Findings and methodology
A report from The Economist Intelligence Unit

Value-based
healthcare:
A globalassessment

Commissioned byValue-based healthcare: A global assessment
Findings and methodology

Contents

About this report2

Acknowledgements

3

Executive Summary

5

Introduction

7

Highlights

9

Alignment with value-based healthcare

10

Domain 1: Enabling context, policy and institutions for value in healthcare

11

Domain 2: Measuring outcomes and costs

13

Domain 3: Integrated and patient-focused care

14

Domain 4: Outcome-based payment approach

15

Total health expenditure as a percentage of GDP and value-based healthcare

16

Cost per outcome point and value-based healthcare

17Conclusion

18

Appendix A: Methodology, sources and detailed indicator descriptions

19

Appendix B: Glossary

26

Appendix C: Table of country scores

28© The Economist Intelligence Unit Limited 2016

1

Value-based healthcare: A global assessment
Findings and methodology

About this report

This report highlights the main findings from theFor further information, please contact:

EIU assessment of value-based healthcare(VBHC) alignment in 25 countries. The study wascommissioned by Medtronic, a global
technology and medical devices company. As
VBHC is an early-stage concept and model, thisThe Economist Intelligence Unit
Atefa Shah, Editor
atefashah@eiu.com

study was an effort to establish a standard of

Mathew Hanratty, Press Officer

evaluation of value-based healthcare alignment

mathewhanratty@economist.com

and establish the core components of the+44 (0)20 7676 8546

enabling environment for VBHC.

© The Economist Intelligence Unit Limited 2016

2

Value-based healthcare: A global assessment
Findings and methodology

Acknowledgements

The Economist Intelligence Unit

Experts interviewed

Project managers: Atefa Shah, Eva Blaszczynski

Professor Ahmad Fuad Afdhal (ISPOR Indonesia),

Project researchers: Michael Paterra, Alan Lovell,

Dr. Ximena Aguilera (Centre of Epidemiology andAnelia Boshnakova

Health Policy in Chile), Ms. Monica Aravena

Project advisors: Annie Pannelay, Rob Cook,(Health Economics Department, Health PlanningDavid Humphreys

Division, Ministry of Health, Chile),

Data tool developer: Marcus Krackowizer

Dr. Rafael Bengoa (Deusto Business School),

Contributing researchers: Trupti Agrawal,

Dr. Oscar Bernal (Universidad de Los Andes),Diane Alarcon, Pepijn Bergsen, Xiaoqin Cai,

Stephen Brenzek (AXA), Dr. Jonathan Broomberg

Marisa Evans, Eileen Gavin, Andrei Franklin,(Discovery Health), Dr. Arturo Vargas Bustamante

Portia Hunt, Tom Felix Joehnk,(UCLA Fielding School of Public Health/Jaekwon (James) Lim, Kate Parker,

Department of Health Policy and Management),

Katharine Pulvermacher, Joaquim Nascimento,

Dr. Thomas Campbell (Gold Coast University

Peter Power, Deen Sharp, Yue Su, Yoshie Ueno

Hospital), Dr. David Chin, M.D., MBA (Johns

Contributing writer: Sarah Murray

Hopkins University Bloomberg School of Public

Copy editor: Janet Sullivan

Health), Mr. Gary Claxton (Kaiser Family

Layout and design: Mike Kenny

Foundation), Dr. Eric Hans Eddes (Director of
Dutch Institute for Clinical Auditing),

International expert advisory panel

Dr. Manal El Sayed (Ain Shams University, Cairo),

Dr. Ingrid Christina Rångemark Åkerman (ICHOM)

Dr. Mark Fendrick (University of Michigan),Dr. Rifat Atun (Harvard T.H. Chan School of Public

Lic. Jose Ignacio Campillo Garcia (FUNSALUD),

Health)Dr. Jennifer Lynn Gibson (University of Toronto),

Dr. Clemens Guth (Artemed SE, Germany)

Professor Paul Glasziou (Bond University),

Dr. Ana Maria Malik (Fundação Getulio Vargas

Dr. Preetha GS (International Institute of HealthSão Paulo School of Management)

Management Research, Delhi),

Dr. Adriano Massuda (Federal University ofProfessor Ramiro Guerrero (Centro de Estudos deParaná, Brazil)

Proteccion Social y Economia de la Salud),

Dr. Michael B. Rothberg (Medicine Institute of theJack Hewson (Al Jazeera Media Network),

Cleveland Clinic)

Dr. Peter Hoppener (Medicinfo),

Professor Qiao Yu (School of Public Policy &Dr. Kang Hee-jung (Social Insurance Research

Management at Tsinghua University)

Department, Korea Institute for Health and Social
Affairs), Dr. Priya Balasubramaniam Kakkar (Public
Health Foundation of India), Dr. Michael Knapp(Schoen-Klinik), Mr. Wenkai Li (China Medical
Board), Dr. Marcelo Nita (University of São Paulo),
Ms. An Mi-ra (Benefit Standard Management© The Economist Intelligence Unit Limited 2016

3

Value-based healthcare: A global assessment
Findings and methodology

Department, Health Insurance Review &Board), Dr. Mahtap Tatar (Hacettepe University),

Assessment Service), Dr. Olusegun S Odujebe,

Dr. Dennis Templeton (UAEU College of Medicine

MD, CISA, PMP, FCCM (Enthusia Consulting Ltd./and Health Sciences), Professor Claudia Travassos

Association for Health Informatics of Nigeria),(Federal University of Rio Janeiro),

Dr. Zeynep Or (Institute for Research and

Dr. Chigozie Jesse Uneke (Ebonyi State University,

Information in Health Economics, France),

Nigeria), Dr. Fred van Eenennaam (Value-Based

Dr. Kayihan Pala (Public Health Department,

Health Care Center Europe),

Uludag University School of Medicine; Turkish

Dr. Jeremy H.M. Veillard (University of Toronto/

Medical Association Delegate), Professor

Canadian Institute for Health Information (CIHI),

Guillermo Paraje (Universidad Adolfo Ibáñez),Tracy Verdumen (Universiteé Paris Sud)

Mr. Adam Roberts (The Health Foundation UK),

Ms. Dr. Vasiliy Vlassov (Society for Evidence Based

Dr. Fredy Rodrıguez-Paez (Universidad Jorge

Medicine), Alexander White (Australian Medical

Tadeo Lozano),The Honourable Nicola Roxon

Association), Ms. Fangqing Wu (Health and Family(Former Minister Ministry of Health Australia),

Planning Commission of Wuhan, Hubei Province),

Dr. Carlos Martín Saborido (Universidad Francisco

Dr. Miroslaw J. Wysocki (National Institute of Publicde Vitoria), Dr. Antonio Sarría (Associate Professor,

Health - National Institute of Health Poland),Public Health Medicine, University of Alcala),

Dr. Yuji Yamamoto (MinaCare),Dr. Virendar Sarwal (Max Super-Speciality

Mr. Yoshinori Yokoyama (The University of Tokyo,

Hospital, Mohali), Dr. Eliezer Silva (Hospital Israelita

Executive Management Programme),

Albert Einstein, Sao Paulo), Mr. Takashi Sugimoto

Mr. Kim Young-hak (Division of Health Insurance(The Graduate School of Public Policy, The

Policy, Ministry of Health and Welfare)

University of Tokyo), Dr. Kun Tang (China Medical© The Economist Intelligence Unit Limited 2016

4

Value-based healthcare: A global assessment
Findings and methodology

Executive summary

Demographic shifts and changing lifestyles areresearch, the EIU first defined value-based

leading to substantial changes in the health of thehealthcare and built a framework of coreglobal population, with many of the world’s

components of VBHC. For the purposes of thiscitizens living longer, but, in many cases, withstudy, the EIU defines value-based healthcare as

multiple and more complex conditions. Acrossthe creation and operation of a health systemcountries, the cost of healthcare is rising fasterthat explicitly prioritises health outcomes thatthan economies are growing. In many developed

matter to patients relative to the cost of

countries, such as the US, France, and Japan,

achieving those outcomes.

more than 10% of GDP is spent on healthcare.

By focusing on
health outcomes,
value-based
healthcare (VBHC)
helps healthcare
providers manage
cost increases,
make the best use
of finite resourcesand deliver
improved care topatients.

To gain a better understanding of how

Value, more than volume, is becoming morecountries are progressing towards VBHC, the EIU

important. The case for countries to align theirevaluated alignment with VBHC components inhealth systems with value-based approaches has

25 countries1. The research is organised aroundperhaps never been stronger. By focusing onfour key components, or domains of VBHC,

health outcomes, value-based healthcarecomprised of a total of 17 qualitative indicators.

