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Our healthcare system is under increasing pressure, both in terms of financial and human capacity, which forces us into difficult choices. Value-based healthcare offers a theory in which the outcomes of care that matter to patients, relative to the costs incurred, are leading in these choices. Important principles of value-based healthcare are organizing care around the patient and gaining insight into care outcomes that matter to patients. In perinatal care, collaboration around the pregnant woman (integrated maternity care) is already underway, but relatively little insight exists into care results from the patient's perspective. In this thesis, we investigated how structured questionnaires on patient-reported outcomes of perinatal care, such as breastfeeding or incontinence, and experiences, such as satisfaction or autonomy, can contribute to improved care. In clinic, we saw that discussing answers individually as part of regular care contacts helped to identify complaints and personalize care, provided that the questionnaires were properly aligned with the care path. At group level, the insight into outcome data gave healthcare providers motivation for quality improvement. Translating the data into recognizable personas helped to achieve substantive discussion and improvement actions. The network-wide approach to measuring and improving outcomes ensured patient-centeredness but hindered implementation. The iterative, context-specific approach of action research helped to achieve change. The findings in this thesis provide direction for the implementation and application of patient-reported measures around pregnancy and childbirth to strengthen the development towards a healthcare system driven by value for patients.

Veselības vadība Veselības aprūpe Health management Health Care Maģistra darba “Krūts vēža ārstēšanas process Latvijā vērtībās balstītas veselības aprūpes kontekstā” mērķis ir izvērtēt krūts vēža ārstēšanas procesa īstenošanu vērtībās balstītas veselības aprūpes pieejas kontekstā un sniegt rekomendācijas tās attīstībai Latvijā. Teorijas daļā secināts, ka Latvijā saslimstība un mirstība no krūts vēža ieņem pirmo vietu starp visiem ļaundabīgajiem audzējiem sievietēm un ir galvenais priekšlaicīgas nāves cēlonis sievietēm 35 - 64 gadu vecumā. Šobrīd aptuveni trešdaļa ļaundabīgo krūts audzēju tiek konstatēti novēloti (slimības III – IV stadijā). Viens no rīkiem kā uzlabot veselības aprūpes sistēmu ir vērtībās balstītas veselības aprūpes koncepcijas ieviešana, kā galveno vērtību izvirzot pacienta ārstēšanas mērķu sasniegšanu visā pacienta klīniskajā ceļā. Pētījuma uzdevumi ir: (1) noskaidrot VBVA pieejas īstenošanas krūts vēža ārstēšanā teorētiskos aspektus; (2) noskaidrot starptautisko pieredzi un citu valstu labos piemērus krūts vēža pacientu VBVA pieejas īstenošanā; (3) izveidot pētījuma modeli, kas balstās uz VBVA pieejas īstenošanu krūts vēža pacientiem; (4) novērtēt esošās krūts vēža pacientu aprūpes atbilstību vērtībās balstītas pieejas īstenošanai; (5) izstrādāt priekšlikumus VBVA īstenošanai krīts vēža pacientiem Latvijā. Darba gaitā autore noskaidrojusi, kādas ir VBVA īstenošanas krūts vēža pacientiem galvenās komponentes, kāda ir esošā krūts vēža ārstēšanas procesa atbilstība VBVA modelim un kas ir nepieciešams, lai īstenotu krūts vēža ārstēšanas procesu atbilstoši VBVA konceptuālai pieejai Latvijā. Pētījuma rezultāti norāda to, ka ir vairākas datu platformas, kas apkopo kvantitatīvus datus par krūts vēža pacientiem un tās ir: “Oficiālais statistikas portāls”, “Latvijas Atvērto datu portāls” un Slimību profilakses un kontroles centra “Veselības statistikas datu bāze”. Krūts vēža ārstēšanas procesa īstenošanai atbilstoši VBVA konceptuālai pieejai jāiesaistās primāri Nacionālajam Veselības dienestam un Veselības Ministrijai, kam jānorāda kā prioritāte un jāiekļauj valdības rīcības plānā. Gavare, Agnese “Krūts vēža ārstēšanas process Latvijā vērtībās balstītas veselības aprūpes kontekstā” Maģistra darbs / zinātniskais darba vadītājs Ph.D., docente Daiga Behmane. Rīga: RSU/RISEBA, 2023. 125.lpp.: 128 zinātniskās literatūras avoti, 21 attēli, 21 tabulas. The aim of the master's thesis "Breast cancer treatment process in Latvia in the context of value-based health care" is to evaluate the process of breast cancer treatment in the context of a value-based health care approach and to provide recommendations for its development in Latvia. In the theoretical part, it was concluded that in Latvia, morbidity and mortality from breast cancer ranks first among all malignant tumours in women. Breast cancer is the leading cause of premature death in women aged 35-64. At present, approximately one third of malignant breast tumours are detected late (in the III-IV stage of the disease). One of the tools to improve the health care system is the introduction of a value-based health care concept, placing the patient as the main value. The tasks of the research are: (1) to find out the theoretical aspects of the implementation of the VBHC approach in the treatment of breast cancer; (2) to find out the international experience and good examples of other countries in the implementation of the VBHC approach for breast cancer patients; (3) to create a research model based on the implementation of the VBHC approach in breast cancer patients; (4) assess the adequacy of existing breast cancer patient care for the implementation of a values-based approach; (5) develop proposals for the implementation of VBHC for breast cancer patients in Latvia. In the course of the work, the author found out what are the main components of the implementation of VBVA for breast cancer patients, what is the compliance of the existing breast cancer treatment process with the VBHC model and what is necessary to implement the breast cancer treatment process according to the VBHC conceptual approach in Latvia. The research results indicate that there are several data platforms that collect quantitative data on breast cancer patients, and they are: “Oficiālais statistikas portāls”, “Latvijas Atvērto datu portāls” and Slimību profilakses un kontroles centra “Veselības statistikas datu bāze”. The National Health Service and the Ministry of Health should be primarily involved in the implementation of the breast cancer treatment process according to the conceptual approach of VBVA, which should be identified as a priority and included in the government's action plan. The expert opinion shows that, to improve the process of breast cancer treatment based on the conceptual approach of health care, the primary Health Protection Service and the Ministry of Health should be involved, which should be identified as a priority and included in the government's action plan. Gavare, Agnese "Breast cancer treatment process in Latvia in the context of value-based healthcare" Master's thesis / scientific supervisor Ph.D., assistant professor Daiga Behmane. Riga: RSU/RISEBA, 2023. 125.pp.: 127 scientific literature sources, 21 images, 21 tables.

