Correspondence to Sundeep Sodhi; [email protected]
STRENGTHS AND LIMITATIONS OF THIS STUDY
Merging the evidence from our extensive search of the grey literature with data from searches across multiple literature databases resulted in a comprehensive review of the high performance health system literature.
The inclusion of all countries facilitates a comprehensive global perspective.
Broad terminology such as system performance has the potential to discuss the full spectrum of performance issues, and since our searches were specifically tailored to high performance, these studies would not have been detected.
The review examined large-scale health systems, rather than concentrating on specific components such as individual hospitals, to illustrate a broader perspective of high-level systems.
Introduction
Health systems are struggling globally. The 2019 SARS-CoV-2 pandemic identified the frailties of medical care infrastructures and the need to reorganise health systems around the world.1 Jurisdictions, regardless of financing system or market orientation, are actively engaged in the process of identifying opportunities to improve and implement high-performing health systems. However, before systems can pursue a particular path, ideally founded in evidence, they need to determine whether the definition of high performing is one that works for them and their unique, diverse populations.2 What is meant by a high-performing health system is often based on the specific priorities of a given population and resource context that may not be broadly shared.2
High performance is the ideal goal for a health system as performance impacts the health status of the population and reflects the health services’ effect on the community served.3 4 A high-performing health system is crucial to the overall health of society and the well-being of individuals, allowing people to engage in productive lives. High-performing health systems play a role in preventing and controlling the spread of disease and responding appropriately to public health emergencies and disasters while delivering quality, cost-effective care.
Previous research has restricted the countries studied, mixed healthcare entities (the term referring to health systems in which there is a blend of both public and private services at play),5 and incorporated broad interpretations of definitions when examining high-performance health systems. A systematic review by Ahluwalia et al6 looked at studies limited to five countries (USA, UK, Canada, Australia and New Zealand) to determine what comprises a high-performing healthcare delivery system. Authors sought an implicit definition by reviewing dimensions (ie, characteristics) used to describe high performance, and broader health systems were assessed along with other entities such as health organisations (eg, a hospital). Many studies examining health systems and performance consider one country only and thus offer a finite perspective on the topic.7–14
This review aims to fill a gap in previous literature by supplying a comprehensive overview of what constitutes a high-performing health system from a global and broader systems-level perspective. This approach focuses on definitions and characteristics in the literature that do not limit themselves to specific jurisdictions, thus providing insights that may be of relevance to high-income countries (HICs) and low-income and middle-income countries (LMICs) alike.
This is a field of research that continues to evolve. We conducted a comprehensive scoping review on health systems and high performance to identify explicit definitions, research outcomes and knowledge gaps. These concepts were identified as key to our review in order to build a repository of knowledge that would coalesce current understandings of high-performing health systems. Furthermore, we anticipate this review may be a helpful tool for applied researchers and policy-makers by providing a shared working definition and commonly referenced research outcomes to enable their thinking on identifying gaps, recommendations or ideas for further inquiry in their respective healthcare contexts.
Our review questions are as follows:
What are the definitions of high-performing healthcare systems?
What research outcomes* are documented on high-performing healthcare systems?
What are the knowledge gaps on high-performing healthcare systems?
*Research outcomes as they relate to the context of this review refer to how the concepts of high performance in health systems were examined in studies included (such as through system evaluation or tool development).
Methods
Protocol
The protocol for the review was developed in alignment with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement for protocols15 and using the JBI Manual for Evidence Synthesis guidance for scoping reviews.16 The PRISMA extension for Scoping Reviews (ScR) was used for reporting the results (online supplemental file 1).17
Searches and data sources
A comprehensive literature search was run with no year or language restrictions in Ovid MEDLINE, Ovid MEDLINE Daily, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Epub Ahead of Print, CINAHL (EBSCOhost), OVID EMBASE and the Cochrane Central Register of Controlled Trials. Searches were performed from inception to July 2024. All search strategies can be found in online supplemental file 2. Grey literature (ie, unpublished, non-indexed) was identified by searching multiple sources (eg, WHO website). All sources and documentation are outlined in online supplemental file 3. Finally, we scanned the references of included studies to identify other potentially relevant articles. The results were imported into Covidence (covidence.org).
Eligibility criteria
The eligibility criteria are listed below according to the Population, Concept, Context mnemonic16:
Population
All human populations.
Concept
The performance of healthcare systems. The review will focus specifically on the high performance of healthcare systems as defined by the author(s) of the included studies. We also considered articles that used synonyms for high performance such as high functioning, best performing, etc.
Context
Healthcare systems in which their primary purpose is to promote, restore and/or maintain the health of populations or groups of people. An individual device made for personal use and described as a healthcare system (ie, an Apple watch), was not eligible for inclusion in the review. The health system described could not be a subsystem or part of a larger healthcare system, (eg, primary care health network or hospital(s)), or only be associated with a specific clinical area or clinical condition, (eg, mental health).
Articles identified as research studies (quantitative or qualitative) had to provide data to support statements related to a healthcare system and its performance. Publications that were not studies (eg, commentaries, editorials), that made statements about healthcare systems and high performance were abstracted verbatim since these types of publications do not traditionally provide data.
Other criteria
Included in the review were studies using quantitative or qualitative methods, as well as any other types of documents such as editorials, commentaries, reports and consensus statements. No restrictions were applied regarding the publication year or language.
Quality assessment
Quality assessment was not conducted as outlined in the guidance on scoping reviews in the JBI Manual for Evidence Synthesis.16
Study selection
A calibration exercise was conducted using 25 citations with 100% agreement among team members. Following this, all titles and abstracts were screened independently by two reviewers (VC, GA and LP). Full-text articles of records identified as relevant were retrieved and independently assessed by two investigators (VC and LP) following a calibration exercise with 96% agreement among the team (VC and LP). Conflicts for both stages of screening were resolved by a third reviewer or by discussion.
