health care cost essay

Understanding why health care costs in the U.S. are so high

The high cost of medical care in the U.S. is one of the greatest challenges the country faces and it affects everything from the economy to individual behavior, according to an essay in the May-June 2020 issue of Harvard Magazine written by David Cutler , professor in the Department of Global Health and Population at Harvard T.H. Chan School of Public Health.

Cutler explored three driving forces behind high health care costs—administrative expenses, corporate greed and price gouging, and higher utilization of costly medical technology—and possible solutions to them.

Read the Harvard Magazine article: The World’s Costliest Health Care

• Issue Brief

Health Care Costs: What’s the Problem?

The cost of health care in the United States far exceeds that in other wealthy nations across the globe. In 2020, U.S. health care costs grew 9.7%, to $4.1 trillion, reaching about $12,530 per person. 1 At the same time, the United States lags far behind other high-income countries when it comes to both access to care and some health care outcomes. 2 As a result, policymakers and health care systems are facing increasing demands for more care at lower costs for more people. And, of course, everyone wants to know why their health care costs are so high.

The answer depends, in part, on who’s asking this question: Why does U.S. health care cost so much? Public policy often highlights and targets the total cost of the health care system or spending as a percentage of the gross domestic product (GDP), while most patients (the public) are more concerned with their own out-of-pocket costs and whether they have access to affordable, meaningful insurance. Providers feel public pressure to contain costs while trying to provide the highest-quality care to patients.

This brief is the first in a series of papers intended to better define some of the key questions policymakers should be asking about health care spending: What costs are too high? And can they be controlled through policy while improving access to care and the health of the population?

What (or Who) Is to Blame for the High Costs of Care? 

Total U.S. health care spending has increased steadily for decades, as have costs and spending in other segments of the U.S. economy. In 2020, health care spending was $1.5 trillion more than in 2010 and $2.8 trillion more than in 2000. While total spending on clinical care has increased in the past two decades, health care spending as a percentage of GDP has remained steady and has hovered around 20% of GDP in recent years (with the largest single increase being in 2020 during the COVID-19 pandemic). 1 Health care spending in 2020 (particularly public outlays) increased more than in previous years because of increased federal government support of critical COVID-19-related services and expanded access to care during the pandemic. Yet, no single sector’s health care cost — doctors, hospitals, equipment, or any other sector — has increased disproportionately enough over time to be the single cause of high costs.

One of the areas in health care with the highest levels of spending in the United States is hospital care, which has accounted for about 30% of national health care spending 3 for the past 60 years (and has remained very close to 31% for the past 20 years) (Figure 1). Although hospital spending is the focus of many cost-control policies and public attention, the increases are consistent with the increases seen across other areas of health care, such as for physicians and other professional services. Total spending for some smaller parts of nonhospital care has more than doubled over the past few decades and makes up an increasing proportion of total spending. For instance, home health care as a percentage of total spending tripled between 1980 and 2020, from 0.9% to 3.0%, and drug spending nearly doubled as a proportion of health care spending between 1980 and 2006, from 4.8% to 10.5%, and currently represent 8.4% of health care spending. 1  

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The largest areas of spending that might yield the greatest potential for savings — such as inpatient care and physician-provided care — are unlikely to be reduced by lowering the total number of insured patients or visits per person, given the growing, aging U.S. population and the desire to cover more, not fewer, individuals with adequate health insurance. 

In the past decade, policymaker and insurer interventions intended to change the mix of services by keeping patients out of high-cost settings (such as the hospital) have not always succeeded at reducing costs, although they have had other benefits for patients. 4  

Breaking Down the Costs of Care

Thinking about total health care spending as an equation, one might define it as the number of services delivered per person multiplied by the number of people to whom services are delivered, multiplied again by the average cost of each service: 

Health Care Spending=(number of services delivered per person)×(number of people to whom services are delivered)×(average cost of each service) 

Could health care spending be lowered by making major changes to the numbers or types of services delivered or by lowering the average cost per service? 

Although recent data on the overall utilization of health care are limited, in 2011, the number of doctor consultations per capita in the United States was below that in many comparable countries, but the number of diagnostic procedures (such as imaging) per capita remained higher. 5 Furthermore, no identifiable groups of individuals (by race/ethnicity, geographic location, etc.) appear to be outliers that consume extraordinary numbers of services. 6 The exception is that the sickest people do cost more to take care of, but even the most cost-conscious policymakers appear to be reluctant to abandon these patients. 

In addition to the fact that the average number of health care services delivered per person in the United States was below international benchmarks in 2020,7 the percentage of people in the United States covered by health insurance was also lower than that in many other wealthy nations. Although millions of people gained insurance8 through the Affordable Care Act and provisions enacted during the COVID-19 pandemic, 10% of the nonelderly population remained uninsured in 2020. 9 When policymakers focus on reducing health care spending, considering the equation above, and see that the United States already has a lower proportion of its population insured and fewer services delivered to patients than other wealthy nations, their focus often shifts to the average cost of services.

It's Still the Prices … and the Wages 

A report comparing the international prices of health care in 2017 found that the median list prices (charges) for medical procedures in the United States heavily outweighed the list prices in other countries, such as the United Kingdom, New Zealand, Australia, Switzerland, and South Africa. 10  

For example, the 2017 U.S. median health care list price for a hospital admission with a hip replacement was $32,500, compared with $20,900 in Australia and $12,200 in the United Kingdom. In comparisons of the list prices of other procedures, such as deliveries by cesarean section, appendectomies, and knee replacements, the U.S. median list prices of elective and needed services were thousands of dollars — if not tens of thousands of dollars — more. 10 Yet, the list price for these services in the United States is often much higher than the actual payments made to providers by public or private insurance companies. 11

Public-payer programs (particularly Medicare and Medicaid) tend to pay hospitals rates that are lower than the cost of delivering care12 (though many economists argue these payments are slightly above actual costs, and providers argue they are at least slightly below actual costs), while private payers historically have paid about twice as much as public payers. 13 (See another brief in this series, “ Surprise! Why Medical Bills Are Still a Problem for U.S. Health Care ,” for more information about public and private payers’ role in health care costs.) However, the average cost per service is still high by international standards, even if it’s not as high as list prices may suggest. The high average costs are partially driven by the highly labor-intensive nature of health care, with labor consuming almost 55% of the share of total U.S. hospital costs in 2018. 14 These costs are growing due to the labor shortages exacerbated by the COVID-19 pandemic. 

Reducing U.S. health care spending by reducing labor costs could, theoretically, be achieved by reducing wages or eliminating positions; however, both of those policies would be problematic, with potential unintended consequences, such as driving clinicians away from the workforce at a time of growing need. 

Wage reductions, particularly for clinicians, would require a vastly expanded labor pool that would take years to achieve (and even then, lower per person wages for nonphysicians may not decrease total spending related to health care labor). 15 Reducing or replacing clinical workers over time would require major changes to policy (both public and private) and major shifts in how health care is provided — neither of which has occurred rapidly, even since the implementation of the Affordable Care Act. 

What’s a Policymaker to Do?

Nearly one in five Americans has medical debt, 16 and affordability is still an issue for a large proportion of the population, whether uninsured or insured, which suggests that policymakers should focus on patients’ costs. This may prove more impactful to the individual than reducing total health care spending. 

A majority of the country agrees that the federal government should ensure some basic health insurance for all citizens. 17,18 Although most Americans consider reducing costs to individuals and expanding insurance coverage to be important, no clear consensus about who should bear any associated increased costs exists among patients or policymakers. Half of insured adults currently report difficulty affording medical or dental care, even when they are insured, because of the rising total costs of care and the increasing absolute amount of out-of-pocket spending. 19 Out-of-pocket spending for health care has doubled in the past 20 years, from $193.5 billion in 2000 to $388.6 billion in 2020. 1 These rising health care costs have disproportionately fallen on those with the fewest resources, including people who are uninsured, Black people, Hispanic people, and families with low incomes. 19 Increased cost sharing through copays and coinsurance may force difficult spending choices for even solidly middle-class families. 

The severity and burden of out-of-pocket spending are hidden by the use of data averages; on average, U.S. residents have twice the average household net adjusted disposable income 20 of many other comparable nations and spend more than twice 21 as much per capita on health care. Yet, for those who fall outside these averages — average income, average costs, or both — the financial pain felt at the hospital, clinic, and pharmacy is very real. 

In any given year, a small number of patients account for a disproportionate amount of health care spending because of the complexity and severity of their illnesses. Even careful international comparisons of end-of-life care for cancer patients demonstrate costs in the United States are similar to those in many comparable nations (although U.S. patients are more likely to receive chemotherapy, they spend fewer days in the hospital during the last 6 months of life than patients in other countries). 22 Similarly, although prevention efforts may delay or avoid the onset of illness in targeted populations, such efforts would not significantly reduce the number of services delivered for many years and may lead to an increase in care delivered over the course of an extended life span.

To the average person in the United States, immediate cost-control efforts might best be focused on reducing the cost burden for families and patients. Policymakers should continue to seek ways to promote better health care quality at lower costs rather than try to achieve unrealistic, drastic reductions in national health care spending. Investing in prevention, seeking to avoid preventable admissions or readmissions, and otherwise improving the quality of care are desirable, but these improvements are not quick solutions to lowering the national health care costs in the near term. Long-term policy actions could incrementally address health care spending but should clearly articulate the problem to be solved, the desired outcomes, and the trade-offs the nation is willing to make (as discussed in two companion pieces). 

The U.S. health care system continues to place a disproportionate cost burden on the patients who can least afford it. In the short term, policymakers could focus on targeted subsidies to specific populations — the families and individuals whose household incomes fall outside the average or who have health care expenses that fall outside the average — whose health care costs are unmanageable. Such subsidies could expand existing premium subsidies or triggers that increase support for costs that exceed target amounts. Targeted subsidies are likely to increase total health care spending (especially public spending) but would address the problem of cost from the average consumer, or patient, perspective. Broader policies to ease costs for patients could also be considered by category of service; for instance, consumers have been largely shielded from the increased costs of care related to COVID-19 by the waiving of copays for patients and families. These policies would likely increase national spending as well, but they would make medical care more affordable to some families.

Download Brief

Cite this source: Grover A, Orgera K, Pincus L. Health Care Costs: What's The Problem? Washington, DC: AAMC; 2022. https://doi.org/10.15766/rai_dozyvvh2

• Centers for Medicare & Medicaid Services. National Health Expenditure Data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet . Published Dec. 1, 2021. Accessed Feb. 24, 2022.
• Schneider EC, Shah A, Doty MM, Tikkanen R, Fields K, Williams RD II. Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries. Washington, DC: The Commonwealth Fund. https://doi.org/10.26099/01DV-H208 . Published August 2021. Accessed April 21, 2022.
• Centers for Medicare & Medicaid Services. National Health Expenditure Data: Historical. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical . Published Dec. 15, 2021. Accessed April 22, 2022. 
• Berkowitz S, Ricks KB, Wang J, Parker M, Rimal R, DeWalt D. Evaluating a nonemergency medical transportation benefit for accountable care organization members. Health Affairs. 2022;41(3):406-413. doi:10.1377/hlthaff.2021.00449.
• Organisation for Economic Co-operation and Development. Health Care Utilisation. Paris, France: Organisation for Economic Co-operation and Development. https://stats.oecd.org/index.aspx?queryid=30166# . Published Nov. 9, 2021. Accessed Feb. 24, 2022.
• Abelson R. Harris G. Critics question study cited in health debate. New York Times. June 2, 2010. https://www.nytimes.com/2010/06/03/business/03dartmouth.html?ref=business&pagewanted=all . Accessed Feb. 24, 2022.
• The Commonwealth Fund. Selected Health & System Statistics: Average Annual Number of Physician Visits per Capita. https://www.commonwealthfund.org/international-health-policy-center/system-stats/annual-physician-visits-per-capita . Published June 5, 2020. Accessed April 21, 2022.
• Tolbert J, Orgera K. Key Facts About the Uninsured Population. San Francisco, CA: KFF. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ . Published Nov. 6, 2020. Accessed April 21, 2022.
• Tolbert J, Orgera K, Damico A. What Does the CPS Tell Us About Health Insurance Coverage in 2020? San Francisco, CA: KFF. https://www.kff.org/uninsured/issue-brief/what-does-the-cps-tell-us-about-health-insurance-coverage… . Published Sept. 23, 2021. Accessed April 21, 2022.
• Hargraves J, Bloschichak A. International Comparisons of Health Care Prices From the 2017 iFHP Survey. Washington DC: Health Care Cost Institute. https://healthcostinstitute.org/hcci-research/international-comparisons-of-health-care-prices-2017-ifhp-survey . Published Dec. 2019. Accessed April 21, 2022.
• Bai G. Anderson G. Extreme markup: The fifty US hospitals with the highest charge-to-cost ratios. Health Affairs. 2015;34(6):922-928. doi:10.1377/hlthaff.2014.1414.
• Congressional Budget Office. The Prices That Commercial Health Insurers and Medicare Pay for Hospitals’ and Physicians’ Services. Washington, DC: Congressional Budget Office. https://www.cbo.gov/system/files/2022-01/57422-medical-prices.pdf . Published January 2022. Accessed April 21, 2022.
• Lopez E, Neuman T, Jacobson G, Levitt L. How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature. San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/ . Published April 15, 2020. Accessed March 22, 2022.
• Daly R. Hospitals Innovate to Control Labor Costs. Westchester, IL: Healthcare Financial Management Association. https://www.hfma.org/topics/hfm/2019/october/hospitals-innovate-to-control-labor-costs.html . Published Oct. 1, 2019. Accessed Feb. 24, 2022. 
• Batson BN, Crosby SN, Fitzpatrick, JM. Mississippi frontline: Targeting value-based care with physician-led care teams. J Miss State Med Assoc. 2022;63(1):19-21. https://ejournal.msmaonline.com/publication/?m=63060&i=735364&p=20&ver=html5 .
• Kluender R, Mahoney N, Wong F, et al. Medical debt in the US, 2009-2020. JAMA. 2021;326(3):250-256. doi:10.1001/jama.2021.8694.
• Jones B. Increasing Share of Americans Favor a Single Government Program to Provide Health Care Coverage. Washington, DC: Pew Research Center. https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/ . Published Sept. 29, 2020. Accessed April 21, 2022.
• Bialik K. More Americans Say Government Should Ensure Health Care Coverage. Washington, DC: Pew Research Center. https://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/ . Published Jan. 13, 2017. Accessed March 22, 2022.
• Kearney A, Hamel L, Stokes M, Brodie M. Americans’ Challenges With Health Care Costs. San Francisco, CA: The Henry J. Kaiser Family Foundation. https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/ . Published Dec. 14, 2021. Accessed Feb. 24, 2022.
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• Bekelman JE, Halpern SD, Blankart CR, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA. 2016;315(3):272-283. doi:10.1001/jama.2015.18603.

In her 2016 essay "Cost of Living" for the Virginia Quarterly Review — later anthologized in The Best American Essays — Emily Maloney unravels the juxtaposition of working to pay down her medical debt at a job where she assigns medical costs to treatments — costs that may, in turn, create the same kind of debt for others.

She writes of being 23 and working as an emergency room technician at a Chicagoland hospital, coding charts into bills, determining what to charge for the level of care each patient received: "Each level had its own exacting specifications, a way of making sense — at least financial sense — of the labyrinthine mess of billing."

But Maloney knew from her own experience that medical billing didn't actually compute in a financial sense. Four years earlier, she had been an ER patient at a hospital in Iowa City after a suicide attempt. That hospital stay resulted in a five-figure bill, one she could scarcely have imagined as a 19-year-old college student. "Sitting on a cot in the emergency room, I filled out paperwork certifying myself the responsible party for my own medical care — signed it without looking, anchoring myself to this debt, a stone dropped in the middle of a stream," Maloney writes.

"Cost of Living" — an indictment of the exorbitant costs of staying alive in America, and the weight of being hounded by a debt that reduces your life to dollars and cents — opens Maloney's debut essay collection of the same name. It's a powerful opening shot, but in the essays that follow, which recount Maloney's experiences as patient, caregiver, observer, and pharmaceutical industry worker, she stumbles before regaining the clarity of purpose and rigor of probing that "Cost of Living" promises.

There are 15 essays in Cost of Living , and the six that follow the titular piece feel as though they are narrated from underwater. Perhaps that is because they trace years in which Maloney herself felt that she had "not gotten the memo regarding how to be a person." She writes of being "too odd for elementary school, then secondary school," of attending seven schools in ten years, of difficulty conversing and maintaining eye contact, of seeing multiple psychologists at once.

Among the murkiest essays is "Clipped," which is at once about working as a dog groomer, deciding whether or not to apply to college, and feeling a need to escape her family. Maloney writes of her home life, "I knew something was wrong, that maybe there was a fire and everyone was inside the house." Something is wrong here, but that something is never clearly identified; I found myself waiting for retrospection that never came. "Clipped" feels, itself, clipped — an issue I had with several other essays, which put too much faith in the power of showing, not telling. "Some Therapy," for instance, is a list of 12 therapists, social workers, psychologists, and psychiatrists that Maloney saw, the reasons she was sent to them, and approximately how much they cost. "A Brief Inventory of My Drugs and Their Retail Price" is, well, what it sounds like. In these instances, I didn't know what to make of the litany: It is clear that both the therapy and the drugs weren't the treatment that Maloney actually needed, but unclear where she places the blame.

That Maloney does not even engage in any kind of questioning in these pieces is what makes them lack tension, fall flat. Later essays, where she takes up the same sort of thinking on the page that gives "Cost of Living" its verve, are far more compelling.

Among the best essays in the collection is "Soft Restraints," where Maloney finds a mirror in a woman she calls Elizabeth, who kept thrashing in her ER bed — and digs into the problem of female patients not being taken seriously. Elizabeth's chart labeled her as having borderline personality disorder and fibromyalgia, "a made-up diagnosis for us then, a kind of early aughts placeholder for female hysteria." In contrast is another woman who presents with "the worst headache of her life" and cannot stop crying. "Usually things like this were some kind of conversion disorder, or maybe psychosis," Maloney writes, but instead of resting in that assumption, this patient is sent for a CT scan that reveals a brain tumor the size of a small orange. Maloney herself ended up more like the "orange woman": she was eventually diagnosed correctly with a developmental disorder, hypothyroidism, and a vitamin deficiency, but realizes how she could have become Elizabeth: "It doesn't take much to get addicted to someone taking an interest in who you are, that sometimes all you are looking for is an answer, an explanation for why you feel this way, maybe a box to check or a space to occupy." This kind of zoom out and sustained inquiry is what I longed for in earlier pieces.

