Dimensions of Health System Performance Assessment: A Scoping Review
,
Abstract
Background: Performance assessment is a key approach to understanding how functions and processes are operating. The first essential step in this process is to determine what aspects should be covered in the assessment. We aimed to identify the dimensions of health system performance assessment in Iran.
Methods: A scoping review was conducted in this study from 2000 to 2024. It was carried out in both Persian and English databases. A total of 17 frameworks or models were identified. Their dimensions, components, and interrelationships were extracted and synthesized. Subsequently, a new framework was developed using the framework analysis approach.
Results: We identified 6 main dimensions and 28 sub-dimensions for health system performance assessment, adopted as a logic model comprising inputs, output, and outcomes. The major dimensions include: Governance and Leadership-vision, policy and planning, communication, monitoring and evaluation; infrastructure, knowledge; standards of care and service of delivery.
Conclusion: Despite the overlap of some of the main dimensions of the frameworks, the consolidated framework has differences from the previous ones, which emphasizes the assessment of qualitative feedback based on their experiences. Therefore, this integrated framework offers a comprehensive structure that is particularly suitable for evaluating the performance of Iran’s health system, taking into account its specific environmental context.
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2. Ominyi JN, Agom DA, Ekuma CV (2019). A qualitative examination of the perceived impact of bureaucratic managerialism on evidence-based practice implementa-tion in Nigeria: a collective case study. J Res Nurs, 24(8):635-46.
3. Giacomelli G, Ferré F, Furlan M, et al (2019). Involving hybrid professionals in top management decision-making: How managerial training can make the dif-ference. Health Serv Manage Res, 32(4):168-79.
4. Jiping S (2010). Mine safety monitoring and control technology and system. Coal Sci Technol, 38 (10):1-4.
5. Farzadfar F, Naghavi M, Sepanlou SG, et al (2022). Health system performance in Iran: a systematic analysis for the Glob-al Burden of Disease Study 2019. Lancet, 399(10335): 1625-1645.
6. Mosadeghrad AM, Dehnavi H (2018). Eval-uation of hospital performance in Iran: A systematic review and meta-analysis. Payesh, 17 (6): 603-615.
7. Fazaeli S, Ahmadi M, Rashidian A, et al (2014). A Framework of a Health System Responsiveness Assessment Information System for Iran. Iran Red Crescent Med J, 16 (6): e17820.
8. Jahanmehr N, Rashidian A, Khosravi A, et al (2015). A conceptual framework for evaluation of public health and primary care system performance in Iran. Glob J Health Sci, 7 (4): 341-57.
9. Shirvani SN, Maleki M, Motlagh M, et al (2011). Self-Assessment of Iran Universi-ties of Medical Sciences Based on Eu-ropean Foundation for Quality Man-agement (EFQM) and Iran Excellence Model. World Appl Sci J, 15 (10): 1391-1397.
10. Rouhani S, Safizade K, Mousavinasab SN, et al (2020). Assessment of the Quality of Routine Information on the Care of the Patients with Diabetes Mellitus in Rural Health Centers of Sari County, Iran. Health Inf Manage, 17 (1): 2-7.
11. Kooshkebaghi M, Dargahi H, Emamg-holipour Sefiddashti S (2023). Problems and Solutions of Taxation to Control Unhealthy Goods: A Qualitative Study. Health Scope, 12 (1): e132036.
12. Skela Savič B, Robida A (2013). Capacity of middle management in health-care or-ganizations for working with people—the case of Slovenian hospitals. Hum Re-sour Health, 11:18.
13. Kakemam E, Janati A, Mohaghegh B, et al (2021). Developing competent public hospital managers: a qualitative study from Iran. Int J Workplace Health Manag, 14(2):149-63.
14. Gholipour K, Tabrizi JS, Farahbakhsh M, et al (2018). Evaluation of the district health management fellowship training programme: a case study in Iran. BMJ Open, 8(3):e020603.
