Both Ontario and The Netherlands have shown interest in health
systems performance assessment and management through the development
of performance indicators within supportive conceptual frameworks [1-7].
The two healthcare systems underwent significant reforms in 2006 that
promise to produce, at lower cost, greater access to and better
outcomes from healthcare than their previous policies do. Both systems
aim to create new efficient healthcare systems that are equitable,
patient-focused, results-driven, accessible and sustainable [8-10].
The respective Ministries of Health have created conceptually-sound
performance indicator frameworks to actively measure, manage and
operationalize the performance of their health systems, thereby linking
performance measurement to ongoing policy and accountability processes.
In an effort to promote common learning and best practise, policymakers
from both constituencies expressed interest in learning from each
Both Ontario and The Netherlands have gone through great lengths to
develop comprehensive health system performance assessment (HSPA)
frameworks that avoid the theoretical, methodological and operational
pitfalls of previous HSPA studies. We will illustrate how these
national and provincial conceptual frameworks can be used to give a
relatively objective picture of performance over time and between
healthcare contexts. This comparative project evaluates how performance
is assessed in two constituencies using differing regulatory regimes
(Ontario's Beveridge and the Dutch Bismarckian systems). Such a
comparative performance assessment study could provide valuable
guidance for future attempts towards benchmarking.
The Canadians were among the first to realize the potential value of
benchmarking efforts, spurred by the September 2000 First Ministers'
Communiqué on Health that has resulted in the development of the
Canadian Health Indicator Framework (CHIF) .
The CHIF has served as the pioneering comprehensive theoretical base
for many modern national and international health system performance
assessment frameworks, including that of The Netherlands and the OECD
Health Care Quality Indicator (HCQI) project [5,6].
The province of Ontario has recently published its personalized Health
System Scorecard (OHSS), an innovative and functional framework
composed of nine strategic health system performance themes
(dimensions), populated by a balanced set of 27 indicators. The themes
are portrayed using a series of cause-and-effect linkages showing how
the system ultimately "creates value" for the population [12,13].
The Dutch have also moved forward with the critical assessment of
performance initiatives, and have focused on measuring the performance
of their national health system. The Dutch Ministry of Health, Welfare
and Sports (Ministerie van Volksgezondheid, Welzijn en Sport, or VWS)
commissions the National Institute of Public Health and Environment
(RIVM) to analyze such reports in an effort to translate the results of
benchmarking analyses into effective policies .
In Dutch health policy a distinction is made between health and
healthcare performance by the release of two separate 2006 national
reports: the Dutch Health Care Performance Report (Zorgbalans) and the
Public Health Status and Forecasts Report (PHSF, or Volksgezondheid
Toekomst Verkenning). The Zorgbalans deals with management and
performance information specific to health care (quality, access and
cost of health care), whereas the PHSF report gives an overview of the
public health perspective (health of the population). The former
focuses on the production of effective and sustainable health care; the
latter on a health system's ultimate goal: health .
The Dutch national health system performance conceptual framework,
heavily based on the CHIF and US National Healthcare Quality Report,
has been adopted as the theoretical framework of the OECD's HCQI
We compared health system performance methodologies in The
Netherlands with Ontario, highlighting what conceptual, operational,
and contextual policy factors must be taken into account when
attempting future benchmark initiatives, and clearly illustrating the
extent of the interrelations between the performance frameworks.