Operationalising value-based payment: a decision-support framework for health system reform

Health systems worldwide face mounting pressure to deliver better outcomes with constrained resources. Improving productivity therefore depends not only on operational efficiency but also on payment approaches that align incentives with value. Value-Based Payment (VBP) models seek to reward quality and efficiency rather than service volume, yet their design and sequencing remain complex, particularly in publicly oriented health systems where sustainability and equity are core objectives.

To develop and validate a decision-support framework that assists policymakers and managers in designing and implementing VBP models to improve system productivity and sustainability.

A two-stage conceptual study was conducted. First, a scoping review of 14 conceptual articles (2015-2025) was undertaken following the Arksey and O'Malley framework and reported in accordance with PRISMA-ScR guidelines. Second, a targeted expert survey (n = 10; response rate = 21.7%) validated and refined the framework's structure. Experts from multiple countries assessed the relevance, coherence, and completeness of framework domains using structured quantitative and qualitative feedback.

The validated framework comprises six iterative phases: (1) Stakeholder Insight and Context Analysis, (2) Problem Definition and Value Proposition, (3) Strategic Co-Design, (4) Operational Design, (5) Pilot Assessment, and (6) Full-Scale Deployment. These stages are supported by cross-cutting components linking value definition, incentive alignment, and organisational readiness. Expert consensus was strongest for early analytical phases and leadership-related capabilities (median confidence >80%), indicating strong conceptual alignment and practical applicability across contexts.

The framework offers a structured roadmap for designing VBP reforms that enhance productivity and financial sustainability without compromising care quality or equity. It supports policymakers in sequencing reforms, aligning incentives, and ensuring readiness for value-based transformation, directly contributing to policy debates on improving health system productivity.