Table 2 Summary of policy and contextual factors

• Defined as "stewardship"

• Integration and decentralization management processes

• Supply-driven management

• System level accountability and multi-level budget allocation (federal/provincial/LHIN/project) through performance measurement

• Public system to be sustained

• Defined as "system responsibility"

• Regulated-market steering mechanism

• Demand-driven management

• System level accountability and transparency through performance measurement

• Focus on suppliers and insurers

• Private sector, public finance

• OHSS strategy map conceptualizes strategy

• Top-down steering mechanism → Government directs various health system actors (central role in system management, despite devolution of power)

• Stewardship, regulation, goal setting, performance expectations

• Zorgbalans has 15 performance dimensions within 3 domains (quality, access and cost)

• No harmonized mapping of strategy → 15 dimensions are categories of information, not strategy-based

• No target setting

• Steering mechanism → Government provides guidelines, but actors set the strategies ("system responsibility")

• Currently undergoing decentralization/regionalization reforms

• Local Health Integrated Networks (LHINs)

• 14 geographical entities, ranging in size

• Concentrated in southwestern Ontario

• Roughly 500,000 inhabitants/LHIN

• Insurers have consolidated (from 100 to 5 currently operating, forming an oligopoly, working on economies of scale)

• Obligatory basic insurance package within a competitive regulated market

• Insurers contract providers (performance measures embedded in this process)

• Equalization fund for the elderly and people with chronic disease is a driver of the strategic behaviour of the insurers. In addition, the Health Insurance Income Support Law (Wet op de Zorgtoeslag) compensates lower-income groups against increases in premiums

• Hospital holdings created to increase market power

• Providers regulated by an Inspectorate for Health Care (Inspectie voor de Gezondheidszorg (IGZ)) through layered inspection, using information management to target site visits

• Ontario Quality Council, Hospital Report (being discontinued and taken up by CIHI), development of electronic performance indicators, ICES Atlases (science-driven themes, not sector-based), Cancer Care Ontario, Frasier Institute, Conference Board of Canada reports, biannual Health Ministers Report, CIHI, Statistics Canada, Canada Quality Council and Ministry of Health Promotion

• RIVM (thematic reports, similar to ICES Atlases), National Cancer Institute (NKI), sector-specific reports, RIVM Public Health Status and Forecasts Report, Cost of Illness (2003) by disease category, Cost of prevention (2003), Health Report from Office of Statistics, Social and Cultural Planning Bureau, and Netherlands Institute for HSR reports (Nivel)

• Ontario Best Practise Registry (IHI model-based listing sector-specific best practices)

• Provincial Performance Fund ($5 million CAD) for providers developing CQI projects with good return on investment

• National overseeing of quality control initiatives carried out by insurers.

• http://www.kiesbeter.nl – Initiative of the Dutch MoH comparing information on care, insurers, hospitals and medicine costs

• College Toezicbt Zorgverzereringen (CTZ) was the specialized body that supervised social health insurance

• No direct link of funding formula with OHSS

• Looking at pay-for-performance and other innovations

• Public Sector Value (PSV) model linking performance framework to accountability mechanisms and budgetary allocations

• Results-based planning and portfolio management mechanisms

• New decentralized model using intermediate "value centers" that are more outcome-based, closer to the service/client interface (moving towards a demand-driven system)

• Use a budget system to link policies (suppliers and insurers), highlighted in the National Budget Report (system responsibilities and budget processes)

• "Department of Finance" philosophy → macroeconomic forecasting of healthcare costs (not entirely a "budget")

• VBTB (Policy Budgets and Policy Accountability, or in Dutch Van Beleidsbegroting Tot Beleidsverantwoording) is a national ministerial policy that links policy goals more explicitly to budgets and financial accountability. VBTB accelerates financial accounting and quality at the request of the Lower House of the Dutch Parliament.

• Mixed tax-based and insurance financing

• Currently modernizing and reforming the budgetary processes through portfolio management, CEA and cost-of-illness data

• Ministry has devolved power for planning and coordinating local healthcare to the LHINs

• 3 year planning reports fed by the OHSS and LHSS → Ministry still regulates planning at the LHIN level

• LHINs can outsource services, engage the community, make proposals to the Ministry and integrate local services

• Ministry uses the 15 themes of the Zorgbalans for health system planning (eg. investments, wait times)

• Zorgbalans to be used as a tool for increasing transparency (planning role and system responsibilities are presented in the Zorgbalans)

• Zorgbalans to be used as an information base for evidence-based planning and decision making