Health System Performance Assessment Framework for Estonia

Annex F. Example of analysis of indicators for HSPA reporting

This annex presents an example of how the HSPA could be used to analyse a particular theme. The aim of this section is to demonstrate the use of HSPA indicators in a comprehensive assessment within the framework and to highlight the interconnectedness of framework domains, which in their complexity allow for rigorous analysis of a particular topic.

The case assessment example is provided to serve as an illustration, with particular emphasis put on international comparison; it shall not be taken as a fully-fledged, nor partial, HSPA assessment. The intention of selected indicators is twofold. First, to show that data for many indicators already exists, and second, to provide examples of possible data visualisation.

During the HSPA implementation phase, it is advised that Estonian stakeholders further discuss data visualisation and presentation and make appropriate choices regarding its analysis. It is important to note that the list of indicators in Annex E, developed during the Estonian HSPA framework project, serves as the input for the implementation of the Estonian HSPA and thus may be further elaborated and/or adjusted based on the further HSPA-implementation discussions.

Efficiency

The domain of efficiency was chosen due to its relevance to Estonian policy priorities and its cross-cutting nature in the framework. Efficiency in the Estonian HSPA describes the extent to which best possible value has been achieved in the use of health services and available resources, including financial resources. Within the framework, 12 indicators have been allocated to the cross-cutting Efficiency domain, of which Table A F.1 shows 3 selected for this case assessment example.

Table A F.1. Efficiency indicators selected for the case assessment example

Domains and sub-domains	Indicator title	Indicator custodian	Disaggregation	Data source
2. Efficiency
2.1. Use of healthcare services – primary healthcare, ambulance and emergency care, specialist care, equipment	Occupancy rate of acute care beds	NIHD	Type of healthcare provider/hospital	NIHD – reports from healthcare providers
	Average length of stay in hospital acute care	NIHD	Type of healthcare provider/hospital	NIHD – reports from healthcare providers
2.2. Medicines	Share of the generic medicinal products in the total volume of pharmaceuticals	SaM	–	SaM

The indicator of occupancy rate estimates the utilisation of acute care beds in hospitals. A higher occupancy rate is generally related to more efficient management and allocation of scarce resources. However, an occupancy rate that is very high may indicate a lack of spare capacity to absorb shocks to the health system, which may not be viewed as an optimal case from the perspective of health system’s resilience. To explore more in detail, another indicator, on the average length of hospital stay, may add to the complexity of the picture: shorter length of hospital stays generally points to more efficient and timely treatment protocols, streamlined processes, and appropriate discharge planning. Yet, a stay too short may not sufficiently address needs of a patient. Comparing country results internationally may be useful to target the common practice, represented by an international average number. Third, a higher share of generic medicines products is generally interpreted as suggesting higher cost-effective prescribing practises, contributing to cost savings in the healthcare system. Figure A F.1 provides graphical illustration of these three indicators in international comparison.

Figure A F.1. Selected indicators in the domain of efficiency

Source: (OECD/European Union, 2022[12]), Health At a Glance: Europe 2022, https://doi.org/10.1787/507433b0-en (Panel A) and (OECD, 2021[13]), Health at a Glance 2021, https://doi.org/10.1787/ae3016b9-en (Panel B and C).

To obtain a holistic understanding of the efficiency of the health system, the indicators in the Efficiency domain are not sufficient to look at separately, and other parts of the HSPA framework can provide the necessary guidance for more complex interpretation of the health system’s efficiency.

Structures linked to efficiency

Indicators on available resources can aid assessment on whether a low or high utilisation might be constricted by low healthcare availability. The Estonian HSPA includes indicators related to the density of hospital beds, doctors, and nurses per population in the 3 different domains of the area of Structures (Table A F.2). In the Estonian HSPA report, these shall be disaggregated by counties, thus providing insights into the availability and distribution of healthcare resources across Estonia. There is no internationally recognised optimal number and ratio of these for healthcare workforce to be sufficient, but international comparison provides useful evidence on common practice. Indeed, these indicators can be further contextualised by the indicators in the Access domain on unmet healthcare needs and timely access (see below).

Other indicators in the Structures area, such as indicators in Financing domain related to health expenditure, e.g. health expenditure as a share of GDP, public sector health expenditures, and out-of-pocket spending, also offer insights into resource allocation and financial efficiency. Balanced expenditure patterns and appropriate allocation of funds are key to efficient utilisation of resources to achieve desired health outcomes.

Table A F.2. Structures indicators linked to efficiency selected for the case assessment example

Domains and sub-domains	Indicator title	Indicator custodian	Disaggregation	Primary use of the indicator
1. Health Infrastructure
1.2. Inpatient care infrastructure – hospital beds	Total number of hospital beds per 100 000 population: Acute care, Day care and Psychiatric care beds	NIHD	County, Public and private sector, Type of hospital	Strategy monitoring Public reporting
2. Workforce
2.1. Volumes and capacity	Practising doctors per 1 000 population: Family physicians, Dentists, Psychiatrist, Occupational health physicians	NIHD	County, Healthcare provider	NHP 2020-2030, Mental Health Action Plan 2023‑26
	Practising nurses and midwives per 1 000 population: Family nurses, Mental health nurses/Psychiatric nurses	NIHD	County, Healthcare provider	NHP 2020-2030, Mental Health Action Plan 2023‑26
3. Financing
3.1. Government spending	Health expenditure as share of GDP	NIHD	Type of financing schemes (HF)	NHP 2020-2030, Public reporting

Figure A F.2 provides graphical illustration of selected Structures area indicators for Estonia in international comparison.

