Case Investing Public Health

THE CASE FOR INVESTING IN PUBLIC HEALTH
A public health summary report for EPHO 8
Assuring sustainable organizational

structures and financing
The case for investing in public health 1

THE CASE FOR INVESTING IN PUBLIC HEALTH
The strengthening public health services and capacity
A key pillar of the European regional health policy framework Health 2020
A public health summary report for EPHO 8

ABSTRACT
The economic crisis has led to increased demand and reduced resources for health sectors. The trend for increasing
healthcare costs to individuals, the health sector and wider society is significant. Public health can be part of the
solution to this challenge. The evidence shows that prevention can be cost-effective, provide value for money and
give returns on investment in both the short and longer terms. This public health summary outlines quick returns on
investment for health and other sectors for interventions that promote physical activity and healthy employment;
address housing and mental health; and reduce road traffic injuries and violence. Vaccinations and screening
programmes are largely cost-effective. Population-level approaches are estimated to cost on average five times less
than individual interventions. This report gives examples of interventions with early returns on investment and
approaches with longer-term gains. Investing in cost-effective interventions to reduce costs to the health sector and
other sectors can help create sustainable health systems and economies for the future.
Keywords
DELIVERY OF HEALTH CARE
HEALTH CARE COSTS
HEALTH CARE ECONOMICS AND ORGANIZATIONS
HEALTH POLICY
PREVENTION
PUBLIC HEALTH
© World Health Organization 2014

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ii
CONTENTS
Acknowledgements............................................................................................................................................................... iv
About this report.................................................................................................................................................................... 1
Scope..................................................................................................................................................................................... 1
Objectives............................................................................................................................................................................ 1
Key messages........................................................................................................................................................................... 1
Overview.................................................................................................................................................................................... 3
Background............................................................................................................................................................................... 5
The economic case for prevention................................................................................................................................... 7
Sustainability of current and future costs............................................................................................................... 8
The cost of health inequalities.................................................................................................................................... 8
The benefits of action........................................................................................................................................................... 11
A summary of the evidence......................................................................................................................................... 12
Other considerations: risk and preparedness........................................................................................................ 22
Conclusions............................................................................................................................................................................... 23
Glossary...................................................................................................................................................................................... 25
References................................................................................................................................................................................. 26
iii
Acknowledgements
This public health summary report was prepared by Joanna Nurse, Stephen Dorey, Lin Yao, Louise Sigfrid and
Platonas Yfantopolous, formerly from Public Health Services, Division of Health Systems and Public Health, WHO
Regional Office for Europe; David McDaid, London School of Economics; John Yfantopolous, University of Athens;
and Jose Martin Moreno, formerly of the WHO Regional Office for Europe.
The authors wish to thank Hans Kluge, Director, Division of Health Systems and Public Health; Melitta Jakab and
Tamás Evetovits, WHO Barcelona Office for Health Systems Strengthening; Elke Jakubowski, Public Health Services,
Division of Health Systems and Public Health; Claudia Stein, Division of Information, Evidence, Research and
Innovation; Gauden Galea, Division of Non-communicable Diseases and Health Promotion, all at the WHO Regional
Office for Europe, for their contributions. Particular thanks are due for the valuable contributions from Fiona Adshead
and the United Kingdom’s Faculty of Public Health – in particular, Lindsey Davies, Alan Maryon-Davies and Pat Troop.
This work builds upon a number of economic reviews, including the work of the European Observatory on Health
Systems and Policies – Josep Figueras, the Organisation for Economic Co-operation and Development and the
London School of Economics – acknowledgements are due in particular to Franco Sassi, Organisation for Economic
Co-operation and Development, and Martin McKee, London School of Hygiene and Tropical Medicine. Special
thanks go to Clive Needle, EuroHealthNet; Darina Sedláková, WHO Country Office, Slovakia; Peter Gaal from
Semmelweiss University; Zsófia Pusztaiand Szabolcs Szigeti from the WHO Country Office, Hungary, who informed
earlier versions of this report and contributed to the panel session and video presented at the WHO conference on
health systems and the economic crisis, in Oslo, April 2013.
iv
About this report
The target audience for this report is public health public health operations (EPHOs). The report specifically
planners and managers, as well as wider decision- supports the strengthening and delivery of EPHO 8:
makers and policy-makers both in national and local assuring sustainable organizational structures and
governmental and professional roles in health and financing.
social care settings and in broader roles influencing
health and well-being. Objectives
The report’s objectives are:
Scope • to describe the economic and health benefits to
Public health is defined as “the art and science of individuals and governments of a public health
preventing disease, prolonging life and promoting approach;
health through the organized efforts of society” • to set out the costs of failing to address current
(Acheson, 1988). It consists of three main domains: public health challenges;
health protection, disease prevention and health • to summarize evidence for the cost–effectiveness of
promotion. These are strengthened by robust public public health and prevention approaches, including
health intelligence and supported by enablers, including the wider determinants of health, resilience, health
sustainable funding and organization, governance, behaviours, vaccination and screening;
workforce development, advocacy and research. • to summarize the recommendations from WHO’s
study of the costs of scaling up action to prevent and
This summary report supports Health 2020, the new reduce the impact of non-communicable diseases
policy framework from the WHO Regional Office for (NCDs) (WHO, 2011a);
Europe, which seeks to support a wide range of actions • to summarize which preventive interventions show
that can improve health (WHO, 2012a), and the European evidence for early returns on investment, and which
Action Plan for Strengthening Public Health Capacities provide longer-term gains.
and Services (WHO, 2012b), which sets out 10 essential
Key messages
1. The current costs of ill health are significant for • Tobacco use reduces overall national incomes by up
governments in Europe: trends suggest to 3.6%.
unsustainable increases in costs unless cost-effective • Air pollution from road traffic costs the countries of
policies are put in place. the EU €25 billion, while road traffic injuries cost
€153 billion each year.
• Ageing populations with higher rates of NCDs have • Obesity accounts for 1–3% of total health
increased demand, while health care costs have expenditure in most countries; physical inactivity
generally increased. costs up to €300 per European inhabitant per year.
• The costs of health inequalities – the total welfare • Mental illness costs the economy £110 billion per
loss across 25 European countries – are estimated at year in the United Kingdom and represents 10.8% of
9.4% of gross domestic product (GDP) or €980 billion. the health service budget.
• Cardiovascular disease (CVD) and cancer cost the
countries of the European Union (EU) €169 billion The economic crisis has increased demand and reduced
and €124 billion respectively each year. resources. Cost-effective preventive approaches can

contribute to improvements in health outcomes at • Evidence shows that preventive approaches
lower and more sustainable costs, while supporting contribute between approximately 50% and 75% to
universal health coverage. The Organisation for the reduction of CVD mortality in high-income
Economic Co-operation and Development (OECD) countries, and 78% globally.
predicts that, according to current trends, if nothing is • The WHO report on reducing the economic impact
done the cost of health care will double by 2050. This of NCDs in low- and middle-income countries (WHO,
will place strain on health systems – which for some 2011a) estimates that a further investment of 1–4%
countries may not be sustainable – and may compromise of current health spending is needed to reduce
quality of care and risk widening health inequalities. escalating health care costs.
• It is estimated that only of 3% of national health
2. The evidence shows that a wide range of preventive sector budgets in Europe (range: 0.6–8.2%) is
approaches are cost-effective, including currently spent on public health and prevention,
interventions that address the environmental and indicating scope for increases in public health
social determinants of health, build resilience and investment in order to enhance cost-effective health
promote healthy behaviours, as well as vaccination and wider outcomes.
and screening. The evidence in this report shows
that prevention is cost-effective in both the short Prevention can give returns on investment within 1–2
and longer term. In addition, investing in public years. Examples include:
health generates cost-effective health outcomes
and can contribute to wider sustainability, with • mental health promotion
economic, social and environmental benefits. • violence prevention
• healthy employment
• The WHO “best buy” interventions for NCDs (WHO, • road traffic injury prevention
2011a) include several that are highly cost-effective, • promoting physical activity
including tobacco and alcohol legislation, reducing • housing insulation
salt and increasing physical activity. • some vaccinations.
• Interventions that affect health behaviours and
enhance resilience – including improving mental A short video presenting the key messages, featuring
health and reducing violence – can give early and international public health experts and ministers of
longer-term returns on investment, with improved health, can be found at the Oslo conference on health
and social benefits. systems and the economic crisis section of the WHO
• Interventions that focus on addressing social and Regional Office for Europe website (WHO, 2013a).
environmental determinants (such as promoting
walking and cycling, green spaces, safer transport
and housing interventions) are shown to have early
returns on investment, with additional social and
environmental benefits. Healthy employment
programmes show returns on investment within 1–2
years.
• Disease prevention interventions such as
vaccinations generally achieve a good return on
investment, while some screening programmes are
shown to be cost-effective.
3.
Even small investments promise large gains to
health, the economy and other sectors, with
sustainable outcomes.
• Investing in health in general has been shown to

give economic returns to the health sector, other
sectors and the wider economy, with an estimated
fourfold return on every dollar invested.
2 The case for investing in public health

