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Fischeretal. Health Economics Review (2022) 12:42
https://doi.org/10.1186/s13561-022-00390-y
REVIEW
Harmonization issues inunit costing
ofservice use formulti-country, multi-sectoral
health economic evaluations: ascoping review
Claudia Fischer1 , Susanne Mayer1* , Nataša Perić1 and Judit Simon1,2
Abstract
Background: Valuation is a critical part of the costing process in health economic evaluations. However, an overview
of specific issues relevant to the European context on harmonizing methodological requirements for the valuation of
costs to be used in health economic evaluation is lacking. We aimed to inform the development of an international,
harmonized and multi-sectoral costing framework, as sought in the European PECUNIA (ProgrammE in Costing,
resource use measurement and outcome valuation for Use in multi-sectoral National and International health eco-
nomic evaluAtions) project.
Methods: We conducted a scoping review (information extraction 2008–2021) to a) to demonstrate the degree of
heterogeneity that currently exists in the literature regarding central terminology, b) to generate an overview of the
most relevant areas for harmonization in multi-sectoral and multi-national costing processes for health economic
evaluations, and c) to provide insights into country level variation regarding economic evaluation guidance. A com-
plex search strategy was applied covering key publications on costing methods, glossaries, and international costing
recommendations augmented by a targeted author and reference search as well as snowballing. Six European coun-
tries served as case studies to describe country-specific harmonization issues. Identified information was qualitatively
synthesized and cross-checked using a newly developed, pilot-tested data extraction form.
Results: Costing methods for services were found to be heterogeneous between sectors and country guidelines and
may, in practice, be often driven by data availability and reimbursement systems in place. The lack of detailed guid-
ance regarding specific costing methods, recommended data sources, double-counting of costs between sectors,
adjustment of unit costs for inflation, transparent handling of overhead costs as well as the unavailability of standard-
ized unit costing estimates in most countries were identified as main drivers of country specific differences in costing
methods with a major impact on valuation and cost-effectiveness evidence.
Conclusion: This review provides a basic summary of existing costing practices for evaluative purposes across sec-
tors and countries and highlights several common methodological factors influencing divergence in cost valuation
methods that would need to be systematically incorporated and addressed in future costing practices to achieve
more comparable, harmonized health economic evaluation evidence.
Keywords: Valuation, Unit cost, Economic evaluation, Health and social care, Education, (criminal) justice, Societal
perspective
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Open Access
*Correspondence: Susanne.Mayer@muv.ac.at
1 Department of Health Economics, Center for Public Health, Medical
University of Vienna, Kinderspitalgasse 15/1, 1090 Vienna, Austria
Full list of author information is available at the end of the article
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Page 2 of 13
Fischeretal. Health Economics Review (2022) 12:42
Background
e increased health needs and demands as well as the
scarcity of resources have resulted in a more promi-
nent role of economic considerations in evidence-based
healthcare decision-making [1]. Nevertheless, conduct-
ing economic evaluations (EEs) in the healthcare set-
ting is a complex task. For instance, a prerequisite for
the validity and usability of health economic evidence is
sound costing methodology. Next to the identification,
definition and measurement of relevant resource use
for consideration in EEs [2], a critical part of the costing
process is the valuation method. Valuation implies that
the different resources used for the production of a unit
of resource use (e.g. service) are multiplied with their
value (e.g. price) and summed up to derive its cost, also
referred to as unit cost. From an economic perspective,
there is a consensus that the derived unit costs should
ideally capture the benefit forgone when a resource is
consumed, i.e. the opportunity cost [3], also referred to
as the true ‘economic cost’ [4]. However, due to the influ-
ence of governmental regulations or stakeholder nego-
tiations, the health and social care sectors are typically
considered imperfect markets and e.g. hospital charges,
physician fees or drug prices do not necessarily reflect
opportunity costs [4].
While these unit costs and valuation sources have none-
theless been accepted for use in EEs in the healthcare
sector [5], the application of different costing approaches
and definitions still seem to be ambiguous [6]. e lack
of harmonization of methodological requirements for
cost valuation results in numerous practical challenges in
relation to costing of health-related services, with many
of these challenges not resolved. For example, no univer-
sal gold standard seems to exist up to date regarding the
choice of overhead allocation method [2]. An important
determinant for the appropriate source of valuation is the
analytical (study) perspective from which the EE (eco-
nomic evaluation) is conducted. e study perspective
(e.g. a) provider, b) third-party payer, c) patient, d) soci-
ety (i.e. the broadest perspective [7, 8]) determines which
cost components (e.g. healthcare costs, patient and fam-
ily out-of-pocket expenses, costs occurring in other sec-
tors) are to be included in an EE [3]. At the same time,
it also determines which sources are appropriate to value
the service use [3]. For instance, charges may well reflect
the costs from a payer’s perspective, while not necessarily
capture the true economic cost of service provision from
a societal perspective. Overall, several comparisons have
shown that unit cost estimates in the healthcare sector
are sensitive to the applied costing method (e.g. [9–11]).
e importance of harmonization of methodologi-
cal requirements in relation to costing increases when
healthcare interventions influence resource use outside
the healthcare sector [12]. ese so-called intersecto-
ral costs and benefits [13] include, e.g. the valuation of
spill over effects on employment and work productiv-
ity. A review shows that substantial differences in the
items considered and methods used are resulting in
major differences in lost productivity estimates [14].
is applies likewise to patient and family costs [15].
Although still a relatively new field of research, costs in
the education and (criminal) justice sectors were found
to be a vital cost component in EEs conducted from the
societal perspective [16], especially in the field of men-
tal health.
