Health system performance assessment (HSPA) plays an integral role in ensuring that health systems are delivering quality health services and population needs are being met. An HSPA involves a comprehensive evaluation that examines the effectiveness, efficiency, equity, and responsiveness of a health system. Through routine systematic assessment of the performance of the health system – by looking at the health outcomes, processes, and structures – HSPA acts as a tool for policy and decision makers to identify areas that need further improvement, enabling efficient resource allocation and evaluation of attainment of policy objectives. By evaluating performance, healthcare managers can identify novel ways to improve health system efficiency, improve patient safety, quality of care, and patient satisfaction. Over the past decades, national HSPA frameworks have been becoming a vital part of health system management and an indispensable tool for ensuring optimal functioning and interconnectedness of all components of a health system, including promotion of healthy choices.
Estonia has a history of assessing the performance of its health system dating back to the mid‑2000s (World Health Organization, 2010[1]). However, although a previous HSPA framework was published in 2009, routine assessments and reporting on the selected indicators have not occurred. Thus far, the only regular monitoring activities of the health system have been those related to the National Health Plan (NHP) 2020‑30. Yet, these activities have failed to generate clear and systematic delineation of tasks in monitoring of the health system. Repetition of assessments of specific aspects of the health system by different organisations lead to inefficient use of resources and challenges remain in generation of necessary data to inform evidence‑based policy making. Other existing efforts to monitor certain aspects of Estonian health system’s performance were similarly fragmented and lacked systematic implementation.
Given these challenges, a need for clear health information system governance and agreement on a systematised list of indicators for monitoring of the health system were identified. Recent efforts to reform the Estonian health system and improve transparency of its performance led the Ministry of Social Affairs (MoSA) to launch an initiative to develop and implement a revised Health System Performance Assessment (HSPA) framework. Drawing from international experience, mediated by the OECD technical support, and with financial support from the European Union for systematic development of national HSPA frameworks, the project was launched in 2021.
The present report is one of the key outputs of the project to develop an HSPA framework for Estonia, alongside a Situational Analysis, which describes the data infrastructure and policy context, and health data governance structures related to HSPA in Estonia (OECD, 2022[2]). The present report describes the process of developing the Estonian HSPA framework, the framework itself, its domains and subdomains, and the indicators that were selected as input for the first implementation of the Estonian HSPA. Additionally, the HSPA governance structure and implementation roadmap are outlined together with a detailed description of the HSPA framework project and future activities to build national HSPA-related capacity.
The final framework contains 18 domains, grouped into five indicator areas to signify specific priority areas. In total, 212 indicators are included in the framework. Comprehensive health system assessments using the framework will lead to improvements in data use, support effective change management, ensure transparency and accountability among stakeholders, and enhance public awareness of health system performance in Estonia.
