Case Investing Public Health
Case Investing Public Health
Case Investing Public Health
Keywords
DELIVERY OF HEALTH CARE
HEALTH CARE COSTS
HEALTH CARE ECONOMICS AND ORGANIZATIONS
HEALTH POLICY
PREVENTION
PUBLIC HEALTH
Cover photos:
Top: ©Shutterstock
Middle: ©iStock.com
Bottom: ©Shutterstock
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
3.
Even small investments promise large gains to
health, the economy and other sectors, with
sustainable 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
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
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
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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).
12
10
8
Current situation (2005)
Cost Pressure/Business as usual (2050)
6
Cost containment (2050)
0
Health care Long term care Total
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
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.
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)
a
DALYs include 3% discounting and age weights.
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
2b 3b
Costs of not acting: “Best buy”
risk factors interventions by
health outcome
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
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
Safety camera enforced speed limits (United Kingdom) (Gains et al., 2005)
• Empirical study
• Timescale: 4 years
• 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
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.
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