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In all these, there are widespread acknowledges the key health policy goals adopted by the perceptions of poor value for the money and effort spent on OECD and its member countries. This article presents a con- health care [1,7].

Effects of Health Care Spending on the U.S. Economy

Methods As a result, there has been a proliferation of health and health care indicators. To manage the proliferation of indicators, aid To develop such a framework, this article builds on i recent prioritization, and ensure coherence, health care and its influence reviews of performance measurement systems [3,11,12], ii on health must be adequately conceptualized using conceptual extensive consultation with the national representatives to the frameworks [3,8—10].

HCQI Project, and iii conceptual analysis. Owing to feasibility Address reprint requests to Onyebuchi A. E-mail: o. Arah et al. The non-health care determinants were largely and to what ends?

Systems thinking for Health Systems Strengthening

We then go on to outline ment, lifestyle, and human biology [15]. For instance, public health—through its classical health and personal health care services. A health system health prevention, promotion, and protection strategies— includes all activities and structures whose primary purpose is influences the host constitution, lifestyle, and environment, to influence health in its broadest sense. This notion is in respectively. This multi-determinant approach to health tion of health determinants, acting singly or in combination.

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Medical care is partly due to con- venience further divided into somatic and mental medical care services that can span the primary, secondary, and tertiary levels of the health care system. Conceptual framework for OECD HCQI Project This response factor represents the final common pathway to health care performance evaluation is, therefore, concerned health; its final manifestation is seen as health change, illness, with linkages between health care and health, mentioned in or disease.

However, The interrelationships among the health care system and in many health care systems, clinical preventive services are other determinants of health can be of at least three types, used to influence clinically relevant lifestyles, for example namely: smoking cessation as part of cardiac care. Again, the main policy ii linkages exist between health care and non-health care goals may be efficiency and equity, but a much wider view of determinants depicted in Figure 1 by the arrows run- the determinants of health and their costs must be adopted. See Table 1 for an illustration of which countries and international agencies have health or health care performance frameworks.

Performance of what—and to what ends? In trying to measure performance, policymakers and Goals researchers need to form a clearer image of what it is they want to measure and the key goals of health policy. Here, we In addition to improving health, there seems to be growing make a distinction between conceptual frameworks for health agreement that the wider goals of health policy include two care system performance or health care performance and key economic and social objectives: efficiency and equity. The concern cient and equitable system of health care without emphasizing for equity extends both to the distribution of the payments an assessment of the non-health care determinants.

In other words, to what extent is vis its established public goals for the level and distribution of payment according to ability to pay and to what extent is the benefits and costs of personal and public health care. A access according to need? Table 1 Illustrations of existing health and health care frameworks Health performance Health care performance framework framework Dimensions of health care performance needs, given the current best evidence [32].

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Safety is a dimen- sion where the system has the right structures, renders serv- Dimensions of health care performance are those definable, ices, and attains results in ways that prevent harm to the user, preferably measurable, attributes of the system that are related provider, or environment [31,32]. Efficiency involves finding the right level of resources for Table 2 gives an overview of commonly used performance the system and ensuring that these resources are used to yield dimensions in selected countries and agencies.

The list that maximum benefits or results [30,31,35]. The OECD frame- follows has been designed to be inclusive. Finding the right level of public expenditure on health care services to all who could benefit but not to those health will be a matter for political judgement. However, a set who would not benefit [3,6,31,33,34]. Donabedian stresses of good performance indicators for a health system—espe- that effectiveness is the extent to which attainable improve- cially measurement of outcomes—can play a valuable part in ments in health are, in fact, attained [35].

For a system to informing such judgements. The table is based on a content analysis of Table 1 references and the findings of a previous extensive review of existing performance frame- works [3]. Effectiveness in the UK includes clinical and cost effectiveness. Accessibility is the ease with which health services are reached.


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Access can be physical, financial, or psychological and requires that health services are a priori available. A closely related dimension, therefore, is equity, which defines the extent to which a system deals fairly with all concerned. Equity deals both with the distribution of the burden of pay- ing for health care [4,29] and with the distribution of health care and its benefits among a people [33,35]. Responsiveness refers to how a system facilitates people to meet their legitimate non-health expectations [4]. Responsiveness and patient-centeredness are often taken to result is a health performance framework that meshes well be equivalent.