Data extraction
A data extraction form was developed (online supplemental file 4), and a pilot test was completed on a 5% random sample of eligible articles by the research team (VC and LP). All included studies were extracted independently by two reviewers. Items extracted included article characteristics, definitions and features of high-performing healthcare systems such as characteristics, facilitators, barriers and outcomes. Differences in abstraction were resolved by a third reviewer or by discussion. Companion documents were identified by matching initiative, timeframe and authors (if appropriate).
Data synthesis and analysis
Synthesis was led by the main study objectives. Guidance from Pollock et al was followed,18 from the preparation, organising and reporting of the data. A collaborative and iterative team strategy was deployed to conduct basic qualitative content analysis that drew primarily from deductive approaches. Data extraction tables were formed that were then examined to determine the presence of dominant groups or clusters of characteristics by which the subsequent analysis could be organised and reported (see online supplemental file 4, Data Charting Form). The authors also made every effort to ensure that articles were not double counted as per the aforementioned guidance.18
Patient and public involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Results
Literature search
After screening 5721 titles and abstracts and 507 full-text articles, 82 records were identified for our study. These records consisted of 35 primary articles and 47 companion documents (figure 1). Primary articles were grouped with accompanying companion documents to indicate a single initiative or a series of papers published by one author. An example is The Commonwealth Fund’s Commission on a High Performance Health System which was introduced in 2005. For this initiative, we specified a primary article by Gauthier et al,19 and it was grouped with 25 companion documents20–44 on this same project. These companion documents were identified as iterative adaptations of the 2005 report that represent the evolution of The Commonwealth Fund’s stance on high-performing health systems over the years. Eight initiatives or series of papers were identified consisting of a primary article accompanied by related companion documents (online supplemental file 5). Companion documents may be reported independently or serve as additional supporting material. Clear labelling will be used for tables, figures, and text to signify their purpose.
Article characteristics
Of the 35 primary articles, the earliest was published in 2000 (table 1) and all articles were written in English. The highest number of primary articles was published (9/35, 26%) during the period spanning from 2005 to 2009. However, the overall count remains low (ie, less than ten articles per year) from 2000 to 2024. A list of the included articles can be found in online supplemental file 6.
Table 1Summary of primary article information
Characteristics | Number (%)* N=35 primary articles |
Year of publication | |
5 (14) | |
9 (26) | |
5 (14) | |
8 (23) | |
8 (23) | |
Geographical region | |
12 (34) | |
8 (23) | |
7 (20) | |
2 (6) | |
1 (3) | |
1 (3) | |
1 (3) | |
1 (3) | |
1 (3) | |
1 (3) |
*Percentages may not total 100 because of rounding.
†Documents published by organisations representing no specific country, for example, WHO, are listed as Global.
OECD, Organisation for Economic Co-operation and Development.
Geographical location
Most articles (20/35, 57%) reported on work conducted in North America (ie, the USA and Canada) and the USA led with 12 articles. Following this were articles that reported on global initiatives (eg, the WHO) (7/35, 20%), Organisation for Economic Co-operation and Development countries (2/35, 6%) and 6 groups (G8 countries, India, Italy, Chile, Spain and multicountry) each describing one programme (1/35, 3%).
Article type/study design
Most records (primary articles and companion documents) were non-research (62 out of 82) with 36 reports being published by groups such as the Commonwealth Fund and the WHO (online supplemental file 7; table 2). Close to a quarter of all records (20/82, 24%) were research studies. The studies conducted were cross-sectional (eg, surveys or questionnaire), focus groups or interviews, case studies, consensus studies (eg, modified Delphi), and systematic/scoping reviews (table 2).
Table 2Summary of primary article and companion document characteristics
Characteristics | Number (%)* N=82 primary articles and companion documents |
Study design/article type | |
Total: 20 | |
9 | |
7 | |
4 | |
2 | |
2 | |
Total: 62 | |
36 | |
15 | |
7 | |
2 | |
2 | |
Definition of high-performing health system reported | |
10 (12) | |
72 (88) | |
Tools Reported That Measure Performance | 8 (9) |
Overall Performance Index60 | 1 |
High Performing Healthcare tool49 | 1 |
Healthcare Quality Indicators tool50 | 1 |
WHO Performance Index | 1 |
Health System Performance Assessment (WHO EURO 2012)56 | 1 |
Health System Analysis for better health system strengthening (World Bank) (Berman and Bitran 2011)56 | 1 |
Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies (WHO 2010)56 | 1 |
Health System Rapid Diagnostic Tool (FHI 360, Wendt 2012)56 | 1 |
Legislation Reported (eg, policy, government Act) | |
11 (13) | |
71 (87) |
*Percentages may not total 100 because of rounding.
†Categories are not mutually exclusive (for study types), for example, mixed methods studies may report two or more studies.
Other
A small number of records (11/82, 13%) described legislation (eg, policy or government act) related to the content of the article. Similarly, a small group of records identified a formal tool for measuring health system performance (8/82, 9%) with only one author identifying that the tool was validated.45 14 records (17%) reported measures used for a high performance health system, including a report by the WHO that stated that “to assess a health system, one must measure five things: the overall level of health; the distribution of health in the population; the overall level of responsiveness; the distribution of responsiveness; and the distribution of financial contribution”. The full list of measures reported as it relates to high-performing health systems can be found in online supplemental file 8.