15. Dukhanin V, Topazian R, DeCamp M (2018). Metrics and evaluation tools for patient engagement in healthcare organ-ization-and system-level decision-making: a systematic review. Int J Health Policy Manag, 7(10):889-903.
16. Hadian SA, Rezayatmand R, Shaarbafchi-zadeh N, et al (2024). Hospital perfor-mance evaluation indicators: a scoping review. BMC Health Serv Res, 24(1):561.
17. Tashobya CK, Da Silveira VC, Ssengooba F, et al (2014). Health systems perfor-mance assessment in low-income coun-tries: learning from international expe-riences. Global Health, 10: 5
18. Arksey H, O’Malley L (2005). Scoping stud-ies: towards a methodological frame-work. Int J Soc Res Methodol, 8(1): 19-32.
19. Kasiri N, Abdollahi M, Dargahi H, et al (2024). Investigation of Occupational Stress and Depression among Nurses in COVID- 19 Wards Compared to other Ward: A Study in Imam Reza Hospital of Mashhad in 2021. J Patient Saf Qual Improv, 12 (1): 47-57.
20. Mehrolhassani M, Haghdoost A, Dehna-vieh R, et al (2017). The proposed framework for monitoring health sys-tem. IRJE, 12 (5): 92-96
21. Kyani P, Pourezzat A, Daneshfard K, et al (2023). Designing a Model for Evaluat-ing the Government Performance in the Field of Health. Public Adm Perspect, 14 (2): 15-39.
22. Rotondo F, Giovanelli L, Fadda N, et al (2018). A methodology to design a per-formance management system in pre-ventive care. BMC Health Serv Res, 18(1):1002.
23. Palmer MG, Johnson CM (2024). Observing the behavior of organisms in organiza-tional behavior management. J Organ Be-hav Manag, 44(2):128-49.
24. Mattke S, Epstein AM, Leatherman S (2006). The OECD Health Care Quality Indica-tors Project: history and background. Int J Qual Health Care, 18 Suppl 1:1-4.
25. Monograph on the internet World Health Organization (2010) . Monitoring the six building blocks of health systems: a handbook of indicators and their meas-urement strategies. World Health Organ-ization.
26. Robin BA, Mccreight M, Battagliac C, et al (2018). Health System Assessment Ap-proach: A How-To Manual. Front Public Health, 6: 1-11
27. Ettelt S, Fazekas M, Mays N, et al (2012). Assessing health care planning–a framework-led comparison of Germany and New Zealand. Health Policy, 106 (1): 50-9.
28. Pyone T, Smith H, Broek N (2017). Frame-works to assess health systems govern-ance: a systematic review. Health Policy Plan, 32(5):710-722.
29. Kumah E, Ankomah SE, Fusheini A, et al (2020). Frameworks for health systems performance assessment: how compre-hensive is Ghana’s holistic assessment tool? Glob Health Res Policy, 5:10.
30. Reeve C, Humphreys J, Wakerman J (2015). A comprehensive health service evalua-tion and monitoring framework. Eval Program Plann, 53: 91-8.
31. Soysa IB, Jayamaha NP, Grigg NP (2016). Operationalizing performance meas-urement dimensions for the Australasian nonprofit healthcare sector. TQM J, 28(6): 954-73.
32. Levesque JF, Sutherland K (2020). Combin-ing patient clinical and system perspec-tives in assessing performance in healthcare: an integrated measurement framework. BMC Health Serv Res, 20 (1): 23.
33. Moses M, Korir J, Zeng W, et al (2021). Per-formance assessment of the county healthcare systems in Kenya: a mixed-methods analysis. BMJ Glob Health, 6(6): e004707.
34. Sevim F, Aldoğan E (2024). evaluation of health systems performance of oecd countries using moora method. J Health Manag, 26(1):172-183.
35. Khosravi MF, Mosadeghrad AM, Arab M (2023). Health System Governance Eval-uation: A Scoping Review. Iran J Public Health, 52 (2): 265-277.