In light of the methodological heterogeneity, it often
remains unclear if differences in (unit) costs observed
between national and international studies are e.g. due to
differences in applied costing methodology or differences
attributable to the service [17]. From a global viewpoint,
such differences could indeed alter the cut-off point
between an efficient versus a non-efficient intervention in
an EE, and eventually the decision on its reimbursement
and implementation. To achieve more comparability
and harmonization in methods across studies, countries
and sectors, identification of the areas of controversy in
cross-sectoral and cross-country cost valuations is a fun-
damental prerequisite. is insight is a vital first step,
even if differences in data availability and formal require-
ments regarding the analytic perspective remain hetero-
geneous. Beyond this, methodological harmonization
is also a relevant stepping-stone towards the increased
transferability of EEs internationally.
e overarching objective of this current scoping
review was to inform the development of an interna-
tional, harmonized and multi-sectoral costing frame-
work, as sought in the European PECUNIA (ProgrammE
in Costing, resource use measurement and outcome
valuation for Use in multi-sectoral National and Inter-
national health economic evaluAtions) project [18]. is
review covers multiple sectors including the health and
social care, criminal justice and education sectors, as well
as several selected countries as represented in the PECU-
NIA project. e specific objectives of the current scop-
ing review were threefold:
a) To establish a set of definitions of central economic
terms and main concepts to determine the degree of
heterogeneity that currently exists in the literature;
b) To generate an overview of the most relevant
potential areas for harmonization in multi-sectoral
and multi-national costing processes for health EEs;
c) To provide insights into country level variation
regarding EE guidance, based on a case study of six
European countries represented in the PECUNIA
project.
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Page 3 of 13
Fischeretal. Health Economics Review (2022) 12:42
Methods
is scoping review was guided by the approach to map
the main concepts, theories, evidence, knowledge gaps
and their main sources as recommended by the Enhanc-
ing the QUAlity and Transparency Of health Research
(EQUATOR) network [19]. e reporting checklist by
the Preferred Reporting Items for Systematic reviews and
Meta-Analyses extension for Scoping Reviews (PRISMA-
ScR) was followed and can be found in the Additional
file1.
Search strategy
With key grey literature and scientific peer-reviewed
articles including multiple sectors (i.e. health and social
care, criminal justice and education) and methodologi-
cal aspects regarding costing not being always clearly
identifiable as such, a comprehensive search strategy was
required.
For the establishment of a set of definitions of central
economic terms and main concepts to determine the
degree of heterogeneity currently existing in the litera-
ture (research aim a)) we screened textbooks and online
glossaries. In addition, we screened all sources identified
in course of the literature search for research aim b) for
definitions. e selection of the economic terms included
in the glossary was based on the criteria ‘relevance’ and
‘likelihood for interpretation differences’, determined by
the research team, who are experts in the field of health
economics. is overview does not make any claim
to comprehensiveness (i.e. providing a complete pic-
ture regarding all existing definitions and descriptions
represented in the literature), but rather aims to high-
light the potential variation and partial contradictions
of existing definitions of costing approaches and their
components. For the identification of general methodo-
logical issues regarding sector-specific valuation issues
(research aim b) potentially causing amenable heteroge-
neity in service use costing, the following approach was
adopted: Publications from previous EU projects linked
to costing methods were screened (i.e. IMPACT HTA,
HealthBASKET, IBenC [20–22]). Reference lists of these
identified publications were screened for peer-reviewed
publications and grey literature. An author and snow-
ball search in Embase and PubMed were conducted to
further identify relevant peer-reviewed methodological
publications including books. In addition, relevant health
economic and HTA websites were searched including the
International Society for Pharmacoeconomics and Out-
comes Research (ISPOR) [23], the international Health
Economics Association (iHEA) [24], and the Unit Costs
Article database collated by the Personal Social Services
Research Unit (PSSRU) at the University of Kent.
For the identification and analysis of country-specific
harmonization issues (research aim c)), six European
countries represented in the European PECUNIA pro-
ject (i.e. Austria, Germany, Hungary, Spain, the Neth-
erlands and England), were selected as case studies
for feasibility reasons. Since these countries represent
different types of health care systems (i.e. tax-funded/
social insurance-funded, different levels of costing
guidance for EEs and use of such evidence, availabil-
ity of standardized unit cost catalogues, geographic
locations within Europe) the overview is nevertheless
expected to provide a fairly complete picture. At the
same time, broader international insights were consid-
ered where identified. As the development of costing
methods and relevant recommendations is often part
of the national Health Technology Assessment (HTA)
agenda, national websites were considered as most
promising to screen for country-specific guidance (i.e.
national EE guidelines and unit cost(ing) manuals, cost-
ing guidelines and unit cost programmes).
e searches were augmented by additional literature
(e.g. national grey literature) from the PECUNIA con-
sortium and scientific advisory board (SAB).
Study selection
e search was conducted throughout 2018 (the start
of the PECUNIA project) and information extraction
limited to publications from the past 10years (i.e. 2008)
to cover timely methods. Full-text publications of peer-
reviewed articles and books as well as grey literature
were included. In regards to EE guidelines, the latest
available publications within the defined search window
were considered. In addition, we conducted an update
of the search until 2021 to include any major advance-
ments after 2018 (i.e. updates of costing guidelines).
Textbooks, online glossaries, peer-reviewed publica-
tions and grey literature were selected if they included
a relevant definition/description of central economic
terms. Relevant health economic and HTA websites,
peer-reviewed and grey literature were selected if
they included main concepts or general methodologi-
cal issues regarding sector-specific valuation issues,
which are of relevance when conducting multi-country,
multi-sectoral health EEs. National EE/HTA guidelines
and manuals, available costing programmes/manuals
and guidelines, and country-specific health economic
and HTA websites were selected in case they included
country-specific information and recommendations
regarding valuation aspects for EEs.
