Rethinking Health System Performance Assessment

3. Populating each dimension of the Framework with indicators

To put the Framework into practice, the various concepts in the Framework need to be broken down into more specific and measurable elements and then populated with indicators. Since various components of the Framework draw from existing frameworks, the OECD has already developed many of such indicators. Consequently, several dimensions of the renewed Framework can already boast a robust collection of indicators. Nevertheless, the HSPA Framework revision also presents opportunities for introducing fresh indicators and enhancing the quality of existing ones.

The reporting of indicators for international comparison and time trends is at the core of OECD’s activities. Over the years, OECD has built a rich collection of indicators for health and the performance of health systems, available at the OECD Health Statistics (OECD, 2023[19]). OECD Health Statistics (released yearly in June/July) covers a broad range of health statistics and indicators for OECD countries and key partners. It has been in existence for over 20 years and consists of 12 detailed datasets each exploring an aspect of health and healthcare systems. The online database is updated annually, drawing information from four distinct data collections, administered across the OECD Health Division. Two of these data collections are managed in conjunction with other international organisations.

Health at a Glance (OECD, n.d.[15]) published biennially since 2001, is an OECD flagship publication and another key output of OECD’s work on health. It started as an innovative way to explore and present OECD Health Statistics, by showing variations and trends in key health indicators across OECD and partner countries, and evolved into a globally anticipated publication. It provides a comprehensive set of indicators on population health and health system performance across OECD members and key emerging economies. The analysis draws from the latest comparable official national statistics and other sources, and is presented both as an overview of relative performance of countries and major trends, and in an indicator-by-indicator format.

Scientific evidence, data availability and policy relevance resulted in the inclusion of an increasing number of indicators across different themes and areas of health system performance. In its latest edition, Health at a Glance 2023 (OECD, 2023[20]), in addition to dashboards providing an overview of comparative health system performance, chapters were dedicated to health status, risk factors for health, access, quality and outcomes of care, health expenditure and financing, health workforce, the pharmaceutical sector, and ageing and long-term care.

In light of its relevance and adoption among policy makers, several regional publications have been launched since this series began in 2001 (see Box 3.1).

Box 3.1. Regional editions of Health at a Glance

Health at a Glance: Europe

Health at a Glance: Europe (OECD, n.d.[21]), is a biennial publication which was started in 2010 reporting on the 27 European Union member states, 5 candidate countries and 3 European Free Trade Association (EFTA) countries. It presents a selection of indicators based, largely, on the European Community Health Indicators (ECHI) shortlist developed to guide the reporting of health statistics in the European Union.

Health at a Glance: Asia/Pacific

Health at a Glance: Asia/Pacific (OECD, n.d.[22]), released every two‑years since 2010, publishes a set of key indicators across 27 Asia-Pacific countries and territories, 4 of which OECD member countries (Australia, Japan, New Zealand and the Republic of Korea) and counts OECD/Korea Policy Center, WHO Regional Office for the Western Pacific (WHO/WPRO), and the WHO Regional Office for South-East Asia (WHO/SEARO) as co‑authors.

Health at a Glance: Latin America and the Caribbean

Health at a Glance: Latin America and the Caribbean (OECD/The World Bank, 2023[23]; 2020[24]), a joint effort of OECD Health Division and the World Bank, provides since 2020 analysis based on comparable data across almost 100 indicators among 33 Latin America and the Caribbean countries.

The Health at a Glance approach has long been underpinned by the OECD Health System Performance Assessment Frameworks. OECD’s implementation of these frameworks can be traced back to the Health Care Quality Indicator expert group work between 2004‑06 on a HSPA framework (Arah et al., 2006[6]). In 2017 the foundational conceptual model – which goes well beyond a focus on quality of care – was updated to the 2015 revision of the HSPA Framework (Carinci et al., 2015[3]) advancing the scope and detail of its analysis.

Without being exhaustive, this section explains the further operationalisations of the different domains of the renewed Framework and describes examples of indicators that could be used or that are already being used to measure each of these domains.

3.1. Health system outcomes

The main objective of any health system is to improve the health of the population that it serves. Consequently, population health is often the first area considered when measuring the performance of a health system. Indicators in this area include measures such as life expectancy, age‑standardised mortality, years of life lost, etc. However, these constitute rather generic information on population health measuring at the same time the effect on the health of the population of many risk factors or environmental conditions as well as the delivery of healthcare. Such perspective creates substantial methodological challenges in seeking to attribute changes in health to any particular policy intervention. This is the reason why more specific indicators have been considered to measure with more accuracy the contribution of healthcare to improved health. This has led to the development of concepts such as avoidable mortality and the use of tracer conditions.

The OECD has been reporting on a range of indicators for its most central element, health status. Table 3.1 reports on these indicators and Figure 3.1 shows an international comparison of a selection of health indicators as reported in Health at a Glance 2023 (OECD, 2023[20]).

Table 3.1. Examples of health status indicators currently collected by the OECD

Indicators	Description / methodological challenges
Life expectancy at birth	Measures how long, on average, people would live based on a given set of age‑specific death rates. This indicator is also reported by gender and by education level.
Mortality rates	Mortality rates are based on the number of deaths registered in a country in a year divided by the population. Rates are directly age‑standardised to the OECD population to remove variations arising from differences in age structures across countries and over time.
Excess mortality	Total number of deaths from all causes in a given year, compared to the average annual number of deaths over the previous five years. Figures are adjusted for population growth in age groups over time. Excess mortality is reported as a percentage increase (or decrease).
Preventable and treatable deaths	Preventable mortality is defined as causes of death amongst people aged under 75 years that can be mainly avoided through effective public health and primary prevention interventions. Treatable (or amenable) mortality is defined as causes of death that can be mainly avoided through timely and effective healthcare interventions, including secondary prevention and treatment. The age threshold of premature mortality is set at 74 years for all causes.
Disease or condition specific mortality	Mortality rates based on numbers of deaths registered in a country for a given group of pathologies or conditions in a year, e.g. mortality from circulatory diseases, cancer, etc.
Healthy life expectancy at birth and at age 65	Healthy life years are defined as the number of years spent free of long-term activity limitation (i.e. disability-free life expectancy).
Chronic conditions	Include indicators such as diabetes prevalence, asthma prevalence, adult mental health, chronic diseases and disabilities among older people (people aged 65 and over with at least two chronic diseases).
Self-rated health	Self-rated health reflects an individual’s overall perception of his or her health.

Figure 3.1. Indicators of health status across the OECD, 2021 (or nearest year)

Note: Largest improvement shows countries with the largest changes in absolute value over time (% change in brackets).

Source: OECD (2023[19]), OECD Health Statistics, https://doi.org/10.1787/health-data-en; IDF (2021[25]), IDF Diabetes Atlas, www.diabetesatlas.org.

3.2. Health system context

3.2.1. Health and environmental threats

The potential impacts of climate change on human health have been well documented: rising sea levels, increasing CO2 levels, rising temperatures are threats to clean air, safe drinking water, nutritious food supply, and safe shelter, and are becoming key determinants of health. As extreme weather events are becoming more frequent, heat waves will lead to a rise in heat-related conditions such as heat strokes or other cardiovascular or respiratory conditions. They can also have impact on well-being more broadly including mental health. Extreme weather events are also related to a rise in the number of wildfires and flooding – which pose an immediate threat to population health with increased risk of injury and death – and can also result in the large‑scale displacement of people affecting their mental health and well-being. Change in climate also leads to changes in the biodiversity in countries, which can alter the epidemiological patterns of infectious diseases. For example, warmer winters and longer summers could lead mosquitos and other arthropods to change their habitat introducing diseases such as Dengue Fever to previously unaffected areas.

OECD’s work on the impact of environmental conditions on health is fairly recent. The Health Committee has already conducted work on the effects of environmental pollution on health, such as the chapter of air pollution and its impact on health in Europe in Health at a Glance: Europe 2020 (OECD/European Union, 2020[26]), and the Healthy People, Healthy Planet brief in 2017 (OECD, 2017[27]), which examined the role of health systems in promoting healthier lifestyles and a greener future. Other parts of the OECD have also been working on the intersection of environment, climate change and health. The OECD Environmental Policy Committee regularly collects and reports data on pollutant emissions and intensities, and air quality and health (OECD, 2023[28]), while the OECD Centre for Well-Being, Inclusion, Sustainability and Equal Opportunity (WISE) has also been working on this issue, for example in the 2021 publication which examined the impacts of air pollution and climate change on health (OECD, 2021[29]).