Figure A F.2. Indicators in the area of Structures hold relevance to interpret efficiency

Source: (OECD/European Union, 2022[12]), Health at a Glance: Europe 2022, https://doi.org/10.1787/507433b0-en (Panels A and C), and (OECD/European Observatory on Health Systems and Policies, 2021[14]), Estonia: Country Health Profile 2021, https://doi.org/10.1787/a6c1caa5-en (Panel B).

Quality of Care and Integrated Care indicators linked to efficiency

Hospital admissions are costly in terms of financial and social resources, and cases that can be managed in primary care are generally viewed as more cost-efficient. Besides, avoiding unnecessary hospital stays is linked with improved quality of care. The Estonian HSPA framework assesses the performance of healthcare outside of hospitals, including its preventive functions and integration by looking at relevant patient outcomes. Figure A F.3 compares performance of primary care across countries to see the number of avoidable admissions for selected chronic conditions (Panel A of Figure A F.2).

Yet, this does not offer a full picture as hospital admissions are not the only adverse outcomes of failures to integrate services and ensure adequate follow-up. Monitoring all possible outcomes can indicate instances where patients may not be receiving efficient, appropriate, and timely care after a health episode, or insufficient follow-up including patient education, and co‑ordination of services (Panel B of Figure A F.3).

Figure A F.3. Strong primary care supports efficiency

Source: (OECD/European Observatory on Health Systems and Policies, 2021[14]) Estonia: Country Health Profile 2021, https://doi.org/10.1787/a6c1caa5-en (Panel A) and (Barrenho et al., 2022[15]), “International comparisons of the quality and outcomes of integrated care: Findings of the OECD pilot on stroke and chronic heart failure”, https://doi.org/10.1787/480cf8a0-en (Panel B).

Care accessibility indicators linked to efficiency

A lack of access to healthcare services indicates value has not been achieved. Therefore, improving efficiency of care that is being provided shall not compromise improvements in accessibility to health services which are hard to reach or inexistent. Self-reported unmet healthcare needs reflect the scope of an issue to which people do not have access to healthcare due to various reasons, including the waiting times. Long waiting times for elective treatments are a sign of a lack of efficiency in healthcare provision.

Once healthcare has been accessed, for its delivery to be efficient, it must be comprehensible to patient. In the Estonian HSPA framework, under the Process area, indicators on person-centredness have been also included. Indicators related to patient reports, such as the doctor spending enough time with the patient assess the quality of doctor-patient communication and patient-centred care. Higher satisfaction rates indicate effective communication and patient involvement in decision making, as well as higher efficiency of care delivery if comprehensible to the patient.

Figure A F.4. Inaccessible or incomprehensible care is inefficient

Source: (OECD/European Union, 2022[12]), Health at a Glance: Europe 2022, https://doi.org/10.1787/507433b0-en.

Health care outcomes linked to efficiency

Avoidable mortality captures the number of deaths that could have been prevented through timely and effective healthcare interventions. Lower rates of avoidable mortality indicate a more efficient healthcare system, emphasising proactive and high-quality care delivery. In connection to the indicators depicting healthcare activities, available resources and access, avoidable mortality indicators in the area of Outcomes and the domain Health Outcomes provide insight to what the result of healthcare activities is. These indicators complement the indicators discussed above on the avoidable hospitalisations.

Another outcome measurement, embedded in the Estonian HSPA, which signals the level of performance of a health system related to its efficiency, are in the domain of care quality and patient safety. These include monitoring of rates of adverse post-surgery events, which among other indicate effectiveness of post-operative care and include preventive measures and appropriate management protocols (Figure A F.5).

Figure A F.5. Outcomes of healthcare activities

Source: (OECD/European Observatory on Health Systems and Policies, 2021[14]), Estonia: Country Health Profile 2021, https://doi.org/10.1787/a6c1caa5-en (Panel A) and (OECD, 2021[13]), Health at a Glance 2021, https://doi.org/10.1787/ae3016b9-en (Panel B).

Monitoring changes in primary care that links to efficiency improvements

The key objective in the HSPA is the management of changes in a targeted manner and monitoring their effects. In their efforts to obtain value – higher health status of people – while using the available resources as efficiently as possible, health systems can use indicators related to access, resources, utilisation and outcomes to reflect the effects of policy changes. These are embedded in the Estonian HSPA for instance in the area of Structures (domain of Digitalisation) and in the area of Outcomes (domain Patient Safety and Quality). Increasing proportion of remote consultations reflects the adoption of digital health technologies and efficient use of technology to enhance access to healthcare services and potentially reduce unnecessary in-person visits, leading to improved efficiency. Monitoring antibiotic use provides insights into appropriate prescribing practices and antimicrobial stewardship (Infographic Figure A F.6).

Figure A F.6. Monitoring changes

Source: (OECD/European Union, 2022[12]), Health at a Glance: Europe 2022, https://doi.org/10.1787/507433b0-en.

There are other domains and indicators in the Estonian HSPA framework as well that provide input into the overall picture on efficiency of the Estonian health system, such as in the domains of health promotion, prevention and environmental indicators. Indeed, the Efficiency domain is truly a cross-cutting one and that is why only some indicators are directly assigned in the Efficiency domain per se and others are kept with their respective (non-cross-cutting) domains, having an outreach to the efficiency. Indicators in the Estonian HSPA should thus be examined with consideration to their complex interconnectedness to other indicators to provide for a comprehensive health system assessment. Given this, comprehensive interpretation of the results of an HSPA would be best done as a collaborative process. Feedback should be collected from stakeholders, including healthcare providers, to support comprehensive interpretation of the HSPA, further explain some domains and guide health policy planning.