Zusammenfassung Hintergrund Die komplexe und dynamische Situation im aktuellen Pandemiegeschehen erfordert eine regional abgestimmte und vernetzte Zusammenarbeit in der Gesundheitsversorgung zwischen den verschiedenen Akteuren des Gesundheitswesens, dem stationaren Sektor sowie dem offentlichen Gesundheitsdienst. Ziel der Untersuchung war, das Versorgungsmanagement hinsichtlich der regionalen Vernetzungs- und Kommunikationsstrukturen wahrend der COVID-19-Pandemie im Jahr 2020 zu beleuchten. Methode Im Rahmen des vom Bundesministerium fur Bildung und Forschung (BMBF) geforderten Projekts „egePan Unimed“ wurde im November 2020 allen Vorstanden der 35 deutschen Universitatskliniken ein Online-Fragebogen zum Pandemiemanagement zugesandt. Im Zentrum des Fragebogens standen die Kernthemen Regionale Vernetzung, Krisenmanagement, Datenaustausch und Kommunikation mit politischen Akteuren. Der Fragebogen bestand aus 37 geschlossenen und drei offenen Fragen. Nach der Pilotierung erfolgte die Einladung zur Befragung dreimal per E-Mail und einmal telefonisch. Ergebnisse Von den befragten Universitatskliniken (n = 25, Response 71,4%) bestand bei 68% eine abgestimmte Zusammenarbeit mit anderen regionalen Krankenhausern und bei 86% mit Vertretern des Offentlichen Gesundheitsdienstes (OGD). Eine koordinierte Zusammenarbeit mit dem ambulanten Sektor wurde seltener (26%) angegeben. 84% der Universitatskliniken gaben an, eine Leitungsfunktion im Rahmen eines regionalen COVID-19-Pandemiemanagements innezuhaben. Ein Datenaustausch im Zuge des Pandemiemanagements fand bei 75% mit regionalen Kliniken und bei 67% mit uberregionalen Kliniken statt. Schlussfolgerung Zur Bewaltigung der regionalen medizinischen Versorgung wahrend der COVID-19-Pandemie im Jahr 2020 nahmen Universitatskliniken sehr haufig eine koordinierende Rolle im komplexen pandemischen Versorgungsgeschehen ein. Es bestanden dabei haufig strukturierte Kooperationen mit regionalen Kliniken und Gesundheitsamtern und vergleichsweise selten mit dem ambulanten Versorgungsbereich. Gerade diese Zusammenarbeit hatte jedoch das Potenzial, Uberbelegungen von Kliniken zu verhindern.

