Marys Medicine

The case for investing in 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 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 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.
DELIVERY OF HEALTH CARE HEALTH CARE COSTS HEALTH CARE ECONOMICS AND ORGANIZATIONS World Health Organization 2014
All rights reserved. This information material is intended for a limited audience only. It may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole,in any form or by Top: Shutterstock Middle: iStock.com Bottom: Shutterstock Design, layout and production by Phoenix Design Aid, Denmark Acknowledgements . ivAbout this report . 1 Scope . 1 Objectives . 1Key messages . 1Overview . 3Background . 5The economic case for prevention . 7 Sustainability of current and future costs . 8 The cost of health inequalities . 8The benefits of action . 11 A summary of the evidence . 12 Other considerations: risk and preparedness . 22Conclusions . 23Glossary . 25References . 26 AcknowledgementsThis 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.
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.
The report's objectives are: • 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 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 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 costs up to €300 per European inhabitant per year.
• The costs of health inequalitiesthe 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 The case for investing in public health 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 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 • 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.
The case for investing in public health 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
Fig. 1. Cost-effective public health interventions
invest to save and improve health
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
violence
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 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 e timescales on returns and cost saving Apr/09/13 3:59 PM have been reported (in green and orange font).
The case for investing in public health Table 1. Summary of interventions found to be cost-effective
Quick wins
Longer-term gains
(over 5 years)
• Road traffic injury preventiona • Removal of lead and mercury • Active transporta • Chemical regulation • Safe green spacesa• Heat wave plana • Healthy employment programmes • Insulating homesa• Housing ventilation for asthma• Community falls prevention • 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 • Mental health in the workplace• Psychosocial groups for older people• Parenting programmes• Depression prevention • 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 • Alcohol legislation, taxation and control (WHO very • Nutrition – reducing salt; replacing trans fatty acids; raising public awareness of healthy dietsa (WHO very • Physical activity mass media awareness (WHO very • For children: norovirus, pneumococcus, rotavirus, • Influenza, pneumococcus • Measles, mumps and rubella; diphtheria, pertussis and • Human papillomavirus; hepatitis B; meningitis C • 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 • 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 case for investing in public health 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.
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.
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 The case for investing in public health 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 start of the North Karelia Project Europe of the last century resulted from addressing the POPULATION 600 causes of disease – such as poor housing and nutrition extension of the Project nationally – rather than just treating the consequences. One example is tuberculosis, which fell from 13% of total mortality in the United Kingdom in 1855 to 0.1% by 1990. Much of this decline took place through improvements in housing before medical interventions such as the Bacillus Calmette–Guérin (BCG) vaccination became available (Donaldson & Donaldson, 2003). More recently, the results of the Finnish North Karelia Project show that preventive approaches can have a major impact on risk factors: the decline in heart disease 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 Beaglehole New Zealand, 1974-81 Nunink USA, 1980-90 IMPACT Scotland, 1975-94 IMPACT New Zealand, 1982-93 IMPACT England and Wales, 1981-2000 IMPACT USA, 1980-2000 IMPACT Poland, 1991-2005 IMPACT Czech, 1985-2007 IMPACT Sweden, 1986-2002 BMJ Finland, 1982-97 IMPACT Finland, 1982-97 IMPACT Iceland, 1981-2006 Source: Ford et al. (2007).
The case for investing in public health 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 – The case for investing in public health 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 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 (%) Current situation (2005) Cost Pressure/Business as usual (2050) Cost containment (2050) 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 The case for investing in public health 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
DALYs lost
Costs at the individual
Costs to health sectors
Costs to governments/
in Europe
€169 billion per year in the EU (Leal Annual cost to society of 10.48% of 2008/9 National Health £110 billion per year in the United 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, Costs for children with Cost of depression: £1.7 billion in severe and complex mental 2007 (United Kingdom) (McCrone health problems: over £1000 per week (United Kingdom) (Clarke et al., 2005) Cost of anxiety disorders: £1.2 billion in 2007 (United Kingdom) (McCrone et al., 2008) 6.5% of health care expenditure in €117 billion per year in the EU the EU (Stark, 2006) (Luengo-Fernandez et al., 2012) Each unplanned influenza Influenza cost the economy admission costs the NHS £6.75 billion in 1999 (United £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, Road traffic
Up to 2% of GDP in middle- and high-income countries in the EU (Racioppi et al., 2004)Road traffic collisions cost €153 billion per yearin the EU (Racioppi et al., 2004) Cost to the NHS: £1.3 billion per year (United Kingdom) (Wanless, 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 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 a DALYs include 3% discounting and age weights.
The case for investing in public health Table 2b. Costs of not acting: risk factors
DALYs lost in Costs at the individual Costs to health sectors
Costs to governments/
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) Alcohol-use disorders cost the Effects on health, well-being and increases the risk of NHS £2.9 billion per year (United productivity reach US$ 300–400 purchasing power parity per capita per year (Rehm et absenteeism, and (attending work while Alcohol-related harm costs £20–55 billion sick) (Anderson et al., per year (United Kingdom)(PMS Unit, 2004) Alcohol cost the EU €125 billion in 2003 (1.3% of GDP) (Anderson &Baumberg, 2006) Unhealthy
Obese individuals incur Obesity accounts for 0.7–2.8% of Obesity accounts for 1–3% of GDP in most 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, Physical
Inactive Danish men Globally physical inactivity Physical inactivity is estimated to cost lose three days of work accounts for 1.5–3% of national €150–300 per inhabitant per year in health care budgets (Oldridge, Europe(Cavill et al., 2006) moderately active men (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 pensions in Denmark (Juel et al., 2008) Direct medical costs to the NHS: £1.06 billion (United Kingdom) (Allender et al., 2007) An estimated total of Lead paint in homes in the Air pollution caused by road traffic costs the 1087 potential years of United States estimated at EU €25 billion per year (TU Dresden, 2012) life lost in 2005 US$ 11–53 billion of annual health care costs in children Air pollution from industrial facilities costs under 6years (Gould, 2009) the European Environment Agency €102–169 billion per year (EEA, 2011) Calculated lost lifetime earnings over US$ 165 billion among Noise pollution from road traffic costs the children estimated to have EU €7 billion per year (TU Dresden, 2012) raised lead levels (Gould, 2009) The cost of road traffic noise pollution in England is estimated to be £7–10 billion per year (United Kingdom)(DEFRA, 2013) Mercury emissions from coal burning in the United States reduce IQ, with a resultant US$ 1.3 billion loss in economic 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.
The case for investing in public health 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 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 Continued delivery of current practice with predicted increase in business as usual
health care costs over time The case for investing in public health 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
Costs of not acting:
"Best buy"
interventions for
by risk factor
to build resilience:
to address social
to address
factors affecting
of health
and outcomes
of health
• Physical inactivity
• Violence and abuse
• Road traffic injuries
• Mental health
• Green space
• Active transport
• Environmental
Costs of not acting:
TIAL SOLUTIONS "Best buy"
risk factors
TEN health outcome
PO • CVD and diabetes
• Respiratory disease
The case for investing in public health Table 3a. "Best buy" interventions by risk factor
Risk factor
Avoidable
Feasibility
(DALYs lost, (core set of "best buys") (Very: <GDP per person; (health system millions; (DALYs averted) Quite: <3 × GDP per (Very low: <US$ 0.50; person; Less: >3 × GDP Quite low: <US$ 1; per person) Tobacco use
Protect people from Combined effect: Very cost-effective Highly feasible: 25–30 million Warn about the dangers of (>50% tobacco Enforce bans on tobacco Raise taxes on tobacco Offer counselling to Quite cost-effective Harmful use
Restrict access to retailed Combined effect: Very cost-effective of alcohol
Enforce bans on alcohol (10–20% alcohol Raise taxes on alcohol Enforce drink–driving laws Quite cost-effective action; feasible Offer brief advice for hazardous drinking Unhealthy
Reduce salt intake Very cost-effective Replace trans fat with polyunsaturated fat 5 million DALYs Promote public awareness interventions: not Restrict marketing of food Very cost-effective? and beverages to children (more studies needed) Replace saturated fat with Quite cost-effective Manage food taxes and Less cost-effective Offer counselling in primary care Provide health education in worksitesPromote healthy eating in Physical
Promote physical activity Not yet assessed Very cost-effective Promote physical activity Not assessed globally Support active transport Quite cost-effective Offer counselling in Less cost-effective Promote physical activity in worksitesPromote physical activity in Prevent liver cancer via Very cost-effective hepatitis B vaccination Source: WHO (2011b).