(VBHC) helps healthcare providers manage cost

The four domains are:increases, make the best use of finite resourcesand deliver improved care to patients.
While the rationale for implementing a VBHC
model is strengthening, it requires a paradigm
shift from a supply-driven model to a morepatient-centred system. The VBHC model is very
new and will require a complete re-thinking ofl Enabling context, policies and institutions forvalue in healthcare (8 indicators);l Measuring outcomes and costs (5 indicators);l Integrated and patient-focused care
(2 indicators); andl Outcome-based payment approach(2 indicators).

decades-old policies and practices - which will
not be easy and will take time. This study shows

Qualitative indicators were scored by the EIU

that value-based approaches are being

using standardised scoring guidelines across all

implemented incrementally and at varying

countries and arriving at binary scores of yes/no,

speeds across the world’s healthcare systems.

or numbered scores of 0-2, 0-3, or 0-4. Individual

Aligning a health system with a VBHC model also

indicator scores were rolled up by domain andrepresents a tremendous shift in culture for all

countries were categorised into one of four

stakeholders. Historically, health consumers—

groups—Low, moderate, high or very high—represented by patients or public/private
payers—have paid for the volume of services
rather than the value of those services.
In this study, the Economist Intelligence Unit
(EIU) examined health systems to determine theiralignment with the VBHC model. To conduct this
© The Economist Intelligence Unit Limited 2016

1

Asia: Australia, China, India, Indonesia, Japan, South Korea
Europe: France, Germany, Netherlands, Poland, Russia, Spain,
Sweden, UK
Middle-east and North Africa: Egypt, Turkey, United Arab Emirates
Sub-Saharan Africa: Nigeria, South Africa
Latin America: Brazil, Chile, Colombia, Mexico
North America: Canada, US

5

Value-based healthcare: A global assessment
Findings and methodology

based on the level of alignment with VBHC. The

have been integrated into an Excel-based tool to

EIU aggregated individual indicator scores into

enable easy analysis of country results. The data

domain scores, and domain scores into an

are also accessible on the digital hub for VBHC.3

overall composite score. Each domain is equallycountries are still in the earliest stages of aligningweighted within each domain. (For more on

their health systems with the components ofthe methodology behind the scoring, see

VBHC. Many have other priorities such as

Appendix A).

improving quality and increasing access to basic

The study evaluates the presence of the…the majority ofcountries are still inthe earliest stagesof aligning theirhealth systems withthe components
of VBHC.

What the study finds is that the majority ofweighted, and each indicator is equally

health services. This is often the case for lower-

enabling infrastructure, outcomes measurement

income and developing countries. However, as isand payment systems that support value-based

seen in the US, even mature economies may notcare. This report summarises and analyses thehave all the core components in place forfindings from the global assessment across the 17

value-based care. While there are leading

indicators, as well as from research and analysis

countries in our research results, rather thanof the enabling environment—policies, institutions,emphasise country comparison, this study is

infrastructure and other support—for VBHC.

designed to deepen understanding of the core

The research began with a comprehensive
literature review (including health policy

components of VBHC and build a standard forevaluation of alignment with the VBHC model.

documents, academic literature, and otherCountries that choose to move towards ahealth system studies) and secondary research,more patient-centric, value-based model

followed by a one-day onsite workshop andconfront forces such as inertia, fragmented

consultation with an international advisory panel.2

systems and the limits of existing healthcare

The EIU explored existing frameworks during thisinfrastructure and operations. Yet, in many

review, and created a draft study framework thatplaces, political will is strong and policymakers

was advised on and validated by the expert

are moving in the direction of a patient-centric

panel. During the country-level research, the EIU

approach. These findings will show how theinterviewed professionals with a wide range ofenabling environment and policies differ acrosshealth system expertise, including practitioners,

countries as well as the varying priorities among

private insurers, policy analysts and academics.

those countries.

The data created by the EIU in the research effort

2

See Acknowledgements page for advisory panel members.

© The Economist Intelligence Unit Limited 20163www.vbhcglobalassessment.eiu.com

6Value-based healthcare: A global assessment
Findings and methodology

Introduction

As increasing life expectancy, accompanied byimpressive advances, with some evidence of the

spending across the world, it has become clear

adoption of forward-thinking approaches. For

to many policymakers and healthcare providers

example, the US Centers for Medicare &that a business-as-usual approach to cost

Medicaid Services (CMS) are in the process ofcontainment is no longer sustainable. To continue

shifting to value-based payments over the next

(or in some cases start) delivering accessible,

five years through the introduction of bundled

high-quality care, policymakers increasingly

payments and other measures.1 In the European

recognise the need to forge a link between

Union (EU), a collaborative of hospitals in thehealthcare costs and outcomes in order toNetherlands, Santeon, is measuring patient

improve value for patients.

outcomes using metrics created by the

In recent decades, healthcare systems inWith tremendous
diversity inhealthcare systems
worldwide, somecountries arebound to facebigger challenges
than others in
shifting to valuebased models.

A few “frontier” countries are making

the rise of chronic diseases, pushes up healthcare

International Consortium for Health Outcomescountries including the UK and US have worked

Measurement (ICHOM),2 and the Organisation for

towards measuring the relative cost efficiency

Economic Co-operation and Development

and comparative effectiveness of different(OECD) is also starting to address areas such as

medical interventions. This approach, known as

payment systems, value in pharmaceuticalvalue-based medicine, followed thepricing3 and the efficiency of healthcare delivery

development of evidence-based medicine andand the need for co-ordination of care.

expanded the concept to include an explicit

However, many others—particularly lower-

cost-benefit analysis, with a focus on the value

income countries, which are facing a range ofdelivered to patients, rather than the traditional

development challenges—have yet to start out

model in which payments are made for theon this journey. With tremendous diversity involume of services delivered.

healthcare systems worldwide, some countries

Nevertheless, making the shift to VBHC is far

are bound to face bigger challenges than othersfrom easy, and the majority of countries are still inin shifting to value-based models. Even for thosethe early stages of assembling the enablingthat have started to make changes, decades-

components for this new approach toold practices and entrenched interests arehealthcare. Implementing the components ofdifficult to dislodge.

VBHC requires a rethink of the overall quality ofpatient outcomes (and the longer-term benefit

1

Bundled Payments for Care Improvement Initiative (BPCI) Fact
Sheet, Centers for Medicare & Medicaid Services, United States,
Aug 13th 2005; https://www.cms.gov/Newsroom/
MediaReleaseDatabase/Fact-sheets/2015-Fact-sheetsitems/2015-08-13-2.html

2“Value-based healthcare in Europe: Laying the foundation”, The
Economist Intelligence Unit; https://www.eiuperspectives.
economist.com/sites/default/files/ValuebasedhealthcareEurope.
pdf

3“Value in Pharmaceutical Pricing”, OECD, July 2013; http://www.
oecd-ilibrary.org/social-issues-migration-health/value-inpharmaceutical-pricing_5k43jc9v6knx-en

relative to the cost of an intervention), rather
than just the quantity of treatments delivered.
Given the deeply rooted culture of fee-for-service
and supply-driven models, in which payments are
made for every consultation or treatment,
introducing new approaches will take time.
© The Economist Intelligence Unit Limited 20167

Value-based healthcare: A global assessment
Findings and methodology

This report summarises our findings in theoutcomes achieved, is very difficult to find. As thisassessment4 of VBHC alignment in 25 countries.

study will show, health data infrastructure can be

Using indicators such as the existence of a

improved in most countries.

high-level policy or plan for VBHC, the presence

For example, data in disease registries thatof health technology assessment (HTA)

track the clinical care and outcomes of aorganisations or the presence of policies thatparticular patient population are often

promote bundled payments (where a single fee

inaccessible, lack standardisation and/or are notcovers the anticipated set of procedures needed

linked to each other, if they exist at all. In someto treat a patient’s medical condition), this study

places, attempts to develop electronic healthintends to paint a picture of the enablingrecords have floundered. In others, they haveenvironment—from policies and institutions to IT

been implemented but lack interoperability

and payments infrastructure—for VBHC

across different providers, which means that theyalignment across a diverse set of countries.

are of limited use in facilitating co-ordinated,

The results of the analysis reveal a mixed

longitudinal care.

picture, with considerable variations across

However, even in developing countries,

countries. These range from those where pay-for-adoption of aspects of VBHC can also be found.

performance models and co-ordinated models

For example, Colombia’s recent health reformsof care are being introduced to countries where

include plans to organise health delivery intosome of the basic tools needed to implement

patient focused-units within 16 co-ordinated carevalue-based care—from patient registries to HTA

programmes.5

organisations—are still not in place.
The challenges are not to be underestimated.

By assessing the existence of core components
of VBHC across countries, this study provides new

In many healthcare systems today, information

insights into the state of the enabling environment

about the overall costs of care for an individualfor value-based care around the world.

patient, and how those costs relate to the5
4

See domains and indicators in the methodology section of the
Appendix.

