A Framework for Health System

Comparisons: the Health Systems

in Transition (HiT) Series
of the European Observatory
on Health Systems and Policies

Bernd Rechel, Suszy Lessof, Reinhard Busse, Martin McKee,

Josep Figueras, Elias Mossialos, and Ewout van Ginneken

Contents The HiT Template: Structuring, Populating, and

Signposting a Comparative Framework . . . . . . . 4
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Ljubljana Charter: HiTs and Health Systems Scope and Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
in Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Signposting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
The Observatory Partnership: HiTs and Policy
Relevance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 HiT Processes: Making Sure Frameworks Are
The Observatory Functions: HiTs in a Wider Used Consistently and Comparably . . . . . . . . . . . . 7
Work Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Authors, Author Teams, and the Role of
(Contributing) Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Long-Term Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
B. Rechel (*) Flexibility, Consistency, and Signaling Gaps . . . . . . . . . 8
European Observatory on Health Systems and Policies, Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
London School of Hygiene & Tropical Medicine,
London, UK Dissemination and Policy Relevance: Helping
e-mail: Bernd.Rechel@lshtm.ac.uk Frameworks Achieve Their Objectives . . . . . . . . 9
Timeliness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
S. Lessof J. Figueras Visibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
European Observatory on Health Systems and Policies, Signaling Credibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Brussels, Belgium
e-mail: szy@obs.euro.who.int; j@obs.euro.who.int Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
The Value of a Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
R. Busse The Importance of Author and Editor Roles . . . . . . . . . 11
Department Health Care Management, Faculty of The Need to Build In Accessibility and
Economics and Management, Technische Universitt, Relevance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Berlin, Germany The Need to Signal Credibility . . . . . . . . . . . . . . . . . . . . . . . 16
e-mail: rbusse@tu-berlin.de The Need to Build in a Review Process . . . . . . . . . . . . . . 16
M. McKee Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
London School of Hygiene & Tropical Medicine,
London, UK References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
e-mail: Martin.McKee@lshtm.ac.uk
E. Mossialos
London School of Economics and Political Science,
London, UK
e-mail: e.a.mossialos@lse.ac.uk
E. van Ginneken
European Observatory on Health Systems and Policies,
Department of Health Care Management, Berlin
University of Technology, Berlin, Germany
e-mail: ewout.vanginneken@tu-berlin.de

# Springer Science+Business Media LLC 2016 1

A. Levy, S. Goring (eds.), Data and Measures in Health Services Research, Health Services Research,
DOI 10.1007/978-1-4899-7673-4_15-1
2 B. Rechel et al.

Abstract speaks of the signicance of context in developing

Comparing health systems across countries comparative frameworks.
allows policy-makers to make informed deci-
sions on how to strengthen their systems. The
European Observatory on Health Systems and The Ljubljana Charter: HiTs and Health
Policies produces a series of proles that sys- Systems in Transition
tematically describe health systems the HiTs.
These capture how a health system is orga- The Observatory can trace its origins to the early
nized, how funds ow through the system, 1990s and the challenges Europe faced as western
and what care it provides. They follow a com- European expectations (and health-care costs)
mon template and are updated periodically. rose and as the countries emerging in the wake
They allow policy-makers and academics to of the Soviet Union looked to overhaul their own
understand each system individually in light health systems. The World Health Organization
of its previous development and in the context (WHO) Regional Ofce for Europe facilitated a
of other European health systems. In effect, the process that culminated in the 1996 Ljubljana
HiTs provide a framework for comparison conference on European Health Care Reforms
across countries. This chapter describes the and the Ljubljana Charter, in which health minis-
Observatorys experience in developing the ters from across the European region committed
framework. It explores the role of the HiT themselves to a set of principles for health system
template, the processes put in place to support reform. These reected a growing understanding
consistency and comparability, and the efforts of healths part in the wider society and economy,
to build in policy relevance. It highlights the the importance of people and patients, the need for
lessons learned so far and what they might policy to be based on evidence where available,
contribute to the development of other compar- and the role of monitoring and learning from
ative frameworks. experience (Richards 2009).
The original HiTs were developed as part of the
preparations for the Ministerial Conference. They
Introduction were addressing a postcommunist Europe in
which more than 15 new countries had emerged
The European Observatory on Health Systems and many more were making a transition from
and Policies (Observatory) is a partnership of state-managed to market economies with all the
countries, international organizations, and aca- accompanying economic upheaval. There were
demic institutions that was set up to provide evi- also growing challenges to the sustainability of
dence for the policy-makers shaping Europes established and wealthy health systems and to
health systems. A central pillar of its work is the notions of solidarity. The HiTs had therefore to
Health Systems in Transition (HiT) series a set establish a common vocabulary for describing
of highly structured and analytic descriptions of health systems and to make sure that the terms
country health systems that are updated periodi- used could be explained and understood in coun-
cally. This experience of monitoring and compar- tries with very different traditions. They had also
ing country health systems and policies, which to provide for the fact that the systems to be
stretches back over 20 years, provides insights compared were contending with signicant dis-
into the challenges researchers face in developing continuities and ongoing change. This prompted
and applying any framework for health system the development of a template to describe health
comparisons. Understanding the background to systems that would set down the bases on which to
the HiT series and the Observatory helps explain make comparisons across countries. It was com-
the specic approach taken to HiTs, but also prehensive, allowed for very different path devel-
opments, and offered detailed explanations to
guide authors.
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 3