The case for investing in public health Table 3b. "Best buy" interventions by health outcome
Avoidable
(DALYs lost, (core set of "best buys") (Very: <GDP per person; (health system millions; % (DALYs averted) Quite: <3 × GDP per (Very low: <US$ 0.50; global burden) person; Less: >3 × GDP Quite low: <US$ 1; per person) Counselling and multidrug 60 million DALYs Very cost-effective therapy (including glycemic control for (35% CVD burden) diabetes mellitus) for people (≥30 years) with 4 million DALYs Very cost-effective 10-year risk of fatal or nonfatal cardiovascular (2% CVD burden) events ≥30%Aspirin therapy for acute myocardial infarction Counselling & multidrug 70 million DALYs Quite cost-effective therapy (including glycemic control for (40% CVD burden) diabetes mellitus) for people (≥ 30 years) with a 10-year risk of fatal and nonfatal cardiovascular Cervical cancer – screening 5 million DALYs Very cost-effective through visual inspection with acetic acid and (6% cancer treatment of pre-cancerous burden) lesions to prevent cervical Breast cancer – treatment 3 million DALYs Quite cost-effective (4% cancer Breast cancer – early 15 million DALYs Quite cost-effective case-finding through mammographic screening (19% cancer (50–70 years) and treatment of all stages Colorectal cancer – 7 million DALYs Quite cost-effective screening at age 50 and (9% cancer Oral cancer – early Not assessed globally detection and treatment Respiratory
Treatment of persistent Quite cost-effective asthma with inhaled corticosteroids & beta-2 (expected to be Source: WHO (2011b).
The case for investing in public health 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.
The case for investing in public health Table 4a. Cost-effective interventions to build resilience: factors affecting health behaviours and outcomes
Return on investment
Cost saving
Violence and
Violence Against Women Act of 1994 (United States) (Clark et al., 2002)
Cost–effectiveness of a programme
to detect and provide better care for
• Empirical evaluation female victims of intimate partner
• Timescale: 1 year violence (United Kingdom) (Norman et
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) The case for investing in public health Table 4a. Cost-effective interventions to build resilience: factors affecting health behaviours and
Return on investment
Cost saving
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 • 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
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 • 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 The case for investing in public health Table 4b. Cost-effective interventions to address social determinants of health
Return on investment
Cost saving
Affordable warm housing: insulation and heating (United Kingdom) (CIEH,
Enhancing ventilation in homes of
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 advice services (United Kingdom) (Knapp et al., 2011)
• Modelling study • Timescale: 2–5 years • Pay-off: £2.92 per £1 expenditure 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): 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 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 • Timescale: 1 year • Cost: £40 000 • Savings: £340 000 within 1 year The case for investing in public health Table 4c. Cost-effective interventions to address environmental determinants of health
Return on investment
Cost saving
Road traffic
Nationwide speed limit reduction (United States) (Shafi et al., 2008)
Injury awareness education
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 • Savings: US$ 50 billion annually • Cost–effectiveness: • cost per offence prevented: Airbag use (United States) (Shafi et al., 2008)
• cost per serious injury avoided: • Timescale: 1 year • Savings: US$ 1.94 billion annually cost per discounted life-year gained: Photo radar speed enforcement programme on an inner city motorway
(Spain) (Perez et al., 2007)• Empirical study • Timescale: 2 years • 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)• Timescale: 2 years • 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 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 Conservation volunteering projects (United Kingdom) (Greenspace
Scotland, 2009)• Empirical study • Timescale: over 5 years • Return on investment: £7.35 for every £1 invested Heat warning systems (Europe) (Toloo et al., 2013)
• Systematic review • Timescale: 4 years • Cost: US$ 210 000 • Savings: US$ 468 million The case for investing in public health Table 4c. Cost-effective interventions to address environmental determinants of health contd.
