HiT methodology and production process

Health system reviews (HiTs) are produced by country experts in collaboration with the Observatory's research directors and staff. The reviews are based on a template that, revised periodically, provides detailed guidelines and specific questions, definitions, suggestions for data sources, and examples needed to compile HiTs. While the template offers a comprehensive set of questions, it is intended to be used in a flexible way to allow authors and editors to adapt it to their particular national context.

Authors draw on multiple data sources for the compilation of HiT reports, ranging from national statistics, national and regional policy documents, and published literature. Furthermore, international data sources may be incorporated, such as those of the OECD and the World Bank. OECD Health Data contain over 1200 indicators for the 34 OECD countries. Data are drawn from information collected by national statistical bureaux and health ministries. The World Bank provides World Development Indicators, which also rely on official sources.

In addition to the information and data provided by the country experts, the Observatory supplies quantitative data in the form of a set of standard comparative figures for each country, drawing on the European Health for All Database (HFA) database. The HFA database contains more than 600 indicators defined by the World Health Organization (WHO) Regional Office for Europe for the purpose of monitoring Health for All policies in Europe. It is updated for distribution twice a year from various sources, relying largely upon official figures provided by governments, as well as health statistics collected by the technical units of the WHO Regional Office for Europe. The standard HFA data have been officially approved by national governments. With its summer 2007 edition, the HFA database started to take account of the enlarged European Union (EU) of 28 Member States.

HiT authors are encouraged to discuss the data in the text in detail, including the standard figures prepared by the Observatory staff, especially if there are concerns about discrepancies between the data available from different sources.

The European Observatory on Health Systems and Policies endorses all the aspects of the International Committee of Medical Journal Editors' Uniform Requirements for Manuscripts Submitted to Biomedical Journals that are relevant to HiT health system reviews. Therefore authors should familiarise themselves with the Uniform Requirements at www.ICMJE.org before submitting their HiT manuscript.

The HiT template was revised in 2010 and consists of 9 chapters:

  1. Introduction: outlines the broader context of the health system, including geography and sociodemography, economic and political context, and population health.
  2. Organization and governance: provides an overview of how the health system in the country is organized and outlines the main actors and their decision-making powers; discusses the historical background for the system; regulation; and describes the level of patient empowerment in the areas of information, rights, choice, complaints procedures, safety and involvement.
  3. Financing: provides information on the level of expenditure, who is covered, what benefits are covered, the sources of health care finance, how resources are pooled and allocated, the main areas of expenditure, and how providers are paid.
  4. Physical and human resources: deals with the planning and distribution of infrastructure and capital stock; the context in which IT systems operate; and human resource input into the health system, including information on registration, training, trends and career paths.
  5. Provision of services: concentrates on patient flows, organization and delivery of services, addressing public health, primary and secondary health care, emergency and day care, rehabilitation, pharmaceutical care, long-term care, services for informal carers, palliative care, mental health care, dental care, complementary and alternative medicine, and health care for specific populations.
  6. Principal health reforms: reviews reforms, policies and organizational changes that have had a substantial impact on health care, as well as future developments.
  7. Assessment of the health system: provides an assessment based on the stated objectives of the health system, financial protection and equity in financing; user experience and equity of access to health care; health outcomes, health service outcomes and quality of care; health system efficiency; and transparency and accountability.
  8. Conclusions: highlights the lessons learned from health system changes; summarizes remaining challenges and future prospects.
  9. Appendices: includes references, further reading and useful web sites.

Producing a HiT health system review is a complex process. It involves:

  • writing and editing the report, often in multiple iterations;
  • external review by (inter)national experts and the country's Ministry of Health – the authors are supposed to consider comments provided by the Ministry of Health, but not necessarily include them in the final version;
  • external review by the editors and international multidisciplinary editorial board;
  • finalizing the report, including the stages of copy-editing and typesetting;
  • dissemination (hard copies, electronic publication, translations and launches).

The editor supports the authors throughout the production process and in close consultation with the authors ensures that all stages of the process are taken forward as effectively as possible. The production of HiT reports is funded exclusively through the Observatory via the grants received from its partner organizations. Authors are required to declare any potential or actual conflicts of interest before being commissioned to write a HiT.