The Observatory Partnership: HiTs

and Policy Relevance Box 1: (continued)
The Observatory is overseen by a
Many of (what came to be) the Observatory team steering committee, made up of representa-
were involved in developing evidence for Lju- tives of all its Partners, which sets priorities
bljana. The Observatory, which took formal and emphasizes policy relevance. Work is
shape in May 1998, was designed to take forward shared across four teams with a secretariat
the approach to evidence for policy, after the in Brussels that coordinates and champions
Charter was agreed (Box 1). The original Partners knowledge brokering and analytic teams in
were WHO Europe, the government of Norway, Brussels, London (at LSE and LSHTM),
the European Investment Bank, the World Bank, and in Berlin (at the University of
the London School of Economics and Political Technology).
Science (LSE), and the London School of The core staff team carries out research
Hygiene & Tropical Medicine (LSHTM). The and analysis but depends (often) on second-
exact composition of the partnership has changed ary research and (almost always) on the
over the years, so that the Observatory today also Observatorys extensive academic and pol-
includes the European Commission, more icy networks. Over 600 researchers and
national governments (Austria, Belgium, Finland, practitioners provide country- and topic-
Ireland, Slovenia, Sweden, and the United King- specic knowledge, insights, and under-
dom), a regional government (Veneto), and the standing. Collectively the Observatory and
French National Union of Health Insurance those who contribute to it equip Europes
Funds (UNCAM); but the concept of a partnership policy-makers and their advisors with eval-
that brings different stakeholders together remains uative and comparative information that can
the same. The idea is that the Observatory, like a help them make informed policy choices.
good health system, is informed by the people
who use its services as well as those providing
them. The Partners have genuine experience of
shaping health systems, and this has prompted a
focus on policy relevance and how decision- The Observatory Functions: HiTs
makers can access and use the evidence generated. in a Wider Work Plan
They have insisted that the HiT series should be
accessible to a nonspecialist, nonacademic The Observatory has four core functions: country
audience and, more specically, be readable, monitoring, analysis, comparative health system
clearly structured, consistent (so that readers can performance assessment, and knowledge
move from one HiT to another and nd compara- brokering (Box 2). The HiTs are a fundamental
ble information), and timely, that is, available part of country monitoring, supported by a (rela-
while the data and analysis are still current. tively) new initiative to provide online updates
the Health Systems and Policy Monitor (HSPM).
They are, to some extent, a stand-alone exercise.
Box 1: The European Observatory on Health However, the fact that the Observatorys portfolio
Systems and Policies of work is broader than country monitoring has
The core mission of the Observatory is to done much to strengthen the comparative frame-
support and promote evidence-based health work. The analysis program runs in-depth studies
policy-making through the comprehensive of issues like governance, insurance mechanisms,
and rigorous analysis of the dynamics of staff mobility, hospitals, primary care, care for
health systems in Europe and through chronic conditions, and the economics of preven-
brokering the knowledge generated. tion, using HiTs, but also reviews of the academic
literature and secondary data collection. These
4 B. Rechel et al.

have provided insights into important health sys-

tem dimensions and how they impact on each Box 2: (continued)
other. At the same time, they create (a positive) meta-analysis and secondary research on
pressure on the HiT series to deliver consistent the issues that matter most to decision-
and comparable information that can feed into makers. All evidence is available open
more in-depth analysis. The performance assess- access to facilitate its use in practice.
ment work has given the Observatory the tools to Performance assessment includes a
understand the use (and misuse) of performance package of methodological and empiri-
measures and address how far systems achieve cal work designed to respond to country
their goals. The contribution of these other needs. There have been two key studies
functions to the HiT makes clear the value of looking at the policy agenda for perfor-
wide-ranging inputs from different specialist and mance comparison to improve health
thematic perspectives in developing a compara- services and separate work on the
tive framework. domains that comprise performance
(efciency, population health,
responsiveness).
Box 2: The Observatorys Core Functions
Knowledge brokering involves engaging
Country monitoring generates system-
with policy-makers to understand what
atic overviews of health systems in
evidence they need and then assembling
Europe (and in key OECD countries
and communicating the relevant infor-
beyond) in the form of Health Systems
mation at the right time. The Observa-
in Transition (HiT) reviews. All HiTs are
tory combines an extensive publication
available on the web, listed in PubMed,
program with face-to-face and electronic
and disseminated at launches and
dissemination to convey evidence on
conferences.
what might work better or worse in dif-
The Health Systems and Policy Mon-
ferent country and policy contexts.
itor (HSPM) is a new initiative to update
HiTs online. It is a web platform that
hosts 27 living HiTs. These are regu-
larly updated by the expert members of
the HSPM network with short reform
logs and longer health policy updates.
These give users news and insights into
The HiT Template: Structuring,
policy processes and developments
Populating, and Signposting
http://www.hspm.org/mainpage.aspx.
a Comparative Framework
The HSPM also allows users to extract
HiTs use a standard questionnaire and format to
and merge specic sections from the
guide authors referred to as the HiT template. It
HiTs for several countries at the same
guides the production of detailed descriptions of
time as a single le, facilitating compar-
health system and policy initiatives so that every
isons http://www.hspm.org/
HiT examines the organization, nancing, and
searchandcompare.aspx.
delivery of health services, the role of key actors,
Analysis provides for in-depth work on
and the challenges faced in the same way, estab-
core health system and policy issues. The
lishes a comparable baseline for reviewing the
Observatory brings together teams of
impact of reforms, and takes a standardized
academics, policy analysts, and practi-
approach to health system assessment. This struc-
tioners from different institutions, coun-
ture is central to the ability of HiTs to inform
tries, and disciplines to ensure rigorous
comparative analysis and facilitates the exchange
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 5

