1. An analytical framework and scorecard for people-centred health systems

Economic growth and social progress have driven major gains in health in recent decades, with life expectancy at birth rising by more than 13 years on average across OECD countries since the Organisation was created in 1960. This progress is unquestionably one of the greatest success stories of the 20th century. At the same time, it has meant that the challenges faced by health systems today are in many cases different from the challenges these systems were developed to address. 

The rising burden of non-communicable diseases offers a key example of this challenge. Successful fight against infectious diseases has led to non-communicable diseases – including cardiovascular disease, cancer, and diabetes – becoming the leading causes of death and disease globally. Yet despite this epidemiological shift, health systems have not necessarily shifted their focus. Only about 3% of total health expenditure is spent on prevention, including prevention of risk factors for chronic non-communicable diseases and core public health functions to respond to threats from emerging infection diseases.

Similarly, improvements in health have contributed to gains in life expectancy and the population ageing is now driving major demographic shifts. Since 2000, life expectancy at birth in OECD countries has increased by more than four years, from 76.9 to 81 years. At the same time, the proportion of the population aged 65 years and older in OECD countries is rising fast and now represents more than 17% of the population on average. This demographic change has brought with it a rise in health conditions and diseases associated with ageing, including Alzheimer’s and other dementias. It has also increased the need for long-term care services, both at home and in care facilities. These factors, together with rising costs associated with new health care technology, are driving further health spending growth, raising total health spending, now accounting for 8.8% of GDP, on average across OECD countries (prior to the COVID-19 pandemic), and projected to rise to 10.2% of GDP by 2030. 

The COVID-19 pandemic has compounded such structural pressures, as health systems must be able not only to maintain continuity of regular services for chronic patients, but also to quickly detect and contain emergent infectious diseases. Continuity of services requires surge capacity and an ability to secure supplies of essential goods in times of disruption. Strong essential public health functions such as surveillance, testing and contact tracing, laboratory capacity, data collection and data sharing, preparations for large scale vaccination need to be managed at speed and scale. Similarly, the pandemic has highlighted the need for strong people’s capabilities to manage their own health and population buy-in and responsiveness to implement containment measures.

Against this already complex scenario, the expectation of what health care systems should provide has also risen. These rising expectations has been driven not only by higher incomes but also increasing access to information, including information available through digital technology. People today are better able than ever to seek information about their health and the care they receive, and to challenge health systems to deliver better care. More educated and internet-savvy health system users today may be far less tolerant of the doctor knows best approach which dominated health care in the 20th century. 

Demographic change, the advancement of digital technologies, the epidemiological shift towards NCDs and the threat of emergent infectious diseases, together with rising expectations over what health systems should deliver require health systems to become more responsive to the people who use them. The growing expectation that people will have a say in decisions about their care requires a systemic shift towards a more person-centred approach. Similarly, non-communicable diseases and age-related health conditions often require a long-term, co-ordinated approach to help manage and care for chronic diseases. By equipping people with the right information and motivation, a people-centred health system can help health service users make wiser health choices. Moving towards people-centred systems also represents a move towards a shared responsibility, encouraging people, where they are able to do so, to take responsibility for maintaining their own health and for contributing to collective efforts to tackle public health threats.

While countries have made significant progress towards putting in place policies that advance a people-centred health systems agenda, progress remains uneven, and thinking around people-centredness too often takes a siloed approach, overlooking how different dimensions of the health system must work together to deliver truly people-centred care.

People-centred care is not a new concept. Putting people at the centre has been a priority for health systems in recent decades. The importance of including patients in their own care was recognised in the 1978 Alma Ata Declaration among other global health commitments. There has been extensive discussion – in the literature and by practitioners and patients – of what matters for people-centred care and what building blocks are needed to achieve it. At the same time, there is no universally agreed-upon definition of what constitutes a people-centred health system, let alone what is needed to accomplish it.

In part, this is due to the necessary complexity of providing care that is responsive to the individual person. What matters for some people may be seen to be unnecessary or objectionable for others; moreover, an individual’s needs are not static, and preferences may change over time (Health Foundation., 2016[1]). The notion of who is at the centre of the health system has itself also changed: the original concept of ‘patient-centred’ care has arguably evolved beyond a focus on just patients, to more holistically consider the broader context of the individual, their families, and other carers (Santana et al., 2018[2]). The interpretation of ‘people-centredness’ has also differed in different contexts: In the United Kingdom and Canada, for example, the idea of ‘patient-centred medicine’ has been associated with primary care, while in the United States, patient-centred care emerged primarily from the patient’s rights movement (Nolte, Merkur and Anell, 2020[3]). The World Health Organization by its turn emphasises the central role of integration in the concept of people-centredness (World Health Organization Regional Office for Europe, 2016[4]).

