Health system performance assessment (HSPA) is the process of monitoring, evaluating and communicating to what extent various aspects of a health system meet key objectives. The central purpose of HSPA is to assess whether progress is being made towards desired goals and whether appropriate activities are undertaken to promote achievement of those goals.

Before elaborating on the concept of health system performance assessment (HSPA) further, it is helpful to first shed some light on the different concepts and terminology related to this topic. The following table illustrates the differences between a ‘healthcare system’ and a ‘health system.’

Table 1. The difference between a healthcare system and a health system, and between healthcare system performance and health system performance

Healthcare systemCombined functioning of public health and personal healthcare services that are under the direct control of identifiable agents, especially ministries of health.
Healthcare system performanceThe efficiency and equitability of the professional public health and personal healthcare services within a system, including a cost-benefit analysis.
Health systemAll activities and structures that determine or influence health in its broadest sense within a given society. This also includes social, environmental and economic determinants of health.
Health system performanceA broader concept that also acknowledges the broad range of determinants of population health that are not directly related to healthcare service delivery. It embraces the notion that the health status of a population is only partly influenced by the quality of the available healthcare services, and that there are many other social, cultural, political, economic, environmental, educational and demographic factors influencing population health.

There are three distinct strengths to a health system performance assessment compared to a healthcare system performance assessment, namely:

  1. A health system performance assessment embodies a holistic approach. The whole system is incorporated, and the assessment surpasses the narrow scope of just the healthcare system.
  2. Involvement of all stakeholders is possible. It gives the various agents a sense of ownership and responsibility, and helps them to make informed decisions.
  3. There is a strong emphasis on the overarching objectives of health systems.


Five key characteristics of HSPA

There are 5 key characteristics for adequately applying the concept of health system performance assessment (HSPA). HSPA should be:

  • Regular: Assessing the performance of a health system is a continuous and iterative process.
  • Systematic: The approach should be structured and consistent.
  • Transparent: The assessment has to be clear, unambiguous and understandable for others.
  • Comprehensive: The whole system should be covered. Furthermore, we have to be aware that the performance of a system does not simply equal the sum of the performance of its various components.
  • Analytical: Complementary sources of information should be consulted to obtain a comprehensive and well-founded overview of the health system’s performance. Quantitative indicators should be supported by qualitative insights, just like performance indicators should be supported by a policy analysis. HSPA is in essence a comparative evaluation, and the reference points for comparison have to be chosen wisely. Some relevant reference points for comparison could be:
    • Developments over time
    • Local, regional, national or international differences
    • Differences between population groups (e.g. based on age, gender, income, SES etc.)
    • Comparisons to certain targets or benchmarks


The WHO Health Systems Framework

The WHO states that a health system consists of all organizations, people and actions whose primary objective is to promote, restore or maintain health. The WHO has developed a model which is comprised of six building blocks. Collectively, these six building blocks represent the ‘complete’ health system. The building blocks are illustrated in the following figure.

Figure 1. The six health system building blocks of the WHO
WHO health systems building blocks

  • Service delivery: This represents the effectiveness, safety and the quality of health interventions. It means that health interventions are available to whoever needs them, regardless of where and when they are needed, with minimum waste of resources.
  • Health workforce: A professional health workforce is responsive, fair and efficient in achieving the best possible health outcomes, making optimal use of the available resources and given circumstances. There should be an adequate number and diversity of competent, productive and responsive medical professionals, distributed fairly amongst society.
  • Health information system: A well-functioning health information system ensures the production, analysis, dissemination and use of reliable and up-to-date information on health determinants, health system performance and health status.
  • Access to Essential Medicines: Essential medical products, vaccines and technologies should be equitably accessible to the population. These medical provisions should be of guaranteed quality, safety, efficacy and cost-effectiveness.
  • Financing: Adequate funding for health should be ensured, to make sure citizens can obtain needed services. Citizens should be protected from disproportionate financial losses when obtaining health services.
  • Stewardship/Governance: Also called leadership. It involves establishing strategic policy frameworks in which effective oversight, coalition-building, adequate regulations and incentives, and accountability issues are all properly implemented and addressed.


Which dimensions and indicators to choose for HSPA?

An indicator is appropriate for inclusion in a HSPA if 5 critera are met, as illustrated in table 2 below.

Table 2. The 5 criteria that make an indicator suitable for inclusion in a HSPA (source: Veilard et al. 2010)

ImportanceThe indicator reflects critical aspects of health system functioning
RelevanceThe indicator provides information that is useful for monitoring and measuring health system performance for an extended time period
FeasibilityThe required data are readily available or can be obtained with reasonable efforts
ReliabilityThe indicator produces consistent results
ValidityThe indicator is an accurate reflection of the dimension it is supposed to represent

To conclude, table 3 provides an overview of potentially relevant dimensions, including several exemplary indicators per dimension.

Table 3. Exemplary dimensions and indicators for HSPA

DimensionExemplary indicators
Access- Physicians per 1000 inhabitants
- Waiting time for an appointment with a GP or medical specialist
- Waiting time for an donor organ
- Geographic coverage of GP practices (percentage of people that are within a 20 minute drive from a GP)
Quality- Immunization rates
- Five year survival rates for breast, cervix and colon cancer
- Percentage of patients treated in accordance with evidence-based guidelines
Safety- Rate of MRSA infections
- Percentage of patients in long-term care facilities with decubitus
- Percentage of patients experiencing side-effects of medication
Equity- Life expectancy at birth
- Avoidable mortality
- Health service utilisation
- Differences per gender, age group, income, living area, SES
Fairness- Government spending on health as a percentage of total government spending
- Total household out-of-pocket payments
- Health insurance affordability and coverage
Continuity- Support after leaving the hospital
- Percentage of chronically ill patients experiencing coordination problems with medical tests
- Patients enrolled in disease management programs
- Patients receiving contradictory information from different healthcare providers
Efficiency- Average length of hospital stay
- Percentage of surgeries in day-clinics
Responsiveness- General satisfaction with the healthcare system
- Patient-perceived interpersonal contact
- Patient involvement in decision-making processes
- Patient-doctor interaction (explanations, possibility for asking questions, check-up telephone calls)
Sustainability- Healthcare expenditure as percentage of GDP
- Cost-effectiveness
Population health- Healthy life years
- Infant mortality
- Obesity rates
- Ischaemic heart disease rates
- Self-perceived health

  • Veillard J, Huynh T, Ardal S, Kadandale S, Klazinga NS, Brown AD. (2010). Making health system performance measurement useful to policy makers: aligning strategies, measurement and local health system accountability in Ontario. Health Policy, 5 (3), 49-65.
  • World Health Organization. (2010). Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva, WHO Press.
  • Special acknowledgement: Dr. Kai Michelsen, Maastricht University