The essay that I cannot stop thinking about, though, is "Failures in Communication," where Maloney digs into the ethics of how physicians talk to patients about what is happening inside their bodies. Here, Maloney is no longer an ER tech but a pure observer in a teaching hospital in Pittsburgh, shadowing in an ICU step-down unit for a bioethics course she took while completing her MFA. This unit is where people go after they have survived intensive care, where "patients are responsive, awake, alert...but nevertheless very sick. This is the hardest part of patients and families to understand: that their loved one may still die, even though he seems fine."

In this liminal space between the worst of sickness and the beginning of what may be recovery or relapse, patients listen as medical students present their cases—explain what is keeping them in a hospital bed—to a group of residents, interns, attending physicians, and nurses during rounds. Medical students must "learn two languages, one for the patients and one for medicine." The language for patients isn't just medical jargon translated into what a layperson may understand, but a language with carefully regulated "nuance, tone, meter, facial expression," one that may include more or less information in order to manage the anxiety of patients and their family members. Writing of the case of woman whose husband always "assumes the worst," Maloney locates the conundrum that comes when translating from one language to another: "The information is incomplete, or they wait to tell the husband until they are sure they are going to do this procedure or that...Is making [patients] the last to know helping or hurting them? Where is the line?"

We will all someday land on the wrong side of the hospital bed, be at the mercy of caregivers who must determine how to treat us, how to talk to us, how to charge us. In the era of COVID — which Maloney touches on only briefly in the last essay — the precarity of health is all the more real. At its best, Cost of Living offers insight into the subculture of medicine and incites the reader to think more deeply about what our health care system is costing us all.

Kristen Martin's writing has also appeared in The New York Times Magazine, The Believer, The Baffler, and elsewhere. She tweets at @kwistent .

Home — Essay Samples — Nursing & Health — Nursing — Argumentative Essay On Health Care Cost

Argumentative Essay on Health Care Cost

• Categories: Nursing

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Words: 949 |

Published: Mar 13, 2024

Words: 949 | Pages: 2 | 5 min read

Table of contents

Escalating costs, implications for individuals and society, potential solutions, rising drug prices, price variation for medical services, administrative costs.

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Americans’ Challenges with Health Care Costs

Lunna Lopes , Alex Montero , Marley Presiado , and Liz Hamel Published: Mar 01, 2024

This issue brief was updated on March 1, 2024 to include the latest KFF polling data. 

For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. These costs and the prospect of unexpected medical bills also rank as the top financial worries for adults and their families, and recent polling shows that lowering out-of-pocket health care costs is by and large the public’s top health care priority. Health care affordability is also one of the top issues that voters want to hear presidential candidates talk about during the 2024 election. This data note summarizes recent KFF polling on the public’s experiences with health care costs. Main takeaways include:

• About half of U.S. adults say it is difficult to afford health care costs, and one in four say they or a family member in their household had problems paying for health care in the past 12 months. Younger adults, those with lower incomes, adults in fair or poor health, and the uninsured are particularly likely to report problems affording health care in the past year.
• The cost of health care can lead some to put off needed care. One in four adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably six in ten uninsured adults (61%) say they went without needed care because of the cost.
• The cost of prescription drugs prevents some people from filling prescriptions. About one in five adults (21%) say they have not filled a prescription because of the cost while a similar share say they have instead opted for over-the-counter alternatives. About one in ten adults say they have cut pills in half or skipped doses of medicine in the last year because of the cost.
• Those who are covered by health insurance are not immune to the burden of health care costs. About half (48%) of insured adults worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.
• Health care debt is a burden for a large share of Americans. About four in ten adults (41%) report having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.
• Notable shares of adults still say they are worried about affording medical costs such as unexpected bills, the cost of health care services (including out-of-pocket costs not covered by insurance, such as co-pays and deductibles), prescription drug costs, and long-term care services for themselves or a family member. About three in four adults say they are either “very” or “somewhat worried” about being able to afford unexpected medical bills (74%) or the cost of health care services (73%) for themselves and their families. Additionally, about half of adults would be unable to pay an unexpected medical bill of $500 in full without going into debt.

Difficulty Affording Medical Costs

Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. About half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (47%). Among those under age 65, uninsured adults are much more likely to say affording health care costs is difficult (85%) compared to those with health insurance coverage (47%). Additionally, at least six in ten Black adults (60%) and Hispanic adults (65%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more than three times as likely as adults in households with incomes over $90,000 to say it is difficult to afford their health care costs (69% v. 21%). (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022 )

When asked specifically about problems paying for health care in the past year, one in four adults say they or a family member in their household had problems paying for care, including three in ten adults under age 50 and those with lower household incomes (under $40,000). Affording health care is particularly a problem for those who may need it the most as one-third of adults who describe their physical health as “fair” or “poor” say they or a family member had problems paying for health care in the past 12 months. Among uninsured adults, half (49%) say they or a family member in their household had problems paying for health care, including 51% of uninsured adults who say they are in fair or poor health.

The cost of care can also lead some adults to skip or delay seeking services. One-quarter of adults say that in the past 12 months, they have skipped or postponed getting health care they needed because of the cost. The cost of care can also have disproportionate impacts among different groups of people; for instance, women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (28% vs. 21%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.

One in four immigrant adults (22%) say they have skipped or postponed care in the past year, rising to about a third (36%) among those who are uninsured. Seven in ten (69%) of immigrant adults who skipped or postponed care (15% of all immigrant adults) said they did so due to cost or lack of health coverage. (Source: The 2023 KFF/LA Times Survey of Immigrants: Apr.-June 2023 )

Six in ten uninsured adults (61%) say they have skipped or postponed getting health care they needed due to cost. Health insurance, however, does not offer ironclad protection as one in five adults with insurance (21%) still report not getting health care they needed due to cost.

KFF health polling from March 2022 also looked at the specific types of care adults are most likely to report putting off and found that dental services are the most common type of medical care that people report delaying or skipping, with 35% of adults saying they have put it off in the past year due to cost. This is followed by vision services (25%), visits to a doctor’s offices (24%), mental health care (18%), hospital services (14%), and hearing services, including hearing aids (10%). (Source: KFF Health Tracking Poll: March 2022 )

A 2022 KFF report found that people who already have debt due to medical or dental care are disproportionately likely to put off or skip medical care. Half (51%) of adults currently experiencing debt due to medical or dental bills say in the past year, cost has been a probititor to getting the medical test or treatment that was recommended by a doctor. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022 )

Prescription Drug Costs

For many U.S. adults, prescription drugs are a component of their routine care. More than one in four (28%) adults say it is either “somewhat” or “very difficult” for them to afford to pay for prescription drugs. Affording prescription drugs is particularly difficult for adults who take four or more prescription medications (37%) and those in households with annual incomes under $40,000 (40%). Black and Hispanic adults are also more likely than White adults to say it is difficult for them to afford to pay for prescription drugs. (Source: KFF Health Tracking Poll: July 2023 )

The high cost of prescription drugs also leads some people to cut back on their medications in various ways. About one in five adults (21%) say in the past 12 months they have not filled a prescription because of the cost. A similar share (21%) say they have taken an over-the-counter drug instead of getting a prescription filled – rising to about one third of Hispanic adults (32%) and more than one in four adults (27%) with annual household incomes under $40,000. About one in ten adults say that in the past 12 months they have cut pills in half or skipped doses of medicine due to cost. (Source: KFF Health Tracking Poll: July 2023 )

Health Insurance Cost Ratings

Overall, most insured adults rate their health insurance as “excellent” or “good” when it comes to the amount they have to pay out-of-pocket for their prescriptions (61%), the amount they have to pay out-of-pocket to see a doctor (53%), and the amount they pay monthly for insurance (54%). However, at least three in ten rate their insurance as “fair” or “poor” on each of these metrics, and affordability ratings vary depending on the type of coverage people have.

Adults who have private insurance through employer-sponsored insurance or Marketplace coverage are more likely than those with Medicare or Medicaid to rate their insurance negatively when it comes to their monthly premium, the amount they have to pay out of pocket to see a doctor, and their prescription co-pays. About one in four adults with Medicare give negative ratings to the amount they have to pay each month for insurance and to their out-of-pocket prescription costs, while about one in five give their insurance a negative rating when it comes to their out-of-pocket costs to see a doctor.

Medicaid enrollees are less likely than those with other coverage types to give their insurance negative ratings on these affordability measures (Medicaid does not charge monthly premiums in most states, and copays for covered services, where applied, are required to be nominal.) (Source: KFF Survey of Consumer Experiences with Health Insurance )

Health Care Debt

In June 2022, KFF released an analysis of the KFF Health Care Debt Survey , a companion report to the investigative journalism project on health care debt conducted by KFF Health News and NPR, Diagnosis Debt . This project found that health care debt is a wide-reaching problem in the United States and that 41% of U.S. adults currently have some type of debt due to medical or dental bills from their own or someone else’s care, including about a quarter of adults (24%) who say they have medical or dental bills that are past due or that they are unable to pay, and one in five (21%) who have bills they are paying off over time directly to a provider. One in six (17%) report debt owed to a bank, collection agency, or other lender from loans taken out to pay for medical or dental bills, while similar shares say they have health care debt from bills they put on a credit card and are paying off over time (17%). One in ten report debt owed to a family member or friend from money they borrowed to pay off medical or dental bills.

While four in ten U.S. adults have some type of health care debt, disproportionate shares of lower income adults, the uninsured, Black and Hispanic adults, women, and parents report current debt due to medical or dental bills.

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

A February 2024 KFF Health Tracking Poll shows unexpected medical bills and the cost of health care services are at the top of the list of people’s financial worries, with about three-quarters of the public – and similar shares of insured adults younger than 65 – saying they are at least somewhat worried about affording unexpected medical bills (74%) or the cost of health care services (73%) for themselves and their families. Just over half (55%) of the public say they are “very” or “somewhat worried” about being able to afford their prescription drug costs, while about half (48%) of insured adults say they are worried about affording their monthly health insurance premium.

Worries about health care costs pervade among a majority of adults regardless of their financial situation . Among adults who report difficulty affording their monthly bills, more than eight in ten say they are worried about the cost of health care services (86%) or unexpected medical bills (83%). Among those who report being just able to afford their bills, about eight in ten say they are worried about being able to afford unexpected medical bills (84%) or health care services (83%). And even among adults who say they can afford their bills with money left over, six in ten nonetheless say they are “very” or “somewhat worried” about being able to afford unexpected medical bills (62%) or the cost of health care services (60%) for themselves and their family. (Source: KFF Health Tracking Poll: February 2024 )

Many U.S. adults may be one unexpected medical bill from falling into debt. About half of U.S. adults say they would not be able to pay an unexpected medical bill that came to $500 out of pocket. This includes one in five (19%) who would not be able to pay it at all, 5% who would borrow the money from a bank, payday lender, friends or family to cover the cost, and one in five (21%) who would incur credit card debt in order to pay the bill. Women, those with lower household incomes, Black and Hispanic adults are more likely than their counterparts to say they would be unable to afford this type of bill. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022 )

Among older adults, the costs of long-term care and support services are also a concern. Almost six in ten (57%) adults 65 and older say they are at least “somewhat anxious” about affording the cost of a nursing home or assisted living facility if they needed it, and half say they feel anxious about being able to afford support services such as paid nurses or aides. These concerns also loom large among those between the ages of 50 and 64, with more than seven in ten saying they feel anxious about affording residential care (73%) and care from paid nurses or aides (72%) if they were to need these services. See The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey for a deeper dive into concerns about the affordability of nursing homes and support services.

• Health Costs
• Racial Equity and Health Policy
• Private Insurance
• Affordability
• High Deductible Plans
• Tracking Poll
• Survey on Racism, Discrimination and Health

Also of Interest

• Survey on Racism, Discrimination and Health Project
• Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills
• KFF Health Tracking Poll – March 2022: Economic Concerns and Health Policy, The ACA, and Views of Long-term Care Facilities
• KFF’s Kaiser Health News and NPR Launch Diagnosis: Debt, a Yearlong Reporting Partnership Exploring the Scale, Impact, and Causes of the Health Care Debt Crisis in America
• How Financially Vulnerable are People with Medical Debt?

What do you think? Leave a respectful comment.

Jason Kane Jason Kane

• Copy URL https://www.pbs.org/newshour/health/health-costs-how-the-us-compares-with-other-countries

Health Costs: How the U.S. Compares With Other Countries

How much is good health care worth to you? $8,233 per year? That’s how much the U.S. spends per person.

That figure is more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom. On a more global scale, it means U.S. health care costs now eat up 17.6 percent of GDP.

A sizable slice of Americans — including some top-ranking politicians — say the cost may be unfortunate but the U.S. has “the best health care in the world.”

But let’s consider what 17 cents of every U.S. dollar is purchasing. According to the most recent report from the Organization for Economic Co-operation and Development (OECD) — an international economic group comprised of 34 member nations — it’s not as much as many Americans expect.

In the United States:

• There are fewer physicians per person than in most other OECD countries. In 2010, for instance, the U.S. had 2.4 practicing physicians per 1,000 people — well below below the OECD average of 3.1.
• The number of hospital beds in the U.S. was 2.6 per 1,000 population in 2009, lower than the OECD average of 3.4 beds.
• Life expectancy at birth increased by almost nine years between 1960 and 2010, but that’s less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. The average American now lives 78.7 years in 2010, more than one year below the average of 79.8 years.

There’s a bright side, to be sure. The U.S. leads the world in health care research and cancer treatment, for instance. The five-year survival rate for breast cancer is higher in the U.S. than in other OECD countries and survival from colorectal cancer is also among the best, according to the group.

This week on the PBS NewsHour broadcast, health correspondent Betty Ann Bowser will explore one hospital system’s unusual approach to improving performance while reducing costs — one based on Toyota’s assembly line model for manufacturing cars. The concept is pretty simple: If waste is rooted out of the “assembly line process,” the result will be better cars (or health outcomes, in this case) and lowered costs. At Virginia Mason Medical Center in Seattle, top officials decided that hospital “waste” can look like anything from unnecessary tests to elaborate waiting rooms to poorly designed floor plans. Tune in for the full report.

In the meantime, for a more detailed update on where the U.S. stands apart from its global peers, we spoke to Mark Pearson, head of Division on Health Policy at OECD.

NewsHour: Let’s start broadly. Where does the U.S. health care spending stand relative to other OECD countries?

Pearson: Whether measured relative to its population or its economy, the United States spends by far the most in the world on health care.

The U.S. spent $8,233 on health per person in 2010. Norway, the Netherlands and Switzerland are the next highest spenders, but in the same year, they all spent at least $3,000 less per person. The average spending on health care among the other 33 developed OECD countries was $3,268 per person.

The U.S. is a very rich country, but even so, it devotes far more of its economy — 17.6 percent of GDP in 2010 — to health than any other country. The Netherlands is the next highest, at 12 percent of GDP, and the average among OECD countries was almost half that of the U.S., at 9.5 percent of GDP.

NewsHour: What are Japan and France doing, for instance, to keep down their costs?

Pearson: France and Japan demonstrate that it is possible to have cost-containment at the same time as paying physicians using similar tools to those used in the U.S. There are three key things that stand out when you compare these countries to the U.S.:

• They use a common fee schedule so that hospitals, doctors and health services are paid similar rates for most of the patients they see. In the U.S., how much a health care service gets paid depends on the kind of insurance a patient has. This means that health care services can choose patients who have an insurance policy that pays them more generously than other patients who have lower-paying insurers, such as Medicaid.
• They are flexible in responding if they think certain costs are exceeding what they budgeted for. In Japan, if spending in a specific area seems to be growing faster than projected, they lower fees for that area. Similarly, in France an organization called CNMATS closely monitors spending across all kinds of services and if they see a particular area is growing faster than they expected (or deem it in the public interest), they can intervene by lowering the price for that service. These countries also supplement lowering fees with other tools. For example, they monitor how many generic drugs a physician is prescribing and can send someone from the insurance fund to visit physicians’ offices to encourage them to use cheaper generic drugs where appropriate. In comparison, U.S. payment rates are much less flexible. They are often statutory and Medicare cannot change the rates without approval by Congress. This makes the system very inflexible for cost containment.
• There are few methods for controlling rising costs in private insurance in the U.S. In running their business, private health insurers continually face a choice between asking health care providers to contain their costs or passing on higher costs to patients in higher premiums. Many of them find it hard to do the former.

NewsHour: Are there particular areas of care where the U.S. spends more? What are some successful models other countries are employing to keep costs down in those areas?

Pearson: Spending on almost every area of health care is higher in the United States than in other countries. For example, nearly $900 per person per year goes on administrative costs. This is far higher than in, say, France, which spends $300 per person, but which also has a system in which health care services are reimbursed in a similar way to the U.S.

In part, higher costs are also because the U.S. has been slow to embrace the advantages of information and communications technology in improving the administration of its system and in cutting down on waste. In Sweden, for example, all drug prescribing is done electronically — a message is sent directly from the doctor’s office to the pharmacy. Not only does this cut down on medical errors, it is also thought to save 1-2 hours of work by the pharmacists per day.

NewsHour: For hospital care in particular, how much more does the U.S. spend? Do we know why it’s more? What might the U.S. learn from other OECD nations in this area?

Pearson: A large amount of higher overall hospital spending in the U.S. can be explained by services costing more in U.S. hospitals rather than because U.S. hospitals are delivering more services. When we look across a broad range of hospital services (both medical and surgical), the average price in the United States is 85 percent higher than the average in other OECD countries. To put this in perspective, a hospital stay in the United States costs over $18,000 on average. The countries that come closest to spending as much — Canada, the Netherlands, Japan — spend between $4,000 and $6,000 less per stay. Across OECD countries, the average cost of a hospital stay is about one-third that of the U.S., at $6,200.

As we have previously said, many OECD countries use strong regulation to set prices that hospitals can charge for different services, and some of them even set budgets for how much hospitals can spend. The quality of care delivered in hospitals in these countries are comparable to that in the U.S., and universities are still able to attract the best students to medicine.

If strict price control is not a path that the U.S. wishes to follow, an interesting example that the U.S. could learn from is Switzerland, where the national government provides a ranking of hospital services from most expensive to least expensive. Groups of insurers and hospitals across different regions then use the national government’s ranking to negotiate what prices they ought to pay across the board.

Such an approach still leaves room for differences in prices across regions and states, but it could help smooth out some of the huge differences you see in prices paid for the same services delivered in the same hospital, depending on whether a patient is on Medicare, Medicaid or their own health insurer.

NewsHour: What about specific procedures? Why is the cost of a hip replacement in the U.S. double what it costs in Germany, for instance?