There have been multiple, often overlapping efforts in the literature to identify and categorise the key components of people-centredness. While differences have emerged in the terminology used around the concepts of ‘people-centred care’, many of these different definitions share common themes. There is much consistency in terms of what the people-centred health system entails: placing people, their families, and communities at the heart of health systems, empowering them, building care around the needs and expectations of the individual, and delivering health in a way that makes the best use of the resources available. Different frameworks have approached categorising people-centred health systems in diverse – though ultimately complementary – ways, including through the role of the person in people-centred health systems, the principles underlying people-centred systems, and how health systems must be organised to deliver people-centred care.

The European Observatory of Health Systems and Policies of WHO Europe has developed a broad framework identifying the three core roles people take in the health system, and how these interact with and influence care: voice, choice, and co-production. Voice refers to the service user as a citizen: they should be involved in health service and systems development and policies, from the micro-level (for example, community participation in service development and design), to the macro-level (taking people’s voices into account by listening to their views and experiences and responding accordingly). Choice relates to the service user as a consumer: they are able to choose payers, providers, and treatments. Co-production denotes the role of the person as a participant in their own health: as a co-producer, through self-management and co-ordination, as well as through their role in shared decision-making and choosing treatments (Nolte, Merkur and Anell, 2020[3]). The idea of co-production moves away from the traditional view of the health system as one that that provides care as a “product” made for and delivered to patients, towards a view of health services continually shaped and reshaped by both, together.

Other frameworks are structured more around the principles of people-centred care than the roles of the service user in it. In the United Kingdom, the Health Foundation has developed a framework around the four guiding principles of people-centred care: personalisation, co-ordination, enablement, and dignity, respect, and compassion (Health Foundation., 2016[1]). Under this framework, people should be expected to receive personalised and co-ordinated care, support or treatment, through a health system that enables them to identify and build their personal abilities and strengths, facilitating a more autonomous and satisfying life.

A third approach takes a ‘roadmap’ approach to what must be in place to achieve people-centredness, focusing on structure, process, and outcome (Santana et al., 2018[2]). At the systems or organisational level, it is critical to facilitate a culture of person-centred care, including co-designing educational programmes, health promotion and prevention programmes, enabling the workforce commitment to person-centred care, developing structures that facilitate good use of health information technology, and develop structures that help to measure and monitor person-centred care (Santana et al., 2018[5]). This forms the structure that enables person-centred care. Cultivating communication, respectful and compassionate care, engaging patients in their care, and integrating care underpin the process by which person-centred care is then delivered. Lastly, to demonstrate the value of person-centred care and ensure that it lives up to its intentions, it is critical that relevant outcomes, including access to care and patient-recorded outcomes, are measured.

In addition to the framework in development by WHO Europe mentioned above, the World Health Organization also published in 2016 an analysis that takes a ‘roadmap’ approach: the Framework on Integrated People-centred Health Services (World Health Organization Regional Office for Europe, 2016[4]). With strong emphasis on the notion of integration of services, the framework proposes five strategies to achieve a vision of people-centred health systems: (1) engaging and empowering people and communities; (2) strengthening governance and accountability; (3) reorienting the model of care; (4) co-ordinating services within and across sectors; and (5) creating an enabling environment.

While existing frameworks for people-centred care propose different structures for thinking about this concept, they share many of the same underlying principles for what key principles must be put in place to move towards a people-centred health system. The OECD Framework for People-Centred Health Systems builds on this previous work to further refine the key dimensions of people-centred health systems and the health systems policies that must be in place to achieve people-centredness. It is intended to work in parallel, and not replace other frameworks developed by the OECD, such as the OECD Framework for Health System Performance Measurement, originally developed in 2006 (Kelley and Hurst, 2006[6]) and revised in 2015 (OECD Health Care Quality Indicators Expert Group, 2015[7]).

The OECD Framework on People-Centred Health Systems takes further the key building blocks identified as foundational to achieving people-centredness. It identifies five dimensions of people-centred care from the literature – including ensuring voice, choice, co-production, respectfulness, and integration – and provides key quantitative indicators for domains and policy benchmarks that can help countries assess to what extent their systems are people-centred. By underpinning the key priorities of people-centred systems with key outcome, process and policy measures, the framework also helps to identify synergies to make health systems more people-centred. The dimensions, domains and policy benchmarks for the OECD Framework for People-Centred health Systems are presented in Table 1.1 below.

