A new conceptual framework for evaluating healthcare quality: shifting from reactive treatment to proactive health preservation

Discussion The proposed framework redefines healthcare quality—from evaluating medical interventions to assessing sustained health outcomes. By combining age-standardised HALE and PPP-adjusted health expenditure, it extends existing models such as Donabedian’s, offering a measurable way to evaluate how well systems preserve health rather than merely treat disease. By using two simple, yet powerful, indicators—HALE and per capita healthcare expenditure—standardised as z-scores, the model allows for intuitive visual comparisons of healthcare systems. It invites policymakers, researchers and the public to assess how well systems deliver on the ultimate goal of healthcare: enabling people to live long, healthy lives with minimal reliance on clinical services. This model also provides a platform for strategic policy discussion. By examining relative positions on the graph, countries can engage in value-based debates about acceptable trade-offs between spending and health outcomes. For example, a country located on the higher-cost, higher-health area may be comfortable with greater investment to achieve marginal health gains, while another may prioritise affordability even if it results in slightly lower outcomes. The model does not prescribe a single optimal path, but rather provides a tool for informed, goal-oriented decision-making. As with any simplified conceptual model, this framework should not be interpreted as capturing the full complexity of healthcare systems, but rather as a heuristic tool to stimulate reflection on strategic orientation and long-term health preservation. A potential limitation of this framework is that relatively low healthcare expenditure should not automatically be interpreted as evidence of higher healthcare quality, as it may also reflect underinvestment, limited access or immature health system development. For this reason, the framework is intended to support reflective comparison rather than simplistic ranking, and should be interpreted alongside broader contextual understanding. Importantly, while this model has been applied to international comparisons of healthcare systems, it is also adaptable to regional comparisons within a country, provided regional-level data on HALE and per capita healthcare expenditure are available. Furthermore, because both HALE and per capita healthcare expenditure are strongly influenced by social, economic and demographic conditions,17–20 the model inherently reflects the broader social determinants of health. In this sense, the outcomes captured by the framework already incorporate these contextual influences, meaning that social and structural factors are not treated as external confounders, but as broader contextual influences that shape the outcomes captured by the framework. Consequently, this model differs from conventional quality frameworks by evaluating how well a system preserves and promotes health rather than merely responding to disease. Since it reflects a more upstream and comprehensive goal of healthcare, direct comparisons with downstream performance-based frameworks may not be meaningful or appropriate. This broader perspective does not imply that healthcare systems are solely responsible for all determinants of health, nor that health budgets should absorb all sectors influencing health. Rather, the proposed framework suggests that healthcare systems should prioritise health-preserving functions within their sphere of influence—such as prevention, health education, health literacy and supportive health-promoting infrastructure—while also playing a coordinating role with other sectors whose primary mandates, including housing, transport, education and welfare, substantially shape health outcomes. The downstream orientation of conventional quality frameworks is not simply a matter of conceptual design, but also reflects structural realities within healthcare systems and governance. Prevention is inherently more difficult to attribute, measure and assign accountability for than discrete clinical interventions. In addition, administrative and legal boundaries often define healthcare systems primarily around service delivery rather than broader social determinants of health, while prevailing reimbursement structures tend to reward treatable events more readily than avoided illness. These institutional dynamics help explain why healthcare quality assessment has historically gravitated toward curative care, even when prevention is widely recognised as essential. While this model offers valuable insights for policymaking and comparative evaluation, implementing such a vision is not without challenges. A core tension lies in the conflict between the goals of healthcare and the incentives of capitalist economic systems. While healthcare aims to reduce medical need by keeping populations healthy, capitalism seeks growth, often measured in increased consumption—including healthcare. In such a system, prevention and reduced utilisation may paradoxically threaten the financial viability of healthcare institutions, pharmaceutical companies and other health-related industries. This raises a profound philosophical and structural question: Can a healthcare system truly prioritise long-term health within an economic model that rewards short-term revenue? The answer may lie in rethinking not only healthcare policy but also the broader principles by which we measure success and allocate resources. To reconcile this contradiction, several shifts may be necessary: Transitioning to value-based financing models that reward prevention and health outcomes rather than volume of services. Increasing public investment in health-promoting infrastructure, such as clean environments, education and nutrition. Encouraging multisectoral collaboration to address social determinants of health that fall outside traditional medical care. And cultivating a cultural shift in which health is recognised as a shared public good, not just an individual commodity. Ultimately, this model is not merely an evaluative tool—it is an invitation to re-envision what healthcare can be. It challenges systems to orient themselves around the ideal of victory without battle—a society in which people thrive because illness is rare, not because treatment is abundant. This framework thus offers not only an evaluative lens but also a strategic compass for policymakers seeking to reorient healthcare systems toward sustainability, prevention and long-term population well-being. By explicitly acknowledging the philosophical tension between healthcare’s highest purpose and the economic structures in which it operates, this framework brings clarity to what is at stake: not only how we measure healthcare quality, but how we define progress and success in modern society.