How can Health System Performance Assessment (HSPA) lead to improved health and equity?

Health System Performance Assessment (HSPA) has become a priority topic at the EU level. HSPA is a tool that governments can use to assess the efficiency and financial sustainability of their health systems, as well as quality and accessibility, in order to improve health outcomes for all.

By Caroline Costongs

Every government is responsible and accountable for the health of their citizens. HSPA can be used as an instrument to improve transparency and accountability and for health systems strategic planning. What opportunities and challenges does HSPA present for the field of health promotion and disease prevention and for those of us striving for greater health equity?

HSPA on the political agenda in EU

First of all, we have to acknowledge that there is high-level support for HSPA at the EU level: President Juncker just provided the new SANTE Commissioner Andriukaitis the mandate to develop expertise for HSPA. EU institutions are already issuing Country-Specific Recommendations on the sustainability of health services to the majority of EU member states. The Social Investment Package (SIP) “Investing in Health” called for the development of a sound methodology for HSPA. The Social Protection Committee drafted an Assessment Framework which is now being piloted. In addition, the European Commission recently issued a communication on effective, accessible and resilient health systems with a focus on HSPA. The Council Working Party on Public Health at Senior Level has just set up a HSPA sub-group, led by Sweden, and HSPA is discussed at a meeting of European health ministers this month.


EuroHealthNet is monitoring these developments and having internal discussions on whether this increased focus on HSPA provides an opportunity for health equity, and whether and how we should get engaged. From our perspective, HSPA should focus on the health system as a whole, including health promotion and disease prevention and if possible even including ‘Health in all Policies’ (HiAP) indicators.

HSPA is relevant for health promotion

It is interesting to see the extent to which the outcomes of such HSPA are relevant to health promotion. For instance, in a peer review on HSPA in Belgium earlier this year, they defined several priorities for policy action as a result of the HSPA exercise. They concluded that increased actions are needed on suicide, obesity, tobacco, alcohol, cancer screening, medical irradiation, diabetes follow up, antibiotics, consumption of anti-depressants, financial access, smooth gate keeping, and on the GP workforce. Most of these recommendations are relevant to public health and health promotion and reflect an opportunity for national and regional health authorities to get involved.

Member state governments should not simply focus on identifying cost-effective means of curing people, they should also focus on finding ways to prevent people from becoming ill in the first place. The focus of HSPA should therefore not only be on healthcare systems, but on health systems as a whole, including health promotion, disease prevention as well as actions to improve the social determinants of health.



HSPA should measure efficiency, access and equity

HSPAs are certainly not easy to undertake. Measuring the efficiency of health systems is a complex task. Inefficiency should be avoided of course: too much money is spent on some people (dual tests, overuse of medicines), money is sometimes spent on the wrong patients, or it is spent providing the wrong treatments. However, this aspect is not well covered in HSPAs and it is difficult to measure waste. Patient-related outcome measures are the only way to find out whether people receive effective interventions that increase their health benefits. This element needs to be part of HSPA and include people from different socio-economic backgrounds.

In terms of equity (i.e. people with equal need get the same care) it is also difficult to measure need. This can be done in surveys by comparing people with the same disease and seeing whether they received the same treatment. However, unmet needs are even more difficult to measure across different patient groups.

CC_Annex 1

It is important to define which methodologies and indicators can best be used to assess value for money and equality of health outcomes at the EU level. In addition, co-operation with WHO and OECD on indicators and data monitoring should be strengthened.

HSPA to inform policy making

HSPA is not yet used by all countries in the EU in similar ways, which in part explains why the EU is focusing on the issue. It is also not yet clear how HSPA can best be embedded into national and European policy making. HSPA is a highly technical exercise, dependent on country-specific contexts and therefore the results do not automatically lead to policy action.

Involvement of policy makers and stakeholders such as public health institutes in the design of HSPA and in the selection of indicators is important, as well as effective dissemination of results among all concerned. International comparison among EU countries, benchmarking between regions within a country and comparison over time can attract the interest of the public, professionals and policy makers to improve performance in their own settings.

HSPA is a potentially useful tool to help design health promoting health systems.

Questions for debate

What are practical ways forward? To what extent can we assess the performance of public health measures, health promotion actions or even include measures from other policy areas that impact on health and health equity? What data and indicators are available and are they linked to socio-economic data?

Many actions related to health promotion and prevention will only start demonstrating outcomes ten to 15 years later on. How can the long-term outcomes in HPSA be assessed? Which short-term, process-related outcome measures could be used instead? How could cost calculations be included? Money spent on health promotion and HiAP is often spent in other sectors and not only in health.

In order to keep things simple, most people argue that HSPA should stay within the remit of ministries of health. Do we agree with that perspective? Health promotion and public health experts should be prepared to get engaged and come up with justified and feasible alternative proposals that can be used to check whether health systems and governments improve health and contribute to health equity.

EuroHealthNet is interested in hearing your views about HSPA and on including health promotion, public health and the wider health determinants within it.

If you are interested in contributing to the debate, please contact the EuroHealthNet office.

Caroline Costongs
Director at EuroHealthNet | + posts

Caroline Costongs is Director of EuroHealthNet.

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