Investment Performance Framework for a $1B Provincial Healthcare Portfolio

The mandate

A billion dollars of public investment. Dozens of programs. Dozens of delivery organizations. No common language for what any of it was worth.

The provincial government knew roughly what it was spending on healthcare. What it didn’t have was a coherent way to compare investments — to say, with any rigour, whether a dollar going into one program was delivering more value than a dollar going into another. Every program reported differently. Every stakeholder had a different definition of success. The portfolio had grown incrementally over years and nobody had stood back to ask whether it made sense as a whole.

Two kinds of complexity

The analytical challenge was real but tractable. Hundreds of individual investments were mapped and consolidated into logical subunits — clusters of related activity that could be measured by the same metrics. A return-per-dollar framework was built to accommodate the particular messiness of public healthcare economics: there is no revenue, the “return” is a combination of health outcomes, system efficiency, and cost avoidance, and different stakeholders weight these differently.

The framework made the underlying value judgments explicit — rather than hiding them in methodology where they would eventually become someone else’s problem. That transparency was intentional. It’s what made it defensible.

The harder challenge was political. Healthcare investment decisions carry commitments, constituencies, and histories that don’t disappear because a framework says they should. Political drivers were mapped alongside financial and clinical ones. The framework was designed to surface tensions between them, not paper over them.

A framework that people feel was imposed on them will not survive the first difficult conversation.

Stakeholder consensus was built before the framework was finalized, not after.

What held

The work was formally commended. More significantly, it catalysed years of follow-on initiatives at lower levels of the health system — program teams and regional agencies adopting the subunit structure and metrics as a template for their own investment alignment work. That kind of durability doesn’t come from the analysis. It comes from the consensus built around it.