The Secretariat already collects some climate and other environment-related indicators. Table 3.2 shows some of these indicators. These can be further developed and adapted to improve measuring the health effects of environmental threats. As a first step, a new OECD indicator set (see Table 3.3 could focus on heat-related mortality, hospitalisations and visits to emergency departments, as well as excess mortality during heat waves, but also on the incidence of vector-borne diseases. In addition, exposure to risk factors such as air pollution could be added. For excess mortality, mortality and hospitalisation rates the OECD may be able to leverage on its existing health data collections. In addition to air pollution, exposure to other risk factors such as extreme weather events could be additional indicator options. In the choice of indicator domains, a discussion is necessary on which ones could be obtained from already existing data sources and which should be part of a new data collection targeted at OECD health data experts.

Table 3.2. Examples of environment and health indicators currently collected by the OECD

Indicators	Description / methodological challenges
Environment and air quality	The OECD Environmental database contains a long time series on mean population exposure to fine particulate matter for all OECD countries and beyond.
Mortality rates	Mortality data for several causes that have been associated with potentially environmentally induced risk factors are currently being collected, including deaths from cardiovascular, acute kidney diseases and respiratory conditions, maternal and infant health, violent behaviour and suicide.
Excess mortality	First introduced in the context of the COVID‑19 pandemic, weekly data on excess mortality can also be used to track impact of acute climatic events e.g. heatwaves.

Table 3.3. Possible new indicators to further assess interactions between health and environmental threats

Indicators	Description / methodological challenges
Hospitalisation rates or emergency departments visits for “heat related” illnesses	Hospitalisation rates or emergency departments visits for conditions such as heat exhaustion, heat cramps, mild heat oedema, heat syncope, and heat stroke could be used as measures of the impacts of heat waves on health.
Hospitalisation rates or emergency departments visits for “air-quality” illnesses	Diseases could include asthma or chronic obstructive pulmonary disease.
Heat-related mortality	Annual rates of deaths per million population that have been classified with International Classification of Disease codes related to exposure to natural sources of heat or listed as a contributory factor (to e.g. cardio-vascular, kidney failure deaths).
Other climate‑induced illness	Climate change brings the potential of rise in incidence rates of tropical/infectious diseases including vector-borne diseases (e.g. dengue, Lyme diseases) and enteric infections and diarrhoea in regions where those conditions were previously not endemic.

Other indicators that go beyond the impact of climate change on population health and exposure to environment-associated risk factors could also be of interest. This could refer in particular to the impact of climate change on health systems more broadly. While countries do not appear to have a specific focus on this at the moment, most have committed to climate resilient and sustainable low carbon health systems at COP 26. Several indicators may prove valuable in evaluating the monitoring, preparedness and management of present and future climate‑related risks and hazards to health systems (World Health Organization, 2023[30]). These could, for example, include the share of health facility built on areas prone to flooding, energy consumption and energy mix in health facilities, excess utilisation in health facilities during heat/cold waves, share of health workers that fall sick during heat/cold waves, and other. It is understood that substantial development work will have to be done before any of these indicators can be included in any data collection.

In addition to monitoring the health effects of environmental factors, monitoring the environmental impacts of health systems activities is also relevant, and related to the sustainability cross-cutting dimension (see below). The case for efforts to reduce the carbon footprint of healthcare delivery is strong. Not only does the sector itself account for around 5% of total emissions, according to preliminary measures, but also global warming will jeopardise progress towards its very purpose, to promote, restore or maintain health. One of the ongoing areas of work on health and climate change is related to the improvement of existing measurements of carbon emissions in the health sector of OECD countries. While some preliminary measures exist, the methodology is being further refined and improved. Most of the data used for the current methods for estimating emissions in the health sector either comes from the OECD or are regularly reported by the OECD, such as data from system of health accounts, input-output matrices or emissions by country.

International studies to compare Green House Gas (GHG) emissions across OECD countries already exist. However, they are not necessarily carried out on a regular basis (and are partially quite dated) and do not appear to use the detailed information on health spending by provider or service categories available for OECD countries. This data is collected annually as part of the Joint Health Accounts Questionnaire (JHAQ) collection (which is based on the System of Health Accounts 2011) and validated jointly by OECD, WHO and Eurostat. Thus, it can be considered in large parts as internationally comparable. Using this data collection for each country – and by multiplying spending for each category with the corresponding emission intensity – this could theoretically allow for a very granular analysis of GHG emissions of the health sector for each country (e.g. hospitals, offices of physicians, pharmacies, nursing homes). Moreover, the timely availability of this data could be an asset. For most OECD countries a detailed spending break-down by provider, type of service and financing scheme is available with a time‑lag of only two years. For some countries, preliminary data on a very detailed level can be available even quicker.

On top of health spending data, the OECD also hosts and maintains its own multi-regional input-output database that could be used to estimate demand-based carbon dioxide emissions: the Inter-Country Input Output (ICIO) database (Carbon dioxide emissions embodied in international trade). Currently, the ICIO covers 45 sectors in 66 countries for years 1995 to 2018. The forthcoming version up until 2020 will extend country coverage to 76. This Framework could potentially be used to measure the carbon footprint of health systems, but further exploration is needed to understand whether the level of detail is sufficient to provide information at a more granular level than the health sector as a whole.

3.2.2. Commercial determinants of health

The commercial determinants of health describe the health effects associated with some of the actions of the for-profit private sector. The impact that commercial activities have on people’s health and well-being can either be positive and negative. Negative effects include the production and marketing of products like unhealthy foods, tobacco, and alcohol, leading to diseases such as cardiovascular disease, diabetes, and obesity. Advertisements and celebrity endorsements, especially targeting young people, can influence unhealthy behaviours. Environmental changes due to commercial activities, such as deforestation, create conditions for disease outbreaks. Factories in disadvantaged communities contribute to air pollution and respiratory diseases. Unsafe work environments, like those in certain sectors of the garment industry, can harm employee mental health. Intellectual property laws can limit access to affordable medicines. On the positive side, some companies contribute to public health by increasing access to essential medicines, reformulating products to reduce harm, ensuring fair wages and benefits, and divesting from harmful products. Workplaces also serve as settings for health promotion and protection, including efforts to promote safety, and encourage healthy behaviours and awareness. (Lee et al., 2022[31])

Commercial determinants also contribute to other factors that shape health and health equities through broader economic systems and economic determinants (see next section). This includes through economic development or trade policies, broader social, economic, and political systems, and finance or investment flows. In recent decades, there has been a significant shift of resources towards private enterprises, which now wield increasing influence over public health policies, regulations, and outcomes. Commercial actors employ various pathways to influence health policy. This includes lobbying and political donations. Additionally, the private sector can subtly shape research directions and outcomes by funding medical education and research, potentially biasing findings. Furthermore, companies may exert influence over civil society by establishing or funding front groups, consumer organisations, and think tanks.

Commercial determinants of health are therefore an important dimension when analysing health system performance, but defining and collecting meaningful indicators for that domain is particularly challenging. In the scientific literature (Lee et al., 2022[31]), some preliminary options have been identified, such as per capita spending on advertising of health-harming products, the number of registered lobbyists, and the gaps in advertising restrictions on alcohol. But availability and comparability of such information remains particularly challenging.

3.2.3. Economic and social impact

A well-functioning health system is essential to a well-functioning economy. The core mission of health systems is to ensure the provision of high-quality and universally accessible healthcare services. Simultaneously, their financial commitments and investments hold significant sway over the functioning and stability of both national and regional economies. Health systems are also assuming an ever more critical role in fostering inclusive and sustainable development through responsible practices related to employment and procurement of goods and services (Cylus, Permanand and Smith, 2018[32]).

While the positive impacts of the health system on public health are widely recognised, the health system’s influence on the broader economy, both directly (as a significant employer) and indirectly (through its effects on public health), has received less attention. Various international initiatives have shed light the connections between the health system and the overall economy. For instance, the 2016 Commission on Health Employment and Economic Growth (OECD, ILO and WHO, 2016[33]) underscored that health employment plays a pivotal role in driving economic growth. Similarly, the 2001 WHO Commission on Macroeconomics and Health (WHO, 2001[34]) contended that improved health outcomes can serve as catalysts for and safeguards of economic growth.