Publications in German, Hungarian, Spanish, Dutch,
and English were considered for inclusion.
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Page 4 of 13
Fischeretal. Health Economics Review (2022) 12:42
Data extraction
Identified publications were screened for their defini-
tions/descriptions of central economic terms and main
concepts. ese were collected, compared and organ-
ized in a table format. General methodological aspects in
respect to sector-specific valuation issues were extracted
and grouped according to the specific issue it related to.
For the identification and analysis of country-specific
harmonization issues, data extraction was conducted
using a newly developed and standardized, pilot-tested
data extraction form created in MS Excel. Synthesised
information on service costing methods recommenda-
tions covered: analytic study perspective (e.g. healthcare,
societal), costs (to be included in an EE), list of national/
regional unit cost lists available, source of valuation (cost
data), the hierarchy of data sources stated for valuation,
costing methodology (valuation of costs), measure-
ment of capital costs, overhead costs and operating costs
(e.g. capital costs), sources used to calculate reference
prices for various healthcare services (e.g. public statis-
tics), physical units (any common units used like hours
of nursing; per visit), reporting of costs (any require-
ment to report costs and quantities/volumes separately),
time horizon, discounting, adjustment for inflation/price
indexation, specific considerations per field/area of appli-
cation, periodicity of costing manual, recommended level
of guideline adherence (e.g. mandatory).
In each stage of the applied methodology, at least two
researchers were involved. e searches in the multiple
information sources were executed by two researchers
(CF, NP). Identified literature was screened against the
above pre-defined inclusion criteria by two research-
ers (CF, NP). Potential disagreements regarding inclu-
sion were resolved by discussion or if needed, by a third
reviewer (SM, JS).
Results
e initial search via previous EU projects (N = 35), rel-
evant books (N = 2), and grey literature (N = 14) resulted
in 51 hits. e search for EE guidelines, unit cost(ing)
manuals/programmes/list of unit costs, health economic
and HTA websites added 46 hits. is resulted in the
inclusion of a total of 97 sources for information synthe-
sis. e overall study selection process is illustrated in the
PRISMA flow diagram (see Additional file1).
Heterogeneity ofdenitions ofcentral economic terms
andmain concepts
Varying definitions and interpretations can be found in
the international context, as the understanding and usage
of a definition are highly dependent on the country con-
text and the analysist’s professional background. Table1
presents definitions and descriptions of central economic
terms and main concepts. e aim of this glossary of
terms is to give an overview of the potential variation
and partial contradictions of existing definition of costing
approaches and their components, which may be a jeop-
ardizing factor for harmonization efforts.
General methodological issues regardingsector‑specic
valuation
e following paragraphs describe the identified gen-
eral sector-specific methodological aspects and cross-
sectoral costing challenges, including problems as well
as potential solutions and recommendations, found in
the screened literature. Table2 provides an overview of
these findings and highlights the multiple open questions
regarding essential methodological aspects.
Methodological issues incosting forthehealth andsocial
care sectors
Common health economic costing methods of services in
the health and social care sectors are micro or gross cost-
ings for cost identification, and bottom-up or top-down
approaches for valuation [22, 42–44]. Based on the avail-
able definitions of these approaches as described in dif-
ferent sources (e.g. [6, 45] however, it becomes apparent
that these methods are not always clearly distinguishable
or uniformly defined/applied [6, 18, 42]. In addition to
the application of valuation approaches to newly devel-
oped unit costs, readily available costing sources may
be used for the valuation of service use, including refer-
ence unit costs, fees, charges and market prices [22, 46].
According to recently published cross-European recom-
mendations regarding the valuation of service use in EEs,
the preferred proxy measure for the opportunity costs
of healthcare and supportive care/social care services
are country-specific reference unit costs, when available
[40]. It remains unclear, however, in what way standard
unit costs differ from market prices or charges, and e.g.
what costing perspective (i.e. long-run, short-run) shall
be incorporated in these estimates. At the same time, the
chosen method is crucial for the resulting unit cost esti-
mate [47]. Top-down and bottom-up approaches were
previously found to yield different results when calculat-
ing the unit cost of cognitive behavioural therapy [47],
although the size of the impact on the results was not
specified. Also other comparisons confirmed the sensitiv-
ity of unit cost estimates in the healthcare sector regard-
ing the applied costing methodology (e.g. [9, 11]).
Bottom-up micro-costing has not been widely used
in assessing the costs of healthcare services [48]. Pre-
sumably, this is mainly due to its feasibility, as this
methodology is time-consuming, especially when
information systems are absent or inadequate [6].
