Health system performance assessment landscape at the EU level: a structured synthesis of actors and actions

A focused search was conducted and documented to identify initiatives in health system performance at the EU level. For simplicity, in this initial step we considered initiatives that are either completely or mostly at EU level covering the following key institutional players: the European Commission and its relevant Directorates-General (DG), EU agencies and the European Council, the Organisation for Economic Cooperation and Development (OECD), and the World Health Organisation Regional Office Europe (WHO-EUR). Initiatives developed at the level of MSs and other international or intergovernmental initiatives that do not pertain to Europe (e.g. Commonwealth Fund, World Bank) were excluded. Due to the nature of institutional websites as the primary source of this search and the inherent linkage between findings, formal systematic review methods were not pursued for the mapping exercise. The following selection criteria for initiatives were applied of which a minimum of three had to be fulfilled:

The current search was conducted on over 25 websites of the key institutions, and the top 50 search hits of the Google website. In addition, the database on completed European and international projects drawn from the Health Data Navigator (HDN) was used [18]. The HDN was developed as part of the EuroREACH project and is continued in BRIDGE Health. The search was limited to a publication date after 2000 and was performed between October 2015 and June 2016 accompanied by three rounds of adjustments based on input from experts of the BRIDGE Health System Indicators Task Force. Included were policy and research documents, consultation and opinion papers, project reports, meeting minutes and other corresponding electronic documents. In total, over 75 websites were searched with the following terms in English to draw out a broad range of relevant initiatives: “health system performance assessment” AND (“framework” OR “initiative” OR “method”) AND (“EU” OR “European” OR “Europe” OR “European Commission”). Tthe search string (“EU” OR “European” OR “Europe” OR “European Commission”) was not used on websites related to the EC and the European Council to avoid redundancy. Reference lists of included literature were also examined. However, the majority of the initiatives included in this synthesis were identified with the search terms on the respective websites.

A visual organizational map was created which features identified initiatives. Such a map is a commonly used diagram in the field of business administration that outlines the roles, responsibilities and relationships between individuals within an organization in just one picture [19, 20]. It typically illustrates the relations and decision making power by linking the different functions depicted as boxes with lines on different levels [19, 20]. For our purpose, the map was organised by institution and the extent of their contributions by making use of graphical forms and colour schemes. The map makes use of angular rectangles to represent these institutions, their associated key directorates the supporting agencies as well as the individual initiatives. We further distinguished the type of resources produced by these initiatives:

Initiatives for which more than one type of output applies are represented by multi-coloured rectangles reflecting their multidimensionality. Lines indicate collaborative or supportive relations between actors and initiatives. While there are of course links between Eurostat and OECD, the map expresses this collaboration via the central role of the EC. A grey line connecting EC and OECD is used to represent this increasingly important collaboration. This synthesis is complemented by a timeline perspective in the form of a flow chart were the evolvement of actors and actions between 1998 and 2016 in the field of HSPA is displayed.

International agencies play an important role in promoting the comparison of health system performance across EU countries [2]. Since the World Health Report 2000, plenty of resources have been developed to facilitate such comparison and support HSPA in general [1]. The OECD and WHO have an instrumental role in driving international comparisons of health systems with their data repositories. The most important data are the OECD Health Statistics including the “Health Care Quality Indicators (HCQI)” [21‐23] and the “WHO Health for All database” [24], and specific annual publications, such as “Health at a Glance” [25] or the “European Health Report” [26, 27]. Furthermore, we identified different HSPA related topics featured explicitly in publications resulting from the OECD’s “health policy studies” [28‐31]. Analytical work on the efficiency of health care systems performed by Joumard and colleagues remains central in this area [29]. More recently, the OECD initiated an “ad hoc reflection group” to seek comments from experts on health care efficiency indicators with the intent that comments would facilitate prioritization of these indicators [32].

A major milestone in the collaboration between the EC, OECD and WHO-EUR was the initiation of the joint data collection in the context of the OECD System of Health Accounts (SHA), the standard framework for producing consistent and internationally comparable health system financial data [1, 33]. Also, the biannual publication series “Health at a Glance: Europe” represents another major and vastly important collaboration output between the EC and OECD.The selection of indicators for this report is largely based on the “European Core Health Indicators (ECHI)” shortlist. This list has been created by the EC with the aim to monitor health in the EU [34]. The “European Observatory of Health Systems and Policies (OBS)” is a further partnership between the EC, the WHO-EUR, the World Bank and certain MSs serving as a prime source for informed and comparable descriptions of health systems [35]. The “European Health Information Initiative (EHII)”, established in March 2015, is another recent collaboration between WHO-EUR, EC, OECD, MSs and related health information networks and associations supporting the development of a single European health information system focusing on a set of targets and indicators as defined in Health 2020 [36]. The “State of Health in the EU” initiative, launched in June 2016, is the youngest collaborative initiative with DG Santé and OECD which is aided by the OBS. Itt aims to develop individual country health profiles to support health policies in EU countries [37].