of reform experiences across countries. Arriving bringing together the collection and allocation of
at a robust template is not straightforward, but the funds, and split the chapter on organization and
Observatorys experience suggests some elements management to address planning and regulation
that can help. separately, reecting shifts in emphasis at the time
in wider academic and policy thinking. In addi-
tion, a new chapter was added, on the assessment
Structure of the health system, again a response to the more
explicit way this issue was being addressed at the
The HiT template benets from a clear structure, time. The 2010 template condensed organization,
based on a functional perspective of health sys- governance, planning, and regulation into a single
tems. It works from the premise that all health chapter again and revised and extended the sec-
systems perform a number of nonnormative core tion on performance assessment as policy-makers
functions (Duran et al. 2012), including the orga- became increasingly interested in understanding
nization, the governance, the nancing, the gen- and contextualizing the evaluations of their health
eration of physical and human resources, and the systems that they were being confronted with.
provision of health services. The rst HiT tem-
plate was developed in 1996. It was revised in
2007 and again in 2010, but all iterations have Scope and Content
used the notion of core functions and have drawn
on the literature and prevailing debate to interpret There were of course other changes to the tem-
what those functions are. plate between iterations in terms of the detail
All revisions have involved input from staff addressed within the relatively stable overall
(editors) and national authors, based on their structure. New questions and issues were added
work on the country proles, but they have also because areas like mental health, child health ser-
included consultation with a wider group of users vices, and palliative care (2007) or public health
and stakeholders (Observatory Partners, various and intersectorality (2010) came to the policy fore
units of WHO and of the European Commissions and as a wide group of experts and users were
health directorate, and, more recently, members of consulted. The 2007 template was particularly
the HSPM network). These review stages have heavily laden with new additions and contributed
helped strengthen the template and build some to longer and more time-consuming HiTs. Cer-
consensus around its structure and approach. tainly there was a marked growth in the length
Table 1 shows the changes over time and the of HiTs in successive iterations with Estonia, for
very marked structural consistency between ver- example, growing from 67 pages in 2000, to
sions. This is in part because of a conscious deci- 137 pages in 2004, and 227 pages in 2008. This
sion to adapt rather than rethink the structure was addressed to some extent in 2010 with a
completely so that HiT users can read backwards tightening of the template (see Box 3) after
in time as well as across countries. It is also a which the 2013 Estonia HiT dropped to
testament to the robustness of the rst iteration. 195 pages, and it is being revisited again in the
The adjustments reect on a wider rethinking on 20152016 update.
how different elements t into the whole and on
what seemed more or less important at particular
Box 3: The 2010 Template, Structure
times.
and Contents
The initial template placed more emphasis on
1. Introduction: the broader context of the
the political, economic, and sociodemographic
health system, including economic and
context and on a countrys historical background,
political context, and population health
because of the proximity to transition for so many
eastern European countries. The 20042007 revi- (continued)
sion consolidated nancing in one chapter,
6 B. Rechel et al.

Table 1 The evolution of the HiT template structure

Version 1: developed 19951996a Version 2: developed 20042007b Version 3: developed 20092010c
Introduction and historical background Introduction Introduction
Organizational structure and management Organizational structure Organization and governance
Health-care nance and expenditure Financing Financing
Planning and regulation
Physical and human resources Physical and human resources
Health-care delivery system Provision of services Provision of services
Financial resource allocation
Health-care reforms Principal health-care reforms Principal health-care reforms
Assessment of the health system Assessment of the health system
Conclusions Conclusions Conclusions
References Appendices Appendices
a
Figueras and Tragakes (1996)
b
Mossialos et al. (2007)
c
Rechel et al. (2010)

Box 3: (continued) Box 3: (continued)

2. Organization and governance: an 6. Principal health reforms: reviews
overview of how the health system in reforms, policies, and organizational
the country is organized, the main actors changes that have had a substantial
and their decision-making powers, the impact on health care, as well as future
historical background, regulation, and developments
levels of patient empowerment 7. Assessment of the health system: pro-
3. Financing: information on the level of vides an assessment based on the stated
expenditure, who is covered, what bene- objectives of the health system, nancial
ts are covered, the sources of health- protection, and equity in nancing; user
care nance, how resources are pooled experience and equity of access to health
and allocated, the main areas of expen- care; health outcomes, health service
diture, and how providers are paid outcomes, and quality of care; health
4. Physical and human resources: the system efciency; and transparency and
planning and distribution of infrastruc- accountability
ture and capital stock, IT systems, and 8. Conclusions: highlights the lessons
human resources, including registration, learned from health system changes and
training, trends, and career paths summarizes remaining challenges and
5. Provision of services: concentrates on future prospects
patient ows, organization and delivery 9. Appendices: includes references, fur-
of services, addressing public health, pri- ther reading, and useful web sites
mary and secondary health care, emer-
gency and day care, rehabilitation,
pharmaceutical care, long-term care, ser-
vices for informal carers, palliative care, Signposting
mental health care, dental care, comple-
mentary and alternative medicine, and The HiT template has also seen a number of
health care for specic populations signicant changes to layout and design. These
have aimed rstly to make the template itself more
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 7

user-friendly for authors and editors and secondly on what belongs in the various subsections. How-
to create easier to read HiTs. ever, despite its denitions and advice on how to
Key changes from the perspective of authors produce a HiT, it is not a tool that can ensure
have been clear signposting of sections or sets of consistency and comparability on its own. This
questions that are essential and of those which is because health systems are so complex and
are only discretionary and some reworking of there are so many layers of information that
the glossary elements and examples that charac- could be deemed relevant. The Observatory has
terized the 1996 template. The intention in ag- therefore developed a range of practice over the
ging what is and what is not essential is to help last 20 years that helps make the template into a
authors and editors to focus and keep HiTs short framework that supports health system
and easier to read and update. The editorial team comparisons.
also drew up word limits for chapters, although
these have not been included in the published
template yet; they are used with authors to agree Data Sources
the length of HiTs. The changes in the way terms
are explained reect the fact that they are now Data is of course a constant issue in seeking to
familiar to authors and readers alike. make comparisons, particularly across countries.
Key changes that have been aimed at readers The Observatory has chosen to supply quantita-
include the reorganization of several subsections tive data in the form of a set of standard compar-
to increase accessibility and clarity and the intro- ative tables and gures for each country, drawing
duction of summary paragraphs with key mes- on the European Health for All Database
sages at the start of chapters, an abstract (of less (HFA-DB) of the WHO Regional Ofce for
than one page), and an executive summary Europe, as well as the databases from the Organi-
(of three to ve pages). These pull out zation for Economic Co-operation and Develop-
(or signpost) ndings in a way that allows ment (OECD), the Eurostat, and the World Bank.
policy-makers and their advisers quick access All of these international databases rely largely on
and is in line with the Observatorys growing ofcial gures provided and approved by national
understanding of knowledge brokering (Catallo governments. These are not unproblematic. The
et al. 2014) and the testing of HiT Summaries WHO Europe HFA database covers the 53 coun-
between 2002 and 2008. tries of its European region and Eurostat the
There is a further round of revision which 28 EU member states and the 4 members of the
started in 2015 and is now being piloted, which European Free Trade Association, while OECD
will ne-tune the HiT template. It will signpost Health Statistics covers the 34 OECD countries
still more explicitly how health systems are doing (of which only 26 are in WHOs European region
by integrating more evaluative elements in the and 22 in the EU). There are also differences in
broadly descriptive sections rather than keeping denitions and data collection methods. However,
them all for a single, policy-focused, assessment they have the merit of being consistently compiled
section. and rigorously checked. National statistics are
also used in the HiTs, although they may raise
methodological issues, as are national and
HiT Processes: Making Sure regional policy documents, and academic and
Frameworks Are Used Consistently gray literature, although these do not of course
and Comparably have comparability built in. Data in HiTs is
discussed and assessed, and there is explicit atten-
The HiT template in its various iterations has tion given to discrepancies between national and
guided the writing of country proles, providing international sources.
a clear overall structure, as well as detailed notes
8 B. Rechel et al.

