Health systems should be designed to withstand emerging shocks and challenges such as the COVID-19 pandemic, and economic and social crises. The ability for a health system to sustain its performance, or even improve it, in the face of a shock can inform policymakers as to how resilient it is. The WHO’s Health System Performance Assessment (HSPA) Framework for Universal Health Coverage (UHC) offers policymakers a conceptual tool for a comprehensive assessment of health system performance. Specifically, it provides a framework from which to examine the performance of the health system itself, but also of the four health system functions - governance, resource generation, financing and service delivery - that make up health systems. The HSPA framework can thus aid policymakers and researchers in examining health systems and considering how shocks may influence the outcomes they produce, as well as the necessary structures that are required for it to produce and sustain performance. In this chapter, we present in detail how the framework can be used to examine how resilient health system performance is to different types of shocks. We consider through a series of case studies both how to use the framework to assess the vulnerabilities of the four key health system functions to different shocks and also how this may translate into changes in performance.

Many studies have documented differences in maternal health outcomes across high-income countries, noting higher and growing maternal mortality in the US. However, few studies have detailed the journeys of care that may underlie or influence differences in outcomes. This study explores how maternity care entitlements and experiences vary among the US and five high-income countries, to study variations in child delivery care practices. Health systems with different organizational structure, insurance coverage and with known differences in maternal care delivery and maternal health outcomes were selected. Data was collected using a structured questionnaire, comparison of secondary data, and literature scan. We find that, while prenatal care approaches were broadly similar across all six countries, there were some important differences in maternity care provision among the comparator countries: (1) the US has more fragmented coverage during pregnancy than comparator countries (2) there were differences with regards to the main provider delivering care, the US relied primarily on physician specialists rather than midwives for prenatal care and delivery which was more common in other countries, (3) the intensity of labor and delivery care varied, particularly with regards to rates of epidural use which were highest in the US and France and lowest in Japan, and (4), there was large variation in the use of postnatal home visits to assess health and wellbeing, notably lacking in the US. The US’ greater use of specialists and more intensive labor and delivery care may partially explain higher costs of care than in comparator countries. Moreover, US maternal mortality is concentrated in the pre- and postnatal periods and thus may be related to poorer access to prenatal care and the lack of an organized, community-based approach to postnatal care. Given the increase in maternal mortality across countries, policy makers should look across countries to identify promising models of care delivery, and should consider investing in more comprehensive coverage in pre- and postnatal care.

More than two decades ago, the Agency for Healthcare Research and Quality developed its Patient Safety Indicators (PSIs) to monitor potentially preventable and severe adverse events within hospitals. Application of PSIs outside the US was explored more than a decade ago, but it is uncertain whether they remain relevant within Europe, as no up-to-date assessments of overall PSI-associated adverse event rates or interhospital variability can be found in the literature. This article assesses the nationwide occurrence and variability of thirteen adverse events for a case study of Belgium. We studied 4,765,850 patient stays across all 101 hospitals for 2016–18. We established that although adverse event rates were generally low, with an adverse event observed in 0.1 percent of medical hospital stays and in 1.2 percent of surgical hospital stays, they were higher than equivalent US rates and were prone to considerable between-hospital variability. Failure-to-rescue rates, for example, equaled 23 percent, whereas some hospitals exceeded nationwide central line–associated bloodstream infection rates by a factor of 8. Policy makers and hospital managers can prioritize PSIs that have high adverse event rates or large variability, such as failure to rescue or central line–associated bloodstream infections, to improve the quality of care in Belgian hospitals.

Irene Papanicolas and colleagues consider the potential of alternatives to quality-based pay-for-performance systems and the remaining challenges

Over the past two decades most healthcare systems have modified the way they pay providers to attach financial incentives directly to quality of care. This type of payment, often referred to as pay for performance, gained momentum in the early 2000s, following several studies highlighting concerns about the quality and safety of healthcare systems.1 However, the evidence suggests they have been largely ineffective in improving quality. In response, health payers in various countries have introduced alternative payment models that encourage more effective, efficient, and integrated healthcare. We examine the early evidence on these alternative models and consider what they can realistically achieve.

Comparing health policy measures before elections and identifying potential gaps in the health policy debate can be challenging. We explored the use of the Health System Performance Assessment for Universal Health Coverage framework to analyse health policy proposals by classifying health policy measures outlined in political manifestos into four health system functions: governance, financing, resource generation and service delivery. As a case study, we analysed the political manifestos of all Portuguese parties with parliamentary representation ahead of the election in March 2024. We calculated the share of measures per health system function for individual political manifestos and identified potential gaps in the health policy debate. When required, we used additional classification criteria and local expertise on political and institutional knowledge.

Wealth-related inequalities in self-reported health status are strong and persistent across countries. Our results suggest that there is meaningful variation across high-income countries in health-wealth dynamics that merits further investigation to better understand whether certain health or welfare systems are more equitable. They also highlight the need to consider social policy and wealth redistribution mechanisms as strategies for improving population health among the less wealthy, in the United States and elsewhere.

Using satisfaction ratings without nuanced approaches in value-based purchasing programmes may mask poor-quality interpersonal services, particularly for historically marginalized patients. Surveys should be designed to accurately capture true levels of dissatisfaction, ensuring that patient concerns are not hidden.

The articles in this issue highlight the importance of regular health systems performance assessment to inform policies that advance progress on health system objectives globally, and offer insights on associated data, methods and applications.

Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic’s tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard preparedness measures. Results support the pre-pandemic hypothesis that countries with greater pandemic preparedness capacities have larger SARS-CoV-2 infection and mortality data completeness rates and lower COVID-19 disease burdens. More high-quality data of COVID-19 impact based on direct measurement are needed.