Overview
Strengthening public health ServiceS and capacity
Fig. 1 shows the range of interventions proven to be
a key pillar of the european regional health policy framework health 2020
cost-effective.
invest to save and improve health

Fig. 1. Cost-effective public health interventions
public health can be part of the solution:

Investment in prevention reduces health costs and lowers welfare benefits
Promoting health and well-being enhances resilience, employment and social outcomes
What works
ants behaviou
ermin rs
det
physical Mental
green health
employment activity
Space
healthy violence
nutrition prevention
environment housing
tobacco limit
transport control alcohol
disease prevention: vaccination and screening
Source: WHO (2013a).
Essential Public Health Operation (EPHO) 8:

Assuring sustainable organisational structures and financing
Table 1 summarizes cost-effective interventions that
provide returns on investment and/or cost savings in
www.euro.who.int/publichealth
the short term (“quick wins”) and longer term. It should
be noted that the table only reflects evidence of
WHO poster OSLO_Final.indd 1 Apr/09/13 3:59 PM
examples where timescales on returns and cost saving

have been reported (in green and orange font).

Table 1. Summary of interventions found to be cost-effective
Intervention Quick wins Longer-term gains

focus (0–5 years) (over 5 years)
Environmental • Road traffic injury preventiona • Removal of lead and mercury
determinants • Active transporta • Chemical regulation
• Safe green spacesa
• Heat wave plana
Social • Healthy employment programmes –
determinants • Insulating homesa
• Housing ventilation for asthma
• Community falls prevention
Resilience • Violence prevention legislation • Preschool programmes
• Prevention of postnatal depression • Prevention of conduct disorder
• Family support projects • Multisystemic therapy for juvenile offenders
• Social emotional learning • Detection of and care for the victims of intimate partner
• Bullying prevention violence
• Mental health in the workplace
• Psychosocial groups for older people
• Parenting programmes
• Depression prevention
Behaviour • Lifestyle diabetes prevention programmea • Alcohol minimum price
• Restricting alcohol availability • Counselling to smokers (WHO quite cost-effective)
• Community-based youth tobacco control intervention • Alcohol brief interventions and alcohol driving breath
• Workplace obesity intervention tests (WHO quite cost-effective)
• Tobacco legislation, taxation and control (WHO very
cost-effective)
• Alcohol legislation, taxation and control (WHO very
cost-effective)
• Nutrition – reducing salt; replacing trans fatty acids;
raising public awareness of healthy dietsa (WHO very
cost-effective)
• Physical activity mass media awareness (WHO very
cost-effective)
Vaccination • For children: norovirus, pneumococcus, rotavirus, • Influenza, pneumococcus

influenza • Measles, mumps and rubella; diphtheria, pertussis and
tetanus
• Human papillomavirus; hepatitis B; meningitis C
Screening • Screening for abdominal aortic aneurysm • Screening for diabetes and impaired glucose tolerance
• Screening for depression in diabetes • Vascular disease health checks
• Cervical cancer screening (WHO very cost-effective) • Breast and colon cancer screening (WHO quite
cost-effective)
Treatment • Treatment of depression in diabetes patients • Treatment of diabetes (WHO quite cost-effective)
• Treatment ofCVD (WHO very cost-effective) • Treatment of asthma (WHO quite cost-effective)
Key: Green: offers a return on investment

Orange: cost-effective
Black: WHO “best buy” interventions – timescales and costs not included; please note that these calculations were performed for low- and
middle-income countries
a
“win win win” approaches with multiple health, social and environmental benefits: these have been shown to be cost-effective, with
potential returns on investment within five years; they also contribute to wider aspects of sustainability, including economic, social and
environmental benefits (Bone and Nurse, 2010).

The WHO “best buy” interventions for NCDs (WHO, comparability of many economics studies. In addition,
2011a) are positioned according to whether they were many studies did not record the timescales of returns or
assessed as very cost-effective (quick wins) or quite may have only examined certain outcomes. In general,
cost-effective (longer-term gains). The table aims to investing in early life interventions is estimated to be
provide an overview so that planners can consider more cost-effective – see the example of the first 1000
interventions appropriate to their own settings, days (Box 1).
recognizing the limitations of a lack of evidence and
Box 1. The importance of the first 1000 days
Maternal and child malnutrition in terms of both under- and overnutrition are areas for continuing and increasing
attention. The 1000 days between a woman’s pregnancy and her child’s second birthday offer a unique window of
opportunity to shape healthier and more prosperous futures. Child undernutrition accounts annually for an estimated
45% of all child deaths, which are more prevalent in low- and middle-income countries. Providing optimal maternal
nutrition, breastfeeding and mineral and vitamin supplementation, however, requires an estimated US$ 9.6 billion
investment to tackle global undernutrition and save approximately 900 000 lives. Costs per life-year saved include
US$ 125 for the management of acute malnutrition, US$ 159 for micronutrient supplementation for children at risk,
US$ 175 for infant and young child feeding (including breastfeeding) and US$ 571 for optimum maternal nutrition during
pregnancy. Increases in maternal and child overnutrition occurring as part of the global nutritional transition are key
stages to intervene to reduce and prevent longer-term NCDs.
For further information see Black et al. (2013) and the 1,000 Days (2014) website.
Background
Many governments have responded to the global Nevertheless, European governments currently spend
economic crisis by reducing budgets. Health is the an average of only 2.8% of their health sector budgets
second largest area of public expenditure for most on prevention. Across the WHO European Region, the
countries; as a consequence, it is in the financial balance of expenditure on preventive versus curative
spotlight. At the same time, there is upward pressure care varies widely from an estimated less than 1% to
from the rising costs of technologies and pharmaceuticals over 8% of total health budgets (WHO, 2014a). In the
and – to a lesser extent – from ageing populations. context of the financial crisis, already vulnerable public
Additional upward pressure comes from ill health health budgets have been further cut in several cases
associated with rising unemployment and, for those in (Mladovsky et al., 2012). Many countries have also seen
employment, job insecurity and wages that fail to keep an increase in unemployment, accompanied by an
up with inflation. Some of these health costs can be increase in mental ill health and suicides, with outbreaks
avoided by shifting investment to prevent harm and of infectious diseases in some countries linked to the
increase activity in health promotion, disease prevention breakdown of surveillance and control systems. In
and health protection. Funding for prevention remains a Iceland, however, which was hit very hard by the crisis,
small proportion of overall health spending, but can there was no worsening of health outcomes. This has
represent excellent value for money, with gains in both been attributed to the country’s maintenance of social
the short and the long term, as well as savings for sectors support and high level of social cohesion (Karanikolos et
other than health. al., 2013).
The economic impact of NCDs – many of which are Set against this picture of weak public health responses
avoidable – amounts to billions of euros per year. is the growth in demand for health care, associated with

a rising burden of NCDs, increasing inequalities and Fig. 2. Age-adjusted coronary heart disease
demographic changes – in particular, population mortality rates in North Karelia and the whole of
ageing. More recent trends such as rising unemployment, Finland among males aged 35–64 years, 1969–2005
combined with more profound threats such as climate
change, are likely to add further challenges to the MORTALITY 700
system. Some of the greatest advances in health in PER 100 000
POPULATION
start of the North Karelia Project
Europe of the last century resulted from addressing the 600

extension of the Project nationally
causes of disease – such as poor housing and nutrition
– rather than just treating the consequences. One 500
example is tuberculosis, which fell from 13% of total North Karelia
mortality in the United Kingdom in 1855 to 0.1% by 400
1990. Much of this decline took place through