Authors, Author Teams, and the Role comparative framework and to acknowledge
of (Contributing) Editors their contribution are demonstrably worthwhile.

HiTs are produced by country experts in close

collaboration with Observatory (analytic) staff. Flexibility, Consistency,
Having a national author is important because and Signaling Gaps
the framework covers so much ground it is
extremely difcult to marshal the range of infor- The experience of writing HiTs makes clear that
mation needed to complete it from outside. It no two health systems are identical. There needs
also creates ownership within the country and the to be an ability, therefore, to apply the template
national academic community which encourages thoughtfully. Each prole should bring out what is
subsequent use of the prole. The choice of important in a country without slavishly rehears-
national experts is important and needs to reect ing details that are not pertinent while simulta-
research expertise and signal credibility. neously maintaining comparability with other
Appointing small teams of national authors can countries. It has proved to be helpful to ag up
also be a helpful way of bringing different skills where data is missing or an element of a system is
and knowledge into the process. However experi- not yet developed rather than simply avoiding
enced the author team, writing a HiT is a complex mention of it, as it helps readers understand
process. The role of the editor is extremely impor- gaps. Editors have an important role in steering
tant and a crucial factor in applying the HiT HiTs between exibility and consistency and
framework so that it can support comparisons. deciding what should be included or omitted.
Observatory editors play a proactive role and are They meet regularly to exchange experience and
expected to address not just the quality of the discuss practice.
individual prole they are working on but its t
with the rest of the series. They are often credited
as authors because of the contribution they make. Review

Review is an essential element of the HiT process.

Long-Term Relationships Each HiT editor works with their supervisor and
the Brussels secretariat as needed to resolve
The HiTs are updated periodically, and the Obser- issues. When the draft HiT is complete to their
vatory has found that building long-term relation- satisfaction, the Observatory combines external
ships with its author teams is efcient in terms of review by academics (typically one national and
minimizing the learning curve (and costs) of new one international) with that of policy-makers. This
iterations and, as importantly, is effective in pro- means quality is addressed not only through aca-
moting focus and consistency. The template is a demic criteria but also in terms of readability,
complicated instrument and familiarity with it credibility, and policy relevance. The draft is
(and a role in shaping it) makes a difference in also sent to the Ministry of Health and the Obser-
authors ability to use it. It also fosters a sense of vatory Partners for comment. Ministries of Health
co-ownership of and commitment to the outputs. are allowed 2 weeks to ag any factual concerns,
The HSPM initiative (Box 3) has strengthened but they do not approve HiTs. In the same way,
these links, engaging authors and contributors by Partners can comment but do not have a clearance
sharing ownership, creating publishing opportu- function. Any feedback provided is handled by
nities (with its dedicated series in Health Policy the editor and introduced only where it is consis-
http://www.hspm.org/hpj.aspx), and holding tent with the evidence. Completed HiTs are given
annual meetings which let authors and editors a nal check by one of the Observatorys codirec-
meet and exchange ideas. Efforts to properly inte- tors or hub coordinators to ensure that they
grate national experts into thinking on a
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 9