Definitions of high-performing healthcare systems
Seven records (7/82, 8%) provided an explicit definition for a high-performing health system. Table 3 provides a listing of the definitions and identifies that only three independent definitions are being used. The Commonwealth Fund’s Commission on a High Performance Health System provided a definition early in their initiative in 2006, which reads as the following, “to help everyone, to the extent possible, lead long, healthy, and productive lives.”23 Following this, the American College of Physicians46 and The European Observatory on Health Systems and Policies47 chose to adopt this definition, and The Commonwealth Fund continued to re-use the definition in future papers.23 26 Baker et al provided two separate definitions.7 48
Table 3High-performing health system definitions (primary articles and companion documents)
Article (reference) | Definition |
Baker 2011 CD48 | High-performing healthcare systems are those that have created effective frameworks and systems for improving care that are applicable in different settings and sustainable over time. |
Baker 20157 | ‘The (Excellent Care for All) Act defines a high-performing healthcare system, where healthcare organisations are responsive and accountable to the public, and focused on creating a positive patient experience and delivering high-quality care’ |
Commonwealth Fund 2006 CD23 | To help everyone, to the extent possible, lead long, healthy, and productive lives |
Ginsburg 200846 (American College of Physician Position Paper) | To help everyone, to the extent possible, lead long, healthy and productive lives |
Commonwealth Fund 2007 CD26 | The Commonwealth Fund Commission on a high-performance health system has defined a high-performance health system as one that helps everyone, to the extent possible, lead longer, healthier and more productive lives |
Wakefield 2006 CD24 | To help everyone, to the extent possible, lead long, healthy and productive lives |
Papanicolas 2013 CD47 (The European Observatory on Health Systems and Policies) | High-performance healthcare system: One that helps everyone, to the extent possible, lead long, healthy and productive lives |
CD, companion document.
Outcome characteristics
Close to a third of the research studies reported on the elements of a high-performing health system (12/20). Examples include two studies using modified Delphi techniques to identify specific elements of health systems that are related to high performance.8 45 Other outcomes recorded include six studies that examined system evaluation (eg, comparison of health systems), as well as two studies that assessed tool development or validation (eg, testing reliability of an assessment tool) (online supplemental file 9). Research outcomes for quantitative cross-sectional studies can be found in table 4, other quantitative studies and qualitative studies in table 5 and mixed-methods studies in table 6. Nine records described facilitators to a high-performing health system, including establishing and tracing metrics.23 Seven records reported barriers, including inadequate information systems and support for the status quo.23 Interestingly, two authors provided a list of facilitators or barriers that they indicated were dependent on the circumstances, that is, it could be considered either a barrier or a facilitator given the current conditions. An example of this is capacity building and leadership improvement.7 A full list of all barriers and facilitators can be found in online supplemental file 10.
Table 4Cross-sectional studies (primary articles and companion documents)
Study (reference) | Study title (study type) | Study duration/type of participants/number of participants | Aim/purpose of study | Research outcomes |
Aqil et al 202355 | Reliability and validity of an innovative HPHC system assessment tool (Cross-sectional study–survey) | Not reported/all those age 18 years or more, who interacted with health system as part of the health system in some capacity or a client were eligible to participate/213 participants | This paper will answer the research question, ‘is the HPHC tool reliable and valid?’ |
|
Bilynsky et al 200210 | Integration’s best performers—seven habits of successful healthcare systems (Cross-sectional study) | Not reported/Chief Executive Officers of integrated healthcare delivery systems in the USA/144 participants | To report on the seven habits of successful healthcare systems |
|
Werle et al 201061 | A study of the effectiveness of performance-focused methodology for improved outcomes in Alberta public healthcare (Cross-sectional study) | 12 months/all healthcare teams (clinicians and managers) involved in hip and knee replacements/all institutions involved in hip and knee replacement surgery | This study evaluates the effectiveness of a performance-focused methodology for engaging multidisciplinary, frontline healthcare teams in making behavioural changes that improve patient care and health system efficiency. |
|
Davis et al 2010 CD39 Companion document to Gauthier 200622 | Mirror, Mirror on the Wall: How the Performance of the US Healthcare System Compares Internationally: 2010 Update (Cross sectional study–survey) | 2010 2) patients/ physicians: 2007–2009/1) Countries studied: Australia, Canada, Germany, the Netherlands, New Zealand, the UK and the USA 2) Patients and physicians (from each country)/(1) 7 countries (2) Number of patients/physicians: 11 910 adults in 2007, 8742 sicker adults in 2008 and 6750 primary care physicians in 2009 | This report—an update to three earlier editions—ncludes data from seven countries and incorporates patients’ and physicians’ survey results on care experiences and ratings on dimensions of care |
|
Hess et al 2008 CD27 Companion document to: Gauthier 200619 | State health policies aimed at promoting excellent systems: a report on States’ roles in health systems performance (Cross-sectional study) | Not reported/5 state agencies: Medicaid; State Children’s Health Insurance Program, public health, state employee health plan, insurance, Governor’s office/150 participants | To identify and describe the kinds of roles, policies and practices that states are implementing and which can contribute to health system transformation |
|
Braithwaite et al 201749 | Health system frameworks and performance indicators in eight countries: A comparative international analysis (Cross-sectional study) | Not reported/OECD countries/8 participants | This study identifies and compares frameworks and performance indicators used in selected OECD health systems to measure and report on the performance of healthcare organisations and local health systems | The most commonly used domains in performance frameworks were safety, effectiveness and access. |
Kruk et al 202462 Companion document to Kruk 20182 | Population confidence in the health system in 15 countries: results from the first round of the People’s Voice Survey (Cross-sectional study–survey) | 14 months/adults 18 years and older (from Kenya, South Africa, Peru, Colombia, Mexico, Uruguay, Argentina, Laos, India, South Korea, Greece, Italy, UK, USA, Ethiopia)/25 245 participants | To report health system confidence among the general population (in 15 countries) and analyse its associated factors |
|
CD, companion document; HPHC, high-performing healthcare; OECD, Organisation for Economic Co-operation and Development.
