In health care, there are many definitions for “high-performing health system” but a lack of consensus on a single, consistent definition. Ask ten experts and you may get ten different answers. As Ontario’s health system continues to navigate increasingly complex challenges, the need for a shared understanding of what high performance means is critical for system alignment.
That’s why the Ontario Hospital Association’s (OHA) Health Policy and Applied Research Lab conducted a global scoping review, published in BMJ Open, to explore how high-performing health systems are defined across literature.
The Lab carried out a descriptive analysis of study designs that examined health system performance across various population groups. Key concepts were charted from the literature to understand how “high performance” is defined in relation to health systems. More than 75 per cent of the records included were non-research sources, such as reports from The Commonwealth Fund and the World Health Organization. This mix of sources reflects the broad and often policy-driven nature of performance discourse in health care.
The review aimed to consolidate existing research and provide a working definition that helps health leaders build a collective understanding of what constitutes as a “high-performing” health system, while supporting more evidence-based and data-informed decision-making.
A Global Lens on Performance
Health systems operate in vastly different contexts shaped by unique demographics, geography, and political and economic conditions. Despite these differences, the review revealed several common themes that were most frequently mentioned: access, quality, safety, patient-centeredness and equity. These characteristics appeared consistently across countries and models, though how they were defined and measured varied significantly.
Only seven of the 82 records reviewed by the Lab provided a clear definition of what a high-performing health system means. The most frequently cited definition came from the Commonwealth Fund: “To help everyone, to the extent possible, lead long, healthy, and productive lives.”
This variation highlights a key challenge: without a shared definition and reliable, standardized indicators, health leaders are left navigating with limited visibility, making it harder to track outcomes, benchmark progress or guide strategic resource allocation. A common understanding lays the foundation for improvement initiatives and ensures that partners across the health system are working toward aligned goals.
The Measurement Gap
A key finding from the review was the limited availability of validated tools for measuring health system performance. Of the eight tools identified by the Lab that referenced formal tools, only one had been validated.
This gap reflects a broader challenge: the absence of clear processes for translating evidence into policy and practice.
Measuring health system performance is both important and complex. It demands a clear articulation of purpose, scope and context. Practical challenges include defining what constitutes a “system,” determining what attributes should be prioritized for measurement, and achieving standardization.
Notably, high performance may look different across countries due to variations in health care system design. Definitions may need to be localized to reflect jurisdictional realities or remain flexible to support inclusivity. Tailored measurements can help foster a more relevant understanding of performance at the local level. In diverse systems, international collaboration may be necessary to establish common standards that enable meaningful comparisons.
Working Toward a More Informed Future
As Ontario’s health system continues to evolve, this scoping review highlights an important opportunity to advance research on clear definitions and shared indicators, enabling health leaders to have reliable measures to guide their work.
This work is part of a broader effort to ground health system improvement in evidence and shared priorities. By clarifying what high performance means, and how it can be measured, the Health Policy and Applied Research Lab aims to support leaders in making informed decisions that drive system change.