achieve expectations on quality and objectivity is both a way of motivating authors to deliver on
and fulll the aims of the series. time and a way of securing impact when they
do. The Observatory has successfully tied HiTs
and HiT launches to EU Presidencies (Denmark
Dissemination and Policy Relevance: 2012, Lithuania 2013, Italy 2014, Luxembourg
Helping Frameworks Achieve Their 2015), to moments of political change (Ukraine
Objectives 2015), and to major reform programs in countries
(Slovenia 2016).
The HiTs are designed to allow comparisons
across countries, but they are not intended purely
to feed into (academic) research and analysis. HiT Visibility
audiences are often national policy-makers who
use the HiT to take stock of their own health HiTs can only be used when potential users are
system and to reach a shared understanding of aware of their existence. The Observatory has
what is happening which different sectors, minis- developed a mix of dissemination approaches to
tries, and levels of the health service (primary, encourage uptake. There are launch events, typi-
secondary, regional, local) can all subscribe cally in the country and in collaboration with
to. They use HiTs in considering reforms, as the national authors, partner institutions, and Minis-
basis for policy dialogue and to explore policy tries of Health. These work particularly well if
options, and to set their own health systems per- linked to a policy dialogue (a facilitated debate
formance in a European context. Other users are about policy options for decision-makers) or a
foreign analysts or consultants trying to get a major national or international conference (like
comprehensive understanding of a health system, the Polish annual National Health Fund meeting
and researchers and students. HiTs are a single or the Czech Presidency of the Visegrad Group) or
source of information and pull together different a workshop or meeting held by other agencies
strands of analysis which otherwise can be sur- (European Commission meeting on health reform
prisingly hard to nd in one place. in Ukraine).
All HiTs are available as open access online on
the Observatorys web site and there are
Timeliness e-bulletins and tweets to draw attention to new
publications http://www.euro.who.int/en/about-
Any comparative evidence will have more impact us/partners/observatory. A list of the latest avail-
if it is delivered when it is still current and if it able HiTs for the various countries is shown in
can coincide with a window of opportunity for Box 4.
reform. The Observatory tries to turn HiTs around
in the shortest possible time, although this is not
Box 4: Latest Available HiTs, September 2016
always easy. The Health Systems and Policy
Albania HiT (2002)
Monitor is, in part, a response to this and provides
Andorra HiT (2004)
a log of policy developments and reforms online
Armenia HiT (2013)
in between formal HiT updates. Other steps to
Australia HiT (2006)
ensure that material is not superseded by develop-
Austria HiT (2013)
ments before it is published include agreeing a
Azerbaijan HiT (2010)
schedule with authors in advance, efforts to keep
Belarus HiT (2013)
HiTs short and focused, and quick turnaround on
Belgium HiT (2010)
review stages, all of which must be underpinned
Bosnia and Herzegovina HiT (2002)
by strong project management on the part of the
HiT editor. Linking HiTs to an entry point where (continued)
they are likely to be considered by policy-makers
10 B. Rechel et al.

Box 4: (continued) Box 4: (continued)

Bulgaria HiT (2012) Ukraine HiT (2015)
Canada HiT (2013) United Kingdom HiT (2015)
Croatia HIT (2014) United Kingdom, England HiT (2011)
Cyprus HiT (2012) United Kingdom, Northern Ireland HiT
Czech Republic HiT (2015) (2012)
Denmark HiT (2012) United Kingdom, Scotland HiT (2012)
Estonia HiT (2013) United Kingdom, Wales HiT (2012)
Finland HiT (2008) United States of America HiT (2013)
France HiT (2015) Uzbekistan HiT (2014)
Georgia HiT (2009)
Germany HiT (2014)
Greece HiT (2010)
Hungary HiT (2011) Translations can also be extremely helpful in
Iceland HiT (2014) facilitating national access, and HiTs have been
Ireland HiT (2009) translated from English into 11 other languages,
Israel HiT (2015) including Albanian, Bulgarian, Estonian, French,
Italy HiT (2014) Georgian, Polish, Romanian, Russian, Spanish,
Italy, Veneto Region HiT (2012) and Turkish. However, translation is expensive
Japan HiT (2009) and requires careful review by national authors
Kazakhstan HiT (2012) as concepts and policy terms often pose problems.
Kyrgyzstan HiT (2011)
Latvia HiT (2012)
Lithuania HiT (2013) Signaling Credibility
Luxembourg HiT (2015)
Malta HiT (2014) Securing visibility alone cannot ensure uptake. It is
Mongolia HiT (2007) helpful also to demonstrate credibility. The Obser-
Netherlands HiT (2016) vatory has gone about this in a number of ways. It
New Zealand HiT (2001) invests considerable resources in presentation, i.
Norway HiT (2013) e., copy-editing and typesetting, so that the HiTs
Poland HiT (2011) signal professionalism. It also endorses all aspects
Portugal HiT (2011) of the International Committee of Medical Journal
Republic of Korea HiT (2009) Editors Uniform Requirements for Manuscripts
Republic of Moldova HiT (2012) Submitted to Biomedical Journals (www.ICMJE.
Romania HiT (2016) org) that are relevant to HiTs. It has also taken time
Russian Federation HiT (2011) to make the HiTs compatible with PubMed/
Slovakia HiT (2011) Medline requirements, and the Health Systems in
Slovenia HiT (2016) Transition series has been recognized as an inter-
Spain HiT (2010) national peer-reviewed journal and indexed on
Sweden HiT (2012) PubMed/Medline since 2010.
Switzerland HiT (2015)
Tajikistan HiT (2016)
The former Yugoslav Republic of Macedo- Lessons Learned
nia HiT (2006)
Turkey HiT (2011) The experience of the HiT series suggests a num-
Turkmenistan HiT (2000) ber of lessons for frameworks for health system
comparisons. These include:
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 11

The Value of a Template manuscript is ready for review. While this may
be less of an issue in frameworks with a narrower
A template that follows a rational and defendable coverage, plans should include sufcient oppor-
structure, establishes a common vocabulary with tunities for authors and editors to exchange views.
clearly dened terms (supported by examples
when appropriate), and is mindful of the way
researchers from different disciplines and national The Need to Build In Accessibility
traditions may understand it is an invaluable tool. and Relevance
It needs to include clear and sensible explanations
on how to use it, be sufciently robust to accom- Users need to be considered in designing the
modate change over time, and allow a certain template, the processes to deliver the compari-
degree of exibility. It should also reect on sons, and the way ndings are disseminated.
what the nal output is expected to be and who Readable, well-structured, well-presented reports
will use it. that allow users to move from one report to
another and nd comparable information easily
will increase uptake and impact. Abstracts, sum-
The Importance of Author and Editor maries, and key messages will all help different
Roles users access the things they need. An example of a
cover and an executive summary of a HiT are
Comparative work demands data collection and shown in Fig. 1 and Box 5. Delivering timely
analysis in different settings and national exper- (current) data and analysis is also important if
tise is key to this. Selecting authors with appro- the evidence generated is to have an impact.
priate skills and credibility is therefore essential Reports that are overly long and detailed can still
and is boosted by clear criteria, by using teams be useful, but they may tend to be used by aca-
rather than single authors, and by building long- demics rather than policy-makers. Furthermore,
term relationships, which is possible through a those developing comparative frameworks need
network like the HSPM. Good authors must be to have an explicit debate as to how best to bal-
complemented by equally skilful editors who can ance the comprehensive against the manageable
support the authors and ensure consistency. and the timely. A mix of approaches to dissemi-
Bringing editors and authors together to agree nation should be considered, paying attention to
expectations around timing and quality can be ease of access, free download from the Internet,
extremely effective, as is keeping editors in and translation into other languages.
touch with each other.
The experience of the Observatory suggests
Box 5: Executive Summary from Germany,
that it is useful to provide for two roles analogous
Health System Review, 2014
to national author and HiT editor, to have clear
The Federal Republic of Germany is in cen-
(academic) criteria for guiding the choice of
tral Europe, with 81.8 million inhabitants
author, to schedule an initial meeting between
(December 2011), making it by some dis-
the editor and author(s) to go through the template
tance the most populated country in the
and clarify expectations, and to agree a clear time-
European Union (EU). Berlin is the
table. In the case of the HiT template, there is
countrys capital and, with 3.5 million resi-
often discussion of how to tailor the HiT to
dents, Germanys largest city.
national circumstances (and specically of which
In 2012 Germanys gross domestic
areas will be addressed in more detail and which
product (GDP) amounted to approximately
in less), but this may not apply to other compara-
32 554 per capita (one of the highest in
tive frameworks. The experience with HiTs also
suggests there needs to be allowance for numer- (continued)
ous drafts and iterations before the overall
12 B. Rechel et al.