Main actors within the European Commission in the field of HSPA are DG Santé, DG RTD, DG ECFIN, Eurostat, DG EAC and DG EMPL. The European Commission has created the “European Core Health Indicators (ECHI)” initiative, which assembles 88 indicators relevant to HSPA, for over 50 of which data are readily available and reasonably comparable. Besides the ECHI indicators and the joint “Health at a Glance: Europe” reports, DG Santé operates the field of HSPA with further initiatives. First, the “Expert Group on HSPA (EG HSPA)” serves as a forum where MSs exchange experiences on the use of HSPA at national level, and receive support in identifying tools and methodologies to develop HSPA further [38]. So far, one relevant report has been produced describing the different strategies MSs apply to assess quality of care. Further work of the EG HSPA will cover prioritised topics such as integrated and primary care [39, 40]. Furthermore, the independent and multidisciplinary “Expert Panel on Effective Ways of Investing in Health (EXPH)” also issued an opinion on identifying criteria for prioritizing areas for HSPA which was based on work of the EG HSPA’s predecessor, called “Sub-group 5 on measuring and monitoring the effectiveness of health investments” [12, 41]. The work of Sub-group 5 was initiated by the Council’s “Working Party on Public Health at Senior Level” in 2011. Most recently, access to health services was also subject to a detailed statement by the EXPH [42]. The “Expert Group on Health Information (EGHI)”, a consultative MSs body, supports the implementation of national and cross-EU health strategies including health information [43]. Core to this is the envisioned set-up of a European Research Infrastructure Consortium (ERIC) on Health Information which is currently being conceptualised within the BRIDGE Health project [43‐45]. Fig. 1 lists most of the projects endowed by BRIDGE Health that collected new data and developed health information frameworks, standardisations and quality control methods. The “European Structural and Investment Funds ESIF for Health” developed a toolkit with a set of widely available indicators deemed useful for the final evaluation of actions supported from the ESIF [46].

Several other relevant projects have been funded under the Commission’s FP7 programme to identify and analyse health data from the perspective of cross-country comparisons including “EuroREACH” [47], “EuroHOPE” [13] and “ECHO” [48]. DG RTD funds EU research programmes as part of Horizon2020 and the Joint Research Centre (JRC). In the recent programme JRC aims to provide science and knowledge service on health and safe environment and consumer health and safety among other non-nuclear topics [49]. In addition, the “European Research Infrastructure Consortia (ERICs)” “SHARE”, “BBMRI” and “ESS” were established to provide resources and related services used by the scientific community to conduct top-level research in the broader field of health [50‐53].

DG ECFIN has produced three relevant pieces of work focusing on the sustainability of health services. For example, in the context of the “European Semester” Country-Specific Recommendations (CSR) are made through the analysis of health system efficiency [54‐57].

At EU level, the European Statistical Office, “Eurostat”, is the main data collection body and main data provider [58]. Its role in the area of high quality health data has enhanced greatly in recent years. In light of the broadened understanding about the importance of wellbeing for economic progress, the “Quality of life” indicators were developed [59]. Together with OECD’s “Better Life initiative” [60] they form a further strand of approaches where relevant indicators are being used. These initiatives are currently only loosely connected. At Eurostat level, the initiative on “Sustainable Development Indicators” is using selected health indicators at different levels of importance for monitoring the sustainable development strategy of the EU [61]. DG EAC monitors the health of Europe’s youth with one tailored tool [62, 63].

Lastly, the “Social Protection Committee (SPC)” and its Indicators Subgroup adapted the “Joint Assessment Framework (JAF)” methodology to the area of health systems. This serves as a reference HSPA tool for supporting the monitoring and assessment of structural reforms focusing on issues related to access, quality and equity [5, 8]. Progress on the social protection policy goals is monitored with a tool called “Social Protection Performance Monitor (SPPM)” that makes use of some specific ECHI indicators [64]. The recent “European Pillar of Social Rights” initiative led by DG EMPL also addresses the importance of timely access to ensure good quality and affordable health care and long-term care for Europeans [3].