In recent years, as countries have moved 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. Initiatives to strengthen patient-reported measures, including the OECD Patient-Reported Indicators Surveys (PaRIS), are critical to understanding people-centredness, but reflect only part of the story of whether health systems as a whole are performing in a people-centred way. Healthcare governance, physical and financing structures, training, incentives, and many other levers can influence whether people are able to receive person-centred care.

To help countries to assess the progress they are making towards people-centred care, and identify whether there are certain dimensions or policy areas that could benefit from particular attention, a Scorecard was developed for this report. It identifies policy benchmarks across the five dimensions of the OECD People-Centred Health Systems Framework. Thirteen policy indicators were selected for inclusion in the Scorecard (Table 1.2). The benchmarks included in the Scorecard were selected based on their policy relevance to each dimension. They also take into account considerable challenges related to data availability across countries. An evaluation of available data conducted for this report strongly indicates that good data to assess people-centred health systems remains the exception rather than the rule. Regularly collecting data across the key dimensions that make up a people-centred system will be critical to effect a transformation towards people-centredness across all levels of care.

The indicators included in the scorecard draw on a range of data sources, including OECD Health Statistics, the European Quality of Life Surveys, and the Commonwealth Fund International Health Policy Surveys. Measures were selected based on their relevance to the underlying dimension of the OECD framework, the robustness of the indicator, data availability, and comparability across countries. While the choice of dimensions was based on a thorough literature review, the choice of indicators was also further influenced by the availability of data. The choice of indicators also reflects a compromise between pertinence to the concept of people-centredness and availability of internationally comparable data. Individual countries may have additional indicators that could further contextualise an analysis of person-centredness in their health system that are not widely internationally comparable, and so excluded from this analysis. The full development of the PaRIS International Survey of People Living with Chronic Conditions will help to improve the availability of indicators, both within countries and internationally.

A measure of a country’s performance on each dimension was taken based on the scorecard indicators, with countries grouped together in the top-, middle-, and lowest-performing third for each indicator. Because the indicators capture different aspects of the dimensions, and because the relationship between different dimensions of person-centredness are complex, no comprehensive ‘ranking’ of countries based on their overall performance across the scorecard was taken. Results of the benchmarking exercise suggest that while countries have made progress towards developing people-centred health systems, no country performs strongly across all dimensions. All countries have room to take further steps towards putting people at the centre of their health systems.

The dimension of voice captures the importance of involving people who use the health system – as well as their families and communities – in macro, or systems-level decision making processes. The ability to make decisions and influence the care they receive is critical to a health system centred on the people who use it. It will be essential to ensure that people are involved in decisions about their health care, from the individual to the systems level. Capturing the extent to which patient voices are in institutionalised in macro decision-making processes – across different levels and areas of the health system – is important to understanding the weight which is given to users of the health system in designing the system.

As part of the benchmarking exercise, a composite indicator that captures the institutionalisation of patient voices in decision-making processes across different areas of the health system was developed, using information from the 2016 OECD Health Systems Characteristics Survey (Box 1.1). The indicator identifies the extent to which patients have a formal role in health policy making by assessing whether patients have a formal role in: (1) licensing of pharmaceuticals, (2) coverage or reimbursement, (3) health technology assessment, (4) decisions related to service planning, and (5) definition of public health objectives. Countries were scored on a 1-3 scale depending on the number of areas in which patients have a formal role: countries with a formal role in none or one area were assigned a score of one, countries with formal roles in two or three areas were assigned a score of two, and countries with four or five areas were assigned a score of three.

Results of the benchmarking exercise (Figure 1.1) indicate that few countries have systematically included patients across all areas of health policy decision-making, with one-third of reporting countries indicating that patients play almost no formal role. Only three countries – Australia, Germany, and Portugal – systematically include patients in at least four areas of health policy making. Involving patients in decision-making processes is important to ensuring that health systems and services are designed to best meet people’s needs – in other words, to ensure health care is people-centred. Studies have shown that where input from patients or other community members is included in health initiatives, outcomes related to social impact – beyond the impact on health – are more likely to be captured and reported (Hoon Chuah et al., 2018[8]).