Hospital costing studies indicate that a full bottom-up
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Fischeretal. Health Economics Review (2022) 12:42
Table 1 Glossary of identified definition(s) of central economic terms and main concepts used in the literature and definitions for
costing
Term Examples of denition/description(s) used in the literature
Average cost: -Total resource cost, including all support and overhead costs, divided by the total units of output [25]
-Total cost divided by the number of units of output [26]
Bottom-up costing: -For cost valuation, in the bottom-up approach, cost components are valued by identifying resource used directly
employed for a patient [27]
-The bottom-up approach assesses the amount of each resource that is used to produce an individual service and
assigns costs accordingly to generate aggregate costs of a system [28]
-Bottom-up approaches, such as activity-based costing, assess the amount of each resource that is used to produce
an individual healthcare service and assigns costs accordingly to generate aggregate costs for a healthcare system
[29]
-To value cost items using the bottom-up approach, patient utilization data needs to be multiplied by unit prices,
leading to cost estimates for individual patients [3]
Capital cost: - The cost to purchase the major capital assets required by the programme (for example, equipment, buildings, and
land) [26, 30]
-Capital costs are one-time expenses typically incurred to set up a service [3]
Fee: -A payment made to a professional or public organization for advice or services [2]
-The amount charged for a resource or service [31]
Fixed cost: -Fixed costs do not vary with the quantity of output in the short run (about 1 year) and vary with time, rather than
quantity: e.g. rent, equipment lease payments, some wages and salaries [3]
-Fixed cost is the one that remains stable regardless of the amount of production output and is actually the running
cost of the department and the cost of equipment. Fixed cost is determined by staff salaries, capital and maintenance
costs [32]
(Bottom up/top down) gross costing: -In gross costing, cost components are defined at a highly aggregated level [27]
-Bottom up gross costing values the cost component for each individual patient [33]
-Top down gross costing values the cost component per average patient by separating out costs from comprehensive
sources [33]
Top-down costing: -In the top-down approach, cost components are valued by separating out the relevant costs from comprehensive
sources [27]
-The top-down approach relies on comprehensive sources, such as annual financial accounts, and divides aggre-
gated costs by the total number of patients [34]
-The step-down method, also known as the top-down method, calculates the unit cost of healthcare services by
allocation of the total hospital cost [35]
-Top-down methods work with aggregate expenditures, which reflect monetary flows at the service level rather than
the value of resources used. This implicitly accepts prevailing prices or charges as the correct valuation of resource
inputs [5]
(Top down/bottom up) micro-costing: -For cost identification, in microcosting, all cost components are defined at the most detailed level [27]
-A detailed list of each component of a patient’s care is created and costed separately for each facet of a patient’s
hospitalization [9]
Bottom-up micro-costing identifies all relevant cost components and values each cost component for all individual
patients resulting in the most accurate cost estimates [33]
Top down micro-costing identifies all relevant cost components, but values each component for average patients by
separating out costs from comprehensive resources such as annual accounts [33]
Opportunity costs: -Benefits forgone [3]
- The cost of a unit of a resource is the benefit that would be derived from using it in its best alternative use. [26]
- The opportunity cost of an intervention is what is foregone as a consequence of adopting a new intervention. [36]
- The ‘value of the next-best alternative’ forgone […] or ‘the value of what is given up’ [37]
Overhead/ indirect costs: -Overhead costs, which consist of employee benefits, administrative staff, and capital costs such as building and
equipment operation and maintenance, cannot be directly attributed to patient care, nor are they as responsive to
changes in patient volume as variable, direct costs [38]
-Indirect cost components generally concern overheads (general expenses, administration and registration, energy,
maintenance, insurance and the personnel costs of non-patient services…) and capital (depreciation of buildings
and inventory and interest) [33]
Unit cost: -The value of all resources (input) used to produce a service, divided by the level of activity (output) it generates [39]
-Standard unit costs are defined as all costs related to the provision of a particular service [40]
Variable cost: -Variable cost is designated by the activities necessary for each patient’s treatment and it includes the cost of medica-
tion, consumables and diagnostic tests [32]
- Costs are often categorised into different types, such as […] fixed and variable costs (reflecting the initial payment
for equipment and the additional cost per use of the consumables). [36]
- Those costs which vary with the level of production and are proportional to quantities produced. [41]
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Fischeretal. Health Economics Review (2022) 12:42
Table 2 Overview of identified challenges and potential solutions/recommendations by sector-specific or cross-sectoral methodological aspects
Health and social care sectors
Methodological aspect Challenges described in the literature Potential solutions described in the literature
Typical cost identication and valuation approaches: top-
down, bottom-up, micro-costing, gross-costing Indistinctness and inconsistency regarding methods definitions
as well as their application;
Practical feasibility hampers wide application of bottom-up
micro-costing (time-consuming, unavailable information); Consideration of bottom-up methodology at least for healthcare
services with large component of overheads;
Costing sources to develop unit costs: reference unit costs,
fees, charges, market prices Lack of clarity regarding the difference of standard unit costs and
market prices/charges and which costing perspective to apply;
Unit cost estimates are sensitive to the applied costing methods;
size of impact of the different choices is unclear;
Ambiguity regarding the costing perspective to apply;
Country specific reference unit costs are the preferred proxy
measure for the opportunity costs of health and social care
services are, however, often unavailable
International comparison of unit costs: Internationally, there are large differences between salaries
of professionals and diverse professions delivering the same
service, potentially resulting in varying unit costs
Consideration of bottom-up methodology in multi-country stud-
ies with large differences between salaries of professionals and
diverse professions delivering the same service;
Costing methods: total costs (fixed and variable), marginal costs Ambiguity regarding cost types and components to consider; Depending on the purpose, consideration of different time hori-
zons and consequently cost components:
Variable costs for services happening within existing infra struc-
ture despite requiring new investments on other levels;
Marginal costs for services that can be offered by using existing
equipment;
Methods for valuation of overhead costs of services: alloca-
tion of weighted service/hourly rate/inpatient day/marginal
mark-up
Absence of universally accepted standard for the estimation of
overhead costs; Micro-costing is not feasible for the determination of overhead
costs for hospitals/large institutions;
Application of the ratio of overhead to direct expenses for similar
departments;
Education and criminal justice sectors
Valuation of health‑related service use in the education and
(criminal) justice sectors Valuation methods of health-related service use in the education
and (criminal) justice sector are less established. Their feasibility
in different countries has yet to be determined;
Methodological choice should be based on the underlying data
and their availability/ reliability;
Feasibility to use opportunity cost method based on micro-
costing is limited, as time consuming;
Reliability, transparency, unrestricted availability and transparent
referencing are a prerequisite for the validity of utilizing market
prices from governmental reports to calculate proxy unit prices,
which is not always possible to determine
Cross‑sectoral costing issues
Perspective to adopt to consider all relevant costs/cross‑
sectoral costs: societal perspective Risk of double-counting due to lack of transparency in costing
components;
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Fischeretal. Health Economics Review (2022) 12:42
methodology should be considered for healthcare ser-
vices with a large component of labour or overheads as
expected for mental health services. In multi-country
studies, international differences between salaries of
comparable professionals may have significant effects
on the unit costs. Moreover, in different countries
diverse professions may deliver the same services
resulting in further variation in the unit cost of specific
services [47, 49–52].
