Non-financial reporting for accountability in the public healthcare sector: a structured literature review Open Access

Public healthcare organizations (PHOs) are getting increasing attention for their unique contribution to social and environmental goals, positioning them at the forefront of the academic and professional discourse on the achievement of sustainable development (Acharya et al., 2018; Bosco et al., 2024). This growing awareness has intensified demands for accountability in reporting their effective use of public resources to address social and environmental issues (Cavicchi, 2016), highlighting the value of disclosing non-financial information (Malmmose and Linneberg, 2024).

Non-financial reporting (NFR) practices are gaining traction among public organizations due to their high societal impact and moral obligations to enhance accountability and transparency but also foster a dialogue with stakeholders aimed at meeting their needs more effectively (Ball and Bebbington, 2008; Kaur and Lodhia, 2019). NFR indeed helps provide a comprehensive perspective of an organization’s non-financial performance and its broader effect on stakeholders (Adams and McNicholas, 2007; Dimes and Molinari, 2024), thereby offering a more holistic and long-term understanding of how organizations create sustainable value (De Villiers et al., 2020). Non-financial reports primarily include sustainability reports, integrated reports, social and environmental reports and corporate social responsibility reports (Dimes and Molinari, 2024).

The distinctive characteristics of PHOs compared to other public entities make NFR particularly relevant within this context, thereby requiring focused scholarly attention (Manes-Rossi et al., 2020). Firstly, PHOs have unprecedented social and environmental impacts. They deliver medical services and offer preventive programs that meet the population health needs, improve citizens’ quality of life and reduce preventable suffering and deaths (Nordgren, 2009; Kokko and Laihonen, 2022). The 2030 Agenda of the United Nations includes Sustainable Development Goal #3 (SDG-3), which specifically aims to “ensure healthy lives and promote well-being”, by reducing inequalities and improving accessibility to high-quality services (United Nations, 2015). SDG #3 is intrinsically linked to all other SDGs (e.g. zero hunger, sustainable cities and gender equality), highlighting the relevance of healthcare sector organizations in the achievement of SDGs. Consistently, the activities of PHOs have a substantial impact on climate change and the ongoing green transition, contributing to a significant carbon footprint, estimated at between 1% and 5% of global greenhouse gas emissions (Tennison et al., 2021). This impact intensifies calls for action in several areas, such as waste management (including biohazardous materials, chemicals and medical devices), reduction in energy and water consumption and the implementation of eco-friendly supply chains (WHO, 2009).

Secondly, PHOs operate within a multifaceted and distinct network of stakeholders—including politicians, citizens, patients, healthcare professionals, third sector organizations, other public organizations and corporations—with multiple accountability and transparency demands, needs and values to be satisfied (Hussain et al., 2019; Grossi et al., 2022).

NFR thus helps demonstrate the commitment of PHOs to address stakeholders’ needs and to sustainable development (Manes-Rossi et al., 2020), ultimately ensuring “Healthy Hospitals, Healthy Planet, Healthy People” (WHO, 2009). However, the adoption of NFR in PHOs remains largely confined to early-stage experiences, primarily driven by voluntary adoption (Hensher and McGain, 2020).

An emerging body of literature has sought to examine current NFR practices in PHOs, focusing on the extent of their diffusion and the underlying drivers to encourage a broader adoption (e.g. Andrades et al., 2024). However, research is highly exploratory and fragmented (Manes-Rossi et al., 2020). While multiple literature reviews have mapped the state of NFR research in the public sector, aiming to identify the specificities of NFR practices in public organizations and encourage future adoption and investigations (e.g. Kaur and Lodhia, 2019; Manes-Rossi et al., 2020; Cappellieri et al., 2025), these works are far from giving a comprehensive overview of NFR research that specifically addresses the distinctive characteristics of PHOs. Academic reviews on the healthcare sector largely focus on defining and framing healthcare sustainability dimensions (e.g. Messmann et al., 2024) and sustainable practices (e.g. Rahat et al., 2024), failing to systematically and critically examine current knowledge on NFR practices in PHOs. These gaps are hindering meaningful research and limiting decision-makers from addressing NFR diffusion and institutionalization, thereby restricting “accountability that in turn creates positive social and environmental change” (Deegan, 2019, p. 2324).

A critical scrutiny of the existing literature on NFR in the healthcare sector is thus called to provide insights and facilitate an evaluation of current NFR trends, formats and drivers, linked to the unique characteristics of PHOs (i.e. their multidimensional impact and the multifaceted stakeholder context) (Manes-Rossi et al., 2020), while also stimulating valuable future explorations. This could help promote a debate on the implementation of NFR practices in PHOs and make organizations improve decision-making and sustainable development processes (Adams and McNicholas, 2007).

To fill this gap, our study presents a structured literature review (SLR) of NFR in the healthcare sector, focusing on PHOs. An SLR provides a critical analysis of the evolution of a specific body of literature (Broadbent and Guthrie, 2008) and avoids “myopia through looking at the totality” of the articles included in the review (Alvesson and Deetz, 2000, p. 21). It also reveals future research avenues that represent a positive way forward (Massaro et al., 2016).

Following previous SLRs in the accounting field (e.g. Massaro et al., 2015; Bracci et al., 2019; Manes-Rossi et al., 2020), this paper aims to answer the following research questions:

Given that the healthcare sector encompasses public, private and non-profit organizations and that the literature on NFR in healthcare spans these domains, this SLR provides a comprehensive analysis of the broader body of NFR research within the healthcare context. This analysis also seeks to offer a contextualized identification of trends, themes, gaps and future research directions within the NFR literature on PHOs.

The paper contributes to a deeper understanding of NFR practices within the unique context of PHOs. It sheds light on current NFR tools and frameworks and reveals the determinants and motivations behind NFR adoption in these settings. The findings offer valuable insights for policymakers and healthcare practitioners on the effective implementation of NFR, which we believe will encourage the healthcare sector to be more accountable regarding their role in sustainable development. In addition, by suggesting future research directions, the paper offers a path forward for advancing this field of knowledge (Alvesson and Deetz, 2000).

The paper is structured as follows. Section 2 describes the SLR methodology and details the research protocol. Section 3 provides an overview of the trends and themes of research on NFR in PHOs. Section 4 highlights the current gaps and future research directions. Section 5 concludes the paper, reflecting on the results and on the limitations of the study.

This study provides an SLR that adheres to the guidelines of Massaro et al. (2016) for the accounting field, as it is particularly suitable when dealing with emerging research fields “for which little literature exists” (Massaro et al., 2016, p. 780). An SLR provides a rigorous collection and critique of the extant literature on NFR in healthcare settings and enables us to “uncover insights[…] and make statements concerning possible future[…] research directions” (Dumay et al., 2016, p. 68). This approach has gained prominence in the sustainability accounting literature (Agostini et al., 2023), also focusing on the public sector (Manes-Rossi et al., 2020).

