Health – a key factor in productivity, economic development and growth
Health 2020 addresses the economic and funding aspects of health and health systems. Social progress and stability have been achieved most successfully in countries that ensure the availability of services promoting good health and education, and of effective social safety nets, through strong public services and sustainable public finances. Failure to achieve these goals can be reflected in a decline in societies’ social capital of civic institutions and social networks.
Health is increasingly acknowledged as significantly affecting both the economic dimensions of a society and its social cohesion. The macroeconomics of health and well-being therefore need to be better understood. In the past 30 years, the health sector has shifted from being a functional sector focused on, and investing mainly in, health care services to constituting a major economic force in its own right. Today health is one of the world’s largest and most rapidly growing industries, associated with more than 10% of the gross domestic product of most high-income countries and about 10% of their workforce. It encompasses a wide range of business sectors, services, manufacturers and suppliers, ranging from the local to the global. During the recent economic recession, the continual growth of the health care industry was a stabilizing factor in many countries. nevertheless, its output and output efficiency clearly deserve to be maximized.
In some countries, increases in health care costs are difficult to manage and can put countries and industries at a competitive disadvantage. Health funding has therefore moved to the fore of the health debate, exploring new ways of raising revenue for health and moving away from exclusive reliance on labour-related direct taxes. These are especially relevant in social insurance systems, which traditionally use payroll taxes. As a result, the boundary between tax-funded and social insurance systems is becoming blurred, since many insurance-based systems use a mix of different revenue sources, including general taxes. These changes raise questions about effects on access to and quality of care.
The economic case for health promotion, health protection and disease prevention
Health expenditure poses a greater challenge to governments than ever before. Health expenditure has grown at a pace exceeding economic growth in many member States, resulting in increased financial pressure that threatens the long-term sustainability of health care systems. A large burden of disease in the European Region, particularly chronic noncommunicable disease, severely affects labour markets and productivity. Diseases fuel disparities in employment opportunities and wages, affect productivity at work and increase sick leave and the demand for welfare benefits.
The development and introduction of expensive medical technologies and treatments drive up the cost of managing chronic diseases and multiple morbidities. These cost pressures provide a strong economic case for action to promote health and prevent disease. Real health benefits can be attained at an affordable cost by investing in health promotion and disease prevention. A growing body of studies on the economics of disease prevention shows how
such policies can bend the cost curve of health expenditure and reduce health inequalities by focusing on the people who are most vulnerable.
not enough use is being made of social and technological advances, especially in information and social media. These now offer huge opportunities to achieve health benefits at an affordable cost, sometimes reducing health expenditure and helping to redress health inequalities at the same time. A tangible share of the burden of disease and of the economic costs associated with it could be avoided through actions promoting health and well-being and by deploying effective preventive measures within and beyond the health care sector.
The rationale for government action to promote healthy behaviour is particularly strong in the presence of negative externalities from unhealthy behaviour or when behaviour is based on insufficient information. The victims of second-hand smoke and drunk drivers provide dramatic examples of negative externalities that can be corrected by either excise taxes on tobacco and alcohol or other policies such as public smoking bans and drink–driving laws. Inadequate consumer information justifies interventions to promote healthier behaviour by informing people about the risks of smoking, obesity and other causes of disease.
The complex nature of chronic diseases, their multiple determinants and causal pathways suggest that pervasive and sustained efforts and comprehensive strategies involving a variety of actions and actors are required to successfully prevent disease. However, the reality is that governments spend, at best, only a small fraction of their health budgets on preventing disease (about 3% of total health expenditure in OECD countries).
Expectations concerning the benefits of disease prevention must be realistic.
Preventing disease can improve health and well-being, with cost–effectiveness that is as good as, or better than, that of many accepted forms of health care.
However, reducing health expenditure should not be regarded as the main goal of disease prevention, because many programmes will not have this effect. narrowing health inequalities may also be difficult to achieve through certain forms of prevention that have shown low uptake among the most vulnerable people and which therefore carry the unintended consequence of further increasing inequalities. Furthermore, the determinants of many diseases and behaviours develop through the life-course, and programmes are therefore often designed only to manage the late effects of disease.
The evidence base The WHO Regional Office for Europe has promoted collaborative work aimed at
presenting the economic case for public health action, particularly preventing chronic noncommunicable diseases. This work moves beyond what is known about the economic benefits of specific actions within health care systems, such as vaccinations and screening, to examine research endeavours to make the economic case for investing upstream – that is, before the onset of noncommunicable diseases and before health care services are required. The work highlights priority actions supported by sound cost–effectiveness or cost–
benefit analyses, including actions to limit risky behaviour such as tobacco use and alcohol consumption, to promote physical and mental health through diet and exercise, to prevent mental disorders and to decrease preventable injuries, such as from road crashes, and exposure to environmental hazards. The full results of this work are forthcoming (36), but some of the early evidence is presented below.
Strong evidence indicates the cost–effectiveness of tobacco control programmes, many of which are inexpensive to implement and have
cost-saving effects. Such programmes include raising taxes in a coordinated way with a high minimum tax (the single most cost-effective action), encouraging smoke-free environments, banning advertising and promotion, and deploying media campaigns. Adequate implementation and monitoring, government policies independent of the tobacco industry and action against corruption are all needed to support effective policies.
A substantive evidence base of systematic reviews and meta-analyses supports the cost–effectiveness of alcohol policies. Impressive cost-effective interventions include restricting access to retailed alcohol; enforcing bans on alcohol advertising, including in social media; raising taxes on alcohol; and instituting a minimum price per gram of alcohol. Less, but still cost-effective measures include enforcing drink–driving laws through breath-testing;
delivering brief advice for higher-risk drinking; and providing treatment for alcohol-related disorders.
Actions to promote healthy eating are especially cost-effective when carried out at the population level. Reformulating processed food to decrease salt, trans-fatty acids and saturated fat is a low-cost intervention that may be pursued through multistakeholder agreements, which may be voluntary or ultimately enforced through regulation. Fiscal measures (including taxes and subsidies) and regulating food advertising for children also have a low cost and a favourable cost–effectiveness. However, conflicting interests could hinder feasibility. Programmes to increase awareness and information, such as mass-media campaigns and food labelling schemes, are efficient investments but have poorer effectiveness, particularly in lower socioeconomic groups.
Promoting physical activity through mass-media campaigns is a very cost-effective action and relatively inexpensive. However, returns in terms of health outcomes may be lower than those provided by more targeted interventions, for instance at the workplace. Changes in the transport system and the wider environment have the potential to increase physical activity, but they require careful evaluation to ascertain their affordability and feasibility, and whether the changes reach those with greater health and social needs. Actions targeting the adult population and individuals at higher risk tend to produce larger effects in a shorter time frame.
Robust evidence indicates that preventing depression, the single leading cause of disability worldwide, is feasible and cost-effective. Depression is associated with premature death and reduced family functioning, it directly affects people’s individual behaviour and it entails extremely high economic costs due to health care and productivity losses, which can be partly avoided through appropriate forms of prevention and early detection. Evidence supports actions across the life-course, starting with early action in childhood to strengthen social and emotional learning, coping skills and improved bonds between parents and children, which can generate benefits lasting into adulthood.
Sound economic evidence supports action to prevent road crashes, such as modifying road design, one-way streets, urban traffic-calming (including mandatory speed limits enforced by using physical measures), and camera and radar speed enforcement programmes, especially in higher-risk areas. Actively enforcing legislation to promote good road safety behaviour can also be highly cost-effective.
Evidence from economic studies supports action to tackle environmental chemical hazards. Examples include comprehensive regulatory reform such as that implemented in 2007 under the European Community regulation on the registration, evaluation, authorization and restriction of chemicals (REACH);
the removal of lead-based paint hazards; the abatement of mercury pollution
from coal-fired power plants; and the abatement of vehicle emissions in high-traffic areas, such as through the congestion charging schemes used in many metropolitan areas, which may produce savings in health care and other costs associated with childhood asthma, bronchiolitis and other respiratory illnesses in early life.
Investing in education is also investing in health. A growing body of empirical research suggests that, when countries adopt policies to improve education, the investment also pays off in terms of healthier behaviour and longer and healthier lives. For example, studies of compulsory schooling reforms adopted in several countries in the European Region conclude not only that the reforms lead to additional years of completed schooling but also that the additional schooling reduces the population rates of smoking and obesity. When countries consider the return on investment in education and other social determinants of health, the analysis should include the potential health gains.
Key approaches Chronic diseases can be tackled cost-effectively through interventions aimed
at modifying behavioural and lifestyle risk factors. This is likely to reduce health inequalities within countries in the long term. However, turning the tide of diseases that assumed epidemic proportions during the twentieth century requires fundamentally changing the social norms that regulate individual and collective behaviour. Such changes require wide-ranging prevention strategies addressing multiple determinants of health across social groups.
most countries are striving to improve health education and information.
However, solely providing information is rarely effective (or cost-effective) in influencing behaviour, and in some instances it can increase inequalities.
Instead, adopting a wider strategic whole-systems approach is essential to increase the impact and effectiveness of efforts. Strategies are needed to directly address the factors within a person’s own control, empowering people and ensuring a clear strategic focus on the individual or community behavioural determinants. Furthermore, the factors that may lie outside their immediate control ensure a clear strategic focus on the wider social determinants that strongly influence individual behaviour. more stringent measures, such as regulating advertising or fiscal measures, are more intrusive on individual choices and more likely to generate conflict among relevant stakeholders, but they are also likely to weigh less on public finances and to produce health returns more promptly.
Changing the behaviour of the population and fostering healthy lifestyles is challenging, but increasing evidence about what works clearly supports adopting strategic and multifaceted approaches to strengthening capability through greater control and empowerment. Although the conventional approach is to attempt to raise awareness through communication campaigns, the evidence indicates that simply providing information about unhealthy and healthy behaviour is not effective in achieving and sustaining behaviour.
Health communication and education initiatives should be delivered as part of a wider portfolio of interventions aimed at creating a social and physical environment that fosters healthy behaviour. The various behavioural strategies are mutually reinforcing, and the effectiveness of behavioural programmes and interventions increases when they are integrated alongside additional strategies that address the wider social determinants.
A wide range of regulatory and fiscal measures have increasingly been put in place in many countries, for instance to the curb consumption of tobacco and alcohol. A minimum age has been set for purchasing cigarettes and alcoholic
drinks, which often carry health warnings printed on their labels. Advertising has been severely restricted, and high taxes have been imposed on the consumption of both commodities. All these measures have contributed to containing consumption, and WHO work has shown that most have very favourable cost–effectiveness profiles. However, fiscal measures are complex to design and enforce; their impact may be unpredictable; and they can bear more heavily on people with low incomes than on those with higher incomes.