Fig. 1 Cover of the 2014

German HiT (Source: Busse
and Blmel 2014)

Box 5: (continued) Box 5: (continued)

Europe). Germany is a federal parliamen- for men and 2.8 years for women, but
tary republic consisting of 16 states narrowed following reunication to
(Lnder), each of which has a constitution 1.3 years for men and 0.3 years for
reecting the federal, democratic, and women. Moreover, differences in life
social principles embodied in the national expectancy in Germany no longer follow a
constitution known as the Basic Law strict eastwest divide. The lowest life
(Grundgesetz). expectancy for women in 2004, for exam-
By 2010, life expectancy at birth in Ger- ple, was observed in Saarland, a land in the
many had reached 78.1 years for men and western part of the country.
83.1 years for women (slightly below the A fundamental facet of the German polit-
Eurozone average of 78.3 years for men and ical system and the health-care system in
84.0 years for women, although the gap particular is the sharing of decision-
with other similar European countries has making powers between the Lnder, the
been narrowing). Within Germany, the gap federal government, and civil society orga-
in life expectancy at birth between East and nizations. In health care, the federal and
West Germany peaked in 1990 at 3.5 years Lnder governments traditionally delegate

(continued)
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 13

Box 5: (continued) Box 5: (continued)

powers to membership-based (with manda- 2012, or 11.4% of GDP (one of the highest
tory participation), self-regulated organiza- in the EU). This reects a sustained increase
tions of payers and providers, known as in health-care expenditure even following
corporatist bodies. In the statutory health the economic crisis in 2009 (with total
insurance (Gesetzliche Krankenver- health expenditure rising from 10.5% of
sicherung (SHI)) system, these are, in par- GDP in 2008).
ticular, sickness funds and their associations Although SHI dominates the German
together with associations of physicians discussion on health-care expenditure and
accredited to treat patients covered by SHI. reform(s), its actual contribution to overall
These corporatist bodies constitute the self- health expenditure was only 57.4% in 2012.
regulated structures that operate the nanc- Altogether, public sources accounted for
ing and delivery of benets covered by SHI, 72.9% of total expenditure on health, with
with the Federal Joint Committee the rest of public funding coming princi-
(Gemeinsamer Bundesausschuss) being pally from statutory long-term care insur-
the most important decision-making body. ance (Soziale Pegeversicherung). Private
The Social Code Book (Sozialgesetzbuch sources accounted for 27.1% of total expen-
(SGB)) provides regulatory frameworks; diture. The proportion of health care
SGB V has details decided for SHI. nanced from taxes has decreased through-
Since 2009, health insurance has been out the last decades, falling from 10.8% in
mandatory for all citizens and permanent 1996 to 4.8% in 2012. The most signicant
residents, either through SHI or private decrease of public expenditure was
health insurance (PHI). SHI covers 85% of recorded for long-term care (over 50%)
the population either mandatorily or vol- with the introduction of mandatory long-
untarily. Cover through PHI is mandatory term care insurance in 1993 shifting nanc-
for certain professional groups (e.g., civil ing away from means-tested social
servants), while for others it can be an alter- assistance.
native to SHI under certain conditions (e.g., The 132 sickness funds collect contribu-
the self-employed and employees above a tions and transfer these to the Central
certain income threshold). In 2012, the per- Reallocation Pool (Gesundheitsfonds; liter-
centage of the population having cover ally, Health Fund). Contributions increase
through such PHI was 11%. PHI can also proportionally with income to an upper
provide complementary cover for people threshold (a monthly income of 4050 in
with SHI, such as for dental care. Addition- 2014). Since 2009 there has been a uniform
ally, 4% of the population is covered by contribution rate (15.5% of income).
sector-specic governmental schemes Resources are then redistributed to the sick-
(e.g., for the military). People covered by ness funds according to a morbidity-based
SHI have free choice of sickness funds and risk-adjustment scheme (morbidittsor-
are all entitled to a comprehensive range of ientierter Risikostrukturausgleich; often
benets. abbreviated to Morbi-RSA), and funds
Germany invests a substantial amount of have to make up any shortfall by charging
its resources in health care. According to the a supplementary premium.
Federal Statistical Ofce (Statistisches Sickness funds pay for health-care pro-
Bundesamt), which provides the latest viders, with hospitals and physicians in
available data on health expenditure, total ambulatory care (just ahead of
health expenditure was 300.437 billion in
(continued)
14 B. Rechel et al.