Table 5Quantitative studies (systematic review and case studies) and qualitative studies (primary articles and companion documents)
Study (reference) | Study title (Study type) | Study duration/type of participants/number of participants | Aim/purpose of study | Research outcomes |
Quantitative studies (systematic review and case studies) | ||||
Ahluwalia 20176 | What defines a high-performing healthcare delivery system: a systematic review (systematic review) | Studies from 2005 to 2015/not applicable/not applicable | To describe health systems and healthcare organisations that are the building blocks of healthcare delivery systems (health plans, hospitals, or provider groups), and evaluated (1) whether a definition of high performance was articulated, (2) the key elements of the definition, and (3) the metrics used to operationalise the definition, if any. |
|
McCarthy 2008 CD29 Companion document to Gauthier 200619 | The North Dakota experience: achieving high-performance healthcare through rural innovation and cooperation (case study) | 1 month/state of North Dakota health system/1 state in the USA (North Dakota) | To learn more about the state’s (ie, North Dakota) achievements, focusing on three key areas: (1) supports for primary care and the concept of a medical home (discussed below), (2) organisation of care through networks of coordination and cooperation; and (3) the innovative use of technology to meet patient needs and hold down costs. |
|
Shih 2008 CD31 Companion document to Gauthier 200619 | Organising the US healthcare delivery system for high performance (case study) | Not reported/diverse types of health delivery systems that have been widely recognised as examples of high performance/total sites=16
| This report from The Commonwealth Fund Commission on a High Performance Health System examines fragmentation in our healthcare delivery system and offers policy recommendations to stimulate greater organisation established mechanisms for working across providers and care settings | Solutions are complex and will require new financial incentives, changes to the regulatory, professional, and educational environments, and support for new infrastructure |
Baker 201154 CDCompanion document to Baker 200863 | A comparative study of three transformative healthcare systems (case studies) | Not reported/3 healthcare systems: (1) Southcentral Foundation, Anchorage, Alaska (2) Jönköping County Council, Sweden (3) Intermountain Healthcare, Salt Lake City, Utah/3 case studies | To analyse the strategies and mechanisms that enabled transformation in three high-performing healthcare systems and identify the lessons that can be learnt for Canadian healthcare systems. |
|
Qualitative studies | ||||
Hortsman 2022 CD44 Companion document to Gauthier 200619 | What an ideal healthcare system might look like: perspectives from older Black and Latinx adults (focus group) | 4 months/Black or Latinx Medicare enrollees aged 65 and older/88 participants | People’s experiences seeking and accessing healthcare, feelings about their providers and the US healthcare system, perceived discrimination and racism while seeking care, and thoughts about how to improve healthcare. |
|
Silow-Carroll 2011 CD41 Companion document to Gauthier 200619 | Lessons from high and low-performing states for raising overall health system performance (interviews) | Not reported/health policy experts and select stakeholders in seven of the high-ranked states and five low-ranked states. representatives from a variety of organisations including state health policy centres/institutes, Medicaid agencies, healthcare commissions and collaboratives, state health foundations, quality improvement organisations, hospital associations, advocacy organisations, and health plans/not reported | The authors of this brief interviewed stakeholders in states with high-ranking and low-ranking health system performance, according to The Commonwealth Fund’s State Scorecard on Health System Performance | High-performing states are more likely to have: a history of continuous reform and government leadership; a culture of collaboration among stakeholders; transparency of price and quality information; and a congruent set of policies that focus on system improvement |
Fullaondo 202464 | Transforming healthcare systems towards high-performance organisations: qualitative study based on learning from COVID-19 pandemic in the Basque Country (Spain)/(Interviews) | 3 months/participants were identified among those with a high level of involvement in the leadership, management, and delivery of public health services (Department of Health and Osakidetza) during the COVID-19 pandemic in the Basque Country/20 | The research aimed to understand what, how and why organisational change occurred to respond to the demands and challenges that the pandemic brought to health services |
|
CD, companion document.