improvements in housing before medical interventions 300
such as the Bacillus Calmette–Guérin (BCG) vaccination All Finland

became available (Donaldson & Donaldson, 2003). More 200
- 85%
recently, the results of the Finnish North Karelia Project - 80%
show that preventive approaches can have a major 100
69 72 75 78 81 84 87 90 93 96 99 2002 2005
impact on risk factors: the decline in heart disease YEAR
mortality in Finland was one of the most rapid in the
world (Puska et al., 2009). Mortality from coronary heart
disease fell by 85% over a 35-year period, from around Source: Puska et al. (2009).
650 to 150 per 100 000 (Fig. 2).
Evidence from several studies suggests that the based measures and individual-based approaches. A
observed decline in many countries in coronary heart reduction in risk factors (such as reducing cholesterol,
disease mortality (one of the most important NCDs in blood pressure and smoking and increasing physical
terms of burden of disease) has resulted from tackling activity) has been shown to account for an estimated
risk factors such as blood pressure, tobacco, cholesterol 50–70% of the decline in global coronary heart disease
and salt: through preventing rather than treating the mortality, with treatment contributing approximately
consequences of disease. This includes both population- 25–50% (Fig. 3).
Fig. 3. Contribution of treatment and risk factor reduction to global heart disease morbidity
Goldman USA, 1968-76 40 54 6

Beaglehole New Zealand, 1974-81 40 60 0
Nunink USA, 1980-90 43 50 7
IMPACT Scotland, 1975-94 35 55 10
IMPACT New Zealand, 1982-93 35 60 5
IMPACT England and Wales, 1981-2000 38 53 11
IMPACT USA, 1980-2000 47 44 9
IMPACT Poland, 1991-2005 43 49 8
IMPACT Czech, 1985-2007 39 60 1
IMPACT Sweden, 1986-2002 36 55 9
BMJ Finland, 1982-97 24 76 0
IMPACT Finland, 1982-97 25 72 5
IMPACT Iceland, 1981-2006 24 74 2
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Treatments Risk factors Unexplained
Source: Ford et al. (2007).

The pale blue bars in the figure represent the population groups already suffering from adverse
contributions of changing risk factors, rather than those effects of health inequality. Investing in upstream
of specific preventive interventions. Nevertheless, these population-based prevention is more effective at
data demonstrate the significant opportunity for reducing health inequalities than funding more
prevention interventions focused on modifying these downstream prevention (Orton et al., 2011) (Fig. 4).
risk factors.
The following sections provide economic evidence for
The economic justification is clear. There is good interventions in different areas relating to health. They
evidence to support an expanded role for health illustrate the cost of inaction (“business as usual”) and
promotion and disease prevention to increase value for outline the cost–effectiveness of interventions. They
money and, for some approaches, create a return on review economic evaluations, highlighting which
investment for health and other sectors, as well as interventions are cost-effective or make a positive return
potentially promoting an increase in economic on investment and the duration over which this return is
productivity. Additional benefits will also occur, with realized. The trend for steadily rising health and social
improved educational and employment outcomes, care costs, as well as the costs of inaction, is an
reduced crime and antisocial behaviour and unsustainable problem. The evidence presented in this
environmental benefits. Many cost-effective report demonstrates the potential benefits of cost-
interventions also help to reduce inequalities – for effective prevention, using whole-system approaches
example, those addressing mental health and violence and intersectoral partnership working. It also shows that
prevention, issues disproportionately affecting public health can be part of the solution.
Fig.4. Levels of prevention
Primary prevention aims to promote population health and well-being and prevent
disease and harm before it occurs – seen as an “upstream approach”.
Secondary prevention aims to detect disease and identify risk factors before they
become harmful to health (e.g. screening).
Tertiary prevention treats disease with cost-effective interventions to slow or reverse

disease progression; it includes rehabilitation for disability – seen as a “downstream approach”.
Source: adapted from Donaldson &Donaldson(2003).
The economic case for prevention

Prevention can be the most cost-effective way to Health economic evaluations are complex, as they take
maintain the health of the population in a sustainable into account both direct health costs and indirect social
manner, and creating healthy populations benefits costs. A growing body of evidence, however, supports
everyone. Concerns about upfront costs and the the economics of prevention (Merkur et al., 2013), for
intangibility of outcomes, however, too frequently lead which this report summarizes where possible the length
to a lack of action and continued investment in of time to receive a return on investments. The report
increasingly expensive curative approaches. sets out the case that prevention is – on the whole –

cost-effective, with a number of interventions providing with private spending adding another 2% (OECD, 2006).
quick returns that can be balanced by investments for If no specific policies are employed to move away from
longer-term benefits. The alternative of treating the past trends, health sector spending is projected to
consequences is likely to be unnecessarily costly and almost double, reaching nearly 13% of GDP by 2050 (Fig.
unsustainable over time, which risks reducing both 5) and leading to what OECD calls the “cost pressure”
quality of and access to care and increasing health scenario. OECD has identified a number of policies,
inequalities, with a knock-on effect on the overall mainly involving efficiencies in core services that could
economy. curb health expenditure, described as the “cost
containment” scenario. Average spending is still
Sustainability of current and future costs predicted to increase, however, to around 10% of GDP
Health spending has risen steadily over the past three by 2050. For many countries the current and projected
decades, and has accelerated since the turn of the costs of health care are not sustainable, and many
century to reach an average of approximately 7% of budgets have been reduced with the economic crisis.
GDP for countries that were OECD members in 2005,
Fig. 5. OECD projections for public spending on health care 2005–2050

PROPORTION OF 14
TOTAL GDP (%)
12
10
8
Current situation (2005)
Cost Pressure/Business as usual (2050)
6
Cost containment (2050)
0
Health care Long term care Total
Source: OECD (2006).
The cost of health inequalities and risk factors, alongside the burden of disease for the
Evidence from a review of the economic cost of health disease or risk area. In particular, they highlight the fact
inequalities in 25 European countries (Mackenbach et that the collective costs of inequalities are substantial.
al., 2011) identified that over 700 000 deaths and
33 million cases of ill health were caused by health Some calculations use disability-adjusted life-years
inequality. These accounted for 20% of total health care (DALYs) lost – a time-based measure that combines years
costs. The loss of labour productivity caused by health of life lost due to premature mortality and years of life
inequalities was estimated to cost 1.4% of GDP, resulting lost due to time lived in states of less-than-ideal health,
in an absolute cost of €141 billion. When reviewing which was developed to assess the global burden of
health inequalities as a capital good, the total welfare disease (GBD) (OECD, 2006). Others use quality-adjusted
loss across the 25 European countries assessed was life-years (QALYs) – a unit of measurement of utility that
estimated at 9.4% of GDP or €980 billion. combines life-years gained as a result of health
interventions/health care programmes with a judgement
Tables 2a and 2bsummarize examples of some of the about the quality of those life-years (NICHSR, 2014).
typical costs of the major health threats within Europe. Although there are differences in study methodologies,
They show recent estimated costs of health outcomes making direct comparisons difficult, the tables provide a

