From Vision to Metrics: Designing Estonia’s Health System Performance Assessment

Abstract Background The Estonian health system lacked a comprehensive mechanism for systematic monitoring and evaluation of its performance. Health reform decisions were often fragmented, limiting the ability to enact coordinated and effective changes. In response, a new HSPA framework was developed, integrating multiple domains-health status, outcomes, processes, structures, and cross-cutting themes-into a comprehensive tool with 285 indicators was developed. HSPA serves as a critical instrument for addressing systemic challenges by enabling continuous monitoring, promoting data-driven reforms, enhancing data collection capabilities, and fostering public accountability. Adoption of such a framework can improve system transparency and ultimately contribute to better health outcomes. Results A structured governance model was established to ensure effective coordination and oversight of the HSPA framework. This involved multiple entities within the Ministry of Social Affairs, with clearly defined roles. Indicators were divided among these entities, ensuring appropriate management. Each indicator was defined using a standardized template, including data sources, methodology, and performance relevance. A comprehensive implementation plan was developed, outlining technical, communication, and risk management strategies. The risk management plan addressed concerns such as data privacy, indicator reliability, and stakeholder expectations. Pilot testing of mental health indicators evaluated their feasibility in real-world settings. The entire process was documented, highlighting challenges and solutions. Conclusions Political support, early financial backing, strategic planning, continuous reviews, and detailed documentation are essential for the successful implementation of HSPA. Estonia's experience demonstrates that a multi-domain, indicator-based framework can support evidence-based reforms and enhance health system transparency. Key messages • HSPA is an essential instrument for enhancing health system performance, ensuring the delivery of high-quality, people-centred care through systematic evaluation and evidence-based decision-making. • Effective governance, strategic and technical planning are critical for the successful implementation and sustained impact of HSPA frameworks.