It is generally agreed that depending on the specific
service and its role in the EE, different costing methods
are appropriate [3]. Besides, depending on the purpose
of the costing exercise, different time horizons and hence
cost components may be considered [3, 46]. For example
[53], total costs (fixed plus variable costs) are relevant
whenever a service requires considerable constructional
changes (e.g. addition of a new operating theatre). Using
variable costs is recommended for services that hap-
pen within existing infrastructure despite requiring new
investments at other levels. Marginal costs are to be con-
sidered for services that can be offered by using existing
equipment, while average costs capture total costs per
unit of output [53].
Overhead costs may largely vary between different
organisations, as do the use of services and the method
of cost allocation [2]. Generally, there are different types
of overhead costs such as capital versus non-capital to
consider separately. ey may be related exclusively to
the management and administrative services, or to main-
tenance (e.g. catering, cleaning, gas, water) [2]. ere are
also several methods for performing overhead calcula-
tions which include the allocation of i) weighted service,
ii) hourly rate, iii) inpatient day, or iv) marginal mark-up
[54]. e weighted service method establishes the rela-
tive cost of the individual patient. Hourly rate yields a
cost per treatment minute by employing service time of
the primary treatment as a proxy for consumption. When
using inpatient day allocation, all patients are assumed
to have the same indirect costs per day irrespective of
the actual resource use. In marginal mark-up allocation,
indirect costs are distributed to direct costs by raising the
direct costs with a mark-up percentage. [33].
Micro-costing is not feasible for the determination of
overhead costs for hospitals and other large institutions
[4]. Instead, it is suggested to apply the ratio of overhead
to direct expenses for a similar subdivision [4]. Never-
theless, to date, there is no universally accepted stand-
ard for the estimation of overhead costs [2]. Potential
double-counting of costs is another risk acknowledged
in the health and social care sectors. For example, double
counting may occur when financing costs are captured in
the healthcare unit cost on the one hand but also sepa-
rately considered as cost on the other hand [5, 55].
Methodological issues incosting fortheeducation
andcriminal justice sectors
Examples for intersectoral costs and benefits (ICBs)
resulting from healthcare interventions that affect the
education sector could include special education ser-
vices and the costs for student transport to the educa-
tion facility [56, 57]. Criminal justice inter-sectoral costs
compromise costs for court proceedings, police services,
or forensic services [56, 58]. e methodology for the
valuation of health-related service use in the education
and (criminal) justice sectors is less established. A first
major step towards the valuation of such service use was
recently taken by determining several methods and test-
ing their applicability in the Netherlands [59]. e four
methods suggested for consideration based on their
accuracy in a hierarchical manner include i) the oppor-
tunity cost method based on micro-costing, ii) utilisation
of market prices from governmental reports, iii) self-
constructed unit prices based on the information given in
governmental reports, and iv) hourly labour costs for the
provision of the relevant services. Although the oppor-
tunity cost method based on micro-costing (method i) is
very accurate in regards to the valuation of ICBs in mon-
etary terms, its feasibility is limited by the time it takes to
calculate these [13]. Method ii) can be applied to deter-
mine proxy unit prices. Examples for relevant sources
include annual reports of governmental and public or
private organizations, which have been granted author-
ity and responsibility for the provision of services related
to ICBs. e reliability, transparency, unrestricted avail-
ability and unambiguous referencing are a prerequisite
for the validity of this method [13]. e third method
(iii) suggests using the previously mentioned annual
reports for the division of the total annual costs by the
total annual output. Labour costs can be used as a fourth
method for valuation (method iv), e.g. from national sta-
tistics and administrative data [13]. e methodological
choice should be based on the availability and reliability
of the underlying data [13].
Country specic requirements andrecommendations
A summary of some key costing recommendations from
national health economic guidelines of the selected
six countries is shown in Table 3 (extended structured
synthesis Additional file 1). While these guidelines are
defined as being mandatory to be followed in the Neth-
erlands and Germany, the Spanish guideline is voluntary.
e application of the Austrian, English and Hungarian
guidelines is (strongly) recommended. is does not nec-
essarily imply, however, that recommendations are also
relevant for the pharmaceutical reimbursement process
as in the case of Austria, where the relevant institution
applies its internal criteria [60].
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Fischeretal. Health Economics Review (2022) 12:42
With regards to the adopted analytical study perspec-
tive of an EE, the German and the English recommend
a healthcare perspective. e Austrian guideline is not
specific in this regard. While the Dutch guideline recom-
mends a societal perspective, the Spanish one recom-
mends both the societal and the healthcare perspectives
to be applied parallel. e Hungarian guideline states
that if costs and outcomes are falling mainly outside of
the healthcare system (e.g. in the case of preventive
health technologies) the societal perspective is suggested
in addition to the healthcare perspective. at what is
meant by societal is, however, is not always explicitly
stated and may vary very much from analysis to analysis.
