Table 2 Categories of values and how they are used
What are they? | Values identified | How do they work | ||
|---|---|---|---|---|
Goals | • Goal of health systems: the achievement of the best health for all according to their needs • Goals are classified as core values and intermediate values • Core values are equity, quality, solidarity and universality • Intermediate values are necessary factors to achieve final goals | Equity - Accessibility - Affordability - Afro-descendant equity - Availability - Cultural appropriateness - Fairness - Gender equity - Indigeneity - Protection of vulnerable population - Social justice Solidarity - Deservedness - Redistribution | Quality - Acceptability - Comprehensiveness - Continuity - Cultural appropriateness - Inclusiveness - Integrality - Reasonableness - Safety - Sufficiency - Timely access - User satisfaction Universality - Acceptability - Accessibility - Affordability - Availability - Equality - Free access - Gradualty - Progressiveness - Suitability - Utilisation | • Core values are guiding principles of health systems Each country in Latin America has prioritised some values to guide their health systems over others [19, 20]; for Costa Rica, they were equity, solidarity and universality; for Mexico, citizenship, fairness and solidarity; for Brazil, equity, participation and universality; for Chile, equity, participation and solidarity; for Colombia, solidarity and universality [21,22,23,24,25] • Intermediate values can be used like midway ends or like means to achieve core values For example, when talking about equity, we consider vertical and horizontal equity as well as accessibility, cultural appropriateness, fairness and gender equity. All these intermediate values not only serve to accomplish one of the core values, but they could also have intricate interrelationships to both help achieve more than one of the core values and to strengthen other intermediate values |
Technical values | Principles that are incorporated into the instruments and strategies adopted by policy-makers to ensure that health-system goals are achieved rationally and informed by scientific evidence as well as the economic and social context | Efficiency related - Cost benefit - Cost effectiveness - Cost efficiency - Effectiveness - Efficacy - Efficiency - Financial protection - Sustainability | Rationale related - Austerity - Evidence based - Feasibility - Planning - Prioritisation - Professional autonomy - Rationality - Rationing | • Technical values are related to the instruments to achieve goals Used as strategies to ensure that the health system is able to deliver the best healthcare for all efficiently and sustainably “The NHS [Cuba] is currently immersed in a thorough analysis of all health care levels with the intent of increasing effectiveness and efficiency, using limited resources to reconfigure services as necessary to achieve better patient-centered and population health outcomes.” ([26], p. e18) |
Governance values | Values of the political decision-making process that ensure the government considers the concerns of society and performs its functions in a transparent and accountable manner | Authority focused - Accountability - Enforcement of regulation - Governance - Responsiveness - Stewardship | Public focused - Public participation - Social participation - Transparency - Trust | • Governance values are related to the process of political decision-making Promote that health policies be developed and implemented with social legitimacy (i.e. policies are desirable, proper or appropriate within some socially constructed system of norms, values and beliefs) “The concept of health governance refers to the way in which political actors within health system (providers) and the civil society (users, community leaders and NGOs), by means of explicit processes and rules, interact to produce, distribute and consume health as a good in relation to health services demand and population health needs” ([27], p. 39) |
Situational values | A broad category considering different factors that represent interests, ideas or visions of the health system, which vary according to changes in government or the social mood and that can strongly influence policy decision-making | Political system related - Hierarchisation - Reciprocity - Separation of functions - Sovereignty Health system structure related - Centralisation - Compulsoriness - Decentralisation - Intersectorality - Pluralism - Unification - Voluntariness Right to health oriented - Citizenship - Democratisation - Empowerment - Millennium Development Goals - Prevention - Primary healthcare - Public financing - Social cohesion | Management related - Institutional autonomy - Cost containment - Financial autonomy - Financial stability - Optimisation - Proportionality - Savings - Self-management - Simplicity - Transferability - Transparent procurement Delivery focused - Flexibility - Implementability - Mobility - Portability Market oriented - Competitiveness - Demand subsidies - Free choice - Individuality - Market - Privatisation - Profitability - Self-financing - Targeting | • Situational values come to be influential according to specific situational circumstances These situational factors depend on policy legacies, changes in the balance of organised forces, changes within the government, or international influences. Some situational values become crucial for a country at a specific time, and governments could incorporate them in the technical or governance categories, or even misrepresent their role and strongly pursue them as though they were a goal of the health system Many countries that implemented private health insurance models commonly asserted competitiveness, cost-containment, efficiency, market, privatisation and targeting as the most appropriate mechanisms to achieve universality in a liberal, market-oriented society [19,20,21, 25, 28,29,30]; those values are identified in the health system reforms of Brazil [21, 31,32,33], Chile [29, 32], Colombia [21, 32–34], Costa Rica [35] and Mexico [20, 28, 36, 37]; however, when we examined the strategies followed by more public financing-oriented governments, other values like public financing, primary healthcare and centralisation, appear |