In this cluster, we define ‘Value’ and ‘Triple Value’. Triple value comprises ‘Personal Value’, ‘Population Value’ and ‘Technical Value’. To understand the full meaning of ‘Personal Value’ and ‘Population Value’, it is important to be aware of the concept of ‘Reasonableness’, which is also defined in this cluster.


… value is expressed as what we gain relative to what we give up – the benefit relative to the cost.

Source: Institute of Medicine of the National Academies (2008) Learning Healthcare System Concepts v. 2008. The Roundtable on Evidence-Based Medicine, Institute of Medicine. Annual Report. 

Example of the term in use:

…, the concept of value in a society in which the needs of the whole population have to be met from a finite budget is broader, because payers have to be on the alert for both overuse, underuse, as well as efficiency.

Gray M with Bevan G, Cripps M, Jani A, Ricciardi W (2017) How To Get Better Value Healthcare. Third edition. Offox Press, Oxford. Page 29.

Triple Value

There are three components to Triple Value: personal value, population value and technical value.

Personal Value

Improving the outcomes that matter to an individual for a given amount of resources (money, leadership, time, assets and carbon) used not only by the health and social care system but also by the individual and their family, recognising that the experience of care is a critical element.

Source: Oxford Centre for Triple Value Healthcare


Personal value, together with population value, are the core goals for health and social care systems. Whenever someone makes a decision about treatment options, especially if it is a fateful decision that cannot be ‘undone’, it is important that they are fully supported to be able to maximise the personal value they might gain. In the case of fateful decisions, the individual is investing their current (or future predicted) state of health and wellbeing in return for a better state of health or wellbeing. If the procedure does them more harm than good, and the decision is fateful, then personal value will have been reduced.

Population Value

Allocating and Investing resources (money, leadership, time, assets and carbon) more wisely within a health and social care system to optimise the health and wellbeing for the whole population for which the health and social care system is responsible

Source: Oxford Centre for Triple Value Healthcare


Population value, together with personal value, are the core goals for health and social care systems. This is because, in health systems that provide universal coverage for a specific population or group of people with a common condition (e.g. end of life, joint pain or people at risk of stroke), resources must be invested wisely to optimise population value within the resources available. This requires a focus on efficiency, unwarranted variation, overuse and underuse (underuse includes people who are already being treated and people with unmet need not receiving treatment).

Technical Value

Net benefit derived in return for a given resource use.

Source: Oxford Centre for Triple Value Healthcare


Technical value is synonymous with technical efficiency, that is, it represents the net benefit achieved for a given amount of resources used. Owing to the narrowness of this definition – it does not always properly address personal value, nor does it consider critical elements of population value (especially those relating to overuse, underuse and equity) – technical value is not a goal in and of itself. It is a useful tool to achieve the two core goals of health and social care systems to increase population and personal value continuously.


Accountability for reasonableness is the idea that the reasons or rationales for important limit-setting decisions should be publicly available. In addition, these reasons must be ones that ‘fair-minded’ people can agree are relevant to pursuing appropriate patient care under necessary resource constraints … . This is our central thesis, and it needs some explanation.

By ‘fair-minded’, we do not simply mean our friends or people who just happen to agree with us.   We mean people who in principle seek to cooperate with others on terms they can justify to each other. Indeed, fair-minded people accept rules of the game – or sometimes seek rule changes – that promote the game’s essential skills and the excitement their use produces.

Source: Daniels N, Sabin JE (2008) Setting Limits Fairly, Learning to Share Resources for Health. Page 44. Oxford University Press.

Two examples of the term in use:

Two central goals of health policy are to improve population health as much as possible and to distribute the improvements fairly. These goals will often conflict. Reasonable people will disagree about how to resolve these conflicts, which take the form of various unsolved rationing problems. The conflict is also illustrated by the ethical controversy that surrounds the use of cost-effectiveness analysis. Because there is no consensus on principles to resolve these disputes, a fair process is needed to assure outcomes that are perceived to be fair and reasonable. One such process, accountability for reasonableness, assures transparency, involves stakeholders in deliberating about relevant rationales, and requires that decisions be revised in light of new evidence and arguments. It has been influential in various contexts including developed countries such as Canada, the United Kingdom, New Zealand, and Sweden, and developing countries, such as Mexico …

Daniels N (2018) Reasonableness and its definition in the provision of healthcare. In Warrell DA, Cox TM, Firth JD (eds) The Oxford Textbook of Medicine. Section 2.4.2. Oxford University Press. DOI: 10.1093/med/9780199204854.003.020402. Online access to the Oxford Textbook of Medicine in low- and middle-income countries is available through the World Health Organization-led HINARI Access to Research in Health programme.

Resource allocation decisions in health care are rife with moral disagreements and a fair, deliberative process is necessary to establish the legitimacy and fairness of such decisions. To hold decision makers accountable for the reasonableness of their decisions, we have argued that the process must be public (fully transparent) about the grounds for its decisions; the decision must rest on reasons that stakeholders can agree are relevant; decisions should be revisable in light of new evidence and arguments; and there should be assurance through enforcement that these conditions (publicity, relevance, and revisability) are met. The form such procedures should take depends on the institutional context. The decisions are in any case constrained by more general considerations of justice, such as the requirement that they not be discriminatory.

Daniels N, Sabin JE (2008) Accountability for reasonableness: an update. BMJ 2008; 337 doi: (Published 09 October 2008) Cite this as: BMJ 2008;337:a1850