The literature review protocol requires a clear strategy for the search, the analytical framework definition, reliability and validity analyses (Dumay et al., 2016; Massaro et al., 2016).

A search of scientific studies aligned with the aims of the SLR was conducted by consulting two major databases: Scopus and Web of Science. When conducting an SLR within an emerging field, keyword searches require the establishment of broad search parameters (Massaro et al., 2016). We implemented a comprehensive one-step keyword search ( Appendix 1), derived from a preliminary field-exploration desk research, by coupling the most frequently used labels (and related acronyms) as alternatives to “sustainability” (e.g. “sustainable development”), with wide-ranging keywords associated with reporting activities. Common keywords from the NFR literature were also included. To limit the search to the healthcare sector, the general keywords “healthcare”, “health care”, “hospital” and “hospitals” were added, using the Boolean operator “AND”. The keyword search deliberately excluded public sector-specific terms. This decision was intended to (1) quantify the relative proportion of contributions focused on PHOs in relation to the overall body of NFR literature in the healthcare sector and (2) offer a comprehensive and contextualized analysis of NFR in PHOs. The search, launched in March 2023 and updated in late September 2024, included the field of Title–Abstract–Keywords in the selected databases to prevent the inclusion of “too many irrelevant articles” (Massaro et al., 2016, p. 776).

The inclusion criteria applied to ensure the quality of the research were:

1. Only documents in English.

2. Only papers from peer-reviewed scientific journals. Books, book chapters and editorials were excluded, but review articles were included.

3. No time limit.

As shown in Figure 1, the database search retrieved 702 contributions. Duplicates were identified through a manual search of the lists of articles and removed, resulting in 475 papers. Each contribution was inspected by carefully examining its title and abstract (Massaro et al., 2016), verifying its focus on NFR in the healthcare sector. When doubts arose, the full text was read. Despite the strict inclusion criteria, articles were also screened to ensure they consisted of English papers published in peer-reviewed journals. Seven additional articles were eliminated. Records on non-financial (sustainability, SDGs, sustainable development, etc.) reporting practices within healthcare organizations were included to gather insights on reporting formats, drivers and frameworks/models. Papers adopting a different focus (e.g. a clinical perspective on the impacts of medical procedures, the sustainability of healthcare buildings, NFR practices of organizations in other fields that address healthcare issues) or conceptualising sustainability in healthcare but lacking insights on NFR were excluded.

Due to the comprehensive number of keywords used in the search, this selection activity was intensive, 418 papers were excluded.

To ensure the relevance of the results and construct validity, in line with previous SLRs (Manes-Rossi et al., 2020), only high-impact articles in the SCImago Journal Ranking were included, resulting in the removal of eight additional articles. Three studies were excluded due to limited access to the full paper and unclear abstracts. As the keyword search was conducted on Title–Abstract–Keywords, following previous SLRs, a final step was also added to capture articles that did not contain the selected keywords in these sections and “complement the selection process and obtain a more representative sample” (Manes-Rossi et al., 2020). This final step entailed conducting a manual search in the main journals that publish sustainability accounting articles (Appendix 2). We used keywords including the characteristics of NFR in PHOs within the search bar to inspect each number and issue over the last 20 years and examined the resulting titles and abstracts. Key journals were retrieved using “pearl(s)” papers as reference (Schlosser et al., 2006), specifically relying on two recent literature reviews, which indicated the main publication sources of articles on NFR in the private (Hsiao et al., 2022) and public (Manes-Rossi et al., 2020) sectors, then screened to include only high-impact journals (Massaro et al., 2016): the Q1 and Q2 journals of the SCImago Journal Ranking on October 1, 2024. In addition, given the focus on the healthcare sector, we also examined Q1 and Q2 healthcare journals in the “business, management and accounting” category of the SCImago Journal Ranking. Three more studies were included at the end of this additional search, resulting in a final sample of 42 articles (marked with * in the reference list).

Drawing from previous seminal studies involving SLRs (e.g. Broadbent and Guthrie, 2008; Guthrie et al., 2012; Dumay et al., 2016; Manes-Rossi et al., 2020) and the common units proposed by Massaro et al. (2016), we identified seven categories (A–G) (Table 3).

The first category involves the jurisdiction covered by the articles, which distinguishes between articles that do not refer to a specific context, articles presenting evidence from organizations belonging to multiple countries, articles on organizations located in a specific nation or region, articles about organizations belonging to the same country and articles on one individual organization. The organizational focus discerns between private, public and non-profit. The category “Other” encompasses papers with different organizational focuses or studies that do not specify the organizational focus.

The country of research constitutes the context where the study is grounded. “None” includes studies that do not analyse any specific country and “Mixed” embeds those including more than one geographical area.

The research methods category classifies the methodological approach used by the article (e.g. case study, survey and literature review). The focus of the literature investigates the areas of research of the paper (e.g. external reporting, auditing and performance measurement). “Others” includes articles that do not fall within any subcategory or that have both external reporting and internal performance management perspectives.

A specific category involves the theoretical frameworks employed in the included studies. These embed the most common theories of NFR in the public sector, i.e. stakeholder theory, legitimacy theory, institutional theory and principal–agency theory. As in prior SLRs (e.g. Agostini et al., 2023), “None” classifies studies not grounded in any theory, while “Other” refers to multiple perspectives or alternative lenses. How aspects of performance are reported depends on the tools used by healthcare organizations to disclose information. These tools are captured within the type of report category. The subcategory “Mixed” includes studies using multiple types of reports, “Others” includes articles focused on other types of reports (e.g. management commentaries and performance measurement reports).

Finally, frameworks and models categorize the way information is reported depending on the standards, measures or indicators used to assess the aspects of performance embedded in NFR. Papers may refer to existing frameworks/models, e.g. Global Reporting Initiative (GRI) standards (GRI, 2023), Sustainability Accounting Standard Board (SASB) sector-specific metrics (SASB, n.d.), SDG indicators, financial indicators, may propose a new framework, set of indicators or an index, or not propose or use any framework/model.

To ensure reliability and mitigate biases, multiple methods were employed. Firstly, authors collaboratively identified the keywords, conducting separate searches, yielding similar results. The total of 702 articles retrieved were then cleaned of duplicates and were independently analysed, focusing on titles and abstracts, with any discrepancies resolved through discussion. The framework categories were jointly determined and one author independently tested it to ensure internal validity (Broadbent and Guthrie, 2008; Guthrie et al., 2012). The remaining articles were independently coded, and their findings compared. To ensure coding accuracy and comprehensiveness, manual data coding was used to address synonymous words and cover all the qualitative aspects of the content (Massaro et al., 2015). Each article was classified within the analytical framework using Excel.

