Introduction

International comparisons of health system performance provided by multilateral organizations such as WHO and the OECD generate much interest. The provision of comparative data presents vast methodological challenges but offers considerable potential for cross-country learning. Policy-makers are looking for examples, benchmarks and solutions to address the pressures imposed by the epidemiological, economic, societal and technological demands on all European healthcare systems.

The use of international performance indicators to assess national economies and public domains such as education, transport and environment has paved the way for their acceptance in the health-care field. Dating back to the 1930s (e.g. Mountin & Perrott 1947), studies on health insurance programmes in western Europe show that international comparisons of health systems were used as a means to guide policy processes (Nolte et al. 2006). Several decades ago, such international assessments focused mainly on structural characteristics (e.g. numbers of physicians, nurses, hospitals) and a few specific outcome parameters (e.g. perinatal mortality, under-five mortality, maternal death, incidence and prevalence of infectious diseases, average life expectancy at birth). In the European region these parameters were complemented by the work on avoidable deaths (Rutstein et al.1976) and release of the first atlas of avoidable deaths in the European Union (Holland 1988 & 1990), thus introducing attempts to assess the contribution of health care to the overall health of populations. Coupled with data on health expenditures (OECD 2001; World Bank 1993), these produced the first picture on the performance of national health systems in relation to the resources used.