Integrating benchmarking practices and variation analysis in designing HSPA in small countries: opportunities and challenges

Background: Geographic variation in the provision of health services is an issue that characterizes, with different intensity, every national health system. In order to deal with it, some authors suggest to integrate benchmarking when designing health system performance assessment (HSPA) frameworks. Small states face serious challenges when assessing internal variation due to various factors, e.g. dimensions, lack of benchmark, institutional arrangements, availability of data, statistical significance of analysis, etc. This work aims at exploring these challenges and at contributing to the HSPA design process in small countries. Methods: This study is based on an analysis of the literature focusing on geographic variation in health systems. Moreover, through the support of the discussions that the authors had during multiple focus groups with Latvian authorities, the contribution analyses and discusses the real experience of including benchmarking practices and variation analysis in the design of the Latvian HSPA framework. Results: As a result, this study confirms the importance to address geographic variation when designing an HSPA framework in small states. The study also outlines how these countries should adapt these analyses to deal with challenges related to their dimensions. In particular, small states may find support in benchmarking practices (internal and external) to compare the performance of each single providers in delivering care according to the national strategies. Conclusions: Dealing with geographic variation is key to address equity in every health system. When assessing variation, small states face serious challenges that may prevent them from undertaking these kinds of analysis. This work provides: a) evidences on the relevance of addressing variation analysis in performance assessment of small states, b) a discussion on challenges and opportunities that this activity entails for these countries.