It takes two to dance the VBHC tango: A multiple case study of the adoption of value-based strategies in Sweden and Brazil

Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs – not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly. •Studying VBHC as a complex innovation uncovers multiple interconnections at various levels of the healthcare system.•Organizations adapt VBHC to emphasize components that best translate into their system.•Choices on how to operationalize VBHC may trigger tensions with traditional business models.•VBHC should be approached as a complex system innovatios, and not as single endeavors as described in many case-reports.