Policymakers in Ontario and The Netherlands have expressed interest
in and support for studies comparing their respective health systems
performance assessment approaches, an important step providing a
conceptual basis for any future benchmarking effort. Stakeholders
representing the Dutch Ministry of Health, Welfare and Sport,
University of Amsterdam Medical Center (AMC), and OMHLTC met in Toronto
to promote such collaborative research and mutual learning.
We explored each constituency's conceptual HSPA framework, the
embeddedness of performance data within management and policy
functions, the extent of any overlap between the two frameworks, and
relevant contextual factors that must be taken into account when
comparing health system performance.
Conceptual Issues
The Dutch framework governing the 2006 Zorgbalans is broad and
comprehensive, composed of a large set of indicator areas that are
relevant to the various departments at their MoH. The 3 chapters, 12
sub-dimensions, and 125 indicators of the Zorgbalans give a thorough
review of areas relevant to the technical quality of healthcare in The
Netherlands. However, the sheer complexity and number of performance
indicators makes it difficult to identify performance areas requiring
attention. The Netherlands should look at iteratively refining their
indicator sets to provide a better picture of performance to
policymakers.
The Zorgbalans fits well with the aims, goals and functions of the
Dutch health system. As of January 2006, The Netherlands has changed
its main steering philosophy from a budget-driven to a regulated market
mechanism [3,21].
Given this steering philosophy, health system integration is not an
explicit strategic priority or goal of the Dutch MoH. Therefore, the
Zorgbalans does not explicitly link performance data to strategy and
management functions. Rather, the onus is on each stakeholder to draw
the conclusions they need from the Zorgbalans [21]. However, without embedding strategy, the current design does not make full use of available performance data.
The 2006 OHSS focuses on health system integration. [12].
Using its Health System Strategy Map, the Ontario Scorecard links
measures, strategies, goals and outcomes, thereby enhancing
accountability and assisting empirically sound evidence-based decision
making across multiple sectors of the system [4,12,24].
However, the balanced set of 27 indicators is perhaps too restrictive
and narrow to truly "best reflect the full extent of the health
system's ongoing performance improvement initiatives".
The Netherlands and Ontario can build on each other's mix of
performance indicator types in order to maintain a multi-stakeholder
perspective, as different stakeholders have different views as to what
processes and outcomes should be measured and how [25-27].
Contextual policy factors
Researchers should also understand the higher-level contextual
meaning behind selected benchmarking measures. The Ontario and Dutch
healthcare systems, characterized mainly as Beveridge and Bismarckian
systems, respectively, are undergoing great structural and regulatory
changes. Ontario is currently transforming its healthcare system
through decentralization/regionalization reforms aimed at health system
integration and supply-side cost containment, whereas The Netherlands
is pioneering a regulated-market steering philosophy focusing on
demand-side rationing. Table 2 lists important policy context factors that must be taken into account when performing a benchmark.
The Zorgbalans' framework was designed to strategically fit with the
new Dutch regulated-market steering philosophy focusing on demand-side
rationing. The Dutch health system, mainly characterized as
Bismarckian, is made up for four key sectors (public health, acute
care, long-term care, and social care) that are regulated and financed
through a mixture of private and public insurance schemes, along with
municipal governmental budgets. Public and private sector actors have
different roles in governing the healthcare sector. Municipalities are
responsible for governing public health and social care (health),
whereas private sickness funds are responsible for acute and long-term
care sectors (healthcare) [28].
Due to the multitude of actors, each stakeholder is expected to draw
relevant conclusions from the Zorgbalans, keeping overall health system
targets in mind. System level accountability and transparency is to be
managed through performance measurement, mainly focusing on suppliers
and insurers, while maintaining a balance of mixed private sector and
public finance.
Central to Ontario's decentralization reforms are the LHINs,
not-for-profit corporation responsible for the planning, integration,
and funding of local health services in fourteen geographic areas in
Ontario. LHIN performance will be managed by cascading Ontario's
performance Strategy Map to the local and provider level.
Such contextual information is necessary to understand the
similarities and differences of their healthcare system approaches,
along with the potential benefits and drawbacks of policies affecting
the structure, design and organization and delivery of health services.
Policymakers are interested in exploring novel regulatory regimes that
encourage providers and patients to make choices that take both costs
and outcomes into account. Canadian stakeholders are interested in
learning from the "mixed market" models being used in Europe to
determine how well they could serve the Canadian system.
Comparing the performance frameworks
Conceptually, we demonstrate that it is possible to map the
theoretical frameworks using a backbone 'five diamond' framework
linking the Dutch Zorgbalans healthcare performance matrix and Ontario
Scorecard. Figure 4
gives a clearer idea of the conceptual and contextual background of any
performance dimensions and measures they intend to use in any future
comparative project. Contextual policy factors were discussed in a
workshop, giving clearer meaning to the comparative framework, and to
stimulate ideas about how each constituency's regulatory model could
serve towards mutual health system performance improvement:
This comparative study has policy implications and lessons for the
development of future international collaborative benchmarking
projects. The purpose behind this study is not to be overly
prescriptive in the sense of pointing policymakers to a particular set
of comparable indicators, but to articulate the interrelations between
the performance dimensions and corresponding indicator sets within and
between each framework. The onus is on them to then choose the
indicators that fit their particular interests and policy priorities,
and to understand their true contextual meaning within each
constituency. Such a theoretically-sound empirical approach can help
give a relatively objective view of performance over time and space,
thereby providing the necessary evidence-base for actionable policy.
Limitations
Considering the complexity of the topic, we acknowledge the
shortcomings of being brief and abstract in each topic of discourse
covered. HSPA is a dynamic field, and both the Dutch Zorgbalans and
Ontario Scorecard are under continuous revision. Therefore information
may and will change by the time this paper is published. We also
acknowledge that certain assumptions and speculations were made when
deriving the harmonized 'five diamond' framework, its performance
dimensions and strategy linkages, all of which may be influenced by
researcher and information bias. Much of the data received was in
Dutch, and there is a possibility of information being lost in
translation to English. Nevertheless, we attempted to be objective and
thorough with our findings, towards giving researchers and policymakers
the global bigger picture of comparative HSPA, in the hopes of
stimulating future research and collaboration across the Atlantic.
Answers to all your Biology Questions