Most guidelines state which costs should be included
in an EE. e majority of them use a traditional cost
component typology referring to health and social care
and out-of-pocket expenses as direct costs and lost
productivity as indirect costs [61]. e Dutch guide-
line, updated in 2016, is an exception and refers to cost
components based on sectors, such as costs within the
healthcare sector, patient and family costs and costs in
other sectors [62].
Table 3 Overview of country-specific costing recommendations in the six selected European countries
a The recommendations stated in the German guidelines by IQWIG (Institute for Quality and Eciency in Health Care) are only binding for the IQWIG itself
b The application of the guideline is dened not by the user, but by the purpose of the analysis. The guideline applies to the assessment of all health technologies for
decision making in public funding
c Specication in the Hungarian guideline: The recommended perspective is the healthcare perspective. However, if the benets and costs are to a signicant extent
outside of the health care system (e.g. in the case of preventive health technologies), it is also suggested to add a social perspective to the analysis
d Cost and outcome results for the entire time horizon of the analysis should also be presented separately by health status and presented in tabular form
Austria England Germany Hungary The Netherlands Spain
Recommended level of guideline adherence
Mandatory xax
Recommended x x xb
Voluntary x
Perspective
Societal x
Societal and health care (x)cx
Health and social care x
Health care x
Not specified x
Discounting recommended x x x x x x
Discount rates costs (sensitivity analysis) 5% (3%-10%) 3.5% (1.5%) 3% (0%, 5%) 3.7% (2%-5%) 4% (not specified) 3% (0%, 5%)
Reporting of costs
Separate reporting x x x xdx
Not explicitly mentioned x
Adjustment for ination/price indexation
Adjustment to a common reference year x x x
Inflation of costs to the present x x
No information found x
Time horizon
A lifelong time horizon x x
Long enough to include all costs/outcomes/effects x x x x x
No information found x
Periodicity of costing manual
Annually x
Regularly x x
As required for methodological reasons (approx. every
4 year) x
Irregularly x
No information found x
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Fischeretal. Health Economics Review (2022) 12:42
e inclusion of social care costs such as those result-
ing from the use of respite care and supportive care
services is explicitly recommended in four guidelines
(England, Germany, the Netherlands, Spain), while the
inclusion of patient (and family) costs (e.g. patient out-
of-pocket expenses, time costs, informal care costs and
travel costs) are recommended in four guidelines (Aus-
tria, Germany, the Netherlands, Spain). In Germany,
patients’ out-of-pocket expenses are included as part
of the perspective of the Statutory Health Insurance
(SHI)-insured community. In contrast, time costs are not
standardly considered, but are examined in the course
of sensitivity analyses. e Hungarian guideline speci-
fies that the inclusion of cost types should be determined
based on the adopted perspective. e inclusion of lost
productivity costs is recommended in four guidelines
(Austria, Germany, the Netherlands, Spain) and are to
be reported separately from direct medical costs). In the
Hungarian guideline the inclusion of productivity costs
is recommended just a complementary element of cost
calculation if majority of costs are falling outside of the
healthcare sector.
ere is large variation between the guidelines regard-
ing the suggested valuation approach. All guidelines
stress that the valuation method chosen should reflect
opportunity costs. In addition, various valuation meth-
ods are recommended in the guidelines, varying from
top-down micro-costing to gross-costing, including the
use of standard unit costs/reference prices, tariffs, mar-
ket prices, administrative data, and diagnosis-related
groups (DRGs). All guidelines name one or more sources,
which should preferably be used for the unit costing. A
standard cost list containing sets of standardized unit
cost estimates is officially recognized and applied by the
HTA agency in the Netherlands (Zorginstituut Neder-
land) [63]. ese have been (partly) published as part of
national costing guidelines/programs and are periodi-
cally updated. In Spain, each region has its own list of
official unit costs [64]. ere are also national statistics
for some of the unit costs (e.g. hospitalization) managed
by the ministry of health [65]. In addition, the unit cost
database OBILUKE is used in Spain to obtain healthcare
unit costs. It is updated annually and uses primary and
secondary sources, such as published articles, reports,
hospital accounting systems, but access to this unit cost
database is not free of charge [66]. Other countries (e.g.
Germany) also have unit cost projects in place that have
been conducted systematically with a clear methodology,
but are not regularly updated. In Austria, a list with unit
costs used in existing Austrian health economic analyses
has been published [48, 67]. Updates of the national unit
cost lists are published periodically spanning from annual
updates (e.g. England and Wales) to updates as required
for methodological reasons or timeliness, e.g. four-yearly
in the Netherlands.
ere is limited information in the majority of the
guidelines about the valuation and allocation of capital/
overhead and operating costs, i.e. costs that cannot be
directly allocated. Austria and Spain do not include rec-
ommendations on this at all. e Dutch guideline names
different methods that can be used to measure over-
heads such as average fixed costs per unit, the equiva-
lence method, and the mark-up method. Although no
specific method is recommended, it is emphasized that
each of these methods has different advantages and dis-
advantages. Based on data from the financial statistics
for Dutch hospitals, an estimation of overhead costs was
conducted in 2012. e derived percentage for overheads
on the directly attributable costs of medical departments
was 38%. e percentage for overheads on housing and
depreciation costs on the directly attributable costs of
medical departments was 6%, adding up to a total of 44%
for overheads. is percentage reflects an average with
huge variations between individual organisations and
services [63].
