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Int J Qual Health Care. 2003 Oct;15(5):377-98.

Conceptual frameworks for health systems performance: a quest for effectiveness, quality, and improvement.

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Netherlands Institute for Health Sciences, Erasmus MC, Rotterdam, The Netherlands.

Erratum in

  • Int J Qual Health Care. 2004 Apr;16(2):189.



Countries and international organizations have recently renewed their interest in how health systems perform. This has led to the development of performance indicators for monitoring, assessing, and managing health systems to achieve effectiveness, equity, efficiency, and quality. Although the indicators populate conceptual frameworks, it is often not very clear just what the underlying concepts might be or how effectiveness is conceptualized and measured. Furthermore, there is a gap in the knowledge of how the resultant performance data are used to stimulate improvement and to ensure health care quality.


This paper therefore explores, individually, the conceptual bases, effectiveness and its indicators, as well as the quality improvement dynamics of the performance frameworks of the UK, Canada, Australia, US, World Health Organization, and Organisation for Economic Co-operation and Development.


We see that they all conceive health and health system performance in one or more supportive frameworks, but differ in concepts and operations. Effectiveness often implies, nationally, the achievement of high quality outcomes of care, or internationally, the efficient achievement of system objectives, or both. Its indicators are therefore mainly outcome and, less so, process measures. The frameworks are linked to a combination of tools and initiatives to stimulate and manage performance and quality improvement.


These dynamics may ensure the proper environment for these conceptual frameworks where, alongside objectives such as equity and efficiency, effectiveness (therefore, quality) becomes the core of health systems performance.

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