Health Care Management

Piloting a systematic assessment of the performance and efficiency of the German health system (Health System Performance Assessment - HSPA)


Health System Performance Assessment (HSPA) is deemed as an useful tool for evidence-based health policy. By WHO definition, an HSPA describes „a country-specific process of monitoring, evaluating, communicating and reviewing the achievement of high-level health system goals based on health system strategies“ (Smith, 2014). In contrary to many (EU) countries running a continuos HSPA, the project by the Technical University Berlin (TUB) will present the first HSPA report on the German health care system in late 2021.

Important parameters to the HSPA pilot was presented to the Federal Ministry of Health in 2019. The feasibility study encompassed a) the development of a conceptual framework (including dimensions and categories) for a German HSPA, b) the development of a set of indicators (including an indicator assessment regarding the suitability for a German HSPA along a standardized template), c) identification of missing or suboptimal indicators in each dimension – especially for efficiency – and d) a suggestion to operationalize HSPA with the current available national and international databases

(Röttger et al., 2019; only available in German).

To this end the feasibility study draw mainly on the work of the EuroREACH and BRIDGE Health projects (Hofmarcher-Holzhacker and Smith, 2013; Perić et al., 2017 and 2018). In addition, a literature review and comprehensive consultation process resulted in the German HSPA framework (see figure below) and the selection of 90 HSPA indicators.

The German HSPA conceptual framework features the dimensions of access to the health system (including financial risk protection); quality of service received; population health attributable to the health system, responsiveness and efficiency and their relationship to each other. It also considers factors that influence health but are not attributable to the health system (e.g. environmental factors), divided into the dimensions context, determinants of health and burden of disease. To measure the efficiency of the German health system, it is also intended to measure inputs and activities as well as performance units (outputs).


The Federal Ministry of Health defined the following aims for the HSPA:

  • support of evidence-based governance,
  • monitor and evaluate progress and measure achievement of the health care system and of specific reforms against stated goals,
  • identify strengths and weaknesses of the German health care system,
  • support a transparent way of illustrating and communicating the performance of the German health care system

In addition, the Federal Ministry of Health of Germany assigned the TUB team the task to ensure comparability of the HSPA across national and international initiatives, but also to reflect on specific characteristics of the German health system (such as the coexistence of SHI and PHI).


Module 1: Module 1 aims at a first HSPA pilot and to review the indicators defined in the feasibility study along lines of measurability, practicability, data availability, as well as international and national comparability. The first HSPA pilot will encompass all 90 indicators of the feasibility study over a chosen period of time (for trend analysis) or at a selected reference year.

Module 2: Module 2 of the project aims at a second HSPA pilot to further refine methodology. After concluding Module 2, the core set of HSPA indicators will be defined.

Module 3: This module will develop a manual for the permanent and continuous implementation of an HSPA, beyond the first two HSPA pilots by the TUB

Project organisation- Project Advisory Board

The TUB is supported by a high ranking advisory board of national institutions for health monitoring and quality assurance in the German health care system. In 2020, the Advisory Board is represented by:

  • Institute for Applied Economic Research (IAW), Rolf Kleimann
  • German National Institute for the Reimbursement of Hospitals (InEK), Dr. Frank Heimig
  • Federall Association of SHI Physicians (KBV), Dr. Bernhard Gibis
  • Robert Koch-Institute or Federal Institute for Infectious and Non-Communicable Diseases (RKI), Dr. Thomas Ziese
  • Scientific Institute of the regional sickness funds (WIdO), Jürgen Klauber
  • Central Research Institute of SHI Physicians (ZI), Dr. Dominik Graf von Stillfried


Hofmarcher-Holzhacker M; Smith P (2013): The Health Data Navigator. Your toolkit for comparative performance analysis. A EuroREACH product. European Centre for Social Welfare Policy and Research. Wien. Online verfügbar unter, last reviewed on 07/06/2020.

OECD (2019): Health at a Glance 2019. OECD indicators. Paris: OECD Publishing. Available online at

Perić N; Hofmarcher-Holzhacker M.; Simon J (2017): Health system performance assessment landscape at the EU level: a structured synthesis of actors and actions. In: Arch Public Health 75, pp. 5. DOI: 10.1186/s13690-016-0173-5.

Perić N, Hofmarcher MM, Simon J. Headline indicators for monitoring the performance of health systems: findings from the european Health Systems_Indicator (euHS_I) survey. Arch Public Health. 2018 Jun 28;76:32. doi: 10.1186/s13690-018-0278-0.

Röttger J, Spranger A, Eckhardt H, Achstetter K, Busse R. (2019) Ergebnisbericht der Machbarkeitsstudie zur Messung der Leistungsfähigkeit (“Health System Performance Assessment”) des deutschen Gesundheitssystems.

Smith P (2014): Health System Performance Assessment. Synthesis Report. Belgium, 19-20 May 2014. Hg. v. European Commission.

Project organisation - Project team

  • Head of research team: Prof. Dr. med. Reinhard Busse
  • Research associates: Katharina Achstetter, Miriam Blümel, Victoria Schwarzbach, Anne Spranger
  • Student assistant: Matthias Haltaufderheide