Pearson: The table below gives some examples of the prices of some common procedures in the United States compared with some of the countries with the best quality health systems in the world. It shows that:

• A coronary bypasses costs between nearly 50 percent more than in Canada, Australia and France, and are double the price in Germany.
• Hip and knee replacements are generally cheaper in other countries than the U.S.
• PTCAs (coronary angioplasty) are much more expensive in the United States than elsewhere.

It is difficult to untangle precisely why prices are higher in the U.S., but two things are apparent: U.S. physicians get higher incomes than in other countries and the U.S. uses more expensive diagnostic procedures. More generally, with so many different kinds of insurance, no one organization has a strong incentive to cut out wasteful practices and ensure that all Americans get value for the very high levels of expenditure incurred when they are sick.

NewsHour: The U.S. system is known for over-testing and over-treating, everything from CT scans and MRIs, knee replacements to coronary bypasses. How severe is the over-testing and why is it occurring? Are there mechanisms in place to prevent this in other OECD countries?

Our data suggests that the U.S. does do more tests than other OECD countries. The U.S. did 100 MRI tests and 265 CT tests for every 1000 people in 2010 — more than twice the average in other OECD countries. It does more tonsillectomies and more knee replacements than any other OECD country. It also has more Caesarean sections and coronary bypass procedures than in most other countries.

These procedures and the use of expensive diagnostic tests are all subject to physician opinion on whether they are desirable or not. The fact that U.S. physicians decide that more procedures and tests are desirable compared to their peers in other countries could be due to a few different things, such as:

• A fear of litigation that sees physicians test for everything so that they cannot be blamed for not having covered all bases
• Payments that mean that physicians get paid more if they do more interventions, regardless of medical necessity.
• Because patients ask for more tests and services. It is often comforting to feel that medical problems are being diagnosed or treated, regardless of whether they are medically necessary. As these services are often paid for by insurance policies, the immediate cost of extra treatment for a patient is often zero or very low.

It is often argued that differences in testing could reflect differences in patients’ needs between and within countries. However, research at the Dartmouth Institute has documented that there are large variations in medical practice across different regions in the United States which cannot be explained by differences in population structure or differences in illness. They found that the rate of coronary bypass was five times greater in certain hospital referral regions in the United States than others between 2003 and 2007. Similarly, regional variations in hip and knee replacement are substantial, with the rates four to five times higher in some regions compared with others in 2005-06.

Some OECD countries have seen their medical profession and health policy makers develop ‘clinical guidelines’ to promote a more rational use of MRI and CT exams. In the United Kingdom, since the creation of the Diagnostic Advisory Committee by the National Institute for Health and Clinical Excellence (NICE), a number of guidelines have been issued on the appropriate use of MRI and CT exams for different purposes

NewsHour: Is the U.S. doing less than other countries in some instances?

Pearson: It is likely that this is happening in some instances. The U.S. has fewer physicians and fewer physician consultations relative to its population. The U.S. also has fewer hospital beds for its population size and shorter average stays in hospital relative to other countries. Indeed, the lower numbers of physicians could help explain why they cost more; there is less competition for patients.

Having fewer hospital beds and shorter hospital stays can also be a good thing — a sign that wasteful overuse of hospitals is being avoided in the U.S. system. Medicare in the U.S. has long pioneered how hospitals are paid, by providing a fixed amount for a patient with a particular condition. This means that hospitals have an incentive to treat patients as quickly as possible and it also demonstrates how broader reform in the U.S. could potentially have large effects on costs.

NewsHour: Where is the U.S. getting value for its health care dollar?

Pearson: If insured, waiting times for U.S. patients are among the lowest in OECD countries. Relatively fewer patients (just 20 percent) wait more than four weeks for a specialist appointment or more than four months for elective surgery (7 percent).

U.S. patients also benefit from better cancer outcomes. OECD Health Data shows that the five-year survival rate for breast cancer is higher in the U.S. than in other OECD countries (89.3 percent compared to an OECD average of 83.5 between 2004 and 2009); survival from colorectal cancer is also among the best (64.5 percent compared to an OECD average of 59.9 percent, 2004-09).

Most obviously, the U.S. leads the world in health care research. Along with the FDA’s comparatively shorter drug approval processes, this means that cutting-edge drugs and treatments are available more quickly to American patients than elsewhere. The average time from first (worldwide) launch of a new drug to use is 1.3 years in the U.S., the lowest of all OECD countries. The U.S. is also trialing more new procedures and treatments, with the National Institutes of Health currently registering 119,469 clinical trials underway in the U.S., vastly more than any other OECD country.

The U.S. has also led the way on safer hospitals and health care quality, with programs such as the Institute of Healthcare Improvement’s 100,000 Lives campaign triggering far-reaching cultural shifts in the several thousand hospitals and clinical facilities that signed. Innovative centers such as the Mayo Clinic and Johns Hopkins that bring laboratory research and clinical practice together have also benefited patients enormously.

The size and diversity of the U.S. system has also provided room for more experimentation to try and find better ways to deliver health care. Examples that the world is watching at the moment include Accountable Care Organisations, which seek to better manage risk-sharing by giving providers flexibility to coordinate and deliver health care while holding them accountable for costs and outcomes and the Medical Home model, which seeks to coordinate care and better engage patients and families, using health coaches, care transition pathways and other interventions to reduce expensive re-hospitalizations. Unfortunately, while the U.S. is better at trying out such innovations on a relatively small scale, it then struggles to roll out successful innovations nationally.

NewsHour: Are there particular areas the U.S. is doing poorly compared to other OECD countries?

Overall, the life expectancy of a U.S. citizen, at 78.2 years, is shorter than the average among OECD countries of 79.5 years and there are a number of specific areas where U.S. health care is weak when compared with other countries.

The U.S. needs stronger policies in tackling lifestyles that lead to poor health. While many states are making efforts to reduce smoking, there are fewer policies to tackle the harmful use of alcohol in the U.S. than you would find in other OECD countries, such as higher taxes on alcohol or minimum prices.

The U.S. could certainly do a lot more on obesity. It’s a big risk factor for poor health in the U.S., more so than you find in other OECD countries. Adult overweight and obesity rates are the highest in the OECD, and have kept growing even in the last couple of years, while they have nearly stabilised in some other OECD countries, such as England, France and Italy. Child overweight and obesity rates are also very high, but they have been relatively stable over the past 10 years. The slides below show that the U.S. does poorly both in terms of diet and physical activity, even in comparison with other high-obesity countries, across all age groups.

The first lady’s “Let’s move” campaign is great, but it cannot achieve a lot if it isn’t supported by other measures. Support for physician counseling and programs to help encourage healthier lifestyles vary widely with different insurance arrangements. The U.S. has a national program to cover breast and cervical cancer screening for low-income women, why not have one to cover lifestyle counseling for low-income people? Advertising regulation is left to the food and beverage industry (e.g. the IFBA “Pledges”) and this is not likely to have a major impact.

In terms of health care services, the biggest areas of concern are the quality of primary care services and coordination of care for long-term conditions. Asthma, a condition readily managed by general practitioners in the community, should require hospital admission on very few occasions. In the U.S. however, hospital admission rates for asthma are more than double the OECD average (120.6 per 100,000 population compared to an OECD average of 51.8, 2009).

A similar picture emerges for chronic obstructive pulmonary disease (230 admissions per 100,000 population compared to an OECD average of 198, 2009). These outcomes can be improved through better health care. In a Commonwealth Fund survey of seven nations (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), 16 percent of American patients reported delays in being notified about an abnormal test result (the highest proportion reported) and only 75 percent of primary care physicians reported often or always receiving correspondence from specialists after referral suggesting systemic problems with care coordination.

Editor’s Note: Tune in to the PBS NewsHour on Wednesday for health correspondent Betty Ann Bowser’s full report on Virginia Mason Medical Center’s Toyota-inspired approach to improving care and bringing down costs . All week on the NewsHour’s health page, we’ll continue to explore why the U.S. health care system is so expensive and what can be done to fix it.

Tuesday: What steps can you take to make your next hospital stay safer and cheaper? Hari Sreenivasan talks with Elizabeth Bailey, author of “The Patient’s Checklist: 10 Simple Hospital Checklists to Keep You Safe, Sane and Organized.”

Wednesday: We illustrate what the U.S. could buy with the $750 billion wasted in American health care each year , and, in a separate post, our partners at Kaiser Health News examine the “Top 7 Drivers of U.S. Health Care Costs.”

Thursday: In a “Reporter’s Notebook,” Betty Ann Bowser examines Virginia Mason’s decision to eliminate a staple of the American hospital: the waiting room.

Friday: What inefficiencies have you seen in the U.S. health care system? We share some of the first-person accounts submitted by NewsHour viewers.

Jason Kane is a PBS NewsHour producer, focusing on health care and national affairs.

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• Open access
• Published: 14 May 2024

An overview of the perspectives used in health economic evaluations

• Manit Sittimart 1 ,
• Waranya Rattanavipapong 1 ,
• Andrew J. Mirelman 2 ,
• Trinh Manh Hung 3 ,
• Saudamini Dabak 1 ,
• Laura E. Downey 4 , 5 ,
• Mark Jit 6 , 7 ,
• Yot Teerawattananon 1 , 8 &
• Hugo C. Turner 9  

Cost Effectiveness and Resource Allocation volume  22 , Article number:  41 ( 2024 ) Cite this article

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The term ‘perspective’ in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders’ viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence.

What is the perspective in health economic evaluations?

Health economic analyses, particularly economic evaluations and costing studies, have an important role in investigating the value-for-money of health interventions and supporting decision-making surrounding resource allocation within the health sector [ 1 , 2 , 3 ]. Such studies are a key element of Health Technology Assessment (HTA) processes and other priority-setting or decision-making processes [ 1 , 4 , 5 ]. When conducting an economic evaluation of a particular health intervention or technology, understanding the perspective, or the point of view from which the evaluation is conducted is important, as it determines the boundary of the study and which types of costs and consequences/outcomes are included within the analysis [ 6 ]. Note that cost is a general term that refers to the value of resources/inputs used to produce a good or service. As different perspectives include (or exclude) different costs and outcomes, they can substantially influence the results of health economic studies and the subsequent recommendations and policies informed by these studies [ 7 ]. Therefore, it is vital that the perspective is carefully considered when conducting, reviewing, or interpreting health economic analyses.

Different types of perspectives have been adopted in health economic studies. However, there is no universally accepted “right” answer regarding which perspective should be applied, and this decision will depend on the context, type of analysis, decision-maker and question that the evaluation aims to answer [ 7 ]. Due to contextual considerations, the perspective is one of the methodological areas that exhibits the largest variation within the currently available guidelines for health economic studies [ 8 , 9 , 10 ]. Therefore, this is a potentially challenging area for stakeholders when conducting and/or interpreting these studies. Consequently, there is a need for an overview outlining the key types of perspectives, along with the corresponding implications of using different perspectives in health economic analyses. This is particularly important in the context of low-and-middle-income countries (LMICs), where there are less well-established guidelines and infrastructure (including data) for conducting economic evaluations and subsequently the potential for more variation in methodology between studies. To date, the Guide to Economic Analysis and Research (GEAR) resource has only identified 14 national guidelines from LMICs related to conducting health economic evaluations [ 11 ].

This article aims to outline and introduce the main types of perspectives used in economic evaluations, as well as to discuss their implications on cost-effectiveness calculations. We also outline ongoing issues and considerations related to perspectives that are important to be aware of when comparing and interpreting economic evaluations. It is expected that greater awareness of these concepts will lead to better consistency in future health economic studies and improve the interpretation and comparison of health economic evidence.

What are the main types of perspectives?

Here we provide a breakdown of the most commonly used perspectives within health economic evaluations and costing studies. These are derived from a review of key texts [ 8 , 12 , 13 ], and recommendations from multiple international and national economic evaluation guidelines listed in the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR) websites [ 11 , 14 , 15 ]. That said, it is important to note that there is variation in terminology used within the field to describe perspectives as well as other terms for perspectives not included here. We have endeavoured to highlight what we consider to be the most established definitions.

The differences between these perspectives relate to what cost (and cost saving) items may be included within an analysis. Figure  1 provides an overview of the different perspectives and the variation of included costs. In the context of cost-effectiveness and cost-utility analysis, the inclusion of non-monetary health outcomes (such as disability-adjusted life year (DALY), quality-adjusted life year (QALY) or cases averted) in the denominator of the cost-effectiveness ratio calculations would not typically be influenced by these perspectives whereas the costs in the numerator would be directly influenced.

Overview of the different perspectives and the variation of included costs within economic evaluations. Y: Included; N: Not included; * The limited societal perspective excludes spillover impacts affecting sectors other than health care whereas the (non-limited) societal perspective includes the spillover impacts on at least one non-health care sector. Note that there is variation in terminology used within the field to describe these different perspectives as well as others not included here. Therefore, it is possible some studies would apply these perspectives differently to what we have outlined

Patient/household

The patient or household perspectives are used to describe the costs borne by individuals or their households, respectively. The patient perspective may be limited to the costs incurred by the patient whereas the household perspective also includes the costs incurred by other members of the household. This distinction is not always made as the terms are at times used interchangeably. Under the patient/household perspective, all costs that patients incur when facing a health issue could be included, such as direct medical costs that are not covered by the patient's health insurance (i.e., out-of-pocket costs, co-payments, and deductibles), direct non-medical costs (such as those from transport to health facilities), and potentially productivity costs—also known as indirect costs (i.e., monetised productivity losses resulting from lost paid and unpaid work due to an illness or an intervention). The extent to which these cost types are included depends on the type of study being conducted. Within the context of an economic evaluation of a health system intervention, all costs borne by the patient would be included. While the patient/household perspective is more likely to be used within cost-of-illness studies or analysis of patient health expenditure/analyses of financial risk protection [ 16 ], it is rarely applied within full economic evaluations. However, some have advocated for using this perspective in economic evaluations in the context of the increasing focus on patient-centred outcomes in health policy research [ 8 , 12 ].

Health care payer or payer

The health care payer perspective includes costs incurred by specific health care payer(s)—typically a third party, such as a specific health organisation, specific control programme or agency that manages an insurance programme [ 9 ]. This would include the costs incurred by a specific health care payer related to treatment, disease management or other health care services [ 9 , 16 ]. However, the costs that are not borne by this specific payer will not be considered (such as the out-of-pocket payments paid by patients). It is important to note that the payer perspective would only relate to the part of the organisation that the funds have been planned or budgeted for [ 17 ]. Therefore, it would capture the costs incurred by a specific control programme but not the costs incurred by the broader health care provider(s). It is noteworthy that in some settings there can be multiple relevant payers (such as multiple insurance programmes).

Health care provider(s)

The health care provider’s perspective will include all costs incurred by a given provider (or group of providers in the health system) in delivering care services to patients. Depending on the context, this can be the same as the health care payer perspective. However, the health care provider(s) perspective is usually broader in terms of its scope of costs included; as the payer perspective only relates to the specific part of the organisation that the funds have been planned/budgeted for [ 17 ]. The difference between the payer and provider perspectives will depend on the context of the study, but it is plausible that the provider’s perspective will give a more complete picture of total costs and hence is used more often in costing exercise [ 16 ].

Healthcare sector

The healthcare sector perspective is similar to the health care provider(s) perspective but broader and accounts for all the costs directly associated with the healthcare sector, regardless of who will bear such costs. This means that it not only includes the direct medical costs incurred by specific third-party payers (such as national health services), but it also includes the out-of-pocket payments for health care made by patients [ 9 ]. Costs that are not directly related to medical services/the health sector are considered outside of the scope of the healthcare sector perspective—such as costs related to the patients' travel or accommodation and productivity costs (indirect costs) [ 18 ]. The distinction between health care payer/provider and healthcare sector perspectives may be particularly important in LMIC settings where out-of-pocket payments by patients can be a significant source of health care expenditure [ 19 ].

Health system

The definition of the health system perspective is more variable within the literature [ 20 , 21 , 22 , 23 , 24 ]. The latest WHO-CHOICE guidelines [ 20 , 21 ] defined the health system perspective as including an ensemble of actions and actors whose primary intent is to improve human health. This therefore includes all direct, market-valued costs, whether public or private, that are required to deliver the intervention, regardless of payer. This would also cover the out-of-pocket payments for health care made by patients but would not account for the patients’ direct non-medical costs (such as travel-related costs), and productivity costs. This definition is subtly broader than the healthcare sector perspective (Fig.  1 ), as it can potentially include costs from other sectors when they are a direct component of the intervention intended to improve human health (e.g., the costs associated with developing health legislation and costs associated with regulation of health care and products) [ 20 ]. It is debatable how often these are included. Costs outside of the health system that are not primarily health oriented would not be included. It should be noted that in some cases, it is possible that the term health system perspective is being defined differently—such as to refer to the costs incurred by a particular publicly funded national healthcare provider. If this was the case, it could be more equivalent to the use of the health care provider(s) perspective as outlined above.

The societal perspective is the broadest and includes all healthcare-related costs, regardless of who is paying, including the patients'/caregivers’ costs for accessing an intervention (such as for travel and accommodation etc.) and their productivity costs [ 9 ]. This perspective can also potentially include other “relevant” non-health-related impacts in other sectors [ 25 ] such as those on social services, education, legal or criminal justice, environment, etc. In practice, there is variation in how far the societal perspective is taken and whether the impact on other sectors is included [ 13 ]. Kim et al. stratified the societal perspective by whether it is limited or not (Fig.  1 ) [ 9 ]. The limited societal perspective includes all healthcare-related costs (including the patients' costs) but excludes spillover impacts affecting sectors other than health care. In contrast, the (non-limited) societal perspective is broader and also includes the cost impacts on at least one non-healthcare sector [ 9 ]. In macroeconomic models, the societal perspective would also include the sectoral impact on other sectors due to changes in demand and supply in the economy [ 26 , 27 ].

It should be noted that there will be other types of perspectives not captured here that can fall in between these categories. For example, the National Institute for Health and Care Excellence (NICE) in the UK recommends “The perspective adopted on costs should be that of the NHS and personal social services.” [ 28 ]. This would be broader than the health system perspective as defined here as it includes the social care related costs, but not as broad as the societal perspective.

Some guidelines now recommend the use of a disaggregated societal perspective [ 29 , 30 ], where the costs and outcomes are disaggregated, either by sector of the economy or by who incurs them—and therefore it is possible to interest the results from a range of perspectives.

It should be noted that there are types of costs that may be excluded from the societal perspective [ 22 ]. For example, some interventions may result in transfer costs or payments; financial flows from one part of society to another, that do not consume resources but simply transfer the power to use resources from one person or sector to another (such as import tariffs as well as unemployment or sickness benefits) [ 31 ]. Transfer payments can be a cost to the paying government or control programme, but a financial gain to another sector or a patient. Therefore, because they do not use or create resources, transfer payments are typically not considered when estimating economic costs using a societal perspective [ 22 , 32 ], but can be included when using a narrower perspective (such as the health care payer perspective).