range of examples of where costs will be experienced society. The examples are drawn from a wide range of
and, where evidence is available, give illustrations of sources, both within Europe and further afield.
costs to the individual, the health sector and wider
Table 2a. Costs of not acting: health outcomes
Health DALYs lost Costs at the individual Costs to health sectors Costs to governments/
topic in Europe level wider society
(millions)a
CVD 36.4 – – €169 billion per year in the EU (Leal
et al., 2006)
Mental 28.9 Annual cost to society of 10.48% of 2008/9 National Health £110 billion per year in the United
health mental illness in childhood: Service (NHS) budget spent on Kingdom (McCrone et al., 2008;
£11–59 000 per child (United mental health services (United Friedli& Parsonage, 2007)
Kingdom) (Suhrcke et al., Kingdom) (Department of Health,
2007) 2012)
Costs for children with Cost of depression: £1.7 billion in
severe and complex mental 2007 (United Kingdom) (McCrone
health problems: over £1000 et al., 2008)
per week (United Kingdom)
(Clarke et al., 2005) Cost of anxiety disorders:
£1.2 billion in 2007 (United
Kingdom) (McCrone et al., 2008)
Cancer 17.0 – 6.5% of health care expenditure in €117 billion per year in the EU
the EU (Stark, 2006) (Luengo-Fernandez et al., 2012)
Commu- 15.9 – Each unplanned influenza Influenza cost the economy
nicable admission costs the NHS £6.75 billion in 1999 (United
disease £347–774 (United Kingdom) Kingdom) (Voelker, 1999)
(Department of Health, 2010)
The measles epidemic cost the
NHS £433 000–995 000 over the
two-year period 2008/9 (United
Kingdom) (Department of Health,
2010)
Road traffic 3.6 – – Up to 2% of GDP in middle- and
injuries high-income countries in the EU
(Racioppi et al., 2004)
Road traffic collisions cost
€153 billion per yearin the EU
(Racioppi et al., 2004)
Diabetes 2.6 – Cost to the NHS: £1.3 billion per –
year (United Kingdom) (Wanless,
2002)
Violence 1.9 Around DKr 65 000 per In 2007, violence cost the NHS an Violence costs the economy in
female victim of violence estimated £2 billion (United England and Wales over £40.1 billion
(Denmark) (Helweg-Larsen Kingdom) (Home Office, 2009) per year (United Kingdom) (Home
et al., 2010) Office, 2009)
Annual costs for the immediate
treatment of injuries resulting Violence against women costs
from violent assaults: nearly Danish society approximately
DKr 11 million (Denmark) (Helweg- DKr 500 million (about €70 million)
Larsen et al., 2010) per year (Denmark) (Helweg-Larsen
et al., 2010)
a
DALYs include 3% discounting and age weights.

Table 2b. Costs of not acting: risk factors
Health DALYs lost in Costs at the individual Costs to health sectors Costs to governments/
topic Europe level wider society
(millions)a
Tobacco 17.7 The average smoker Smoking-related conditions cost US$ 500 billion per year to the global
spends two months’ the NHS more than £5 billion per economy(Shafey et al., 2009)
wages per year on year (United Kingdom)
cigarettes (Albania) (University of Oxford, 2009) Tobacco use reduces overall national
(Viscusi&Hersch, 2008) incomes by up to 3.6% (Shafey et al., 2009)
Private mortality costs

per packet: US$ 222
(men) and US$ 94
(women) (United States)
(Viscusi&Hersch, 2008)
Harmful 17.3 Heavy drinking Alcohol-use disorders cost the Effects on health, well-being and
alcohol increases the risk of NHS £2.9 billion per year (United productivity reach US$ 300–400 purchasing
use unemployment, Kingdom)(NICE, 2010) power parity per capita per year (Rehm et
absenteeism, and al., 2009)
presenteeism
(attending work while Alcohol-related harm costs £20–55 billion
sick) (Anderson et al., per year (United Kingdom)(PMS Unit, 2004)
2012) Alcohol cost the EU €125 billion in 2003
(1.3% of GDP) (Anderson &Baumberg, 2006)
Unhealthy 15.3 Obese individuals incur Obesity accounts for 0.7–2.8% of Obesity accounts for 1–3% of GDP in most
diet health expenditure total health expenditure in most countries, but is as high as 5–10% of GDP in
more than 30% higher countries (Withrow& Alter, 2011) the United States (Sassi, 2010)
than those of normal
weight(Withrow& Alter,
2011)
Physical 8.2 Inactive Danish men Globally physical inactivity Physical inactivity is estimated to cost
inactivity lose three days of work accounts for 1.5–3% of national €150–300 per inhabitant per year in
compared to health care budgets (Oldridge, Europe(Cavill et al., 2006)
moderately active men 2008)
(Juel et al., 2008)
Physical inactivity accounted for
Lack of physical activity 2.9% of total health expenditure
could account for 8% of in 2000 (Denmark) (Juel et al.,
all social disability 2008)
pensions in Denmark
(Juel et al., 2008) Direct medical costs to the NHS:
£1.06 billion (United Kingdom)
(Allender et al., 2007)
Environ- 2.5 An estimated total of Lead paint in homes in the Air pollution caused by road traffic costs the
mental 1087 potential years of United States estimated at EU €25 billion per year (TU Dresden, 2012)
risks (includes life lost in 2005 US$ 11–53 billion of annual
occupational (Switzerland)(FOEN, health care costs in children Air pollution from industrial facilities costs
risks, urban 2009) under 6years (Gould, 2009) the European Environment Agency
outdoor air €102–169 billion per year (EEA, 2011)
pollution, Calculated lost lifetime earnings
unsafe water, over US$ 165 billion among Noise pollution from road traffic costs the
sanitation, children estimated to have EU €7 billion per year (TU Dresden, 2012)
hygiene, raised lead levels (Gould, 2009) The cost of road traffic noise pollution in
indoor smoke England is estimated to be £7–10 billion per
from solid year (United Kingdom)(DEFRA, 2013)
fuels, lead
exposure and Mercury emissions from coal burning in the
global United States reduce IQ, with a resultant
climate US$ 1.3 billion loss in economic
change) productivity(Trasande et al., 2005)
Global costs from loss of productivity due to
mercury pollution are expected to rise to
US$ 29.4 billion by 2020 (Pacyna et al., 2008)
a
DALYs include 3% discounting and age weights.

These tables demonstrate the importance of preventing only does this fail to solve the current problem, it may
disease and maintaining well-being for the wider lead to widening inequalities that could become
economy. Simply reducing health sector spending is increasingly difficult and expensive to address. What
likely to reduce its effectiveness, thereby shifting these matters is not just the amount of money spent but how
costs onto the wider society. Reducing public health it is spent. A relatively small shift in spending from
budgets also poses a risk to population health and treatment to prevention and health promotion over a
increases the risk of disease outbreaks such as HIV and few years, with a focus on cost-effective solutions, will
malaria and the spread of multidrug resistant infections, help to reduce health care costs in a sustainable way, as
as seen in some countries since the economic crisis. Not well as contributing to the overall economy.
The benefits of action

Containing or reducing the costs of health care without that are cost-saving but do not produce a return on
negative effects on health outcomes requires cost- investment can increase overall costs. Nevertheless,
effective prevention interventions to play a much more they frequently achieve better outcomes and can
substantial role. If health spending is to be reduced or therefore be considered better value for money for
even stabilized without compromising quality and improving health outcomes than “business as usual”.
outcomes, further measures are needed. One approach Many high-income countries judge health care
is to consider the relative cost–effectiveness of different interventions to be cost-effective if they cost less than
interventions, looking first at those that are both cost- US$ 50 000 per DALY gained. The preventive
effective and achieve a positive return on investment, interventions listed in the “cost saving” columns in Tables
followed by those that are cost-effective and produce 4a–4d can be considered to be as good as or better than
savings, with better health benefits at lower cost and this. Those listed in the “return on investment” columns
finally considering “business as usual” options (Fig. 6). are examples of interventions thathave the potential to
provide a return on investment, while also achieving
It needs to be recognized that all approaches require health and wider benefits.
initial investment and that cost-effective approaches
Fig. 6. A suggested hierarchy of prevention interventions
Cost-effective approaches where the financial benefits to health

Return on investment and other sectors outweigh the initial investment, giving a return
on investment
Cost-effective approaches that generate additional health (and other)

Cost saving benefits at a cost that society is willing to pay: these will be cost-saving
if the additional benefits are generated at a lower cost than usual practice
Cost pressure/ Continued delivery of current practice with predicted increase in

business as usual health care costs over time

A summary of the evidence effective but also feasible and appropriate to implement
This report provides a number of summary tables to within the constraints of low- and middle-income
illustrate the concepts outlined above (Fig. 7). Tables 3a countries’ health systems”. Owing to the scope of the
and 3b set out known “best buy”interventions, according study, however, costs and timescales for the areas
to the WHO report on reducing the economic impact of covered by the NCD “best buys” report were not
NCDs in low- and middle-income countries (WHO, included.
2011a). These are considered “not only highly cost-
Fig. 7. Conceptual diagram of the summary tables
2a 3a 4a 4b 4c 4d
Costs of not acting: “Best buy” Cost effective Cost effective Cost effective Cost effective
health outcomes interventions interventions interventions interventions interventions for
by risk factor to build resilience: to address social to address vaccionation and
factors affecting determinants environmental screening
• Tobacco health behaviours of health determinants
• Alcohol and outcomes of health
• Diet • Housing
• Physical inactivity • Violence and abuse • Debt • Road traﬃc injuries
POTENTIAL SOLUTIONS
• Infection • Mental health • Employment • Green space

