The concern with measuring the performance of health systems and health care is not recent. In the 1860s Florence Nightingale pioneered the systematic collection, analysis and dissemination of comparative hospital outcomes data in order to understand and improve performance. Fifty years later, Ernest Codman promoted the need for scrupulous collection and public release of surgical outcome data (Spiegelhalter, 1999). However, there were many practical, professional and political impediments to making such principles operational. It is only in the last ten years that the vision of using large-scale data sources to help improve health system performance has become a reality...

A common goal among the health systems of OECD nations is to optimise the health of individual patients and populations in an equitable, efficient and effective manner that is acceptable to patients, providers and administrators. No “magic bullets” have been found that will achieve this goal through reforms of service delivery or finance. Instead, improvement appears to require incremental change at all levels of health systems. This evolutionary process, in turn, depends on systematic measurement of health system performance, coupled to decision-making processes grounded in evidence...

OECD health systems are under stress. That stress arises from the combination of the buoyant demand for health services and the continuing private and public desire for limitation of the rate of growth of health expenditure. It also arises from concern about continuing inequities in health and in access to health care...

This paper charts the development of performance measures in health care in England and their current use in managing the NHS. The last 10 years have seen a shift from measures of activities and costs, to measures of outputs and outcomes and from a focus on efficiency to a “balanced scorecard” approach to monitoring and measuring performance. It has also been recognised that performance measures are only one element of a performance management system. The current framework for assessing NHS performance, “The Performance Assessment Framework (PAF)” is complemented by mechanisms for defining standards and targets (the NHS Plan, National Service Frameworks and National Institute for Clinical Excellence), by systems of incentives (including NHS Performance Ratings, a system of “earned autonomy” and a new NHS Performance Fund), and by services to monitor and support behavioural change (clinical governance, a Commission for Health Improvement and a Modernisation Agency). The paper reflects on what has been learnt from the NHS’s experience with performance measurement and performance improvement to date. It ends with some thoughts about future developments.

Swedish health care is publicly financed through local county taxes. Care is delivered either by institutions run by the county councils or, increasingly, by private organisations, often owned by the county councils. The National Board of Health and Welfare is independent from the Ministry of Health and is non-political. It has two tasks: to issue guidelines on evidence-based medicine and good practice; and to undertake surveillance of institutions and personnel providing health care...

This paper provides a market-based example of using performance measurement to promote health care quality improvement. Underlying this approach is a model of informed consumers making choices among competing health care providers based on cost and quality. Providing information to consumers on quality can create incentives for providers to improve their performance as they attempt to maintain or expand their market share. The paper focuses on efforts in the United States to provide performance information to consumers. It provides an overview of current performance measurement and reporting efforts and summarizes empirical literature on the effects of such efforts on quality improvement. In brief, these efforts are in their early stages and have not yet had a large impact.... 

The Dutch health care system has both in financing and health care provision a hybrid nature. Financing is realized through a mixture of public and private insurance executed by care insurers with a (semi) private status. Health care is provided through professions and institutions that function to a large extent as not-for-profit private entities within a highly regulated context, reimbursed through a mixture of budgetary, pro-capita and fee-for-service schemes. The role of the state has changed over the years. Roughly one can claim that in the fifties and sixties the welfare state was created, in the seventies and eighties government tried to control the growing costs through managing the structure of health care by planning regulation and in the nineties the processes within the system (regulated market) were the main policy paradigm. At the turn of the century the steering paradigm is shifting towards the input (needs assessment) and outcome (performance measurement) of the system. Not only production and costs, but also performance in terms of health outcomes and consumer satisfaction are deemed relevant management factors…

What are the appropriate levels and methods of funding, and the optimal mix of services for improving health care system performance? Policy-makers confronted with this question often look to other countries for answers. What they find is much variation across countries, with little understanding of how this relates to performance. The purpose of our paper is to demonstrate how a disease-based approach for comparing health care systems can help us better understand what drives health care system performance...

Policy makers have long been concerned with improving the performance of their health systems with reforms targeting all system functions – financing, provision, stewardship and resource generation (Maynard and Bloor, 1995; Collins et al., 1999). Yet the evidence of what types of changes to health systems improve their performance is limited, inconsistent and inconclusive. Accordingly, WHO has developed a wide ranging work plan to develop the scientific basis to ensure that its technical advice on health system development is based on the best available evidence. One component of this work was to summarise and disseminate the available evidence on the links between health policy, system design and system performance in the World Health Report 2000 (WHO, 2000) and the Executive Board of WHO has committed the Organization to report on the health system performance of all WHO Member States regularly…

This paper focuses on the patient’s perspective on health care quality. We look first at data on patients’ experience of hospital care in five countries: United States, United Kingdom, Germany, Sweden and Switzerland. Having identified the extent and nature of the problems from the patient’s point of view, we then describe various policy initiatives that have been taken in the United States and the United Kingdom to try to improve the patient’s experience, looking at research evidence on the actual and likely impact of these.

This paper uses methods proposed by Wagstaff and Van Doorslaer (2000) to generate new international comparative evidence for 1996 on the degree of horizontal equity achieved in health care utilisation in 14 OECD countries. The index of horizontal inequity used measures deviations in the degree to which the use of doctor visits is distributed according to need. The data for the 12 European Union member states are taken from the third wave of the European Community Household Panel, the data for Canada are from the second wave National Population Health Survey and the US data stem from the first wave of the Medical Expenditure Panel Survey. We find that in all countries physician visits tend to be significantly more concentrated among the worse-off. After standardising for need differences across the income distribution, significant horizontal inequity in total physician visits emerges in only four of the countries studied: Portugal, the United States, Austria and Greece…

The quality of hospital care has become a focal point in the regulation of health systems. This can be put down to several factors: the funding crisis, greater public demands on health care professionals owing in part to the wider availability of health-related information and, finally, the development of new data processing technologies. This combination of factors has caused the medical profession’s monopoly to be called into question and has prompted calls for the development of external schemes to monitor, and even control, service provision…

Our objective lies in clarifying the basic issues in long-term care (LTC) policy, describing instruments for the comprehensive assessment of those receiving LTC in institutional and community settings, and demonstrating how the assessment database could be used to measure quality…

There exist several dimensions along which health system performance might be measured, and numerous indicators of performance have been proposed. Many such indicators do indeed capture important aspects of system behaviour, but each is to some extent partial, and as a result potentially misleading. Given the intense policy interest in system performance, the question therefore arises: can some form of aggregation of indicators yield a more satisfactory insight into performance than the partial view offered by individual indicators? This paper examines the extent to which some sort of aggregation is possible and useful. It starts with a discussion of some of the key economic concepts associated with system performance…

The cycle of performance measurement and management begins with explicitly establishing goals which are reflected in the adoption of specific performance indicators, followed by analysis and actions aimed at producing change to improve performance in a variety of dimensions such as equity, access, effectiveness, efficiency and social responsiveness. The application of performance indicators may involve simply reporting data to actors for accountability purposes, or it may involve, in addition, taking action to stimulate change…

A mere summary of the proceedings would not adequately convey the importance of the conference organised by the OECD in Ottawa. What was said there reflected so much breadth of experience, and was presented in so much depth, that such a synthesis is impossible. This chapter will seek to report on the conference differently and in three ways...