Cardiovascular healthcare is continuously evolving. Biochemical,-and surgical discoveries from past decades improved patient survival to outstanding heights. However, with an ever growing aging patient population and scarce resources, cardiovascular healthcare has to become more value-driven. Value Based Healthcare (VBHC) research is becoming increasingly important in that matter, which questions the relevance (i.e. value) of contemporary evidence-based interventions in relation to patients’ health status and personal preferences.It is difficult to obtain a comprehensive view of ‘valuable outcome’ for both patients and professionals as individual and subjective perspectives on the value of treatment are ever present. This thesis presents a methodological ‘toolbox’ to assess clinical cardiovascular care, unravel the ‘value of care’ for its stakeholders and develop it further in a meaningful way. Patients were assessed on a national level using claims data, which enables insight into care patterns and helps unravel if that which is perceived as valuable by the professional (i.e. guideline evidence), is truly applied in daily practice. Second, cardiovascular care on a local hospital level is qualitatively assessed via Human Factors (HF) science, a novelty in clinical research. In line with VBHC, it helps to understand how the patient and professional experience healthcare within a certain context.

Introduction There is a worldwide trend towards value-based health care, which strives to control healthcare costs while maximising value for clients. The main concept of value has been defined as health outcomes achieved per US dollar spent. This research explored how clients of occupational therapy services, managers and occupational therapists perceived value in occupational therapy services. Method A qualitative design was used to explore the perspectives of clients ( n = 11), occupational therapists ( n = 7) and occupational therapy managers ( n = 7). Appreciative inquiry guided the two phases of semi-structured interviews ( n = 5) and focus groups ( n = 6). Inductive and deductive coding were used to establish themes. Findings Three themes encompassed the participants’ perceived value of occupational therapy services: (1) outcomes which are meaningful to daily life, (2) a constructive client–therapist relationship and (3) affordable, coordinated and understandable therapy. Conclusion Participants attributed value to occupational therapy services when they encountered personalised goal setting, focused on meaningful outcomes, managed personal costs and experienced positive therapeutic relationships. Enhancing services could focus on (1) developing skills in collaborative goal setting, (2) determining suitable outcome measures which are meaningful at personal- and service-level reporting, (3) encouraging self-management strategies, and (4) emphasising therapeutic relationships and supporting therapeutic communication skill development.

Background/aims Lymphoedema can be a life-long burden to patients. Value-based lymphoedema services should aim to empower patients and meet expectations of care. This study evaluated the attendance rates and experiences of patients accessing a mobile health unit for lymphoedema care. Methods A questionnaire was shared with all adult patients with lymphoedema at 16 mobile unit clinics in south Wales over 3 months in 2019. Attendance rates and questionnaire data were explored descriptively. Results Out of 417 patients, 175 (37%) participated in the study. Of these, a considerable majority (132/148, 89%) expressed a preference for the mobile unit compared to hospital-based services. Reasons for this preference included ease of access, excellent staff and parking facilities. Non-attendance rates of 8% were observed at the mobile unit. Conclusions Patients favoured attending the mobile unit, suggesting that mobile care is a key aspect of value-based healthcare, allowing services to be planned around patient needs. However, this did not fully resolve the issue of non-attendance. The impact of such community-based services on health outcomes, costs and staff experiences should be explored before widespread adoption is implemented.

Background The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology’s central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Purpose This study aims to explore the institutionalization of value-based healthcare (VBHC) in the public healthcare system in the state of Victoria, Australia. Design/methodology/approach The empirical part of this paper is based on a content analysis of 34 policy and industry-commissioned reports that have guided the development of health-care strategy in Victoria from 1988 to 2020. Findings This study sheds light on how VBHC in Victoria has been institutionalized over time, through three key phases (centralization, transitioning and digitalization), how the conceptualization of best value has changed in each phase and the implications each phase has presented for other actors in the health-care system. Practical implications This study highlights the key opportunities and challenges for organizational actors that emerge when a health-care system transitions toward VBHC, and derives implications for vendors, health-care procurement, policymakers and governmental agencies. Originality/value This study develops a longitudinal analysis that describes the evolution and institutionalization of a VBHC approach in a complex societal system over three decades and highlights the key implications for other organizational stakeholders.

All over the world, awareness exists to change healthcare systems from the volume-based to the value-based models. The move to value-based healthcare (VBHC) is a promising strategy to deliver bette...