The reliability test Krippendorff’s α was calculated for each category via R software (Krippendorff, 2013), with all values surpassing 0.8 due to the extensive discussions on the sub-categories before article coding. These results were collectively reviewed, discussing conflicting interpretations. External validity was addressed by conducting multiple queries and continually reviewing the literature throughout the writing process.

Figure 2 illustrates the chronological evolution of research on NFR in healthcare, distinguishing between the total number of articles per year (including private, non-profit and PHOs) and the number of articles focusing on PHOs per year. From 2000 to 2018, the academic output was low, especially regarding the public healthcare sector. Since 2019, there has been a discernible increase in interest in this field of research. The figure shows that articles on PHOs peaked in 2019 but began to decline again in 2020, suggesting a shift toward private-sector studies, given that the total number of articles remained stable. In 2022, there is a peak in the overall trend, while a second peak in public-sector publications occurs in 2023, indicating a slight delay in the renewed focus on the public healthcare sector.

Table 1 reports the number of articles per publication journal. Both considering the overall sample and the articles on PHOs, there is a high level of heterogeneity across the publication outlets. The presence of international accounting journals (e.g. Sustainability Accounting, Management and Policy Journal) reflects the growing interest in NFR practices in PHOs. In fact, five of the eight articles published in accounting journals focused on the public healthcare sector. The exploration of sustainability measurement and reporting within PHOs extends beyond the traditional boundaries of accounting, with some papers published in specialized healthcare (e.g. Health Affairs) and environmental science (e.g. Environmental Science and Pollution Research) journals. Notably, all three articles published in the journal “Business Strategy and the Environment” focus on PHOs, highlighting opportunities for further debate on public sector topics in journals which have traditionally focused on environmental management and sustainable development in business.

Finally, while public management journals appear among the publication sources, each journal includes only one paper.

An analysis of the number of citations provides evidence of the novelty and relevance of the studies and of the articles and authors with a significant influence in this research field.

Table 2 presents the top 10 articles by citation and by citations per year (CPY)^[1] as of 20 October 2024, showing those that focus on PHOs. Based on the average number of CPY, the second ranking mitigates the fact that older articles are often more predominant in the literature. Several recent studies have a relatively higher number of CPY, indicating their influence and relevance in the field. Although the most frequently cited literature pertains to the private healthcare sector, many recent articles focus on PHOs (e.g. Rattan et al., 2022; Suha and Sanam, 2023).

Table 3 presents the results of the coding of the 42 articles, highlighting how the research on NFR in PHOs has evolved across each of the categories and sub-categories of the analytical framework.

Most of the articles analyse organizations belonging to the same country (five on PHOs), which aligns with the need to understand how NFR is developing in the PHOs of countries where these practices are voluntarily adopted and standards are lacking. These articles represent attempts to assess the national spread of NFR practices in PHOs and identify commonalities within one nation in terms of content and formats of disclosure practices (e.g. Andrades et al., 2021), to understand why healthcare organizations, particularly PHOs, engage in NFR (e.g. Marasca et al., 2020; Pratici et al., 2024) or to assess the factors driving such practices (e.g. Pizzi et al., 2020). As expected, heterogeneity emerges within national contexts (Andrades et al., 2024), which is not typically the case for private sector organizations that follow mandatory NFR.

Focusing on an individual organization (in 10 cases PHOs), studies report pioneering experiences with NFR standards and tools (e.g. Cavicchi et al., 2019), analyse the motivations behind NFR practices (e.g. Monfardini et al., 2013) or demonstrate the importance of new sustainability assessment and performance management tools, such as the Balanced Scorecard (e.g. Khalid et al., 2022), to improve the performance of both PHOs and specific healthcare services (e.g. radiology in the study of Benmamoun et al., 2023).

Articles serving a broader national purpose, for example, offer recommendations on sustainability reporting and performance management for healthcare organizations, emphasizing models of excellence, e.g. the experiences of the United Kingdom and Australia (Hensher and McGain, 2020). The supra-national/organizational perspective is limited to a few articles that compare the experiences of the best international cases and analyse the scope, determinants and quality of sustainability reporting practices (e.g. Berniak-Woźny and Kwasek, 2020; Garzoni et al., 2024), demonstrating heterogeneity in the quantity and quality of sustainability reporting (Pizzi et al., 2020). These studies cover both EU and non-EU countries. They reveal that size, public status and teaching status positively impact the amount of sustainability information disclosed.

We found 15 articles focused on PHOs and 4 comparing private and public healthcare organizations. These articles cover academic teaching hospitals, local healthcare trusts and autonomous hospitals. The teaching status places them under greater public scrutiny, thus resulting in a driver of sustainability disclosure through their websites (Garzoni et al., 2024). PHOs are mainly located in countries without a prescribed format for non-financial information, prompting scholars to investigate the freedom of NFR practices in such countries (Malmmose and Linneberg, 2024).

Private sector organizations predominantly involve biotechnology, pharmaceuticals or medical equipment companies (e.g. Dhanda, 2013; Demir and Min, 2019; Consolandi et al., 2020). Compared to PHOs, these companies are subjected to NFR requirements and follow existing standards, such as the GRI or environmental, social governance (ESG) frameworks.

Only four works address non-profit organizations, which are considered as hybrid organizations, attuned to meet the demands of multiple constituents, such as governments, citizens and markets (Ahunov, 2023). The studies propose a revised application of the International Integrated Reporting Framework (IIRF) (e.g. Dameri and Ferrando, 2021, 2022), highlight the relevance of the ESG framework to create comparable documents that can act as benchmarks for similar institutions when dealing with social reporting (Pratici et al., 2024) and emphasize the application of the 2022 Corporate Sustainability Reporting Directive by including the environmental dimension in NFR (Bauer and Greiling, 2024).

Notably, some studies focus on multiple types of organizations and four of these compare public and private organizations (Andrades et al., 2021; Suha and Sanam, 2023; Garzoni et al., 2024). These studies emphasize the role of public status as a driver of NFR. Compared to private firms, public entities have moral obligations to undertake organizational activities that are accepted in society and NFR practices represent a non-imposed norm that helps PHOs gain legitimacy from stakeholders.

