Introduction
This report underscores a critical trend among G20+ nations grappling with increasing healthcare costs and inequities in access and outcomes. The overarching goal is to evolve their healthcare systems to provide ‘value for money and value for many’ by focusing on efficiency, effectiveness, equity, and responsiveness. Although efforts have been initiated at various levels, no large-scale population-level impact has been observed so far. Harvard University’s Health Systems Innovation Lab (HSIL) has developed a High-Value Health System Model (HVHS) consisting of 10 components that cover digital data systems, analytics, cost, and outcomes measurement systems, benchmarking, integrated care pathways, value-based payment and procurement models, integrated provider networks, and strategic change and innovation ecosystems. However, the study notes that while all countries have implemented some components, none have fully integrated all aspects to achieve a complete HVHS transition.
The report applies the HSIL framework to gauge G20+ nations’ progress towards the HVHS transition, using expert surveys, interviews, and desk research. Although progress has been made, the extent of implementation varies significantly among countries. The most significant improvement was seen in digital data systems and strategic change initiatives, while moderate progress was noted in analytics and cost and measurement systems. The components related to value-based payment models and value-based procurement were identified as areas needing accelerated progress. While most nations have established health data ownership and usage policies and are using digital data systems extensively, there is scope to increase the use of existing data systems and analytics to enhance policy and practice. However, less than half of the countries have established performance datasets allowing regional or provider comparisons. Slow progress in aligning financial incentives and setting up regular cost and outcome measurement systems was also noted. Despite these challenges, the report highlights successful initiatives that could serve as models for countries seeking to expedite their HVHS transition.
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The Harvard High-Value Health System Components
Conceptual Model
This study is underpinned by the Harvard High-Value Health Systems Model (HVHS). The Harvard HVHS model consists of 10 interdependent and mutually reinforcing design components (Figure 1) that characterize the ongoing transition in health systems towards a ‘value’ predominant system orientation. The HVHS model is detailed in Building a High-Value Health System,Transition to Health Systems: A Primer and a position paper on Rethinking Health System Design: Towards a High-Value Health System Model.
The conceptual model builds on and represents an evolution of several critical HSIL frameworks, notably the HSIL Health System Framework and HSIL Complex Healthcare Innovation Framework – both of which have been used to examine health system performance and analyze the adoption and diffusion of innovations in health systems and have been applied in more than 30 countries. This prior knowledge and empirical evidence have helped to understand better how health systems behave in different countries, the major forces that influence their performance, and the policies, programs, institutional arrangements, and interventions designed to enhance system performance and ultimately inform the Harvard HVHS model.
Methodology
The study used a combination of surveys, interviews, and desk research to generate relevant information in relation to the HVHS framework and enable data triangulation from multiple sources to understand concepts and empirical data from multiple perspectives.
The research team used the desk review to inform the development of an integrated dataset to ascertain the presence of each of the 10 HVHS components and their constituent value-enhancing measures in selected G20+ countries and examine country transition to the HVHS model. The dataset consisted of 19 qualitative indicators for the 10 components. Each of the value-enhancing measures were assessed using ascending numbered scores ranging between 0-1, 0-2, and 0-3, with 1, 2, or 3 the highest number for each indicator representing advanced progression and 0 indicating that prioritization and progress is needed.
Given that each component had a different range for scoring (0-1; 0-2; or 0-3) with four potential scores (0, 1, 2, and 3), the research team translated each range into a 1-3 standardized scale with three categories represented by numbers and colors to compare the progression for each HVHS component across countries. Level 1 (grey) represents some progress, Level 2 (teal) moderate progress, and Level 3 (black) represents major progress (Table 2). This system enabled the research team to develop a ‘heat map’ to compare the survey results by country and indicator.
Findings from the desk research, surveys, and interviews were synthesized into country profiles that summarize G20+ country transition to the HVHS model and provide a case study from an initiative related to one or multiple HVHS components. Each country profile incorporates a radial chart that summarizes the findings in the standardized scoring system.
Results
This study highlights the advancements in the adoption of digital data systems by healthcare providers globally, with most countries having national policies regarding the ownership and usage of health data. There’s notable progress in France, Singapore, and Turkey towards a unified national health record system, though fragmentation across different providers and care levels pose challenges. In terms of analytics, although most countries have taken necessary steps, there’s significant potential for using existing data systems more effectively and scaling up analytics. Some countries have successfully made healthcare prices and outcomes transparent, while others lag behind in citizen empowerment. Regarding cost measurement systems, several countries, including Australia, India, France, Italy, Singapore, and the U.S., have made significant progress by mandating cost data collection across their integrated care pathways. However, achieving unified health records remains a daunting task.
In terms of outcome measurement, while some countries have made strides in enabling providers to report outcomes data and integrate them into electronic health record systems, there is still a need for more comprehensive integrated digital health records. Countries like India, Indonesia, and Turkey have made significant progress in building outcomes registries across integrated care pathways. However, performance benchmarking is less established, with less than half of the studied countries having relevant datasets. On the integrated care pathways front, few countries have providers bundling services for numerous conditions, with the fee-for-service model still predominating in many health systems. In terms of value-based procurement, Italy and Singapore lead, with major payors implementing value-based procurement practices. Lastly, integrated provider networks and health system transformation initiatives are being established, but more action is needed. Despite notable progress across the ten components of the High-Value Health System framework, this study reveals significant opportunities for acceleration and cross-learning among nations.
Discussion
As countries improve their health systems and each actor adopts different initiatives and strategies to provide services and technologies, they could move towards a value-based health system. However, governments can accelerate this transition in an organized and structured way so that their countries can achieve a high-value health system in the shortest possible time to benefit citizens, patients, health providers, and payers. In this section, we present three different strategies that countries have adopted to move towards the Harvard HVHS model, and propose five enablers that governments could prioritize to accelerate their transition.
Strategies to transition to the HVHS model
Each country conceives, designs, and sequences the development of each of the 10 components differently based on its motivations to transition to a HVHS, health system dynamics, and the balance of various political, economic, and social forces. However, there are three strategies that all countries can follow when transitioning to the HVHS model and could be used to inform and develop a national HVHS strategy to accelerate country transition:
(1) Extension Strategy: implies extending the scope of the HVHS components—going from one to multiple components—followed by expanding the geographic scale—going from a small initiative to a health system-wide intervention;
(2) Expansion Strategy: indicates expanding the scale followed by the extension of scope (note that the difference between the extension and the expansion strategies is the order); and
(3) Transformation Strategy: a hybrid approach that simultaneously combines extension with expansion with the introduction of system level transformations.
While most countries appear to follow the expansion or extension strategies, the biggest potential could be achieved if countries embarked on a transformational approach.
