Mapping the process of implementing Health System Performance Assessment into political decision-making: expert survey among 22 European countries

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Background Health System Performance Assessment (HSPA) is an essential tool for evaluating and improving health system efficiency, transparency, and accountability. While existing research has focused mainly on HSPA frameworks, indicators and methodological issues, less attention has been paid to how HSPA results are reported, reviewed and linked to policy-making. Objectives This study maps the implementation of HSPA across European countries and examines its reported relevance for policy-making from the perspective of national HSPA representatives. Methods The study is based on a structured expert survey with descriptive comparative analysis among country representatives in the European Commission’s Expert Group on HSPA. The questionnaire covered organizational arrangements, technical and resource-related aspects, methodological characteristics, dissemination strategies, reported integration into policy-making, and barriers and facilitating factors. In total, representatives from 22 European countries participated. Survey data were complemented by a targeted literature and document search and validated through country-level tables and figures shared with national representatives. Results The findings demonstrate variation in the legal basis, frequency, methodological design, reporting practices and institutional embedding of HSPA. Respondents from Finland and Italy reported legal requirements linking HSPA results to policy decisions, while in most countries HSPA results are reported to be used on a voluntary basis. Reported barriers include fragmented data systems, limited resources, decentralized governance structures, and insufficient political commitment. Conclusions HSPA is increasingly used across European countries, but its reported policy relevance remains unevenly institutionalized. Strengthening the links between HSPA, policy review and accountability could enhance its contribution to evidence-informed health system governance.

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