Implications on economic evaluations

There are several implications of the study perspective on health economic evaluations. The first is the scope of costs related to the intervention that are included. Generally, in terms of the cost of the intervention, the broader the perspective the higher the potential cost of the intervention (the impact will depend on the context). For example, when looking at the costs of providing a vaccine at a health clinic, the health care provider(s) perspective would only include the costs that are incurred by the government’s health service (such as those associated with the staff’s time, and the purchase of the vaccine etc.). However, under the societal perspective, the costs that are incurred by the patients in order to go to the clinic and get the vaccine would also be included (such as their travel costs and potentially their productivity costs associated with lost paid or unpaid work), increasing the overall cost of the intervention. Similarly, for cost-of-illness studies, the broader the perspective the wider the scope of costs included.

A related implication is that the choice of study perspective can have a significant impact on both the source of cost data and the method used for data collection. For example, this determines whether patient interviews may be needed. Having different sources of cost data and the way they are collected can contribute to the variation of cost values included in studies. For example, the costs for treating a patient at a hospital may be based on 'reimbursement rates’ under the payer perspective whereas the full cost of the resources utilised may be used under the health care provider perspective.

It is also important to note that, theoretically, the chosen perspective of an economic evaluation should not influence whether financial or economic costs should be adopted [ 33 ]. Nonetheless, the chosen perspective can influence how economic costs are valued and whether adjustments to market prices are required [ 33 ]. For example, if adopting the health care provider or payer perspective, it might be appropriate to use the market prices of a drug or vaccine that the provider has procured. However, if using the societal perspective, these prices may need to be adjusted to reflect their social opportunity costs (their value in their next best alternative use—only reflecting their short-run manufacturing and distribution costs), rather than their market price [ 22 , 34 ].

A further implication within economic evaluations is that the perspective will determine the consequences/outcomes that are included. A key example is that it affects if/what “cost savings” or cost offsets are included within the analysis. These “cost savings” are effectively deducted from the intervention cost within the cost-effectiveness ratios. These cost savings could include the costs associated with disease cases that are averted due to the intervention (for example in the case of measles vaccination, they would consider the cost savings associated with the averted measles cases that it prevents—such as the medical costs associated with hospitalised cases). The broader the perspective, the broader the types of costs included within these savings, and with the societal perspective, it can include prevented productivity costs that would have been associated with the morbidity and mortality of the cases and even costs outside the healthcare sector.

A further implication of the perspective is regarding the inclusion of future unrelated costs within these analyses [ 35 , 36 , 37 , 38 , 39 ]. Health interventions can increase the life expectancy of patients and consequently influence the consumption of both unrelated medical and non-medical resources during the additional lifetime they generate. These future unrelated costs are typically grouped into future medical costs (e.g., the costs of treating people with other future unrelated health conditions) and future non-medical costs (the costs related to consumption of non-medical resources, such as food, housing, utilities etc.). Which types of future unrelated costs that could be included within an economic evaluation, would be influenced by the perspective (with the societal perspective potentially including both future unrelated medical and non-medical costs). If these future costs are taken into account, adopting a broader perspective, could lead to a greater increase in the net cost of the intervention when it impacts the patient’s survival. This can therefore subsequently impact the estimated cost-effectiveness of the intervention. There is currently ongoing debate about the inclusion of these future unrelated costs in health economic analyses [ 35 , 36 , 37 , 38 , 39 ]. This debate and variation should be considered when interpreting different studies. The inclusion of future unrelated costs is still uncommon, and further guidance on this area is needed [ 35 ].

A particular area of debate is regarding the inclusion of future unrelated medical costs [ 35 ]. A key issue here is that the costs and outcomes of unrelated events in the future will depend on decisions not yet made and are therefore difficult to predict. This debate and variation should be considered when interpreting different studies.

Ultimately, although in some cases the use of different perspectives may only have a small impact on the cost-effectiveness ratios, it can also have a significant impact and could fundamentally change the conclusions of studies (Table  1 ). In some cases, broadening the perspective will not greatly change the estimated cost of the intervention, but could result in more cost-savings being included, resulting in the estimated cost-effectiveness ratio decreasing (Table  1 ). On the other hand, it is also possible that broadening the perspective would increase the cost of an intervention—potentially making its cost-effectiveness ratio increase (if this increase in the intervention cost outweighs any potential increase in the cost-savings). This relative impact and direction of the change on the cost-effectiveness ratio will depend on the context of the study and the intervention being investigated (Table  1 ). It should be noted that in some cases, health interventions may be estimated to be cost saving (i.e., have negative ICER values) even when using a more restricted perspective. For example, Owen et al. [ 40 ] found that among the cost-effectiveness analysis of public health interventions examined between 2005 to 2018 by the National Institute for Health and Care Excellence (NICE) in the UK, 21% were projected to generate cost savings even without using a societal perspective. In these cases, changing to a societal perspective would be unlikely to influence the results/policy recommendation. However, this will not always be the case and the perspective can have a significant impact (Table  1 ). This is particularly important to consider in countries in which the patients incur higher costs for assessing/receiving health care.

Due to this variation, if studies have used different perspectives, a direct comparison of results may be misleading. Of concern, even when the same perspective is reported to be used, the variation in the specific cost items included (Table  1 ) could still negatively impact the comparability of studies. A key driver in the variation of cost-effectiveness ratios between the use of the societal and other perspectives, is the specific types of costs being considered and if/what types of productivity costs are being included. Notably, there are issues surrounding the inclusion of productivity costs and potential double counting (outlined in Box 1). This highlights the importance of considering the perspective when comparing studies and the need to clearly report methodology regarding productivity costs.

Box 1: Issues surrounding productivity costs within economic evaluations (adapted from [ 46 ])

What is used in practice.

A review of the perspectives used in costing in cost-effectiveness analysis between 1974–2018 has been conducted by Kim et al. [ 9 ]. Interestingly, they found that studies often misspecified or did not clearly state the perspective used. After re-classification by registry reviewers, they found that a healthcare sector or payer perspective was the most common (74%) and that cost-effectiveness analysis rarely included impacts on non-healthcare sectors [ 9 ].

In terms of the available national economic evaluation guidelines (including from high income countries), a cross-country comparison by Sharma et al. [ 13 ] found that of the 31 guidelines they reviewed, 15 (48%) recommended using one of the non-societal perspectives (such as payer, health care provider health sector, health system etc.). However, the corresponding terminology used to describe these perspectives was variable. Three guidelines (10%) stated that any perspective relevant to the research question may be considered. Eight guidelines (26%) recommended using the societal perspective for the primary analysis, and 10 (26%) recommended using the societal perspective for additional analysis if required [ 13 ]. Yet, Sharma et al. also highlighted that even when the societal perspective was recommended, there was variation regarding the specific recommendations on the type of costs that should be included [ 13 ]. For example, the guidelines for Portugal recommended that intangible costs should also be included under the societal perspective [ 58 ], whereas the guidelines for Norway recommended using a societal perspective but the inclusion of productivity costs was optional [ 59 ]. In addition, while several guidelines recommended including all costs and outcomes within and outside the healthcare sector, others recommended for the more limited societal perspective excluding the impacts of the intervention on non-healthcare sectors [ 13 ]. This highlights the notable variation surrounding the societal perspective. A recent review of how the societal perspective is defined within guidelines by Avşar et al. also found substantial variation of the definition, including insufficient guidance on what to include under different perspectives [ 8 ]. Among 46 guidelines included in their review, the societal perspective featured in 30 guidelines, of which 21 (70%) explicitly considered this perspective (at times it was recommended within additional analysis). In several guidelines where productivity costs were allowed in additional analysis, this was usually referred to as a broader perspective (than healthcare), instead of explicitly defining it as a societal perspective. Interestingly, countries with multiple payers in the health systems were more likely to consider the societal perspective.

Table 2 highlights the recommendations regarding what perspective to use within key international/LMIC economic evaluation guidelines. The national economic evaluation guidelines were extracted from GEAR [ 11 ] (please note that some guidelines were not included as their text was not available in English). The focus on LMICs in Table  2 was chosen because literature providing contextual insights/case studies from LMICs are typically limited (despite the need for increased capacity in these settings). In terms of international guidelines, the WHO-CHOICE 2003 guidelines on cost-effectiveness analysis recommended using the societal perspective but excluding productivity costs [ 55 ]. The WHO-CHOICE's latest guidelines have now adopted a health system perspective [ 21 ]. In contrast, the International Decision Support Initiative (iDSI) reference case for economic evaluation recommended using a disaggregated societal perspective (where the costs and outcomes are disaggregated, either by sector of the economy or by who incurs them, making it possible to interpret the results from a range of perspectives) [ 29 , 30 ]. In terms of the available LMIC national economic evaluation guidelines, recommendations for the use of one of the non-societal perspectives were the most common. This could be because adopting these non-societal perspectives is relatively less complex and requires fewer data. That said, the societal perspective was recommended in several cases. In contrast, the perspective recommended for budget impact analysis is generally more consistent within guidelines, with the public payer or service purchaser perspectives typically recommended [ 60 ].

Selecting the perspective

In practice, it is important to note that there is no one-size-fits-all recommendation regarding what perspective should be used. The right perspective will depend on the research question, context, and goals of the decision-makers [ 7 , 34 , 71 ]. For example, if the goal is to understand the affordability of an intervention, the payer perspective may be the most appropriate.

When choosing the perspective, it is important to consider the role of patient out-of-pocket payments. Crucially, the payer and health care providers perspectives will not account for any costs paid by patients (including their out-of-pocket payments). They therefore may not be suitable for interventions that require co-payment by patients—as they will underestimate the cost of the intervention and potentially lead to inefficient policy recommendations. This is particularly important in a global heath context as patient out-of-pocket payments are one of the most critical healthcare funding sources in many LMICs [ 72 ]. In this context, at least the use of a healthcare sector perspective (if not a broader perspective) would be needed to account for these out-of-pocket payments (as outlined in Fig.  1 ).

Key considerations regarding navigating the use of societal perspective

In terms of selecting perspective, it should be noted that there is ongoing debate regarding the role of the societal perspective and when it should be used. The societal perspective is often referred to as the gold standard for economic evaluations [ 73 , 74 , 75 ] and recommended in several guidelines. The reasons for this relate to the fact that it considers a more complete picture of costs and consequences/outcomes. This has important advantages in the context of evaluating health interventions and promoting total welfare and the good of society. For example, since the societal perspective considers a full set of information regarding conceivable costs and outcomes, it has been argued that it offers a higher level of decision-supportive power and will be less dependent on the study commissioners, as well as the political and social character of the society that the study is intended for [ 73 , 74 , 76 , 77 , 78 ]. A focus solely on the health care payer/provider perspective could overlook interventions that demonstrate cost-effectiveness from a broader societal standpoint. Furthermore, excluding important costs and outcomes within an economic evaluation, as seen in more restricted perspectives, could lead to inefficient resource allocation decisions [ 78 ]. The societal perspective can identify cost-shifting between sectors and on to patients/their families [ 78 ] (e.g., if the costs to the health systems are decreased but the costs to patients are increased), which may not be accounted for with more restricted perspectives. Consequently, many have argued that the societal perspective is preferable to others [ 73 , 75 , 78 ].

However, there are important further considerations that need to be made when considering the societal perspective—particularly in a global health context [ 7 , 71 ]. Firstly, having an all-inclusive analysis from a societal perspective, where in theory all conceivable costs and outcomes are considered, may require more costs and effort in order to acquire the additional data and information. As such, there needs to be a balance between the costs of acquiring additional information needed to use the societal perspective and increasing the quality of the decision being made. In the context of having inadequate or inaccessible datasets (such as those related to epidemiology, resource uses, unit costs, baseline distribution of health outcomes and data to inform the cost-effectiveness threshold), there is a greater challenge to the adoption of a broader perspective [ 79 ]. This is the rationale why the proponents of adaptive HTA suggest that a more limited perspective can be used in more nascent systems [ 80 ]. Applying a narrower perspective, especially in the cases of limited data, may be more pragmatic, albeit presenting some degree of omitted variable bias.

Although the societal perspective has often been advocated for, less consideration has been given to what this should include and its practical implementation [ 74 , 81 ]. In practice, it is not always easy to define what the conceivable or relevant costs and outcomes to be captured are. Consequently, there can be uncertainty regarding which costs should be included, and the way the societal perspective is conceptualised and interpreted can vary [ 82 ]. Even studies that state they are using it can omit potentially relevant costs and outcomes, and the societal perspective is often less comprehensive than it could be [ 8 ]. This is notable as the choice of its conceptualisation can seriously affect the result of a health economic analysis and the variation in how it is implemented can make comparisons more challenging. More generally, it could be argued that the societal perspective increases the risk of gaming as methods are less standardised, and there are more prominent data gaps [ 7 ].

A further consideration surrounding the use of the societal perspective and the variation in its implementation relates to the ongoing debate regarding the inclusion of indirect non-health benefits within economic evaluations (i.e., averted productivity costs) [ 52 , 53 , 55 ]. From a broad utilitarian moral standpoint, including these benefits in economic evaluations is important to ensure the maximisation of the collective benefit to society from the allocation of healthcare resources. However, including productivity gains could lead to the prioritization of the treatment of one group of patients over another because one group generates greater non-health benefits, thereby failing to give equal moral concern and weight to each person’s health care needs. Consequently, there is also a potential moral argument for ignoring productivity gains, in line with Kant's moral theory and that the equitable distribution of healthcare resources should be based on individual health needs [ 83 ]. A further factor is that quantifying all relevant non-health outcomes and productivity gains could potentially be double-counting the effectiveness of interventions [ 53 ], and this is an area of debate within the field (outlined previously in Box 1). Due to these factors, even under the societal perspective, the inclusion of productivity costs (as well as types of productivity costs) is variable. It is also important to note that productivity costs are particularly sensitive to the methodology used to calculate them, and the different methods used can generate significantly different results (Box 1) [ 84 ]. It is vital to consider this variation regarding the types of productivity costs being considered and their calculation within economic evaluations when making comparisons between studies.

A further issue relates to what “society” should be considered under the societal perspective: does “society” refer to the entire world or the society of an individual country. This issue becomes more prominent when evaluating interventions with a limited supply or that involve cross-border issues [ 22 ]. Although this can influence to what degree societal costs will be included, it is not always clear what is the scope of the society of interest within studies.

Even if the societal perspective is being used correctly, it can be unclear how the information produced informs choices across different settings and decision-makers—particularly when decision-makers may have different judgements about what outcomes are relevant to their relative values [ 85 ]. This is an important limitation for which progress is being made: for example, Walker et al . [ 74 ] developed a framework for the economic evaluation of policies with the costs and outcomes falling on different sectors (e.g., health, criminal justice, education) and involving different decision makers.

To summarise, while the societal perspective offers some significant advantages, corresponding issues and challenges should also be acknowledged, particularly in LMIC settings. It is worth noting that the societal perspective will not always be required as, ultimately, economic evaluations must align with and serve the stated goals of the decision-maker. In the United Kingdom, the primary focus of the decision-maker is to enhance health outcomes efficiently within a fixed health budget [ 28 , 85 ]. Therefore, in this context, adopting a health care provider perspective is typically considered more justifiable than a societal perspective. In contrast, this perspective could be misleading in settings where co-payments by the patients are notable, when the goal is to enhance the health system’s efficiency as a whole. Consequently, the choice of the perspective will depend on the purpose of the analysis, who needs to know/use the results and policymakers'/stakeholders’ viewpoints. It is also important to consider that the adoption of the societal perspective can involve notable additional data needs and the corresponding resource needs for collecting this data. This is not to discourage adoption of the societal perspective but rather to highlight that it is not a universal gold standard and the aforementioned factors/challenges are a consideration regarding its adoption.

Recommendations for policy and research

The terminology used to describe perspectives is variable within the literature. We have endeavoured to use the most established definitions, but it is possible that studies have interpreted and used them differently as well as potentially referred to terminology not included here. We recommend that the global health economic field set more standard definitions of the different perspectives and boundaries between these terms. This is to prevent confusion and misunderstanding not only among researchers but also policymakers and the public as a whole.

A related issue is that broader perspectives consider a wider range of costs, and therefore are likely to capture greater potential cost savings resulting from health interventions. If the healthcare budget is fixed, then this would imply that the cost-effectiveness threshold should be lower for a broader perspective, i.e. that different perspectives should be accompanied by different thresholds. However, the implications go beyond simply lowering the threshold. Some of these cost savings may extend beyond the designated budget holder (e.g. the health care provider), and the presence of budget constraints and trade-offs with other sectors need to be considered. For example, switching from the health care provider perspective to the societal perspective would mean that the provider (e.g. Department of Health) is effectively subsidising other sectors and without increasing the budget, the change could effectively decrease the amount of health being generated. Hence, we recommend that future studies further explore how to more accurately account for the interaction between the chosen perspective and appropriate cost-effectiveness threshold, considering the corresponding impact of budget constraints and trade-offs with other sectors [ 85 ]. In addition, not accounting for the impact of the use of different perspectives could potentially lead to biases in decision making, with interventions that have been evaluated with the societal perspective (including more cost savings) more likely to be favoured compared to those that have been evaluated with a narrower perspective.

A factor that needs to be further investigated on the implications of the chosen perspectives is the presence and impact of budget constraints as well as the desired time scale of investment returns.

A key issue to consider when evaluating and interpreting health economic studies is the potential inclusion of productivity costs when using the societal perspective. Estimates of productivity costs are highly sensitive to the method used [ 56 ], and it is important to be aware of the potential variation in methodology when comparing studies. In addition, the types of productivity costs included can vary—even when using the societal perspective. We recommend that this is an area that should have more comprehensive and consistent reporting in future studies. Having more standardised productivity cost estimates (potentially within country specific economic evaluation reference cases/guidelines) could be helpful to ensure increased consistency between studies for a particular country setting.

In this paper, we focused on the implications of the perspectives used in economic evaluations such as cost-effectiveness and cost-utility analysis. However, it is also important for future work to consider how the perspective interacts with other health economics methods and frameworks used within public health [ 86 , 87 , 88 , 89 ].

When conducting an economic evaluation of a particular intervention, or health technology, the concept of perspective is paramount. There are different types of perspectives which are used in economic evaluations with corresponding differences in the types of costs that are considered, as well as what outcomes are included (for example it can affect if/what “cost savings” are included). The choice of perspective can have a significant impact on the results of economic evaluations. Its relative impact on the results will depend on the context of the study and the intervention being investigated.