For the adjustment of unit costs from different calendar
years, the Austrian and Spanish guidelines recommend
that costs should be adjusted to a common reference
year, but they fail to provide further details. e Hun-
garian guideline states that costs shall be uprated to the
same date. e consumer price index (inflation) should
be chosen as inflation rate, irrespectively of whether
the costs (or savings) arise within or outside the health-
care sector, with the official publications of the Hungar-
ian Central Statistical Office as recommended source.
Both the German and Dutch guidelines specify that all
costs should be inflated to the present value by using the
official price index from national statistics. e Dutch
guideline also tackles the aspect of correcting for infla-
tion in case of including costs from different European
countries. It is suggested that the Indices of Consumer
Prices (HICP) of the European Central Bank, which were
specially designed for international comparisons of con-
sumer price inflation, need to be used.
Discussion
For EEs to be able to inform efficient resource allocation
based on valid high-quality evidence, it is crucial that
both outcomes and costs are assessed rigorously [68].
In contrast to outcomes, costs appear to have suffered
neglect regarding methodological research, resulting in
the absence of an universally accepted costing methodol-
ogy for the healthcare sector [69], as well as other sectors
affected by the impact of healthcare interventions such as
the education and criminal justice sectors [13]. Unit cost
estimates between studies and countries are often not
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Fischeretal. Health Economics Review (2022) 12:42
comparable due to differences in costing methodologies
[70] and the lack of detailed methodological guidance,
which may also result in decision-makers’ low confidence
as a barrier to the uptake of EEs [43, 71]. As of now, col-
lections of cost estimates are not routinely available for
services across European countries, especially beyond
the health and social care sectors [72]. If available, it is
unclear whether differences in cost estimates stem from
differences in the service composition, intensity and defi-
nition (unit of analysis), differences in the unit of meas-
urement, or differences in methodological approaches
for costing including input costs (unit of valuation) [73],
calling for more transparency and harmonization in this
respect.
is scoping review highlights multiple methodologi-
cal problems challenging the harmonization of service
unit costs for (inter)national, multi-sectoral health EEs.
For the health and social care sectors, these include
ambiguity and feasibility problems regarding the defini-
tion and application of cost identification and valuation
approaches. Several problems regarding the data source
used to develop unit costs were identified: the impact of
choice of the costing sources, the applied costing per-
spective and unavailable proxy measures, as well as the
absence of a standard to estimate overhead costs.
Moreover, the limited cross-country comparability of
labour costs and ambiguity concerning the application
of cost types were identified as further difficulties. Chal-
lenges in respect to the education and criminal justice
sectors concern the valuation of health-related service
use in these sectors, unestablished valuation methods,
and missing feasibility testing in the international con-
text, as well as difficulties regarding the generation of
proxy unit prices. Double counting of costing compo-
nents also may not only be an issue within the health care
sector as previously reported, but also cross-sectorial.
For example, double counting of out-of-pocket expenses
may occur as part of the unit cost of a health care service
and as part of patients’ out-of-pocket costs, which may
arise due to lacking transparency in the reported costing
components. e analysis of national costing guidelines
revealed extensive variation concerning the recommen-
dations with respect to guideline adherence, analytical
study perspective, valuation approach and inflation.
e early FP6-funded HealthBasket project (2004–
2007), which focused on harmonization of costing in
the healthcare sector, already concluded one decade
ago that “the prerequisite for international cost com-
parison is mutually accepted methodological guidance
(standard costing method) and reasonably good com-
pliance with it” [22]. Furthermore, it stated that con-
sensus alone on basic scientific principles would not be
sufficient to achieve meaningful comparability. Instead,
it was proposed to “standardize” the most important
and frequently used methods, including resource use
measurement, cost allocation methods, including allo-
cation base and allocation techniques and valuation
methods, as well as capacity utilisation and to include
detailed instructions on how to implement these
instruments in practice [22]. Another recent editorial
also recommended that an independent group should
be mandated with the production of standard coun-
try-specific unit costs available to national and inter-
national researchers and decision-makers [70]. ese
challenges were one of the key motivations for setting-
up the European PECUNIA project, aiming among
others to systematically address the above heterogene-
ity-causing factors in costing methods and to develop
unit costs for different countries and sectors based on
harmonized methods [18, 74].
At the same time, some practical limits to the harmo-
nization of costing will remain. Firstly, unit costs are one
major ingredient to the valuation aspect in EEs. Limited
guidance regarding the calculation of overheads result-
ing in assumptions are a very much under-discussed,
under-researched and under-reported area. Both, exten-
sive sensitivity analysis or transparent overhead calcula-
tion as one harmonization aspect for unit costs would be
potential ways forward. ere are, however, also broader
costing issues [45], such as questions about the inclusion
of future medical costs [75], the choice of the discount
rate [40], and the choice of the analytical study perspec-
tive [76] that may introduce systematic differences in cost
estimates [77, 78]. Secondly, where newly developed har-
monization strategies are not fully in line with existing
national EE guidelines, especially those relevant for reim-
bursement decisions, their implementation most likely
will face resistance. e quality and transferability of
international EE studies that include multiple countries
would, however, still greatly benefit from such standardi-
sation approaches [40]. e same applies to national EEs
where such perceived conflict does not exist, or the eval-
uation perspective is expected to be expanded to a multi-
sectoral, societal one. On the other hand, the compulsory
nature of EE guidelines seem to promote the availability
of more comprehensive and standardised unit cost cata-
logues (e.g. England, Netherlands) and the use of more
harmonised costing methods.
To the best of our knowledge, this is the first review
on costing methods across several sectors affected by
healthcare interventions focusing on a set of selected
European countries and healthcare systems. Other publi-
cations focusing on differences between EE guidelines do
exist (e.g. [79, 80]), but they cover different aspects (e.g.
methods for price and currency adjustment, uncertainty
analysis), additional countries outside of Europe (e.g.