PurposePatients are experts in their own health and should be treated as equal partners in their care. Patient-reported outcome measures (PROMs) are an effective way of gathering patient feedback and can facilitate effectiveness and cost-effectiveness analysis to improve decision making and service improvement. The PROMs, PREMs & Effectiveness Programme was initiated in 2016 and aimed to develop an electronic platform to facilitate collection of PROMs and Patient-reported experience measures (PREMs) from secondary care patients across Wales.MethodsWe worked with all Health Boards in Wales, the NHS Wales Informatics Service (NWIS), and Cedar (a healthcare technology research centre) to identify and meet technical requirements to develop a platform which is fit for purpose. Patient groups were included throughout the development to gather feedback and for extensive testing. Clinical teams helped identify the most appropriate tools, with licences, translations and electronic formatting issues being managed centrally.ResultsThe developed platform is integrated with patient administration systems minimising the need for manual input, with processes in place to allow automatic collection triggers according to nationally agreed schedules. We have over 30 nationally agreed PROMs ‘pathways’ with over 110,000 PROMs collected to date. Responses are fed back to clinicians via the electronic patient record and to each health board via feeds to the national data warehouse, making data easily accessible to different teams, maximising use and application.DiscussionThe national platform has provided a co-ordinated approach to PROMs collection in Wales, offering an effective means of communicating with patients outside the traditional clinic visit.

Purpose: The submitted article focuses on how to solve the problems faced by the European healthcare systems. Design/Methodology: The article consists of two sections. The first one is theoretical and presents interdisciplinary achievements of researchers. The second section includes examples of solutions applied in Sweden, Germany and Great Britain. In the theoretical part, books and articles on the methodology of VBHC creation were reviewed. The empirical part is based on reports on the introduction of VBHC. Findings: The desire to improve cost and clinical effectiveness indicates the need for a value-based healthcare (VBHC). Thus, the concept of VBHC should contribute, according to experts, economists as well as finance and management specialists, to the economic efficiency and clinical effectiveness. Research limitations/implications: Unfortunately, this is a lengthy process to be preceded by many activities. Healthcare registers and databases belong to the most important ones. Thanks to them, it is possible to create the key performance indicators (KPI) allowing for a rational health policy. Original value: To the achievements contained in the publications, the submitted article adds the need to take into account appropriately selected KPIs analyzing the macroeconomic environment for the functioning of hospitals.

SUMMARYIn value-based healthcare (VBHC) value is defined as outcomes that matter to patients divided by the cost of achieving these outcomes. Value is measured for discrete medical conditions across the whole cycle of care. Data on the value achieved by different providers is openly shared. Providers increase value using quality improvement (QI) techniques to improve outcomes, reduce costs or both. Patients or commissioners choose the provider achieving the greatest value. Units should compete regionally or nationally. There are challenges to implementing such ideas in the mental health services in the UK. However, measuring outcomes, understanding costs and using QI to drive up value may be possible without adopting the complete model that has developed in the context of a North American and acute hospital healthcare system.

In this viewpoint, we discuss the approach promoted by the Italian Drug Agency (AIFA) to the assessment of the value of new pharmaceuticals in the Italian Healthcare Service. On top of traditionally acknowledged components, such as quality adjusted life years gained and net costs, the overall value framework might include other elements such as productivity and adherence, equity, severity of disease, reduction in uncertainty, spillover effects. There is a residual dimension in the value framework that may capture the option value or reduction in fear of contagion for infectious disease treatments. We debate measurement issues on these elements of value and discuss open issues from a methodological and policy standpoint.

OBJECTIVE: As part of the value-based healthcare programme in our hospital, a set of patient-reported outcome measures was developed together with patients and implemented in the dedicated Turner Syndrome (TS) outpatient clinic. This study aims to investigate different aspects of health-related quality of life (HR-QoL) and psychosocial functioning in women with TS in order to establish new possible targets for therapy.DESIGN/PARTICIPANTS: A comprehensive set of questionnaires (EQ-5D, PSS-10, CIS-20, Ferti-QoL, FSFI) was developed and used to capture different aspects of HR-QoL and psychosocial functioning in a large cohort of adult women with Turner syndrome. All consecutive women, ≥18 years, who visited the outpatient clinic of our tertiary centre were eligible for inclusion.RESULTS: Of the eligible 201 women who were invited to participate, 177 women (age 34 ± 12 years, mean ± SD) completed at least one of the validated questionnaires (88%). Women with TS reported a lower health-related quality of life (EQ-5D: 0.857 vs 0.892, P = .003), perceived more stress (PSS-10:14.7 vs 13.3; P = .012) and experienced increased fatigue (CIS-20: P < .001) compared to the general Dutch population. A relationship between noncardiac comorbidities (eg diabetes, orthopaedic complaints) and HR-QoL was found (R = .508).CONCLUSIONS: We showed that TS women suffer from impaired HR-QoL, more perceived stress and increased fatigue compared to healthy controls. A relationship between noncardiac comorbidities and HR-QoL was found. Especially perceived stress and increased fatigue can be considered targets for improvement of HR-QoL in TS women.