Table 6Mixed-methods research studies (primary articles and companion documents)
Study (reference) | Study title (study type) | Study duration/type of participants/number of participants | Aim/purpose of study | Research outcomes |
Baker 200863 | High-performing healthcare systems: delivering quality by design (case studies and interviews) | Not reported/case Studies: 7 healthcare systems; Interviews: Individuals (experts) at each of the health systems studies/7 case studies; 21 interviewees | To try to identify the common elements of high-performing healthcare systems from around the world | (1) Policy and leadership matter; (2) Policy without tools is ineffective; tools without policy are highly limited; (3) Transformation is never complete, and in some areas progress can take a long time; (4) Integrating key providers into the system and engaging them in goal setting and performance improvement are essential to success; (5) Let people experiment, fail, regroup, and improve; (6) Be wary of narrow targets and isolated successes; (7) Successful transformers are dissatisfied with the status quo. |
Sharma 20199 | Comprehensive measurement of health system performance at district level in India: Generation of a composite index/(cross sectional study (survey) and interviews) | 3–4 years/clients using services in the public health facilities/surveys: 460 participants; Interviews: 2595 interviewees | This study was undertaken to develop a composite indicator to measure health system performance at district level in India |
|
Khodyakov 202158 | Alignment between objective and subjective assessments of health system performance: findings from a mixed-methods study (cross-sectional study (survey) and interviews) | 3 years (2017–2019)/from the list of health systems in these states (California, Minnesota, Washington, and Wisconsin), we purposively chose 24 to ensure variability in size (small, medium, and large) and performance (low, medium, and high), using quality measures/ Survey: 24 health systems; Interviews: 138 C-suite executives (in the 24 health systems) | Whether subjective performance assessments from health system executives match objective performance assessments and qualitatively explores ways to achieve high performance |
|
Bergevin 201611 | Towards the Triple Aim of Better Health, Better Care and Better Value for Canadians: transforming regions into high-performing health systems (Scoping review and Interviews) | Not reported/interviews: Senior health leaders from across Canada (included current and former deputy ministers and assistant deputy ministers, current and former Chief Executive Offiers of Regional Health Authorities, senior academics including a dean, and leaders of key Canadian health organisations)/30 interviewees | To provide insight and evidence on the impact that regionalisation across Canada has had on the Triple Aim of Better Health, Better Care and Better Value. |
|
Carinci 201545 | Towards actionable international comparisons of health system performance: Expert revision of the OECD framework and quality indicators/(Consensus study - Modified Delphi procedure) | 7 months/members of the OECD HCQI expert group/5 experts | To review and update the conceptual framework, indicator content and research priorities of the OECD HCQI project, after a decade of collaborative work |
|
Ridgely 20208 | What are the determinants of health system performance? Findings from the literature and a technical expert panel /(Consensus study - Modified Delphi procedure) | Not applicable/technical expert panel composed of leaders in health systems and health services research/8 member panel of C-suite level leaders of health systems and physician organisations and researchers with expertise in economics, business administration, public health, and medicine | We sought to extend this work (of naming dimensions used to measure performance) by identifying the specific attributes of health systems that are related to high performance and considering the factors that contribute to achieving high performance. |
|
CD, companion document; HCQI, Healthcare Quality Indicator; OECD, Organisation for Economic Co-operation and Development.
The 35 primary articles were examined for characteristics of high performance in a health system. 10 articles provided characteristics with access mentioned most often. This was followed by quality (n=9) and safety (n=9). Patient-centredness (n=8) and equity (n=7) round out the top five characteristics reported most often. Online supplemental file 11 provides the full complement of characteristics including the 44 characteristics mentioned only once. A variety of names were used as synonyms for the word ‘characteristics’ with dimensions(n=3), characteristics (n=2) and attributes (n=2) presented most often. In total, we identified 62 characteristics that were provided by authors.
Knowledge gaps
Lack of a common definition
Three authors (4%) identified the absence of a consistently used definition for a high-performing health system and its component parts as an important gap in knowledge.6 47 49 The lack of consensus on what constitutes the boundaries of health systems when discussing high performance as well as its inconsistent definitions, is noted as problematic, in particular when making international comparisons.6 47 49
Common indicators
Inter-related with the lack of a common definition is the absence of common indicators used to examine health system performance (6/82, 7%).45 50–54 This was described as necessary in a general sense (eg, to improve international comparability),45 50 in relation to specific frameworks (eg, WHO framework for health systems performance measurement),51–53 and for distinct jurisdictions (eg, the Canadian healthcare context).54
Moving evidence into policy and practice
Several records (8/82, 10%) reported the need to use research-based evidence for promoting policy or practice.7 9 39 45 46 49 50 55 These papers focused on overall system performance9 45 55 (eg, associations between inputs and outcomes,9 55 accuracy of indicators in reporting system functions),45 ability to describe incremental differences within a health system9 50 (eg, indicators demonstrating relative achievements,50 reasons for variations in health system performance),9 use of technology39 46 (eg, assist patients/physicians in making evidence-based decisions,46 interoperable information systems for improved coordinated care)39 and support patient-focused care7 39 (eg, capture informative measures/metrics in patient-focused ways).7
Comparison across health systems
A set of records (6/82, 7%) listed the challenges of comparing health systems. This included the importance of identifying the overarching goal of the health system,56 ongoing reflection of how governments should be involved in healthcare,57 comparability of quality indicators,58 variation in alignment between subjective and objective assessments in health system performance45 and differences in health system management (eg, distribution of resources).46 All knowledge gaps are presented in table 7.
Table 7Knowledge gaps (primary articles and companion reports)
Article (reference) | Identified gap in knowledge/need for future research | Knowledge gaps | |||
Common definition | Evidence to policy | Common indicator | Comparison across health systems | ||
Ahluwalia 20176 |
| ✔ | |||
Aqil 202355 |
| ✔ | |||
Baker 20157 |
| ✔ | |||
Baker 2011 CD54 Companion document to Baker 200863 |
| ✔ | |||
| ✔ | ||||
Braithwaite 201749 |
| ✔ | |||
| ✔ | ||||
Carinci 201545 |
| ✔ | |||
| ✔ | ||||
Ginsburg 200846 |
| ✔ | |||
| ✔ | ||||
Khodyakov 202158 |
| ✔ | |||
Murray 2000 CR57 Companion document to WHO 2000a3 |
| ✔ | |||
Smith 2012 CD56 Companion document to WHO 2000a3 |
| ✔ | |||
Papanicolas 2013 CD47 Companion document to WHO 2000a3 |
| ✔ | |||
Papanicolas 202251 |
| ✔ | |||
Rajan 2022 CD50 Companion document to Papanicolas 202251 |
| ✔ | ✔ | ||
Sharma 20199 |
| ✔ | |||
Davis 2010 CD39 Companion document to Gauthier 2006a19 |
| ✔ | |||
WHO 200152 |
| ✔ | |||
OECD 201752 |
| ✔ | |||
Kruk 202462 Companion document to Kruk 20182 |
| ✔ | |||
Totals | 3 | 8 | 6 | 6 |
CD, companion document; OECD, Organisation for Economic Co-operation and Development.