© The Economist Intelligence Unit Limited 2016

“Política de Atención Integral en Salud”, El Ministerio de Salud
Protección Social, 2016; https://www.minsalud.gov.co/
Normatividad_Nuevo/Resoluci%C3%B3n%200429%20de%202016.
pdf

8

Value-based healthcare: A global assessment
Findings and methodology

Highlights

l Sweden is the only country that emerges withl Moving from siloed, single-provider-based carevery high alignment with VBHC and the UK is theto co-ordinated, team-based care remains

only country with high alignment with VBHC.

challenging. About one quarter of the countries in(Alignment can be Low, moderate, high, or very

the study (Egypt, Indonesia, Nigeria, Netherlands,high). Most developed countries in the study

Russia and the US) have no national co-ordinatedhave moderate alignment with value-based care

care pathways in any of the five therapy areas

approaches.

reviewed (mental health care, diabetes care, HIVl India and China—the two countries in the
study with populations greater than 1 billion—
have generally similar results yet diverge strongly
on levels of health coverage, with just 18% of

patient care, maternal care and elderly care). In
the US, co-ordinated care pathways exist but only
within hospitals or provider groups, and they are
not standardised nationally.

India’s population covered by some form ofl The advantage of bundled payments forhealth insurance while in China, more than 95%

co-ordinating care and focusing on the patient isof the population is covered by public healthincreasingly being recognised. In six of the 25

insurance.

countries, bundled payments are being

l Strong policy support, which helps countries

implemented by one or more payers.

align their health systems more closely with thel High health spending does not always mean atenets of VBHC, tends to be found in wealthierpresence of supporting factors for alignment withcountries. Of the seven countries with a high-level

VBHC: neither Japan nor the US—two countries

policy or plan for VBHC, only two—Turkey andthat spend more than 10% of GDP on health—

Colombia—are developing countries.

has a recognised national HTA organisation.

l The impetus to measure outcomes and costs is

l How countries score on the United Nations

strengthening through the presence of disease(UN) Human Development Index (HDI)1 correlates

registries and efforts by many countries towith alignment with VBHC: Countries with low- or

implement electronic patient records. However,

medium-level HDI scores (South Africa, Indonesia,

in many instances, these sources of health data

India, Egypt and Nigeria) need to focus on otherare not co-ordinated and the IT systems are notchallenges, including increasing basic access tointeroperable. Moreover, outcomes data, which

healthcare, so establishing the enabling

are a prerequisite for alignment with value-based

environment for VBHC is lower on the list ofcare, are almost universally lacking.

national priorities.

1© The Economist Intelligence Unit Limited 2016

Human Development Index (HDI), United Nations Development
Programme; http://hdr.undp.org/en/content/humandevelopment-index-hdi

9Value-based healthcare: A global assessment
Findings and methodology

Alignment with value-based
healthcare

As this study reveals, many countries are in thefor general practitioners. While the changes are

earliest stages of adopting the requisite institutions

being driven partly by the need to cut costs,

and value-based approaches in order to deliverpolicymakers and other health stakeholders—the best outcomes to patients relative to cost.

from medical specialists and primary care

Variations emerge in the four domains featured inphysicians to insurers to other payers such as

this study—the enabling context of policy andprivate companies and national healthinstitutions for value in healthcare; measurement

institutions—are strongly supportive of theof outcomes and costs; integrated and patient-

implementation of more patient-centric carefocused care; and outcome-based paymentthat maximises value.

approaches. However, most countries have either…a country’s
ability to afford
comprehensive
care for its
population candetermine its
ability to move tovalue-based
care…

About half the countries in the study emerge

low or moderate overall alignment with awith low alignment with VBHC. While muchvalue-based approach to healthcare, reflecting

variation is evident among the four different

the fact that the concept of VBHC is very new

domains, broadly, several patterns emerge. For

and in the early stages of adoption (if adoption is

example, a country’s ability to afford

taking place at all).

comprehensive care for its population can

Sweden is the only country that emerges withdetermine its ability to move to value-based

very high alignment with VBHC. While value-care, with richer countries that largely fund theirbased care has not been comprehensively

countries’ healthcare seeing VBHC as a means of

implemented, Sweden has a system structured toaddressing the rising cost of care. However,use decades of evidence-based treatment

wealthy countries do not necessarily fund their

guidelines and disease registries as well as anations’ healthcare. In the US, for example, a

healthcare workforce that is largely salaried,fragmented reimbursement system—which

creating fewer incentives to adhere to a fee-for-includes corporate payers, private insurers andservice model. Moreover, Sweden is moving

government funders such as the CMS—makes

towards outcomes-based reimbursement for

the adoption of VBHC more complex and difficult

specialised care.

to co-ordinate, since each payer has different

Meanwhile, the UK is the only country with

objectives.

high alignment with VBHC. In the UK, National

By contrast, countries that cannot yet afford

Health Service England (NHS)—which covers thecomprehensive healthcare for their populations

majority of the British population (Scotland,

are still struggling to increase access to care,

Wales and Northern Ireland have separate

and are not currently focused on measures thatsystems)—has been experimenting with newwould align their health systems more closely

team-based healthcare delivery models andwith the tenets of VBHC. In Nigeria, for example,

new forms of payment, such as bundledless than 10% of the population has healthpayments and pay-for-performance measuresinsurance and the policy focus is on reducing© The Economist Intelligence Unit Limited 201610

Value-based healthcare: A global assessment
Findings and methodology

fragmentation, achieving universal access tohealthcare and ensuring minimum standards ofcare.1Other factors driving alignment with valuebased approaches are the degree to whichgovernment is involved in designing the structure

Domain 1:
Enabling context, policy
and institutions for value inhealthcareof the health system, the distribution of healthpolicymaking responsibility, the strength of health

While outcomes measurement, patient-focusedsystem stakeholder support and the quality of thecare practices and outcomes-based payment

health information technology infrastructure.

systems are all important in underpinning

Most developed countries in the study havealignment with VBHC, countries also need anmoderate alignment with VBHC. However, in aecosystem of institutional and policy structures

few cases, high-income countries have lowthat support value-based approaches.

alignment. This is the case for Chile, Spain, theStakeholder buy-in is also key—from providers,

UAE and Russia. In these countries, the reasons

payers, and patients.

behind low alignment vary. For example, neither

While government
plays a key role insetting the policy
agenda, support
for VBHC fromotherstakeholders—such as private
insurers andprofessional
associations—isalso critical.

Some of the countries that are moving towards

Spain nor Chile has a high-level policy or officialaligning with value-based healthcare—such as

national plan for VBHC. Even so, the presence of

Sweden and the Netherlands—have support

a national policy is not always reflective of

from national policymakers but lack national-

progress for an entire country. In the case oflevel policies. The health systems in Sweden4 andSpain, for example, value-based alignment is

the Netherlands are organised at the local level

stronger at the regional level, with some regions

and it is here that components of value-based

making major strides in reorganising aroundcare exist. In Canada there is establisheddelivering value.

stakeholder support for the tenets of VBHCAll middle-income (or developing) countries inwithout a high-level policy or national plan in

the study have low alignment with VBHC, except

place.5 And in Australia’s decentralised health

Colombia, which has moderate alignment.

system though, fragmentation of care andColombia is aided by the fact that the country

inconsistent outcomes are a challenge—andhas been moving towards achieving universal

may be an obstacle to value-based healthcare.6

healthcare, with more than 95% of the population

However, strong national-level policy support forhaving access to health insurance.2 It has also

VBHC can certainly be an advantage. What

implemented recent reforms that aim to focus

emerges from the study is that, generally

the health system around the patient.3

speaking, it is the richer countries that have thispolicy support in place. Of the seven countries
with a high-level policy or plan for value-basedcare, only two—Turkey and Colombia—aredeveloping countries.
While government plays a key role in setting
the policy agenda, support for VBHC from otherstakeholders—such as private insurers andprofessional associations—is also critical. Moreoften than not, this stakeholder support tends to
4“The Swedish Health Care System”, The Commonwealth Fund,
2015; http://international.commonwealthfund.org/countries/
sweden/“Country Cooperation Strategy: Colombia”, World HealthOrganization, 2014; http://www.who.int/countryfocus/
cooperation_strategy/ccsbrief_col_en.pdf?ua=1

5

Gregory P Marchildon, “European Observatory on Health Systems
and Policies, Canada Health System Review: 2013”; http://www.
euro.who.int/__data/assets/pdf_file/0011/181955/e96759.pdf“Política de Atención Integral en Salud”, El Ministerio de Salud
Protección Social, 2016; https://www.minsalud.gov.co/
Normatividad_Nuevo/Resoluci%C3%B3n%200429%20de%202016.
pdf

6

Review of Medicare Locals, Report to the Minister for Health andMinister for Sport, Department of Health, Australia, May 2014;
http://www.health.gov.au/internet/main/publishing.nsf/content/
review-medicare-locals-final-report

1

A Nicholls, “Healthcare Report: Nigeria, 3rd quarter 2015”, The
Economist Intelligence Unit, Oct 1st 2015.

