From metrics to meaning: using performance pathways to make health system performance assessment speak for policy
By guest contributors Dheepa Rajan, Nathan Shuftan
Health system performance assessment (HSPA) has long relied on quantitative indicators to describe how health systems function and whether they meet goals. While such metrics are essential, they often provide only a partial picture: they can reveal what is happening but far less about why performance looks the way it does or how it might be improved. As health challenges persist—ranging from demographic change and chronic disease to strained public health cooperation—there is an increasing need for approaches connecting data to the underlying mechanisms shaping health system performance.
To address this, we propose an approach combining quantitative indicators with structured qualitative insights to build performance pathways. These pathways make the connections between system functions, sub‑functions and health system objectives explicit, enabling clearer understanding of relationships between inputs, processes, outputs and outcomes. They bring qualitative depth to quantitative trends, allowing analysts and policymakers to move from measurement to actionable explanation.
Why integrate qualitative evidence into HSPA?
Across many countries, HSPA activities remain siloed, often focusing on specific areas—workforce, financing, governance—each with its own data landscape and analytical practice. This can obscure the interdependencies that drive health system performance. For example, waiting times may be measured precisely, but structural, financial and governance conditions that shape them often require context‑specific, qualitative understanding – without which that waiting time metric is essentially meaningless.
By integrating qualitative evidence such as policy documentation, implementation reviews, or monitoring insights in a targeted and structured approach, performance pathways can help reveal the drivers behind quantitative indicators. This is especially valuable in environments where health systems face overlapping pressures and where policy decisions require anticipation of system‑wide effects.
The WHO–Observatory HSPA Framework: developed with linkages in mind
The HSPA Framework (Figure 1), developed by WHO and the European Observatory on Health Systems and Policies (OBS), offers a structure designed to trace associative (and causal) linkages across health system functions. Building on the World Health Report 2000, the framework positions governance as the enabling function, shaping financing, resource generation and ultimately service delivery.
- Governance sets strategic direction, works across sectors, is participatory, promotes evidence-informed policy, and regulates
- Resource generation covers infrastructure, medical devices, pharmaceuticals and health workers.
- Financing concerns raising revenues, pooling funds and purchasing health services.
- Service delivery can be seen as an outcome of the other three functions, and is the most visible of all functions as it is where (financed and governed) resources come together
Figure 1. HSPA Framework Source: Papanicolas et al (2022)
Put differently, the ways that the other functions contribute to reaching health system goals are seen in service delivery – their impacts on performance hinge on providing the right resources at the right time for optimal use (enabling service delivery).
The HSPA Framework further delineates the functions into relevant sub-functions and links, via service delivery, with the intermediate objectives and final goals of the health system, highlighting various interlinkages between them and placing everything within the wider socioeconomic and societal context (Figure 2). Sub-functions represent key focus areas that matters most for the respective functions in terms of overall performance, while assessment areas provide high-level indications of what can be done to improve performance. Assessment areas, when feasible, are linked to a selection of indicators and data that reflect the performance of functions or sub-functions.
Figure 2. Expanded HSPA Framework Source: Papanicolas et al (2022)
What performance pathways offer
Performance pathways use “entry points”— sub‑functions, assessment areas, objectives or goals—and trace linkages in a structured way. The framework’s design reflects a deliberate effort to strengthen the ability of analysts to map plausible pathways of association, i.e. a “performance pathway”. It sits alongside other useful HSPA approaches, each with its own focus and purpose, but adds value by weaving together the functional architecture and the evidence to support mixed‑methods, systems‑oriented performance analysis.
For example:
Policy priority or policy question: how can avoidable hospitalizations be reduced to improve system efficiency?
Entry point: High rates of avoidable hospitalizations for chronic conditions.
Backward tracing: Limited primary care availability → workforce shortages → rigid staffing norms and slow recruitment → governance and financing constraints.
Forward tracing: Increased financial burden on households (decreased financial protection), low primary care access à pressure on hospital capacity, inequities in effective coverage.
Policy leverage points: Revising staffing regulations, adjusting purchasing arrangements, strengthening chronic care models, monitoring unintended effects on provider capacity.
This approach brings together quantitative indicators (e.g., Eurostat, WHO EURO’s financial protection monitoring, OECD Health Statistics) with qualitative research (e.g., the European Observatory’s health system reviews (HiTs), policy analyses, stakeholder interviews). The combination allows pathways to be both empirically grounded and contextually meaningful.
How this helps policymakers, technical agencies and researchers
Using performance pathways within the WHO–OBS framework offers several advantages:
- Diagnosing root causes, not just symptoms, of performance problems.
- Aligning policy design/evaluation with the actual mechanisms driving observed outcomes.
- Testing the potential impact of policy actions across the system.
- Identifying spillovers and trade‑offs, supporting more resilient reforms.
- Promoting consistency in how analysts interpret health system data.
For the policy community—and for those working at the interface of evidence generation and system improvement—the pathways approach supports a shift from isolated metrics to a deeper, mechanism‑oriented understanding of health system performance.
A shared foundation for evidence‑informed reform
The HSPA Framework offers a structured way to understand what drives and shapes health systems, but its value lies in how to operationalize it: constructing credible, evidence‑informed narratives about performance that can be regularly updated as new data emerge. The framework builds on work by the WHO‑hosted UHC2030 Technical Working Group on Health Systems Assessment (2017–2020) and is detailed in Health System Performance Assessment: A Framework for Policy Analysis (Papanicolas et al., 2022) as well as the 2023 policy brief Health system performance assessment: A renewed global framework for policy-making (Rajan et al., 2023)
By grounding HSPA in both quantitative trends and qualitative insights, performance pathways help move global health discussions from “what the numbers show” to “why the system behaves the way it does”—and what can realistically be done to improve it.
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About the authors
Dr Dheepa Rajan joined the European Observatory on Health Systems and Policies in July 2022, before which she spent over 15 years at WHO headquarters in various health system roles, covering national health planning, health system performance, participatory governance, and primary health care. She led various key WHO and European Observatory publications on those topics such as the WHO Handbook on Social Participation, the Primary Health Care Primer, and Health System Performance Assessment: A Framework for Policy Analysis. She did an MD at the University of Göttingen in Germany, followed by a Master’s degree in health economics and policy from the UK, and completed her doctorate on traditional medicine in India.
Nathan Shuftan works as a Research Fellow and is part of Observatory’s Berlin Hub based at the Berlin University of Technology. His work covers health system and policy developments through projects like the State of Health in the EU programme, Health System Reviews (HiTs), policy briefs, peer-reviewed journal articles and Observatory studies, including the Observatory’s workstream on Health System Performance Assessment. Nathan previously worked at the Observatory as a research assistant while he earned his Master of Public Policy from the Hertie School of Governance in Berlin. He also holds a BA in Political Science from the University of Illinois. He is also a managing editor of the scientific journal Health Policy and teaches at the Berlin School of Public Health.
Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.
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