- Comparing health system performance assessment and management approaches in the Netherlands and Ontario, Canada
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.
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 . However, without embedding strategy, the current design does not make full use of available performance data.
The 2006 OHSS focuses on health system integration. . 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) . 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.
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.
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