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Background HIV patients face considerable acute and chronic healthcare needs and battling the HIV epidemic remains of the utmost importance. By focusing on health outcomes in relation to the cost of care, value-based healthcare (VBHC) proposes a strategy to optimize quality of care and cost-efficiency. Its implementation may provide an answer to the increasing pressure to optimize spending in healthcare while improving patient outcomes. This paper describes a pragmatic value-based healthcare framework for HIV care. Methods A value-based HIV healthcare framework was developed during a series of roundtable discussions bringing together 16 clinical stakeholder representatives from the Belgian HIV reference centers and 2 VBHC specialists. Each round of discussions was focused on a central question translating a concept or idea to the next level of practical implementation: 1) how can VBHC principles be translated into value-based HIV care drivers; 2) how can these value-based HIV care divers be translated into value-based care objectives and activities; and 3) how can value-based HIV care objectives and activities be translated into value-based care indicators. Value drivers were linked to concrete objectives and activities using a logical framework approach. Finally, specific, measurable, and acceptable structure, process and outcomes indicators were defined to complement the framework. Results Our framework identifies 4 core value areas where HIV care would benefit most from improvements: Prevention, improvement of the cascade of care, providing patient-centered HIV care and sustaining a state-of-the-art HIV disease management context. These 4 core value areas were translated into 12 actionable core value objectives. For each objective, example activities were proposed. Indicators are suggested for each level of the framework (outcome indicators for value areas and objectives, process indicators for suggested activities). Conclusions This framework approach outlines how to define a patient- and public health centered value-based HIV care paradigm. It proposes how to translate core value drivers to practical objectives and activities and suggests defining indicators that can be used to track and improve the framework’s implementation in practice.