Timeliness is the degree to which health care is into the one suggested by the International Organization for provided within the most beneficial or the necessary time Standardization ISO for its health informatics network [36]. Timeliness may become part of accessibility The shaded area in the resulting framework Figure 5 rep- or responsiveness so as to reflect patient experiences of resents the current focus of the HCQI Project.

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  6. Within this promptness of health care [4]. Acceptability is conformity to area, the Expert Group which advises the OECD on the the wishes, desires, and expectations of health care users and HCQI project suggested that indicators should be developed their families [35]. As such, acceptability is often presented as in the following priority areas: i cardiac care, ii mental a part of or substitute for patient-centeredness, as seen in health, iii diabetes mellitus, iv patient safety, and v pri- Canada see footnote in Table 2.

    Clearly, a linkage of various dimensions of per- ferent health service areas, and a discussion about priorities at formance within a coherent, comprehensive, and parsimoni- the first meeting of the HCQI Expert Group in January The list above cannot provide such a framework denote potential causal pathways shown in Figure 5 , which because it contains overlaps and perhaps gaps , but it does represent: provide a quarry for a proposal for a more unified, compre- i health—to capture the broader measures of the health hensive, and parsimonious structure.

    More which affect costs, expenditure, and utilization patterns specifically, the proposed framework builds on the common and which are necessary for appreciating and contextu- dimensions of performance which are incorporated into a alizing the findings of the health care performance tier. The third tier in and on the WHO and OECD proposals for identifying key Figure 5 is a matrix of dimensions of health care performance economic and social goals for health policy Figure 4.

    The columns by health care needs rows. Adapted from [10]. These dimensions are, in essence, those centeredness are taken to be the core quality dimensions. Equity is concerned continuity, timeliness, and acceptability could easily be with the fairness of the distribution of health care across pop- accommodated within other dimensions, as was partly done ulations and also with the fairness of payment for health care. For example, appropriateness based on its nants of health and for health status. These criteria have been addressed in to reflect evolving needs over the life cycle [25].

    Health care and explicit evidence of measures, and their feasibility i. The Netherlands is already the first coun- HCQI Project by first exploring the place of health care in try to apply this OECD framework to its biennial health care sys- health system performance and by revisiting health care as tem performance report [38]. The proposed OECD framework one of the determinants of health. We saw that a health per- will serve to infuse coherence and balance into current and future formance framework subsumed a health care performance work on performance measurement across OECD countries.

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    A framework when a model of health determinants was taken as good conceptual framework is particularly essential when there a valid basis for performance evaluation. Firstly, it allows for the reality that although high qual- ity health care should produce desired health outcomes and responsiveness to consumers, such outcomes will vary Acknowledgements between and across individuals, communities, and health care systems because of varying preferences, structures, and We acknowledge the insightful comments of Dr Margarita responsibilities.

    This paper Figure 5. This new framework embeds health care within reflects the opinion of the authors and not an official position the broader health system and even within the economic, of the OECD, its Member countries or institutions participat- social, and political context of OECD countries. Secondly, ing in the project. A framework that is unduly narrow and clinical in its focus will miss this larger Disclosure picture and interpretation.

    Having a complex and integral framework such as the 1. Organization for Economic Cooperation and Development. Paris: Organization for theoretical ends—no matter how desirable that might be— Economic Cooperation and Development, Smith PC, ed. Measuring Up. Improving Health System Performance in of the system in question. Conceptual frameworks for health systems performance: a of the need for conceptual clarity in performance measure- quest for effectiveness, quality and improvement. Int J Qual Health ment [2,3,8]. Care ; — World Health Organization.

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    The World Health Report Health National Health Performance Committee National Report Systems: Improving Performance. Factors that contribute to spending growth encompass changes in health care utilization, population demographics, price inflation, and advances in medical technology. This background paper focuses on a somewhat broader topichow health care spending impacts the economy of the United States.

    The relationship between health care spending growth and the U. At an aggregate level, economists have cautioned that rising health care spending could lower economic growth and employment. A December survey of CEOs found that employee health care costs are the foremost cost concern in the minds of Americas business leaders Figure 1. Some economists note that rising health care spending has important benefits, often outweighing the increased costs. Technology often leads to more spending, but outcomes improve by even more. At a local level, health care spending growth is more likely to be viewed as beneficial.

    It creates health care jobs, increases wages for health care workers, expands local tax revenues, and increases demand for related goods and services. The remainder of this paper is organized into five sections. The next section contains a brief overview of trends in health care spending.