The distribution of studies on healthcare organizations, particularly PHOs, across countries highlights how the context heavily influences the development of research in NFR in the public healthcare sector. Most of the articles analyse southern Europe, particularly, Italy (9) (e.g. Dameri and Ferrando, 2021) and Spain (5) (e.g. Andrades et al., 2020), focusing on PHOs. Both countries have national healthcare systems and are currently experiencing mounting pressure to disclose non-financial information to meet transparency and accountability objectives, propelled by national guidelines, such as the Italian Gruppo Bilancio e Sostenibilità (GBS).

Despite several papers on NFR in public sector organizations that consider Oceania (Manes-Rossi et al., 2020), NFR healthcare research in this context is still limited (two papers involving Australia) (Khalid et al., 2019, Khalid et al., 2022).

Studies on the private sector are primarily conducted in the USA (e.g. Castagnini et al., 2022) because of the privatised healthcare system characterizing this country. In the USA, the focus of healthcare sustainability measurement and reporting has typically been on corporate social responsibility and climate risk disclosure (Hensher and McGain, 2020).

Notably, the focus on sustainability measurement and reporting in developing countries is prominent, suggesting an increasing interest in analysing PHOs. Although healthcare services in these countries have significant shortcomings, the population mainly relies on struggling public facilities. For example, studies show how measuring social sustainability is a standard and beneficial practice in a government hospital in Tehran (Khosravi and Izbirak, 2019). Similarly, in Morocco, a framework to evaluate the sustainability performance of the radiology service was effectively set up in a university hospital (Benmamoun et al., 2023), as well as a Sustainability Balanced Scorecard was developed (Regragui et al., 2023). The findings highlight that patient satisfaction, efficiency, effectiveness, access to care and waste production are among the most important criteria of sustainable performance. One study also identifies indicators to measure the contribution of PHOs in India to SDGs (Rattan et al., 2022).

Lastly, a multi-country perspective is also adopted mainly in the form of quantitative explorations of factors driving NFR, such as gender diversity on hospital boards of directors and trustees or to identify the most relevant sustainability dimensions or practices (e.g. Garzoni et al., 2024). Their findings show that, compared to the USA, European countries tend to prioritize the social dimension over environmental issues (e.g. Migdadi and Omari, 2019; Berniak-Woźny and Kwasek, 2020).

This category shows the theoretical and empirical paces of research. Confirming the results of previous research (Manes-Rossi et al., 2020), scholars prefer field studies and content analyses, which have been widely used in sustainability accounting research. Nearly 50% of the articles use a qualitative case study methodology (e.g. Gigli and Tieghi, 2012; Cavicchi et al., 2019), often combined with interviews, to explore NFR practices in PHOs. These case studies examine motivations for social sustainability reporting (e.g. Monfardini et al., 2013), the institutionalization of this practice (Andrades et al., 2024), barriers and incentives for incorporating environmental factors in the Balanced Scorecard (e.g. Khalid et al., 2022), the mechanisms and benefits of external reporting through management commentary (Cavicchi et al., 2019) and the rationale and application of integrated reporting (e.g. Marasca et al., 2020).

Content analysis (10 articles) is widely used to examine the formats, content, discourse and quality of non-financial reports (Malmmose and Linneberg, 2024), the accountability of non-financial information on SDG-3 (Pizzi et al., 2020) and factors influencing sustainability disclosure (Andrades et al., 2020). This analysis also includes hospital websites to assess online disclosure practices, which are developing driven by legitimacy concerns (Andrades et al., 2021; Garzoni et al., 2024).

Surveys are used to identify sustainability assessment tools (Suha and Sanam, 2023), while quantitative empirical studies are increasing (Garzoni et al., 2024). Factor analyses aid in identifying sustainability indicators for PHOs (Rattan et al., 2022).

Lastly, one commentary article reports on how to build safer and low-carbon healthcare through sustainability reporting and performance measurements (Hensher and McGain, 2020), and four articles conduct a literature review. A narrative review highlights sustainability reporting as a priority in healthcare (Sherman et al., 2020), while three systematic reviews identify taxonomies and indicators for hospital sustainability assessment (Messmann et al., 2024), best practices in sustainability performance measurement (Cavicchi, 2016) and NFR practices in hybrid organizations (Ahunov, 2023).

The highest emphasis is on external reporting (19 articles), reflecting the growing accountability pressures on PHOs to report social and environmental issues. Scholars, attracted by non-financial disclosure practices, provide both theoretical and practical contributions (e.g. Garzoni et al., 2024).

Numerous are also studies (six focusing on PHO) that explore non-financial performance measurement and control systems and sustainability strategic planning (e.g. Regragui et al., 2023). This perspective mirrors a growing tendency to use sustainability reports to inform internal stakeholders’ decision-making processes. Few studies focus on auditing activities, highlighting the role of sustainability reports in certification processes (e.g. ISO 14001 and ISO 26000) by complying with sustainability standards (Dettenkofer et al., 2000; Romero and Carnero, 2019). The definition of a shared model, including sustainability indicators, is said to aid internal auditing and decision-making when environmental management system’s certifications need to be addressed (Romero and Carnero, 2019).

Although research on accountability and governance remains limited, scholars are increasingly recognizing the governance mechanisms and managerial processes behind NFR practices. Healthcare managers must be transparent, accountable and responsible in pursuing sustainable development (Pizzi et al., 2020), engaging multiple PHO stakeholders (Khosravi and Izbirak, 2019). In these studies, NFR is seen as a tool supporting dynamic relationships between PHOs and key institutional stakeholders (Gigli and Tieghi, 2012).

Lastly, scholars have started to acknowledge the relevance of employing a dual perspective when dealing with NFR, which involves both internal recipients for decision-making and external recipients for accountability and legitimacy purposes (e.g. Blass et al., 2017).

The decision to adopt NFR within the public health sector is predominantly voluntary, making the explanation of the reason why PHOs adopt NFR particularly relevant. Only a few articles explicitly draw on the established theoretical framework of NFR in the public sector (13).

Among these, stakeholder theory ranks as one of the most widely used theories (seven articles – two on PHOs), explaining the aim of PHOs to understand and meet the needs, values and expectations of a wider range of stakeholders (e.g. employees, citizens, patients and regional authorities), as well as to address external accountability pressures (e.g. Khalid et al., 2019; Pratici et al., 2024). While private organizations primarily focus on external stakeholders (mainly, shareholders), PHOs are driven by the need to satisfy both internal and external stakeholders (Marasca et al., 2020; Ahunov, 2023), who are “actors participating in the pursuit of the organization’s mission” (Dameri and Ferrando, 2022, p. 747). Citizens are becoming active resources of PHOs, which need to consider their needs and expertise when preparing non-financial reports. Gaining legitimacy is also considered a common motivator of NFR. An example is when hospitals choose to disclose sustainability information to gain consensus from stakeholders regarding their activities (Garzoni et al., 2024). Legitimacy can be symbolic, to positively influence the public impression of the organization or substantial by changing the behaviour of PHOs through the adoption of different managerial practices and meeting the expectations of key stakeholders (Andrades et al., 2021). NFR can then be motivated by mimetic purposes, whereby it becomes an institutionalized norm within the organization because it has been adopted by peers (Khalid et al., 2022; Andrades et al., 2024).

Notably, some recent investigations have relied on the combination of legitimacy and institutional theories to unravel the motivations (Marasca et al., 2020; Andrades et al., 2021) and drivers (Andrades et al., 2020) of NFR in PHOs, finding complementarity between the two theoretical lenses. Although legitimacy and institutional frameworks may have initially explained the motivations behind NFR adoption, scholars increasingly argue that these lenses possess inherent limitations (Monfardini et al., 2013). Obtaining legitimacy from NFR cannot be taken for granted and depends on reporting practices, content and compilation methods. These factors are influenced by stakeholder demands for accountability and the moral obligation of transparency to justify substantial public expenditure (Monfardini et al., 2013).

Furthermore, while none of the articles included in the study identify an agency-related incentive, many studies rely on the concept of accountability. NFR plays a crucial role in demonstrating the allocation of public resources (e.g. Pizzi et al., 2020), thus strengthening “accountability relationships” and providing valuable information for both internal and external decision-making processes (Cavicchi et al., 2019).

The literature highlights the adoption of a diverse array of non-financial reports by PHOs as a means of meeting accountability demands and demonstrating their broader impact.

Studies report that PHOs mainly disclose sustainability information through ad hoc reports. Compared to the private sector, where it is a long and established practice, sustainability reporting in PHOs is still in its early stages and is not an institutionalized practice, even in Italy and Spain, where NFR research is significant (Andrades et al., 2024).

Evidence shows a heterogeneity of sustainability reporting practices both in quantity and quality of information disclosed, including the general structure and naming of the document sections (Garzoni et al., 2024). This heterogeneity stems from the voluntary nature of NFR in PHOs, coupled with the absence of guidelines and standards specifically designed for these organizations (Pizzi et al., 2020; Ahunov, 2023). Mandatory sustainability reporting is therefore the subjected of heated debate, as it would establish a common system for measuring and reporting sustainability for PHOs (Andrades et al., 2020). Progress has been made in some countries, such as the UK National Health Service (NHS), which has been committed since 2008 to achieving net zero carbon by 2040, by implementing a comprehensive approach to sustainability reporting and a Sustainable Health Dashboard.

However, if on one side, some scholars argue that mandatory reporting may limit innovative practices and strategies to avoid risks associated with the disclosure of failures (Pizzi et al., 2020), on the other side, voluntary approaches require guidelines and participatory stakeholder practices to identify comparable standards and measures (Hensher and McGain, 2020).

Heterogeneity in contents undermines the multidimensional disclosure of sustainability that includes economic, environmental and social aspects (Garzoni et al., 2024). Less than half of the articles refer to all three dimensions, which can encourage comprehensive decision-making processes to achieve the 2030 Agenda promoted by the UN SDGs (Pizzi et al., 2020). In some cases, the ecological dimension is prioritized by focusing on environmental reporting, which is seen as an enabler of PHOs’ certification processes (Romero and Carnero, 2019) or as a catalyst for green strategies and operations (e.g. Maamari et al., 2017; Migdadi and Omari, 2019). Social reporting mainly involves the Italian context (e.g. Monfardini et al., 2013).

To improve external accountability, PHOs disclose non-financial information through websites to reach a wider plethora of stakeholders (Andrades et al., 2020). Scholars, however, show how this practice is still poorly employed (Andrades et al., 2021).

The need for more integrated reporting practices has prompted some PHOs to disclose non-financial information through the IIRF (Marasca et al., 2020), which supports organizations in preparing and disclosing documents containing information on performance, strategy and value creation across six capitals (financial, manufacturing, intellectual, human, social and relational and natural) (IIRC, 2013). However, this framework is mainly designed for private sector organizations, remaining overlooked by PHOs. One article highlights its adoption through a standalone report, while another study documents the application of the six capitals using the management commentary as a reporting tool. While the use of management commentaries as an NFR tool can potentially provide key data for internal and external decision-making, research suggest its limited utility as an integrated report (Cavicchi et al., 2019; Malmmose and Linneberg, 2024). It is indeed seen as redundant, complex and lengthy, which discourages readers. To effectively function as an integrated report, it needs to be customized and developed in collaboration with stakeholders to be aligned with their needs.

Another problem with integrated reporting in PHOs is its narrow focus on creating value for patients, neglecting other important stakeholders, such as healthcare professionals (Marasca et al., 2020). To address this issue, a revision of the IIRF is proposed in a case study of a non-profit organization (e.g. Dameri and Ferrando, 2022), thereby providing the foundation for future efforts involving PHOs.

Building the structure and themes of non-financial reports based on a target audience is essential for all types of non-financial reports (Monfardini et al., 2013). Stakeholders need to be interested in the information provided; otherwise, the usefulness and understandability of the reports are undermined (Pratici et al., 2024; Marasca et al., 2020). For example, evidence shows that both preparers (e.g. managers, employees) and users (e.g. regional or local institutions, patients and citizens) of non-financial reports complain about the lack of information on future actions, improvement objectives and stakeholders’ opinions (Monfardini et al., 2013).

Language is also crucial in healthcare, where there is often a predominant use of technical terms. However, oversimplification can hinder communication with healthcare professionals. In public healthcare, internal stakeholder involvement is crucial, as professionals in this context enjoy a high degree of autonomy (Andrades et al., 2021). PHOs could thus provide customized versions of the report depending on the stakeholders they intend to reach (Marasca et al., 2020) and use graphical presentations to improve data reliability and the success of the NFR (Monfardini et al., 2013).

The necessity of meeting internal stakeholders’ information needs for decision-making purposes has prompted PHOs to integrate sustainability performance management systems, such as Sustainability Balanced Scorecards (e.g. Regragui et al., 2023). However, this integration is far from unproblematic. These systems require the collection of additional data, the definition of rules and routines supported by leaders and a sustainability-oriented organizational culture (Khalid et al., 2019). Research has thus increased on the factors influencing sustainability performance management. Notably, studies confirm the relevance of internal drivers (e.g. organizational rules and routines) but also show the influence of external pressures (e.g. government interventions) (Khalid et al., 2022).