When choosing the perspective, it is important to consider the role of patient out-of-pocket payments. Crucially, the payer and health care provider(s) perspectives will not account for any costs paid by patients (including other out-of-pocket payments). They therefore may not be suitable for interventions that require co-payments by patients, as they could underestimate the cost of interventions and potentially lead to inefficient policy recommendations. This is particularly an important consideration in LMIC settings where out-of-pocket payments can be a significant source of health care expenditure [ 19 ].

Concerningly, the terminology used to describe the different perspectives is variable within the literature. We have endeavoured to highlight what we consider to be the most established definitions. We recommend that the global health economic field set more standard definitions of the different perspectives and boundaries between these terms.

Finally, it is important to note that despite the advantages of the societal perspective, its adoption does involve additional data needs and there is notable variation in how it is implemented, particularly surrounding what types of productivity costs are considered. Ultimately, there is no universal gold standard regarding what perspective should be used as it depends on the context (including policymakers'/stakeholders’ viewpoints and data/resource availability) as well as the question that the evaluation aims to provide an answer to [ 7 ].

Availability of data and materials

The authors confirm that the data supporting the findings of this study are available within the article.

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Acknowledgements

The authors alone are responsible for the views expressed, which do not necessarily represent the views, decisions or policies of the institutions with which the authors are affiliated.

HCT acknowledges funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/X020258/1), funded by the UK Medical Research Council (MRC). This UK funded award is carried out in the frame of the Global Health EDCTP3 Joint Undertaking. The Health Intervention and Technology Assessment Program (HITAP) is a semi-autonomous research unit in the Ministry of Public Health, Thailand, and supports evidence-informed priority-setting and decision-making for healthcare. HITAP is funded by national and international public funding agencies. HITAP is also supported by the Health Systems Research Institute (HSRI), the Thai Health Promotion Foundation (ThaiHealth), the World Health Organization (WHO), the Access and Delivery Partnership, which is hosted by the United Nations Development Programme and funded by the Government of Japan, among others. The findings, interpretations and conclusions expressed in this article do not necessarily reflect the views of the funding agencies. MJ was supported by the NIHR Health Protection Research Unit in Modelling and Health Economics (grant code HPRU-2019-NIHR200908). MJ was also supported by the NIHR Health Protection Research Unit in Immunisation (HPRU-2019-NIHR200929). The views expressed are those of the authors and not necessarily those of the United Kingdom (UK) Department of Health and Social Care, the National Health Service, the National Institute for Health Research (NIHR), or the UK Health Security Agency. For the purpose of open access, the author has applied a ‘Creative Commons Attribution’ (CC BY) licence to any Author Accepted Manuscript version arising from this submission.

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Sittimart, M., Rattanavipapong, W., Mirelman, A.J. et al. An overview of the perspectives used in health economic evaluations. Cost Eff Resour Alloc 22 , 41 (2024). https://doi.org/10.1186/s12962-024-00552-1

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What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review

• Olivia R. Phillips 1 , 2   na1 ,
• Cerian Harries 2 , 3   na1 ,
• Jo Leonardi-Bee 1 , 2 , 4   na1 ,
• Holly Knight 1 , 2 ,
• Lauren B. Sherar 2 , 3 ,
• Veronica Varela-Mato 2 , 3 &
• Joanne R. Morling 1 , 2 , 5  

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There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non-engaging.

To determine the strengths and limitations to using creative PPI methods in health and social care research.

Electronic searches were conducted over five databases on 14th April 2023 (Web of Science, PubMed, ASSIA, CINAHL, Cochrane Library). Studies that involved traditional, non-creative PPI methods were excluded. Creative PPI methods were used to engage with people as research advisors, rather than study participants. Only primary data published in English from 2009 were accepted. Title, abstract and full text screening was undertaken by two independent reviewers before inductive thematic analysis was used to generate themes.

Twelve papers met the inclusion criteria. The creative methods used included songs, poems, drawings, photograph elicitation, drama performance, visualisations, social media, photography, prototype development, cultural animation, card sorting and persona development. Analysis identified four limitations and five strengths to the creative approaches. Limitations included the time and resource intensive nature of creative PPI, the lack of generalisation to wider populations and ethical issues. External factors, such as the lack of infrastructure to support creative PPI, also affected their implementation. Strengths included the disruption of power hierarchies and the creation of a safe space for people to express mundane or “taboo” topics. Creative methods are also engaging, inclusive of people who struggle to participate in traditional PPI and can also be cost and time efficient.

‘Creative PPI’ is an umbrella term encapsulating many different methods of engagement and there are strengths and limitations to each. The choice of which should be determined by the aims and requirements of the research, as well as the characteristics of the PPI group and practical limitations. Creative PPI can be advantageous over more traditional methods, however a hybrid approach could be considered to reap the benefits of both. Creative PPI methods are not widely used; however, this could change over time as PPI becomes embedded even more into research.

Plain English Summary

It is important that patients and public are included in the research process from initial brainstorming, through design to delivery. This is known as public and patient involvement (PPI). Their input means that research closely aligns with their wants and needs. Traditionally to get this input, interviews and group discussions are held, but this can exclude people who find these activities non-engaging or inaccessible, for example those with language challenges, learning disabilities or memory issues. Creative methods of PPI can overcome this. This is a broad term describing different (non-traditional) ways of engaging patients and public in research, such as through the use or art, animation or performance. This review investigated the reasons why creative approaches to PPI could be difficult (limitations) or helpful (strengths) in health and social care research. After searching 5 online databases, 12 studies were included in the review. PPI groups included adults, children and people with language and memory impairments. Creative methods included songs, poems, drawings, the use of photos and drama, visualisations, Facebook, creating prototypes, personas and card sorting. Limitations included the time, cost and effort associated with creative methods, the lack of application to other populations, ethical issues and buy-in from the wider research community. Strengths included the feeling of equality between academics and the public, creation of a safe space for people to express themselves, inclusivity, and that creative PPI can be cost and time efficient. Overall, this review suggests that creative PPI is worthwhile, however each method has its own strengths and limitations and the choice of which will depend on the research project, PPI group characteristics and other practical limitations, such as time and financial constraints.

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Introduction

Patient and public involvement (PPI) is the term used to describe the partnership between patients (including caregivers, potential patients, healthcare users etc.) or the public (a community member with no known interest in the topic) with researchers. It describes research that is done “‘with’ or ‘by’ the public, rather than ‘to,’ ‘about’ or ‘for’ them” [ 1 ]. In 2009, it became a legislative requirement for certain health and social care organisations to include patients, families, carers and communities in not only the planning of health and social care services, but the commissioning, delivery and evaluation of them too [ 2 ]. For example, funding applications for the National Institute of Health and Care Research (NIHR), a UK funding body, mandates a demonstration of how researchers plan to include patients/service users, the public and carers at each stage of the project [ 3 ]. However, this should not simply be a tokenistic, tick-box exercise. PPI should help formulate initial ideas and should be an instrumental, continuous part of the research process. Input from PPI can provide unique insights not yet considered and can ensure that research and health services are closely aligned to the needs and requirements of service users PPI also generally makes research more relevant with clearer outcomes and impacts [ 4 ]. Although this review refers to both patients and the public using the umbrella term ‘PPI’, it is important to acknowledge that these are two different groups with different motivations, needs and interests when it comes to health research and service delivery [ 5 ].

Despite continuing recognition of the need of PPI to improve quality of healthcare, researchers have also recognised that there is no ‘one size fits all’ method for involving patients [ 4 ]. Traditionally, PPI methods invite people to take part in interviews or focus groups to facilitate discussion, or surveys and questionnaires. However, these can sometimes be inaccessible or non-engaging for certain populations. For example, someone with communication difficulties may find it difficult to engage in focus groups or interviews. If individuals lack the appropriate skills to interact in these types of scenarios, they cannot take advantage of the participation opportunities it can provide [ 6 ]. Creative methods, however, aim to resolve these issues. These are a relatively new concept whereby researchers use creative methods (e.g., artwork, animations, Lego), to make PPI more accessible and engaging for those whose voices would otherwise go unheard. They ensure that all populations can engage in research, regardless of their background or skills. Seminal work has previously been conducted in this area, which brought to light the use of creative methodologies in research. Leavy (2008) [ 7 ] discussed how traditional interviews had limits on what could be expressed due to their sterile, jargon-filled and formulaic structure, read by only a few specialised academics. It was this that called for more creative approaches, which included narrative enquiry, fiction-based research, poetry, music, dance, art, theatre, film and visual art. These practices, which can be used in any stage of the research cycle, supported greater empathy, self-reflection and longer-lasting learning experiences compared to interviews [ 7 ]. They also pushed traditional academic boundaries, which made the research accessible not only to researchers, but the public too. Leavy explains that there are similarities between arts-based approaches and scientific approaches: both attempts to investigate what it means to be human through exploration, and used together, these complimentary approaches can progress our understanding of the human experience [ 7 ]. Further, it is important to acknowledge the parallels and nuances between creative and inclusive methods of PPI. Although creative methods aim to be inclusive (this should underlie any PPI activity, whether creative or not), they do not incorporate all types of accessible, inclusive methodologies e.g., using sign language for people with hearing impairments or audio recordings for people who cannot read. Given that there was not enough scope to include an evaluation of all possible inclusive methodologies, this review will focus on creative methods of PPI only.

We aimed to conduct a qualitative systematic review to highlight the strengths of creative PPI in health and social care research, as well as the limitations, which might act as a barrier to their implementation. A qualitative systematic review “brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together” [ 8 ]. This review can then advise researchers of the best practices when designing PPI.

Public involvement

The PHIRST-LIGHT Public Advisory Group (PAG) consists of a team of experienced public contributors with a diverse range of characteristics from across the UK. The PAG was involved in the initial question setting and study design for this review.

Search strategy

For the purpose of this review, the JBI approach for conducting qualitative systematic reviews was followed [ 9 ]. The search terms were (“creativ*” OR “innovat*” OR “authentic” OR “original” OR “inclu*”) AND (“public and patient involvement” OR “patient and public involvement” OR “public and patient involvement and engagement” OR “patient and public involvement and engagement” OR “PPI” OR “PPIE” OR “co-produc*” OR “co-creat*” OR “co-design*” OR “cooperat*” OR “co-operat*”). This search string was modified according to the requirements of each database. Papers were filtered by title, abstract and keywords (see Additional file 1 for search strings). The databases searched included Web of Science (WoS), PubMed, ASSIA and CINAHL. The Cochrane Library was also searched to identify relevant reviews which could lead to the identification of primary research. The search was conducted on 14/04/23. As our aim was to report on the use of creative PPI in research, rather than more generic public engagement, we used electronic databases of scholarly peer-reviewed literature, which represent a wide range of recognised databases. These identified studies published in general international journals (WoS, PubMed), those in social sciences journals (ASSIA), those in nursing and allied health journals (CINAHL), and trials of interventions (Cochrane Library).

Inclusion criteria

Only full-text, English language, primary research papers from 2009 to 2023 were included. This was the chosen timeframe as in 2009 the Health and Social Reform Act made it mandatory for certain Health and Social Care organisations to involve the public and patients in planning, delivering, and evaluating services [ 2 ]. Only creative methods of PPI were accepted, rather than traditional methods, such as interviews or focus groups. For the purposes of this paper, creative PPI included creative art or arts-based approaches (e.g., e.g. stories, songs, drama, drawing, painting, poetry, photography) to enhance engagement. Titles were related to health and social care and the creative PPI was used to engage with people as research advisors, not as study participants. Meta-analyses, conference abstracts, book chapters, commentaries and reviews were excluded. There were no limits concerning study location or the demographic characteristics of the PPI groups. Only qualitative data were accepted.

Quality appraisal

Quality appraisal using the Critical Appraisal Skills Programme (CASP) checklist [ 10 ] was conducted by the primary authors (ORP and CH). This was done independently, and discrepancies were discussed and resolved. If a consensus could not be reached, a third independent reviewer was consulted (JRM). The full list of quality appraisal questions can be found in Additional file 2 .

Data extraction

ORP extracted the study characteristics and a subset of these were checked by CH. Discrepancies were discussed and amendments made. Extracted data included author, title, location, year of publication, year study was carried out, research question/aim, creative methods used, number of participants, mean age, gender, ethnicity of participants, setting, limitations and strengths of creative PPI and main findings.

Data analysis

The included studies were analysed using inductive thematic analysis [ 11 ], where themes were determined by the data. The familiarisation stage took place during full-text reading of the included articles. Anything identified as a strength or limitation to creative PPI methods was extracted verbatim as an initial code and inputted into the data extraction Excel sheet. Similar codes were sorted into broader themes, either under ‘strengths’ or ‘limitations’ and reviewed. Themes were then assigned a name according to the codes.

The search yielded 9978 titles across the 5 databases: Web of Science (1480 results), PubMed (94 results), ASSIA (2454 results), CINAHL (5948 results) and Cochrane Library (2 results), resulting in 8553 different studies after deduplication. ORP and CH independently screened their titles and abstracts, excluding those that did not meet the criteria. After assessment, 12 studies were included (see Fig.  1 ).

PRISMA flowchart of the study selection process

Study characteristics

The included studies were published between 2018 and 2022. Seven were conducted in the UK [ 12 , 14 , 15 , 17 , 18 , 19 , 23 ], two in Canada [ 21 , 22 ], one in Australia [ 13 ], one in Norway [ 16 ] and one in Ireland [ 20 ]. The PPI activities occurred across various settings, including a school [ 12 ], social club [ 12 ], hospital [ 17 ], university [ 22 ], theatre [ 19 ], hotel [ 20 ], or online [ 15 , 21 ], however this information was omitted in 5 studies [ 13 , 14 , 16 , 18 , 23 ]. The number of people attending the PPI sessions varied, ranging from 6 to 289, however the majority (ten studies) had less than 70 participants [ 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Seven studies did not provide information on the age or gender of the PPI groups. Of those that did, ages ranged from 8 to 76 and were mostly female. The ethnicities of the PPI group members were also rarely recorded (see Additional file 3 for data extraction table).

Types of creative methods

The type of creative methods used to engage the PPI groups were varied. These included songs, poems, drawings, photograph elicitation, drama performance, visualisations, Facebook, photography, prototype development, cultural animation, card sorting and creating personas (see Table  1 ). These were sometimes accompanied by traditional methods of PPI such as interviews and focus group discussions.

The 12 included studies were all deemed to be of good methodological quality, with scores ranging from 6/10 to 10/10 with the CASP critical appraisal tool [ 10 ] (Table  2 ).

Thematic analysis

Analysis identified four limitations and five strengths to creative PPI (see Fig.  2 ). Limitations included the time and resource intensity of creative PPI methods, its lack of generalisation, ethical issues and external factors. Strengths included the disruption of power hierarchies, the engaging and inclusive nature of the methods and their long-term cost and time efficiency. Creative PPI methods also allowed mundane and “taboo” topics to be discussed within a safe space.

Theme map of strengths and limitations

Limitations of creative PPI

Creative ppi methods are time and resource intensive.

The time and resource intensive nature of creative PPI methods is a limitation, most notably for the persona-scenario methodology. Valaitis et al. [ 22 ] used 14 persona-scenario workshops with 70 participants to co-design a healthcare intervention, which aimed to promote optimal aging in Canada. Using the persona method, pairs composed of patients, healthcare providers, community service providers and volunteers developed a fictional character which they believed represented an ‘end-user’ of the healthcare intervention. Due to the depth and richness of the data produced the authors reported that it was time consuming to analyse. Further, they commented that the amount of information was difficult to disseminate to scientific leads and present at team meetings. Additionally, to ensure the production of high-quality data, to probe for details and lead group discussion there was a need for highly skilled facilitators. The resource intensive nature of the creative co-production was also noted in a study using the persona scenario and creative worksheets to develop a prototype decision support tool for individuals with malignant pleural effusion [ 17 ]. With approximately 50 people, this was also likely to yield a high volume of data to consider.

To prepare materials for populations who cannot engage in traditional methods of PPI was also timely. Kearns et al. [ 18 ] developed a feedback questionnaire for people with aphasia to evaluate ICT-delivered rehabilitation. To ensure people could participate effectively, the resources used during the workshops, such as PowerPoints, online images and photographs, had to be aphasia-accessible, which was labour and time intensive. The author warned that this time commitment should not be underestimated.

There are further practical limitations to implementing creative PPI, such as the costs of materials for activities as well as hiring a space for workshops. For example, the included studies in this review utilised pens, paper, worksheets, laptops, arts and craft supplies and magazines and took place in venues such as universities, a social club, and a hotel. Further, although not limited to creative PPI methods exclusively but rather most studies involving the public, a financial incentive was often offered for participation, as well as food, parking, transport and accommodation [ 21 , 22 ].

Creative PPI lacks generalisation

Another barrier to the use of creative PPI methods in health and social care research was the individual nature of its output. Those who participate, usually small in number, produce unique creative outputs specific to their own experiences, opinions and location. Craven et al. [ 13 ], used arts-based visualisations to develop a toolbox for adults with mental health difficulties. They commented, “such an approach might still not be worthwhile”, as the visualisations were individualised and highly personal. This indicates that the output may fail to meet the needs of its end-users. Further, these creative PPI groups were based in certain geographical regions such as Stoke-on-Trent [ 19 ] Sheffield [ 23 ], South Wales [ 12 ] or Ireland [ 20 ], which limits the extent the findings can be applied to wider populations, even within the same area due to individual nuances. Further, the study by Galler et al. [ 16 ], is specific to the Norwegian context and even then, maybe only a sub-group of the Norwegian population as the sample used was of higher socioeconomic status.

However, Grindell et al. [ 17 ], who used persona scenarios, creative worksheets and prototype development, pointed out that the purpose of this type of research is to improve a certain place, rather than apply findings across other populations and locations. Individualised output may, therefore, only be a limitation to research wanting to conduct PPI on a large scale.

If, however, greater generalisation within PPI is deemed necessary, then social media may offer a resolution. Fedorowicz et al. [ 15 ], used Facebook to gain feedback from the public on the use of video-recording methodology for an upcoming project. This had the benefit of including a more diverse range of people (289 people joined the closed group), who were spread geographically around the UK, as well as seven people from overseas.

Creative PPI has ethical issues

As with other research, ethical issues must be taken into consideration. Due to the nature of creative approaches, as well as the personal effort put into them, people often want to be recognised for their work. However, this compromises principles so heavily instilled in research such as anonymity and confidentiality. With the aim of exploring issues related to health and well-being in a town in South Wales, Byrne et al. [ 12 ], asked year 4/5 and year 10 pupils to create poems, songs, drawings and photographs. Community members also created a performance, mainly of monologues, to explore how poverty and inequalities are dealt with. Byrne noted the risks of these arts-based approaches, that being the possibility of over-disclosure and consequent emotional distress, as well as people’s desire to be named for their work. On one hand, the anonymity reduces the sense of ownership of the output as it does not portray a particular individual’s lived experience anymore. On the other hand, however, it could promote a more honest account of lived experience. Supporting this, Webber et al. [ 23 ], who used the persona method to co-design a back pain educational resource prototype, claimed that the anonymity provided by this creative technique allowed individuals to externalise and anonymise their own personal experience, thus creating a more authentic and genuine resource for future users. This implies that anonymity can be both a limitation and strength here.

