policy recommendations and interventions. The Advisory Board will partake in continuous development of Estonia’s HSPA framework by ensuring its relevance to the health policy strategic objectives, including being in line with the Estonia’s National Health Plan 2020‑30.
The HSPA Co‑ordination Board will be established within the health division of the Ministry of Social Affairs. It will organise the process of completing the assessment and ensure adherence to the agreed timelines, provide technical input to the Task Force, and co‑ordinate meetings of the Advisory Board. Finally, the Co‑ordination Board will contribute to the wider dissemination of the HSPA results by managing the creation of a dedicated website, and by organising regular HSPA seminars and workshops with various health system stakeholders, interest groups, and media.
The HSPA Task Force will be led by the National Institute for Health Development (NIHD) and include data providers and users from across the health system. The members will be technical experts involved in work related to routine generation and interpretation of the indicators. The Task Force will take responsibility for the substantive and technical completion of the HSPA reporting and for co‑operation with other health system stakeholders, including compiling data, calculating indicators, and interpreting results. The Task Force will be responsible for conducting the assessment, drafting the HSPA report, and will contribute to further development of the HSPA framework through recommendations provided to the Advisory Board. The Task Force will ensure results of the assessment are regularly published and updated on the upcoming HSPA website, which will be set up specifically for this purpose, and will provide input to policy actions based on the results of the HSPA assessment.
Figure 4.1. Governance structure of the Estonian HSPA
Source: The Estonian HSPA framework project.
4.2. Working to obtain the objectives set in HSPA purpose and scope
Stakeholders will work towards the objectives defined in the Estonian HSPA purpose and scope through concrete assignment of responsibilities throughout the HSPA reporting cycle: from completion of the assessment to systematic use of the HSPA results for improvement of the Estonian health system across various domains (see Figure 4.2).
The HSPA Advisory Board will ensure all stakeholders will set common objectives and priorities with the aim of improving the population health in Estonia through systematic engagement of organisations involved in its activities. Within the scope of its role as the lead in the Task Force, the NIHD will contribute to the collection and use of the vast amount of health data generated through Estonia’s digitalised healthcare system in a targeted manner, as well as perform continuous health behaviour research. Dissemination activities performed by the NIHD will additionally aim to increase public awareness of the population’s health status and health system performance, as well as indicate and plan health-related prevention activities and targeted interventions.
The EHIF and the Health Board will take responsibility for increasing the transparency of the health system and accountability of the stakeholders, a key sub-objective of the HSPA. This will involve targeted communication on the results of the assessment with various interest groups and using them in strategic planning and assignment of health policy responsibilities. The scope of EHIF as the main funder of healthcare in Estonia allows it to take lead on financing and healthcare quality-related communication with its contracted healthcare providers and other partners. The Health Board will ensure proactive use of the results of the HSPA in healthcare quality and outcomes improvement, patient safety, and surveillance activities.
The MoSA will take responsibility for ensuring results of the HSPA are used in a targeted manner to manage changes in the health system, aligning any modifications to the objectives set out in the National Health Plan 2020‑2030. Substantive results emerging from the various domains of the HSPA will allow improved evidence‑based decision making, targeted interventions in allocation of capital and financial investments, and impact assessments to support evidence‑based decision and policy making.
For the communication and HSPA dissemination part, it is strongly advised to involve communication experts as part of the HSPA Co‑ordinating Board. It is recommended the HSPA report is well developed not only in terms of the data it presents, but also in terms of the data visualisation, i.e. how the HSPA indicators are presented and communicated. The latter is crucial for getting a good HSPA outreach to general and expert public and health policy makers (see Section 5.3). The infographics compiled in Annex F present examples of existing indicator visualisations, and may serve as the starting point for the HSPA visualisation plan.
Figure 4.2. Key leaders with responsibilities to support the attainment of objectives set out in the Estonian HSPA purpose
Source: The Estonian HSPA framework project.
4.3. Assigning indicator custodians
The final list of indicators in Annex E includes a custodian assigned to each indicator. The distribution of custodians across the Estonian health system reflects the distribution of workload, engagement, and representation of all aspects of the health system within the HSPA. The role of a custodian in the HSPA varies by indicator and function of the organisation within the Estonian health system, reflecting complexities and fragmentation within the health data infrastructure. Table 4.1 provides an overview of allocation of HSPA indicators into the custody of Estonian health system key stakeholders.
The role of indicator custodian reflects strategic operations performed on the data. While some custodians collect and provide data for the calculation of the indicator assigned to them, others perform the calculations and analysis on their collected data themselves. In general, an indicator custodian is responsible for indicator methodology, or its development, and/or its adaptation to the context and data infrastructure available in Estonia.
The complexity in assignment of custodian roles is demonstrated on the example of clinical care quality indicators, some of which can be calculated by different organisations. For instance, the EHIF calculates and publishes a selection of indicators for the Hospital Network Development Plan hospitals, while the NIHD calculates and provides internationally reported data on healthcare quality and outcomes indicators defined by the OECD. Although both use data extracted from EHIF claims data submitted by care providers for reimbursement, the methodology of some indicators can differ (e.g. defining the new cases, including different ICD-10 codes or age groups). The EHIF uses the results for quality improvement. Although the NIHD does not collect primary data itself, it is still assigned the role of custodian for some of these indicators, reflecting its responsibility for international reporting and choice of methodology used for the indicator within the HSPA.
For indicators for which assignment of the HSPA custodian was not straightforward, including many of the placeholder indicators, the MoSA provisionally assumes this role. However, these indicators will likely be reassigned during the HSPA implementation process during their further development. In case an indicator has been assigned to a custodian that is not explicitly named among the Task Force members, its experts will be asked to engage in the HSPA process and reporting on a case‑by-case basis.
Custodians report to the NIHD as the leader of the Task Force, which is responsible for collecting all results, preparing the HSPA report, and disseminating its conclusions. Following the completion of an assessment, each custodian should reflect on the results and propose relevant changes to the collection or calculation methodology of the indicators or other relevant improvements to the framework for discussions in the Advisory Board. However, custodians should not make changes to the agreed-upon methodology without bringing it up to the Advisory Board as this could lead to misinterpretation of the data and may endanger the interpretability of the HSPA framework as a whole.
Table 4.1. Allocation of the indicator custodian role across key stakeholder institutions
For additional information:
OECD (2022[2]), Situational Analysis Report: The Development of the Estonian Health System Performance Assessment Framework, https://www.oecd.org/health/Development-of-Estonian-Health-System-Performance-Assessment-Framework.pdf.
Annex F: Example of analysis of indicators for HSPA reporting