36. Dias NP, Zotti MJ, Montoya P, et al (2018). Fruit fly management research: a sys-tematic review of monitoring and con-trol tactics in the world. Crop Prot, 112: 187-200.
37. Tabrizi JS, Pourasghar F, Nikjoo RG (2019). Governance of iranian primary Health Care System: perceptions of experts. Iran J Public Health, 48(3):541-548.
38. Kooshkebaghi M, Dargahi H, Emamg-holipour S (2024). Examining the Prob-lems and Solutions to Facilitate the Payment and Receipt of Health Taxes. Iran J Public Health, 53 (5): 1146-1154.
39. Alster K. Radwin LE (2004). The deserved care framework for evaluating health care quality. Home Health Care Manag Pract, 16 (5): 332-8.
40. Chatterjee S, Pandit N (2017). Challenges of Manpower Problems and Its Solution (With special reference to public health sector). JMSCR, 5(12):32202-12
41. Kiboi GK, Kilonzo DJ, Iravo PM (2018). Determinants of effective monitoring and evaluation in health service deliv-ery: A case of Nairobi city county health facilities. Int J Manag Commer Innov, 6:231-45.
42. Rawal LB, Mahmud K, Islam SM, et al (2016). Training mid-level health cadres to improve health service delivery in ru-ral Bangladesh. Prim Health Care Res Dev, 17(5):503-13.
43. World Health Organization (2024). Support tool to strengthen health information systems: guidance for health infor-mation system assessment and strategy development. World Health Organization.
44. Danforth K, Ahmad AM, Blanchet K, et al (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ Glob Health, 8(Suppl 1):e010726.
45. Byrne E, Heywood A (2023). Use of routine health information systems data in de-veloping and monitoring district and facility health plans: a scoping review. BMC Health Serv Res, 23(1):1049.
46. Gopichandran V, Krishna AKI (2013). Monitoring ‘monitoring’ and evaluating ‘evaluation’: an ethical framework for monitoring and evaluation in public health. J Med Ethics, 39 (1): 31-5.
47. Dunford-Stenger A, Holcomb S, Hetling A, Krepcio K (2021). Defining and pursu-ing goals in a work first environment: An analysis of public assistance recipi-ents’ experience and perception of pub-lic policy on the frontlines. Hum Serv Or-gan Manag Leadersh Gov, 45(1):13-28.
48. Coles E, Anderson J, Maxwell M, et al (2020). The influence of contextual fac-tors on healthcare quality improvement initiatives: a realist review. Syst Rev, 9(1):94.
49. Williams I, Brown H, Healy P (2018). Con-textual factors influencing cost and qual-ity decisions in health and care: a struc-tured evidence review and narrative syn-thesis. Int J Health Policy Manag, 7(8):683-695.
50. Huybrechts I, Declercq A, Verté E, et al (2024). How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the imple-mentation of goal-oriented primary care. Implement Sci, 19(1):32.
51. Pereira SA, Ferreira JJ, Rammal HG, et al (2023). Strategic change in the health sector: a literature review and future challenges. J Organ Change Manag, 36(2):346-88.
52. Chen LW, Xu L, Yu F, et al (2012). The rela-tionship between county variation in macro contextual factors and the per-formance of public health practice in regional public health systems in Ne-braska. J Public Health Manag Pract, 18(2):132-40.
53. Such E, Smith K, Woods HB, et al (2022). Governance of intersectional collabora-tions for population health and to re-duce health inequalities in high-income countries: a complexity-informed sys-tematic review. Int J Health Policy Manag, 11(12):2780-2792.
54. Haldane V, Chuah FL, Srivastava A, et al (2019). Community participation in health services development, implemen-tation, and evaluation: A systematic re-view of empowerment, health, commu-nity, and process outcomes. PLoS One, 14(5):e0216112.
55. Rifkin SB (2014). Examining the links be-tween community participation and health outcomes: a review of the litera-ture. Health Policy Plan, 29 Suppl 2(Suppl 2):ii98-106.