The health system constitutes a significant portion of most economies, particularly in high-income nations, where it serves as a crucial source of employment across various skill levels. As per data from the International Labour Organization, the proportion of jobs in health and social work in Europe and central Asia has risen from 7.4% of total employment in 2000 to 9% in 2017. In Northern, Southern, and Western Europe, health and social work employment accounted for over 12% of total jobs in 2017. Consequently, the size and character of the health system are likely to have profound direct repercussions on the overall economic performance, independent of their impact on public health.

In addition, numerous research findings demonstrate that individuals in better health experience enhanced opportunities for economic participation and higher earnings in comparison to their less healthy counterparts (see the equity cross-dimension for complementary information). Good health is associated with increased rates of engagement in the labour market and extended working lives resulting in higher overall economic productivity. Conversely, poor health can have both direct consequences, such as incurring healthcare costs and the need for caregivers, and indirect consequences, like limiting one’s ability to participate in the labour market. Moreover, some research has explored the impact of chronic diseases and related lifestyle factors on employment, productivity, and income (OECD, 2019[35]). The evidence strongly suggests that conditions like obesity and smoking have detrimental effects on employment prospects, wages, and labour productivity. Additionally, the influence of health systems on the development of human capital spans a person’s entire life. For instance, children experiencing health issues may face challenges attending school regularly and developing the cognitive skills required for many professions. Ill health may also diminish an individual’s capacity or motivation to invest in education and training. Furthermore, older adults in poor health may be reluctant or unable to invest in their human capital if they believe that their productive life expectancy is likely to be cut short due to illness or death, making such investments seem less worthwhile. In contrast, as health and life expectancy improve, it becomes increasingly valuable for individuals and their families to invest in skills that promise greater returns over a longer and more productive lifetime. Therefore, through reduced costs, and higher productivity and increased human capital, investments to reduce the main determinants of burden of disease have the potential to sustainably stimulate the loop of health and economic growth.

Overall, quantifying the relationship between health, health systems and socio-economic indicators provides insights into the broader implications of healthcare policies, such as its macroeconomic importance, and helps direct investments to areas with the highest returns in both health and socio-economic outcomes. Table 3.4 presents some indicators describing aspects of the socio-economic impacts of health and health systems currently collected by the OECD and other partners.

Table 3.4. Examples of indicators describing the socio-economic impacts of health and health systems collected by the OECD and other institutions

Indicators	Description / methodological challenges
Business enterprise expenditure for pharmaceutical R&D (BERD) and government outlays for health-related R&D (GBARD)	Business enterprise expenditure on R&D (BERD) covers R&D carried out by corporations, regardless of the origin of the funding, which can include government subsidies. Government budgets for R&D (GBARD) capture R&D performed directly by government and amounts paid to other institutions for R&D.
Employment in health and social work as a share of total employment	Health and social work is one of the economic activities defined according to the major divisions of the International Standard Industrial Classification of All Economic Activities.
Employment rate among people aged 50‑59, with and without chronic diseases or by risk factor	Data collected through the Survey of Health, Ageing and Retirement in Europe (SHARE).
Number (median) of sick days in the last 12 months among employed people aged 50‑59, by chronic diseases
Additional days in annual sickness absence among workers aged 50‑59 due to depression symptoms
Early retirement and unemployment rates among people aged 50‑59, by chronic diseases

3.2.4. Risk factors

Indicators such as tobacco use, unhealthy diets, physical inactivity, and exposure to environmental hazards are major determinants of people’s health. Measuring risk factors is therefore an important dimension of health system performance assessment as it provides critical insights into the effectiveness of public health interventions. Understanding how risk factors are spread across the population helps develop targeted prevention strategies and interventions to mitigate their consequences, reduces the burden of preventable diseases and contributes to a more efficient allocation of resources. Evaluating risk factors may also highlight disparities in risk exposure among different population groups, and is a crucial information for tackling health inequalities. Table 3.5 details some indicators reporting on risk factors currently collected by the OECD, and Figure 3.2 shows an international comparison of a selection of risk factors indicators as reported in Health at a Glance 2023 (OECD, 2023[20]). New risk factors indicators have also recently been added to OECD’s database, such as the proportion of regular users of vaping products (defined as the percentage of the population aged 15 years and over who report using vaping devices at least monthly, with or without nicotine).

Figure 3.2. Risk factors for health across the OECD, 2021 (or nearest year)

Note: Preliminary data, not for circulation; largest improvement shows countries with the largest changes in absolute value over time (% change in brackets).

Source: OECD (2023[19]), OECD Health Statistics, https://doi.org/10.1787/health-data-en; OECD (2021[36]), OECD Environment Statistics, https://doi.org/10.1787/env-data-en.

Table 3.5. Examples of risk factors indicators currently collected by the OECD

Indicators	Description / methodological challenges
Daily smokers	The percentage of the population aged 15 years and over who report smoking tobacco every day.
Smoking among 15‑year‑olds	Percentage of adolescents who smoked at least once in the last 30 days based on self-reporting.
Alcohol consumption	Litres consumed per capita, based on sales of pure alcohol data.
Drunkenness among 15‑year‑olds	Percentage of adolescents who have reported drunkenness at least twice in life.
Daily consumption of sugar-sweetened beverages among population aged 15 and over	Reports the frequency of drinking regular soft drinks, whether carbonated or not carbonated, bottled iced tea, energy drinks, syrup-based drinks and similar or any other non-alcoholic soft drinks that contain a lot of sugar.
Insufficient physical activity among adults	Defined as attaining less than 150 minutes of moderate‑intensity physical activity per week, or less than 75 minutes of vigorous-intensity physical activity per week.
Daily vegetable consumption among population aged 15 and over	Defined as the proportion of adults who consume at least one vegetable per day, excluding juice and potatoes.
Overweight/obesity	Overweight includes both pre‑obesity and obesity
Deaths due to ambient particulate matter, especially PM 2.51	Ambient (outdoor) particulate matter pollution results from emissions from industrial activity, households, cars and trucks, which are complex mixtures of air pollutants, many of which are harmful to health.

3.3. Measuring healthcare services and public health interventions

3.3.1. People’s needs and preferences

In recent years, as countries have started moving towards developing more people‑centred health systems and services, a range of frameworks and definitions have attempted to capture what components are most necessary in transforming existing systems. While there have been growing efforts to capture patient voice through the development and implementation of patient-reported measures, there have not been similar efforts to benchmark the extent to which health systems as a whole are delivering people‑centred care.

A thorough data compilation of indicators on people‑centredness was presented for the first time in the report Health for the People, by the People: Building People‑centred Health Systems (PCHS) (OECD, 2021[4]), in the form of a scorecard that accompanied the PCHS Framework (see Chapter 1 and Annex A for more details). A full description of the indicators categorised by dimension of people‑centredness included in the scorecard is listed in Table 3.6.

Table 3.6. The People‑Centred Health Systems Scorecard

Dimensions	Scorecard indicators
Voice	Participation in decision-making bodies: Patients having a formal participation role in health policy
Choice	Choice of healthcare providers: Patient choice for primary, specialist and hospital care Access to healthcare: Unmet need due to affordability
Co-production	Patients given accessible information: Share of patients receiving easy-to‑understand explanations by their doctor Patients are consulted about their care: Share of patients being informed or consulted about their care Share of individuals using digital tools for health: Proportion of patients using patient portals and apps Patients are engaged in their care: Share of individuals using the internet for seeking health information in the previous 3 months
Integration	Use of digital technology for integration of care: Computers used by primary care physician for common tasks Use of electronic clinical records: Share of primary care physician offices using Electronic Clinical Records Co‑ordination of care: Share of patients not experiencing a problem with care co‑ordination
Respectfulness	High personal attention: Share of patients who spent enough time with their regular doctor or any doctor during the consultation Fair treatment: Share of people agreeing that people are treated equally in their area Respectful treatment: Share of hospital patients treated by doctors and nurses with respect

Source: OECD (2021[4]), Health for the People, by the People: Building People‑centred Health Systems, https://doi.org/10.1787/c259e79a-en.

In the renewed OECD HSPA Framework, indicators to reflect people‑centredness of health systems sit at the centre of the figure, overlapping the resources and services sections. This has important implications for the revision of the Framework, as more data collection and analysis efforts are needed. While some indicators for people‑centredness are included in the regular HCQO data collection and also reported in Health at a Glance (see Table 3.7), such as doctors spending enough time with patient, providing easy-to‑understand explanations, and involving patients’ decisions about care and treatment, good data to assess people‑centred health systems remains the exception rather than the rule and more effort is needed in the collection and reporting of indicators related to people‑centredness (OECD, 2021[4]).

