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Measuring What Really Matters - Revisiting Health System Performance Measurement


Jason Yap

Saw Swee Hock School of Public Health, Singapore, SG
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Faced with a rapidly ageing population, increasing burden of chronic disease, dramatic medical advances and concomitant escalating healthcare costs, Singapore’s healthcare system is forced to adapt with new governance structures, care models and resourcing mechanisms. In the process of this rapid evolution, the approach to measuring and monitoring how health (and social) care is produced, delivered and consumed must also evolve in order to continue to meet the needs and demands of the population without endangering economic sustainability.

Modern healthcare delivery is highly complex, comprising many interlocking parts. Piecemeal measurements of even well-founded salient or sentinel indicators can lead to imprecise perceptions and blind spots, untoward emphases and ineffective leverage, and unintended behaviours and gaming. Healthcare system performance measurement must balance simultaneously between multiple priorities and constraints, and identify opportunities to improve efficacy, effectiveness, efficiencies and effect (or impact).

Context & Population

Although Singapore has done well in many population-level (eg life expectancy, infant and maternal mortality, childhood vaccination, etc) and provider-level (eg hospital waiting times, specific clinical outcomes, range of medical capabilities, etc) indicators of good healthcare performance, and is often cited as an exemplar of a well-performing healthcare system, there are nonetheless some disturbing observations of poor outcomes (for example, high rates of end stage renal disease and of diabetic amputation with many diabetics diagnosed shortly before their amputations) that would dispute that reputation.

Moving forward on multiple tracks of healthcare reform in the acute, primary, intermediate and long-term care sectors, we must also consider the monitoring, control and management (and resourcing) not just of the separate units for healthcare delivery but also their integration, balance and coherence, to achieve their common goal of the best possible health of the patient and the population.

Highlights & Transferability

In this presentation, we will review health system performance measurement approaches and selected observations of their utility, strengths, limitations and corollaries; and propose design principles for the intentional, comprehensive and coherent measurement, monitoring and management of the (integrated) performance of a health and social care system.

While the immediate application of the design principles are for our local context, key observations and principles of design and construction are pitched at the generic healthcare system and would be insightful for other constituencies. In particular, the identification of key points for improvement at “rate-limiting steps” (as described in the Theory of Constraints) will be discussed.


It is often said that healthcare is a complex, adaptive system which is not susceptible to simple “silver bullet” solutions. To cope with such systems is challenging, and we hope to share our learnings on the foundational step to their management: knowing what is going on and where the opportunities for improvement lie.

How to Cite: Yap J. Measuring What Really Matters - Revisiting Health System Performance Measurement. International Journal of Integrated Care. 2022;22(S1):108. DOI:
Published on 08 Apr 2022.


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