A Strong Sustainability Paradigm based Analytical Hierarchy Process (SSP-AHP) method to evaluate sustainable healthcare systems

The recent studies signify the growing concern of researchers towards monitoring and measuring sustainability performance at various levels and in many fields, including healthcare. However, there is no agreed approach to assessing the sustainability of health systems. Moreover, social indicators are less developed and less succinct. Therefore, with this work, authors seek to map sustainable reference values in healthcare and propose a conceptual and structured framework that can guide the measurement of the social sustainability-oriented health systems. Based on a new multi-criteria method called Strong Sustainability Paradigm based Analytical Hierarchy Process (SSP-AHP), the presented approach opens the availability for systems’ comparison and benchmarking. The Strong Sustainability Paradigm incorporated into the multi-criteria evaluation method prevents the exchangeability of criteria by promoting alternatives that achieve good performance values on all criteria, implying sustainability. The research results offer insights into the core domains, sub-domains, and indicators supporting a more comprehensive assessment of the social sustainability of health systems. The framework constructed in this study consists of five major areas: equity, quality, responsiveness, financial coverage, and adaptability. The proposed set of indicators can also serve as a reference instrument, providing transparency about core aspects of performance to be measured and reported, as well as supporting policy-makers in decisions regarding sectoral strategies in healthcare. Moreover, the presented approach can be helpful while performing cross-national comparisons. Our findings suggest that the most socially sustainable systems are Nordic countries. They offer a high level of social and financial protection, achieving very good health outcomes. Furthermore, their social sustainability is safeguarded by balancing all identified values. On the other hand, the most unsustainable systems, located in central and eastern European countries, have a high level of unmet needs, experiencing shortages in the workforce and underfunding of healthcare. A key challenge for them is to achieve sustainability by increasing the share of public expenditure on health and limiting the substantial dependence on out-of-pocket payments.