Table 3.7. Examples of people‑centredness indicators that have been reported by the OECD

Indicators	Description / methodological challenges
Doctor involving patient in decisions about care and treatment	Data refer to patient experiences with any doctor in ambulatory settings in some countries, but patient experiences with a regular doctor or regular practice in others.
Percentage of people who made an appointment with a health practitioner on line	Data previously collected by the Commonwealth Fund and the OECD
Percentage of people who sought health-related information on line
Doctor spending enough time with patient during consultation
Doctor providing easy-to‑understand explanations
Doctor involving patient in decisions about care and treatment

In addition, the OECD’s Patient-Reported Indicator Surveys initiative (www.oecd.org/health/paris/) (PaRIS)2 will further refine and improve the indicators for people‑centredness, as well as improve their availability across countries participating in the survey. Examples are PaRIS survey items on coproduction of care that are currently being measured in 20 countries:

• I have difficulty understanding a lot of the health information that I read;

• My health professionals and I work together to manage my health;

• I leave it to health professionals to make the right decisions about my health;

• Are you involved as much as you want to be in decisions about your care?

• Do you discuss with the health professionals involved in your care what is most important for you in managing your own health and well-being?

• Do you have enough support from the healthcare professionals to help you to manage your own health and well-being?

Health literacy is another major dimension of people centredness that requires more attention. Health literacy encompasses the knowledge, motivation and skills required to access, comprehend, assess, and apply information to make informed decisions regarding healthcare, disease prevention and the enhancement of overall well-being over the life course. It has far-reaching consequences for individuals’ ability to manage their health, use preventative services and take part in decision making regarding their health and well-being. At the societal level, health literacy impacts healthcare use, prevention and health promotion programmes, equity and social justice, as well as productivity. At the 2017 OECD Meeting of Health Ministers, Ministers agreed that in order to make health systems more people‑centred, “efforts are needed to address barriers to health literacy of the population”.

Several indicators could also be considered in order to monitor health literacy at the individual and system levels, such as:

• Proportion of health institutions proposing health coaching;

• Existence of prevention and counselling training courses for health professionals;

• Percentage of persons whose healthcare provider gives easy-to‑understand instructions;

• Percentage of persons whose healthcare provider asks how instructions will be followed;

• Percentage of persons whose healthcare provider offers help in filling out forms.

3.3.2. Access and coverage

Access relates to accessibility of health services. For example, how easy it is to get to a primary care facility or hospital. Coverage refers to the extent to which public health interventions reach the target population. These two concepts are related but not interchangeable. Coverage also refers to the proportion of the population that is eligible to receive certain health services, which in turn affects the (financial) accessibility of these services. Table 3.8 presents a range of indicators for access and coverage that have been reported by the OECD in recent years and Figure 3.3 shows an international comparison on a selection of indicators related to coverage and access.

Table 3.8. Examples of indicators describing access and coverage collected by the OECD

Indicators	Description / methodological challenges
Population coverage	Population coverage for healthcare is defined as the share of the population eligible for a core set of healthcare services – whether through public programmes or primary private health insurance.
Population reporting unmet needs for medical care	People being asked whether there was a time in the previous 12 months when they felt they needed medical care but did not receive it.
Extent of coverage	Government and compulsory insurance spending as proportion of total health spending by type of care.
Share of households with catastrophic health spending	Catastrophic health spending is an indicator of financial protection used to monitor progress towards universal health coverage. It is defined as out-of-pocket payments that exceed a predefined percentage of the resources available to a household to pay for healthcare.
Unmet healthcare needs	Unmet needs for medical/dental examination due to financial, geographic or waiting time reasons.
Waiting times for elective surgery	Waiting times from specialist assessment to treatment (mean number of days).
Number of doctor consultations per person	Consultations with doctors refer to the number of face‑to-face (in-person) contacts with physicians, including both generalists and specialists.
Physician density across regions, by territorial level	Regions are classified in two territorial levels. The higher level (territorial Level 2) consists of large regions corresponding generally to national administrative regions. The lower level is composed of smaller regions classified as predominantly urban, intermediate or rural regions, although there are variations across countries in the classification of these regions.

Figure 3.3. Indicators of access to care across the OECD, 2021 (or nearest year)

Notes: Largest improvement shows countries with the largest changes in absolute value over time (% change in brackets). Values for population coverage, satisfaction, are based on 2022 data.

Source: OECD (2023[19]), OECD Health Statistics, https://doi.org/10.1787/health-data-en; Gallup World Poll 2023, Eurostat based on EU-SILC.

Digital access is another dimension of access. It means that patients and healthcare providers have timely and accurate health data and information (OECD, 2019[37]). When health data and information are understandable and valid for a range of uses and users, new digital health services and applications become possible. From telehealth to artificial intelligence, new digital health services may lead to better access to healthcare and better patient experience, especially among those patients that face the most barriers to traditional face‑to-face care services. More and more countries now allow patients to view and interact with their own electronic health records. It may include information on their health status or outcomes, or report on experiences or incidents related to their care (Oderkirk, 2017[38]). Finally, while supporting individual literacy skills is important (see people‑centredness dimension), health literacy is also facilitated through clear and easy communication with professionals, but also accessible information on websites, media campaigns, and patient portals. Such information needs to be structured, understandable and tailored to specific populations, and provide evidence‑based information which contributes to improved access (Moreira, 2018[39]). The OECD has recently been reporting on new indicators to describe digital access. In the 2023 edition of Health at a Glance (OECD, 2023[20]), rates of teleconsultations are presented, covering remote consultations with both generalist and specialist medical practitioners, with all technologies used (notably phone or virtual calls).

3.3.3. Quality

The OECD has been reporting a range of indicators for quality of care in Health at a Glance since a long time. The current Health Care Quality Outcome indicator set includes 64 indicators.

A key subdimension of quality is effectiveness, which is the degree of achieving desirable outcomes, given the correct provision of evidence‑based healthcare services to all who could benefit, but not to those who would not benefit (Kelley and Hurst, 2006[2]). Examples of indicators for effectiveness cover the following dimensions (see Table 3.9 for more indicators and Figure 3.4 to see a selection of quality indicators and related international comparisons):

• Avoidable mortality, a general indicators for quality of care which can be broken down into:

  • Preventable mortality: covering the causes of death that can be mainly avoided through effective public health and primary prevention interventions (i.e. before the onset of diseases/injuries, to reduce incidence).

  • Treatable mortality: covering the causes of death that can be mainly avoided through timely and effective healthcare interventions, including secondary prevention and treatment (i.e. after the onset of diseases, to reduce case‑fatality).

• Effectiveness of primary care: avoidable hospital admissions for e.g. diabetes and COPD;

• Effectiveness of acute care: 30‑day mortality rates following a stroke or acute myocardial infarction;

• Effectiveness of cancer care: 5‑year survival rates for various types of cancer.

The second subdimension of quality is safety. Patient safety is the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum, while an acceptable minimum refers to the collective notions of current knowledge, resources available and the context in which care was delivered and weighed against the risk of non-treatment or alternative treatment (Slawomirski and Klazinga, 2022[40]). Examples of indicators for patient safety reported by the OECD are presented in Table 3.9 and Figure 3.4 shows a selection of quality indicators and related international comparisons):

Table 3.9. Examples of quality indicators collected by the OECD

Dimensions	Possible indicators
General indicators for quality of care	Avoidable mortality (preventable and treatable) Routine vaccinations (e.g. vaccination against influenza)
Effective primary care	Avoidable COPD hospital admission in adults Avoidable Diabetes hospital admission in adults People with diabetes prescribed recommended antihypertensive medication in the past year in primary care
Effective secondary care	Thirty-day mortality after admission to hospital for acute myocardial infarction Thirty-day mortality after admission to hospital for ischaemic stroke
Effective cancer care	Five‑year net survival by cancer sites
Effective mental health care	Inpatient suicide among patients with a psychiatric disorder Suicide following a hospitalisation for a psychiatric disorder, within one year of discharge
Integrated care	Patient outcomes one year after discharge from stroke and heart failure
Safe primary care	Overall volume of antibiotics prescribed Proportion of chronic opioid users in the adult population Elderly patients with prescriptions for benzodiazepines or related drugs
Safe acute care	Health worker perceptions of patient safety culture domains, handoffs and transitions and overall perceptions of safety Obstetric trauma, vaginal delivery with and without instrument Post-operative sepsis per 100 000 hospital discharges Foreign body left in during procedure
Effective preventive care	Breast cancer screening within the past two years Cervical cancer screening Colorectal cancer screening

Figure 3.4. Indicators of quality of care across the OECD, 2021 (or nearest year)

Note: Largest improvement shows countries with the largest changes in absolute value over time (% change in brackets).

