Title page 1

Contents 6

Foreword 4

Acknowledgements 5

Acronyms 9

Executive summary 12

1. Introduction: Health System Performance Assessment as a policy tool 14

1.1. Structuring health data information for shared and informed decision making 15

1.1.1. Health System Performance Assessment is a comprehensive evaluation of how a health system meets population needs,... 15

1.1.2. National HSPA frameworks are strategic tools that build on international learning and benchmarking 15

1.1.3. A systematised approach is needed to make an HSPA operational and sustainable 16

1.2. Towards a commonly shared HSPA framework in Luxembourg 18

1.2.1. Objectives and scope of this report 18

1.2.2. Setting up the HSPA in Luxembourg: a stakeholder-inclusive process 19

References 22

2. Luxembourg's HSPA framework 24

2.1. The purpose and scope of Luxembourg's HSPA 25

2.2. Luxembourg's HSPA framework domains and subdomains 27

2.3. Stakeholder ownership of the HSPA framework in Luxembourg 31

2.3.1. Building consensus among stakeholders to develop the first framework draft 31

2.3.2. Improving the framework draft for structural coherence based on expert inputs 33

References 33

3. Indicators to assess the performance of Luxembourg's health system 34

3.1. Indicator selection methodology and process 35

3.1.1. From a comprehensive indicator repository to a pre-selected indicator set 36

3.1.2. Stakeholder scoring and prioritisation for the first draft list of indicators for the HSPA 37

3.1.3. Finalisation of the list of indicators for the HSPA 38

3.2. Indicators populating Luxembourg's HSPA framework 39

3.2.1. Outcomes: Health status domain 41

3.2.2. Outcomes: Person centredness domain 43

3.2.3. Processes: Access to care domain 46

3.2.4. Processes: Value-based care domain 48

3.2.5. Processes: Integrated care domain 52

3.2.6. Inputs: Governance domain 55

3.2.7. Inputs: Infrastructure domain 56

3.2.8. Inputs: Workforce domain 60

3.2.9. Inputs: Finances domain 62

3.2.10. Cross-cutting: Sustainability domain 64

3.2.11. Cross-cutting: Determinants of health domain 66

3.2.12. Cross-cutting: Equity domain 68

3.3. Use case example: assessing mental healthcare and outcomes through HSPA indicators 69

3.3.1. Mental health and care-related input indicators can help assess workforce and physical capacity in mental healthcare delivery 70

3.3.2. Process indicators related to mental health and care can capture how mental healthcare is organised, accessed and delivered 72

3.3.3. Mental health and care-related outcome indicators can capture the effectiveness of the mental health system and... 74

3.3.4. Cross-cutting indicators related to mental health in the HSPA framework bring a preventive perspective to the mental health system... 76

References 77

Notes 78

4. HSPA governance and implementation in Luxembourg 80

4.1. Laying the ground for Luxembourg's HSPA governance structure 81

4.1.1. Process and steps undertaken in designing Luxembourg's HSPA governance structure 81

4.2. HSPA governance structure and roles of key stakeholders 83

4.2.1. Key organisations in Luxembourg's HSPA governance 83

4.2.2. HSPA governance bodies 83

4.2.3. Indicator custodianship, data governance and stakeholder accountability in Luxembourg's HSPA governance structure 85

4.3. Embedding the HSPA intelligence in Luxembourg's policymaking 88

4.3.1. Designing reporting cycles for maximum impact and sustainability 88

4.3.2. Leveraging HSPA for health policy planning and monitoring 89

4.3.3. Strengthening the use and impact of HSPA through effective dissemination 90

4.4. The HSPA methodological report as a blueprint to transition from development to HSPA implementation 91

References 91

Annex A. Luxembourg's HSPA project - main project activities during the framework development and indicator selection process 92

References 100

Annex B. Health data landscape in Luxembourg as a basis for the HSPA 101

References 110

Annex C. Indicator sheets - technical information 111

References 115

Annex D. Contextualising indicators for selected HSPA indicators 116

Annex E. The HSPA framework for Luxembourg - domains and subdomains in French 117

Table 1.1. Principal Working Group meetings and workshops in 2024-2025 22

Table 2.1. Description of Luxembourg's HSPA framework domains and subdomains 29

Table 3.1. PWG members were asked to evaluate each indicator using two core criteria: significance for health system performance and... 37

Table 3.2. Population outcomes indicators 42

Table 3.3. Mental health indicators 43

Table 3.4. Patient-centred care indicators 44

Table 3.5. Health literacy indicators 45

Table 3.6. Patient experience indicators 45

Table 3.7. Financial protection indicators 47

Table 3.8. Operational access indicators 47

Table 3.9. Patient safety indicators 48

Table 3.10. Guidelines compliance indicators 49

Table 3.11. Quality of care indicators 50

Table 3.12. Cost-efficiency indicators 51

Table 3.13. Prevention indicators 52

Table 3.14. Co-ordination of care indicators 53

Table 3.15. Continuity of care indicators 54

Table 3.16. Leadership indicators 55

Table 3.17. Transparency & accountability indicators 56

Table 3.18. Physical resources indicators 57

Table 3.19. Pharmaceuticals indicators 58

Table 3.20. Digital health indicators 58

Table 3.21. Research and development indicators 60

Table 3.22. Training indicators 60

Table 3.23. Workforce capacity indicators 62

Table 3.24. Fiscal sustainability indicators 62

Table 3.25. Financial allocation indicators 64

Table 3.26. Resilience indicators 65

Table 3.27. Climate change indicators 66

Table 3.28. Behavioural risk factors indicators 66

Table 3.29. Non-behavioural determinants indicators 67

Table 3.30. Demographic and geographic equity indicators 68

Table 3.31. Socio-economic equity indicators 69

Table 3.32. Input indicators that can be used to capture mental healthcare in Luxembourg's framework 71

Table 3.33. Process indicators that can be used to capture mental healthcare in Luxembourg's HSPA framework 72

Table 3.34. Outcome indicators that can be used to capture mental healthcare in Luxembourg's HSPA framework 74

Table 3.35. Cross-cutting indicator that can be used to capture mental healthcare in Luxembourg's HSPA framework 76

Table 4.1. HSPA indicator custodianship among different stakeholders in Luxembourg's HSPA 86

Table 4.2. Data custodianship among different stakeholders in Luxembourg's HSPA 87

Boxes 15

Box 1.1. What is a Health System Performance Assessment (HSPA)? 15

Box 1.2. Concepts behind national HSPA frameworks development and international practice 16

Box 1.3. Luxembourg's stakeholders participating in the project and actively involved in the development of Luxembourg's HSPA... 20

Box 2.1. What is an HSPA framework domain? 27

Box 2.2. The process and methodology of the development of the first HSPA framework draft proposal for Luxembourg 32

Box 3.1. Stakeholders in Luxembourg's health system contributed actively to the HSPA indicator selection process 39

Box 3.2. Explanations of technical information included in indicator tables within Section 3.2 41

Table A D.1. Contextualising indicators 116

Annex Boxes 103

Box B.1/Box B.2. Administrative and survey data coverage in key datasets Luxembourg varies, depending on the country... 103

Box B.2/Box B.3. Sources of indicators in Luxembourg's HSPA derived from international collections 107