2

3© The Economist Intelligence Unit Limited 201611

Value-based healthcare: A global assessment
Findings and methodology

go hand in hand with the presence ofgovernment policy.
When it comes to the presence of training

Figure 1.

Presence of enabling elements forvalue-based healthcare (Indicator 1.3)

professional curricula. This is the case even whencountries have broad stakeholder support for
Of the 13 countries with this stakeholder
support for VBHC, only five (Australia, Canada,
Japan, the Netherlands and the US) have any
professional training in value-based care.
However, this supporting element of VBHC may
take longer to establish since integrating newmaterial into the medical curriculum can be aslow process, requiring multiple layers or steps forapproval.
Successful adoption of the components ofCountry

value-based care.

Australia✓

Quality standardisation

training) there is little evidence of it in health-

Outcomes-based care,patient-centred caresomething that is generally part of medical

Bundled / block payments;
Payment for performance /linked to quality

programmes focused on providing VBHC (not✓BrazilCanada

✓

✓

✓

✓

Chile
China

✓

that can set and review guidelines, examine theColombia✓

medical, social, economic and ethical impact of

Egypt

VBHC also requires countries to have institutions

health interventions (usually through HTAs), andprovide funding for research that addresses
health-related knowledge gaps.
On the whole, it appears that richer countries

France✓Germany

✓

✓
✓

✓

India

✓

the UAE is the only developed country that does

Indonesia✓

not currently have its own evidence-basedJapan

are better equipped in this respect. For example,

guideline-producing organisation (it does,
however, have dedicated health researchfunding organisations, but without mandates foraddressing knowledge gaps), while all EU
countries in the study have an HTA organisation
with clear independence from providers.

MexicoNetherlands

✓

✓

✓

✓

✓

Nigeria
Poland✓RussiaSouth Africa
South Korea

✓

✓
✓

Spain
Sweden✓✓✓Turkey

✓

✓

✓

✓

✓

UAE
UK

✓

✓

✓

US

✓

✓

✓

Source: EIU© The Economist Intelligence Unit Limited 201612

Value-based healthcare: A global assessment
Findings and methodology

Domain 2:
Measuring outcomes andcosts

public payers. In the US, for example, a number
of applications and websites now allow patients
to compare costs for different treatments.
Governments are responding to demand as well.
In the UK, the NHS Choices website publishes
reviews and ratings on health and social care

Data and measurement—allowing for the ability

services.

to conduct cost-benefit analyses and to tap into

countries, less evidence emerges of attempts toadoption of VBHC. Disease registries are

increase pricing transparency and per-patient

important here too, since they constitute a criticalcost measurement. China and Colombia are thepart of the underlying infrastructure needed for

only developing countries currently collecting

the creation of patient outcomes data. But

patient treatment cost data in some areas. In

progress in this area remains mixed.

China, for example, while the government does

In the developed world, many countries havenot collect all patient treatment cost data andsystems in place that collect patient treatment

only public hospital costs can be collected, thecost data, at least in some areas (see Table 1).

National Health and Family Planning Commission

Australia and UAE are the only high-incomeof the People’s Republic of China will publish

countries not currently collecting these data,

data on annual total treatment costs in different

although Australia—which applies a rigorous cost-

regions and the average treatment cost among

benefit analysis to government-funded

individuals.8 Average hospitalisation cost data arepharmaceutical provision7—does have aalso available for 30 diseases in China. And innational policy or plan to collect patient

Colombia, high cost diseases (such as HIV andtreatment cost data that is not implemented yet.

cancer) have a dedicated unit—Cuenta de Alto

The impetus to collect data on treatment costs
is not just coming from policymakers. In mature

Costo—that tracks costs across providers andregions at the disease and patient level.9

economies, as citizens become healthOn the other hand, most countries in the study

consumers, many expect more transparency on

have at least some form of national disease

healthcare pricing, either because they have toregistries, with Brazil, South Africa and UAE the

pay out of pocket, or because they are

only countries lacking these. In fact, UAE is theconcerned about the financial sustainability of

only developed country in the study without one.

Table 1.

Score

Data collection on patient treatment costs (Indicator 2.4)

Countries

Data andmeasurement—
allowing for theability to conduct
cost-benefit
analyses and to
tap into patient
outcomes data—
are critical tosuccessful
adoption of VBHC.

However, when it comes to developing

patient outcomes data—are critical to successful

0: No broad policy oreffort to collect dataon patient treatment
costs*

1: Government and/or
major payer(s) has apolicy or plan tocollect patient
treatment cost data

2: Government and/or
major payer(s) are
actively collecting
patient treatment cost
data in some areas

3: Government and/or
major payer(s) are
actively collecting
comprehensive
patient treatment cost
data

Brazil, Egypt, India,
Mexico, Nigeria,
United Arab Emirates

Australia, Indonesia,
South Africa, Turkey

Canada, Chile, China,
Colombia, France,
Japan, Netherlands,
Poland, Russia, Spain,
UK, US

Germany, South
Korea, Sweden

Note: *For example, what the payer(s) pays to the provider
Source: EIU

7

The Australian Commission on Safety and Quality in Health Care,
http://www.safetyandquality.gov.au/© The Economist Intelligence Unit Limited 2016

8

“China Statistical Yearbook of Health and Family Planning”, The
National Health and Family Planning Commission of the People’s
Republic of China, Peking Union Medical College Press, 2013.

9

Cuenta de Alto Costo; https://cuentadealtocosto.org/site/index.
php/publicaciones

13

Value-based healthcare: A global assessment
Findings and methodology

Meanwhile, the pressure to developinteroperable electronic health records ismounting, with just five countries (Colombia,
Egypt, Indonesia, Nigeria, and Russia), in the
study without a stated effort to develop these.

Domain 3:
Integrated and patientfocused care

Electronic health records (EHRs) not only enable
healthcare to become more patient-focused,

While definitions of care co-ordination vary, there

but tracking outcomes and costs also allows

is a growing recognition among healthcare

countries to gain more comprehensive views ofproviders and policymakers that integrated

how their health systems are delivering value toapproaches to care—which move away from a

individual patients. The research found thatsiloed, fee-for-service based provision of carethough most countries have or are working onorganised around medical specialty to a focus

EHRs, they all must put significant effort into

on overall health outcomes—can generate

improving the quality of information,

efficiencies, reduce duplication, cut costs andstandardisation and linkage of data acrossprovide better care to patients.

information platforms in order to gain the ability

Yet, as this study shows, countries faceto track a patient’s progress over time.

tremendous systemic and cultural barriers toCollectively, these records can be a source ofintroducing this approach. First, care co-knowledge about patterns and trends that canordination relies heavily on electronic patient

inform healthcare decision-making.

records and interoperable IT systems, somethingthat many countries still lack. In the Netherlands,
for example, a national electronic health records
system was rejected by the Upper House of
Parliament in 2011 due to privacy concerns10 andis unlikely to be implemented in the near future.
Meanwhile, systems that have long paid foreach consultation and treatment need to beredesigned to create financial incentives forco-ordinated approaches—and putting a pricetag on overall health is harder than charging for
an individual intervention.
So it is no surprise to find that some countries inthe study (Indonesia, Nigeria, Russia and the US)
have no national co-ordinated care pathways in
any of the five therapy areas reviewed. This does
not mean that co-ordinated care pathways do
not exist in these countries at all. In the US, forexample, co-ordinated care pathways exist
within hospitals and provider groups even though

10 “International review: Secondary use of health and social caredata and applicable legislation”, Deloitte, 2016; https://www.sitra.
fi/julkaisut/Muut/International_review_secondary_use_health_data.pdf© The Economist Intelligence Unit Limited 201614

Value-based healthcare: A global assessment
Findings and methodology

they are not standardised nationally.11
Nevertheless, some countries are making
progress in this area. For example, even though its
health information technology system is lagging
behind, the UK is experimenting with innovative

Domain 4:
Outcome-based
payment approach

payment models, such as bundled payments
and team-based approaches.12

At the heart of the VBHC model are the payment
mechanisms that either encourage effective
treatments that deliver value or create
disincentives for those that are not cost effective
and do not deliver value. For example, bundled
payments cover end-to-end procedures, such as
one payment for all treatments that takes place
in a hip replacement, from consultations and theprocedure through to rehabilitation, as opposed

At the heart of the
VBHC model are
the payment
mechanisms thateither encourage
effective
treatments thatdeliver value orcreatedisincentives for
those that are notcost effective anddo not deliver
value.

to paying for each intervention. Countries alsoneed mechanisms for withdrawing resources fromtreatments, drugs or other interventions that are
not proving cost-effective.
In the study, countries that have high levels ofspending on healthcare also tend to have apresence of outcome-based payment
approaches. All countries in the study withhealthcare spending greater than 10% of GDP—
the US, Canada, France, Germany, Japan and
the Netherlands (see Table 2)—are planning (ifnot implementing) bundled payments.
Also, of the countries that spend more than
10% of GDP on healthcare, all but two—Japanand the US—have a mechanism for identifying
and disinvesting in services that are not costeffective.
Regional and economic differences emerge
in the study. Of the six countries that reporthaving a bundled payment system in place,those with such payments operational in several
areas include Chile, Turkey, the US, Sweden,
France and Germany. Four of the five countries
where a bundled payment option was not foundare in Africa or Asia (the fifth is Russia). However,Nigeria uses capitation in some areas and South
Africa is developing a national health insurance
policy based on capitation.

11 Dr Mark A Fendrick, University of Michigan, Interview, Mar 2nd
2016.
12 “The NHS payment system: evolving policy and emerging
evidence”, Nuffield Trust, Feb 2014; http://www.nuffieldtrust.org.
uk/sites/files/nuffield/publication/140220_nhs_payment_research_
report.pdf© The Economist Intelligence Unit Limited 201615

Value-based healthcare: A global assessment
Findings and methodology

Total health expenditure
as a percentage of GDP
and value-based
healthcare

Table 2.

Total health expenditure (THE) as apercent of Gross Domestic Product(GDP) (Background indicator)
THE as % of GDP

Country%< 5%Indonesia

3.1

United Arab Emirates

3.2

adopt VBHC components. In this respect, theNigeria

3.7

study reveals a divergence between countries

India

4.0

Egypt

5.1

China

5.6

Turkey5.6

Indonesia, Nigeria and UAE) have low alignment

Mexico6.2

with VBHC (see Table 2). Of the countries that

Russia6.5

Poland

6.7

Colombia

6.8

South Korea

7.2

Chile

7.7

South Africa

8.9

Spain

8.9

spending more than 10% of GDP on healthcare,

United Kingdom

9.1

Canada, Japan, the Netherlands, France,

Australia

9.4

Brazil9.7

Sweden

9.7

Japan

10.3

healthcare is high, there is a powerful incentive to

Canada10.9

find ways to cut costs by implementing VBHC.

Germany

11.3

France11.7

Netherlands

12.9

United States

17.1

Overall health expenditure emerges in the study
as a strong indicator of a country’s ability tothat are able to afford comprehensive
healthcare for their populations and those that…in countries
where spendingon healthcare ishigh, there is a
powerful incentive
to find ways to cut
costs byimplementing
VBHC.

5-10%

cannot.
In the study, all of the countries with total
health expenditures of less than 5% of GDP (India,

spend less than 5% of GDP on health, only India
has an established organisation to identify
health-related knowledge gaps. But with this low
spending on health, India also has very low
overall health insurance coverage for its
population.
By contrast, higher healthcare spending tends
to correlate with many of the elements needed
to support VBHC approaches. Of those countries

Germany and the US all are developing or using
interoperable electronic health records (though
full interoperability remains a goal). All thesecountries also have stakeholder support for VBHC.
Moreover, in countries where spending on> 10%

Source: World Health Organization, 2013

© The Economist Intelligence Unit Limited 201616

Value-based healthcare: A global assessment
Findings and methodology

Table 3.

Health spend per
head

Cost per outcome
point

Cost per outcome point (US$)
Health Outcomes
Index

Cost per outcome point1
and value-based
healthcare

Score

US$

US$

United States

85.50

9216.0107.8

payments that encourage interventions that are

Netherlands

90.30

6103.067.6

not effective. In short, high spending does not

Australia

94.10

6173.065.6

Canada91.60

5692.062.1

diet and exercise to lifestyle issues such as

Sweden92.50

5258.056.8

smoking and injury rates.

Germany

89.80

4964.055.3

France92.20

4959.0

53.8

Japan

98.40

4714.047.9

outcomes achieved per dollar spent) and yet not

United Kingdom

89.00

3679.041.3

all of its citizens have health insurance—roughly

Spain

93.80

2717.029.0South Korea

90.80

1834.020.2

United ArabEmirates

80.80

1394.017.3

South Africa

40.50

643.0

15.9

relatively low budgets. In the study, four countries

Russia

60.30

888.0

14.7

with a low cost per outcome point—China,

Brazil73.40

1049.0

14.3

Chile

87.00

1102.012.7

health insurance. And while having health

Poland

78.90

852.0

10.8

coverage does not necessarily equate toTurkey

76.40

665.0

8.7

Mexico

79.30

639.0

8.1

indication that a country is investing in the health

Colombia

80.40

521.0

6.5

of its citizens. Given these findings, the question

Nigeria

35.00

165.0

4.7

China

80.50

337.0

4.2

Egypt

65.50

161.0

2.5

Indonesia

66.80

106.0

1.6

India

55.00

62.0

1.1

While healthcare spending is a good indicator ofhealth outcomes, in many places around theworld, there is a gap between the amount ofCountry

money spent on healthcare and a country’s
overall health outcomes. Health spending itself
may be inefficient, with duplication of services ornecessarily equate to good health. Moreover,other factors influence a nation’s health, fromHigh spending also does not guarantee
universal healthcare. For example, the US has ahigh cost per outcome point (that is, patient

89% of its population is covered. In contrast, South
Korea has a moderate cost per outcome pointand has full health coverage for its citizens. Bothcountries have moderate alignment with VBHC.
It is also possible to deliver value to patients on

Colombia, Mexico and Turkey—have 90–100% of
their population covered by public or privatedelivering high-quality outcomes at low cost, orwithout asking the patient to pay for it, it is anfor some policymakers is, how are these countries
achieving this coverage, and are there lessons tobe learned by their peers about delivering value?

Source: EIU, “Health outcomes and cost: A 166-country
comparison”, 2014

1

“Health outcomes and cost: A 166-country comparison”,
Economist Intelligence Unit, 2014; http://stateofreform.com/
wp-content/uploads/2015/11/Healthcare-outcomes-index-2014.
pdf© The Economist Intelligence Unit Limited 201617

Value-based healthcare: A global assessment
Findings and methodology

Conclusion

As this study reveals, many countries are still in theand longitudinal data. Some developing

earliest stages of establishing the enabling

countries, meanwhile, are still struggling withenvironment for realigning care provision aroundbasic issues of coverage and access tovalue. In many cases, initiatives are being

healthcare.

implemented individually, and are rarely part of a

However, it is encouraging to see thatco-ordinated value-based healthcare strategy.

countries are starting to put in place some of the

However, while only a few countries are making

elements needed for the adoption of VBHC. As

significant moves towards aligning theirtechnology advances and new value-based

healthcare systems with the broad tenets ofapproaches take hold in wealthy economies,

VBHC, others are taking the first steps needed tothose countries that are still investing inreorganise their health systems around thedeveloping their health systems have an

patient, with a greater focus on delivering value.

opportunity—to “leapfrog” older systems andFor mature economies, there is the challenge

move directly to value-based-care, savingof shifting long-held cultural norms, changing

precious resources and delivering better long-payment systems to be tied to value, andterm care—resulting in improved outcomes forstandardising IT infrastructure for interoperable

their citizens.

© The Economist Intelligence Unit Limited 201618

Value-based healthcare: A global assessment
Findings and methodology

Appendix A:
Methodology, sources and detailed
indicator descriptions

Methodology

Constructing the matrix

The methodology of this study was created by

A. Scoring

the EIU research team in consultation with

Scores were assigned by the research managers

Medtronic and an international advisory panel ofand the EIU’s team of analysts according to ahealthcare experts. The EIU used a combination

specific set of research criteria and scoringof primary and secondary research as well as

guidelines. All qualitative indicators were scoredinternal healthcare industry expertise to

on an integer basis (0-2, 0-3, 0-4, and yes/no).

conceptualise the overall framework, indicator list
and research focus.
The EIU researched, assessed and scored

B. Normalisation of scores
Indicator scores were normalised to a 0-100 scalecountries across a set of 17 original qualitative

to make the indicators comparable across all

indicators that evaluate both the current

countries in the matrix and then aggregatedalignment of each country’s health system withacross domains to enable a comparison of

the components of value-based healthcare as

broader concepts across countries. Normalisation

well as the enabling environment for VBHC withinrebases the raw indicator data to a common unit

a given health system. The 17 indicators span four

so that it can be aggregated. The indicators

domains: (1) Enabling context, policy andhave been normalised on the basis of theinstitutions for value in healthcare; (2) Measuringfollowing:outcomes and costs; (3) Integrated and patient
focused-care; and (4) Outcome-based payment

x = (x - Min(x)) / (Max(x) - Min(x))

approach. These four domains aim to capture

Where Min(x) and Max(x) are, respectively, thethe main components of the VBHC model andlowest and highest values in the 25- country set

the level to which individual countries havefor any given indicator. The normalised value isadopted or aligned themselves with this model.

then transformed from a 0-1 value to a 0-100

The countries included in the Assessment ofscore to make it directly comparable with other

Healthcare Systems are:indicators. This in effect means that the country

Asia: Australia, China, India, Indonesia, Japan,

with the highest raw data value will score 100,South Korea
Europe: France, Germany, Netherlands, Poland,
Russia, Spain, Sweden, UK
Middle-east and North Africa: Egypt, Turkey,
United Arab Emirates
Sub-Saharan Africa: Nigeria, South Africa
Latin America: Brazil, Chile, Colombia, Mexico
North America: Canada, US© The Economist Intelligence Unit Limited 2016

while the lowest will score 0. High normalised
scores are indicative of the highest alignment
with the tenets of VBHC captured in this study.
The four domain composite scores are averaged
to yield an overall country score (ie “Overallalignment with value-based healthcare”).
Normalised scores are not published in thedata matrix, but score ranges are used to19Value-based healthcare: A global assessment
Findings and methodology

determine like-country groupings for analytic andl United Nations Human Development Index (4comparative purposes (see next section below).

clusters)l Average life expectancy, total population (2C. Clustering of countries

groups)In addition to making country-level comparisonsl Population (4 groups)

at the individual indicator level, the matrix clusters

l Total health expenditure (THE) as acountries based on their overall alignment withpercentage of GDP (3 groups)

VBHC as well as alignment with the four domains,l Cost per (health) outcome point (US$) (3which allows for broader comparisons amonggroups)countries.
In the matrix, countries were clusteredSources

together into four groups based on normalised

The EIU’s research team gathered information forscores, according to the process described

the VBHC study from the following sources:

above. Each of the four clusters (Low, moderate,l Interviews and/or questionnaires from healthhigh, or very high) group countries based on theand country experts

level of their alignment with VBHC, or withl Departments/Ministries of Healthindividual components of VBHC in the case ofl Health policy documents and guidelines

the four domains. See the table below for scorel Medical associations

ranges and country clusters.

l Medical journals

In addition to the study-based clusters,
countries were also grouped based on severall Research institution websitesl International Network of Agencies for Healthrelevant background indicators. These groups, orTechnology Assessment (INAHTA)“tags”, were based on pre-determined groupingsl UN Development Programme (UNDP)

of countries from the source organisations. Thesel The World Bank

additional tag groups (clusters) are:l World Health Organization (WHO)l World Bank income group (3 clusters)l Economist Intelligence Unitl Gross domestic product (2 clusters)

Country clustering criteria
Overall study

Domain 1

Domain 2

Domain 3

Domain 4

Score range

Alignment with
VBHC

Enabling
context, policy
and institutions
for value inhealthcare

Measuringoutcomes andcosts

Integrated andpatient-focusedcare

Outcomebased payment
approach

0-49.99

Low

Low

Low

Low

Low

50-74.99

Moderate

Moderate

Moderate

Moderate

Moderate75-89.99

High

High

High

High

High

90-100

Very HighVery HighVery HighVery HighVery High© The Economist Intelligence Unit Limited 201620

Value-based healthcare: A global assessment
Findings and methodology

Indicator framework

Value-based Healthcare: An Assessment of Healthcare Systems
DomainEnabling context, policy andinstitutions for value in healthcare

Measuring outcomes and costs

Integrated and patient-focusedcare

Outcome-based payment
approach#

Indicator name

1.1

Health coverage of the population

1.2

High-level policy or plan

1.3

Presence of enabling elements for value-based healthcare

1.4

Other stakeholder support

1.5

Health professional education and training in VBHC

1.6

Existence and independence of health technology
assessment (HTA) organisation(s)1.7

Evidence-based guidelines for healthcare

1.8

Support for addressing knowledge gaps

2.1

National disease registries

2.2

Patient outcomes data accessibility

2.3

Patient outcomes data standardisation

2.4

Data collection on patient treatment costs

2.5

Development of interoperable Electronic Health Records(EHRs)

3.1

National policy that supports organising health delivery into
integrated and/or patient-focused units

3.2

Care pathway focus

4.1

Major system payer(s) promotes bundled payments

4.2

Existence of mechanism(s) for identifying interventions forde-adoption (disinvestment)

Detailed indicator definitions

2 = 51–75% of the population is covered by public
or private health insurance;

Domain 1: Enabling context, policy andinstitutions for value in healthcare:

3 = 76–90% of the population is covered by publicThis domain, containing eight indicators, captures

4 = Universal health coverage (or 90–100% of thethe level of government and other health system

population is covered by public or private healthstakeholder commitment to value-based

insurance)

healthcare as well as the existence of the

Source: Economist Intelligence Unit

enabling institutions for the VBHC model.

Methodology: Desk research; primary interviews

1.1 Health coverage of the population (0-4)

1.2 High-level policy or plan (Y/N)

Scoring guidelines:

Scoring guidelines:

0 = Less than 25% (<25%) of the population isCountry scored a “Yes” if there is an explicit

covered by public or private health insurance;

strategy or plan either published or expressed by

1 = 25–50% of the population is covered by public

the government or health ministry to move awayor private health insurance;or private health insurance;© The Economist Intelligence Unit Limited 201621

Value-based healthcare: A global assessment
Findings and methodology

from a fee-for-service payment system towards a

1.5 Health professional education and training in

health system that is organised around thevalue-based healthcare (0-2)

patient. Plan can include fee for performance,

Scoring guidelines:

value-based payment schemes, and/or a focus

0 = No training in VBHC;

on outcomes-based care.

1 = Some/minimal training (less than 10 hours) in

Country scored a “No” if there is no explicit

VBHC;

strategy or plan.

2 = Substantial training in VBHC (such as a

Source: Economist Intelligence Unit

dedicated course of more than 10 hours on value

Methodology: Desk research; primary interviewsin health or similar)
Source: Economist Intelligence Unit

1.3 Presence of enabling elements for value-

Methodology: Desk research; primary interviews

based healthcare (0-3)
Scoring guidelines:

1.6 Existence and independence of health

0 = The government or major provider(s) has

technology assessment (HTA) organisation(s)implemented none of the VBHC elements below;(0-2)

1 = The government or major provider(s) has

Scoring guidelines:

implemented one of the VBHC elements below;

0 = No recognised HTA organisation(s);2 = The government or major provider(s) has

1 = HTA organisation(s) exist but without clear

implemented two of the VBHC elements below;

independence from providers;

3 = The government or major provider(s) has

2 = HTA organisation(s) exist with clear

implemented three of the VBHC elements below:

independence from providers(A) Outcomes-based care/patient-centred care;

Source: Economist Intelligence Unit

(B) Bundled/block payments; payment for

Methodology: Desk research; primary interviews

performance / linked to quality;(C) Quality standardisation

1.7 Evidence-based guidelines for healthcare

Source: Economist Intelligence Unit

(0-4)

Methodology: Desk research; primary interviews

Scoring guidelines:
0 = Country does not have an established

1.4 Other stakeholder supports (Y/N)

evidence-based guideline producing

Scoring guidelines:

organisation/is not a member of a regional orCountry scored a “Yes” if one or moreinternational guideline producing organisation;

stakeholders (for example physicians’

1 = Country is a member of or has established aassociations, other health professional

national guideline producing organisation or

associations or private insurers/payers) exhibit

participates in a regional or international

support for VBHC. “Support” includes signs ofguideline producing organisation;

endorsement of outcome-based, patient-

2 = Country has established an evidence-based

centred care, including bundled payments andguideline producing organisation, and guidelines

quality standardisation.

include general care of patients;

Country scored a “No” if other stakeholder

3 = Country has established an evidence-based

support does not exist.

guideline producing organisation, and guidelines

Source: Economist Intelligence Unit

contain a grading system that grades evidence;

Methodology: Desk research; primary interviews

4 = Country has established an evidence-based
guideline producing organisation, and guidelines
contain a grading system that grades evidence
and include a move towards outcomes-based
healthcare
Source: Economist Intelligence Unit
Methodology: Desk research; primary interviews© The Economist Intelligence Unit Limited 201622

Value-based healthcare: A global assessment
Findings and methodology

1.8 Support for addressing knowledge gaps (0-2)

2.3 Patient outcomes data standardisation (0-2)

Scoring guidelines:

Scoring guidelines:

0 = No health-related research funding

0 = No standardised disease registries exist;

organisation exists;

1 = Data in disease registries is standardised, but

1 = Dedicated health-related research funding

not linked;

organisation exists;

2 = Data in disease registries is standardised and

2 = Dedicated health-related research funding

linkedorganisation exists and has clear mandate to

Source: Economist Intelligence Unit

identify health-related knowledge gaps

Methodology: Desk research; primary interviews

Source: Economist Intelligence Unit
Methodology: Desk research; primary interviews

2.4 Data collection on patient treatment costs(0-3)
Scoring guidelines:

Domain 2—Measuring outcomes andcosts:

0 = No broad policy or effort to collect data on

This domain, containing five indicators, captures

pays to the provider;

the existence of the current IT and data

1 = Government and/or major payer(s) have ainfrastructure within a healthcare system as wellpolicy or plan to collect patient treatment cost

as forward-looking aspirations for data collection

data;that align with the components of value-based

2 = Government and/or major payer(s) arehealthcare delivery.

actively collecting patient treatment cost data inpatient treatment costs, ie what the payer(s)some areas;
2.1 National disease registries (0-4)

3 = Government and/or major payer(s) are

Scoring guidelines:

actively collecting comprehensive patient

0 = No national disease registry exists;

treatment cost data

1 = National disease registries exist;

Source: Economist Intelligence Unit

2 = Multiple diseases are covered in national

Methodology: Desk research; primary interviews

disease registries;
3 = Multiple diseases are covered and registry

2.5 Development of interoperable Electronic

data are regularly updated and accessible to

Health Records (EHRs) (Y/N)

healthcare stakeholders;

Scoring guidelines:

4 = A comprehensive system consolidates existing

Country scored a “Yes” if there is an effort on the

disease registries and data are regularly updated

part of the government and/or major healthand accessible to healthcare stakeholders

provider(s) to develop interoperable EHRs.

Source: Economist Intelligence Unit

Country scored a “No” if there is no stated or

Methodology: Desk research; primary interviews

apparent major effort.

2.2 Patient outcomes data accessibility (0-2)

Source: Economist Intelligence Unit
Methodology: Desk research; primary interviews

Scoring guidelines:
0 = No disease registries exist;
1 = Disease registries exist, but there is limitedaccessibility to outcomes data for research
purposes;
2 = Disease registries exist, and there is broad
accessibility to outcomes data for research
purposes
Source: Economist Intelligence Unit
Methodology: Desk research; primary interviews© The Economist Intelligence Unit Limited 201623

Value-based healthcare: A global assessment
Findings and methodology

Domain 3—Integrated and patientfocused care:

2 = National/regional initiative to developThis domain, containing two indicators, captures

3 = Bundled payment system implemented bynational efforts to co-ordinate and integrate care

one or more major payers

around the patient.

Source: Economist Intelligence Unit

bundled payment system;

Methodology: Desk research; primary interviews
3.1 National policy that supports organising
health delivery into integrated and/or patient-

4.2 Existence of mechanism(s) for identifying

focused units (Y/N)

interventions for de-adoption (disinvestment)

Scoring guidelines:(Y/N)

Country scored a “Yes” if there is a national policy

Scoring guidelines:

in place that supports organising health delivery

Country scored “Yes” if the government or major

into integrated and/or patient-focused units. This

provider(s)/payer(s) has a mechanism

also includes a national policy that encourages a(committee, agency) for identifying less effective

management system to follow a patient throughinterventions for de-adoption (disinvestment) inthe entire multi-step episode of care.

treatment plans.

Country scored a “No” if neither of these two

Country scored “No” if such a mechanism does

policies exist.

not exist

Source: Economist Intelligence Unit

Source: Economist Intelligence Unit

Methodology: Desk research; primary interviews

Methodology: Desk research; primary interviews

3.2 Care pathway focus (0-2)

Background indicators

Scoring guidelines:
0 = No established co-ordinated care services for

5.1 Nominal GDP (GDP level) (US$bn)

any of the below therapy areas;

Gross domestic product (GDP) at current market

1 = One to two (1–2) of the below therapy areas

prices in US$. Derived from GDP at current

have co-ordinated care services;market prices and period-average exchange

2 = Three or more (3+) of the below therapy areasrate.

have co-ordinated care services
Therapy areas: Mental health; Diabetes; HIV;
Maternal health; Elderly care
Source: Economist Intelligence Unit
Methodology: Desk research; primary interviews

Domain 4—Outcome-based payment
approach:This domain, containing two indicators, captures
the extent to which a health system is moving
away from fee-for-service to an outcome-based
payment approach.
4.1 Major system payer(s) promotes bundled
payments (0-3)
Scoring guidelines:
0 = No efforts towards bundled payments—thepayment system is mainly fee-for-service;

Source: Economist Intelligence Unit, 2014
5.2 GDP per capita (US$)
Nominal GDP divided by population.
Source: Economist Intelligence Unit, 2014
5.3 Personal disposable income (per head) (US$)
The amount of disposable income per person
available for spending and saving after income
taxes have been accounted for.
Source: Economist Intelligence Unit, 2014
5.4 Total health expenditure (THE) as percentage
of GDP (%)
Total health expenditure (both public andprivate) as percentage of GDP.
Source: World Health Organization, 2013

1 = Capitation system is used by one or more
major payers;© The Economist Intelligence Unit Limited 201624

Value-based healthcare: A global assessment
Findings and methodology

5.5 General government expenditure on health5.11 Hospital beds per 1,000

as a percentage of total expenditure on health

Number of hospital beds per 1,000 population.

(%)

Hospital beds include inpatient beds available in

Government expenditure on healthcare as apublic, private, general, and specialised hospitals

percentage of the total expenditure on

and rehabilitation centres. In most cases beds forhealthcare (both public and private).

both acute and chronic care are included.

Source: World Health Organization, 2013

Source: Economist Intelligence Unit, 2013

5.6 Out-of-pocket expenditure as a percentage

5.12 Cost of doctors visit (local currency unit)of total expenditure on health (%)

Cost of a routine check-up, in local currency

Out-of-pocket expenditure is any direct outlay byunits, at a family doctor in the country’s mosthouseholds to health practitioners and suppliers

populous city.

of pharmaceuticals, therapeutic appliances, andSource: EIU, Worldwide Cost of Living Survey, 2014

other goods and services whose primary intent is
to contribute to the restoration or enhancement

5.13 Health Outcomes Index (score)of the health status of individuals or population

A composite health outcome was generated

groups. It is a part of private health expenditure.

from all four indicators and standardised into an

Source: World Health Organization, 2013

outcomes index score, on a scale of 0 to 100(with higher scores indicating better outcomes).

5.7 UN Human Development Index (category)

Source: EIU, “Health outcomes and cost: A

The UN Human Development Index (HDI) is a

166-country comparison”, 2014

composite statistic of life expectancy, education,and income per capita indicators, which is used

5.14 Health spend per head (US$)

to rank countries into four tiers of human

The average amount spent on healthcare perdevelopment.

person.

Source: UNDP, 2014

Source: EIU, “Health outcomes and cost: A

5.8 Life expectancy, total (years)

166-country comparison”, 2014

The average period that a person may expect to5.15 Cost per outcome point (US$)

live based on the year of their birth, their current

The cost of each extra point on the Healthage and other demographic factors.

Outcomes Index.

Source: Economist Intelligence Unit, 2014

Source: EIU, “Health outcomes and cost: A

5.9 Population
Population of the country

166-country comparison”, 2014
Methodology: Health outcomes index score
divided by total health spending

Source: Economist Intelligence Unit, 20145.16 Health Outcomes: Tier
5.10 Doctors per 1,000

Health Outcomes Index scores were divided into

Number of physicians per 1,000 population.

five tiers: Top Tier; Tier Two; Tier Three; Tier Four;

Physicians include generalist and specialist

Bottom Tier

medical practitioners.

Source: EIU, “Health outcomes and cost: A

Source: Economist Intelligence Unit, 2013166-country comparison”, 2014

© The Economist Intelligence Unit Limited 201625

Value-based healthcare: A global assessment
Findings and methodology

Appendix B:
Glossary

Bundled payments: A single payment that covers

Evidence-based medicine: A type of medicine

services delivered by two or more providers

based on using the best evidence from scientificduring a single episode of care or over a specificand medical research to make decisions about

period of time.

the care of individual patients.

Capitation: A payment system based on

Fee-for-service: A method in which doctors andpayment per person, rather than payment perother healthcare providers are paid for eachservice provided. There are many variations onservice performed. Examples of services include

the range of services covered under capitatedtests and office visits (see also Pay-for volume).

arrangements.
Clinical practice guidelines: Statements that
include recommendations intended to optimise
patient care and that are informed by asystematic review of evidence and anassessment of the benefits and harms ofalternative care options.1

Health outcome: A measurable component
observed after an intervention has been applied.
Health technology assessment (HTA): The
systematic evaluation of the properties andeffects of a health technology, addressing thedirect and intended effects of this technology, as
well as its indirect and unintended

Electronic health record (EHR): An electronic

consequences, aimed mainly at informing

version of a patient’s medical history that isdecision making regarding health technologies.

maintained by the provider over time, and may
include all of the key administrative clinical data
relevant to that person’s care under a particularprovider, including demographics, progress notes,
problems, medications, vital signs, past medical
history, immunisations, laboratory data andradiology reports.
Evidence-based healthcare: The care andservices flowing from the application of theprinciples of evidence-based medicine to all
professions associated with healthcare, including
management and the purchase of goods andservices.

Interoperability: The extent to which systems anddevices can exchange data, and interpret thoseshared data. For two systems to be interoperable,
they must be able to exchange data andsubsequently present those data such that they
can be understood by a user.
Pay-for-performance: A healthcare payment
approach where a health insurer or other payer
compensates physicians according to an
evaluation of physician performance, typically as
a potential bonus on top of the physician’s
fee-for-service compensation.
Pay-for-volume: A method in which doctors andother healthcare providers are paid for each1

Development of Clinical Practice Guidelines, Infographic, Step 4,
Institute of Medicine of the National Academies, http://resources.
nationalacademies.org/widgets/systematic-review/infographic.
html.

© The Economist Intelligence Unit Limited 2016service performed. Examples of services include
tests and office visits (see also Fee-for-service).

26

Value-based healthcare: A global assessment
Findings and methodology

Pay-for-value: A reimbursement method thatencourages doctors and other health careproviders to deliver the best quality care at the

SourcesAmerican Medical Association

lowest cost.

Centers for Medicare & Medicaid Services

Total health expenditure: The sum of public andEconomist Intelligence Unit

private health expenditure. It covers the provisionof health services (preventive and curative),family planning activities, nutrition activities, andHealthcare Information and Management
Systems Society

emergency aid designated for health but does

Health Technology Assessment international

not include provision of water and sanitation.

(HTAi)

Universal healthcare: For a community or country

International Network of Agencies for Healthto achieve universal health coverage, several

Technology Assessment (INAHTA)

factors must be in place, including:World Health Organization

1. A strong, efficient, well-run health system thatmeets priority health needs through peoplecentred integrated care (including services forHIV, tuberculosis, malaria, non-communicablediseases, maternal and child health) by:a. informing and encouraging people tostay healthy and prevent illness;b. detecting health conditions early;
c. having the capacity to treat disease;andd. helping patients with rehabilitation.
2. Affordability—a system for financing healthservices so people do not suffer financial
hardship when using them. This can beachieved in a variety of ways.
3. Access to essential medicines andtechnologies to diagnose and treat medical
problems.
4. A sufficient capacity of well-trained, motivatedhealth workers to provide the services to meetpatients’ needs based on the best available
evidence.

Value-based healthcare: A health system thatprioritises patient-centred outcomes relative to
cost.

© The Economist Intelligence Unit Limited 201627

Value-based healthcare: A global assessment
Findings and methodology

Appendix C:
Unit

SourceAustralia

BrazilCanada

Chile

China

Colombia

Egypt

FranceGermany

India

Indonesia

Japan

MexicoTable of country scores

0-4

The Economist
Intelligence Unit

4

4

4

4

4

4

1

4

4

0

2

4

4

Y/N

The Economist
Intelligence Unit

N

N

N

N

N

Y

N

N

Y

N

N

Y

N

0-3

The Economist
Intelligence Unit

2

0

3

1

1

1

0

2

3

1

1

0

0

Y/N

The Economist
Intelligence Unit

Y

N

Y

N

N

N

N

Y

Y

N

N

Y

Y

1.5) Health professional education andtraining in VBHC

0-2

The Economist
Intelligence Unit

1

0

1

0

0

0

0

0

0

0

0

1

0

1.6) Existence and independence of
health technology assessment (HTA)
organisation(s)

0-2

2

1

2

0

2

2

0

2

2

1

1

0

1

1.7) Evidence-based guidelines forhealthcare

0-4

The Economist
Intelligence Unit

2

2

3

2

3

3

0

3

3

2

2

2

3

1.8) Support for addressing knowledge
gaps

0-2

The Economist
Intelligence Unit

1

2

2

1

1

2

0

2

2

2

1

1

2

0-4

The Economist
Intelligence Unit

2

0

3

3

2

2

2

2

2

2

1

3

2

0-2

The Economist
Intelligence Unit

1

0

1

1

1

1

1

1

1

1

1

1

1

2.3) Patient outcomes data
standardisation

0-2

The Economist
Intelligence Unit

1

0

0

0

0

1

0

1

1

0

0

1

0

2.4) Data collection on patient
treatment costs

0-3

The Economist
Intelligence Unit

1

0

2

2

2

2

0

2

3

0

1

2

0

2.5) Development of interoperable
Electronic Health Records (EHRs)

Y/N

The Economist
Intelligence Unit

Y

Y

Y

Y

Y

N

N

Y

Y

Y

N

Y

Y

N

N

N

N

N

Y

N

N

N

N

N

Y

N

(See appendix A for scoring guidelines)

1) Enabling context, policy andinstitutions for value in healthcare1.1) Health coverage of the population
1.2) High-level policy or plan
1.3) Presence of enabling elements forvalue-based healthcare
1.4) Other stakeholder support

The Economist
Intelligence Unit

2) Measuring outcomes and costs
2.1) National disease registries
2.2) Patient outcomes data accessibility3) Integrated and patient-focused care
3.1) National policy that supports
organising health delivery into
integrated and/or patient-focused units
3.2) Care pathway focus

Y/N

The Economist
Intelligence Unit

0-2

The Economist
Intelligence Unit

2

1

2

2

2

1

1

2

1

2

0

2

2

4.1) Major system payer(s) promotes
bundled payments

0-2

The Economist
Intelligence Unit

2

1

2

3

2

2

0

3

3

0

0

2

1

4.2) Existence of mechanism(s) for
identifying interventions for de-adoption(disinvestment)

Y/N

Y

N

Y

N

N

N

N

Y

Y

N

N

N

N

4) Outcomes-based payment approach

The Economist
Intelligence Unit

© The Economist Intelligence Unit Limited 201628

Value-based healthcare: A global assessment
Findings and methodology

Unit

SourceNetherlands

Nigeria

PolandRussiaSouth Africa

South Korea

Spain

SwedenTurkeyUnited ArabEmirates

United Kingdom

United States

Appendix C:

0-4

The Economist
Intelligence Unit

4

0

4

4

0

4

4

4

4

2

4

3

Y/N

The Economist
Intelligence Unit

N

N

N

N

N

Y

N

N

Y

Y

Y

N

0-3

The Economist
Intelligence Unit

3

0

2

1

0

2

1

3

3

2

3

3

Y/N

The Economist
Intelligence Unit

Y

N

Y

N

N

Y

N

Y

Y

N

Y

Y

1.5) Health professional education andtraining in VBHC

0-2

The Economist
Intelligence Unit

1

0

0

0

0

0

0

0

0

0

0

1

1.6) Existence and independence of
health technology assessment (HTA)
organisation(s)

0-2

2

0

2

0

0

1

2

2

1

1

2

0

1.7) Evidence-based guidelines forhealthcare

0-4

The Economist
Intelligence Unit

3

1

2

2

2

4

2

4

2

1

2

3

1.8) Support for addressing knowledge
gaps

0-2

The Economist
Intelligence Unit

2

1

1

1

2

2

1

2

1

1

2

2

0-4

The Economist
Intelligence Unit

3

1

2

2

0

4

2

4

1

0

3

3

0-2

The Economist
Intelligence Unit

2

1

1

1

0

2

1

2

1

0

1

2

2.3) Patient outcomes data
standardisation

0-2

The Economist
Intelligence Unit

1

0

1

1

0

2

1

2

0

0

2

1

2.4) Data collection on patient
treatment costs

0-3

The Economist
Intelligence Unit

2

0

2

2

1

3

2

3

1

0

2

2

2.5) Development of interoperable
Electronic Health Records (EHRs)

Y/N

The Economist
Intelligence Unit

Y

N

Y

N

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

N

N

N

N

Y

N

N

Y

Y

Table of country scores

1) Enabling context, policy andinstitutions for value in healthcare1.1) Health coverage of the population
1.2) High-level policy or plan
1.3) Presence of enabling elements forvalue-based healthcare
1.4) Other stakeholder support

The Economist
Intelligence Unit

2) Measuring outcomes and costs
2.1) National disease registries
2.2) Patient outcomes data accessibility3) Integrated and patient-focused care
3.1) National policy that supports
organising health delivery into
integrated and/or patient-focused units
3.2) Care pathway focus

Y/N

The Economist
Intelligence Unit

0-2

The Economist
Intelligence Unit

0

0

1

0

1

2

2

2

1

1

2

0

4.1) Major system payer(s) promotes
bundled payments

0-2

The Economist
Intelligence Unit

2

1

2

0

0

2

1

3

3

2

2

3

4.2) Existence of mechanism(s) for
identifying interventions for de-adoption(disinvestment)

Y/N

Y

N

Y

N

N

N

N

Y

N

N

Y

N

4) Outcomes-based payment approach

The Economist
Intelligence Unit

© The Economist Intelligence Unit Limited 201629

Value-based healthcare: A global assessment
Findings and methodology

Whilst every effort has been taken to verify theaccuracy of this information, neither The Economist
Intelligence Unit Ltd. nor the sponsor of this report can
accept any responsibility or liability for reliance byany person on this report or any of the information,
opinions or conclusions set out in the report.

Image: Getty Images/iStockphoto© The Economist Intelligence Unit Limited 201630

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