Source: OECD (2023[19]), OECD Health Statistics, https://doi.org/10.1787/health-data-en; ECDC (2023[41]), European Centre for Disease Prevention and Control, www.ecdc.europa.eu/en/data (for EU/EEA countries on antibiotics prescribed).

In a more recent development, under the PaRIS initiative, the OECD has undertaken the collection of Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) tailored to specific diseases. These encompass PROMs administered both before and after surgeries for conditions like breast cancer and hip and knee replacements, as well as PREMs related to mental health. Furthermore, the OECD is actively gathering data on safety aspects, considering the viewpoints of both healthcare professionals (including safety culture) and patients (involving the occurrence and nature of safety incidents). Additionally, the organisation is reporting indicators concerning the quality of end-of-life care, including metrics like unplanned hospital admissions.

3.4. Measuring health systems resources, characteristics and policy

Health systems resources, characteristics and policy covers a broad range of topics. Figure 3.5 shows examples of some indicators that were reported in Health at a Glance 2021 (OECD, 2021[42]) that related to healthcare facilities, workforce and financing. Most of the indicators that are currently reported can be found in OECD.Stat (https://stats.oecd.org/) under the categories “Health Care resources” (which includes workforce availability and healthcare facilities) and Health Expenditure and Financing. Table 3.10 lists those most frequently used.

Figure 3.5. Health system capacity and resources indicators across the OECD, 2021 (or nearest year)

Note: Largest increase shows countries with largest changes in absolute value over time (% change in brackets).

Source: OECD (2023[19]), OECD Health Statistics, https://doi.org/10.1787/health-data-en.

3.4.1. Expenditure and financing

For health expenditure and financing, the System of Health Accounts (SHA) provides a standard framework for producing a set of comprehensive, consistent and internationally comparable accounts to meet the needs of public and private sector health analysts and policy makers. The SHA has become an international standard for comparing expenditures. Expenditures are reported per capita, as percentage of GDP, percentage of public spending and can be broken down by financing, types of care, disease and medical goods per disease (see Table 3.10). (OECD/Eurostat/WHO, 2017[43])

3.4.2. Workforce

Over the past two decades, the health workforce has been under considerable strain, both in terms of numbers and the skills needed to work with new technologies and adapt to new roles. Changes in the demographic, epidemiological and socio-economic profile of populations will continue to change the demand for health services going forward and are likely to put further pressure on the demand for health workers. For example, population ageing goes hand in hand with an increasing demand for healthcare, while also shifting the type of care that is demanded. At the same time, population ageing could strain the supply of health workers, as the size of the working age population declines (International Labour Organization, 2019[44]). The shortage of health workers is a global problem. The COVID‑19 pandemic has exacerbated these shortages and underscored the importance of a resilient and well-educated health workforce. Equipping healthcare workers with the right skills is essential to respond to future health crises and to prepare for the increasing use of digital technologies and demographic change, among other trends. Dissatisfaction and burnout are widespread among health workers and this is associated with worse outcomes for patients (Bodenheimer and Sinsky, 2014[45]).

In this renewed Framework, the workforce domain includes three dimensions:

• availability and quantities of health workers

• the skills of health workers

• health works safety and well-being.

The availability and quantities of health workers is a “classic” category on which the OECD has built long time trends data. Typical indicators are numbers of doctors and nurses, but more granular data (i.e. at specialty level) should be considered for future rounds of data collection.

The focus on skills is from a more recent date. However, skill shortages are a global issue. The COVID‑19 pandemic has further aggravated these shortages and emphasised the importance of resilient and well-skilled healthcare workforces. Equipping health workforces with the right skills is essential to responding to future health crises, and to preparing for increasing use of digital technologies and demographic change, among other trends. (OECD/ILO, 2022[46]). The safety and well-being of health workers is a relevant element of the workforce domain, and OECD work on this topic has recently begun. The COVID‑19 pandemic has highlighted this issue. Particularly in times of crisis, it is clear that shortages, skills and staff well-being are interlinked. Addressing health workforce shortages requires increased investment in education and training, increased recruitment to reduce workload and pressure on existing staff, and improved retention by improving working conditions and pay rates for traditionally undervalued categories of workers. (OECD, 2023[5]).

Possible new indicators on health workforce retention will be given great attention in the renewed Framework. A survey of 23 000 nurses working in medical and surgical hospital wards in 10 countries (Belgium, Finland, Germany, Ireland, the Netherlands, Norway, Poland, Spain, Switzerland and the United Kingdom) reported that overall, 33% intended changing jobs in the next year, whilst 9% of the nurses intended to leave their profession. This “leaving the profession” turnover rate varied from 5 to 17% across the 10 countries (Heinen et al., 2013[47]). The Swedish Nurses Association announced the results of a survey showing that 7% of the nursing workforce (5 700 nurses) considered resigning due to the increased pressure and workloads in the pandemic. In Denmark, a survey conducted by the Danish Nurses’ Organization in 2020 found that nine out of ten nurses in municipalities and regions considered leaving their jobs. Of those, more than a third were considering leaving the profession altogether (International Council of Nurses, 2022[48]). High turnover rates can lead to a loss of valuable institutional knowledge and a decrease in the continuity of care. By prioritising staff retention, health systems can ensure a more stable workforce, improve patient outcomes, and foster a positive work environment where employees feel valued and supported. New indicators on retention could include dimensions on turnover rates (number of leavers divided by the average number of staffs in post in the year), absenteeism rates, number of applicants for designated jobs/posts, vacancies (number of funded posts that are unfilled) (International Center on Nurse Migration, 2018[49]).

3.4.3. Data and digital

The data and digital dimension covers health data infrastructure, security and management. As already reported in other dimensions of the Framework, the OECD collects several indicators related to digitalisation in health. A few examples are the adoption of electronic medical records and use of telemedicine and teleconsultations, but perhaps the most structured data collection related to health data digitalisation is based on monitoring of the OECD Health Data Governance Recommendation, adopted in 2016 in recognition of a growing need for an international standard to harmonise approaches to health data governance. Some of the indicators on health data governance include:

• timeliness of key national health datasets

• key datasets linked on a regular basis and

• record linkage projects used to regularly monitor healthcare quality or health system performance.

More recently, the OECD has been reflecting on the concept of digital health readiness (OECD, 2023[20]), which is a comprehensive measure of a health system’s capacity to effectively utilise analytics, data, and technology to improve individual, community, and public health outcomes. It encompasses various aspects (see below), each essential for a well-functioning digital health ecosystem, and that could each be populated with new indicators:

• Analytic readiness evaluates a system’s ability to create and employ analytics that lead to responsible and trusted insights, promoting equitable health outcomes.

• Data readiness assesses a healthcare system’s capability to collect, access, and utilise health data efficiently. It seeks to ensure integrated, high-quality health data that can support healthcare delivery, public health efforts, system enhancements, research, and innovation.

• Technology readiness examines the system’s preparedness to securely handle data input, storage, and transfer. The aim is to maintain robust technology that can withstand digital security risks and outages while preserving data integrity.

• Human factor readiness gauges the overall readiness of the digital health ecosystem, including culture and technology. It ensures that adequate resources are available, stakeholders trust the system, co‑operation is encouraged, and adaptation to emerging challenges occurs.

