hence only partially explain differences in outcomes (32). Health systems can directly address differences in exposure and vulnerability through advocacy, by promoting intersectoral action to improve health status, and by leading by example in ensuring equitable access to care.
Health ministers and ministries have a vital role to play in shaping the functioning and contribution of health systems to improving health and well-being within society, and in engaging other sectors to address their contribution to health and its determinants. unfortunately, their capacity to do so often falls short of what is required, and the organization of health systems has not kept pace with the changes that societies are undergoing.
In particular, public health services and capacity are relatively weak, and too little attention has been paid to developing primary care, including especially health promotion and disease prevention. Further, the usual hierarchical organization of health systems makes them less capable of responding rapidly to technological innovation and to the demands and desire for participation of service users. Because of these factors, health systems are significantly less productive in producing health than they could be.
Technological developments in health care
Health technology can be defined in different ways. It can mean the procedures, equipment and processes by which health care is delivered. This would include applying new scientific areas of knowledge, such as genomics, new medical and surgical procedures, drugs, medical devices and new patient support systems. The term can also more narrowly describe the devices used to prevent, diagnose, monitor or treat diseases or conditions that affect humans.
Examples would be drug-eluting stents, magnetic resonance imaging (mRI) scanners, pacemakers, minimally invasive surgery, wound and incontinence management, and devices that support self- or home management of disease, such as blood glucose testing kits, supported by counselling based on information technology.
The management of coronary artery disease provides a good example of how technology has changed the treatment and prevention of disease over time.
In the 1970s, cardiac care units were introduced to manage irregular heartbeat after heart attack. Later, beta-blocker drugs were used to lower blood pressure after the attack, and then thrombolytic drugs became widely used. Coronary artery grafting became more widespread. In the 1980s, blood-thinning agents were used after heart attack to prevent reoccurrences, and angioplasty came into use after people were stable. In the 1990s, angioplasty was used more widely for immediate treatment and revascularization, along with stents to keep blood vessels open. In the 2000s, better tests were used to diagnose heart attacks, drug-eluting stents were used and new drug strategies were devised.
A well-known example of technological development is new techniques for diagnostic and treatment imaging. Techniques such as computed tomography (CT) scanning, mRI and positron emission tomography have revolutionized diagnosis and clinical practice, enabling much more accurate diagnosis in greater numbers and changing the potential and capacity of interventions.
Another example of a technological development potentially affecting practice and costs in both prevention and treatment is nanotechnology, which involves manipulating properties and structures at the nanoscale.
nanotechnology is being used for more targeted drug therapies or “smart drugs”. These new drug therapies have already been shown to cause fewer side effects and be more effective than traditional therapies. In the future, nanotechnology will also aid in the formation of molecular systems that may be strikingly similar to living systems. These molecular structures could be the basis for regenerating or replacing body parts that are currently lost to infection, accident or disease. For example, nanotechnology is already being used as the basis for new, more effective drug delivery systems and is in early stage development as “scaffolding” in nerve regeneration. It is also hoped that investment in this branch of nanomedicine could lead to breakthroughs in terms of detecting, diagnosing and treating various forms of cancer.
Other examples include telemedicine, e-health (electronic health) and m-health (mobile health), which already have significant potential for increasing patient participation and empowerment and for streamlining systems of monitoring and care while reducing costs. new patient-based connectivity and medical devices allow for increasing home-based care and enable people to stay active and to contribute to society. These information technology–based developments may be linked with new self-management tools, health applications and devices for patients and their caregivers to better manage their health or chronic disease from home.
One technological development is of great potential importance. Work on the human genome during the past decade may change the nature and outcomes of disease. This work is substantially changing public health research, policies and practice, facilitating numerous discoveries on the genomic basis of health and disease. Rapid scientific advances and tools in genomics have contributed to understanding disease mechanisms. The prospect is of characterizing each person’s unique clinical, genomic and environmental information, providing potential new applications for managing human health during the whole life-course. In 2005, a formal definition of public health genomics was agreed as “the responsible and effective translation of genome-based science and technologies for the benefit of human health” (33). The mission of public health genomics is to integrate advances in genomics and biomedicine into public health research, policy and programmes. These advances will increasingly be integrated into strategies aiming at benefiting population health.
While there are many ethical issues to be considered (34), it is likely that modern genomics will support the trend towards more personalized and individualized medicine and health care in several aspects, including health promotion, disease prevention, diagnosis and curative services. The future will see more effective tools for early detection and treatment. Developments in systems biology (35) should enable the progression of diseases to be detected using molecular markers, long before the first disease symptoms arise. These early markers are expected to be at the level of protein expression, as markers of the gene networks of the human genome.
All diseases have a genomic component, and host genomic factors play an important role in whether and how a disease is manifested. For some diseases (such as cystic fibrosis and Down syndrome), genetics is the only factor that
makes a person sick. The disease group defined as noncommunicable diseases (including cardiovascular diseases, diabetes, obesity, osteoporosis, mental disorders, asthma and cancer) has a varying degree of genetic background, but genetics is not the only factor, as behavioural and environmental factors interact with this genetic background. This disease group is therefore also called chronic complex diseases. Even the disease group currently called communicable diseases, which used to be considered to be caused solely by infectious pathogens, is known to have a genetic component. From this perspective, the separation between communicable and noncommunicable diseases is predicted to diminish in the future and, similar to the concept of health, diseases will be approached holistically.
various characteristics of individuals will probably be used in an integrative way for risk management, disease management and case management in noncommunicable diseases and to promote health and improve the quality of life. These characteristics include genome-based information (covering not only the genetic level but also epigenetic, expression and protein-level information); lifestyle factors, including diet, physical activity, exercise and smoking habits; mental, economic and social factors, covering home, work and social life; personal medical history and family health history; and the interaction of these factors. Another field of application where work has already started is using molecular markers to stratify diseases into subgroups to be treated with different medicines or interventions. Cancer is one of the leading fields here, with several current examples.
Securing a real paradigm shift in the use of technology depends on a willingness to restructure policies and on the ability to provide the necessary training to public health professionals. Health care systems and policy-makers urgently need to be prepared responsibly and effectively to translate genome-based knowledge and technologies into public health: this is a major task of public health genomics and an important area of potential innovation in Europe. Health policies should prepare to meet this future vision of medicine and health. This means that, instead of solely focusing on the biological determinants of health or emphasizing mainly social determinants, health will need to be approached through the perspective of all its determinants, including biological, lifestyle, environmental and social factors and the interactions between them. In the future, public health genomics will probably provide the vision and tools to integrate genome-based information (as a part of the biological determinants of health) into health care systems and policies.
Such technologically based innovations have already created new opportunities to improve health and health care. These changes substantially affect aggregate health care costs, especially when numerous organizational and professional factors support their use. This is illustrated by the dramatic increases in health care costs in the last years of life. To the extent that technology enables newer or better treatments, greater spending may involve increasing the level of health care purchased rather than unnecessary or wasted cost. Some technologies, such as the self-measurement of blood glucose, may have an upfront cost but reduce expenses related to complications further down the road.
Whether a particular new technology will increase or decrease health expenditure depends on several factors. How does it affect the cost of treating an individual person? How many times is the new technology used? On what basis can its use be rationed? Does the new technology extend existing treatments to new conditions? Does the technology cost more immediately but lead to later savings? new technologies may extend life expectancy, affecting both the type and amount of health care that people use in their
lifetime. The real balance of costs and savings can often only be evaluated by long-term epidemiological and health economic studies.