At the same time, official patient involvement in decision-making bodies should be considered a necessary but not sufficient component of a person-centred health systems approach. Even where patients or public representatives may be involved in decision-making, there remains continued debate over what effective public involvement means and looks like (Rozmovits et al., 2018[9]). Experts have called on decision makers to carefully consider the ethical challenges of designing high-quality patient involvement, including the ethics of patient selection and the frequent power imbalance between patient participants and other members of decision-making groups such as health technology assessments (HTA) (Vanstone et al., 2019[10]). In Australia, interviews with stakeholders involved in HTA and health funding decisions demonstrated a lack of consensus between representatives of patient organisations and other stakeholders in the adequacy of existing processes and what should be considered as evidence to guide decision making, with patient representatives more likely to consider broader social and emotional factors beyond bioclinical outcomes ( (Lopes, Carter and Street, 2015[11]; Lopes et al., 2016[12]). Similar tensions around the conceptualisation of evidence were found in a review of assessments for cancer drug reviews in Canada (Rozmovits et al., 2018[9]).

Patient voice is not included evenly across areas of health policy decision-making: just over one-third (35%) of countries reported that a patient or citizen representative is included in decision-making around the licensing of pharmaceuticals, compared with nearly three-fifths (57%) that reported patients or citizen representatives are involved in coverage or reimbursement decisions.

During the COVID-19 pandemic, the speed at which decisions were made – particularly at the beginning of the pandemic – meant that patient voices were often excluded from decision making processes (Richards and Scowcroft, 2020[14]). Evidence from COVID-19 task forces across 24 countries suggests that not only were patients largely excluded from decision making, but that response efforts were largely concentrated among politicians, virologists and epidemiologists, with less input from frontline workers, civil society and social policy experts (Rajan et al., 2020[15]). Ensuring any public health response is person-centred must anticipate the way that policies will affect all populations – particularly responses that so drastically upend the social fabric and daily lives of much of the population. A failure to include patients in consultation and decision making – and a failure to consider the diverse backgrounds of people more broadly – will make it more difficult to anticipate the impacts that rapidly developed containment policies will have on different groups of people in society.

Including patients proactively in health emergency and pandemic response structures could help to ensure patient and family voices are not lost during health shocks. In Ontario, Canada, the Kingston Health Sciences Centre, a university hospital, included patient advisors in scenario planning before pandemic restrictions were imposed, and ensured the chair of the Patient and Family Advisory Council was a full member of the Incident Command team responsible for changing services during the pandemic. Input from patients and family members were directly responsible for certain policy changes implemented during the pandemic, including policies around in-person family visits (Bardon, 2021[16]).

Individuals are consumers of health services and goods, and increasingly wish to have a say in which goods and services they choose, and how. This dimension recognises the importance of providing care that meets people’s expectations, including providing multiple options and alternatives to how care is delivered, to ensure it best meets their needs. At its most straightforward, patients can be given literal choice in the health care services they seek out – for example, choice of physician or hospital. In some cases, this choice is unencumbered, with no gatekeepers, incentives, or other barriers. Even beyond the policy barriers put in place, however, other factors – such as affordability and geography – can create limitations to the ability of patients to exercise the choice they have on paper (OECD, 2019[17]).

The measures of choice included in the OECD benchmarking exercise were selected to measure two components of choice: what is available according to the health system policies of a country, and the level of access patients have based on extrinsic barriers, including affordability (Box 1.2). To evaluate patient choice throughout the health care system, a composite measure based on choice in primary, specialist, and hospital care was created, using data from the 2016 OECD Health Systems Characteristic Survey. Countries were scored on a 1-3 scale based on whether patients have a choice in their selection of their primary care physician, specialist care services, and hospital services. Where the choice of providers is not possible, or is only possible for one level of care, countries received a score of one. Countries where choice was possible on two of the three levels of care (irrespective of which levels these were) were given a score of two, while those where choice was reported possible across all three levels were assigned a score of three.

Patient choice appears to be well institutionalised across a majority of OECD countries. More than half of OECD countries responding to the OECD Health Systems Characteristics Survey reported that patients were given free choice in their selection of primary, specialist, and hospital care, with fewer than 10% reporting that patients were strictly limited in their choice of care (Figure 1.3). A plurality of countries attempt to influence patient choice using financial incentives – particularly at the specialist and hospital levels – though patient choice is not fully circumscribed.

In half (16) of countries, primary care acts as some form of gatekeeper to specialist care – either through strictly requiring primary care referrals to access specialist care (9 countries), or through financial incentives (7 countries) for patients to receive a referral from their primary care physician for further specialist care (Figure 1.4).

