Advancing global health economics and policy of palliative and end-of-life care: insights from Ireland, Norway, Finland, Argentina, and India

Large and growing population health needs for palliative care have been documented in international and national policy, and research studies worldwide (1). According to the World Health Organization, while 57 million people need palliative care, only 14% receive it (1). Individuals with serious illnesses account disproportionately for healthcare costs while experiencing poor outcomes, often due to modifiable factors such as unmanaged pain, depression, and fragmented care that are inconsistent with patient preferences. Despite the known prevalence of low-value care near the end of life, evidence to inform service planning and improvement is scant, particularly in economic evaluations, which are rare in this field.

Several factors contribute to this gap, many related to methodological challenges. Palliative and end-of-life care differ significantly from curative care, lacking consistent frameworks, guidelines, and terminology. Specific gaps include inconsistency in patient identification and follow-up, absence of gold standards for outcome measures, and limited, heterogeneous cost data. These complexities are especially pronounced in low- and middle-income countries, where full costs, outcomes, and intervention effects often remain unmeasured.

Therefore, an editorial team spanning five international health economists created a special series on the value of palliative care in the Annals of Palliative Medicine that aims to enhance understanding of palliative and end-of-life care interventions by inviting papers on outcomes and costs in economic evaluations. Our goal was to advance systematic, evidence-based methodological approaches and increase the rigor of future economic evaluations. We considered original empirical research, conceptual and theoretical work, reviews, and applied research. Contributions were made from all parts of the health and social care system, including informal and unpaid care, and from all countries and regions.

The potential practical and conceptual issues considered the following topics but were open to other related areas:

• Applied economic evaluations of palliative and end-of-life interventions using generic methods [e.g., cost per quality adjusted life year (QALY) for the health system].
• Applied economic evaluations of palliative and end-of-life interventions testing methodological innovations (e.g., applying societal perspective, including outcomes beyond the patient).
• Applied economic evaluations of palliative and end-of-life interventions comparing generic and innovative approaches.
• Approaches to outcome measurements that better reflect patient needs and so may capture some hitherto unmeasured effects from palliative and end-of-life care.
• Measuring the impact of palliative and end-of-life care to the patients’ network outcomes (e.g., post-bereavement effects, assessment of the wide reach of these effects).
• Assessing costs beyond the health care sector (e.g., spillover costs for family, costs of informal caregiving, productivity losses).
• Applying approaches from other areas of (health) economics in palliative and end-of-life care (e.g., recent advances in quasi-experimental methods).
• Timely and targeted patient selection (e.g., advanced screening tools) for palliative and end-of-life phase.

Nine international scholars contributed a diverse mix of empirical studies and evidence syntheses to this special series, spanning economic evaluations, modeling, methodological discussions, secondary analyses of hospital data, and comparative studies. The applied economic evaluations assessed the impact of specialist palliative care nurse-patient consultations, informal caregiving for cancer patients at the end of life, and the effects of palliative care on quality of life (2). Other investigations examined determinants of place of death and unmet needs among palliative care professionals.

Two cost-effectiveness analyses modeled structured palliative care interventions: one evaluated nurse-patient consultations and case conferencing for non-cancer patients in a randomized clinical trial (1), while another developed a Markov model of informal home-based palliative care for cancer patients in Argentina (3). Analysis of Irish public hospital data showed that early provision of palliative care can shorten hospital length of stay (4). A comparative study across Norway and Finland found similar patterns in place of residence at end of life, with younger adults supported by informal care more often living at home, while older adults more frequently resided in long-term care facilities (5).

One methodological paper provided a framework for understanding the equation of specialist palliative care covering implementation, payment models, and outcomes for multiple stakeholders (6). Evidence synthesis included a global scoping review of unmet palliative care needs across the continuum from initiation of care through bereavement (7). Additional practical and conceptual issues related to outcomes measurement, including patient-reported outcomes in value assessments and study design, were discussed across several papers (6,8,9).

The series encompassed diverse geographic and cultural settings. A study from India adapted a multidomain framework psychosocial, legal, economic, behavioral, spiritual, and bereavement to assess patient and family needs, demonstrating how community partners can support palliative care delivery in rural regions (9). Another article offered an international perspective on the importance and challenges of delivering evidence-based, low-cost palliative care in primary care across age groups (10).

The editorial team hopes the special series will bridge the knowledge gap and provide valuable insights into understanding of palliative care, raise awareness of the needs and provide a resource to guide improvements in low-cost palliative care practices, and policy globally.

Claudia Fischer

Gudrun Waaler Bjørnelv

Rui Dang

Peter May

Preeti Pushpalata Zanwar

Acknowledgments

We would like to thank the International Health Economics Association (iHEA) Special Interest Group (SIG) on Economics of Palliative and End-of-Life Care to bring the editorial team together for this special series.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine, for the series “Value of Palliative Care”. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-142/coif). The series “Value of Palliative Care” was commissioned by the editorial office without any funding or sponsorship. All authors served as the unpaid Guest Editors of the series. C.F. reports payment for teaching from Paracelsus Universität Salzburg. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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