¿Por qué es importante cambiar las preguntas sobre el valor? El valor público sanitario debe ser incorporado

Illness is an individual and collective experience. The entire process of a sick person is its own, unique, trusting, wounded and adverse territory. In this individuality the fragility of the collective self is frequently reflected. Illness is always explained with a border meaning between the I and the we, between the biological and the social, between the untimely present and the collective history of which we are part and that we construct. Individual illnesses shape a social life within which it unfolds.

It is when health care, care, opens or closes a crossroads in a life.

One of the giant dreams conquered is the consideration that health care from a public health system is not related to the social condition of those in front of us. It is offered only according to the health need you present and not your rental level. The substantial value of public health care thus provided is rooted in a logic: that of the common good, that of public purpose, that of social ethics. Different from other logic consistent with the commercialization of health. Health or illness from the perspective of the common good are performative in the sense that they refer to specific actions. Two differential ways of understanding and acting.

Science and questions

A health system is an organization full of responses to face uncertainty. From what antibiotic to administer when indicated, how to clinically approach a diagnosis of breast or colon carcinoma, what public health measure to improve, what to investigate, to how to shape health care as services. Among many others.

It is a system full of answers… but what questions? Because not everything is clinical or about micromanagement.

How many times has it been made clear how the National Health System, in Spain as in other countries, constituted a great asset and the first line of defense of the economy when the COVID pandemic remained confined to the population in their homes for three months? (González López-Valcárcel, B., 2020) How many appealed to the contribution to collective well-being and the economy that said contribution represented?

How much is taken into consideration the fact that medical bills are the first reason (66.5%) for a family economy to be ruined in a country like the US? USA? And that every year 530,000 American families file for bankruptcy due to medical bills? (Himmelstein et al., 2019).

Or this one: What is the most important thing in an industry, in a company or in an organization to gain the trust of a client or a person? Create value. Create and ensure an impression of value.

And why is public health value not measured? Why is the value not measured of that which protects us as people, of that which builds us civically as a society and that ensures collective well-being -based on science and socially fair-, or of that which gives us security in uncertainty?

The history of science is the history of questions. Progress is made when the questions are changed (Wagensberg, 2018). We do not advance as much with the variety of answers as when we change the questions.

Public health value is a category that can be analyzed by limiting itself only to ethical aspects; or it can be an object of approximation susceptible to scientific analysis based on empirical evidence.

Sometimes it is justified that value is created only in the private sector, using merely discursive arguments devoid of data – if not prevailing and deep-rooted beliefs – to highlight the inability of governments and the public sector to create value.

Societies today are systems of enormous complexity and with relevant social dissonance. The public health sector is part of this complexity: due to the nature of its activity, due to the economic magnitude it represents as a public good, due to its organizational and professional component, and due to the scientific, social and health impacts.

However, as highlighted Margulis and Sagán (2013) On systems of increasing complexity that maintain symbiosis between their members, the benefit of the whole redounds to the individual and vice versa.

Complexity, just due to laziness, inefficiency or interest, becomes an opportunistic or plotting narrative that anticipates a theory of the private.

Progressing in scientific thinking about the generation of these value structures and their significance is today crucial in the analysis of health systems and public policies, in addition to generating critical thinking and objective thinking that samples it.

Health public value: measuring what matters

“What you measure affects what you do,” he maintains. Stiglitz (2018)). The change of focus is decisive.

The term value in the health field – not public value – emerged in the US. (Porter, ME and Teisberg, EO, 2004; Porter and Teisberg, 2006) not exempt from criticism since its inception – from the economic sphere itself – for its underlying approach (Reinhardt, 2006).

There are no official statistical operations that measure the public value created by services as important as healthcare. Gross domestic product is measured in terms of collective well-being, which is not the same. On many occasions, all this leads to what? To a deduction that justifies that the value is generated exclusively in the private sector and not in the public sector (health, innovation and social, economic and scientific value…). The term public value does not exist in economics. (Mazzucato, 2019).

Efficiency is necessary. But efficiency at the service of what? At the service of whom? The value script needs to be rewritten. “Don’t even bother talking about efficiency unless you know what it’s for,” emphasizes economist Mazzucato. (Aguilera, M, 2025). Uwe Reinhardt, to whom a well-deserved tribute was paid in this AES blog, concluded his analysis of efficiency and equity in this regard, as follows: «sometimes, considering efficiency alone can be useful, even in health policy. At other times, it can be analytically elegant, but only trivially relevant to the conduct of public policies. In fact, beginning to explore alternative proposals for the reform of our health system without first establishing explicitly and very clearly the social values to those who must adhere to the reformed system it seems, at least to me, clearly inefficient: It’s a waste of time. Wouldn’t it be more? efficient limit yourself to exploring the relative efficiency of alternative proposals that conform to the social values widely shared?” (Reinhardt, EU, 1992, p. 315).

We are in an era of profound health changes. For example, they are projected into the use of public health data with, in some cases, disturbing and controversial externalizations (Abbasi, 2025; Member, 2025; Mihranian Osborne, 2024; Wilding, M, 2025). Just as occurs in the expansion of large technology companies under a monopoly regime through data and digitalization in the health sector. (Rikap, 2023) or in the emergence and increase of capital risk in the healthcare sector and its negative impacts both on quality and costs and on healthcare professionalism (Bhatla et al., 2025; Goozner, 2023; Kannan et al., 2025; Rechel et al., 2023; Rechel et al., 2025; Singh et al., 2025). As happens with the growing inequalities and inequities in health (Horton, 2025; The Lancet, 2025). Rewriting, through the necessary alliances, a scenario of shared values ​​at the service of collective well-being is the best scientific and ethical certainty imaginable, and a primary imperative to advance equality. The sequencing of the human genome was, for example, an extraordinary example of how a scientific effort coordinated by the public managed to impose a result from the perspective of the common good. In this way, the commercial privatization of similar knowledge was avoided. (Sulston, 2003).

Source: Image taken from PIXABAY

The public health value is the critical intersection of four essential aspects: the axiological question of social values, the economic question of the measurement of collective well-being and the decommodification of health, the scientific question of how to understand efficiency adjusted to values, and the social question of how to move towards equity and consolidate health as a fundamental human right.

Health care should not be subject to people’s income level. Dying or living must not be subjugated to any kingdom, as it reminds us Susan Sontag. The reason lies in an unsustainable social maxim without funding and without philosophy: we must use science to help without distinctions. We must defend the need to be fair and urgently demand the need for the common health good. We have to delve into social ethics from moral axiology, not from productive performance. Here is the reason for this work: to naturalize health care as a human right and defend the need to build a health economy based on public health value.

The problem, perhaps, is not in the consensus or disagreement about these statements, which we consider to be cultural hegemony in much of our Western world. Read Rawls and reflect on his ideological projection in modern philosophy. The problem is in how, in the questions we ask ourselves at the outset and in the social and economic forces linked to said process. It is at the very foundation of the question: What is value for us and who has constructed its meaning? What is health value? Is it only an economic category linked to commercial performance or can it be, contrary to the facts, a category that emanates from the public and that, singularly, through the public generates value for itself?