• Climate
• Active transport
• Environmental
hazards
COSTS
2b 3b
Costs of not acting: “Best buy”
risk factors interventions by
health outcome
• CVD and diabetes

• Cancer
• Respiratory disease

Table 3a. “Best buy” interventions by risk factor
Risk factor Intervention/action Avoidable Cost–effectiveness Implementation Feasibility

(DALYs lost, (core set of “best buys”) burden (Very: <GDP per person; cost (health system
millions; (DALYs averted) Quite: <3 × GDP per (Very low: <US$ 0.50; constraints)
% GBD) person; Less: >3 × GDP Quite low: <US$ 1;
per person) Higher: >US$ 1)
Tobacco use Protect people from Combined effect: Very cost-effective Very low Highly feasible:
(>50; 3.7) tobacco smoke 25–30 million strong
Warn about the dangers of DALYs averted framework
tobacco (>50% tobacco (WHO
burden) Framework
Enforce bans on tobacco Convention on
advertising Tobacco Control
Raise taxes on tobacco (WHO, 2003))
Offer counselling to Quite cost-effective Quite low Feasible
smokers (primary care)
Harmful use Restrict access to retailed Combined effect: Very cost-effective Very low Highly feasible
of alcohol alcohol 5–10 million
(>50; 4.5) Enforce bans on alcohol DALYs averted
advertising (10–20% alcohol
Raise taxes on alcohol burden)
Enforce drink–driving laws Quite cost-effective Quite low Intersectoral

(breath-testing) action; feasible
Offer brief advice for (primary care)
hazardous drinking
Unhealthy Reduce salt intake Effect of salt Very cost-effective Very low Highly feasible
diet Replace trans fat with reduction:
(15–30; 1–2) polyunsaturated fat 5 million DALYs
Promote public awareness averted
about diet Other
interventions: not
Restrict marketing of food yet assessed Very cost-effective? Very low Highly feasible
and beverages to children globally (more studies needed)
Replace saturated fat with
unsaturated fat Quite cost-effective Higher Feasible
Manage food taxes and (primary care)
subsidies Highly feasible
Less cost-effective
Offer counselling in
primary care
Provide health education in
worksites
Promote healthy eating in
schools
Physical Promote physical activity Not yet assessed Very cost-effective Very low Highly feasible
inactivity (mass media) globally
(>30; 2.1) Promote physical activity Not assessed globally Not assessed Intersectoral
(communities) globally action
Support active transport Quite cost-effective Higher Feasible
strategies (primary care)
Offer counselling in
Less cost-effective Highly feasible
primary care
Promote physical activity in
worksites
Promote physical activity in
schools
Infection Prevent liver cancer via Not yet assessed Very cost-effective Very low Feasible
hepatitis B vaccination (primary care)
Source: WHO (2011b).

Table 3b. “Best buy” interventions by health outcome
Disease Intervention/action Avoidable Cost–effectiveness Implementation Feasibility

(DALYs lost, (core set of “best buys”) burden (Very: <GDP per person; cost (health system
millions; % (DALYs averted) Quite: <3 × GDP per (Very low: <US$ 0.50; constraints)
global burden) person; Less: >3 × GDP Quite low: <US$ 1;
per person) Higher: >US$ 1)
CVD and Counselling and multidrug 60 million DALYs Very cost-effective Quite low Feasible
diabetes therapy (including averted (primary care)
(170; 11.3) glycemic control for (35% CVD burden)
diabetes mellitus) for
people (≥30 years) with 4 million DALYs Very cost-effective Quite low
10-year risk of fatal or averted
nonfatal cardiovascular (2% CVD burden)
events ≥30%
Aspirin therapy for acute
myocardial infarction
Counselling & multidrug 70 million DALYs Quite cost-effective Higher
therapy (including averted
glycemic control for (40% CVD burden)
diabetes mellitus) for
people (≥ 30 years) with a
10-year risk of fatal and
nonfatal cardiovascular
events ≥ 20%
Cancer Cervical cancer – screening 5 million DALYs Very cost-effective Very low Feasible
(78; 5.1) through visual inspection averted (primary care)
with acetic acid and (6% cancer
treatment of pre-cancerous burden)
lesions to prevent cervical
cancer
Breast cancer – treatment 3 million DALYs Quite cost-effective Higher Not feasible in
of stage I averted primary care
(4% cancer (diagnosis and
burden) treatment
requires
Breast cancer – early 15 million DALYs Quite cost-effective Higher secondary or
case-finding through averted tertiary care)
mammographic screening (19% cancer
(50–70 years) and burden)
treatment of all stages
Colorectal cancer – 7 million DALYs Quite cost-effective Quite low
screening at age 50 and averted
treatment (9% cancer
burden)
Oral cancer – early Not assessed Not assessed globally Not assessed
detection and treatment globally
Respiratory Treatment of persistent Not assessed Quite cost-effective Very low Feasible
disease asthma with inhaled globally (primary care)
(60; 3.9) corticosteroids & beta-2 (expected to be
agonists small)
Source: WHO (2011b).

An evidence review was conducted to cover a wide The final four tables (4a–4d) provide examples of
range of public health approaches, including interventions that generate a return on investment or
environmental and social determinants of health, are cost-effective. Table 4a shows key factors affecting
mental health and violence prevention, which are health behaviours. Violence (Brown et al., 2009; CDC,
framed as interventions promoting resilience. An 2013) and poor mental health (Walsh et al., 2013) are
overview of cost-effective vaccinations was also known to be associated with other more proximal health
included. The evidence review looked at peer-reviewed behaviours and are recognized as complex issues,
literature from Cochrane Evidence Reviews and PubMed. manifesting as both determinants and outcomes of
The search terms used were “cost saving” or “cost- poor health and well-being. Tables 4b and 4c look at
effective”, together with the 12 different individual social and environmental determinants of health
categories presented in Tables 4a–4d. In total, 545 behaviour and, in turn, outcomes. Table 4d outlines
papers were screened by title and abstract for inclusion, measures within what can be seen as the traditional
of which 53 met the eligibility criteria for the review. remit of the health sector, which can save money by
These criteria included randomized control trials, directly preventing disease and include vaccination and
reviews and modelling studies that contained cost– screening interventions not covered in the “best buys”
effectiveness or cost savings/return on investment tables (3a and 3b).
calculations. The information was collected, reviewed
and categorized into a series of tables. Although these tables present the cost–effectiveness of
specific interventions, greater potential efficiencies can
The review adds to the evidence of the WHO “best buy” be gained by strengthening the overall functioning of
interventions report, with a wider range of preventive public health services within the context of a health-
approaches to provide an overview of cost-effective systems approach. A recent global survey of health
interventions. Its aim is to provide planners and experts reported that 63% considered strengthening
managers with an overview of examples to assist in health systems over the coming years to be the most
planning and decision-making, showcasing the benefits critical investment in global health (PSI, 2014).
of prevention and highlighting what can be achieved
with early prevention in the short and long term, Note: the greatest quantity of evidence was found for
including a focus on the wider determinants of health vaccinations. For that category, a further selection was
and factors affecting behaviour. It should be noted that made and a range of evidence on different types of
the studies are from a range of different countries with infections from a variety of countries considered most
varied funding and organizational systems – differences relevant to the widest audience in terms of disease
that need to be considered before piloting in other prevalence and target groups was selected.
countries or settings. Factors such as uptake of
interventions will also affect cost–effectiveness.

Table 4a. Cost-effective interventions to build resilience: factors affecting health behaviours and outcomes
Focus Return on investment Cost saving

Violence and Violence Against Women Act of 1994 (United States) (Clark et al., 2002) Cost–effectiveness of a programme
abuse to detect and provide better care for
• Empirical evaluation female victims of intimate partner
• Timescale: 1 year violence (United Kingdom) (Norman et
al., 2010)
At the government level • Modelling study
• Cost: US$ 1.6 billion for programmes over 5 years • Timescale: 10 years
• Saving: US$ 14.8 billion in net averted social costs • Cost: £5210 per year
• Incremental cost–effectiveness ratio
(ICER): £742 per quality-adjusted
At the individual level life-year (QALY) (societal perspective)
• Cost: US$ 15.50 per woman
• Saving: US$ 159 per woman in averted costs of criminal victimization
School-based interventions to reduce bullying (United Kingdom) (Knapp et

al., 2011)
• Modelling study
• Timescale: no finite timescale
• Cost: £15.50 per pupil per year
• Saving: £1080 per pupil
Perry preschool program in Ypsilanti, Michigan (United States) (Anderson

et al., 2003)
• Modelling study
• Timescale: lifetime estimate
• Net savings: US$ 108 516 for males and US$ 110 333 for females
Cost–benefit analysis of multisystemic therapy (MST) with serious and

violent juvenile offenders (United States) (Klietz et al., 2010)
• Timescale: 13.7 years
• Cost: US$ 10 882 per MST participant
• Return on investment: US$ 9.51–23.59 for every dollar spent on MST
(savings to taxpayer and crime victims)
Identification and Referral to Improve Safety (IRIS), a domestic violence

training and support programme for primary care (United Kingdom)
(Devine et al., 2012)
• Modelling study
• Timescale: within 1 year
• Cost: £136 per woman registered in the primary care practice
• Savings: £37 per woman registered in the primary care practice (£178
saved to a cost of £136) (societal perspective)

Table 4a. Cost-effective interventions to build resilience: factors affecting health behaviours and
outcomes contd.
Focus Return on investment Cost saving

Mental health Early identification of postnatal depression with intervention (health Cost–effectiveness analysis of
visitor) (United Kingdom) (Petrou et al., 2006) parenting programmes for parents
of children at risk of developing
• Empirical study conduct disorder (United Kingdom)
• Timescale: 18 months (Bywater et al., 2009)
• Cost: preventive intervention group cost £119 more than standard
treatment • Costs for children with conduct
• Net savings: £383 per mother–infant pair per month (societal) problems reduced from £5350 to
£1034 after 18 months following
parent training intervention
Antisocial behaviour family support projects (United Kingdom) (Nixon et
al., 2006)
Population cost–effectiveness of
• Empirical study interventions designed to prevent
• Timescale: 2 years childhood depression (ages 11–17)
• Cost: £8000–15000 per family per year (Australia) (Mihalopoulos et al., 2012)
• Savings: £17–44 for every £1 spent
• Modelling study
• ICER: US$ 5400 per DALY (health
Reducing conduct problems through school-based social and emotional sector perspective)
learning (United Kingdom) (Knapp et al., 2011)
• Cost: £132 per pupil per year Cost–effectiveness of a stepped care
• Savings of £39 to health sector in first year, rising to £751 by fifth year intervention to prevent depression
• Net societal savings of £6369 for whole of society by fifth year (mostly and anxiety in late life (Netherlands)
through reduced crime) (Van’t Veer-Tazelaar et al., 2010)
• Experimental study
Intervention for prevention of childhood conduct disorder for a one-year • Timescale: 1 year
cohort (United Kingdom) (Friedli& Parsonage, 2007) • Cost: €563 per recipient
• Empirical study • € 4367 per disorder-free year gained
• Timescale: based on projected lifetime savings
• Cost: £210 million or £6000 per individual programme Mental health promotion and the
• Savings: £5.2 billion or £150 000 per case prevention of depression in older
age: regular participation in exercise
Psychosocial group therapy for older people identified as lonely (Finland) classes by older people in England
(Pitkala et al., 2009) (United Kingdom) (Munro et al., 2004)
• Empirical study • Timescale: within 2 years
• Timescale: 2 years • Cost-effective in England: €17 172
• Cost: €881 per person per QALY (2004 prices) (health
• Savings: Mean net reduction in health care costs: €943 per person per year system perspective)
One-day training programme for police officers that improves Befriending of older adults (United
interactions with mentally ill individuals (Canada) (Krameddine et al., 2013) Kingdom) (Knapp et al., 2011)
• Experimental study • Timescale: in the first year for the
• Timescale: 6 months NHS
• Cost: US$ 120 per officer • Cost £85 per older person
• Savings: more than US$ 80 000 in the following 6 months • Approximate savings of £40 per £85
invested

Table 4b. Cost-effective interventions to address social determinants of health
Determinant Return on investment Cost saving

Housing Affordable warm housing: insulation and heating (United Kingdom) (CIEH, Enhancing ventilation in homes of
2008) children with asthma (United
Kingdom) (Edwards et al., 2011)
• Investment of £251 million to reduce domestic impacts of excess cold
• Savings of £859 million (assuming full coverage) will result in a £608 million • Cost–effectiveness study alongside
return of savings to NHS (England) randomized control trial
• Return on investment within 0.3 years • Timescale: 12 months
• Cost: £1718 per child given tailored
Supported housing for families with complex emotional needs and package of housing interventions
chaotic lives (United Kingdom) (Department of Health, 2009) (ventilation and heating)
• ICER: £234 per point improvement
• Empirical study(pilot project in 1999) on asthma scale (£165 for children
• Timescale: unavailable with severe asthma)
• Savings: £12 000 per client for local authorities
Preventing bath water scalds: a cost–effectiveness analysis of Falls prevention leaflets (United
introducing bath thermostatic mixer valves in social housing (United Kingdom) (Irvine et al., 2010)
Kingdom) (Phillips et al., 2011)
• Timescale: 12 months
• Costs: treating bath water scald £25 226–71 902 • Cost: £349 per person
• Net saving: £1887–75 520 • ICER: £3320 per fall averted
• Return on investment: £1.41 saved for every £1 spent
Debt Debt advice services (United Kingdom) (Knapp et al., 2011) –
• Modelling study
• Timescale: 2–5 years
• Pay-off: £2.92 per £1 expenditure
Employment Individual active treatment combined with group exercise for acute and Seasonal influenza vaccination of
subacute low back pain (United Kingdom) (Wright et al., 2005) healthy working-age adults (United
States) (Gatwood et al, 2012)
• Savings: £250–578 per patient
• Timescale: 1–2 weeks • Review of economic evaluations
• Costs: US$ 85.92 per person
Coordinated and tailored work rehabilitation undertaken with workers • Net savings: US$ 68.96 per person
on sick leave due to musculoskeletal disorders (Denmark) (Bultmann et al., • Cost–effectiveness ratio (2 studies):
2009) US$ 26 565–50 512 per QALY
(societal perspective)
• Economic evaluation based on a randomized controlled trial
• Timescale: 6–12 months
• Cost: US$ 2200 per person
• Savings: US$ 1366 per person at 6 months; US$ 10 666 per person at 12
months
Workplace screening for depression and anxiety disorder (United

Kingdom) (Knapp et al., 2011)
• Modelling study
• Timescale: 1–2 years
• Cost: £20 600 in first year (per 500 employees)
• Savings: £19 700 (500 employees) in first year and £63 500 by second year
Mental health promotion and prevention of depression in the

workplace: early diagnosis and intervention for employees with
depressive symptoms (United States) (Wang et al., 2007)
• Empirical study
• Timescale: 1 year
• Cost: US$ 100–400 per person per year
• Savings: US$ 1800 per employee per year
Promoting well-being in the workplace (United Kingdom) (Knapp et al.,

2011)
• Modelling study
• Cost: £40 000
• Savings: £340 000 within 1 year

Table 4c. Cost-effective interventions to address environmental determinants of health

Road traffic Nationwide speed limit reduction (United States) (Shafi et al., 2008) Injury awareness education
injuries programme on outcomes of juvenile
• Cost–benefit analysis justice offenders in western Australia
• Timescale: 1 year (Australia) (Ho et al., 2012)
• Savings: US$ 13 billion annually (including a US$ 2 billion reduction in
trauma care costs) • Economic analysis
• Timescale: 5 years
• Cost of programme: US$ 33 735
Seat-belt use (United States) (Shafi et al., 2008) • Annual savings: US$ 3765 (from
• Timescale: 1 year serious injury)
• Savings: US$ 50 billion annually • Cost–effectiveness:
• cost per offence prevented:
US$ 3124;
Airbag use (United States) (Shafi et al., 2008) • cost per serious injury avoided:
• Timescale: 1 year US$ 42 169;
• Savings: US$ 1.94 billion annually cost per discounted life-year gained:
US$ 17 910
Photo radar speed enforcement programme on an inner city motorway

(Spain) (Perez et al., 2007)
• Empirical study
• Cost: €14.5 million
• Net savings: €6.8 million over 2 years
Economic cost savings associated with state motorcycle helmet laws

(United Sates) (CDC, 2012)
• Savings: US$ 725 per registered motorcycle (societal perspective)
Alcohol-impaired driving: “The Australian Campaign” (Australia) (Elder et

al., 2004)
• Modelling study
• Timescale: 23 months
• Costs: AU$ 403 174 per month
• Savings: AU$ 8 324 532 per month, including AU$ 3 214 096 in averted
medical costs
Safety camera enforced speed limits (United Kingdom) (Gains et al., 2005)
• Empirical study
• Costs: £96 million per year
• Savings: £258 million per year
Green space The US study for Philadelphia city parks (United States) (Trust for Public –
Land, 2008)
• Empirical study
• Timescale: within 5 years
• Savings: US$ 69.4 million per year through avoided health care costs
Conservation volunteering projects (United Kingdom) (Greenspace

Scotland, 2009)
• Empirical study
• Timescale: over 5 years
• Return on investment: £7.35 for every £1 invested
Climate Heat warning systems (Europe) (Toloo et al., 2013) –
• Systematic review
• Cost: US$ 210 000
• Savings: US$ 468 million

Table 4c. Cost-effective interventions to address environmental determinants of health contd.

Active Switching from car to active transport (United Kingdom) (Davis, 2011) Counselling programmes to promote
transport physical activity and a community-
• Modelling study based walking scheme (United
• Timescale: 1 year Kingdom) (Windle et al., 2008)
• Benefits of moving from car to walking: £1220 per year
• Benefits of moving from car to cycling: £1121 per year • Timescale 6 months
• Cost: £9.50–220 per participant
(community-based)
Introducing pedestrian crossings and other pedestrian facilities for 579 • QALY gains: from 3.0 per 1000
schemes (United Kingdom) (Gorell&Tootill, 2001) individuals over 6 months (physical
• Timescale: 1 year activity counselling intervention) to
• Net first year rate of return – 246% 28.3 per 1000 individuals over 6
months (community-based walking
programme)
Effect of increasing active travel in urban England and Wales on costs to
the NHS (United Kingdom) (Jarrett et al., 2012)
• Savings: £17 billion for the NHS (reduction in the prevalence of type 2
diabetes, dementia, ischaemic heart disease, cerebrovascular disease and
cancer)
Environmental Reducing childhood exposure to mercury through mercury and air toxics –
hazards standards (MATS) (United States) (EPA, 2011)
• Empirical study
• Savings: > US$ 37 billion per year in health benefits
Window replacement and residential lead paint hazard control (United

States) (Dixon et al., 2012)
• Net savings: US$ 1700–2000 per housing unit
Removal of lead from domestic paint and plumbing in at-risk

neighbourhoods (France) (Pichery et al., 2011)
• Modelling study
• Timescale: projected life-year
• Cost: €3600–9200 per home
• Savings: €8800–51 400 reduction in cost of illness per de-leaded home

Table 4d. Cost-effective interventions for vaccination and screening
Intervention Return on investment Cost saving

Vaccination Pneumococcal vaccination in Spain (children under 2) (Spain) (Morano et Hepatitis B vaccination (United States)
al., 2011) (Margolis et al., 1995)
• Timescale: 1 year • Modelling study
• Cost: €38.36 per dose + €4.88 administration per person • Timescale: projected lifetime
• Savings: €22 million • US$ 164 per life-year saved for
perinatal immunization (societal
perspective)
Human norovirus vaccine (United States) (Bartsch et al., 2012)
• Timescale: 2 years Rotavirus vaccination (Armenia) (Jit et
• Cost of vaccine: US$ 400 million–1 billion al., 2011)
• Savings: US$ 2.1 billion
• Cost: US$ 220 000 in 2012;
Rotavirus vaccine and health care utilization for diarrhoea in children US$ 830 000 in 2016; US$ 260 000 in
(United States) (Cortes et al., 2011) 2025
• Timescale: 2 years • Cost effectiveness: US$ 650 per DALY
• Savings: US$ 278 million in reduced treatment costs (health sector perspective); US$ 820
per DALY (societal perspective)
Measles, mumps and rubella (MMR) vaccination (United Kingdom) (WHO,
2013b) Implementation of bivalent Human
papillomavirus vaccination in young
• Modelling study women in addition to cervical cancer
• Timescale: 10 years screening for women over 40 years
• Costs: £0.17–0.97 per person (Netherlands) (Coupe et al., 2009)
• Savings: £240 730–544 490 over 10 years in reduced treatment costs
• Cost–effectiveness: €19 500 per
Flu vaccine (United Kingdom) (Scuffham& West, 2002; Burls et al., 2006) QALY
• Modelling study
• Timescale: projected lifetime Human papillomavirusvaccination
• Return on investment: £1.35 for every £1 spent on targeted flu vaccination programmes (Austria) (Zechmeister et
• Savings rise to £12 per vaccination when health care workers are al., 2009)
vaccinated
• ICER for girls: €64,000 per life-year
gained and €50,000 per life-year
gained (payer’s and societal
perspectives, respectively)
Human papillomavirus vaccination

(Iceland) (Oddsson et al., 2009)
• Modelling study
• ICER: €18 500 per QALY saved
Screening – Standard vascular disease health
check (France) (Schuetz et al., 2013)
(Note: cancer
screening not • Timescale: 30 years
included here • Cost–effectiveness: offering health
as covered in checks to all: €14 903 per QALY;
Table 3b) offering health checks only to
higher-risk(obese) individuals:
€10 200 or less per QALY
Screening for diabetes and impaired

glucose tolerance (United Kingdom)
(Gillies et al., 2008)
• Modelling study
• Cost–effectiveness: £6242 per QALY

Other considerations: risk and preparedness likelihood and impact of risks. In response to anticipated
High-impact high-risk events – including pandemics risks, policy-makers can build capacity andensure
such as avian flu and natural disasters such as flooding preparedness of systems and development and testing
or heat-waves – are particularly difficult to plan for but of emergency plans.
can be extremely costly. For example, flooding in 2007
gave rise to £3 billion of damages in the United Kingdom Climate change vastly complicates suchissues by
(Pitt, 2008). There may be long gaps between such increasing the probability and severity of extreme
events, making their timing impossible to predict. events while reducing their predictability. It is therefore
Setting such large sums of money aside when there is essential to invest in and modernize health protection
no guarantee when they will be used can be seen as services – including control of communicable diseases,
politically unappealing. Health and environmental environmental health and emergency preparedness – in
impact assessments, including estimation of future order to address current and future public health
trends and costs, are helpful methods to quantify the challenges.