The use of creative PPI methods is impeded by external factors

Despite the above limitations influencing the implementation of creative PPI techniques, perhaps the most influential is that creative methodologies are simply not mainstream [ 19 ]. This could be linked to the issues above, like time and resource intensity, generalisation and ethical issues but it is also likely to involve more systemic factors within the research community. Micsinszki et al. [ 21 ], who co-designed a hub for the health and well-being of vulnerable populations, commented that there is insufficient infrastructure to conduct meaningful co-design as well as a dominant medical model. Through a more holistic lens, there are “sociopolitical environments that privilege individualism over collectivism, self-sufficiency over collaboration, and scientific expertise over other ways of knowing based on lived experience” [ 21 ]. This, it could be suggested, renders creative co-design methodologies, which are based on the foundations of collectivism, collaboration and imagination an invalid technique in the research field, which is heavily dominated by more scientific methods offering reproducibility, objectivity and reliability.

Although we acknowledge that creative PPI techniques are not always appropriate, it may be that their main limitation is the lack of awareness of these methods or lack of willingness to use them. Further, there is always the risk that PPI, despite being a mandatory part of research, is used in a tokenistic or tick-box fashion [ 20 ], without considering the contribution that meaningful PPI could make to enhancing the research. It may be that PPI, let alone creative PPI, is not at the forefront of researchers’ minds when planning research.

Strengths of creative PPI

Creative ppi disrupts power hierarchies.

One of the main strengths of creative PPI techniques, cited most frequently in the included literature, was that they disrupt traditional power hierarchies [ 12 , 13 , 17 , 19 , 23 ]. For example, the use of theatre performance blurred the lines between professional and lay roles between the community and policy makers [ 12 ]. Individuals created a monologue to portray how poverty and inequality impact daily life and presented this to representatives of the National Assembly of Wales, Welsh Government, the Local Authority, Arts Council and Westminster. Byrne et al. [ 12 ], states how this medium allowed the community to engage with the people who make decisions about their lives in an environment of respect and understanding, where the hierarchies are not as visible as in other settings, e.g., political surgeries. Creative PPI methods have also removed traditional power hierarchies between researchers and adolescents. Cook et al. [ 13 ], used arts-based approaches to explore adolescents’ ideas about the “perfect” condom. They utilised the “Life Happens” resource, where adolescents drew and then decorated a person with their thoughts about sexual relationships, not too dissimilar from the persona-scenario method. This was then combined with hypothetical scenarios about sexuality. A condom-mapping exercise was then implemented, where groups shared the characteristics that make a condom “perfect” on large pieces of paper. Cook et al. [ 13 ], noted that usually power imbalances make it difficult to elicit information from adolescents, however these power imbalances were reduced due to the use of creative co-design techniques.

The same reduction in power hierarchies was noted by Grindell et al. [ 17 ], who used the person-scenario method and creative worksheets with individuals with malignant pleural effusion. This was with the aim of developing a prototype of a decision support tool for patients to help with treatment options. Although this process involved a variety of stakeholders, such as patients, carers and healthcare professionals, creative co-design was cited as a mechanism that worked to reduce power imbalances – a limitation of more traditional methods of research. Creative co-design blurred boundaries between end-users and clinical staff and enabled the sharing of ideas from multiple, valuable perspectives, meaning the prototype was able to suit user needs whilst addressing clinical problems.

Similarly, a specific creative method named cultural animation was also cited to dissolve hierarchies and encourage equal contributions from participants. Within this arts-based approach, Keleman et al. [ 19 ], explored the concept of “good health” with individuals from Stoke-on Trent. Members of the group created art installations using ribbons, buttons, cardboard and straws to depict their idea of a “healthy community”, which was accompanied by a poem. They also created a 3D Facebook page and produced another poem or song addressing the government to communicate their version of a “picture of health”. Public participants said that they found the process empowering, honest, democratic, valuable and practical.

This dissolving of hierarchies and levelling of power is beneficial as it increases the sense of ownership experienced by the creators/producers of the output [ 12 , 17 , 23 ]. This is advantageous as it has been suggested to improve its quality [ 23 ].

Creative PPI allows the unsayable to be said

Creative PPI fosters a safe space for mundane or taboo topics to be shared, which may be difficult to communicate using traditional methods of PPI. For example, the hypothetical nature of condom mapping and persona-scenarios meant that adolescents could discuss a personal topic without fear of discrimination, judgement or personal disclosure [ 13 ]. The safe space allowed a greater volume of ideas to be generated amongst peers where they might not have otherwise. Similarly, Webber et al. [ 23 ], , who used the persona method to co-design the prototype back pain educational resource, also noted how this method creates anonymity whilst allowing people the opportunity to externalise personal experiences, thoughts and feelings. Other creative methods were also used, such as drawing, collaging, role play and creating mood boards. A cardboard cube (labelled a “magic box”) was used to symbolise a physical representation of their final prototype. These creative methods levelled the playing field and made personal experiences accessible in a safe, open environment that fostered trust, as well as understanding from the researchers.

It is not only sensitive subjects that were made easier to articulate through creative PPI. The communication of mundane everyday experiences were also facilitated, which were deemed typically ‘unsayable’. This was specifically given in the context of describing intangible aspects of everyday health and wellbeing [ 11 ]. Graphic designers can also be used to visually represent the outputs of creative PPI. These captured the movement and fluidity of people and well as the relationships between them - things that cannot be spoken but can be depicted [ 21 ].

Creative PPI methods are inclusive

Another strength of creative PPI was that it is inclusive and accessible [ 17 , 19 , 21 ]. The safe space it fosters, as well as the dismantling of hierarchies, welcomed people from a diverse range of backgrounds and provided equal opportunities [ 21 ], especially for those with communication and memory difficulties who might be otherwise excluded from PPI. Kelemen et al. [ 19 ], who used creative methods to explore health and well-being in Stoke-on-Trent, discussed how people from different backgrounds came together and connected, discussed and reached a consensus over a topic which evoked strong emotions, that they all have in common. Individuals said that the techniques used “sets people to open up as they are not overwhelmed by words”. Similarly, creative activities, such as the persona method, have been stated to allow people to express themselves in an inclusive environment using a common language. Kearns et al. [ 18 ], who used aphasia-accessible material to develop a questionnaire with aphasic individuals, described how they felt comfortable in contributing to workshops (although this material was time-consuming to make, see ‘Limitations of creative PPI’ ).

Despite the general inclusivity of creative PPI, it can also be exclusive, particularly if online mediums are used. Fedorowicz et al. [ 15 ], used Facebook to create a PPI group, and although this may rectify previous drawbacks about lack of generalisation of creative methods (as Facebook can reach a greater number of people, globally), it excluded those who are not digitally active or have limited internet access or knowledge of technology. Online methods have other issues too. Maintaining the online group was cited as challenging and the volume of responses required researchers to interact outside of their working hours. Despite this, online methods like Facebook are very accessible for people who are physically disabled.

Creative PPI methods are engaging

The process of creative PPI is typically more engaging and produces more colourful data than traditional methods [ 13 ]. Individuals are permitted and encouraged to explore a creative self [ 19 ], which can lead to the exploration of new ideas and an overall increased enjoyment of the process. This increased engagement is particularly beneficial for younger PPI groups. For example, to involve children in the development of health food products, Galler et al. [ 16 ] asked 9-12-year-olds to take photos of their food and present it to other children in a “show and tell” fashion. They then created a newspaper article describing a new healthy snack. In this creative focus group, children were given lab coats to further their identity as inventors. Galler et al. [ 16 ], notes that the methods were highly engaging and facilitated teamwork and group learning. This collaborative nature of problem-solving was also observed in adults who used personas and creative worksheets to develop the resource for lower back pain [ 23 ]. Dementia patients too have been reported to enjoy the creative and informal approach to idea generation [ 20 ].

The use of cultural animation allowed people to connect with each other in a way that traditional methods do not [ 19 , 21 ]. These connections were held in place by boundary objects, such as ribbons, buttons, fabric and picture frames, which symbolised a shared meaning between people and an exchange of knowledge and emotion. Asking groups to create an art installation using these objects further fostered teamwork and collaboration, both at an individual and collective level. The exploration of a creative self increased energy levels and encouraged productive discussions and problem-solving [ 19 ]. Objects also encouraged a solution-focused approach and permitted people to think beyond their usual everyday scope [ 17 ]. They also allowed facilitators to probe deeper about the greater meanings carried by the object, which acted as a metaphor [ 21 ].

From the researcher’s point of view, co-creative methods gave rise to ideas they might not have initially considered. Valaitis et al. [ 22 ], found that over 40% of the creative outputs were novel ideas brought to light by patients, healthcare providers/community care providers, community service providers and volunteers. One researcher commented, “It [the creative methods] took me on a journey, in a way that when we do other pieces of research it can feel disconnected” [ 23 ]. Another researcher also stated they could not return to the way they used to do research, as they have learnt so much about their own health and community and how they are perceived [ 19 ]. This demonstrates that creative processes not only benefit the project outcomes and the PPI group, but also facilitators and researchers. However, although engaging, creative methods have been criticised for not demonstrating academic rigour [ 17 ]. Moreover, creative PPI may also be exclusive to people who do not like or enjoy creative activities.

Creative PPI methods are cost and time efficient

Creative PPI workshops can often produce output that is visible and tangible. This can save time and money in the long run as the output is either ready to be implemented in a healthcare setting or a first iteration has already been developed. This may also offset the time and costs it takes to implement creative PPI. For example, the prototype of the decision support tool for people with malignant pleural effusion was developed using personas and creative worksheets. The end result was two tangible prototypes to drive the initial idea forward as something to be used in practice [ 17 ]. The use of creative co-design in this case saved clinician time as well as the time it would take to develop this product without the help of its end-users. In the development of this particular prototype, analysis was iterative and informed the next stage of development, which again saved time. The same applies for the feedback questionnaire for the assessment of ICT delivered aphasia rehabilitation. The co-created questionnaire, designed with people with aphasia, was ready to be used in practice [ 18 ]. This suggests that to overcome time and resource barriers to creative PPI, researchers should aim for it to be engaging whilst also producing output.

That useable products are generated during creative workshops signals to participating patients and public members that they have been listened to and their thoughts and opinions acted upon [ 23 ]. For example, the development of the back pain resource based on patient experiences implies that their suggestions were valid and valuable. Further, those who participated in the cultural animation workshop reported that the process visualises change, and that it already feels as though the process of change has started [ 19 ].

The most cost and time efficient method of creative PPI in this review is most likely the use of Facebook to gather feedback on project methodology [ 15 ]. Although there were drawbacks to this, researchers could involve more people from a range of geographical areas at little to no cost. Feedback was instantaneous and no training was required. From the perspective of the PPI group, they could interact however much or little they wish with no time commitment.

This systematic review identified four limitations and five strengths to the use of creative PPI in health and social care research. Creative PPI is time and resource intensive, can raise ethical issues and lacks generalisability. It is also not accepted by the mainstream. These factors may act as barriers to the implementation of creative PPI. However, creative PPI disrupts traditional power hierarchies and creates a safe space for taboo or mundane topics. It is also engaging, inclusive and can be time and cost efficient in the long term.

Something that became apparent during data analysis was that these are not blanket strengths and limitations of creative PPI as a whole. The umbrella term ‘creative PPI’ is broad and encapsulates a wide range of activities, ranging from music and poems to prototype development and persona-scenarios, to more simplistic things like the use of sticky notes and ordering cards. Many different activities can be deemed ‘creative’ and the strengths and limitations of one does not necessarily apply to another. For example, cultural animation takes greater effort to prepare than the use of sticky notes and sorting cards, and the use of Facebook is cheaper and wider reaching than persona development. Researchers should use their discretion and weigh up the benefits and drawbacks of each method to decide on a technique which suits the project. What might be a limitation to creative PPI in one project may not be in another. In some cases, creative PPI may not be suitable at all.

Furthermore, the choice of creative PPI method also depends on the needs and characteristics of the PPI group. Children, adults and people living with dementia or language difficulties all have different engagement needs and capabilities. This indicates that creative PPI is not one size fits all and that the most appropriate method will change depending on the composition of the group. The choice of method will also be determined by the constraints of the research project, namely time, money and the research aim. For example, if there are time constraints, then a method which yields a lot of data and requires a lot of preparation may not be appropriate. If generalisation is important, then an online method is more suitable. Together this indicates that the choice of creative PPI method is highly individualised and dependent on multiple factors.

Although the limitations discussed in this review apply to creative PPI, they are not exclusive to creative PPI. Ethical issues are a consideration within general PPI research, especially when working with more vulnerable populations, such as children or adults living with a disability. It can also be the case that traditional PPI methods lack generalisability, as people who volunteer to be part of such a group are more likely be older, middle class and retired [ 24 ]. Most research is vulnerable to this type of bias, however, it is worth noting that generalisation is not always a goal and research remains valid and meaningful in its absence. Although online methods may somewhat combat issues related to generalisability, these methods still exclude people who do not have access to the internet/technology or who choose not to use it, implying that online PPI methods may not be wholly representative of the general population. Saying this, however, the accessibility of creative PPI techniques differs from person to person, and for some, online mediums may be more accessible (for example for those with a physical disability), and for others, this might be face-to-face. To combat this, a range of methods should be implemented. Planning multiple focus group and interviews for traditional PPI is also time and resource intensive, however the extra resources required to make this creative may be even greater. Although, the rich data provided may be worth the preparation and analysis time, which is also likely to depend on the number of participants and workshop sessions required. PPI, not just creative PPI, often requires the provision of a financial incentive, refreshments, parking and accommodation, which increase costs. These, however, are imperative and non-negotiable, as they increase the accessibility of research, especially to minority and lower-income groups less likely to participate. Adequate funding is also important for co-design studies where repeated engagement is required. One barrier to implementation, which appears to be exclusive to creative methods, however, is that creative methods are not mainstream. This cannot be said for traditional PPI as this is often a mandatory part of research applications.

Regarding the strengths of creative PPI, it could be argued that most appear to be exclusive to creative methodologies. These are inclusive by nature as multiple approaches can be taken to evoke ideas from different populations - approaches that do not necessarily rely on verbal or written communication like interviews and focus groups do. Given the anonymity provided by some creative methods, such as personas, people may be more likely to discuss their personal experiences under the guise of a general end-user, which might be more difficult to maintain when an interviewer is asking an individual questions directly. Additionally, creative methods are by nature more engaging and interactive than traditional methods, although this is a blanket statement and there may be people who find the question-and-answer/group discussion format more engaging. Creative methods have also been cited to eliminate power imbalances which exist in traditional research [ 12 , 13 , 17 , 19 , 23 ]. These imbalances exist between researchers and policy makers and adolescents, adults and the community. Lastly, although this may occur to a greater extent in creative methods like prototype development, it could be suggested that PPI in general – regardless of whether it is creative - is more time and cost efficient in the long-term than not using any PPI to guide or refine the research process. It must be noted that these are observations based on the literature. To be certain these differences exist between creative and traditional methods of PPI, direct empirical evaluation of both should be conducted.

To the best of our knowledge, this is the first review to identify the strengths and limitations to creative PPI, however, similar literature has identified barriers and facilitators to PPI in general. In the context of clinical trials, recruitment difficulties were cited as a barrier, as well as finding public contributors who were free during work/school hours. Trial managers reported finding group dynamics difficult to manage and the academic environment also made some public contributors feel nervous and lacking confidence to speak. Facilitators, however, included the shared ownership of the research – something that has been identified in the current review too. In addition, planning and the provision of knowledge, information and communication were also identified as facilitators [ 25 ]. Other research on the barriers to meaningful PPI in trial oversight committees included trialist confusion or scepticism over the PPI role and the difficulties in finding PPI members who had a basic understanding of research [ 26 ]. However, it could be argued that this is not representative of the average patient or public member. The formality of oversight meetings and the technical language used also acted as a barrier, which may imply that the informal nature of creative methods and its lack of dependency on literacy skills could overcome this. Further, a review of 42 reviews on PPI in health and social care identified financial compensation, resources, training and general support as necessary to conduct PPI, much like in the current review where the resource intensiveness of creative PPI was identified as a limitation. However, others were identified too, such as recruitment and representativeness of public contributors [ 27 ]. Like in the current review, power imbalances were also noted, however this was included as both a barrier and facilitator. Collaboration seemed to diminish hierarchies but not always, as sometimes these imbalances remained between public contributors and healthcare staff, described as a ‘them and us’ culture [ 27 ]. Although these studies compliment the findings of the current review, a direct comparison cannot be made as they do not concern creative methods. However, it does suggest that some strengths and weaknesses are shared between creative and traditional methods of PPI.

Strengths and limitations of this review

Although a general definition of creative PPI exists, it was up to our discretion to decide exactly which activities were deemed as such for this review. For example, we included sorting cards, the use of interactive whiteboards and sticky notes. Other researchers may have a more or less stringent criteria. However, two reviewers were involved in this decision which aids the reliability of the included articles. Further, it may be that some of the strengths and limitations cannot fully be attributed to the creative nature of the PPI process, but rather their co-created nature, however this is hard to disentangle as the included papers involved both these aspects.

During screening, it was difficult to decide whether the article was utilising creative qualitative methodology or creative PPI , as it was often not explicitly labelled as such. Regardless, both approaches involved the public/patients refining a healthcare product/service. This implies that if this review were to be replicated, others may do it differently. This may call for greater standardisation in the reporting of the public’s involvement in research. For example, the NIHR outlines different approaches to PPI, namely “consultation”, “collaboration”, “co-production” and “user-controlled”, which each signify an increased level of public power and influence [ 28 ]. Papers with elements of PPI could use these labels to clarify the extent of public involvement, or even explicitly state that there was no PPI. Further, given our decision to include only scholarly peer-reviewed literature, it is possible that data were missed within the grey literature. Similarly, the literature search will not have identified all papers relating to different types of accessible inclusion. However, the intent of the review was to focus solely on those within the definition of creative.

This review fills a gap in the literature and helps circulate and promote the concept of creative PPI. Each stage of this review, namely screening and quality appraisal, was conducted by two independent reviewers. However, four full texts could not be accessed during the full text reading stage, meaning there are missing data that could have altered or contributed to the findings of this review.