Beyond the institutional rules governing patient choice, the ability to choose health care – including selecting physicians or facilities, but also more basic questions of seeking care – is further influenced by factors, such as affordability or geography, that are exogenous to the direct rules of a health care system but can nevertheless impact access to services. To capture how choice may be constrained by access, a measure of the affordability of care – defined as the proportion of the population who had forgone care due to cost – was included in the Scorecard.

Across 22 OECD countries with available data, more than one in six adults (17.2%) reported having forgone care despite a health need (Figure 1.5). The prevalence of forgone care is particularly high among low-income individuals: more than one in four (27.5%) individuals in the lowest income quintile reported going without care due to cost issues, compared with just 8.9% among the highest income quintile. More than one-third of the population in Ireland (34.4%) and Latvia (34.7%) reported foregoing care, while nearly half of all adults in the lowest income quintile reported doing so in Estonia (46.9%), Latvia (55.2%), and Portugal (47%). Less than 10% of the population reported forgoing care in only seven (Austria, the Czech Republic, Lithuania, the Netherlands, Norway, the Slovak Republic, United Kingdom) of the 22 countries.

A people-centred health system cannot be designed without the participation of those who use it. Co-production captures the extent to which health systems have taken steps to involve people and local communities in their own care. Patients must be adequately consulted about their care, including receiving sufficient information from their doctors, and must have the health literacy and information they need to make decisions that are well-informed. Previous research has indicated that despite a growing recognition of the need to improve health literacy, levels of literacy nevertheless remain low across many OECD countries (Moreira, 2018[19]). Increasing levels of health literacy is particularly critical given the growing ownership many patients are taking in decisions around their health, and new sources of information – often outside they health system – they are consulting in doing so (OECD, 2019[20]).

Four measures were identified to capture the extent to which patients are active participants in their care, as well as how much opportunity they feel they are given by the health system to do so (Box 1.3). Two measures evaluate the extent to which patients feel the health system offers them the ability to make decisions about their care. To evaluate whether patients feel they are consulted and given sufficient information to make informed decisions, a patient-reported measure of the share of patients receiving easy-to-understand explanations by their doctor was constructed, using data from the OECD Health Statistics (based on data from national sources and the Commonwealth Fund). A second measure, using the same sources, measures the patient experience in being involved as much as they wish to be in decisions about their care and treatment.

In addition to the variables that evaluate the degree to which the health system – through its doctors and medical staff – give patients the tools and opportunities they need to make informed decisions about their health, two further variables were included that consider how patients avail themselves of information. Using information from the OECD Information and Communication Technology Statistics, a measure of how patients seek information from general sources was included based on the share of individuals who reported seeking health information on the internet during the previous three months. A further measure capturing patient engagement with tools developed by health systems, based on data from the Commonwealth Fund, was also included for a more limited set of countries.

Results indicate that patients report being largely satisfied with the accessibility of information they are given by their doctors, and broadly feel included in decisions about their care. On average across 17 OECD countries, more than nine in ten (91.2%) respondents reported feeling that they received easy-to-understand explanations by their doctor, while more than four in five (84.4%) reported being involved with their doctor in decisions about their care. Fewer than 80% of respondents felt involved in their care in four countries (Estonia, France, Poland, Spain). The fewest respondents reported receiving easy-to-access information and being involved in their care in Poland, where just under four in five (79%) respondents reported being given accessible information, and just over three in five (61.5%) reporting that they were consulted about their care. At least nine in ten patients reported both being given accessible information and involved in their care in five countries – Australia, Israel, Luxembourg, Portugal, and the United States.

Over the past decade, the proportion of people using the internet on a regular basis has increased dramatically, as has the frequency and intensity of internet usage. These trends are reflected in the proportion of adults (aged 16-74) reporting that they had recently used the internet to seek health information. Between 2010 and 2020, the share of individuals reporting that they had gone online for information about health increased by nearly 70% on average across OECD countries, from just over one-third of adults (34.1%) to nearly three in five (57.4%). In more than one in four (8/30) countries with available data, the proportion of adults using the internet for health information more than doubled between 2010 and 2020.