Conclusions
The evidence presented in this report shows that countries, US$ 1.50 in lower middle-income countries
interventions targeting the environmental and social and US$ 3 in upper middle-income countries. These
determinants of health; those that build resilience, figures represent just 1–4% of current health spending.
affecting factors such as mental health and violence; Interventions examined were categorized as being
those that promote healthy behaviours; and those for either population-based or individual-level approaches.
screening and vaccination can be cost-effective and give
returns on investment in the short and longer term. In It is recognized that a comprehensive strategy needs to
particular, theresearchers found a number of include a combination of population and targeted
interventions with quick returns on investment within individual preventive approaches, but it should be
one or two years in a number of areas, including for noted that, on average, individual-level approaches
mental health promotion, healthy employment, reducing were found to cost five times more than interventions at
road traffic injuries and promoting safe active transport. the population level (WHO, 2011a). In general, evidence
also shows that investing in upstream population-based
Public health services have been shown to be at risk in prevention is more effective at reducing health
several areas, however. Many structures for delivering inequalities than more downstream prevention (Orton
public health services in the WHO European Region are et al., 2011). Meanwhile, the National Institute for Health
already facing substantial cutbacks, and public health and Care Excellence in the United Kingdom found that
programmes and interventions in several countries many public health interventions were a lot more cost-
have been reorganized or scaled down. These short- effective than clinical interventions (using cost per
term measures risk escalating demand and costs in the QALY), and many were even cost-saving (Kelly, 2012).
future – costs that evidence shows can be prevented
with cost-effective measures. Funding for public health Aside from the pressures to reduce health sector costs
and prevention approaches can come from a range of resultingfrom the economic crisis, the general trend has
mechanisms, such as through a combination of taxes, been for costs and demand on health care services to
health insurance funds and private sources (Savedoff et increase over time owing to increasing lifeexpectancy,
al., 2012). NCDs and the costs of health technologies. By applying
a strategic approach to investing wisely in public health
Protected budgets for public health services and services, especially for health promotion and primary
preventive measures have been established in some preventive interventions that provide greater returns on
countries, and some have dedicated cross-sector funds investment, funding can be freed up in health and other
from the ministry of finance. Benefits to investing in sectors. This can contribute to achieving greater
public health can be seen across the health sector and sustainability of budgets with better health and wider
contribute to the sustainability of health care funding. outcomes.
Providing public health services is part of the universal
health coverage approach advocated by WHO and Investing in health in general has been shown to give
contributes to reducing health inequalities (Frenk & de economic returns to the health sector, other sectors and
Ferranti, 2012). Strengthening public health approaches the wider economy, with an estimated fourfold return
also has the potential to contribute to improving health on every dollar invested (described as the “fiscal
outcomes in sustainable ways, even in lower-resource multiplier” (Reeves et al., 2013)). For example,
settings (Sachs, 2012). interventions that promote mental health within
childhood contribute to better educational outcomes
WHO has developed a financial planning tool to assist and employment opportunities, while those that
low- and middle-income countries in scaling up a core promote health within the workplace can increase
set of interventions to tackle NCDs(WHO, 2011a). This productivity and economic returns. As a result, some
provides a valuable indication of the likely costs of such countries have agreed cross-sector funding to public
actions. The per capita cost is low, representing an health approaches in order to reflect these wider
annual investment of under US$ 1 in low-income benefits.

In addition, efficiencies can be further increased by This report summarizes a wide range of cost-effective
clustering a variety of cost-effective approaches in the health promotion and preventive interventions that can
design and delivery of programmes to enhance the be delivered by public health services, the wider health
effectiveness and efficiency of overall services. For system and other sectors in a health-in-all-policies
example, working to a common vision of safe urban approach. Much of the existing research collated for the
design, a cluster of cost-saving interventions and report,however, is from higher-income countries;
approaches – such as safe green spaces, safer driving further research is needed for low- and middle-income
and encouragement of walking and cycling – can be settings. In particular, greater understanding is required
identified, potentially resulting in multiple health, social of the optimum investment for public health services to
and environmental benefits. Moreover,focusing on make a more substantial contribution to the
upstream prevention earlier in the life-course has the sustainability of health systems and universal health
potential to bring economic, social and health gains, coverage. In particular, more knowledge is needed
and in some cases environmental benefits, as part of a about the cost–effectiveness of public health services,
more sustainable approach to achieving well-being including the operations of health intelligence, health
(Nurse et al., 2010). Strengthening integrated public protection, promotion and prevention and enabling
health services within a health systems approach will functions within a range of settings, especially for lower-
provide the infrastructure required to deliver cost- resource situations.
effective interventions in an efficient manner, thereby
maximizing health and wider outcomes, including well-
being, in a sustainable way.

Glossary
Cost between different population groups – for example,

Theeconomic definition of cost (also known as differences in mobility between elderly people and
opportunity cost) is the value of opportunity forgone younger populations or differences in mortality rates
(strictly the best opportunity forgone) as a result of between people from different social classes. It is
engaging resources in an activity. Note that there can be important to distinguish between inequality and
a cost without the exchange of money. In addition, inequity in health. Some health inequalities are
economists’ notion of cost extends beyond the cost attributable to biological variations or free choice;
falling on the health service alone: it includes, for others are attributable to the external environment and
example, costs falling on other services and on patients conditions mainly outside the control of the individuals
themselves (NICHSR, 2014). concerned. In the first case it may be impossible or
ethically or ideologically unacceptable to change the
Cost–effectiveness analysis health determinants, so the health inequalities are
This is an economic evaluation in which the costs and unavoidable. In the second, the uneven distribution
consequences of alternative interventions are expressed may be unnecessary and avoidable, as well as unjust
as cost per unit of health outcome. Cost–effectiveness and unfair, so that the resulting health inequalities also
analysisis used to determine technical efficiency: lead to inequity in health (WHO, 2013c).
comparison of costs and consequences of competing
interventions for a given patient group within a given Public health
budget(NICHSR, 2014). WHO uses the following definition of public health: “the
art and science of preventing disease, prolonging life
Disability-adjusted Life Year (DALY) and promoting health through the organized efforts of
One DALY can be thought of as one lost year of “healthy” society” (Acheson, 1988).
life. The sum of these DALYs across the population, or
the burden of disease, can be thought of as a Quality-adjusted life-year (QALY)
measurement of the gap between current health status QALYs are units of measurement of utility that combine
and an ideal health situation where the entire population life-years gained as a result of health interventions/
lives to an advanced age, free of disease and disability health care programmes with a judgement about the
(WHO, 2014b). quality of those life-years. A common measure of health
improvement used in cost–effectiveness analysis, it
Health inequality and inequity measures life expectancy adjusted for quality of
Health inequalities can be defined as differences in life(NICHSR, 2014).
health status or in the distribution of health determinants

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The WHO Regional Office for Europe
The World Health Organization (WHO)

is a specialized agency of the United
Nations created in 1948 with the primary
responsibility for international health matters
and public health. The WHO Regional Office
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THE CASE FOR INVESTING IN PUBLIC HEALTH

A public health summary report for EPHO 8

Assuring sustainable organizational

The case for investing in public health 1

A public health summary report for EPHO 8

© World Health Organization 2014

Design, layout and production by Phoenix Design Aid, Denmark

The case for investing in public health 1

• Investing in health in general has been shown to

2 The case for investing in public health

invest to save and improve health

public health can be part of the solution:

disease prevention: vaccination and screening

Source: WHO (2013a).

Essential Public Health Operation (EPHO) 8:

examples where timescales on returns and cost saving

The case for investing in public health 3

Intervention Quick wins Longer-term gains

Vaccination • For children: norovirus, pneumococcus, rotavirus, • Influenza, pneumococcus

Key: Green: offers a return on investment

4 The case for investing in public health

Box 1. The importance of the first 1000 days

The case for investing in public health 5

Europe of the last century resulted from addressing the 600

example is tuberculosis, which fell from 13% of total North Karelia

mortality in the United Kingdom in 1855 to 0.1% by 400

1990. Much of this decline took place through

such as the Bacillus Calmette–Guérin (BCG) vaccination All Finland

Goldman USA, 1968-76 40 54 6

Treatments Risk factors Unexplained

Source: Ford et al. (2007).

6 The case for investing in public health

Fig.4. Levels of prevention

Tertiary prevention treats disease with cost-effective interventions to slow or reverse

Source: adapted from Donaldson &Donaldson(2003).

The economic case for prevention

The case for investing in public health 7

Fig. 5. OECD projections for public spending on health care 2005–2050

Source: OECD (2006).

8 The case for investing in public health

Table 2a. Costs of not acting: health outcomes

The case for investing in public health 9

Private mortality costs

10 The case for investing in public health

The benefits of action

Fig. 6. A suggested hierarchy of prevention interventions

Cost-effective approaches where the financial benefits to health

Cost-effective approaches that generate additional health (and other)

Cost pressure/ Continued delivery of current practice with predicted increase in

The case for investing in public health 11

Fig. 7. Conceptual diagram of the summary tables

• Infection • Mental health • Employment • Green space

• CVD and diabetes

12 The case for investing in public health

Risk factor Intervention/action Avoidable Cost–effectiveness Implementation Feasibility

Enforce drink–driving laws Quite cost-effective Quite low Intersectoral

Source: WHO (2011b).

The case for investing in public health 13

Disease Intervention/action Avoidable Cost–effectiveness Implementation Feasibility

Source: WHO (2011b).

• Investing in health in general has been shown to

Vaccination • For children: norovirus, pneumococcus, rotavirus, • Influenza, pneumococcus