Executive summary

Health system performance assessment (HSPA) plays an integral role in ensuring that health systems are high-performing and delivering quality care to their patients. It is a critical tool for healthcare policy makers and is used to ensure that services are meeting the needs of the population, patients, and healthcare providers. With the goal of achieving better health outcomes for the Estonian population, and to ensure the sustainability and resilience of the national health system, the Estonian Ministry of Social Affairs identified a need for the development and implementation of a HSPA framework, methodology, and governance plan. The project “Health System Performance Assessment for Estonia” responds to this need by developing a country-specific HSPA framework, tailored to the Estonian needs and recognised by its health system stakeholders, that will establish sustainable monitoring of its health system.

The HSPA framework for Estonia acts as a tool for policy makers to guide health reforms in an evidence-based and targeted manner. It resulted from close co-operation between the Estonian Ministry of Social Affairs and health system stakeholders, supported by the technical assistance from the OECD and the support of the European Commission. This report outlines the Estonian HSPA framework and documents its development through a highly inclusive and consultative process. It also reports on indicators that were selected to populate the first Estonian HSPA report, their selection criteria and core methodologies, and describes the HSPA governance structure, implementation plan, and HSPA-related capacity building.

The purpose of the Estonian HSPA is to guide the establishment of common objectives between health stakeholders, to allow for targeted and evidence-based change management, and to improve the collection and utilisation of health data. Furthermore, the HSPA aims to contribute to raising public awareness of the population health status through regular HSPA reporting and to improve the transparency and accountability of healthcare stakeholders. The implementation of the Estonian HSPA will address the need to monitor policy objectives and strategic goals outlined in various national strategies in a comprehensive and continuous manner. The High-Level Advisory Board, composed of the Estonian health system authorities and key-role organisations, regularly took note of the development of the HSPA framework, and approved its final version, related governance structures and implementation roadmap.

The Estonian HSPA framework is composed of 18 domains grouped into 5 areas of health status, outcomes, processes, structures, and cross-cutting themes. The domains are further detailed into 64 subdomains, covering different aspects of the Estonian health system to align with the defined HSPA scope and purpose. The visualisation of the HSPA framework displays the domains in a circular diagram, with population health status as the main health policy target in the centre, encircled by the areas of processes, outcomes, and structures, while the three cross-cutting themes surround the diagram. The framework thus highlights the main policy direction of the Estonian health system to become more person-centred, and embeds equity, efficiency, and resilience into all domains.

In total, 212 indicators populate the Estonian HSPA framework, which were selected via a comprehensive multi-stage selection procedure and further clarified with health system stakeholders and custodians by means of individual consultations. A higher number than the original target of 100 indicators, the selection represents a consensual list of most relevant indicators for the key Estonian stakeholders to provide a complex and comprehensive picture of their health system. Most of the indicators already exist and many are reported to international databases; there are 81 placeholders which require further development, both in terms of development of methodology and/or in terms of relevant national data collection.

The selection process of indicators assessed both their fitness-for-use (data availability and readiness), and fitness-for-purpose (relevance for policy priorities and for HSPA purpose), along with their benchmarking possibilities for international and regional comparison. Considering national health objectives and policy priorities, some HSPA indicators are directly related to strategic priority monitoring.

The governance structure for HSPA was designed to facilitate the co-operation of stakeholders beyond the initial project that established the framework. The implementation and daily use of HSPA will be facilitated by a three-part governance structure, with clearly assigned roles and responsibilities to the key organisations. The HSPA Advisory Board involves main health system stakeholders and is tasked with the overall oversight and HSPA stewardship role. The Co-ordination Board, led by the Ministry of Social Affairs, will be complemented by Task Force, led by the National Institute for Health Development.

The HSPA implementation plan proposes a list of step-by-step activities necessary to conduct the initial HSPA analysis and draft the first HSPA report for the second half of 2024. These are complemented by activities proposed to support sustainability of the HSPA for subsequent reporting cycles, and proposals for continued national HSPA capacity building and educational programs. The report thus provides a guideline to embed the HSPA in Estonian governance processes in a sustainable manner.

Serving as a reference guide for the HSPA implementation phase, this report also provides input into further stakeholder discussions by listing detailed information on each indicator’s possible data disaggregation, benchmarking, methodology, data source, and initial suggestion for distribution of HSPA indicators into stakeholders’ custody. Further discussions among HSPA stakeholders are foreseen to develop detailed indicator technical sheets during the implementation phase.

In its effort to establish sustainable national HSPA reporting, Estonia is joining other countries which have been using, or are developing, their own HSPA frameworks. Implementing the HSPA will improve systematised public reporting on health system performance in Estonia, thus increasing transparency and accountability of stakeholders and public awareness and involvement in the health policy making.


This work is published under the responsibility of the Secretary-General of the OECD. The opinions expressed and arguments employed herein do not necessarily reflect the official views of the Member countries of the OECD.

This document was produced with the financial assistance of the European Union. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

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