Box 5: (continued) Box 5: (continued)

pharmaceuticals) being the main expendi- number of acute hospital beds is still almost
ture blocks. Hospitals are nanced through 60% higher than the EU15 (15 EU Member
dual nancing, with nancing of capital States before May 2004) average. The aver-
investments through the Lnder and run- age length of stay decreased steadily
ning costs through the sickness funds, pri- between 1991 and 2011, falling from 12.8
vate health insurers, and self-pay patients to 7.7 days.
although the sickness funds nance the Health care is an important employment
majority of operating costs (including all sector in Germany, with 4.9 million people
costs for medical goods and personnel). working in the health sector, accounting for
Financing of running costs is negotiated 11.2% of total employment at the end of
between individual hospitals and Lnder 2011. According to the WHO Regional
associations of sickness funds and primarily Ofce for Europes Health for All Database,
takes place through diagnosis-related 382 physicians per 100 000 were practicing
groups (Diagnose-bezogene Fallpauschale; in primary and secondary care. Thus, the
DRGs). Public investment in hospital infra- density of physicians in Germany was
structure has declined by 22% over the last slightly above the EU15 average and sub-
decade and is not evenly distributed; in stantially higher than the EU28 (Member
2012, hospitals in the western part of Ger- States at 1 July 2013) average; the relative
many received 83% of such public numbers of nurses and dentists are also
investment. higher than the EU average. With the EU
Payment for ambulatory care is subject enlargements of 2004 and 2007, a growing
to predetermined price schemes for each migration of health professionals to Ger-
profession (one for SHI services and one many had been expected. In fact, the num-
for private services). Payment of physicians ber of foreign health workers grew from
by the SHI is made from an overall 2000 and reached its peak in 2003, thus
morbidity-adjusted capitation budget paid before the enlargements. The extent of
by the sickness funds to the regional asso- migration to Germany is relatively small
ciations of SHI physicians (Kassenrztliche compared with that to other destination
Vereinigungen), which they then distribute countries in the EU.
to their members according to the volume of Ambulatory health care is mainly pro-
services provided (with various adjust- vided by private for-prot providers.
ments). Payment for private services is on Patients have free choice of physicians, psy-
a fee-for-service basis using the private fee chotherapists (including psychologists pro-
scale, although individual practitioners typ- viding psychotherapy, since 1999), dentists,
ically charge multiples of the fees indicated. pharmacists, and emergency room services.
In 2012, there were 2017 hospitals with a Although patients covered by SHI may also
total of 501 475 beds (6.2 beds per 1000; go to other health professionals, access to
higher than any other EU country). Of reimbursed care is available only upon
these, 48% of beds were in publicly owned referral by a physician. In 2012, of the
hospitals, 34% in private non-prot, and 121 198 practicing SHI-accredited physi-
18% in private for-prot hospitals. Both cians in Germany (psychotherapists not
SHI and PHI (as well as the two long-term included), 46% were practicing as family
care insurance schemes) use the same pro- physicians and 54% as specialists. German
viders. Although acute hospital beds have hospitals have traditionally concentrated on
been reduced substantially since 1991, the
(continued)
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 15

Box 5: (continued) Box 5: (continued)

inpatient care, with strict separation from and although some elements of public
ambulatory care. This rigid separation has health have been included in SHI in recent
been made more permeable in recent years decades (such as cancer screening), and
and now hospitals are partially authorized to other interventions have separate agree-
provide outpatient services and to partici- ments (e.g., immunizations), a prevention
pate in integrated care models and disease act at federal level intended to consolidate
management programs (DMPs). and clarify responsibilities in this area in
For pharmaceuticals, while hospitals 2005 was ultimately rejected by the Federal
may negotiate prices with wholesalers or Assembly (Bundesrat).
manufacturers, the distribution chain and Governmental policy since the early
prices are much more regulated in the phar- 2000s has principally focused on cost con-
macy market. In both sectors, manufac- tainment and the concept of a sustainable
turers are free in theory to set prices nancing system. The government in ofce
without direct price controls or prot con- at the time of writing, again a grand coali-
trols. However, there is a reference pricing tion of Christian Democrats and Social
system for SHI reimbursement, which has Democrats, has agreed a focus on quality,
been steadily strengthened over recent especially in hospitals.
years, whereby reference prices are In international terms, the German
dened nationally for groups of similar health-care system has a generous benet
pharmaceuticals with reimbursement basket, one of the highest levels of capacity
capped at that level. Although prices can as well as relatively low levels of cost shar-
be set higher (with the patient paying the ing. Expenditure per capita is relatively
difference), in practice very few drugs high, but expenditure growth since the
exceed the reference price. For pharmaceu- early 2000s has been modest in spite of a
ticals with an additional benet beyond growing number of services provided both
existing reference price groups, reimburse- in hospital and ambulatory care, an indica-
ment amounts are negotiated between the tion of technical efciency. In addition,
manufacturer and the Federal Association access is good evidenced by low waiting
of Sickness Funds (GKV-Spitzenverband). times and relatively high satisfaction with
Patients generally pay co-payments for out-of-hours care.
pharmaceuticals of 510; there are also However, the German health-care sys-
other cost-saving measures, such as provi- tem also shows areas in need of improve-
sions for generic substitution. Of the phar- ment if compared with other countries. This
maceutical industrys total turnover in 2011 is demonstrated by the low satisfaction g-
of 38.1 billion, 14.3 billion was gained in ures with the health system in general;
the domestic market and 23.8 billion from respondents see a need for major reform
exports (62.5%); Germany is the third larg- more often than in many other countries.
est producer of pharmaceuticals in the Another area is quality of care, in spite of
world after the United States and Japan. all reforms having taken place. Germany is
Public health is principally the responsi- rarely placed among the top OECD or EU15
bility of the Lnder, covering issues such as countries, but usually around average, and
surveillance of communicable disease and sometimes even lower.
health promotion and education. Histori- In addition, the division into SHI and
cally, the Lnder have resisted the inuence PHI remains one of the largest challenges
of the federal government on public health,
(continued)
16 B. Rechel et al.