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Page 11 of 13
Fischeretal. Health Economics Review (2022) 12:42
Australia, ailand, Japan), or include older guideline
versions.
e selected countries included in the PECUNIA
Project differ regarding their health care systems with
varying feasibility and acceptability of EEs in evidence-
informed decision-making. Some countries have estab-
lished national unit cost programmes/lists (DE, NL, UK),
some early stage initiatives (AT, ES, HU). Availabilities
of health utility value sets for outcome evaluations and
requirements in terms of the study perspective also differ.
Nevertheless, the country selection is not necessarily bal-
anced in regards to the aforementioned aspects.
Study selection and data extraction was challenging in
some cases, especially when slightly divergent informa-
tion on one topic was identified. However, two research-
ers were involved in the study selection process and data
extraction phase, and with two additional researchers
consulted in case of disagreements, which enabled exten-
sive discussions and thorough assessment of the identi-
fied material. Due to the broad topic area and expected
spread of relevant information between different types
of publications, mostly within the grey literature needed
to be included. Our search strategy to identify grey lit-
erature was very comprehensive and national experts
were involved to complement our findings. In addition,
a search update was conducted to enhance the review’s
timeliness. Although the applied strategy to identify
peer-reviewed publications was expected to capture all
relevant key topics, as it covered different approaches
which were explained in our methods section, it cannot
be ruled out that some potentially relevant material has
been left out, despite our attempts to be as comprehen-
sive as possible.
Conclusions
Several methodological issues were identified that lead to
the current heterogeneity in valuation methods in health
EEs used across sectors and countries. To address these
explicitly in future costing guidelines and tools is a key
step towards more comparability and harmonization in
national and international health EEs.
Abbreviations
BIA: Budget impact analysis; Catsalut: The Catalan Health Service (Servei
Català de la Salut); CBS: Statistics Netherlands (Centraal Bureau voor de
Statistiek); CPI: The consumer price index; DoH: Department of Health;
DRGs: Diagnose-related groups; EE(s): Economic evaluation(s); EU: European
Union; EQUATOR: The Enhancing the QUAlity and Transparency Of health
Research Network; FCA: The friction cost approach; FTE: Full Time Equiva-
lent; HBCs: Diagnosis Related Group, DRG (homogen betegsegcsoport);
HCA: The human capital approach; HES: Hospital Episode Statistic; HICP:
The Indices of Consumer Prices; HRG: Healthcare Resource Group; HTA:
Health Technology Assessment; ICBs: Inter-sectoral costs and benefits; iHEA:
The international Health Economics Association; ISPOR: The International
Society for Pharmacoeconomics and Outcomes Research; IQWIG: The
independent Institute for Quality and Efficiency in Health Care (Institut für
Qualität und Wirtschaftlichkeit im Gesundheitswesen); n/a: Not available;
NHS: National Health Service; NZA: Dutch healthcare authority (Neder-
lands Zorg Autoriteit); OENO: International Classification of Procedures in
Medicine; OSTEBA: Basque Office for Health Technology Assessment; PPP:
Purchasing power parities; PSS: Personal social services; PECUNIA: The Euro-
pean ProgrammE in Costing, resource use measurement and outcome valu-
ation for Use in multi-sectoral National and International health economic
evaluAtions; PSSRU: The Personal Social Services Research Unit; RRISMA-
ScR: Preferred Reporting Items for Systematic reviews and Meta-Analyses
extension for Scoping Reviews; SA: Sensitivity analysis; SHI: Statutory Health
Insurance; UKE: The University Medical Center Hamburg-Eppendorf; VAT:
Value-added tax.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s13561- 022- 00390-y.
Additional le1: Figure1. Adapted PRISMA flow chart of study selection.
Table2. Preferred Reporting Items for Systematic reviews and Meta-Anal-
yses extension for Scoping Reviews (PRISMA-ScR) Checklist. Table3. Syn-
thesis of country-specific recommendations regarding valuation aspects
from economic evaluation guidelines of six selected European countries.
Acknowledgements
The authors would like to thank Valentin Brodszky, Mencia Ruiz Gutierrez
Colosia, Silvia Evers,, Leona Hakkaart-van Roijen, Timea Helter and Joanna
Thorn for their assistance with the analysis of the country specific documents
in their national languages. We are also grateful for essential national literature
provided by the PECUNIA Group.
Authors’ contributions
SM and JS conceived the idea for this review. CF and NP conducted the search
and collated, synthesized and summarized the results with inputs from SM
under the supervision of JS. JS secured the funding for the project. Based
on the write-up of the results, SM together with CF drafted the manuscript,
which was revised based on comments from NP and JS. All authors read and
approved the final version of this manuscript.
Funding
This study was conducted as part of the PECUNIA (ProgrammE in Costing,
resource use measurement and outcome valuation for Use in multi-sectoral
National and International health economic evaluAtions; grant agreement
No 779292) research project funded by the European Union’s Horizon 2020
research and innovation programme. All views and opinions expressed in this
article are those of the authors and do not necessarily reflect the views of the
funding agency.
Availability of data and materials
All data generated or analysed during this study are included in this published
article.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
Authors have no conflicts to declare.
Author details
1 Department of Health Economics, Center for Public Health, Medical Uni-
versity of Vienna, Kinderspitalgasse 15/1, 1090 Vienna, Austria. 2 Department
of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 12 of 13
Fischeretal. Health Economics Review (2022) 12:42
Received: 22 February 2022 Accepted: 26 July 2022
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