Research recommendations

Given that creative PPI can require effort to prepare, perform and analyse, sufficient time and funding should be allocated in the research protocol to enable meaningful and continuous PPI. This is worthwhile as PPI can significantly change the research output so that it aligns closely with the needs of the group it is to benefit. Researchers should also consider prototype development as a creative PPI activity as this might reduce future time/resource constraints. Shifting from a top-down approach within research to a bottom-up can be advantageous to all stakeholders and can help move creative PPI towards the mainstream. This, however, is the collective responsibility of funding bodies, universities and researchers, as well as committees who approve research bids.

A few of the included studies used creative techniques alongside traditional methods, such as interviews, which could also be used as a hybrid method of PPI, perhaps by researchers who are unfamiliar with creative techniques or to those who wish to reap the benefits of both. Often the characteristics of the PPI group were not included, including age, gender and ethnicity. It would be useful to include such information to assess how representative the PPI group is of the population of interest.

Creative PPI is a relatively novel approach of engaging the public and patients in research and it has both advantages and disadvantages compared to more traditional methods. There are many approaches to implementing creative PPI and the choice of technique will be unique to each piece of research and is reliant on several factors. These include the age and ability of the PPI group as well as the resource limitations of the project. Each method has benefits and drawbacks, which should be considered at the protocol-writing stage. However, given adequate funding, time and planning, creative PPI is a worthwhile and engaging method of generating ideas with end-users of research – ideas which may not be otherwise generated using traditional methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Critical Appraisal Skills Programme

The Joanna Briggs Institute

National Institute of Health and Care Research

Public Advisory Group

Public and Patient Involvement

Web of Science

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Acknowledgements

With thanks to the PHIRST-LIGHT public advisory group and consortium for their thoughts and contributions to the design of this work.

The research team is supported by a National Institute for Health and Care Research grant (PHIRST-LIGHT Reference NIHR 135190).

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Olivia R. Phillips and Cerian Harries share joint first authorship.

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Nottingham Centre for Public Health and Epidemiology, Lifespan and Population Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK

Olivia R. Phillips, Jo Leonardi-Bee, Holly Knight & Joanne R. Morling

National Institute for Health and Care Research (NIHR) PHIRST-LIGHT, Nottingham, UK

Olivia R. Phillips, Cerian Harries, Jo Leonardi-Bee, Holly Knight, Lauren B. Sherar, Veronica Varela-Mato & Joanne R. Morling

School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK

Cerian Harries, Lauren B. Sherar & Veronica Varela-Mato

Nottingham Centre for Evidence Based Healthcare, School of Medicine, University of Nottingham, Nottingham, UK

Jo Leonardi-Bee

NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, NG7 2UH, UK

Joanne R. Morling

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Contributions

Author contributions: study design: ORP, CH, JRM, JLB, HK, LBS, VVM, literature searching and screening: ORP, CH, JRM, data curation: ORP, CH, analysis: ORP, CH, JRM, manuscript draft: ORP, CH, JRM, Plain English Summary: ORP, manuscript critical review and editing: ORP, CH, JRM, JLB, HK, LBS, VVM.

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Correspondence to Olivia R. Phillips .

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Additional file 1: Search strings: Description of data: the search strings and filters used in each of the 5 databases in this review

Additional file 2: Quality appraisal questions: Description of data: CASP quality appraisal questions

40900_2024_580_moesm3_esm.docx.

Additional file 3: Table 1: Description of data: elements of the data extraction table that are not in the main manuscript

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Phillips, O.R., Harries, C., Leonardi-Bee, J. et al. What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review. Res Involv Engagem 10 , 48 (2024). https://doi.org/10.1186/s40900-024-00580-4

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Cost of living help and a future made in Australia

Strengthening medicare and the care economy.

Building a better health system than improves outcomes

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High‑quality health services through Medicare

Boosting access to essential health services

Building a better healthcare system

The Government is investing $2.8 billion to continue its commitment to strengthen Medicare. This includes the $1.2 billion package to address pressures facing the health system, which provides:

• $882.2 million to support older Australians avoid hospital admission, be discharged from hospital earlier and improve their transition out of hospital to other appropriate care.
• $227 million to deliver a further 29 Medicare Urgent Care Clinics and boost support for regional and remote clinics. This will increase the total number of clinics across Australia to 87. Since commencing last year, existing clinics have already provided almost 400,000 bulk‑billed visits.
• $90 million to address health workforce shortages by making it simpler and quicker for international health practitioners to work in Australia.

Rohan’s daughter Zoya has been  off school with a runny nose and a cough. By 6pm, she is lethargic and has a fever.

Rohan is concerned because his regular GP is now closed. Instead of waiting for hours at the emergency department, he takes Zoya to a Medicare Urgent Care Clinic, without having to make an appointment. 

During the bulk billed visit, Zoya is diagnosed with an infection by the doctor and prescribed appropriate medication. Rohan and Zoya leave within an hour of arrival. Zoya makes a full recovery.

Improving health outcomes

Almost half of Australians live with a chronic condition. This Budget will provide $141.1 million for research and services for people living with chronic conditions, including bowel and skin cancer, diabetes and dementia.

To improve health outcomes, the Government is providing:

• Support for Australians to enjoy healthier, more active lives by investing $132.7 million in sport participation and performance programs.
• $825.7 million to ensure Australians can continue to access testing for and vaccinations against COVID‑19. The Government is also ensuring continued access to oral antiviral medicines on the Pharmaceutical Benefits Scheme.
• $41.6 million over two years to continue funding for alcohol and other drug treatment and support services, including the Good Sports alcohol management program for community sporting clubs.

The Government is allocating an additional $411.6 million (for a total $1.6 billion over 13 years) through the Medical Research Future Fund to continue existing research and introduce two new research missions for low‑survival cancers and reducing health inequities.

Improving access to medicines

The Government is investing $3.4 billion for new and amended listings to the Pharmaceutical Benefits Scheme, which means eligible patients can save on treatment costs.

By expanding the Closing the Gap Pharmaceutical Benefits Scheme Co‑payment Program, eligible First Nations patients will have free or cheaper access to all Pharmaceutical Benefits Scheme medicines.

Australians will benefit from $141.1 million to support and expand the National Immunisation Program.

Mental health support

The Government’s $888.1 million mental health package over eight years will help people get the care they need, while relieving pressure on the Better Access initiative and making it easier to access services.

A free, low‑intensity digital service will be established to address the gap for people with mild mental health concerns. From 1 January 2026, Australians will be able to access the service without a referral and receive timely, high‑quality mental health support. Once fully established, 150,000 people are expected to make use of this service each year.

The Government is improving access to free mental health services through a network of walk‑in Medicare Mental Health Centres, built on the established Head to Health network. The upgraded national network of 61 Medicare Mental Health Centres will open by 30 June 2026. They will provide clinical services for adults with moderate‑to‑severe mental health needs.

For Australians with complex mental health needs, funding will be provided for Primary Health Networks to partner with GPs to deliver multidisciplinary, wraparound support services and care coordination.

Improving the aged care system

Providing quality care

The Budget provides $2.2 billion to deliver aged care reforms and continue implementing recommendations from the Royal Commission into Aged Care Quality and Safety.

The new Aged Care Act will put the rights and needs of older people at the centre of the aged care system. The new Act will provide the framework for fundamental change within the aged care sector.

More Home Care Packages

The Government is investing $531.4 million to release an additional 24,100 Home Care Packages in 2024–25. This will help reduce average wait times and enable people to age at home if they prefer to do so.

Improving aged care regulation

Funding of $110.9 million over four years will support an increase in the Aged Care Quality and Safety Commission’s regulatory capabilities.

The Government is investing $1.2 billion in critical digital systems to support the introduction of the new Aged Care Act and contemporary IT systems.

The My Aged Care Contact Centre will receive $37 million to reduce call‑waiting times for people seeking information and access to aged care.

Higher wages for aged care workers

The Government has committed to fund the Fair Work Commission decision to increase the award wage for direct and indirect aged care workers once the final determination is made. This will build on the $11.3 billion already allocated to support the interim 15 per cent wage increase for aged care workers.

The Government is providing $87.2 million for workforce initiatives to attract nurses and other workers into aged care.

Reforming the disability sector

Better and more sustainable services

Getting the National Disability Insurance Scheme (NDIS) back on track

A further $468.7 million is being provided to support people with disability and get the NDIS back on track. This includes:

• $214 million over two years to fight fraud and to co‑design NDIS reforms with people with disability, announced earlier this year
• $160.7 million to upgrade the NDIS Quality and Safeguards Commission’s information technology
• $45.5 million to establish a NDIS Evidence Advisory Committee
• $20 million to start consultation and design on reforms to help NDIS participants and people with disability navigate services.

This builds on $732.9 million provided in the 2023–24 Budget.

In December 2023, National Cabinet agreed to work together to improve the experience of participants and restore the original intent of the Scheme to support people with permanent and significant disability, within a broader ecosystem of supports. This builds on an earlier decision by National Cabinet to ensure Scheme sustainability and achieve an 8 per cent growth target by 1 July 2026, with further moderation as the NDIS matures.

Improving employment for people with disability

A $227.6 million investment will support a new specialised disability employment program to replace the existing Disability Employment Services program by 1 July 2025. This includes a modern digital platform for providers and participants. These reforms will support more people with disability into sustainable work, through a program with greater flexibility, increased individual supports, and better service quality. Eligibility will be expanded to include volunteers outside the income support system and those with less than eight hours per week work capacity.

Delivering essential services

Investing in reliability and security

Strengthening resourcing for Services Australia

The Government is delivering safer and more efficient government services for all Australians.

A $1.8 billion provision will support delivery of customer and payment services. This includes funding for frontline and service delivery staff to manage claims, respond to natural disasters and improve the cyber security environment. The Government is providing $314.1 million over two years to strengthen safety and security at Services Australia centres.

The Government is investing $580.3 million over four years and $139.6 million per year ongoing to sustain the myGov platform and identify potential enhancements. A further $50 million will improve usability, safety and security of the myGov platform and ensure Services Australia can support people to protect their information and privacy.

Strengthening the Australian Taxation Office (ATO) against fraud

There will be $187.4 million to better protect taxpayer data and Commonwealth revenue against fraudulent attacks on the tax and superannuation systems. Funding will upgrade the ATO’s information and communications technologies and increase fraud prevention capabilities to manage increasing risk, prevent revenue loss, and support victims of fraud and cyber crime.

Looking after our veterans

Veterans’ claims processing is prioritised with an additional $186 million for staffing resources and $8.4 million to improve case management and protect against cyber risk. The Government will provide $222 million to harmonise veterans’ compensation and rehabilitation legislation.

A further $48.4 million will be available for Veterans’ Home Care and Community Nursing programs and $10.2 million to provide access to funded medical treatment for ill and injured veterans while their claims for liability are processed.

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Anatomic Pathology Laboratory Centralization Research Paper

Introduction.

The cost of health care services in the U.S. and the world is significantly unaffordable to many people. The sector is no longer controlled by individual payers, who can demand high quality at minimal cost, but by insurance firms requiring more revenues. Even most privately operated care facilities in America do not care about the patients as they focus on money. The matter leads uncountable healthcare providers to initiate business operations targeting the investors’ personal interests, not the masses. Anatomic Pathology Laboratory (APL) aims to trigger transformation in the sector. The facility is a charitable academic health system operated by a public health trust. Currently, Anatomic Pathology Laboratory operates from four different regions in the U.S. The aspect exposes the not-for-profit organization to numerous costs and other shortcomings, including the inability to share products and technologies, cooperate with operations, and effectively manage the staffing issue. Consequently, the facility opts to adopt the centralization strategy to manage these issues and deliver improved care at a minimal cost. APL’s plan is biblical and draws basis from Ecclesiastes 4 and 1 Corinthians 12, which reinstate the need for combining resources for augmented helpfulness.

Organization Overview

Anatomic Pathology Laboratory is a significantly unique care promotion facility in the U.S. Unlike many other players in the sector, the organization hardly targets profits and handles all walks of citizens. The haves and have-nots find Anatomic Pathology Laboratory’s services highly reliable, leading to significant overcrowding of service seekers and excess utilization of the facility’s resources. Foregoing revenue generation strategies make APL dependent on donations to operate. Funds from the public are often hard to budget because of their unstable flow (Alaerts, 2019). Equally, running the public health trust demands appropriate financial management for effective operations and accountability purposes. Initially, the desire to extend services to customers located in several locations pushed APL to establish several branches. However, the tactic presently seems unsustainable due to several issues. Examples of the problems faced by the charitable pathology corporation due to the existing operational strategies are discussed below.

Challenged Sharing of Technologies and Products

Operating pathological labs is a costly endeavor based on the involved factors. The facilities require fine technologies costing lots of money. The fact that no entity plays singly in a market further necessitates the acquisition of the best technology in the market to realize competitive benefits. Medical conditions’ diagnosis procedures keep changing rapidly, forcing lab operators to adopt advancing technologies. Church and Naugler (2022) observe that a significant percentage of medical laboratory business’s costs goes to the replacement of obsolete technologies or acquiring new machinery. Accordingly, the more branches an organization operates, the higher the cost of sustaining the necessary know-how (Naugler & Church, 2019). The matter is not a big deal to many pathology establishments receiving reimbursements from the government and other private insurance firms in the U.S. However, relying on charity contributions makes it significantly hard for APL to continue its present scattered outlets, compelling the firm to think of an alternative strategy for survival.

APL’s current strategy exposes it to the challenge of sharing technologies. Often, the money reaching the organization is only adequate for buying emergent equipment or tools for some of the branches. The facet makes several other outlets lack the necessary tools to function well. Therefore, the corporation’s management bears significant pressure in apportioning the available finances and tech to the four subsidiaries. To function well, APL must find reliable ways to fit within its budget. Shutting some of the facility’s branches thus becomes necessary if the entity intends to maintain its present low-cost strategies. The centralization plan will help APL identify a specific convenient location for centralized operations. That way, APL will be able to use the scarce finances to equip the single facility to meet the correct standards. Similarly, centralization promises to reduce the management’s pressure, allowing them to adopt and implement fine-tuned strategies for the organization’s true growth.

Operational Gaps

Pathology lab serves to provide essential platforms for an investigation into the particulars and physiognomies of ailments to assist in determining an appropriate diagnosis. The Pathology lab is correspondingly a venue of knowledge development for medical scholars and medical specialists. Having an effective design and up-to-date technology makes for well-operated labs to help investigative services for hospitals and clinicians and augments the capacity to conduct leading-edge explorations. With countless pathology labs compressing a horde of pathological analysis, operational designs play a principal role in fashioning a systematized, unified and awareness-sharing venue (Khatab & Yousef, 2021). With four locations scattered around the U.S., APL is one of the most conspicuous healing benefactors and academic health organizations in the nation. However, with functions detached all over locations, the entity must merge laboratory operations. The facet is necessitated by the shifting currents in the healthcare sector and advances in management and technology, and the requirement to accommodate progress in health coordination and patient volume. Accordingly, failing to act now exposes APL to noteworthy operational challenges in the future as the available resources may become inadequate for decentralized operations.

Centralizing services will permit new workflows and practice enhancements around novel technologies that cannot be assimilated fittingly in the prevailing floor plates or spaces. The centralization plan thus purposes to establish a modern reference pathology lab, serving a myriad of healthcare facilities in the nation. APL will identify a central location for the amalgamated operations and undertake the necessary renovations to make the facility suitable. The renovation process for the laboratory will include modern elevators’ installation, new electrical settings, plumbing, fire protection installations, new security features, modern IT infrastructure, and renovated stairs, egress, and washrooms. Necessary services to be integrated into the new centralized lab should include medical pathology, anatomical pathology, clinical pathology, mass spectrometry, microbiology, genomics services, cytogenetic and molecular pathology, and electron microscope labs (Bach-Mortensen & Barlow, 2021). Having these indispensable services condensed under one roof inspires teamwork and exploration and heightens proficiency while promoting resource utilization. Accordingly, maintaining the present decentralized operations scheme leaves APL with an inefficient design, an incompetent construction design, and a hard-to-manage services plan. However, centralizing the lab services will help streamline services, leading to capital and time management gains.

Challenging Staffing Model

Operating four significantly independent pathology laboratories forces APL to have an equivalent number of staffing offices for effective operations. The staffing model is significantly involving and costly to the organization. For example, each outlet has a staffing department including at least five people, al working together to identify potentially beneficial position applicants for selection and placement. Accordingly, the four current subsidiaries lead to about twenty staffing employees. This lot hardly provides directly beneficial services to the organization but receives substantial allowances for sustenance. Moreover, having the various teams work in scattered locations leads to more critical concerns, particularly the aspect of ensuring cohesion, as diversity often leads to dissimilarities (Ohrling et al., 2021). Centralization thus remains a highly viable option for the facility. Eliminating the unnecessary branches and establishing a large central place for the team create room for the facility to realize a synergetic effect while delivering a solution for the staffing problem.

Research Support

Benefits of centralized care systems.

Centralized care systems offer real benefits to investors, care seekers, and management teams, as revealed by numerous scholarly investigations. Fay et al. (2020) provide consolidated schemes as the ultimate solution to unaffordable American care. According to scholars, hospitals and laboratory services’ desire to expand and generate more money constitute the primary source of the many financial issues witnessed in the country. Fay et al. (2020) compare decentralized models of care to hives, where different corporation subdivisions exist, each running its own activities to contribute to the establishment’s overall attainment. The organization works significantly better for the big enterprise-level businesses that take advantage of shifting recruitment and staffing tasks to local employment managers to streamline practices, improve productivity, and offer a better candidate experience. However, the approach may fail to work in settings where the management aims to control resources’ utilization for augmented productivity and quality, increased efficiency, and proper time management (Hasselgren et al., 2020). Therefore, scientific investigations significantly back the establishment of centralized systems due to their various benefits, including the following.

Greater Productivity

Centralized hospital operations promote greater productivity by facilitating speedier decision-making to meet the prevailing market trends. Like other corporations, healthcare organizations make critical decisions affecting their operations and survival. The faster a system can decide on a matter, the easier it is to succeed, according to Khan et al. (2020). Ravaghi et al. (2019) provide centralized structures as the best plans for hospitals and healthcare laboratories focusing on advancing therapeutic knowledge. The sensitivity of the undertaken activities in these sectors demands close monitoring by a central body whose effectiveness may reduce when required to cover several parties. Ravaghi et al.’s (2019) description substantially cover APL’s situation. The organization presently has four branches operating under a central governing body that proves new procedures and defends novel findings. Therefore, APL stands to benefit meaningfully by reducing its outlets from four to one, as the focus given to the many outstations will now concentrate on a single effective facility.