Health systems have invested significantly in scaling up patient-oriented digital health tools, including the development of patient portals and apps that offer patients direct access to their health data and information (often linked to electronic health records), the ability to communicate with health professionals, the ability to access prescriptions, and other tools. Previous analyses have suggested that uptake of many of these tools remained relatively low (OECD, 2019[20]). Data from the 2020 Commonwealth Fund International Health Policy Survey confirms that patient portal use is not yet widespread. On average across the 11 countries surveyed, just three in ten patients reported having used patient portals or apps to communicate with their doctors or download health information. Fewer than one in five patients reported using patient portals and apps for these purposes in nearly half of all reporting countries (Australia, Canada, Germany, Switzerland, United Kingdom). Norway, Sweden and the United States reported close to or more than half of respondents engaging with patient portals and apps to communicate with their doctors or download health information.

Nevertheless, while health-seeking behaviour has increased dramatically, a significant plurality of the population does not yet use the internet for health information purposes. Fewer than half of adults report using the internet for health information in eight (27%) countries, with just over one-third (35%) of adults in Italy having done so. In Finland, the country with the highest share of respondents using the internet for health information, just over three-quarters (77%) of adults reported having sought health information online within the previous three months. Individuals with higher levels of educational attainment, as well as younger adults, were more likely to have reported going online to seek out health information, compared with older and less highly educated adults. Among adults with high educational attainment, three-quarters (75%) reported having sought out health information online recently, compared with just over two in five (42%) adults with low educational attainment. These trends echo broader patterns of unequal access to new digital tools, and risk exacerbating existing inequalities affecting high-quality person-centred care, including around issues of choice (access to services) and co-production (health literacy) (OECD, 2019[20]).

The reduction in in-person consultations and health care services during the COVID-19 pandemic engendered a rapid rise in the adoption of teleconsultations and other digital health tools. On average across 22 European OECD countries, nearly half (45%) of respondents reported that they had used a teleconsultation service during the pandemic. Data from Israel, Norway and Australia suggest that in at least some cases, an uptick in the use of teleconsultation services replaced many of the in-person visits that were postponed or forgone due to the pandemic: In Israel, the number of teleconsultations per capita nearly doubled between 2019 and 2020, while in Norway teleconsultations per capita increased eightfold between 2019 and 2020 (OECD, 2021[21]).

In addition to the implications of fragmentation on overall efficiency and outcomes, poor integration within the health system makes navigating care and services difficult for the people who need them. Better integrated care among patients with chronic conditions has been found to improve well-being and quality of life, while helping to improve self-management of care (Coulter et al., 2015[22]; Kruis et al., 2013[23]). Yet operations within the health system remain too fragmented, too often, with poor co-ordination of care around patients, and frequent fragmentation between health sectors, such as primary and hospital care.

To capture the extent to which health systems have the capacity to deliver integrated care to patients, three measures were identified for inclusion in the scorecard. Two concern the extent to which there has been progress in integrating primary health services – arguably the most critical node for co-ordinating care – with other parts of the health system, with the third measure reflecting the patient’s views on the extent to which they have experienced problems with co-ordination after being discharged from hospital.

Primary care is a central node for delivering co-ordinated, person-centred care, and digital tools are a critical and promising tool to help overcome fragmentation between primary care and other parts of the health system. Yet despite this potential, and the broader scale-up of digital tools in health care, primary care has remained one of the most poorly linked sectors within the health system. While uptake of new digital tools has sometimes been slower in primary care, the majority of countries (15/25) reported that at least three-quarters of primary care physicians use computers to complete all identified tasks, including making appointments, issuing prescriptions, ordering laboratory tests, sending referrals, sending prescriptions to pharmacies, and being alerted of drug dose or drug interaction issues.

Encouragingly, the proportion of primary care physician offices who report using electronic clinical records in their practices has increased dramatically in recent years. The proportion of primary care offices using electronic clinical records increased from 70% in 2012 to 93% in 2021 (OECD, 2019[18]). More than 60% of responding countries reported that 90% or more primary care physician offices used electronic records in 2021, up from less than half in 2012.

In addition to having primary care serve as an important co-ordinating node for care management – particularly for patients with chronic conditions, ensuring a strong continuity of care as patients transition between sectors of the health systems is also important to ensuring health systems are well integrated. In a survey of hospitalised patients across 11 countries, nearly one in three (29%) reported that they had experienced problems with co-ordination of care when they left the hospital – either poor follow-up care arrangements from the hospital, or that their regular doctors did not appear to be informed and up to date about their care – including at least one in five patients in every responding country. That a large plurality of patients did not experience good follow-up upon hospital discharge is particularly concerning because poor or delayed follow-up care following a hospital admission has been associated with worse outcomes and an increased risk of hospital readmission, as well as poorer patient satisfaction (Jackson et al., 2015[24]; Braun et al., 2009[25]; Jack et al., 2009[26]). Many health systems have identified improving co-ordination of care between hospitals and the community as an important policy priority.

Compassion and respect are fundamental bedrocks of building a people-centred health system. Making sure that people are treated fairly and with respect, have their voices heard, and needs attended to, must be made the basic standard that people experience in their interactions throughout the health system.

Encouragingly, nearly nine in ten patients (89%) across 11 OECD countries surveyed by the Commonwealth Foundation report feeling that both doctors and nurses treated them with respect during a recent hospital stay, ranging from just over three-quarters of patients in the United Kingdom to nearly 95% in France. Nearly as many (83%) across 20 OECD countries reported being satisfied with the level of attention given to them by their regular physician in primary care, reporting that their regular doctor spent enough time with them during their consultation. A relatively high proportion of respondents in a number of countries reported insufficient time spent with their regular doctor: In Japan, nearly three-fifths of respondents felt their doctors did not spend enough time with them, while about three in ten patients felt similar in Poland, Sweden and the United Kingdom.

While patients reported a relatively high level of satisfaction at the level of respectfulness they usually experience within the health system, there is substantially less trust in whether the health system treats others fairly. When asked whether the they agreed that people in their area are treated equally, an average of just over three-fifths of respondents across 22 OECD countries responded affirmatively, including close to half or fewer in the Czech Republic, Greece, Italy and the Slovak Republic.

Despite the broad agreement among OECD countries about the importance of people-centredness, empirical evidence on the association of the dimensions of people-centredness and people’s perception of higher performance of the health system can strengthen the support for policy case even further. Therefore, an empirical exercise was conducted to examine whether people who had a better experience of the dimensions of the OECD Scorecard for People-Centred Health Systems were also more likely to agree that their health system performs better. This analysis may provide indication that people who have a better experience of voice, choice, co-production, integration, and respectfulness are more likely to agree that the performance of their health system is strong.

The policy question was examined with the help of a person-level dataset collected and published by Commonwealth Fund within its ongoing series of International Health Policy Survey (known as IHP survey). The IHP survey dataset used for the empirical analysis contains information from 22 961 adult health care users in 11 OECD countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, United States), who answered questions related to their experiences with care and the health system in the first semester of 2020.

As indicated in the description of the 13 indicators of the OECD Scorecard presented in the previous sections, the IHP survey served as the primary source of data (i.e. for all countries) for the construction of 4 out of 13 indicators, namely “use of patient portals and apps”, “patients do not experience a problem with co-ordination”, “patients are treated with respect”, “doctors spent enough time with patients”; and as a secondary source of data (i.e. for some countries) for other 2 indicators, namely “doctors provide easy to understand explanations”, and “patients are involved in decision-making”. Moreover, the IHP survey contains similar data to one more indicator, which is the absence of financial barriers of access to consultations. As such, the IHP survey has data covering the dimensions of choice, co-production, integration, and respectfulness of the OECD Framework for People-Centred health Systems. The only dimension of the OECD Framework for which person-level data was not available in the IHP survey is voice, which tends to be a system-level characteristic, for example when national policy includes patients in formal committees for decision making about the health system.

The empirical analysis confirmed that people who experienced higher levels of choice, co-production, integration of care, and respectfulness of care were more likely to agree that their health system performs well, even when gender, self-rated health status, and income level are taken into account. The methods used in the analysis are described in Box 1.6.

The operationalisation of the indicators using in this analysis may differ somewhat from the ones presents in the scorecard for PCHS. However, the underlying concepts expressed by the variables in the present patient-level analysis and in the country-level scorecard are similar enough to ensure the validity of the exercise (Davis, Schoenbaum and Audet, 2005[28]). A definition of the variables in the regression model is presented in Box 1.7.

Given that two variables are only available for people who were hospitalised in the last two years (on integration, arrangements and information for follow-up care after hospitalisation were made, and on respectfulness, doctors and nurses treat patient with respect in hospital), two separate models were estimated, one including all people with complete data for all variables (3 289 observations) and another one including all people with complete data for all but the variables related to hospitalisation (18 269 observations). The results of the regression models are presented in Table 1.4.

The results of the regression analysis indicate that people with a more positive experience across the dimensions of choice, co-production, integrated care, and respectful care are significantly more likely to agree that the health system performs well, controlling for income, health status, and gender, and country-level characteristics. Across 11 OECD countries, for the people who were hospitalised in the past 2 years, and when compared with people who did not have the experiences below, the probability of agreeing that the health system performed well was, on average:

  • 2.12 times higher for people who did not skip a doctor visit because of cost (choice);

  • 2.06 times higher for people who received easy to understand information from the doctors (co-production);

  • 1.49 times higher for those who had arrangements made by their hospital for a follow up care after hospitalisation and their usual provider was well-informed about hospitalisation (integration);

  • 1.97 times higher for people who reported receiving respectful treatment for doctors and nurses while hospitalised (respectfulness); and

  • 1.55 times higher for people who reported that their doctors spent enough time with them (respectfulness).

The results for the larger sample including people who were not hospitalised in the last two years were mostly similar in direction and magnitude of association, and as expected, the precision of the estimates increased. However, no variable was available about integration of care, since the concept of integration necessarily represents different levels or areas of the health system. Across 11 OECD countries, for respondents and when compared with people who did not have the experiences below, the probability of agreeing that the health system performed well was, on average:

  • 2.34 times higher for people who did not skip a doctor visit because of cost (choice);

  • 1.70 times higher for people who received easy to understand information from the doctors (co-production);

  • 1.51 times higher for people who were involved in decisions about their health care (co-production); and

  • 1.80 times higher for people who reported that their doctors spent enough time with them (respectfulness).

In both models, people with higher income and with good health status were more likely to agree that their health system performed well. Males were more likely to agree that their health system performed well in the model including people hospitalised in the previous two years only. Age was not included in the model because data was not available for one of the countries, but a sensitivity analysis for the 10 remaining countries including a control variable on age showed very similar results in magnitude, direction, and precision of the estimates.

The analysis confirmed that people who experience their health care system to be people centred are more likely to have confidence in their health system. The more people experienced to have choice in their care, being able to co-produce their care path, experience respect and integrated care, showed to be associated with positive views of the health system and positive self-rated health. The data used in this section derived from The Commonwealth Fund capture data on patient level on a broad range of topics. It covers a geographically diverse sample of OECD countries, including Europe, America and Oceania.

The results in this section confirm the relevance of the dimensions of choice, co-production, respectful care, and integrated care, given their empirical association, at the patient-level, with perception of high performance of the health system. The scorecard was developed to stimulate the discussion of the main domains and policy benchmarks that are relevant for People-Centred Health Systems, to understand how countries might measure domains of people-centredness, and to identify measurement gaps that may impede progress towards strengthening the people-centredness of health systems. It is not intended to rank countries according the levels of people-centredness, nor to provide an aggregated measure.

The indicators included in the Scorecard underscore the dearth of relevant, comparable data on key aspects of people-centredness for the health system. There is an urgent need to expand the collection of person-centred indicators beyond the scale up of patient-reported measures. While the focus on scaling up and integrating patient-reported measures is an essential component of assessing health systems performance addresses a critical measurement gap, there has been less attention paid to how to better measure other key components of people-centredness, and how key health systems characteristics – including governance, financing structures, and the overall architecture of health systems delivery – do or do not facilitate the broader delivery of people-centred care. In particular, measures that capture the extent of the embeddedness of the collective patient voice – as a complement to the individual-level focus of patient-reported measures – is needed.

At the same time, a key limitation of this benchmarking exercise was that challenges of data comparability and quality precluded the inclusion of certain variables that may have been even more relevant to assessing the people-centredness in certain dimensions. Health literacy, for example, is critically important to informing the ability of individuals to take advantage of the choices available to them within the health system, to make informed decisions as a co-producer of their health, and to self-manage their health (Moreira, 2018[19]). Yet a lack of comparable cross-country data meant that no measure of health literacy was included in the benchmarking exercise.

A lack of thorough measurement across the five dimensions of people-centred health systems underscores that countries have further to go to delivering systematically people-centred policies, across sectors, services, and levels of the health system. Benchmarking across the five dimensions of the OECD Framework has highlighted that while certain countries appear to perform relatively strongly across the different dimensions of people-centredness, very few countries perform uniformly well across voice, choice, co-production, integration and respectfulness in orienting their health systems to be people centred. Moreover, data availability across all measures and dimensions by country remains inconsistent. The lack of available data to measure progress across all five dimensions underscores how far many countries have to go to better embedding people-centredness as a key actionable principle throughout their health systems. All countries have room to improve the people-centredness of their health systems.


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