Discussion
We conducted a comprehensive scoping review on high performance and health systems using JBI guidance for conducting scoping reviews and the PRISMA-ScR guidance for reporting. We identified 35 primary articles reporting on high performance in health systems that were published between 2000 and 2024. A subset of these primary articles (8/35) was associated with an initiative or series of papers, and as a result, we found 47 companion documents to give a total of 82 papers on our topic. One of these initiatives, The Commonwealth Fund’s Commission on a High Performance Health System, generated 26 articles (1 primary article; 25 companion documents) comprising close to one-third (31%) of the articles in our review.
We found no articles published before 2000 and the papers published since then signal an increase in interest and importance in this area. Few of our articles defined what was meant by a high-performing health system, and only three explicit definitions were found.5 7 48 The majority (62/82) of the records were non-research papers. For the 20 research studies, most relied on self-reports (interviews, surveys), expert opinions (Delphi approach) or accounts from observers (case studies). Our study identifies a lack of empirical evidence related to definitions and common indicators. This makes it difficult for policy and decision makers to implement evidence in real world settings and may rely on a biased or uninformed understanding of the problem at hand.59 The absence of a data-driven approach can lead to inefficient resource allocation and a lack of trust in decision-making.2
Across the studies, the most common research outcomes were elements (ie, characteristics) of health system performance, health system evaluation, and tool development or validation. The most common knowledge gaps were identifying processes to move evidence to policy and practice, the lack of common indicators, how to make comparisons across health systems and the lack of a common definition.
Measuring health system performance is important yet complex. It requires a clear declaration of purpose, scope and context. Challenges lay in practical issues such as how a system is defined, what attributes are prioritised for measurement and standardisation. High performance may look different across countries based on the specific design of their respective healthcare system.6 41 Definitions of a high-performance health system may have to be localised for specific jurisdictions, or flexible if the goal is inclusivity. Measurements may also need to be tailored to promote a more relevant understanding of performance at local levels. Diverse systems may require international collaborations to establish key common standards that allow for meaningful comparisons.
There is an opportunity for primary research in the area of health systems and high performance, including the impact of system characteristics on performance, the role of technology and importance of data in high-performing systems, assessing the impact on equity and inclusivity, and effective strategies for translating research findings on high-performing health systems into actionable policies and practices.
Policy implications
The lack of a common definition of a high-performing health system has significant policy implications for decision-makers. Without a standardised framework, policy-makers may struggle to set concrete targets for performance and may find it difficult to prioritise areas for improvement and direct resources effectively. Comparative performance measurement between health systems is difficult, making it challenging to assess the effectiveness of policies aimed at improving performance, identify which levels of intervention make the greatest impact and consistently track progress. Inconsistent evaluation across health systems further complicates efforts to share best practices and facilitate learning across regions. The absence of a clear performance standard may result in a lack of accountability and lead to a wide variability in the quality of care and access to services. Policy reforms risk becoming fragmented as differing perspectives on health system performance emerge. This also complicates global health efforts, as international organisations and national governments may base their development plans on varying assumptions of system improvement, making coordinated global health strategies difficult. Addressing the gap in defining high-performing health systems is important to align policies, set clear performance standards and drive meaningful improvements in healthcare delivery and outcomes.
Limitations
There are several limitations to this scoping review. Most of the records identified were from HICs. This suggests a gap in the literature as our results may not be generalisable to LMICs. We relied on authors to explicitly identify information related to barriers, facilitators, and gaps in knowledge for our data abstraction. For instance, if an author described something as a challenge, we did not list this as a barrier to prevent making assumptions about the consistent use of these words as an appropriate substitute. As a result, this section of the review may not be comprehensive. Our review focused on high performance and relied on authors to use this language (or an appropriate synonym) in their title or abstract for it to be captured by our search. There may be articles that examined performance and discussed it as a spectrum, thus not explicitly calling it high performance (or using appropriate synonyms), and we would not have been able to detect these articles due to the search function limitations of literature databases.
Conclusions
There is a lack of evidence in all areas related to high performance in health systems. The literature identified was mostly composed of non-research articles, with the studies identified being predominantly retrospective. Current research offers a limited use of study design and a deficit in validated data collection tools. The deficiencies related to definitions and common indicators create challenges for decision-makers to promote the uptake of research findings into clinical or policy contexts.
We thank Georgina Archbold for screening some of the titles and abstracts.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Not applicable.
Contributors LP conceptualised the study, wrote the protocol, coordinated the review, created and conducted the literature and grey literature search strategies, screened citations and full-text articles, charted data, analysed data, interpreted the results, wrote the manuscript, provided methodological and technical expertise. TP conceptualised the study, designed the study. VC screened citations and full-text articles, charted data. JT interpreted the results, provided content expertise. SS, AK, MP, HH, AD and AB provided methodological and content expertise throughout the project. All authors read and approved the final manuscript. SS is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
1 Filip R, Gheorghita Puscaselu R, Anchidin-Norocel L, et al. Global Challenges to Public Health Care Systems during the COVID-19 Pandemic: A Review of Pandemic Measures and Problems. J Pers Med 2022; 12: 1295. doi:10.3390/jpm12081295
2 Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018; 6: e1196–252. doi:10.1016/S2214-109X(18)30386-3
3 World Health Organization. The world health report 2000. Health systems: improving performance. 2000.
4 Arteaga O. Health systems. In: Michalos AC, ed. Encyclopedia of quality of life and well-being research. Dordrecht: Springer Netherlands, 2014.
5 Clarke D, Cocozza A, Appleford G, et al. Data-driven governance and the private sector in mixed health systems. BMJ Glob Health 2024; 8: e014705. doi:10.1136/bmjgh-2023-014705
6 Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf 2017; 43: 450–9. doi:10.1016/j.jcjq.2017.03.010
7 Baker GR, Axler R. Creating a high performing healthcare system for Ontario: evidence supporting strategic changes in Ontario. Toronto: Ontario Hospital Association, 2015. Available: https://www.oha.com/Documents/OHA%20High%20Performing%20Healthcare%20System%20Paper.pdf
8 Ridgely MS, Ahluwalia SC, Tom A, et al. What Are the Determinants of Health System Performance? Findings from the Literature and a Technical Expert Panel. Jt Comm J Qual Patient Saf 2020; 46: 87–98. doi:10.1016/j.jcjq.2019.11.003
9 Sharma A, Prinja S, Aggarwal AK. Comprehensive measurement of health system performance at district level in India: Generation of a composite index. Int J Health Plann Manage 2019; 34: e1783–99. doi:10.1002/hpm.2895
10 Bilynsky U. Integration’s best performers--seven habits of successful health care systems. Health Care Strateg Manage 2002; 20: 12–4.
11 Bergevin Y, Habib B, Elicksen-Jensen K, et al. Transforming Regions into High-Performing Health Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians. Healthc Pap 2016; 16: 34–52. doi:10.12927/hcpap.2016.24767
12 Casalino LP. Health Systems-The Present and the Future. JAMA 2023; 329: 293–4. doi:10.1001/jama.2022.24141
13 Beaulieu ND, Chernew ME, McWilliams JM, et al. Organization and Performance of US Health Systems. JAMA 2023; 329: 325–35. doi:10.1001/jama.2022.24032
14 Lewis VA, Murray GF, DeWalt DA. Disentangling the Role of Health Care Systems in Producing High-Quality Care. JAMA 2023; 329: 287–8. doi:10.1001/jama.2022.24728
15 Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 2015; 350: g7647. doi:10.1136/bmj.g7647
16 Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth 2020; 18: 2119–26. doi:10.11124/JBIES-20-00167
17 Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018; 169: 467–73. doi:10.7326/M18-0850
18 Pollock D, Peters MDJ, Khalil H, et al. Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evid Synth 2023; 21: 520–32. doi:10.11124/JBIES-22-00123
19 Gauthier A, Schoenbaum SC, Weinbaum I. Toward a high performance health system for the United States. New York: The Commonwealth Fund, 2006.
20 Davis K. Toward a high performance health system: the Commonwealth Fund’s new commission. Health Aff (Millwood) 2005; 24: 1356–60. doi:10.1377/hlthaff.24.5.1356
21 Davis K. Aiming high: 10 steps to a high-performance health system. MedGenMed 2006; 8: 66.
22 Gauthier AK, Davis K, Schoenbaum SC. Commentary--Achieving a high-performance health system: High reliability organizations within a broader agenda. Health Serv Res 2006; 41: 1710–20. doi:10.1111/j.1475-6773.2006.00617.x
23 The Commonwealth Fund. Framework for a high performance health system for the United States. New York: The Commonwealth Fund, 2006.
24 Wakefield MK. High-performance health care: how do we get there? Nurs Econ 2006; 24: 265–7.
25 Davis K. Learning from high performance health systems around the globe. Invited testimony: Senate Health, Education, Labor, and Pensions Committee: Hearing on “Health Care Coverage and Access: Challenges and Opportunities”. New York City: The Commonwealth Fund, 2007.
26 The Commonwealth Fund. High performance health system for the United States: an ambitious agenda for the next president. New York City: The Commonwealth Fund, 2007.
27 Hess C, Schwartz S, Rosenthal J, et al. State health policies aimed at promoting excellent systems: a report on states’ roles in health systems performance. National Academy for State Health Policy, 2008.
28 Hess C, Schwartz S, Rosenthal J, et al. States’ roles in shaping high performance health systems. New York City: The Commonwealth Fund, 2008.
29 McCarthy D, Nuzum R, Mika S, et al. The North Dakota experience: achieving high-performance health care through rural innovation and cooperation. New York: Commonwealth Fund, 2008.
30 The Commonwealth Fund. National scorecard on US health system performance, 2008, Chartpack. New York: Commonwealth Fund, 2008.
31 Shih A, Davis K, Schoenbaum S, et al. Organizing the US health care delivery system for high performance. New York: The Commonwealth Fund, 2008.
32 Davis K, Stremikis K, Hollander C. Closing the quality chasm: opportunities and strategies for moving toward a high performance health system. New York: The Commonwealth Fund, 2009.
33 The Commonwealth Fund. The path to a high performance US health system: a 2020 vision and the policies to pave the way. New York: The Commonwealth Fund, 2009.
34 Davis K, Schoen C. Putting the U.S. health system on the path to high performance. Invited testimony: U.S. house of representatives, committee on ways and means: hearing on “health reform in the 21st century: expanding coverage, improving quality, and controlling costs” New York City: The Commonwealth Fund, 2009.
35 McCarthy D, How SK, Schoen C, et al. Aiming higher: results from a state scorecard on health system performance, 2009. New York City: The Commonwealth Fund, 2009.
36 Moody G, Silow-Carroll S. Aiming higher for health system performance: a profile of seven states that perform well on the commonwealth fund’s 2009 state scorecard. New York: The Commonwealth Fund, 2009.
37 Davis K, Guterma S, Collins SR, et al. Starting on the path to a high performance health system: analysis of health system reform provisions of reform bills in the house of representatives and senate. New York: The Commonwealth Fund, 2009.
38 Schoenbaum SC, Trends CC. Creating the framework for high performing health care organizations. New York: The Commonwealth Fund, 2010.
39 Davis K, Schoen C, Mirror SK. Mirror on the wall: how the performance of the U.S. health care system compares internationally: 2010 update. New York: The Commonwealth Fund, 2010.
40 Guterman S, Schoenbaum SC, Davis K, et al. High performance accountable care: building on success and learning from experience. New York: The Commonwealth Fund, 2011.
41 Silow-Carroll S, Moody G. Lessons from high- and low- performing states for raising overall health system performance. Issue Brief (Commonw Fund) 2011; 7: 1–11.
42 The Commonwealth Fund. Why not the best? Results from the national scorecard on U.S. health system performance, 2011. New York City: The Commonwealth Fund, 2011.
43 The Commonwealth Fund. Four health care lessons the U.S. can learn from top-performing countries. New York: The Commonwealth Fund, 2017.
44 Horstman C, Seervai S, Pandit E, et al. What an ideal health care system might look like: perspectives from older Black and Latinx adults. New York: The Commonwealth Fund, 2022. Available: https://doi.org/10.26099/9kkg-kq37
45 Carinci F, Van Gool K, Mainz J, et al. Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators. Int J Qual Health Care 2015; 27: 137–46. doi:10.1093/intqhc/mzv004
46 Ginsburg JA, Doherty RB, Ralston JF, et al. Public Policy Committee of the American College of Physicians. Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med 2008; 148: 55–75. doi:10.7326/0003-4819-148-1-200801010-00196
47 Papanicolas I, Smith P. Health system performance comparison: an agenda for policy, information and research. McGraw-Hill Education (UK), 2013.
48 Baker GR. The roles of leaders in high-performing health care systems. Paper commissioned by The King’s Fund, United Kingdom, 2011. Available: https://www.kingsfund.org.uk/sites/default/files/roles-of-leaders-high-performing-health-care-systems-ross-baker-kings-fund-may-2011.pdf
49 Braithwaite J, Hibbert P, Blakely B, et al. Health system frameworks and performance indicators in eight countries: A comparative international analysis. SAGE Open Med 2017; 5: 2050312116686516. doi:10.1177/2050312116686516
50 Rajan D, Papanicolas I, Karanikolos M, et al. Health system performance assessment: a primer for policy-makers. Copenhagen (Denmark): European Observatory on Health Systems and Policies, 2022.
51 Papanicolas I, Rajan D, Karanikolos M, et al. Health system performance assessment: a framework for policy analysis. World Health Organization, 2022.
52 World Health Organization. Regional consultation of the Americas on health systems performance assessment. Washington, DC: World Health Organization, 2001.
53 The Organization for Economic Cooperation and Development. Caring for quality in health lessons. lessons learnt from 15 reviews of health care quality. The Organization for Economic Cooperation and Development, 2017.
54 Baker GR, Denis JL. A comparative study of three transformative healthcare systems. Canadian Health Services Research Foundation, 2011.
55 Aqil A, Saldana K, Mian NU, et al. Reliability and validity of an innovative high performing healthcare system assessment tool. BMC Health Serv Res 2023; 23: 242. doi:10.1186/s12913-022-08852-z
56 Smith P, Papanicolas I. Health system performance comparison: an agenda for policy, information and research. Policy summary 4. World Health Organization 2012 and World Health Organization, on behalf of the European Observatory on Health Systems and Policies. 2012.
57 Murray CJ, Evans DB, eds. Health systems performance assessment: debates, methods and empiricism. World Health Organization, 2003.
58 Khodyakov D, Buttorff C, Xenakis L, et al. Alignment Between Objective and Subjective Assessments of Health System Performance: Findings From a Mixed-Methods Study. J Healthc Manag 2021; 66: 380–94. doi:10.1097/JHM-D-20-00249
59 Cairney P, Oliver K. Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? Health Res Policy Syst 2017; 15: 35. doi:10.1186/s12961-017-0192-x
60 In search of a high-performing health system. Qual Lett Healthc Lead 2005; 17: 16422152.
61 Werle J, Dobbelsteyn L, Feasel AL, et al. A study of the effectiveness of performance-focused methodology for improved outcomes in Alberta public healthcare. Healthc Manage Forum 2010; 23: 169–74. doi:10.1016/j.hcmf.2010.08.007
62 Kruk ME, Kapoor NR, Lewis TP, et al. Population confidence in the health system in 15 countries: results from the first round of the People’s Voice Survey. Lancet Glob Health 2024; 12: e100–11. doi:10.1016/S2214-109X(23)00499-0
63 Baker GR, MacIntosh-Murray A, Porcellato C, et al. High performing healthcare systems: delivering quality by design. Toronto: Longwoods, 2008.
64 Fullaondo A, Erreguerena I, Keenoy E de M. Transforming health care systems towards high-performance organizations: qualitative study based on learning from COVID-19 pandemic in the Basque Country (Spain). BMC Health Serv Res 2024; 24: 364. doi:10.1186/s12913-024-10810-w
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Abstract
Objectives
To determine how high performing is defined in relation to a health system and chart the literature on the definitions and key concepts of high-performing healthcare systems.
Design
Scoping review.
Data sources
MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were searched from inception to July 2024. The grey literature was also searched.
Eligibility criteria
Included studies reported on health systems and high performance to identify explicit definitions, research outcomes and knowledge gaps.
Results
Two reviewers independently screened 5721 citations and 507 full-text articles, resulting in the inclusion of 35 primary articles and 47 companion documents in the review. Three independent definitions for a high-performance health system were identified. 24 research studies reported outcomes on the elements of a high-performing health system (58%), system evaluation (32%) and tool development or validation (10%). Knowledge gaps identified were the lack of a common definition, a lack of common indicators, strategies for moving evidence into policy and practice, and difficulties with comparisons across health systems.
Conclusions
We found limited definitions and a lack of empirical evidence on our topic. There is an opportunity for primary research in the area of health systems and high performance.
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Details

1 Ontario Hospital Association, Toronto, Ontario, Canada
2 Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada