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Abstract

This paper aims to conduct a systematic literature review (SLR) on value-based health care (VBHC) in Brazil, providing an overview of the state-of-the-art practice of an emerging and strategic topic for the country’s health system. The SLR involved analyzing academic literature (AL) and gray literature (GL) in separate and parallel analyses to answer seven research questions. The results show that Brazil’s VBHC theme has evolved from a theoretical and practical perspective in recent years. However, the topic still needs more consensus, which makes it difficult to share best practices or compare health organizations. The practical initiatives on the subject are punctual and partial and show, in most cases, an attempt to measure results and care costs with an emphasis on economic aspects. The findings also showed the challenges for the Brazilian health system in modifying its structure to correct the flaws that prevent the delivery of value-based health care. This study makes three central contributions to the literature: (i) it shows the scenario of VBHC initiatives in Brazil; (ii) validates the use of GL in SLR for the health area, and (iii) links the state of the art and practice, bringing academia closer to health institutions with theoretical, practical, and managerial implications for VBHC initiatives in the country. This paper presents the current status of the VBHC reality in the country and the challenges to be faced so that the Brazilian health system can seek the required transformation and anticipate its future needs.

Plain language summary

Understanding value-based healthcare in Brazil: Progress and challenges

This study explores the concept of Value-Based Healthcare (VBHC) in Brazil. VBHC focuses on improving patient health outcomes relative to the costs of healthcare services. Although Brazil has adopted a universal public health system since 1988, it faces unique challenges, such as underfunding in public healthcare and a need for better resource management in the private sector. This research provides an overview of the current state of VBHC in Brazil, analyzing academic and non-academic sources to gain a comprehensive understanding. The findings highlight that while there have been significant discussions and some practical initiatives around VBHC, there is still a lack of consensus on measuring results and effectively implementing the concept. One innovative aspect of this study includes “gray literature,” which consists of non-peer-reviewed materials like reports, theses, and government documents, offering practical insights often missing from academic studies. Key challenges identified include the need for more standardized protocols, better use of healthcare resources, and the integration of new payment models that reward quality over quantity. Additionally, the study emphasizes the importance of continuous education and engagement of all stakeholders, including healthcare professionals and patients, to successfully implement VBHC. By addressing these issues, Brazil can improve its healthcare system’s efficiency and effectiveness, ultimately leading to better health outcomes for its population. This study is critical in understanding how VBHC can be adapted and scaled in Brazil, providing valuable insights for policymakers, healthcare providers, and researchers.

Keywords

value-based healthcare VBHC Brazil structure of the health system business models grand challenges barriers

Introduction

In recent decades, global health systems have been forced to correct flaws and imperfections of a structurally inefficient system. In this challenging scenario, Porter and Teisberg (2006) presented a strategy to modify the structure of the health system as a potential solution to correct its failures by delivering value-based health care (VBHC). Value measurement occurs in terms of the value equation, which is the health outcomes achieved per unit of cost spent across the care delivery chain for a patient with a specific medical condition (Porter & Teisberg, 2006). However, more than a decade after seminal work on the topic, the global literature reveals a conceptual diffusion, interpretive variability, and a need for an integrative strategy among the few academic works that have evaluated the implementation of the value agenda (van Staalduinen et al., 2022). Historically, the practical implementation of the VBHC theme also has been a challenge in Brazil (Pronk & Kortstee, 2019).

Brazil is the largest country in Latin America and the only capitalist country in the region that has implemented a universal public health model since 1988 (Giovanella et al., 2018). The Brazilian health system has three distinct and interconnected subsectors, including a public and two private parts (Paim et al., 2011). The system is complex and fragmented, characterized by the public subsector’s underfunding and, in the private subsector, a need for standardized protocols and efficient resource use (Pereira da Veiga et al., 2019). Although the VBHC theme has the potential to bring promising results for the Brazilian health subsystem, the evolution of the theme has been limited in the country, both from a practical perspective (The Economist, 2016) and from a theoretical perspective (van Staalduinen et al., 2022).

Whether in Brazil or globally, for topics like VBHC that present analysis complexity, low levels of consensus on how the results are measured, and a low volume and quality of evidence (van Staalduinen et al., 2022), it is highly desirable to carry out a systematic literature review (SLR) incorporating both academic literature (AL) and gray literature (GL) (Benzies et al., 2006; Higgins et al., 2022; Moher et al., 2009; Zhang et al., 2021). GL is a library and information science document category encompassing electronic and print materials not governed by commercial publishing (Adams et al., 2016; Mahood et al., 2014; Rothstein & Hopewell, 2009). This includes a wide range of non-peer-reviewed materials such as newsletters, reports, theses, government documents, fact sheets, conference proceedings, and other publications that are freely distributed and not typically found in academic journals (Mahood et al., 2014; Rothstein & Hopewell, 2009). Although GL presents limitations (Cook et al., 2001; Schöpfel & Prost, 2021), it offers a perspective on the practical experience of the topic and can support the development of a comprehensive content synthesis (Rothstein & Hopewell, 2009).

RQ1. How is VBHC defined and conceptualized within the Brazilian context?

RQ2. What are the most commonly studied VBHC components in Brazil?

RQ3. What step(s) of implementation are VBHC initiatives in Brazil at?

RQ4. What are the challenges for implementing and scalability of VBHC initiatives in the country?

RQ5. What are the main stakeholders and institutions involved with the dissemination of theoretical concepts and the practical implementation of VBHC in the country?

RQ6. How has the VBHC theme evolved over time in Brazil?

RQ7. To what extent does GL contribute to synthesizing content in the SLR on VBHC?

This study advances the existing body of literature through three pivotal contributions. As far as is known, it is the first study to conduct an SLR on VBHC within the Brazilian context. The significance of this research is underscored by its potential implications for Brazil’s socio-economic landscape, especially considering that Brazil allocates a comparatively lower proportion of its public budget to healthcare (10.5%) than the average expenditure observed in countries within the Organization for Economic Cooperation and Development (OECD) (15.3%) (OECD, 2021). Moreover, there is an impending necessity for the government to strategize for anticipated increases in healthcare spending and to proactively address the long-term care demands of an aging demographic (OECD, 2021).

Secondly, this investigation affirms the relevance of incorporating GL in healthcare SLRs, elucidating the challenges and advantages of engaging non-conventional research sources. This validation marks a significant step toward broadening the methodological frameworks within health research. Lastly, this research bridges the theoretical and practical realms, facilitating a closer synergy between the academic community and healthcare institutions. It delineates the theoretical, practical, social, and managerial ramifications of VBHC initiatives, enriching the discourse and understanding of VBHC’s role and impact in the Brazilian healthcare system.

Materials and Methods

Study Design

To provide the state of the art and practice of VBHC in Brazil, the SLR covered the selection of works from AL and GL that involved the theme in the context of the Brazilian health system. The topic is strategic for Brazil, and its recent maturation in the academic environment and discussions at professional meetings justifies the need for a review that summarizes the main findings and shows the direction of future research. This SLR applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA-P guidelines (Shamseer et al., 2015) (See Supplemental Material, S1), and its scope was registered in the Open Science Framework (OSF). The methodology involved a hybrid approach, combining a structured review with a bibliometric review, both manifestations of what can be called a domain-based review (Paul et al., 2021) and which address RQs. The structured review produced a synthesis of the content for each research question. At the same time, the bibliometric study carried out exclusively in AL brought the evolution of the development of the theme over time, its trend, and other descriptive information. A bibliographic coupling analysis was also produced to enrich the SLR, supported by Vosviewer and Voyant Tools software.

Search Strategy

To fulfill the primary aim and address the seven RQs, this review selected AL from prominent databases such as Scopus, Web of Science, Science Direct, PubMed, and Lilacs. This strategy ensured a thorough coverage of the scientific literature (Chadegani et al., 2013; Chersan et al., 2020). Given the discovery of a limited corpus of studies on VBHC in Brazil across multiple databases, this work chose to continue without temporal delimitation. The variability in terminology necessitated search term variations, especially given the absence of a standardized Medical Subject Heading (MeSH) for VBHC in PubMed. The search methodology utilized two sets of keywords: one set comprising variations of “value-based healthcare” and another involving variations of “Brazil.” These terms were searched in Portuguese, English, and Spanish, with words within each set linked by the Boolean operator “OR” and between sets by “AND” to refine and focus the search parameters.

The selection of GL involved applying the same search strategy used for AL on the website of the four leading hospitals in Brazil according to The World’s Best Hospitals of Newsweek 2022 (Cooper, 2022), namely, (i) Hospital Israelita Albert Einstein, (ii) Hospital Sírio Libanês, (iii) Hospital Moinhos de Vento, and (iv) Hospital Alemão Oswaldo Cruz. The websites of companies that work exclusively with the VBHC theme and that were mentioned in the AL were also consulted, such as Academia VBHC (Makdisse et al., 2018, 2020), Instituto Brasileiro de Valor em Saúde (IBRAVS) (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022), and 2iM (C. Abicalaffe et al., 2022). Table 1 presents the details of the search strategy carried out on December 14, 2022. It is recommended that SLRs involving AL and GL be conducted in parallel yet separately, especially in contexts related to healthcare delivery. Previous research indicates that discrepancies between results obtained from AL and GL can affect the development of a comprehensive content synthesis (Rothstein & Hopewell, 2009). In some instances, GL’s contribution to the methodological process might be deemed insignificant (Cook et al., 2001; Schöpfel & Prost, 2021).

Table 1.

Search Criteria Used for the Systematic Review – Strings.

Database	Search strategy	Results (n)
Scopus	TITLE-ABS-KEY((“Value-based healthcare” OR “Value based healthcare” OR “value-based health care” OR “value based health care” OR “value based care” OR “vbhc” OR “valor na saúde” OR “valor em saúde” OR “saúde baseada em valor” OR “valor no sistema de saúde” OR “medição de valor”) AND (“Brazil” OR “Brazilian” OR “Brasileiro” OR “Brasileira”))	44
Lilacs	(“Value-based healthcare” OR “Value based healthcare” OR “value-based health care” OR “value based health care” OR “value based care” OR “vbhc” OR “valor na saúde” OR “valor em saúde” OR “saúde baseada em valor” OR “valor no sistema de saúde” OR “medição de valor”) AND (“Brazil” OR “Brazilian” OR “Brasileiro” OR “Brasileira”) AND (db:(“LILACS”))	35
Science Direct	(“Value-based healthcare” OR “Value based healthcare” OR “value-based health care” OR “value based health care” OR “value based care” OR “vbhc” OR “valor na saúde” OR “valor em saúde” OR “saúde baseada em valor” OR “valor no sistema de saúde” OR “medição de valor”) AND (“Brazil” OR “Brazilian” OR “Brasileiro” OR “Brasileira”)	50
Web of Science	TS=(“Value-based healthcare” OR “Value based healthcare” OR “value-based health care” OR “value based health care” OR “value based care” OR “vbhc” OR “valor na saúde” OR “valor em saúde” OR “saúde baseada em valor” OR “valor no sistema de saúde” OR “medição de valor”) AND (“Brazil” OR “Brazilian” OR “Brasileiro” OR “Brasileira”)	44
Pubmed	((“Value-based healthcare” OR “Value based healthcare” OR “value-based health care” OR “value based health care” OR “value based care” OR “vbhc” OR “valor na saúde” OR “valor em saúde” OR “saúde baseada em valor” OR “valor no sistema de saúde” OR “medição de valor”)[Title/Abstract] AND (“Brazil” OR “Brazilian” OR “Brasileiro” OR “Brasileira”)[Title/Abstract])	41

Eligibility of Studies

After selecting AL and GL, inclusion criteria were applied to define the documents composing the final textual corpus. The main eligibility criterion involved the direct correlation between the two groups of keywords used in the search strategy; that is, the papers included needed to discuss, empirically or not, elements of the VBHC framework in Brazil. Articles on VBHC-related concepts that served the search strategy were also included, which involved references to payment models or broader conceptualizations, such as variation in population health outcomes. Complete articles or articles from congresses in Portuguese, English, or Spanish were included for AL, while GL covered non-conventional publications available on previously selected websites.

As the GL is more diversified and less controlled than the AL, applying the eligibility criteria is particularly time-consuming and challenging, given the need to read the entire document (Adams et al., 2016; Benzies et al., 2006). Due to this peculiar characteristic of GL, works were excluded that presented (i) content marketing, (ii) promotion of services offered by the institution, (iii) presentation of the work team and event participation, (iv) podcasts, books, video cases, and interviews, (v) pages that were only partially available during the analysis period, discussed the application of VBHC concepts in countries other than Brazil, or reviewed works already captured by AL.

Selection of Studies

All works captured in AL and GL were exported to a Microsoft Excel spreadsheet. Subsequently, all duplicate works were removed. Eligibility screening was performed by reading all papers independently by two reviewers who discussed disagreements in the selected documents. When necessary, a third reviewer was invited to participate in the process.

Data Extraction and Synthesis

Three reviewers performed data extraction and evaluation. The following extraction fields were used to organize and summarize the results of the AL studies: author, year, journal, research classification according to genre (empirical/non-empirical) and regarding the methodological approach (quantitative, qualitative, or mixed), stakeholders and health institutions involved, VBHC conceptualization, VBHC components present in the research, VBHC implementation stage in empirical works and, finally, strategic challenges for the implementation and scalability of VBHC initiatives.

The evaluation of the VBHC components present in the research was based on the seminal work of Porter and Teisberg (2006). In this perspective, these authors shed light by presenting the operationalization of the value agenda in six interdependent and adaptable components to the structure of health organizations involving (i) coordination of health care in Integrated Practice Units, (ii) measurement of outcomes and costs for each patient; (iii) changing the payment model so that they are grouped by cycles of care; (iv) integration of health care delivery taking place in separate facilities; (vi) expansion of value-based health care services; (vi) development of a capable information technology platform.

The classification according to the stage of implementation of VBHC in the empirical works was based on the five steps of sequential transformation necessary to achieve value-based care (E. Teisberg et al., 2020; E. O. Teisberg & Wallace, 2009), which are: (a) identification of a segment of patients who share a consistent set of needs; (b) developing solutions to improve health outcomes; (c) integration of dedicated teams to facilitate the coordination of care and to drive continuous improvements in care and efficiency; (d) measurement of health outcomes and service delivery costs for each patient; (e) expanding partnerships to reach more patients. Additionally, this paper considered the engagement and awareness of all stakeholders as a previous step for the necessary transformations to take place in the health system.

The strategic challenges for implementing and scalability VBHC initiatives were classified into four types based on a content convergence matrix: (i) processes, (ii) technological and economic challenges, (iii) human resources challenges, and (iv) regulatory challenges. The data extracted from AL works were used to respond to RQs 1 to 7 (RQ1–RQ7). The following fields of extraction were used to organize and summarize the results of the GL works: author, year, institution, research classification, and, when applicable, the objective of the VBHC initiative according to components described in the seminal work of Porter and Teisberg (2006). Data extracted from GL’s works were used to respond to RQ7. Figure 1 illustrates the research methodology adopted in the work. The search protocol can be consulted in the Supplemental Material S2 and S3: Operationalization of data extraction fields.

Figure 1.

Research methodology of the systematic literature review.

Results

The search in the AL databases yielded 214 articles. After eliminating duplicates and excluding a study not conducted in Brazil, we proceeded with 26 articles. Additionally, we included five articles cited in GL (C. Abicalaffe et al., 2016; Hirt et al., 2022; Makdisse et al., 2018; Makdisse & van Eenennaam, 2021; Mutlaq, 2019) that met the AL inclusion criteria but were published in journals not indexed in the evaluated databases. The AL comprised 31 articles, 7 from conferences, and 24 complete works published in scientific journals. Among the works published in conferences, it is essential to highlight that 71% of them were presented at the conference of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) (Bernz et al., 2022a, 2022b; Gargano et al., 2022; Makdisse et al., 2019; Vaz et al., 2020). On the other hand, this research showed a greater dispersion of results for works published in scientific journals, with a prevalence of works from the Brazilian Journal of Health Economics (28%) (C. Abicalaffe et al., 2022; C. L. Abicalaffe & Schafer, 2022; Ballalai et al., 2019; Follador, 2022; Pinto, 2020) written in the Portuguese language.

Empirical works predominated in AL (69%), applying different research methodologies. Qualitative works represented the minority and involved content analysis using secondary databases (P. Ramos et al., 2021) or in-depth interviews (Ballalai et al., 2019; Gilardino et al., 2018; Pinto, 2020). Quantitative studies used a prospective (Etges et al., 2022a) or secondary (Bernz et al., 2022a; Cohen et al., 2021; Etges et al., 2021a, 2021b; Follador, 2022; Mutlaq, 2019; Negrini et al., 2021) database, while mixed studies used a combination of methods involving surveys of physicians (Makdisse et al., 2018; Makdisse et al., 2019), medical students (Hirt et al., 2022), managers (Bernz et al., 2022a, 2022b; Makdisse, Ramos et al., 2022; L. Ramos et al., 2022), or patients (Etges et al., 2022b; Gargano et al., 2022) along with secondary database analysis. Nine AL papers were non-empirical, covering VBHC-related thematic reviews (Schreider et al., 2019; Uzuelli et al., 2019) and expert points of view (C. Abicalaffe et al., 2022; C. L. Abicalaffe & Schafer, 2022; Follador, 2022; Magalhães, 2021; Makdisse et al., 2020; Makdisse & van Eenennaam, 2021; Mutlaq, 2021).

The GL search returned 129 web pages, 65% belonging to Academia VBHC and 2iM. After applying the eligibility criteria, GL followed up with 14 web pages covering practical information about VBHC initiatives in Brazil (2iM Inteligência Médica, 2022a, 2022b, 2022c, 2022d; Almeida, 2022; Gonçalves, 2018; Hospital Alemão Oswaldo Cruz, 2022; IBRAVS, 2021; Magalhães, 2021) and some expert opinion articles (C. Abicalaffe, 2022; Gray, 2022; Makdisse, Magalhães, & Diegoli, 2022; Mutlaq, 2021). As demonstrated in the AL, the VBHC theme has aroused greater interest only in recent years in Brazil, so 64% of the works captured in the GL were published in 2022. The flowchart of the results of the search strategy and selection of the works is found in Figure 2. The remainder of this section will present the results to answer the seven RQs.

Figure 2.

Flowchart of the results obtained by applying the search strategy – based on the PRISMA protocol.

RQ1. How is VBHC Defined and Conceptualized Within the Brazilian Context?

VBHC was defined in 12 AL papers, the majority (Etges et al., 2022c; Gilardino et al., 2018; Makdisse et al., 2018; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022; P. Ramos et al., 2021) following the concept derived from the seminal work of Porter and Teisberg (2006) or the work of Porter (C. Abicalaffe et al., 2022; Etges et al., 2022a; Makdisse et al., 2019; Negrini et al., 2021; Porter, 2010). As demonstrated in a previous global literature review (van Staalduinen et al., 2022), the definition of VBHC in Brazil presents high interpretive variability. It may be limited to the concept of the value equation in some works (Etges et al., 2022a, 2022c; Makdisse et al., 2018, 2019; Makdisse & Ramos, 2018; Negrini et al., 2021; P. Ramos et al., 2021) or just a few components of the comprehensive framework presented by C. Abicalaffe et al. (2022), Follador (2022), Gilardino et al. (2018), Makdisse and Ramos (2018), Makdisse, Ramos et al. (2022), and Porter and Teisberg (2006). This finding suggests that there is a relative awareness of VBHC in Brazil. Still, there needs to be a greater understanding of its core concepts (Makdisse, Ramos et al., 2022) and measuring health value, especially considering the particularities of Brazilian reality (C. Abicalaffe et al., 2022).

Surveys that assessed the awareness of physicians (Makdisse et al., 2019; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022) and medical students (Hirt et al., 2022) about the concepts of VBHC showed a need for more knowledge (Hirt et al., 2022; Makdisse et al., 2019) and a certain lack of interest (Hirt et al., 2022; Makdisse et al., 2019) in the subject. Additionally, using fewer specific terms and the high level of conceptual variation for VBHC (Makdisse, Magalhães, & Diegoli, 2022; Makdisse, Ramos et al., 2022; Negrini et al., 2021) can make the concept less tangible and at risk of being reduced to a management “fad.” Such research (Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022) confronts previous literature (Fredriksson et al., 2015) that suggests a dilution rather than diffusion of the original concepts of VBHC published more than 10 years ago.

Despite the conceptual dilution detected in Latin America (Makdisse, Magalhães, & Diegoli, 2022; Makdisse, Ramos et al., 2022), investment in education or self-education (Hirt et al., 2022), the implementation of a value management office (Makdisse & Ramos, 2018), the involvement of physicians in decision-making on VBHC initiatives in some hospitals (Makdisse & Ramos, 2018), as well as the expansion of discussion forums promoted in Brazil (C. L. Abicalaffe & Schafer, 2022; Makdisse & Ramos, 2018) show signs of a potential and discrete conceptual diffusion. Although there is greater awareness of VBHC in Brazil, many health professionals attribute the increased discussions to pressure from payers for cost-restricting measures (Ballalai et al., 2019; Bernz et al., 2022a; Etges et al., 2021a, 2021b; Makdisse et al., 2019; Makdisse & Ramos, 2018; Pinto, 2020; P. Ramos et al., 2021) rather than as a solution to achieve better health outcomes.

RQ2. What Are the Most Commonly Studied VBHC Components in Brazil?

The predominant VBHC component in AL was measuring the results and costs of each patient (44%) (C. Abicalaffe et al., 2022; Cohen et al., 2021; Etges et al., 2021a, 2022a, 2022b; Follador, 2022; Gargano et al., 2022; Hirt et al., 2022; Makdisse & van Eenennaam, 2021; Negrini et al., 2021; Pinto, 2020; P. Ramos et al., 2021; Schreider et al., 2019). Most of these works used the theoretical framework of the activity-based costing method driven by time (Time-Driven Activity-Based Costing, TDABC) to perform micro-costing through bottom-up evaluations (Ballalai et al., 2019; Etges et al., 2021a, 2021b, 2022a, 2022b, 2022c; Gargano et al., 2022; Negrini et al., 2021; P. Ramos et al., 2021), which is supported by previous literature that considers TDABC as the best costing method to be applied in health systems (Keel et al., 2017). On the other hand, value measurement is much more complex. It may require a multicriteria decision analysis, allowing a systematic, explicit, and weighted consideration of multiple factors influencing decision-making (C. Abicalaffe et al., 2022).

It is also important to mention that ten works from AL addressed more than one component of VBHC in the publication (Gilardino et al., 2018; Hirt et al., 2022; Magalhães, 2021; Makdisse et al., 2018; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022; Mutlaq, 2019; Negrini et al., 2021; P. Ramos et al., 2021). Half of them present an empirical evaluation of the subject (Hirt et al., 2022; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022; Negrini et al., 2021; P. Ramos et al., 2021). On the other hand, as in different countries, VBHC has been applied within a select group of strategies to the detriment of the entire framework (P. Ramos et al., 2021). While the need for regional adaptation of VBHC and its piecemeal implementation according to feasibility and urgency is understandable, the organizational effort will be considered an example of VBHC only if some key components of the value equation are present (P. Ramos et al., 2021). This represents a challenge for VBHC in Brazil, given that some stakeholders need to be aware of the value equation concept or associate it with purely economic aspects (Makdisse & Ramos, 2018; P. Ramos et al., 2021).

RQ3. What Step(s) of Implementation Are VBHC Initiatives in Brazil at?

To assess how VBHC is understood, adapted, and applied, the 22 empirical works of AL were classified according to the stage of implementation of VBHC initiatives according to the framework of E. O. Teisberg and Wallace (2009). Most of these works are at the stage of measuring health outcomes and costs (Ballalai et al., 2019; Bernz et al., 2022a; Cohen et al., 2021; Etges et al., 2021a, 2022a, 2022b; Gargano et al., 2022; Hirt et al., 2022; Mutlaq, 2019; Negrini et al., 2021; Pinto, 2020; P. Ramos et al., 2021; Schreider et al., 2019), although it is impossible to assume that the previous and fundamental steps have been fulfilled. In a few works (Etges et al., 2022b; Negrini et al., 2021; P. Ramos et al., 2021; Schreider et al., 2019), it is possible to infer the maturity of VBHC initiatives with details of the implementation of the process and search for the expansion of partnerships to reach more patients and overcome the challenges encountered.

Other works show the early stages of VBHC initiatives, demonstrating the need for engagement and greater knowledge of the subject by different stakeholders (Bernz et al., 2022a, 2022b; Hirt et al., 2022; Makdisse et al., 2019; Makdisse & Ramos, 2018) or a natural integration of healthcare cycles (Makdisse, Ramos et al., 2022) before moving forward with the projects. It is also important to mention that some work has designed solutions to improve health outcomes involving establishing risk-sharing agreements (Pinto, 2020) and using real-world evidence (Ballalai et al., 2019) in decision-making. These proposed solutions meet the restriction of high health costs but do not represent a resolutive proposition centered on the needs of patients.

RQ4 What Are the Challenges for Implementing and Scalability of VBHC Initiatives in the Country?

All AL works, whether empirical or non-empirical, were evaluated regarding the challenges faced in Brazil for the implementation or scalability of VBHC initiatives. The challenges were classified into four different perspectives, as detailed below.

Challenges From a Procedural Perspective

Challenges from a procedural perspective were identified in 29 works and involved evaluating initiatives, coordinating health care, and making necessary procedural adjustments for continuous strategic alignment. With the diffusion of VBHC concepts over time, the development of evaluation processes has become a critical component for the transition of the theme from a theoretical field to the implementation of the value agenda in health institutions. In this sense, the challenges of the evaluation processes are in developing key performance indicators (Gilardino et al., 2018; Mutlaq, 2019), mainly those centered on the patient (Bernz et al., 2022a; Cohen et al., 2021; Etges et al., 2021b, 2022b, 2022c; Gargano et al., 2022; Hirt et al., 2022; Makdisse et al., 2018; Negrini et al., 2021; Schreider et al., 2019). The works also consider the importance of the origin of the data used in the evaluation process (C. Abicalaffe et al., 2022; Ballalai et al., 2019; Etges et al., 2022c; Makdisse et al., 2018; Pinto, 2020), its applicability to the Brazilian reality (C. Abicalaffe et al., 2022), and the wide dissemination of the results found (C. L. Abicalaffe & Schafer, 2022; Follador, 2022; Makdisse et al., 2019; Makdisse & Ramos, 2018; Pinto, 2020) so that the processes are transparent and accepted (Follador, 2022; P. Ramos et al., 2021).

In addition to developing patient-centered metrics, the seminal literature by Porter and Teisberg (2006) demonstrates that VBHC initiatives must consider the entire journey of value healthcare. In this sense, the care coordination process is a fundamental premise for delivering health value to society (Uzuelli et al., 2019). Given the highly fragmented health system in Brazil (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Follador, 2022; Makdisse, Ramos et al., 2022; P. Ramos et al., 2021), as well as operational decentralization and the autonomy of the professionals involved (Mutlaq, 2021; P. Ramos et al., 2021), there is a challenge in the country to monitor patients and their outcomes during the entire cycle of care in different health providers (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Gilardino et al., 2018; P. Ramos et al., 2021). The literature proves that the development of protocols (Gilardino et al., 2018), the strategic alignment between stakeholders (Makdisse et al., 2018; Mutlaq, 2021), and the formation of care networks (Negrini et al., 2021; Uzuelli et al., 2019) facilitate the coordination of health care (Etges et al., 2021a, 2022c), making the system more efficient and viable (Ballalai et al., 2019; A. P. B. D. S. Etges et al., 2021a, 2022c). It is also important to mention the importance of creating a value management office (Makdisse et al., 2018; Makdisse, Ramos et al., 2022) to coordinate the implementation processes of VBHC initiatives in some health institutions in Brazil.

Finally, it is essential to emphasize the revolutionary process through which global health systems have been submitted in the last decade, with the introduction of new technologies (Ballalai et al., 2019; Makdisse & van Eenennaam, 2021) and the considerable need for change in current processes and business models. In addition to the intrinsic complexity of the environment itself, “VBHC adoption acts on the context, and the context reacts to it, in a set of non-linear adaptive feedback loops that may, and in most cases will, generate unpredictable outcomes beyond the health system boundaries with effects on society more broadly” (P. Ramos et al., 2021, p.2). In this sense, the implementation and scalability of VBHC initiatives depend on a continuous adjustment process (Etges et al., 2022b; Negrini et al., 2021; P. Ramos et al., 2021; Schreider et al., 2019) so that there is an adaptation to the current context since VBHC is not “one size fits all” and requires tailored processes for different conditions and realities (Etges et al., 2022a; Makdisse et al., 2018; P. Ramos et al., 2021).

Even in healthcare institutions where part of the VBHC framework has begun to emerge, tension with the underlying business models is expected, mainly due to the prevalence of the fee-for-service (FFS) payment model (Etges et al., 2022c; Follador, 2022; Makdisse, Ramos et al., 2022; P. Ramos et al., 2021). Academic works show that this payment model is counterproductive as it generates waste and does not reward organizational efforts to improve the quality of care (P. Ramos et al., 2021; Uzuelli et al., 2019). Such works also show that the greater the fragmentation of care, the greater the unnecessary use of resources and the worse the quality and results of care, contributing to increased health costs (Etges et al., 2022a; Makdisse, Ramos et al., 2022).

On the other hand, in bundled payment models in which a single payment is made for the entire episode of care, the revenue is distributed among the providers involved in providing health services, and the efficiency of the process can be significantly increased (Miller, 2009). Although there are pay-per-package initiatives in Brazil (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022), more than this model may be needed to provide VBHC initiatives. The implementation and scalability challenges of pay-per-package models involve the incorporation of preventive or health promotion strategies (P. Ramos et al., 2021), the use of outcomes of interest to the patient in the final product to be delivered (Follador, 2022), as well as linking pay to performance based on clinical outcome metrics (Makdisse, Ramos et al., 2022).

As the implementation of VBHC initiatives is influenced by contextual factors at the system and organizational levels (P. Ramos et al., 2021), the processes of adjustment and redesign of workflows taking advantage of the learning curve of organizations (Etges et al., 2022b; Schreider et al., 2019), the review of protocols (Negrini et al., 2021), the continuous and active strategic alignment (Etges et al., 2021a, 2021b) of multiple stakeholders and the selection of the appropriate patient that is associated with a higher value delivery (Cohen et al., 2021) represent fundamental elements for the success of the project.

Conversely, it is essential to remember the growing power imbalance in the Brazilian health system since those who usually define “the rules of the game” are the payers. Negotiations occur within an environment of information asymmetry and are carried out based on financial performance indicators. In this sense, there is great concern in the AL that the constant adjustments and adaptations of VBHC initiatives contribute to the lack of understanding of the subject or limit its scope to a mere cost-reduction process (Follador, 2022; Pinto, 2020).

Challenges From a Human Resources Perspective

Twenty papers identified challenges from a human resources perspective. These involved the need to engage different stakeholders, support from an influential stakeholder, and training/education of people responsible for leading or executing VBHC initiatives. The most complex and vital stakeholder for the implementation of VBHC initiatives in Brazil is the doctor, which is understandable given the autonomy of action and the complexity of managing this health professional (Makdisse, Ramos et al., 2022; Mutlaq, 2021; P. Ramos et al., 2021).

Academic works show that VBHC initiatives depend on the engagement, satisfaction, and integration of qualified and experienced medical teams (Follador, 2022; Hirt et al., 2022; Makdisse et al., 2019; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022; Negrini et al., 2021; Pinto, 2020) to develop collaborative effort (Makdisse et al., 2018) and systemic thinking (Makdisse & van Eenennaam, 2021) to mitigate the inappropriate use of health resources (Negrini et al., 2021) and to effectively establish a new payment model (Negrini et al., 2021). Patients (Follador, 2022), healthcare service flows (Bernz et al., 2022b; Follador, 2022; P. Ramos et al., 2021), the pharmaceutical industry (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Ballalai et al., 2019; Follador, 2022), payers (Follador, 2022; P. Ramos et al., 2021), and other stakeholders (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Pinto, 2020) should also be part of engagement efforts to follow the transformation desired by VBHC initiatives. A rupture in the negotiation processes is necessary, involving a change of paradigm and culture in the current business model (Ballalai et al., 2019; Bernz et al., 2022b; Follador, 2022; P. Ramos et al., 2021).

In addition to engaging and changing the mindset of the multiple players involved, the endorsement of an influential stakeholder (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Bernz et al., 2022b; Mutlaq, 2021; Pinto, 2020) and the presence of a third party (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; P. Ramos et al., 2021) to avoid conflicts of interest can also assist in the successful implementation of VBHC initiatives. Additionally, every human resource that deals directly with the transformational process of VBHC needs to acquire the ability to deal with a set of data for decision-making adapted to different care models (C. Abicalaffe et al., 2022; Ballalai et al., 2019; Etges et al., 2022b; Gilardino et al., 2018; Hirt et al., 2022; Makdisse et al., 2018; Makdisse, Ramos et al., 2022). Therefore, changes are necessary for the pedagogical higher education of clinical practice, avoiding the focal specialization of health professionals (Cohen et al., 2021; Uzuelli et al., 2019) and including VBHC themes in the curriculum of health professional entry programs in the country (Hirt et al., 2022).

Challenges From a Technological and Economic Perspective

Challenges from a technological and economic perspective were identified in 23 works and involved the operationalization of the information system and the necessary investments to implement a technological platform (Ballalai et al., 2019; Bernz et al., 2022b; Cohen et al., 2021; Etges et al., 2021b, 2022a, 2022b, 2022c; Gargano et al., 2022; Hirt et al., 2022; Makdisse, Ramos et al., 2022; Mutlaq, 2021; Negrini et al., 2021; Uzuelli et al., 2019). After identifying the specific medical condition under analysis and defining the set of key performance indicators, it is necessary to have periodic access to the data that will generate the desired metrics at each stage of the care cycle, the comorbidities, and the clinical and financial results (C. Abicalaffe et al., 2022; Etges et al., 2021a, 2022a, 2022b, 2022c; Makdisse et al., 2018, 2019; Makdisse & Ramos, 2018; Negrini et al., 2021; Pinto, 2020; P. Ramos et al., 2021).

Given the fragmentation of the health system in Brazil (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; P. Ramos et al., 2021), one of the main demands for the implementation of VBHC initiatives is the development of an efficient information system (C. Abicalaffe et al., 2022; Ballalai et al., 2019; Bernz et al., 2022b; Cohen et al., 2021; Etges et al., 2021a, 2022a, 2022b, 2022c; Gargano et al., 2022; Hirt et al., 2022; Makdisse et al., 2018; Negrini et al., 2021; Uzuelli et al., 2019) and its integration between the clinical and financial areas (Cohen et al., 2021; Makdisse et al., 2018), ensuring intra and interoperability (Gilardino et al., 2018) with longitudinal and real-time measurements (Pinto, 2020). In addition to the lack of data systematization, a cultural change is also required since there is a fear of sharing data in Brazil due to possible judgments of the published clinical results (Follador, 2022). The use of a business intelligence system (Makdisse, Ramos et al., 2022) and the development of a single database of health records with full sharing among health professionals (Uzuelli et al., 2019) represent good practices identified in AL.

Challenges From the Regulatory Perspective

Challenges from the regulatory perspective were identified in 10 studies (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Ballalai et al., 2019; Bernz et al., 2022a, 2022b; Etges et al., 2022b; Gilardino et al., 2018; Makdisse, Magalhães, & Diegoli, 2022; Makdisse, Ramos et al., 2022; Pinto, 2020; P. Ramos et al., 2021; Uzuelli et al., 2019). The health system in Brazil is highly regulated, and AL studies show that government agencies (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Bernz et al., 2022a, 2022b) can play a leading role in the transformation process required by VBHC initiatives (Uzuelli et al., 2019). These initiatives involve, but are not limited to, the creation of an environment of trust and accountability (Gilardino et al., 2018), the development of public-private partnerships to meet access challenges in Brazil (Etges et al., 2022b), the promotion of a new payment model that is not counterproductive as the FFS (P. Ramos et al., 2021), the approval of a legal basis that allows the establishment of risk-sharing agreements between stakeholders (Pinto, 2020), and, finally, the reduction of information asymmetry so that decision-making of patients is well-informed (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022).

RQ5 What Are the Main Stakeholders and Institutions Involved With the Dissemination of Theoretical Concepts and the Practical Implementation of VBHC in the Country?

The base of the Brazilian health system in the last 30 years was built under a hierarchical structure with the hospital as the center (Uzuelli et al., 2019). Over time, the hospital-centric rationale has diminished its role to gradually and discreetly give space to horizontal relationships that enable a systemic and networked view strengthened by primary health care and the collective health strategy (P. Ramos et al., 2021), especially in the public health system (Uzuelli et al., 2019). Given the need for a more efficient and sustainable healthcare model, the dissemination of VBHC concepts has taken place among multiple stakeholders that are part of the Brazilian health system involving hospitals (Cohen et al., 2021; Etges et al., 2022a, 2022b, 2022c; Makdisse et al., 2018; Makdisse, Magalhães, & Diegoli, 2022; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022; P. Ramos et al., 2021; Schreider et al., 2019, 2019), other health service providers (Ballalai et al., 2019; Etges et al., 2021b; Makdisse, Ramos et al., 2022; Makdisse & van Eenennaam, 2021), public (Etges et al., 2022a, 2022b, 2022c; Hirt et al., 2022; Uzuelli et al., 2019) and private payers (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Bernz et al., 2022a, 2022b; Pinto, 2020), technical experts (C. Abicalaffe et al., 2022; Follador, 2022; Gilardino et al., 2018; Hirt et al., 2022; Makdisse et al., 2018, 2019) and patients (Etges et al., 2022b; Gargano et al., 2022; Schreider et al., 2019). On the other hand, AL corroborates previous studies on the fact that VBHC can be interpreted differently among different stakeholders and is highly dependent on local needs (van Staalduinen et al., 2022).

AL works also demonstrate that VBHC concepts can be discussed in a generalized way in health systems (C. Abicalaffe et al., 2022; Ballalai et al., 2019; Bernz et al., 2022a; Hirt et al., 2022; Makdisse et al., 2018; Makdisse & Ramos, 2018; Makdisse, Ramos et al., 2022; Pinto, 2020; P. Ramos et al., 2021), but are useful and applicable in specific clinical conditions such as cardiovascular problems (Etges et al., 2021b, 2022a, 2022b, 2022c), depression (Hirt et al., 2022), bone problems (Ballalai et al., 2019), obesity (Negrini et al., 2021), chronic kidney disease (Gilardino et al., 2018; Schreider et al., 2019), infectious diseases (Etges et al., 2021a), rare diseases (Gargano et al., 2022), as well as in specific procedures such as evaluation of telemedicine (Etges et al., 2022b), different therapeutic regimens (Ballalai et al., 2019), obstetrics (Cohen et al., 2021) and outpatient endoscopy (Makdisse et al., 2019). Some works compare the results of VBHC initiatives in Brazil with Sweden (P. Ramos et al., 2021), with the United States (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022), and also with Latin America (Makdisse, Ramos et al., 2022). Each nation presents particular challenges for VBHC, but the experiences of pioneering organizations can serve as a reference for institutions in other regions that are starting similar ventures (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Makdisse, Ramos et al., 2022).

Finally, some private institutions were cited in the empirical applications of VBHC, such as Hospital Israelita Albert Einstein (Hirt et al., 2022; Makdisse et al., 2019; Makdisse & Ramos, 2018; P. Ramos et al., 2021), Hospital Alemão Oswaldo Cruz (Negrini et al., 2021), and Hospital Moinhos de Vento (Mutlaq, 2021). The AL also mentions incentive projects for VBHC initiatives promoted by the National Supplementary Health Agency (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Bernz et al., 2022a, 2022b; P. Ramos et al., 2021), the National Association of Private Hospitals (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022), the National Network of Rare Diseases (Gargano et al., 2022), and the Brazilian Stroke Network (Etges et al., 2022a).

RQ6. How Has the VBHC Theme Evolved Over Time in Brazil?

VBHC initiatives have advanced significantly in the private sector (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; P. Ramos et al., 2021). Although some works consider Brazil to be in its “infancy” in implementing VBHC projects (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022), the number of publications almost tripled between 2016 and 2019 (eight works) and 2020 to 2022 (23 works); that is, 76% of the works were published from 2020 onward.

Additionally, while 50% of the works published between 2016 and 2019 were empirical, 78% of the publications from the 2020 to 2022 period migrated from the theoretical field or suggestions for specialists to evaluate the theme practically. Most of the publications captured by AL occurred in 2022 (13 papers), and the objective of the empirical papers reinforces the emerging movement around the establishment of performance indicators by measuring the results and costs of each patient (Ballalai et al., 2019; Bernz et al., 2022a; Etges et al., 2022a, 2022b; Gargano et al., 2022; Makdisse et al., 2019; Schreider et al., 2019), with a predominance of the TDABC costing methodology (Ballalai et al., 2019; Etges et al., 2022a, 2022b, 2022c; Gargano et al., 2022; Makdisse et al., 2019; Schreider et al., 2019). All RQ6 information is available in Supplemental Material S2.

The analysis of coupling in AL carried out with the help of Vosviewer and Voyant Tools software demonstrates the formation of three thematic areas, corroborating the other research findings. Figure 3A shows that the three scientific domains of AL involve care results in the assessment of VBHC (Cohen et al., 2021; Gilardino et al., 2018; Hirt et al., 2022; Makdisse et al., 2019; Makdisse & Ramos, 2018), the development of new remuneration models (Ballalai et al., 2019; Bernz et al., 2022a, 2022b; Makdisse et al., 2018; Makdisse, Ramos et al., 2022; Pinto, 2020; P. Ramos et al., 2021), and practical applications of VBHC (C. Abicalaffe & Schafer, 2020; C. L. Abicalaffe & Schafer, 2022; Etges et al., 2022a; Gargano et al., 2022; Hirt et al., 2022; Makdisse et al., 2019; Negrini et al., 2021). Each theme’s principal authors and works are detailed in Figure 3B. More information is needed on the clinical performance of health institutions in Brazil. These institutions often select service providers based on indicators that have little direct relationship with health or on opinions and external appearances (Follador, 2022). While the recent advances are undeniably significant, more is needed to bring about the VBHC theme and the structural transformation required in the Brazilian health system. Active and continuous involvement of multiple stakeholders is needed to sustain positive feedback loops, allowing VBHC to adapt, scale up, and spread in the transformation context (P. Ramos et al., 2021).

Figure 3.

(a and b): Result of the AL’s bibliographic coupling.

RQ7. To What Extent Does GL Contribute to Synthesizing Content in the SLR on VBHC?

This paper corroborates previous literature by questioning the methodological rigor and quality of the content captured by GL. Only 14 web pages met this research’s eligibility criteria, demonstrating that Brazilian institutions often use their websites for self-promotion and for implementing content marketing strategies and tactics (Terho et al., 2022). The search strategy applied to GL yielded findings illustrating various activities associated with implementing VBHC initiatives in Brazil. These activities include:

Notably, the establishment of value management offices at key institutions such as Hospital Mãe de Deus (Almeida, 2022) and within the National Union of Self-Management Institutions in Health (UNIDAS) (2iM Inteligência Médica, 2022c) has been instrumental in driving VBHC initiatives.

Creating performance metrics for clinical staff at Hospital Marcelino Champagnat (2iM Inteligência Médica, 2022a) and across nine private hospitals (2iM Inteligência Médica, 2019).

The transition to a new remuneration model at Hospital Alemão Oswaldo Cruz (Gonçalves, 2018).

The development of integrated lines of care at various institutions, including the Caixa de Assistência dos Servidores do Estado de Mato Grosso do Sul (Cassems) (2iM Inteligência Médica, 2022d), the AMO network specializing in oncology and hematology services (2iM Inteligência Médica, 2022b Hospital Alemão Oswaldo Cruz (Hospital Alemão Oswaldo Cruz, 2022), and initiatives recognized by IBRAVS (IBRAVS, 2021) and the VBHC Prize 2021 (Magalhães, 2021).

These VBHC initiatives, particularly those focused on developing an integrated line of care, have successfully engaged multiple stakeholders (2iM Inteligência Médica, 2022b, 2022d; Hospital Alemão Oswaldo Cruz, 2022). However, the lack of published results from these initiatives, potentially due to the novelty of the partnerships, most of which were established from 2021 onward, underscores the need for continued observation and documentation of these initiatives’ outcomes and impacts.

GL also involved expert opinion articles on the causes of unwarranted variation in health outcomes (Gray, 2022), decision-making based on stewardship concepts and their impact on the value equation (Makdisse, Magalhães, & Diegoli, 2022), and a call for healthcare reform. The remuneration model seeks a logic based on value (C. Abicalaffe, 2022) and includes the personal experience of a hospital manager who is working on the first steps to implement the VBHC model in a health institution (Mutlaq, 2021).

Despite the limitations of using the GL, the information captured by this source would not be known if the SLR were limited to academic works. Given the low volume of academic evidence and the importance of the practical perspective in implementing VBHC initiatives in Brazil, the contextual information obtained through GL is potentially relevant for synthesizing the theme’s progress in the country’s health institutions and developing an agenda for future research.

Results and Discussion

This study conducted an SLR on VBHC in Brazil, aiming to offer a contemporary overview and insights into an emerging and strategic topic within the Brazilian health system. Over a decade since the seminal work’s publication, this SLR addressed seven research questions (RQs), revealing the nuanced reality of VBHC in the country. Similar to trends observed in other countries (van Staalduinen et al., 2022), the findings from RQ1 highlight a need for more theoretical and practical consensus on VBHC in Brazil, which makes it difficult to share best practices or compare health organizations. Echoing the metaphor of the blind men and the elephant (Daigneault, 2013), stakeholders and health institutions often interpret VBHC initiatives through the lens of their specific, limited experiences. This is further complicated by each entity’s unique organizational structure and varying needs, which may align with different aspects of the VBHC framework.

A comprehensive evaluation of VBHC conducted in 2016 (The Economist, 2016) revealed that prominent health organizations in Latin America were initiating a shift toward alternative payment models alongside the assessment of outcomes and cost management. This study’s findings underscore that the impetus for the escalated discourse on VBHC within Brazil has persisted unchanged since that time, focusing on identical elements of VBHC with a pronounced emphasis on its economic dimensions (E. Teisberg et al., 2020).

Teisberg and Wallace (2009) have observed, “Although few dispute that the goal of health care is health, reformers rarely focus on health outcomes, on the improvements in health resulting from care. Instead, the discussion emphasizes cost, cost-shifting, and access.” This challenge, anticipated from both practical and managerial perspectives, reflects the ongoing pressure to curtail healthcare costs, a phenomenon observed in Brazil (OECD, 2021) and globally (Sonymol & Shankar, 2022).

The findings related to RQ2 illustrate that efforts to reduce healthcare costs by employing VBHC components simultaneously underscore a prevalent misunderstanding. While VBHC initiatives are designed to enhance system efficiency and prioritize health resources that deliver greater value from the patient’s perspective, they do not inherently assure a cost reduction (Follador, 2022). It is imperative to recognize that any endeavor to reduce costs, if disassociated from quality, fundamentally undermines the VBHC concept, where the essence of value is intrinsically linked to the outcomes of care provided.

Despite the constrained conceptual and practical breadth of VBHC in Brazil, a phased approach to transforming organizational structures and implementing VBHC components is advisable. Initially, this might be limited to aspects deemed most feasible or pressing (Miller, 2009). Nonetheless, the pressing demand for tangible outcomes from VBHC interventions underscores the imperative to expedite structural reforms from both practical and managerial standpoints.

While this study evidences the widespread diffusion of the VBHC concept in recent years, practical implementations have yet to advance at a comparable pace. Research Question 3 (RQ3) findings reveal that VBHC initiatives tend to be punctual and partial, predominantly characterized by efforts to measure outcomes and care costs across various clinical conditions. As stated by an expert, the current challenge is in “how to do it” because the stakeholders of the Brazilian health system are already aware of the need for change, and many practical methodologies are already available to achieve this goal (C. Abicalaffe, 2022).

To expedite the necessary transformation from both practical and managerial perspectives, managers must understand the essential data required and the mechanisms for accessing it. The availability and reliability of data are critical for enabling the indicators that underpin a VBHC initiative. On the other hand, investment in data analysis projects requires resources that most health institutions do not have (Mutlaq, 2021). Accordingly, establishing partnerships, fostering educational initiatives, and facilitating the exchange of best practices among international and national health institutions emerge as potentially effective strategies, albeit with limitations, to implement solutions at a reduced cost.

As demonstrated in the responses to RQ4 and RQ5, VBHC initiatives face many challenges in becoming a reality in the Brazilian health system. The theme’s evolution over time (response to RQ6) demonstrated that the recent advances in VBHC in Brazil are critical but insufficient for the structural transformation required in the Brazilian health system. The challenges in the procedural, human, technological/economic, and regulatory perspectives are intrinsically related to the need for cultural change and the access and use of information.

In this sense, it is crucial to understand the role of the various stakeholders, regardless of whether or not they occupy a managerial position in the health institution. Incorporating the VBHC concept into the education and training of all professionals, both directly and indirectly involved with the health system, is imperative to foster a paradigm shift in mindset. VBHC initiatives necessitate a commitment from all stakeholders—be they prescribers, users, or demanders within the health system—to the judicious management of limited health resources.

The achievement of the benefits promised by the VBHC is anchored in the sharing of a goal that brings together the conflicting interests and divergent actions of the many parties involved. Changing regulations, investing in data analysis technology, and improving processes, although important tactics, cannot generate the required transformation in the Brazilian health system. Only committed people can do it and sustain this change.

Lastly, the findings from RQ7 underscore that GL plays a modest yet pivotal role in informing SLRs. Contrary to what happens in other countries, there is no pressure on health professionals working in universities and tertiary hospitals in Brazil to publish their work in scientific journals (Xiang et al., 2022). Additionally, the lack of structure and incentives for academic publications (Menezes Filho, 2023) and the limited scope of the Portuguese language can mean that many potential VBHC initiatives developed by Brazilian institutions need to be globally known, reinforcing the importance of incorporating the GL in the SLR (Pereira da Veiga et al., 2023).

The adoption of VBHC initiatives from the GL perspective shows corporate investments for the first steps in developing integrated care lines, creating the value management office, and developing performance metrics for the clinical staff of health institutions. The practical examples GL captured, and expert opinion exposure show the professional adoption and emergence of a conceptual foundation for VBHC. This version succinctly emphasizes the recommendation to include GL in SLR, especially those relevant to Brazilian contexts.

This study has some limitations related to the data source and eligibility criteria that must be considered when interpreting the research findings. The search strategy was limited to works from five databases and seven websites. Therefore, relevant research may be published in other AL and GL sources not considered in the analysis.

Likewise, although the authors have endeavored to include as many keywords as possible in the search strategy, not all articles related to the topic could have been retrieved. In addition, the search in the data sources took place until 2022, and the results showed a significant tendency toward an increase in the number of works that met the eligibility criteria. Therefore, future SLR studies contemplating AL and GL must confirm this research’s findings and obtain new contributions that drive the advancement of the theme.

Conclusion

The Brazilian health system faces significant challenges that can be addressed by solutions proposed by VBHC initiatives, which are adaptable to the different business models that coexist in the country. Although more is needed, the theme has evolved in Brazil from a theoretical and practical perspective, with the pressure for cost reduction as its primary motivation. This work used AL and GL to show the current status of the VBHC reality in the country and the challenges to be faced so that the Brazilian health system seeks the required transformation and adequately anticipates its future needs. This SLR was not intended to exhaust such a complex topic but to highlight issues Brazil must discuss as a potential solution to meet its sustainable development objectives.

Supplemental Material

sj-docx-1-sgo-10.1177_21582440241298770 – Supplemental material for Challenges and Prospects ofValue-Based Healthcare in Brazil

Supplemental material, sj-docx-1-sgo-10.1177_21582440241298770 for Challenges and Prospects ofValue-Based Healthcare in Brazil by Cassia Rita Pereira da Veiga, Yasmin Yohana Saliba, Luciana Faluba Damázio, César Luiz Lacerda Abicalaffe, Fabio Rocha, Thales Stevan Guedes Furquim and Claudimar Pereira da Veiga in SAGE Open

Supplemental Material

sj-docx-2-sgo-10.1177_21582440241298770 – Supplemental material for Challenges and Prospects ofValue-Based Healthcare in Brazil

Supplemental material, sj-docx-2-sgo-10.1177_21582440241298770 for Challenges and Prospects ofValue-Based Healthcare in Brazil by Cassia Rita Pereira da Veiga, Yasmin Yohana Saliba, Luciana Faluba Damázio, César Luiz Lacerda Abicalaffe, Fabio Rocha, Thales Stevan Guedes Furquim and Claudimar Pereira da Veiga in SAGE Open

Supplemental Material

sj-docx-3-sgo-10.1177_21582440241298770 – Supplemental material for Challenges and Prospects ofValue-Based Healthcare in Brazil

Supplemental material, sj-docx-3-sgo-10.1177_21582440241298770 for Challenges and Prospects ofValue-Based Healthcare in Brazil by Cassia Rita Pereira da Veiga, Yasmin Yohana Saliba, Luciana Faluba Damázio, César Luiz Lacerda Abicalaffe, Fabio Rocha, Thales Stevan Guedes Furquim and Claudimar Pereira da Veiga in SAGE Open

Footnotes

Acknowledgements

he authors wish to express their gratitude the Editor and Anonymous Reviewers for their constructive input and insightful feedback.

Authors’ Contributions

C.R.P.d.V., Y.Y.S., L.F.D., C.L.L.A., F.R., T.S.G.F, and C.P.d.V. conceived the work, reviewed the literature, drafted and edited the manuscript. All authors approved the manuscript for submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author, Claudimar Pereira da Veiga, thanks the National Council for Scientific and Technological Development—CNPq, Brazil (Grants number: 312023/2022-7) for its financial support of this work.

Ethics Approval and Consent to Participate

Not applied.

Consent for Publication

Not applicable.

ORCID iDs

Thales Stevan Guedes Furquim

Claudimar Pereira da Veiga

Availability of Data and Material

The relevant data and material are available in the article. Other support data may be requested from the corresponding author.

Supplemental Material

Supplemental material for this article is available online.

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