ABSTRACT:
Health systems worldwide are facing rising costs and uneven quality, creating an urgent need for reform (1). Value-Based HealthCare (VBHC), which seeks to maximize patient outcomes relative to costs, has gained momentum as a strategic response (2). However, its implementation remains fragmented, and its equity implications are contested (3). A narrative review was conducted to synthesize the barriers, facilitators, and equity implications of VBHC. A comprehensive search of six databases identified peer-reviewed studies published between 2006 and 2025. After screening, 34 studies were included for thematic analysis, guided by Braun and Clarke’s six-phase approach(4). The thematic synthesis produced four interconnected themes. (1) Systemic and Structural Misalignment between VBHC principles and existing healthcare architectures, particularly fee-for-service payment models, fragmented IT systems, and siloed organizational designs, undermines effective VBHC implementation. (2) The "Translation" Imperative, where VBHC requires context-specific adaptation, often resulting in selective focus on outcomes or costs rather than the full value equation. (3) The Primacy of Culture, Leadership, and People, where clinical leadership, stakeholder trust, and workforce well-being consistently shape implementation outcomes, trumping strategic design. (4) Equity at the Crossroads, positioning VBHC as a double-edged sword that can either reduce disparities or perpetuate inequities if not intentionally designed with marginalized populations in mind. In conclusion, VBHC implementation faces a fundamental paradox as its transformative potential might be undermined by the flexibility that enabled its global adoption. Successful implementation depends more on ‘skilled translation’ to local contexts than on rigid adherence to theoretical models while prioritizing clinical leadership, workforce well-being, and genuine patient-centeredness. Furthermore, without intentional equity-focused design, VBHC risks perpetuating healthcare disparities. Therefore, policymakers should view VBHC as a guiding compass and explicitly embed equity-focused, context-sensitive design as a core requirement for future VBHC strategies.