“Value for money and value for many”: a push for better G20 health systems in a post-pandemic world

What does “value in health” mean? The answer depends on who you ask. 

A clinician might say that value is achieved when the pros of a particular medical intervention outweigh the cons according to clinical protocols. For a patient, value might mean getting treatment that leads to what they understand as a better life. A health minister might say that value means getting the best health outcomes possible with the limited resources available, which means making tough allocation choices among various health priorities and medical institutions. 

Definitions get trickier the more you think about it. If entire societies ultimately rely on having robust health systems – as the COVID-19 pandemic made painfully clear – then the value of this system cannot be assessed with a health lens alone (since health systems create social and economic value, too). What’s more, narrowly-defined health outcomes are often largely predicted by social and economic factors, such as whether people live in sanitary environments, complete school, or are drawn to political groups in which disinformation spreads. Given these “social determinants of health”, surely it’s hard for healthcare systems to do the heavy lifting towards delivering health outcomes that societies (and politicians) expect of them? 

These are some of the questions explored on a new report developed by João Pedro Caleiro, a writer-researcher in the Lemann Foundation Programme (LFP), a research programme in the Blavatnik School. The report has been discussed in a series of events around the G20 in Brazil this year, and builds on the work by Anna Petherick, Director of the LFP and Associate Professor at the School, as well as insights from a workshop that the Programme ran in Brazil in September 2023 with health secretaries and specialists, and Associate Professor Emily Jones. 

How should we interpret “value-based care”? 

“Value-based care” began with a straightforward formula, conceived by Michael Porter, a US-based Business professor in the mid-2000s, who defined value as “quality divided by cost”. This perspective suggests that health outcomes should be properly measured on a long-term scale, acknowledging that different people value different things. Instead of paying a fee for a specific intervention, a value-based approach would recommend rewarding results. For example, a group of patients (e.g., older women with back pain) would be identified, a clear clinical pathway would be designed for them, and the health outcomes would be evaluated over the long term, with benchmarks defined in relation to other clinical settings, where different, more “valuable” practices are being tried. 

Over time, different hospitals experimented with the idea of value-based care, and different countries have emphasised different aspects of value. Some countries, like Saudi Arabia, articulate this perspective front and centre in their national health strategies; others never mention value-based care, but nonetheless implement measures that are similar in approach. Value-based care has been gradually incorporated into many universal health care systems, and as this has happened, the concept has come to increasingly incorporate equity as a central concern. 

A focus on co-ordination and equity 

By examining value from this perspective, our new report focuses on two key areas. The first is co-ordination: achieving value is very hard if the parts of the health system are not working together. The report highlights examples from different countries that illustrate this. In Brazil, for example, the universal health care system relies on municipal, state, and federal levels working well together. In Argentina, fragmentation within the system necessitates building co-ordination from the ground up through targeted subsidies that establish common standards and structures over time. 

In the United Kingdom, recent efforts have focused on co-ordinating the NHS with other care services, recognising that many factors affecting health outcomes, such as the social determinants of health, fall outside the immediate purview of healthcare. Co-ordination becomes even more critical during shocks like pandemics and challenges like climate change, which impacts health in manifold ways. 

These impacts are, of course, not equally distributed across populations, and often disproportionately affect the poorest and most vulnerable people. Thus, the report also emphasises health equity. Indeed, achieving universal health coverage is a Sustainable Development Goal agreed by all countries and it could go a long way towards addressing health equity concerns. However, progress in this direction had stalled even before COVID-19 hit. 

Even countries that are politically committed to universal health coverage and working hard to achieve it, such as Indonesia, find navigating dilemmas challenging, and the measures to track equity across groups are often inadequate. In Italy, where the health system is universal but highly decentralised and unequitable, one potential pathway towards equity involves fostering interregional learning through “soft power” systems of collaboration that incorporate measurement and benchmarking. 

Where do we go from here? 

As the final G20 meetings of 2024 approach, the Lemann Foundation Programme and its partners will continue to emphasise co-ordination and equity as central concerns, encouraging cross-system learning. The goal is that in “normal” or non-emergency times, health systems worldwide can emerge stronger than they went into the COVID-19 pandemic, and continue to build resilience by promoting co-ordination and equity.