Não se Aplica The management of Health Systems, whether public or private, faces challenges in different realities around the planet. The main challenges are related to sustainability, rising costs and accessibility. Porter et al. (2006) were pioneers in studies to understand why the competitiveness and technological development that accelerated the growth and accessibility of other markets did not present the same benefit in health markets and systems, especially in the private market such as the USA (United States of America), abundant in technology and financial resources. From this investigation, Porter et al. (2006) found that the current zero-sum competition relationships and cost pass-throughs between market actors are not focused on generating value for the user, but mainly on their profitability. Based on this criticism, they created a proposal for a health model based on competition for the generation of value to the end user, and that the generation of this value would be, in short, an equation that produces the best quality related to clinical outcomes and user experience with the rational use of the necessary resources. In other words, the most efficient actors in generating Value to the user would be more competitive and better remunerated in this new model. However, unlike the industry, which has production and logistics processes with less variability, health systems are affected by different cultures, political models, legislation, economic models, social and genetic characteristics of each population. This makes the creation of solutions for these internally and externally heterogeneous systems more complex. Despite the greater complexity of health systems and markets in relation to other markets and industries, the Lean Philosophy originated in the post-War reconstruction of the Japanese automobile industry was successfully adapted to optimize different work processes related to health services, this adaptation being described in the literature most often as Lean HealthCare. This systematic review investigated different Lean initiatives applied in health care and found evidence that the complex challenge of structuring Value-based health systems can through Lean HealthCare, a management philosophy that contains the necessary tools for continuous process optimization and cost reduction, efficiently operationalize these systems, despite their complexity and variability between different population groups and/or pathologies. The findings demonstrate, with statistical significance, that more than 50% of the studies related to Lean HealthCare resulted in the generation of value through one or more components of this equation. This study finds evidence to justify the investment in Lean initiatives in order to organize the different processes in complex health systems and optimize the results of the Value equation. New studies that prospectively evaluate the results of these Lean initiatives, as well as the inter-influence of the quality and cost components of the equation, can provide more robust data and new operational strategies to generate more sustainable and value-capable health systems. A gestão de Sistemas de Saúde, sejam estes públicos ou privados, enfrenta desafios em diferentes realidades ao redor do planeta. Os principais desafios estão relacionados à sustentabilidade, custos crescentes e acessibilidade. Porter e colaboradores (2006) foram pioneiros nos estudos para compreender por que a competitividade e desenvolvimento tecnológico, que acelerou crescimento e acessibilidade de outros mercados, não apresentou o mesmo benefício nos mercados e sistemas de saúde, principalmente no mercado privado, como dos Estado Unidos da América (EUA), abundante em tecnologia e recursos financeiros. A partir desta investigação, Porter e colaboradores (2006) descobriram que as relações vigentes de competição de soma zero e repasses de custos entre atores do mercado não estão focadas na geração de valor para o usuário, mas principalmente em suas rentabilidades. A partir desta crítica, criaram uma proposta de modelo de saúde baseada em competição pela geração de valor ao usuário final, e que a geração deste valor seria, em síntese, uma equação que produza a melhor qualidade relacionada aos desfechos clínicos e experiência do usuário, com uso racional dos recursos necessários. Ou seja, os atores mais eficientes na geração de valor ao usuário seriam mais competitivos e mais bem remunerados neste novo modelo. Entretanto, diferentemente da indústria que possui processos de produção e logística com menor variabilidade, os sistemas de saúde são afetados por diferentes culturas, modelos políticos, legislações, modelos econômicos, características sociais e genéticas de cada população. Isso torna mais complexa a criação de soluções para estes sistemas tão heterogêneos interna e externamente. Apesar da maior complexidade dos sistemas e mercados de saúde em relação aos demais mercados e indústrias, a filosofia Lean, originada na reconstrução da indústria automobilística japonesa pós-Guerra, foi adaptada com sucesso para otimizar diferentes processos de trabalho relacionados aos serviços de saúde, sendo esta adaptação descrita na literatura mais frequentemente como Lean HealthCare. Esta revisão sistemática investigou diferentes inciativas Lean aplicadas na assistência à saúde e encontrou evidências de que o complexo desafio de estruturação de sistemas de saúde baseados em Valor pode, através do Lean HealthCare, uma filosofia de gestão que contém as ferramentas necessárias para otimização contínua dos processos e redução de custos, operacionalizar de forma eficiente estes sistemas, apesar de sua complexidade e variabilidade entre diferentes grupos populacionais e/ou patologias. Os achados demonstram, com significância estatística, que mais de 50% dos estudos relacionados ao Lean HealthCare resultaram na geração de valor através de um ou mais componentes desta equação. Este estudo encontra evidências para justificar o investimento em iniciativas Lean com o intuito de organizar os diferentes processos nos complexos sistemas de saúde e otimizar os resultados da equação de Valor. Novos estudos que avaliem prospectivamente os resultados destas iniciativas Lean, bem como a interinfluência dos componentes de qualidade e custos da equação, podem fornecer dados mais robustos e novas estratégias operacionais para geração de sistemas de saúde mais sustentáveis e capazes de gerar valor.

Background: Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of Sustainable Development Goal (SDG) 3. Value-based healthcare (VBHC) could potentially surpass traditional input-oriented approaches to create a high-quality health system and to improve maternal, newborn and child health (MNCH) outcomes. This paper describes the implementation of VBHC in urban and rural Kenya with the aim to significantly improve MNCH outcomes.Methods: We developed a theory of change (ToC) and used an incremental cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated. We sought to leverage local resources and used a mobile phone-based platform to support pregnant women and MNCH providers throughout the patient journey, using the system for communication, payment and data collection. We created dashboards and used interviews and focus group discussions to gather feedback and to collect the data to describe the implementation process in this paper.Results: We implemented all elements of VBHC, starting small and expanding cohort by cohort. Short and long learning cycles between cohorts enabled implementation of the framework in a relatively short time frame. Data on outputs and outcomes show that the VBHC framework had impact on three levels: Mothers’ improved adherence to maternal healthcare, incentivizing providers to improve quality of care, and transparency of outcomes and costs. This paper describes the implementation process and while the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a low cost per enrolled person.Conclusion: This study has shown that implementation of the VBHC framework in an LMIC setting is possible with some adaptations to the local context. The incremental, cohort-based approach enabled an iterative learning process, which could support the restructuring of health systems in low resource settings going from a supply-driven model to a value-driven model.Trial registration: Not applicable

SUMMARYValue-based healthcare holds great potential to transform healthcare globally. This commentary reviews the historical milestones in its evolution and raises critical questions regarding how it should proceed.