Research productivity has become an increasingly prominent component of surgical residency selection. As publication expectations rise, scholarly outputs may serve as visible signals within a competitive application process. Yet the longitudinal and institutional distribution of medical student authorship in major surgical journals has not been well characterized. We examined trends in medical student first authorship across leading general surgery journals and characterized the institutional distribution of these publications.

As common problems call for more global cooperation in research, cross-border partnerships struggle to get money from national funding agencies

Researchers and policy-makers have long compared health system performance. International comparisons raise awareness of health systems’ relative strengths and shortcomings, prompting policy debates and informing policy decisions. Yet determining how these international comparisons can be used to improve health system performance is challenging. Health systems can differ in many ways, including how they are governed, how they are funded, how they generate and deploy resources, and how they deliver services. While the international health community widely agrees that these functions influence health system performance, understanding of how much they matter, which ones matter most, and how they are affected by the context in which they operate remains limited. To gain relevant and meaningful insights from health systems comparisons that offer lessons for policy, we must agree on how to compare health systems. In this article, we argue that doing so requires collecting better, more granular data on a broad range of health system characteristics and using those data to choose the most appropriate health system comparators.

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

In their Letter to the Editor, Olivença and colleagues question the benefit of adopting health technology assessment (HTA) in the US, and suggest it could result in fewer drugs being available to patients. They raise 3 main critiques of our study.1

First, Olivença et al note that patients in countries with HTA have voiced concerns about inadequate access to new therapies, citing 5 media reports from negative coverage decisions in England. The extent to which these reports represent the broader views of society is unclear. Recent decades have seen global consensus that universal health coverage is desirable for health care systems. Achieving universal coverage requires decisions about which services should be made available to maximize population health. As many new drugs offer little or no added therapeutic value,2 no coverage may be acceptable unless pharmaceutical companies offer reasonable prices (otherwise, funds would not be available to pay for other health services). In our study, we observed good coverage in all countries of high-value drugs following HTA review.

Total hip arthroplasty (THA) is among the most commonly performed elective surgeries in high-income countries, and wait times for THA have frequently been cited by US commentators as evidence that countries with universal insurance programs or national health systems “ration” care. This novel qualitative study explores processes of care for hip replacement in the United States and 6 high-income countries with a focus on eligibility, wait times, decision-making, postoperative care, and payment policies. We found no evidence of rationing or government interference in decision-making across high-income countries. Compared with the 6 other high-income countries in our study, the United States has developed efficient care processes that often allow for a same-day discharge. In contrast, THA patients in Germany stay in the hospital 7–9 days and receive 2–3 weeks of inpatient rehabilitation. However, the payment per THA in the United States remains far above other countries, despite far fewer inpatient days.

Brown’s new Center for Health System Sustainability (CHeSS), led by Professor Irene Papanicolas, aims to standardize data from across global health systems, then compare them in order to inform policy choices and improve health care value and patient care.

Multisite observational research reusing sensitive data requires a federated approach. Building on the lessons learned in several international research projects, we will discuss key issues in the deployment of federated research including how to achieve the data-visiting principle, the orchestration of the nodes in a federation, and the need for semantic and technical interoperability. Some tools for the deployment of federated research projects will be proposed.

Ageism is the discrimination of older adults based on their age and the negative portrayals of older adults as derived from age-based stereotypes centered on illness, irrelevance, and incompetence. The insidious consequences of ageism on health prompted 194 member countries to collectively work through the World Health Organization on a global campaign to combat ageism. Join us as Dr. Ng discusses innovative methods in analyzing the historical narratives of aging over 200 years, contemporary media portrayals of older adults, and strategies to reframe aging.

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Sara Machado Ph.D. uses the HSPA framework to examine the health policy propositions being debated by parties in the 2024 Portuguese legislative elections.

Medical crowdfunding is a key source of finance for individuals facing high out of pocket costs, including organ transplant candidates. However, little is known about racial disparities in campaigning activity and outcomes, or how these relate to access to care. In this exploratory nationwide cross-sectional study, we examined racial disparities in campaigning activity across states and the association between U.S. campaigners’ race and ethnicity and crowdfunding outcomes using a novel database of organ-transplant related campaigns, and an algorithm to identify race and ethnicity based on name and geographic location. This analysis suggests that there are racial disparities in individuals’ ability to successfully raise requested funds, with Black and Hispanic campaigners fundraising lower amounts and less likely to achieve their monetary goals. We also find that crowdfunding among White, Black, and Hispanic populations exhibit different patterns of activity at the state level, and in relation to race specific uninsurance and wait list additions, highlighting potential differences in fundraising need across the three groups. Policy efforts should consider not only how inequalities in fundraising ability for associated costs influences accessibility to care, but also how to identify clinical need among minorities.

Most high-income countries except the US rely on health technology assessment (HTA) to ensure that prices paid for new medicines reflect the value they provide.1,2 Health technology assessment bodies assess the relative clinical or economic impact of new drugs to guide pricing and coverage decisions. These assessments usually occur after marketing authorization by a medicines regulatory body (eg, European Medicines Agency), and patients may have little or no access to therapies not assessed favorably by HTA bodies. As Medicare considers using comparative effectiveness data to negotiate drug prices, examining HTA decisions abroad can inform US policymakers about how HTA affects the availability and coverage of new medicines.3 We analyzed HTA outcomes and review times in 6 countries (Australia, Canada, England, France, Germany, and Switzerland) for novel therapeutic agents approved by the US Food and Drug Administration (FDA).