56. Siddiqi S, Masud TI, Nishtar S, et al (2009). Framework for assessing governance of the health system in developing coun-tries: gateway to good governance. Health Policy, 90 (1): 13-25.
57. Dargahi, H, Kooshkebaghi M, Isazadeh N (2024). Explaining the concepts and ex-amples of conflict of interest and its management in the medical laboratory system of Iran: A scoping review. J Educ Health Promot, 13: 238.
2. Ominyi JN, Agom DA, Ekuma CV (2019). A qualitative examination of the perceived impact of bureaucratic managerialism on evidence-based practice implementa-tion in Nigeria: a collective case study. J Res Nurs, 24(8):635-46.
3. Giacomelli G, Ferré F, Furlan M, et al (2019). Involving hybrid professionals in top management decision-making: How managerial training can make the dif-ference. Health Serv Manage Res, 32(4):168-79.
4. Jiping S (2010). Mine safety monitoring and control technology and system. Coal Sci Technol, 38 (10):1-4.
5. Farzadfar F, Naghavi M, Sepanlou SG, et al (2022). Health system performance in Iran: a systematic analysis for the Glob-al Burden of Disease Study 2019. Lancet, 399(10335): 1625-1645.
6. Mosadeghrad AM, Dehnavi H (2018). Eval-uation of hospital performance in Iran: A systematic review and meta-analysis. Payesh, 17 (6): 603-615.
7. Fazaeli S, Ahmadi M, Rashidian A, et al (2014). A Framework of a Health System Responsiveness Assessment Information System for Iran. Iran Red Crescent Med J, 16 (6): e17820.
8. Jahanmehr N, Rashidian A, Khosravi A, et al (2015). A conceptual framework for evaluation of public health and primary care system performance in Iran. Glob J Health Sci, 7 (4): 341-57.
9. Shirvani SN, Maleki M, Motlagh M, et al (2011). Self-Assessment of Iran Universi-ties of Medical Sciences Based on Eu-ropean Foundation for Quality Man-agement (EFQM) and Iran Excellence Model. World Appl Sci J, 15 (10): 1391-1397.
10. Rouhani S, Safizade K, Mousavinasab SN, et al (2020). Assessment of the Quality of Routine Information on the Care of the Patients with Diabetes Mellitus in Rural Health Centers of Sari County, Iran. Health Inf Manage, 17 (1): 2-7.
11. Kooshkebaghi M, Dargahi H, Emamg-holipour Sefiddashti S (2023). Problems and Solutions of Taxation to Control Unhealthy Goods: A Qualitative Study. Health Scope, 12 (1): e132036.
12. Skela Savič B, Robida A (2013). Capacity of middle management in health-care or-ganizations for working with people—the case of Slovenian hospitals. Hum Re-sour Health, 11:18.
13. Kakemam E, Janati A, Mohaghegh B, et al (2021). Developing competent public hospital managers: a qualitative study from Iran. Int J Workplace Health Manag, 14(2):149-63.
14. Gholipour K, Tabrizi JS, Farahbakhsh M, et al (2018). Evaluation of the district health management fellowship training programme: a case study in Iran. BMJ Open, 8(3):e020603.
15. Dukhanin V, Topazian R, DeCamp M (2018). Metrics and evaluation tools for patient engagement in healthcare organ-ization-and system-level decision-making: a systematic review. Int J Health Policy Manag, 7(10):889-903.
16. Hadian SA, Rezayatmand R, Shaarbafchi-zadeh N, et al (2024). Hospital perfor-mance evaluation indicators: a scoping review. BMC Health Serv Res, 24(1):561.
17. Tashobya CK, Da Silveira VC, Ssengooba F, et al (2014). Health systems perfor-mance assessment in low-income coun-tries: learning from international expe-riences. Global Health, 10: 5
18. Arksey H, O’Malley L (2005). Scoping stud-ies: towards a methodological frame-work. Int J Soc Res Methodol, 8(1): 19-32.
19. Kasiri N, Abdollahi M, Dargahi H, et al (2024). Investigation of Occupational Stress and Depression among Nurses in COVID- 19 Wards Compared to other Ward: A Study in Imam Reza Hospital of Mashhad in 2021. J Patient Saf Qual Improv, 12 (1): 47-57.
20. Mehrolhassani M, Haghdoost A, Dehna-vieh R, et al (2017). The proposed framework for monitoring health sys-tem. IRJE, 12 (5): 92-96
21. Kyani P, Pourezzat A, Daneshfard K, et al (2023). Designing a Model for Evaluat-ing the Government Performance in the Field of Health. Public Adm Perspect, 14 (2): 15-39.
22. Rotondo F, Giovanelli L, Fadda N, et al (2018). A methodology to design a per-formance management system in pre-ventive care. BMC Health Serv Res, 18(1):1002.
23. Palmer MG, Johnson CM (2024). Observing the behavior of organisms in organiza-tional behavior management. J Organ Be-hav Manag, 44(2):128-49.
24. Mattke S, Epstein AM, Leatherman S (2006). The OECD Health Care Quality Indica-tors Project: history and background. Int J Qual Health Care, 18 Suppl 1:1-4.
25. Monograph on the internet World Health Organization (2010) . Monitoring the six building blocks of health systems: a handbook of indicators and their meas-urement strategies. World Health Organ-ization.
26. Robin BA, Mccreight M, Battagliac C, et al (2018). Health System Assessment Ap-proach: A How-To Manual. Front Public Health, 6: 1-11
27. Ettelt S, Fazekas M, Mays N, et al (2012). Assessing health care planning–a framework-led comparison of Germany and New Zealand. Health Policy, 106 (1): 50-9.
28. Pyone T, Smith H, Broek N (2017). Frame-works to assess health systems govern-ance: a systematic review. Health Policy Plan, 32(5):710-722.
29. Kumah E, Ankomah SE, Fusheini A, et al (2020). Frameworks for health systems performance assessment: how compre-hensive is Ghana’s holistic assessment tool? Glob Health Res Policy, 5:10.
30. Reeve C, Humphreys J, Wakerman J (2015). A comprehensive health service evalua-tion and monitoring framework. Eval Program Plann, 53: 91-8.
31. Soysa IB, Jayamaha NP, Grigg NP (2016). Operationalizing performance meas-urement dimensions for the Australasian nonprofit healthcare sector. TQM J, 28(6): 954-73.
32. Levesque JF, Sutherland K (2020). Combin-ing patient clinical and system perspec-tives in assessing performance in healthcare: an integrated measurement framework. BMC Health Serv Res, 20 (1): 23.
33. Moses M, Korir J, Zeng W, et al (2021). Per-formance assessment of the county healthcare systems in Kenya: a mixed-methods analysis. BMJ Glob Health, 6(6): e004707.
34. Sevim F, Aldoğan E (2024). evaluation of health systems performance of oecd countries using moora method. J Health Manag, 26(1):172-183.
35. Khosravi MF, Mosadeghrad AM, Arab M (2023). Health System Governance Eval-uation: A Scoping Review. Iran J Public Health, 52 (2): 265-277.
36. Dias NP, Zotti MJ, Montoya P, et al (2018). Fruit fly management research: a sys-tematic review of monitoring and con-trol tactics in the world. Crop Prot, 112: 187-200.
37. Tabrizi JS, Pourasghar F, Nikjoo RG (2019). Governance of iranian primary Health Care System: perceptions of experts. Iran J Public Health, 48(3):541-548.
38. Kooshkebaghi M, Dargahi H, Emamg-holipour S (2024). Examining the Prob-lems and Solutions to Facilitate the Payment and Receipt of Health Taxes. Iran J Public Health, 53 (5): 1146-1154.
39. Alster K. Radwin LE (2004). The deserved care framework for evaluating health care quality. Home Health Care Manag Pract, 16 (5): 332-8.
40. Chatterjee S, Pandit N (2017). Challenges of Manpower Problems and Its Solution (With special reference to public health sector). JMSCR, 5(12):32202-12
41. Kiboi GK, Kilonzo DJ, Iravo PM (2018). Determinants of effective monitoring and evaluation in health service deliv-ery: A case of Nairobi city county health facilities. Int J Manag Commer Innov, 6:231-45.
42. Rawal LB, Mahmud K, Islam SM, et al (2016). Training mid-level health cadres to improve health service delivery in ru-ral Bangladesh. Prim Health Care Res Dev, 17(5):503-13.
43. World Health Organization (2024). Support tool to strengthen health information systems: guidance for health infor-mation system assessment and strategy development. World Health Organization.
44. Danforth K, Ahmad AM, Blanchet K, et al (2023). Monitoring and evaluating the implementation of essential packages of health services. BMJ Glob Health, 8(Suppl 1):e010726.
45. Byrne E, Heywood A (2023). Use of routine health information systems data in de-veloping and monitoring district and facility health plans: a scoping review. BMC Health Serv Res, 23(1):1049.
46. Gopichandran V, Krishna AKI (2013). Monitoring ‘monitoring’ and evaluating ‘evaluation’: an ethical framework for monitoring and evaluation in public health. J Med Ethics, 39 (1): 31-5.
47. Dunford-Stenger A, Holcomb S, Hetling A, Krepcio K (2021). Defining and pursu-ing goals in a work first environment: An analysis of public assistance recipi-ents’ experience and perception of pub-lic policy on the frontlines. Hum Serv Or-gan Manag Leadersh Gov, 45(1):13-28.
48. Coles E, Anderson J, Maxwell M, et al (2020). The influence of contextual fac-tors on healthcare quality improvement initiatives: a realist review. Syst Rev, 9(1):94.
49. Williams I, Brown H, Healy P (2018). Con-textual factors influencing cost and qual-ity decisions in health and care: a struc-tured evidence review and narrative syn-thesis. Int J Health Policy Manag, 7(8):683-695.
50. Huybrechts I, Declercq A, Verté E, et al (2024). How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the imple-mentation of goal-oriented primary care. Implement Sci, 19(1):32.
51. Pereira SA, Ferreira JJ, Rammal HG, et al (2023). Strategic change in the health sector: a literature review and future challenges. J Organ Change Manag, 36(2):346-88.
52. Chen LW, Xu L, Yu F, et al (2012). The rela-tionship between county variation in macro contextual factors and the per-formance of public health practice in regional public health systems in Ne-braska. J Public Health Manag Pract, 18(2):132-40.
53. Such E, Smith K, Woods HB, et al (2022). Governance of intersectional collabora-tions for population health and to re-duce health inequalities in high-income countries: a complexity-informed sys-tematic review. Int J Health Policy Manag, 11(12):2780-2792.
54. Haldane V, Chuah FL, Srivastava A, et al (2019). Community participation in health services development, implemen-tation, and evaluation: A systematic re-view of empowerment, health, commu-nity, and process outcomes. PLoS One, 14(5):e0216112.
55. Rifkin SB (2014). Examining the links be-tween community participation and health outcomes: a review of the litera-ture. Health Policy Plan, 29 Suppl 2(Suppl 2):ii98-106.
56. Siddiqi S, Masud TI, Nishtar S, et al (2009). Framework for assessing governance of the health system in developing coun-tries: gateway to good governance. Health Policy, 90 (1): 13-25.
57. Dargahi, H, Kooshkebaghi M, Isazadeh N (2024). Explaining the concepts and ex-amples of conflict of interest and its management in the medical laboratory system of Iran: A scoping review. J Educ Health Promot, 13: 238.
| Files | ||
| Issue | Vol 54 No 11 (2025) | |
| Section | Review Article(s) | |
| Keywords | ||
| Health system assessment Health Performance management Monitoring and evaluation | ||
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How to Cite
1.
Safizade K, Dargahi H, Mosadeghrad A, Jaafaripooyan E. Dimensions of Health System Performance Assessment: A Scoping Review. Iran J Public Health. 2025;54(11):2421-2434.