Extended research emerges not only on the drivers of sustainability performance measurement but also on the broader determinants of NFR. Among the most influential aspects, studies highlight the role of organizational, geographical, clinical, political and socio-economic factors (Cavicchi, 2016; Andrades et al., 2020; Pizzi et al., 2020). Firstly, as they are under public scrutiny, PHOs are more encouraged than private organizations to report non-financial aspects to legitimize their activity and meet stakeholders’ demands (Monfardini et al., 2013). Then, larger organizations, those located in cities with higher rates of Internet access and ranked high in transparency rankings and in regions governed by conservative political parties, are more likely to disclose sustainability reports (e.g. Andrades et al., 2020). When considering the determinants of the amount of sustainability information disclosed through websites, the size, public and teaching status of organizations are confirmed to have a positive impact (Garzoni et al., 2024).

The presence of female directors and stakeholder involvement at different stages (e.g. strategic planning or report preparation) (Monfardini et al., 2013; Cavicchi et al., 2019) also appears to reinforce the breadth and depth of the NFR. Institutional pressures play a crucial role in shaping sustainability reporting and performance management (e.g. Khalid et al., 2022; Andrades et al., 2024). These pressures drive organizations to improve ESG performance to meet societal expectations and gain legitimacy, thereby highlighting the importance of external influences in shaping corporate behaviour and practices.

On the contrary, the lack of dedicated staff and funding for sustainability projects, as well as time constraints, emerge as factors that hinder NFR practices (Andrades et al., 2020). For example, PHOs use websites to primarily publish mandatory information, as updating information requires dedicated communication offices and time.

Corporate social responsibility reports also emerge as a medium for the dialogue between society and these companies regarding their impacts, risks, policies and actions (Demir and Min, 2019).

The absence of sector-specific standards for healthcare, particularly in the public healthcare sector coupled with the lack of mandatory non-financial accountability requirements, has prompted several studies to explore the frameworks or models employed by PHOs (e.g. Andrades et al., 2020).

In most cases, PHOs refer to frameworks and models originally oriented to private sector organizations. The GRI guidelines are the most frequently mentioned framework, given their long and widespread adoption (e.g. Creixans-Tenas et al., 2019; Basumatary and Sar, 2024). The ESG framework provided by the SASB is cited with reference to both public and private healthcare organizations. Although it identifies financially relevant sustainability topics for healthcare sectors’ organizations, it is, however, highly tailored to the private sector. The framework is suitable for building specific scores and quantifying the level of ESG reporting, thereby enabling to explore potential determinants, such as gender diversity in the board of directors or trustees. This mechanism could, however, be risky for organizations, as it creates a “tick-box” attitude that would inevitably lose the framework’s transformative potential (Pratici et al., 2024). To tackle this challenge, an organizational culture is necessary that makes the ESG paradigm part of the organization mission rather than an additional burden. ESG standards are said to help assess the contribution of PHOs to the SDGs (Consolandi et al., 2020). The UN SDGs are primarily recognized as outcomes rather than a comprehensive framework for NFR (Pizzi et al., 2020).

Only a few cases employ the IIRF to report on the six capitals (e.g. Marasca et al., 2020), highlighting the inadequacy of the model to embrace the characteristics of PHOs. A case study provides a review of the framework in order to enhance the identification of all relevant stakeholders’ needs and expectations and redesign activities (Dameri and Ferrando, 2021, 2022).

Some national guidelines emerge, such as the “Social reporting for healthcare structures”—GBS—Document No. 9 in Italy, which do not provide mandatory standards but encourage PHOs to use a common definition of NFR.

Some studies (22) have attempted to explore or develop new frameworks or models to address the lack of such frameworks in the public healthcare sector, highlighting the urgent need for tailored NFR tools. They provide tools to assess hospital sustainability (Buffoli et al., 2014; Messman et al., 2024), improve audit activities (e.g. Khosravi and Izbirak, 2019; Nagariya et al., 2022), assess the contribution to SDGs (Rattan et al., 2022) and measure the performance of improvement projects (Benmamoun et al., 2023).

Given the pressing call for action on the 2030 Agenda (United Nations, 2015) attempts to develop a comprehensive list of SDG-based indicators for PHOs have emerged (Rattan et al., 2022). One literature review draws on previous studies that defined sustainable healthcare to provide taxonomies and indicators (Messmann et al., 2024).

Finally, some papers in the literature do not propose or use any framework/model. This subcategory includes papers that explore the motivations behind NFR in PHOs (e.g. Monfardini et al., 2013), systematic reviews of NFR in hybrid organizations (Ahunov, 2023) and literature reviews on sustainability performance measurements in hospitals (Cavicchi, 2016; Sherman et al., 2020). This evidence highlights the need to develop new tools to link external reporting and internal decision-making practices.

The necessity to involve stakeholders in the identification of NFR indicators and measures is highlighted, suggesting benefits in terms of better understandability of NFR and the ability to meet stakeholders’ information needs (e.g. Monfardini et al., 2013; Cavicchi et al., 2019).

The literature review reveals a growing scholarly interest in NFR within PHOs, as evidenced by the significant proportion of articles focused on the public healthcare sector. This trend reflects the broader pace of NFR research in the healthcare sector, encompassing both public and private healthcare contexts. The analysis also highlights consistent gaps in the literature, which point to four key paths for future investigations.

• Path#1: Promoting comparability and harmonization of NFR formats in the public healthcare sector to support a multidimensional approach to sustainability.

The conflicting evidence on mandatory versus voluntary NFR (Andrades et al., 2024), together with the predominantly voluntary nature of NFR practices in the public healthcare sector (e.g. Andrades et al., 2021; Ahunov, 2023) merits future research that explores opportunities and challenges of both approaches (Hensher and McGain, 2020; Pizzi et al., 2020). The findings emphasize that mandatory NFR practices are mainly present in countries with private healthcare as the predominant system, such as the USA, thereby highlighting a tacit link between the ownership and the presence of mandatory practices. Mandatory NFR would ensure a greater adoption of these practices in PHOs, reducing heterogeneity and improving the comparability of reports. On the other hand, in voluntary NFR, PHOs might be more incentivized to provide meaningful and useful information rather than simply adhering to coercive pressures and complying with regulatory requirements (Manes-Rossi et al., 2020). Furthermore, given the inherent diversity of healthcare organizations (Pratici et al., 2024), it is crucial to maintain flexibility and adapt NFR frameworks to the specific context of each organization (Cavicchi et al., 2019). Future research could thus adopt a multi-country comparative perspective, analysing exceptional cases of public healthcare systems with mandatory NFR regulations (e.g. the UK) in contrast to those operating under voluntary sustainability reporting frameworks (Andrades et al., 2020).

The literature analysed highlights that the limited diffusion of NFR, together with the heterogeneity of practices, is also linked to other unresolved issues that warrant further investigation (Garzoni et al., 2024). Current NFR frameworks and models often fail to capture the full spectrum of impacts generated by PHOs (Bosco et al., 2024) and to adequately address value creation for a broader range of stakeholders beyond patients, such as healthcare professionals (Rattan et al., 2022; Messman et al., 2024). PHOs face a dual challenge compared to private organizations: the absence of both mandatory requirements and dedicated frameworks. Future investigations could thus focus on developing and validating NFR standards and frameworks, incorporating quantitative and comparable indicators that specifically reflect the distinctive characteristics of PHOs, including their economic, social and environmental impacts (Maamari et al., 2017; Migdadi and Omari, 2019; Ahunov, 2023). The literature confirms that NFR is highly context-specific, based on the organization or country to which it belongs. For example, while environmental issues remain underrepresented in some cases of sustainability reporting, “lagging behind” compared to social and financial issues (Bauer and Greiling, 2024; Pratici et al., 2024), environmental reporting has been the focus of several articles.

In this context, the role of information technologies and artificial intelligence in supporting non-financial accounting and performance reporting warrants the attention of scholars (Regragui et al., 2023; Suha and Sanam, 2023).

In addition to reporting frameworks and standards, further exploration is needed to determine the most suitable tools for non-financial disclosure (e.g. stand-alone reports, management commentaries and websites) (Gigli and Tieghi, 2012; Cavicchi et al., 2019). Innovative approaches to reporting merit additional attention. Some studies have called for a deeper understanding of integrated reporting and why adoption of this practice has been impeded (Cavicchi et al., 2019; Marasca et al., 2020). Integrated reporting has the potential to improve transparency in value creation, yet current practices predominantly focus on patient-related value, neglecting a comprehensive view of the capitals outlined in the IIRF (Marasca et al., 2020; Dameri and Ferrando, 2021).

Furthermore, despite the potential of digital platforms (e.g. websites or social media) as more direct communication channels with stakeholders, especially citizens, few studies have examined the extent of online disclosure (Garzoni et al., 2024), and none of the articles have investigated social media as a communication tool. Future research could explore the barriers to this practice, such as the underutilization of hospital websites, the lack of dedicated communication resources and the role of emerging technologies in facilitating the clear and accessible dissemination of information (Garzoni et al., 2024).

• Path#2: Fostering stakeholder engagement in NFR practices to address the needs of internal and external PHO stakeholders.

A critical gap in the literature concerns the participatory role of stakeholders in PHOs’ NFR processes (Cavicchi et al., 2019). While studies highlight the need for active stakeholder participation in various stages of the reporting process, such as planning, identifying tools and developing contents (Monfardini et al., 2013; Cavicchi, 2016; Pratici et al., 2024)—there is limited exploration of how this involvement influences the effectiveness of NFR in PHOs. For example, as the findings suggest that reports are often too technical or incomprehensible for non-experts (Marasca et al., 2020), the potential for stakeholder collaboration in improving the clarity and usefulness of reports merits further attention.

Moreover, the current literature neglects the practical aspects of determining which stakeholders need specific information (Monfardini et al., 2013), designing indicators tailored to their information needs (Andrades et al., 2021), as well as how interested these stakeholders are in being involved in the preparation of reports (Pratici et al., 2024; Khalid et al., 2019). Future research needs to address the complexities surrounding the identification of internal and external stakeholders within PHOs (Khosravi and Izbirak, 2019; Marasca et al., 2020), particularly in exploring the implications of involving stakeholders in NFR on decision-making, organizational sustainability actions and the emotional dynamics within PHOs (Georg and Füssel, 2000; Blass et al., 2017).

• Path#3: Unravelling NFR drivers to facilitate its adoption within PHOs.

Research on the drivers behind NFR is a lively area of inquiry. The shift from an initial emphasis on external motivations, such as accountability (Cavicchi et al., 2019), legitimacy (e.g. Andrades et al., 2021) and institutional pressures (e.g. Andrades et al., 2024), to alternative theoretical explanations warrants further exploration. As recent findings increasingly align with stakeholder theory perspectives (e.g. Khalid et al., 2019; Pratici et al., 2024), future research is essential to critically reassess outdated theories related to the public sector, such as the principal–agency theory and provide a deeper understanding of NFR processes in the public healthcare landscape, which is predominantly shaped by a multiplicity of stakeholder needs and expectations (Marasca et al., 2020). In this context, studies could adopt the public value perspective to investigate the connection between NFR and the creation of sustainable public value (Farneti and Dumay, 2014).

Regardless of new perspectives on the motivation behind NFR in PHOs, further research is still needed to ensure that social and environmental accountability is effectively achieved (Andrades et al., 2021). Moreover, the conflicting findings regarding the relationship between NFR and legitimacy (Monfardini et al., 2013), as well as the extent to which the emulation of best practices serves to institutionalize NFR (Andrades et al., 2024), require greater conceptual clarification. On the contrary, it is crucial to examine how PHOs leverage NFR to increase and show their efforts towards sustainable development rather than complying with regulations (Hensher and McGain, 2020).

In addition to theoretical explanations, the literature calls for a deeper exploration of the heterogeneity of factors influencing NFR processes (Andrades et al., 2020). The variables selected by current studies are largely based on those commonly used in sustainability disclosures by other public sector organizations, such as governments (e.g. Andrades et al., 2020). Future research could benefit from identifying determinants specifically adapted to the socioeconomic context of PHOs (Andrades et al., 2020; Rattan et al., 2022). Comparisons between European and non-European countries are essential, as well as between private and public healthcare organizations (Rattan et al., 2022). This would help to unravel why PHOs, which are more subjected to moral obligations and accountability demands, face difficulties in NFR, beyond the mandatory vs voluntary discourse.

The articles analysed highlight that the success of NFR not only depends on facilitating factors but also on the mitigation of barriers (Khalid et al., 2022), which are mainly related to the introduction within PHOs of new accounting routines and to the knowledge-intensive nature of these organizations, where professionals exercise a high degree of autonomy (Monfardini et al., 2013). However, evidence is lacking on the perspectives of report writers (e.g. PHO managers) regarding the constraints that hinder the acceptance of sustainability reporting, integrated reporting and online disclosure (Khalid et al., 2022; Andrades et al., 2024; Garzoni et al., 2024). For example, cynicism towards sustainability reporting particularly merits further investigation (Monfardini et al., 2013). Additional research on the relationship between NFR and organizational change in PHOs are also needed to examine the impact of the organizational culture (Pratici et al., 2024) or the role of incentives in supporting the collection and analysis of sustainability data (Khalid et al., 2022).