Conclusions
Box 5: (continued)
for the German health-care system as risk The HiT series is, at least in Europe, in many
pools differ and different nancing, access, respects a gold standard for comparing health
and provision lead to inequalities. systems. It has a long and positive track record
Source: Busse and Blmel 2014 with HiTs for 56 European and OECD countries,
often in several editions, and a total of some
130 HiTs overall. It has made information on
health systems and policies publicly available in
a format that cannot be found elsewhere and
The Need to Signal Credibility supported comparative analysis across countries,
including analytic studies, more detailed country
If evidence is to be used, the reader needs to have case studies, and explicitly comparative works,
condence in it. Using expert inputs and consul- for example on countries emerging from the
tation in developing the template can support this. Soviet Union (Rechel et al. 2014), the Baltic states
External review stages of the HiT are of course (van Ginneken et al. 2012), the central Asian
also important and ideally will include academic countries (Rechel et al. 2012), or the Nordic coun-
and practitioner perspectives. It is also crucial that tries (Magnussen et al. 2009). HiTs are some of
any review by governments or other authorities the most downloaded documents held on the
with a potential conict of interests is handled in WHO web site and are used not just in Europe
such a way that it is not seen to compromise the but beyond. They have served as a guide for the
integrity of the work. Professional presentation, Asia Pacic Observatory on Health Systems and
launches and links to major events, as well as Policies (which was mentored by the European
other efforts to publicize the materials may Observatory and launched in 2011) which uses an
also enhance the reputation of the work. Those adapted version of the template to produce coun-
developing comparative frameworks will also try reviews for its region. The average impact
have to be clear about the sources of data they factor of (European Observatory) HiTs, calculated
use, their quality, and the extent to which they are internally using Thomson Reuters methodology,
compatible with each other. was 3.6 between 2012 and 2014, with a high of
4.26 in 2013 although this only captures citations
in journals listed on PubMed/Medline. Google
The Need to Build in a Review Process Scholar, which also recognizes the gray literature,
shows that some HiTs achieve several hundred
The experience of the Observatory has shown the citations per edition.
value of a comprehensive review process for The Observatorys experience with HiTs has
developing templates for health system compari- generated insights that others developing frame-
sons. While it is clear that consulting widely works for health system comparison might use-
brings new perspectives and creates acceptance fully draw on. It demonstrates the importance of a
for a model, it does run the risk of diluting the user-friendly template that helps authors and edi-
frameworks focus. The Observatory has found tors produce accessible, relevant, and credible
that making it clear in advance that there are outputs with a focus on what is expected from
space constraints and giving those consulted the comparisons and on who is going to use
some explanation of how or why their suggestions them. However, it also suggests that no template
have been acted on (or not) lessens the pressure to is perfect. There are different ways of categorizing
expand the framework indenitely and helps and grouping key functions (of a health or any
those consulted see that their inputs are valued other system) or of conceptualizing systems and
even if they are not always used. different levels of tackling and reporting
A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series. . . 17

evaluation. To some extent these are a matter of accepted tools (OECD et al. 2011) that help, but
preference. There are also and always tradeoffs in many there are no agreed standard denitions
between comprehensiveness and accessibility, (with health professionals being a case in point).
completeness and timeliness, and inclusiveness Other comparative projects will need both to draw
and readability. The current HiT template can be on the latest available knowledge and frameworks
seen as a pragmatic trade-off based on almost and to invest in methodological work as the
20 years of experience. How other teams chose Observatory team has done, for example, with
to balance these will depend on the focus of their the conceptual model (the three-dimensional
comparisons and the people who are to use cube) to explain coverage (Busse et al. 2007;
their work. Busse and Schlette 2007). They will also need to
The Observatory has also found ways of com- tailor responses to data and evidence availability
bining (excellent) national authors with its own in parts of Europe (particularly but by no means
technical editors. This is not always straightfor- exclusively in central, eastern, and southeastern
ward as not all European countries have the same Europe) and to hope that EC/OECD/WHO initia-
capacity in health system research and national tives on data will ultimately ll the gaps. There
experts with strong analytical and English writing will still and inevitably be differences in the infor-
skills can be hard to nd (Santoro et al. 2016) and mation available in countries, in the issues which
may move on rapidly. Moreover, HiT and HSPM are important to them, and in the interests and
authors are not normally remunerated but, at strengths of authors. Those developing frame-
best, receive only small honoraria. The HiT works for comparison will have to address these
series has addressed these challenges by identify- tensions in light of their overarching objectives
ing and linking formally with leading institutions, and in the knowledge that health systems are
cultivating long-term relationships with HiT constantly evolving. They may also nd, as the
author teams, and, most recently, through its Observatory has, that a comparative framework
HSPM network. This mix of approaches may simply cannot capture everything and that analy-
have helped build capacity in countries. It has sis for more specialized issues may require sepa-
certainly developed the understanding and rate study.
research (and people) management skills of the Despite the challenges, the Observatory would
editorial team. Other comparative initiatives with hold that there is real value in a framework for
limited resources might also want to consider health system comparison, particularly one that
what they can do in terms of sharing ownership relates to a dened user need and which can
and recognition to create non-monetary incentives be sustained over time. Much follows from know-
for national counterparts and to develop their ing who will use a set of comparisons and why.
own team. Longevity allows a framework to evolve to
Comparability is and will remain a challenge, improve, strengthen comparability, and build up
despite the standard template, tables, and gures, successive levels of knowledge. Combining the
and is likely to be an issue for all other compara- two means a framework can move beyond the
tive projects. This is somewhat obvious when it descriptive to the truly evaluative so that it cap-
comes to quantitative data given the divergent tures and assesses aspects of health system perfor-
geographic coverage of international databases mance in ways that speak to policy-makers or the
and the differences in denitions and data collec- research community or, ideally, both.
tion methods, not to mention the challenges at the
individual country level. While it is clear that
caution must be exercised when comparing quan- References
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