Localized Experience

Centralization promotes localized experiences’ development in organizations by allowing an entity’s workforce to act as a unit. Grilli et al. (2021) say that branched businesses operating under division heads experience varied managerial skills, even under highly bureaucratized settings. The matter leads to the creation of multiple independent parties forced to work uniformly under different platforms. Centralized organizational structures solve this issue by having a specific party in charge. A central manager or superintendent medic in centralized medical facilities manages activities of different departments operating under one roof or in the same venue. That way, every member of the workforce acquires identical work values, grows functional relationships in the organization, and develops a more intensive sense of belonging (Franklin et al., 2020). Managers further help employees grasp a holistic knowledge about the employer, with specific individuals managing to align their personal values to those of the organization better. Therefore, having employees work in a centralized functional organization converts the frequently strenuous undertakings into enjoyable experiences directly nurtured by an effective leader, thus promoting an overall positive organizational culture.

Personal Touch

Centralized organizations promote communication between individual employees and central executives, leading to a more vivid personal touch. Based on Jimenez et al.’s (2019) observation, many employees serving in decentralized corporations work and even retire or leave the job without meeting the organization owner or CEO. The aspect triggers the ‘us’ versus ‘them’ feeling, leading to psychologically distracted employees. Generally, workers operating in subsidiaries located far away from the headquarters have the feeling that their labor is more important to the business owner than their individual beings. The feeling implies derogative sensations that limit workers’ commitment (Jimenez et al., 2019). However, centralized businesses where workers interact with senior officials in the organization and receive compliments directly from them boost personal touch. Businesses operating centrally promote this aspect, allowing them to realize significantly functional job settings. Equally, the point that all employees in such working atmospheres receive similar treatment eliminates the frequent envy among the workforce working in different locations due to perceived benefits or advantages over others. Consequently, APL’s interest in centralizing operations places the organization with a better opportunity to manage work culture and realize superior productivity.

Empowerment

Centralization allows managers and function heads in an organization to deliver concentrated services. For example, a human resources executive in an integrated entity specifically handles employees’ issues without necessarily multitasking with other corporate activities, as it frequently happens in decentralized units (Trullen et al., 2020). Therefore, the expressively dedicated attention to issues in centralized organizations, especially on matters of HR, promotes employees’ empowerment relative to the decentralized entities. Gunawan et al. (2019) reiterate the essence of a satisfied and empowered workforce in promoting organizations’ interests and objectives. The matter justifies APL’s desire to centralize its activities by dropping three of its current branches to establish a single reformed pathology lab with highly productive, motivated workers with above-average self-determination and love towards humanity and the services they render.

Cost and Resources Management

Centralized recruitment permits an institute to simplify processes and construct business process efficiencies associated with policy development, pay practice, technology, and resources administration. The move equally helps organizations by significantly reducing error chances due to close monitoring and ease of delivering high-intensity training to the condensed team. Gunawan et al. (2019) provide flexibility and accountability as distinguished benefits of organizational centralization. According to scholars, managing a smaller team in consolidated establishments allows managers to handle changes quickly by reorganizing resources as the need arises. Accountability and transparency arise from the relaxed control of issues in the centralized entities. Daily and weekly staff conferences with the management team, where parties account for their activities in the consolidated establishment, leave no room for careless mistakes. One crucial benefit of centralized healthcare units is the reduction in unit-based nurses detachable to other items (Verguet et al., 2021). Verguet et al. (2021) say that the strategy helps clinics to fill resources’ needs from an inside float pool, often including staff prepared to handle multiple cases. Accordingly, APL’s move to centralize operations will help it forecast resources’ needs for flexibility and greater efficiencies.

Several issues affect APL because of its present decentralized plan. Examples of such challenges include staffing constraints, resource deprivation, technological problems, and general decision-making issues. The following work offers an analysis of the organization’s current situation and how centralizing will help.

Staffing Constraints

APL runs on public trust funds, unlike many other healthcare organizations in the U.S. Such means that the entity cannot generate enough money to pay high-quality employees or use financial incentives to attract or retain workers as it is done elsewhere in for-profit settings. Therefore, APL depends on volunteering medical professionals to deliver most of its services to the public. Students undertaking medical training and retirees particularly help the agency greatly. Depending on these aspects to acquire employees frequently makes some of the branches operate with minimal staff. The matter challenges the organization’s productivity and customer service potential. Therefore, the point that APL still manages to operate its four subsidiaries with the often unavailable volunteers means that reducing its size to form a single mega pathology lab runs smoothly. The strategy will bring together all the volunteering staff in the various outstations under one roof or in the same venue, thus giving APL substantial economies of scale. Thus, having the consolidated services stands to solve APL’s staffing problem and cushion the facility from shocks.

Resources Deprivation

A decline in donors’ contributions to APL affects the pathology laboratory organization significantly. Generally, APL relies on charitable giving by groups and individuals to acquire almost all its resources. Operating as a decentralized facility puts pressure on the available finances, almost pushing the firm to charge money to clients, who are mostly minorities. Some branches already lack adequate material to run smoothly but cannot be closed before the decision to centralize the entity is made. On the other hand, assets available to the corporation are adequate for a centralized unit. The finances and labor contributions the firm receives every year beats that of many for-profit agencies. Centralizing operations will thus help the firm immensely by reducing pressure on the available inputs from the public. Certainly, APL will deliver even superior after executing the new strategy relative to now. Consequently, the organization’s management should move with urgency to seal the deal for the closure of the less-performing branches and establish a super strategic establishment for all the services rendered presently and the emergent ones.

High-tech Inaccessibility

Distributing resources to the four branches challenges APL’s potential to acquire modern high-tech necessary in the pathology sector. Zhang et al. (2020) note that infections and medical conditions among humans keep on emerging, requiring pathology specialists to remain updated on matters of high-tech availability. Equally, technology’s tendency to become obsolete as inventions emerge necessitates healthcare organizations dependent on expertise to remain focused on evolving discoveries to remain relevant. Attaining this milestone requires money and a highly trained workforce, which APL significantly lacks. For example, the entity relies on some highly skilled high-tech professionals’ service donations during their free time to analyze critical samples or cases. Furthermore, APL frequently subcontracts other pathology organizations to investigate situations that seem complex to the firm. The condition often involves significant uncertainties due to the reliance on external factors. Looking for more donors or seeking partnerships with more pathology professionals only solves the symptoms partly while leaving the root cause. APL needs to consolidate operations to realize a lasting solution. Accordingly, the choice to centralize the four current branches will save APL substantial money to afford the necessary technology and technicians to manage challenging cases.

Inefficiency

Pathology laboratories handle highly sensitive cases involving substantial urgency and resolution. The aspect demands the ability to handle cases promptly and precisely, which APL presently lacks. Therefore, the Anatomic Pathology Laboratory operates reactively currently, particularly due to the inability to decide speedily on matters affecting the now decentralized units. Therefore, APL fails to realize its mandate to deliver superior services to American citizens, most of who are the have-nots, due to inefficiency. The matter contradicts the many donors’ interests to touch souls, making APL not only unfair to self but also to the benefactors using it for philanthropic missions. Concentrating efforts through centralized operations will help the organization unravel the current catch. Equally, centralization will promote decision-making and make the firm flexible to changes. Eliminating the decentralized system thus stands to make APL a modern pathology laboratory agency, possibly becoming the leading facility in the nation. Importantly, consolidating operations will help APL meet and exceedingly accomplish the needs of the many minorities depending on the organization for improved care. Therefore, the strategic move rhymes with the entity’s spiritual foundation of touching souls through quality service delivery to the poor.

Recommendations

Innovative recommendations for improvement.

Focusing on the stabilized supply of human resources and technological inventions for the centralized system is critical for APL to realize real benefits. Presently, the organization can only depend on scarce resources to run, with the only relieving pressure being that the firm will not have to divide its workforce among scattered units. To realize these two fundamental milestones, APL must remain innovative enough to secure connections with top-notch pathology training institutions and global high-tech firms specializing in medical equipment design and fabrication. Undertaking the initiatives will give the organization reliable access to skilled workers, especially pathology graduates seeking practical experiences after training. The tech manufacturers partnering with APL will certainly donate innovative equipment and tools to the organization to improve its operations. The innovative strategies will aid APL to operate seamlessly while maximizing its potential to touch souls. Looking for other philanthropic entities to partner with, such as TOMS, is crucial for APL to grow in publicity and acquire more resources. Accordingly, centralizing operations alone is not enough for APL as the not-for-profit organization requires stable resource flow to develop a super accessible and affordable pathological establishment for all.

Field Activity’s Contribution to the Social Responsibility Initiatives of the Organization

APL’s primary objective is to bridge the healthcare accessibility problem among minorities. Unlike for-profit organizations, APL hardly targets generating revenues for investors. Instead, the organization aims to operate a functional pathology agency that helps the have-nots and all Americans access quality, affordable care through donations made by charitable parties. APL recognizes the ongoing healthcare crises in the U.S. and many other countries worldwide, where the cost of care continues to escalate to affordable margins. Presently, Kanwar et al. (2020) note that even having a reliable job and contributing to personal medical cover never guarantees one access to quality medication. The only solution for America and related states is to return health care services to the philanthropic church-based hospitals and laboratories originally serving it to people. Making medication money-oriented kills the good societal values of stewardship and compassion, which the bible provides as crucial for healthy communities. This field activity helps APL realize its weaknesses in acting responsibly to societies. The firm must eliminate the underperforming decentralized units to become helpful to the community based on the field activity’s findings.

Field Activity’s Impact on the Strategic Goals of the Organization

The present field activity rhymes meaningfully with the APL’s strategic objectives of using sponsors’ donations to cause a real impact to care seekers, especially among minorities. APL exists among several other not-for-profit agencies seeking to transform the healthcare sector. The organization wants to reverse the emergent erroneous mentality that lacking money implies dying early or leading a poor quality of life. Banskota et al. (2020) report that nowadays, Americans without medical cover survive over-the-counter drugs that worsen their conditions. That is the very problem that APL aims to resolve by ensuring that all Americans access quality medical diagnosis for accurate medication. The focus on diagnosis operations is informed by investigations, such as Alonso-Padilla et al. (2019). The scholars report that many not-for-profit clinics and hospitals targeting minorities fail to deliver real results due to the absence of an affiliate highly effective diagnosis agency. Therefore, APL seeks to solve this issue and believes to have been realizing its objectives hitherto. However, the current field activity proves the organization’s decentralized operations a critical hindrance to the goal’s realization. Consequently, the (field) undertaking justifies the centralization move for APL.

Biblical Integration

APL’s centralization strategy receives significant biblical backing, direction, and approval. For example, Ecclesiastes 4:9-10 and 1 Corinthians 12:17-20 reiterates the essence of centralization tactics among organizations seeking to promote effective resource utilization (Bible, 2020). The first biblical statement in Ecclesiastes 4:9-10 declares that “two are superior to one because they have a respectable return for their efforts: If either of them falls down, one can support the other up. But pity somebody who falls and has no one to help them up” (Bible, 2020). The verses inform believers about the necessity for supportive teammates for the accomplishment of great things. APL’s previous desire to maintain four outlets amidst scarce assets, including human resources, violates these verses’ directives. The aspect threatened the organization’s death through the failure of individual branches, making the facility pitiable. However, centralization will promote teamwork among the pathology lab’s available volunteers, making it of true help to the targeted minority groups.

1 Corinthians chapter 12 equally reiterates APL’s necessity to centralize, which reinstates the need for combining resources. The biblical statement notes that “If the whole body were an eye, where would the sense of hearing be? If the whole body were an ear, where would the sense of smell be? But in fact God has placed the parts in the body, every one of them, just as he wanted them to be. If they were all one part, where would the body be? As it is, there are many parts, but one body” (1 Corinthians 12:17-20, Bible, 2020). According to 1 Corinthians 12, some decentralization approaches adopted by humans are mistaken, especially when the dispersed units deliver complementary services (Bible, 2020). APL’s situation presents it as the body, with each subsidiary resembling a body part. Failing to generate revenue for operations proves the agency’s dependence, just like the body. The organization feeds from the same ‘mouth’ that receives donations from well-wishers. The management then distributes the ‘nutrients’ or resources to parts, including HR, technology, security, and material acquisition. Therefore, centralization reveals APL’s keenness to regain control and realize synergetic vigor.

Lastly, APL’s determination to transform the healthcare sector by promoting charitable support to care delivery among minorities is biblical. The tactic reveals the organization’s focus on human stewardship and compassion, two essential elements necessary in human-centred civilizations (McComsey et al., 2020). America’s insurance firms-dependent health care industry converts humans into unfeeling money-oriented creatures. The matter allows many wealthy Americans to sit back and watch numerous have-nots suffer and die due to a lack of quality health care. The situation violates Deuteronomy (15:11), which says that “the land will never lack for needy persons; that is why I command you: Open your hand freely to your poor and to your needy kin in your land” (Bible, 2020). Accordingly, centralizing operations to intensify donations’ impact on the needy makes APL an essential player in converting the contemporary generations into Gog-fearing beings. Similarly, depending on public trust funds to touch souls rhymes with Mathew (25:40), which says that “As you did it to one of the least of these my brothers, you did it to me” (Bible, 2020). Therefore, APL is a quintessential partner in U.S. society based on the organization’s intricate roles.

APL is a unique healthcare organization in the U.S. specializing in pathology services provision. The facility’s objective is to promote access to quality health care for Americans, mostly minorities, by offering cost-less diagnosis and learning support to medical facilities. APL closes a crucial gap based on many healthcare facilities’ inability to treat impoverished groups properly due to a lack of reliable, affordable diagnosis support. The entity survives on charitable donations, thus not charging for its services. Initially, APL operated four scattered branches, which put substantial pressure on its resources. The facility now exhibits the centralization strategy and stands to benefit immensely from it. Accordingly, APL’s operations and the present agenda comply with the biblical teaching about teamwork and philanthropy deeds, making the organization quintessential to the nation and contemporary generations.

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One of the budget papers will be all about women. Here's what you need to know

For the fourth consecutive year, the pile of budget papers deposited on the desks of journalists this afternoon will contain a booklet dedicated exclusively to women.

Inflation is making everything more expensive, including  essentials women can't avoid buying.

On top of that, on average women are  earning less than a man in the same sector and doing more of the work that they don't get paid for at home too.

And that's before you get to facing an increased risk of violence  and chronic shortages of essential products women need.

For women of colour, those with disabilities or from low-income backgrounds, these problems are even greater.

The booklet will detail how the government plans to improve their lives and how particular measures will help 51 per cent of the country's population.

But how much of a difference will that actually make to most women? And what do we know about what's already inside?

Shout-out to the ladies

The Women's Budget Statement, first introduced in the 1980s by the Hawke government, was a longtime fixture of budget day. It was then stopped by the Abbott government, resumed in the last years of the Morrison government, and has been a consistent feature under the Albanese government.

Most budget measures are not specific to women, so the women's budget statement is often used as a place for the government to spruik the ones that stand out as benefiting them, or to reframe general policies in terms of their benefit to women.

For example, the first item mentioned by Treasurer Jim Chalmers in a Mother's Day message about the women's statement was "a bigger tax cut for more than 90 per cent of women", a cut which also applies to men.

But the Albanese government has also used the statements to highlight targeted changes to address economic gender equality.

Super on paid parental leave

As first announced on International Women's Day, the government will pay superannuation on the publicly funded Paid Parental Leave (PPL) scheme starting in the 2025-26 financial year.

That's a proposal the government says will help close the gender gap in retirement incomes, since the vast majority of the 180,000 who receive the payment every year are women.

Labor first promised the move at the 2019 election, then ditched it at the 2022 election owing to its cost. Previous modelling suggested it would cost about $200 million a year, but the government confirmed on Sunday it would cost $623.1 million a year.

That's in part because the government is in the process of increasing the number of weeks that can be accessed under the scheme, up to 26 by 2026. There will also be incentives for parents to share more leave.

Higher wages in aged care and child care

The budget will also provision a "multi-billion-dollar" amount for higher wages in two female-dominated workforces, aged care and child care.

In both cases, its hand has been forced by the Fair Work Commission (FWC), which approved a pay rise for aged care workers in 2023 and is expected to do the same for childcare workers in June. The government supported both cases before the FWC.

Other female-dominated workforces will get support targeted at the trainee level through the introduction of paid placements in teaching, nursing, midwifery and social work courses, each to the value of $319.50 a week and benefiting an estimated 73,000 students.

But Students Against Placement Poverty has criticised the measure as insufficient, saying the commitment amounts to about $8 an hour for a full work week, and many students will miss out because it's means-tested.

Beyond that, the government has pointed to a range of general measures which will disproportionately benefit women, such as the decision to reduce indexation of HELP debts and other student loans, since 58.5 per cent of outstanding debt is held by women.

Endometriosis funding

The government has already announced that longer specialist consultations for women with endometriosis and other complex gynaecological conditions such as chronic pelvic pain and polycystic ovary syndrome (PCOS) will now be covered under Medicare from July next year.

Two new rebates will be added to the Medicare Benefits Schedule, enabling extended consultation times and increased rebates for specialist care.

The $49.1 million investment is expected to provide about 430,000 more services to women across the country.

Including this new funding, the federal government has committed a total of $107 million in endometriosis support for women since coming to government, including by establishing endometriosis and pelvic pain clinics across the country and providing funding for research and awareness.

They've also flagged a scholarship fund to encourage nurses and midwives to get a higher qualification so they have the power to prescribe, order pathology and give their patients referrals.

The Primary Care Nursing and Midwifery Scholarship Program will run for four years, costing the government $50 million.

In May 2023, a Senate inquiry found women around Australia were facing major challenges to accessing abortion, contraception, pregnancy and birth care.

Health Minister Mark Butler and Assistant Health Minister Ged Kearney said a recent Senate inquiry into access to reproductive and sexual healthcare would help inform how those commitments would be reached.

The government's response to the report's recommendations is now nearly a year overdue.

Violence against women and their children

The government has promised additional measures to support women's safety, building on the already-announced $915 million over five years to make permanent a trial program which has seen women fleeing violence paid up to $5,000 in financial support.

But this has been heavily criticised as not going far enough to protect some of those most vulnerable to violence because it only covers violence by an intimate partner — not a carer or family member.

Women with disabilities say they're being left behind , while the federal government says they should approach Centrelink or the NDIS  if they're being abused by a carer.

And Social Services Minister Amanda Rishworth has said the government has no plans to expand that eligibility.

Treasurer Jim Chalmers has also said there will be "additional steps" on welfare payments, the level of which is often identified as a barrier to women seeking to leave violent relationships.

But it's not clear whether this will include an increase to the JobSeeker unemployment benefit or the Single Parenting Payment.

Instead, the government has hinted it is likely to increase the more narrowly available Commonwealth Rent Assistance payment.

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