• Path #4: Addressing the role of NFR in supporting decision-making towards the attainment of SDGs.

The influence of NFR on internal and external PHOs’ decision-making processes warrants further investigation, particularly related to the potential of these practices to aid PHOs in addressing sustainable development issues (Migdadi and Omari, 2019). Existing studies do not adequately examine how PHOs leverage NFR to facilitate genuine transformations in sustainability and to address economic, social and environmental challenges, rather than simply enhancing their image and legitimacy (Garzoni et al., 2024). Investigating management processes underpinning NFR practices could provide valuable insights into how sustainability is quantified, disclosed and integrated into decision-making processes within PHO management frameworks (Pratici et al., 2024). Future research is therefore essential to explore how PHOs use NFR to assess their progress and formulate strategies to address the UN 2030 Agenda.

It has been highlighted that PHOs should implement training programs for managers and employees to improve their sustainability literacy (Andrades et al., 2021). Such efforts would facilitate the institutionalisation of sustainability disclosure and encourage participatory approaches within the organization (Monfardini et al., 2013; Garzoni et al., 2024). Future analyses could delve deeper into how PHOs address the lack of sustainability knowledge within their organizations (Andrades et al., 2021; Khalid et al., 2022), as well as the role of sustainability advocates and sustainability committees/commissions within PHOs in supporting sustainability initiatives and NFR (Sherman et al., 2020).

Despite the growing resonance of the unique role of PHOs in the achievement of sustainable development (Bosco et al., 2024), our study reveals that these organizations have been largely overlooked in NFR research. Addressing the call of previous studies (Manes-Rossi et al., 2020), this paper contributes to the literature on NFR in the public sector by offering a critical review of existing studies, outlining gaps and providing avenues for future explorations on NFR in PHOs. To achieve this, an SLR methodology was employed, inspired by Massaro et al. (2016) and previous papers in the field of accounting and NFR (e.g. Dumay et al., 2016; Manes-Rossi et al., 2020). Including private sector studies allowed us to emphasize the weight of NFR research focusing on PHOs, drawing contextualized insights and comprehensive future research directions. The findings show that the existing literature on NFR in healthcare and particularly in the public healthcare sector is emerging. However, there is a lack of conceptual and empirical studies, particularly from an accounting perspective, thereby suggesting the need for further research from both theoretical and methodological perspectives.

The study emphasizes that compared to other public entities, PHOs are a valuable context for in-depth analyses. Firstly, the primary activities of PHOs have significant economic, social and environmental impacts (Bosco et al., 2024). Secondly, PHOs operate within a complex network of internal and external stakeholders with different expectations and needs who exert accountability pressures, seeking transparency on non-financial information (Khosravi and Izbirak, 2019; Marasca et al., 2020). Thirdly, the public healthcare context is primarily characterized by the voluntary nature of NFR, which creates heterogeneity and significant delays in the adoption of these practices (Garzoni et al., 2024).

This study identifies four paths to advance research in the emerging field of NFR in PHOs, which also encourage practitioners and policy makers to act. Firstly, the study calls for the development of frameworks and standards tailored to the multidimensional impact of PHOs, which would improve the diffusion of NFR practices while reducing heterogeneity in both quality and quantity of information disclosed. When designing NFR frameworks and models for PHOs, policy makers should consider several influential factors such as the context and complexity of PHOs (Andrades et al., 2020). This call includes tailoring NFR guidelines and incentive policies accordingly. Secondly, the study points out that stakeholder engagement throughout the NFR process deserves scholarly and professional attention. In doing so, it suggests some drivers, such as training initiatives that would enhance engagement by improving the sustainability literacy of internal and external stakeholders. Thirdly, the study focuses on the key factors, such as cynicism among managers and healthcare professionals, board gender diversity and incentive mechanisms, that influence the adoption of NFR practices. These factors are areas in which decision makers are called to act for promoting NFR in PHOs. Lastly, it highlights that NFR can improve decision-making to meet stakeholders’ needs and achieve the SDGs rather than simply achieve external accountability requirements. This discussion transcends the “voluntary or mandatory” debate (Hensher and McGain, 2020).

Limitations of this study need acknowledging. Although we have conducted a rigorous and comprehensive literature search, the criteria selected for the inclusion, classification and analysis of studies may have influenced our results. Moreover, only English-language articles were included, which may have omitted national case studies published in other languages. Nevertheless, we believe that this paper serves as a catalyst for new NFR research in the public healthcare field, offering valuable insights for both academics and practitioners. This would support PHOs in enhancing accountability and decision-making for the achievement of SDGs, strengthening their efforts in creating sustainable public value for current and future generations. This opens a broader and ultimate question that warrants future investigations: How can PHOs leverage NFR to enhance sustainable public value creation?

The project was performed within the MUSA – Multilayered Urban Sustainability Action – project, funded by the European Union – NextGenerationEU, under the National Recovery and Resilience Plan (NRRP) Mission 4 Component 2 Investment Line 1.5: Strengthening of research structures and creation of R&D ‘innovation ecosystems’, set up of ‘territorial leaders in R&D’. We acknowledge financial support within the ‘Fund for Departments of Excellence academic funding’ provided by the Ministero dell’Università e della Ricerca (MUR), established by Stability Law, namely the ‘Legge di Stabilità n.232/2016, 2017’ – Project of the Department of Economics, Management, and Quantitative Methods, University of Milan.

(“sustainable development report*” OR “sustainable development measur*” OR “sustainable development performance” OR “sustainable development indicator*” OR “sustainable development impact*” OR “sustainable development outcome*” OR “sustainable development assess*” OR “sustainable development evaluat*” OR “sustainable development account*” OR “sustainable development disclos*” OR “ESG report*” OR “ESG measur*” OR “ESG performance” OR “ESG indicator*” OR “ESG impact*” OR “ESG outcome*” OR “ESG assess*” OR “ESG evaluat*” OR “ESG account*” OR “ESG disclos*” OR “nonfinancial report*” OR “non-financial report*” OR “SDG report*” OR “sustainable development goal* report*” OR “sustainable development goal* account*” OR “SDG account*” OR “SDG disclos*” OR “sustainable development goal* disclos*” OR “sustainability report*” OR “sustainability measur*” OR “sustainability performance” OR “sustainability indicator*” OR “sustainability impact*” OR “sustainability outcome*” OR “sustainability assess*” OR “sustainability evaluat*” OR “sustainability account*” OR “sustainability disclos*” OR “integrated report*” OR “integrated thinking” OR “social report*” OR “environmental report*”) AND (“healthcare” OR “health care” OR “hospital” OR “hospitals”)