Return on investment
Cost saving
Switching from car to active transport (United Kingdom) (Davis, 2011)
Counselling programmes to promote
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 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 Effect of increasing active travel in urban England and Wales on costs to
the NHS (United Kingdom) (Jarrett et al., 2012)
• Timescale: 20 years
• Savings: £17 billion for the NHS (reduction in the prevalence of type 2 diabetes, dementia, ischaemic heart disease, cerebrovascular disease and Environmental Reducing childhood exposure to mercury through mercury and air toxics
standards (MATS) (United States) (EPA, 2011)
• Empirical study
• Timescale: 10 years • Savings: > US$ 37 billion per year in health benefits Window replacement and residential lead paint hazard control (United
States) (Dixon et al., 2012)• Timescale: 12 years • 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 The case for investing in public health Table 4d. Cost-effective interventions for vaccination and screening
Return on investment
Cost saving
Pneumococcal vaccination in Spain (children under 2) (Spain) (Morano et
Hepatitis B vaccination (United States)
(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 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 • Savings: US$ 2.1 billion • Timescale: 1 year • 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) • 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,
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 • Timescale: 10 years • Cost–effectiveness: €19 500 per Flu vaccine (United Kingdom) (Scuffham& West, 2002; Burls et al., 2006)
• 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 • ICER for girls: €64,000 per life-year gained and €50,000 per life-year gained (payer's and societal Human papillomavirus vaccination
(Iceland) (Oddsson et al., 2009)• Modelling study • ICER: €18 500 per QALY saved Standard vascular disease health
check (France) (Schuetz et al., 2013)
• Timescale: 30 years • Cost–effectiveness: offering health checks to all: €14 903 per QALY; 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 • Timescale: 50 years • Cost–effectiveness: £6242 per QALY The case for investing in public health 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.
The case for investing in public health 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, 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.
The case for investing in public health 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- effective interventions in an efficient manner, thereby maximizing health and wider outcomes, including well- being, in a sustainable way.
The case for investing in public health 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 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
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 The case for investing in public health 1,000 Days (2014). Resources [website].Washington, Brown D W, Riley L, Butchart A, Meddings DR, Kann DC: 1,000 Days (www.thousanddays.org/resources/ L, Harvey AP (2009). Exposure to physical and essential-documents/, accessed 2 September 2014).
sexual violence and adverse health behaviours in African children: results from the Global School- Acheson, D (1988). Public health in England: the based Student Health Survey. Bull World Health report of the Committee of Inquiry into the Future Organ. 87:447–455 (http://www.who.int/bulletin/ Development of the Public Health Function. London: volumes/87/6/07-047423/en/index.html, accessed 5 September 2014).
Allender S, Foster C, Scarborough P, Rayner M (2007).
Bultmann U, Sherson D, Olsen J, Hansen CL, Lund The burden of physical activity-related ill health in the T, Kilsgaard J (2009). Coordinated and tailored work UK.J Epidemiol Community Health. 61(4):344–348.
rehabilitation: a randomized controlled trial with economic evaluation undertaken with workers on sick Anderson LM, Shinn C, Fullilove MT, Scrimshaw SC, leave due to musculoskeletal disorders. J OccupRehabil. Fielding JE, Normand J et al. (2003). The effectiveness of 19(1):81–93.
early childhood development programs: a systematic review. Am J Prev Med. 24(3S):32–46.
Burls A, JordanR, BartonP, OlowokureB, WakeB, AlbonE et al. (2006). Vaccinating healthcare workers against Anderson P, Baumberg B (2006). Alcohol in Europe: a influenza to protect the vulnerable – is it a good public health perspective: a report for the European use of healthcare resources? A systematic review of Commission. London: Institute of Alcohol Studies the evidence and an economic evaluation. Vaccine. 5 September 2014).
Bywater T, Hutchings J, