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Brief analytical summaries or syntheses #20

Performance Measurement for Health System Improvement

Experiences, Challenges and Prospects


Given the increasing demand for measurement of health provider performance, there is a need to better define what role measurement can play in securing health system improvement. This volume, first published in 2009 and now free to download, meets this need by presenting the opportunities and challenges associated with performance measurement in a framework that is clear and easy to understand.


Performance measurement instruments have two goals: to promote accountability and to improve the performance of the health system. The modern health system is immensely complex, comprising diverse agents such as insurers, provider organizations, health-care professionals and central and local governments. Measurement of the actions and outcomes of these agents is a necessary condition if the health system is to be held properly to account by citizens and patients. That accountability may be considered a good thing in its own right as it enhances transparency and promotes informed debate about the health system. Furthermore, by providing reassurance that finances are being used effectively, performance measurement can increase government and citizens’ willingness to invest additional resources in the health system. The prime focus of this book is to see how performance measurement and the increased accountability it offers directly promote the achievement of health system objectives – higher quality and more cost-effective health care and improved population health.

Analysis and results

Measurement alone is not sufficient to achieve these objectives. Numerous instances of technically satisfactory performance measurement initiatives that have failed to make material impacts on health systems or have had perversely adverse impacts are cited in this book. There are examples of public performance reporting schemes being ignored; professional improvement efforts becoming moribund; and centrally mandated targets inducing perverse results. To have maximum effect, performance measurement needs to be aligned with other aspects of system design such as financing, market structure, governance arrangements and regulation. Moreover, great attention needs to be paid to the political context within which any performance measurement scheme is implemented. Without careful attention to these broader health system considerations, the best performance measurement system will be ineffective. The effectiveness of any performance measurement initiative should be evaluated not only in relation to statistical properties such as accuracy and validity but also by the extent to which it promotes or compromises broader health system objectives.


Effective performance measurement alone is not enough to ensure performance improvement; broad health system objectives need to be taken into consideration. This book emphasizes the need for a global view of performance measurement while recognizing that performance measurement offers scope for major health system improvements.
Health systems are in the early days of performance measurement and there is still huge potential for improvement. There is a policy-making imperative to consider the role of performance measurement within the health system; implement initiatives of proven effectiveness; undertake careful trials of less established mechanisms; and monitor and update performance measurement systems as new knowledge and capacity emerge.

Implications and recommendations

It is important that policy-makers consider what makes performance indicators effective in improving system performance and accountability. Although there is no conclusive answer to this question, experience suggests that any policy development should take account of the following recommendations:

  1. Develop a clear conceptual framework and a clear vision of the purpose of the performance measurement system in alignment with the accountability relationships inherent in the health system.
  2. Ensure that definitions of performance indicators are clear and consistent and fit the chosen conceptual framework.
  3. Develop indicators that aim first to measure what matters, specifically to promote health, improve patient care and ensure prudent utilization of health system resources. Second, they must be statistically sound and straightforward to interpret in order to reduce the likelihood of manipulation or misinterpretation. And finally, any data limitations must be fully acknowledged, including levels of uncertainty and lack of timeliness.
  4. Pay more attention to improving the comprehensibility and utility of performance data, particularly how to improve its interpretation by patients, providers and practitioners.
  5. Enhance managers’ and clinicians’ capacity to understand and use information. Use of performance data should become an intrinsic part of clinical education and lifelong professional development.
  6. Incentives to act upon performance measures should be designed carefully. Monitor closely how performance information impacts on behaviour and take action to enhance beneficial outcomes and negate adverse consequences.
  7. Policy-makers should pay particular attention to the broader health system, ensuring that performance measurement is aligned with the design of mechanisms such as finance and market structures and recognizing the organizational context within which performance data are collected and disseminated.
  8. Performance measurement systems should be monitored frequently and evaluated to identify opportunities for updating and improvement and any unintended side effects.
  9. Ensure effective management of the political process of performance measurement. Amongs other things, encourage healthy political debate and ensure that specific interest groups do not capture the performance information system.


Performance Measurement for Health System Improvement: Experiences, Challenges and Prospects