3.4.4. Technologies and pharmaceuticals

Despite remarkable progress in some areas of technologies and pharmaceuticals, recent trends raise several concerns. Launch prices of new medicines have risen in some therapeutic categories, sometimes without commensurate health benefits. At the same time, new, effective medicines are not always affordable for all patients who need them, putting pressure on health budgets. There is also an imbalance in innovation and new product development. For example, progress in important areas such as infectious and chronic diseases is not occurring at the same pace as in cancer. These trends raise questions about the incentives at work in the pharmaceutical sector and the sustainability of current pricing models. Ensuring access to medicines involves a complex web of factors, including availability, affordability, accessibility, acceptability, and quality. Each of these dimensions comprises various elements tied to different stages in a medicine’s lifecycle. This includes aspects like obtaining marketing authorisation, conducting health technology assessments, making coverage and pricing decisions, determining the timing of product launches, establishing clinical guidelines, prescribing and dispensing practices, and ultimately, how patients utilise these medicines. The OECD has recently released a working paper that delves into potential strategies for monitoring access to innovative medicines across these multifaceted dimensions on a global scale and that could serve as a basis for new indicators development in that domain (Chapman, Szklanowska and Lopert, 2023[50]).

Reporting on infrastructure, facilities and other technologies is also a crucial aspect of health system performance assessment. Evaluating these components helps to gauge the system’s capacity, accessibility, and quality of care. For instance, the distribution and geographic accessibility of healthcare facilities, including hospitals, clinics, primary care centres, and specialised treatment centres help determine whether these are sufficient to meet the healthcare needs of the population, particularly in underserved or remote areas. Also, assessing whether facilities are operating at or near capacity and if there are disparities in utilisation rates between regions or population groups contributes to identifying inequalities in access and coverage.

3.4.5. Knowledge and innovation

Knowledge and innovation play pivotal roles in the development and improvement of health systems. They drive advancements in healthcare delivery, medical treatments, public health strategies, and the overall effectiveness of health systems. Technological innovation, such as the development of telemedicine, and advanced diagnostic tools, has revolutionised healthcare delivery, expanding access to care, improving diagnostics, and enhancing patient outcomes and safety. Innovation also refers to novel approaches to healthcare service design, delivery, and management, such as accountable care organisations or Value‑Based care models. This dimension also connects with the “pharmaceuticals and health technologies” one. Indeed, pharmaceutical advancements, including the development of new drugs, therapies, and medical treatments, have significantly improved the quality of healthcare by providing additional and/or more effective solutions for various medical conditions. These innovations often lead to better patient outcomes, reduced hospitalisations, and improved overall health, contributing to the sustainability of health systems. The number of clinical trials conducted within a health system and the patent activity can serve as markers of the knowledge and innovation dimension. A high volume of clinical trials reflects a health system’s commitment to advancing medical knowledge, improving patient care, and staying at the forefront of medical research. It indicates a willingness to explore cutting-edge treatments, therapies, and interventions, which can lead to the discovery of more effective. Moreover, a robust clinical trial ecosystem often attracts top-tier researchers, pharmaceutical companies, and healthcare professionals, fostering collaboration and knowledge creation and brokering.

3.4.6. Governance

Lastly, one key area of health system capacity and resources refers to a broad set of governance elements including the institutional architecture of health policy, leadership, and organisational structure, financing arrangements, and even the mechanisms for patient voice and participation. The OECD has collected several waves of data including these indicators via the Health Systems Characteristics Survey (OECD, n.d.[16]), for which a new data collection is ongoing. It describes country-specific arrangements to organise the population coverage against health risks and the financing of health spending. It depicts the organisation of healthcare delivery, focusing on the public/private mix of healthcare provision, provider payment schemes, user choice and competition among providers, as well as the regulation of healthcare supply and prices. It further includes information on governance and resource allocation in health systems, such as decentralisation in decision-making, nature of budget constraints, priority-setting, and areas where patient participation takes place (Paris, Devaux and Wei, 2010[51]).

Table 3.10. Examples of indicators describing the health systems resources, characteristics and policy section

Dimensions	Possible indicators
Health expenditure and financing	Health expenditure as a share of GDP Health expenditure per capita Health care volumes per capita compared to health expenditure per capita Health expenditure by type of financing Health expenditure from public sources as a share of total government expenditure Health expenditure by type of service Spending on primary healthcare services as a share of current health expenditure Health expenditure by provider Annual capital expenditure on health as a share of GDP
Workforce	Practising doctors per 1 000 population Share of doctors aged 55 and older Share of female doctors Share of different categories of doctors Remuneration of doctors Practising nurses per 1 000 population Remuneration of hospital nurses Hospital workforce composition Medical and nursing graduates Share of foreign-trained doctors and nurses Practising pharmacists
Health technologies and pharmaceuticals	Expenditure on retail pharmaceuticals by type of financing Expenditure on retail pharmaceuticals per capita Annual average growth in retail and hospital pharmaceutical expenditure Consumption of medicines for selected chronic conditions Share of generics in the total pharmaceutical market Availability and use of diagnostic technologies – CT scans, MRI and PET scans Hospital beds per 1 000 population Hospital discharges per 1 000 population Occupancy rate of curative (acute) care beds
Data and digital	In-person consultations and teleconsultations with doctors Share of adults who received services from a doctor via telemedicine Percentage of primary care physician practices using Electronic Medical Records Key national health datasets availability, maturity and use Percentage of key national health datasets available and regularly linked for monitoring and research Proportion of national population covered by national dataset Percentage of available national healthcare datasets coded to a terminology standard
Knowledge and innovation	Business enterprise expenditure for pharmaceutical R&D (BERD) and government outlays for health-related R&D (GBARD) Number of clinical trials per 100 000 population Patent Activity (the number of patents filed by healthcare institutions or professionals within the health) Publication output (e.g. indexed in Medline) Amount of medical research funding per capita
Governance	Characteristics of basic healthcare coverage Regulation of health insurance markets for basic healthcare coverage Competition between health insurers offering basic healthcare coverage and consumer choice Provision of healthcare and payment of health services Employment status and remuneration of healthcare professionals Pay-for-performance and other financial incentives for providers Patients’ choice and competition among providers Infrastructure and service delivery planning Section Price regulation for healthcare services Co‑ordination and continuity of care Utilisation of HTA to make coverage decisions or set reimbursements Budgeting practices for health

3.5. Measuring cross‑cutting dimensions of the Framework

3.5.1. Efficiency and equity

Improving the efficiency of health systems is a key policy objective in most countries to reconcile growing demands for healthcare with limited budgets. Based on conventional economic theory, “efficiency” is the relationship between one or more inputs and one or more outputs. Two types of efficiency indicators can be distinguished:

• Technical efficiency i.e. producing the greatest outputs or outcomes for a given level of inputs (either financial resources, or labour or physical/capital resources) or producing the same outputs or outcomes at a lower cost. Examples of technical efficiency indicators include the number of consultations per doctor in a given year or the number of operations per surgeon (or surgery unit).

• Allocative efficiency i.e. the allocation of resources to achieve the greatest health outcomes at the least cost. Examples of allocative efficiency indicators include avoidable hospital admissions (as an indicator of the potential benefits to reallocate some resources from hospital to the primary care sector) which might results in better health outcomes at a lower cost, and the possible benefits of reallocating resources from care to prevention.

Efficiency in the health sector can be measured at three levels: system-wide level; sub-sector level; and disease‑based level. Each of these levels of analysis has its advantages and disadvantages, and requires more or less aggregated data on various inputs, outputs and/or outcomes. Table 3.11 lists some of these indicators for each level of analysis (OECD, 2016[52]).

The main advantage of a system-wide level approach to measuring efficiency in healthcare is the accessibility of aggregate data on key indicators like health expenditure, human resources, and population health measures. However, there are two significant disadvantages. Firstly, as discussed in previous sections; population health measures are influenced by factors beyond healthcare, making it challenging to isolate the impact of healthcare inputs on health outputs. Secondly, system-wide analysis often does not provide actionable insights for policy makers regarding specific areas of inefficiency. To address these limitations, using indicators of amenable mortality, which focus on treatable deaths and can be broken down by causes, may offer a more targeted approach to assessing healthcare efficiency.

The sub-sector approach has the advantage of focusing on more concrete and specific activities of health systems and might therefore more easily lead to sector-specific policy recommendations and actions. Many efficiency analyses have focussed on the hospital sector because this sector still accounts for a large part of total health spending and data on human resource inputs and on outputs tend to be more widely available. Frequently used measures of hospital efficiency include reductions in average length of stay for different causes of hospitalisation and increases in the share of same‑day surgeries for different surgical interventions. Efficiency in the primary care sector can be measured by relating certain measures of inputs (either in terms of the availability of human resources like GPs or in terms of spending) to outputs (e.g. the number of consultations per doctor) or outcomes (measured either directly through measures of effective control of chronic diseases for example, or indirectly through avoidable hospital admissions for conditions that should normally be treated outside hospital). Pharmaceutical spending is also a dimension of efficiency that is frequently analysed. The share of the generic market is often used as an indicator of efficiency in pharmaceutical spending, as generics are cheaper than on-patent drugs while providing the same health outcomes. The quality and appropriateness of pharmaceutical prescribing is also a domain of efficiency analysis.

A disease‑specific approach to measuring efficiency has the advantage of possibly using more precise information on health outcomes related to specific diseases or treatments (measured most frequently in terms of survival rates, but also possibly in terms health-related quality of life measured for instance through patient-reported outcome measures). However, it often faces the challenge of relating these health outcomes measures (where they exist) with specific information on inputs (e.g. expenditure by disease or treatment). One recent example of a disease‑based approach to measuring efficiency is the 2013 OECD report on cancer care (OECD, 2013[53]). The exploratory analysis of efficiency in cancer care offered in this report described the relationship between a number of inputs (in terms of spending, but also human resources and technical resources), along with other cancer care system characteristics, with the outcome measure defined as cancer survival following diagnosis. There are however two main limitations with disease‑based efficiency analysis: complete and reliable information on inputs (notably costs) by disease is lacking in most countries (except in those few countries that carry out regular cost-of-illness studies); and reliable health outcomes data are also missing for most diseases or treatments, with the notable exception of cancer.

One last dimension of efficiency relevant to the analysis of health system performance relates to administrative efficiency. Administration plays a crucial role in modern health systems at both macro and provider levels. While reducing administrative costs is often considered to control healthcare spending, it is important to recognise that administration serves essential public health functions like ensuring patient safety. The range of administrative tasks has expanded over time to address key objectives such as equity, or access, and mechanisms are put in place to address trends like increased provider autonomy and innovations such as pay-for-performance. Proper administration can enhance care delivery efficiency, responsiveness, and patient safety, potentially leading to cost savings in the long run. Yet, one major hurdle when measuring administrative efficiency relates to the lack of standardised definitions and criteria for what constitutes administrative costs and activities across different health systems and providers. Indeed, healthcare administrative functions are highly heterogeneous, ranging from billing and claims processing to regulatory compliance and quality reporting, and they often overlap with clinical tasks. Additionally, data collection and reporting can be problematic, with costs dispersed across various items, making it difficult to obtain accurate and comprehensive data. The complexity of health systems, including public and private sectors, insurance companies, and regulatory bodies, further complicates measurement efforts.

Table 3.11. Examples of indicators reported by the OECD measuring health systems efficiency

Dimensions	Possible indicators
System-wide efficiency	Life expectancy vs. health expenditure Treatable/amenable mortality vs. health expenditure Life expectancy vs. health workforce Treatable/amenable mortality vs. health workforce
Hospital care efficiency	Length of stay Same‑day surgery Outcome measures (e.g. 30‑day case fatality rates for acute conditions) vs. input data (expenditure, workforce, etc.)
Primary care efficiency	Number of consultations per doctor Proportion of patients who visited an emergency department because the primary care physician was not available Avoidable admissions for ambulatory care sensitive conditions vs. input data (expenditure, workforce, etc.)
Pharmaceutical sector efficiency	Share of generics in the total pharmaceutical market Price comparisons of medicines Antibiotics consumption Observance (e.g. persistent pharmaceutical utilisation rates for hypertension and diabetes) Proportion of doctors using e‑Prescribing software

As already discussed, health is influenced by a range of social, economic and environmental determinants, but by ensuring access to care of good quality, as well as through prevention and public health policies, health systems play a key role in improving health outcomes. Health systems can also contribute to reducing inequalities if they enable access to services based on needs rather than the actual ability to access (financially, geographically, etc.). In most OECD countries, national health system strategies and policies highlight the importance of ensuring access to quality care for everyone and protecting all people against the cost of illness.

Overall, poorer health, high exposure to risk factors and problems accessing the health system tend to go hand in hand and to be more common among the less well-off and disadvantaged. On the other hand, those with higher socio‑economic status generally adopt healthier lifestyles, find it easier to access the health system and are in better health overall. These effects can also reinforce each other and also influence labour market and educational outcomes (see Section 3.2). A range of health policy levers exist to redress these health-related inequalities. These include, for example, public health interventions to reduce the high exposure of risk factors among disadvantaged population groups, making sure a sufficient number of health providers are available in less affluent areas, and guaranteeing that the entire population is covered against the cost of healthcare.

Importantly, the challenge of health inequalities also needs to be seen in a country-specific context. In many OECD countries, particular population groups such as indigenous peoples, first nations, ethnic and linguistic minorities concentrate socio‑economic disadvantages but may also face additional barriers to access. In other countries, barriers of access may be concentrated in certain regions that are economically disadvantaged or scarcely populated.

Ensuring fair and inclusive access to effective, and reasonably priced healthcare stands as a foundational goal within the Framework of social policy across OECD nations. These objectives find endorsement in both national and international policy documents. Several notable initiatives, including the EU’s 2009 Communication on “Solidarity in Health: Reducing health inequalities in the EU”, the WHO conference addressing “Social Determinants of Health” in 2011, the adoption of the “Health 2020” strategy in 2012, the embrace of the “2030 Agenda for Sustainable Development” in 2015, and the establishment of the “EU Joint action on Health inequalities” in 2018, exemplify the unwavering commitment of government leaders to pursue health equity.

In sum, equity is a major dimension when crafting health policies. Designing policies with equity in mind means ensuring that healthcare services and resources are distributed according to needs rather than privileges, with a particular focus on vulnerable and marginalised populations. By addressing disparities in access to care and health outcomes, health policies can contribute to social justice and inclusivity and result in healthier, more cohesive, and economically robust societies. Table 3.12 presents some indicators measuring equity of health systems that have been presented in recent OECD publications (OECD, 2019[35]).

Table 3.12. Examples of indicators measuring the equity dimension of health systems

Dimensions	Possible indicators
Equity in health	Standardised probability of reporting a poor-self assessed health status by education level Standardised probability of reporting limitation in daily activities by education level Standardised probability of reporting multiple chronic conditions by education level
Equity in health determinants	Standardised probability of smoking by education level Standardised probability to be overweight by education level Standardised probability to be a heavy drinker by education level
Equity in service utilisation	Needs-standardised probability of a doctor visit in the past 12 months, by income quintile Inequality levels in the probability of a doctor visit Needs-standardised probability and frequency of a GP visit, by income quintile Needs-standardised probability of a hospitalisation in the past 12 months, by income quintile Prevalence of cancer screening, by income quintile or educational level Probability of a dental visit in the past 12 months, by income quintile Probability of flu vaccination, by income quintile
Equity and unmet needs	Proportion of the population forgoing care because of the cost, by income quintile
Equity and financial protection	Share of households with difficulties to afford healthcare services Share of households with catastrophic out-of-pocket spending by consumption quintile,

Gender equality is an aspect of the health equity question that deserves a particular attention since it is a core value and a strategic priority for the OECD, and the organisation is committed to accelerating the development of policy options to help close gender gaps and ensure that all its analysis, research and policy advice integrates a gender balance perspective (OECD, 2023[54]). Among the key actions to achieve this objective are the expansion of efforts to measure gender gaps, and mainstreaming gender dimensions in all relevant policy work. It is important to better incorporate the gender equality perspective in the revision of the OECD HSPA Framework and the analytical and indicator work based on it. For example, more efforts can be made to ensure that indicators are gender-disaggregated (i.e. data that are broken down by gender), gender-relevant (i.e. measurements specifically designed to capture changes in gender equality or inequality over time) (OECD, 2021[55]), and intersectional (i.e. measures that aim to account for intersecting between gender and social stratifiers, such as “race”/ethnicity, indigeneity, geography, age, disability/ability, migration status) (Larson et al., 2016[56]).

While Table 3.13 includes a selection of gender-disaggregated and gender-relevant health indicators regularly collected and reported by the OECD, more can be done to expand the gender equality perspective, expanding collection and reporting to other health indicators and including intersectional ones. A few examples of gender-disaggregated indicators that are currently not collected include: per capita health spending; doctor consultations; remuneration of doctors and nurses. Other gender-disaggregated indicators are already collected, but not regularly reported, such as hospital admissions; length of hospital stay; and hospital discharge diagnostic category. Some of the data disaggregation will require additional efforts and work with countries to ensure that the gender equality perspective is included in all data collections. Moreover, there are some important opportunities for further development ahead. Data from the PaRIS survey, for example, will allow for some key dimensions of patient experience to be disaggregated by gender, including: doctor spent enough time with the patient; doctor involved the patient in treatment decisions; and doctor explained things in a way that patients could understand. Delegates are also invited to provide further feedback in how the gender equality perspective can be better incorporated into the Framework.

Table 3.13. Examples of indicators measuring gender equity in health and health systems

Dimensions		Possible indicators
Gender equality	Sex-disaggregated indicators	Life expectancy, by gender Causes of mortality, by gender Potential years of life lost, by gender Perceived health status, by gender Cancer, number and incidence by gender Daily smoking, by gender Overweight and/or obesity by gender
	Gender-sensitive indicators	Share of female physicians Long-term care formal workers, by gender (number/share) Long-term care recipients, by gender (number/share)

3.5.2. Sustainability and resilience

Sustainability and resilience are essential objectives of high performing health systems. Sustainability revolves around the responsible management of resources (financial and others), ensuring that healthcare services can be consistently delivered over the long term without depleting essential assets or undermining future generations. Resilience, on the other hand, focuses on a system’s ability to withstand and rebound from disruptive events. By bolstering resilience, a health system not only safeguards the sustainability of its activities over time but also enhances its adaptive capacity and ability to maintain high-quality care in the face of unexpected challenges. Together, these two principles create a dynamic equilibrium that underpins a health system’s ability to ensure the health and well-being of its population in both routine and extraordinary circumstances.

In the past two decades, public health spending has consistently grown faster than the GDP in all OECD countries. Although this increased spending has led to improvements in health outcomes, there are apprehensions about the sustainability of this upward trajectory. Without effective measures to control costs, OECD forecasts indicate that public expenditures on healthcare and long-term care are projected to approach nearly 9% of GDP by 2030 and could even reach as high as 14% by 2060.

The OECD defines fiscal sustainability as the ability of a government to maintain public finances at a credible and serviceable position over the long term (OECD, 2015[17]). Fiscal sustainability implies governments are able to maintain policies and expenditure into the future, without major adjustments and excessive debt burdens for future generations. The term refers to overall government spending, revenues, assets and liabilities that reflect past commitments and adapt to future trends such as socio‑economic trends and environmental factors. In the context of the healthcare sector, fiscal sustainability should be viewed as a general constraint rather than a goal on itself. This suggests that the methods employed by governments to attain fiscal sustainability are crucial, as it should not merely involve indiscriminate cost-cutting measures. For instance, raising user fees for healthcare services might appear as a straightforward means to reduce budget deficits, but it can undermine health system objectives related to financial protection and improved health outcomes. A more effective approach would involve for instance eliminating interventions that are not cost-effective.

Possible indicators of fiscal sustainability include:

• Average annual growth rate of real public health spending and GDP per capita;

• Public health spending as a share of GDP;

• Projected public expenditure on health and long-term care as a percentage of GDP;

• Health spending as a share of total government spending;

• Revenue sources for funding government health expenditures;

• Relative share of public and private spending.

Yet, the concept of sustainability in health systems extends beyond fiscal considerations and encompasses several additional dimensions. One important aspect is the need for a long-term strategic perspective and innovativeness, which connects with the governance dimension (Fischer, 2014[57]). Sustainable health systems require shifting from incremental decision-making to long-term planning based on strategic analysis. This involves setting clear, long-term goals and implementing lasting reforms that balance social and financial imperatives while fostering open discussions about trade‑offs in society. Another dimension is the institutionalisation of environmental concerns within health systems. Sustainability in healthcare recognises the ecological environment as a critical factor, emphasising the need to minimise the negative impact of resource consumption (see earlier section on environment and health dimension).

Resilience is understood as the ability of systems to prepare for, absorb, recover from and adapt to major shocks (OECD, 2020[9]). It is not simply about minimising risk and avoiding shocks: resilience is also about recognising that shocks will happen. Such shocks are defined as high-consequence events that have a major disruptive effect on society. This concept touches on almost all elements of health systems design, policy, process, outcomes and impacts. The COVID‑19 pandemic revealed weaknesses in health systems and in how they respond to shocks, highlighting the need to improve their resilience. Health systems need to prepare better for shocks – not only pandemics but also antimicrobial resistance; armed conflict; climate change; biological, chemical, cyber, financial and nuclear threats; natural and environmental disasters; and social unrest. Health systems also need to be able to absorb such disruptions, to recover as quickly as possible and with minimal cost, and to adapt by learning lessons to improve performance and manage future risks. Rather than relying solely on planning for, avoiding and absorbing shocks, a resilience approach acknowledges that some shocks will be of a size and scale that will disrupt an entire health system. In this scenario, it is important that the health system is capable of recovering and adapting for the future.

Assessing the resilience domain requires indicators to cover the entire shock cycle and to capture the dynamic nature of resilience – how a health system performs before, during and after a shock. This is clear in applications of resilience assessment and testing that is conducted in other sectors, such as financial and banking services (Baudino et al., 2018[58]), or electricity utilities (DeMenno, Broderick and Jeffers, 2022[59]). What is common across such methods is that it views the resilience of systems as a dynamic characteristic that is based on the response to simulated stress. This assessment is challenging as performance during a shock depends not only on the available resources but also on a rapid and co‑ordinated response that may extend beyond the health system (Fleming et al., 2022[60]).

The inclusion of resilience as a cross-cutting dimension in the proposed revision of the OECD Health System Performance Assessment Framework is a reflection of the need to ensure that it maintains policy-relevance in the current context. This considers not only the lessons of the major shock of the COVID‑19 pandemic, but also other ongoing threats such as the rapidly escalating effects of climate change and its consequences in societies and health systems.

Table 3.14 includes a sample of indicators that have been used to infer health system resilience across several areas of the OECD Health System Performance Assessment Framework. A more thorough assessment of resilience will require that these indicators are further refined, and expanded to better reflect dynamic aspects of health systems (e.g. the ability to rapidly increase health workforce, redeploy them across the territory, or even retrain them to face new challenges).

The incorporation of resilience as a cross-cutting analytical in the Framework also highlights the importance of the issues of timeliness and disaggregation of data. The pandemic provided a clear example of the need for real-time data, and yet timeliness of the indicators is still a constraint, with most indicators being available for year t‑2 and only a few being available for year t‑1. Regional disaggregation of indicators within countries, as well as disaggregation of data by gender (the gender equality perspective discussed above), income, education or other areas of socio‑economic status, as well as ethnicity and migrant status is the exception, rather than the norm for most indicators, and yet these are also key for analysis of resilience.

Table 3.14. Examples of indicators measuring health systems resilience

Dimensions	Possible indicators
Preparation / Health systems capacity	General vulnerability of the population: proportion of people aged 65 and over; poverty rates; prevalence of chronic conditions and risk factors; etc. [currently collected] Capital expenditure on health as a share of GDP [currently collected] Laboratory capacity [currently collected] Hospital bed capacity and occupancy (curative and intensive care) [currently collected] Workforce capacity and strategies to increase that capacity (rapid hire, mobilisation of retired professionals, etc.) [not systematically collected] Preparedness plans: disaster plans exercised, crisis communication protocols defined, etc. [not systematically collected] Mature surveillance and early detection systems [not systematically collected]
Performance under pressure	Excess mortality [currently collected] Health workforce motivation and well-being, support to staff (childcare, psychological assistance), staff protection (vaccination rates, enhanced surveillance of staff health) [not systematically collected] Increased use of telehealth [currently collected] Reduction in activity of essential services: elective diagnostic and surgical care cancelled or delayed, backlog of elective care, screening programmes disrupted, etc. [not systematically collected] Participation of the private sector to the crisis response [not systematically collected] Impact on timeliness: increased waiting times, etc. [not systematically collected]

Notes

← 1.  This indicator could also be considered among the environment and health indicators currently collected by the OECD, some of which are presented in Table 3.2. We defer from doing so here given its particular focus on fine particulate matter (PM 2.5) a major health risk related to the broader concept of air pollution.

← 2.  The PaRIS International Survey of People Living with Chronic Conditions is the first international survey of patient-reported health outcomes and experiences of adults living with one or more chronic conditions who are managed in primary or other ambulatory care settings. It is the first of its kind to assess the outcomes and experiences of patients managed in primary care across countries.