What health reforms promise and what evaluations measure: A comparative policy analysis of reform evaluation in six predominantly tax-funded high-income countries.

BACKGROUND

Predominantly tax-funded high-income countries are undertaking large-scale reforms to address demographic, workforce and fiscal pressures, digital transformation and fragmented care. Reforms in Australia, England, Canada, Denmark, Norway and Sweden emphasise integration, primary and community care, and sustainability, but their evaluation alignment remains unclear.

OBJECTIVE

To compare alignment between national reform objectives and evaluation models across six predominantly tax-funded high-income systems, identifying where reform promises translate into measurable progress.

METHODS

We conducted a mixed-methods document review and comparative policy analysis. Initial extraction occurred during April-June 2025, with targeted updating and source verification in May 2026. Government, agency, independent organisation and policy documents in English, Danish, Swedish and Norwegian were included. Structured extraction and explicit coding rules mapped reform objectives and evaluation indicators to an adapted World Health Organization Health System Performance Assessment framework across Functions, Intermediate Objectives and Final Goals.

RESULTS

Reforms covered system Functions and most Intermediate Objectives. Evaluation indicators were strongest where routine administrative data were available, particularly activity, financing, access, utilisation, service efficiency and selected safety measures. Measurement was weaker for people-centredness, integration, continuity, prevention, health improvement, financial protection and system equity. The recurring problem was misalignment between reform ambitions and what evaluation models measured.

CONCLUSIONS

These six systems showed a recurrent gap between reform ambition and evaluation practice. Evaluation could be strengthened by planning at inception, pairing objectives with indicators, improving cross-sector data infrastructure, transparently reporting evaluation resourcing, and strengthening governance for longitudinal learning and accountability. These findings inform evaluation design in comparable tax-funded systems.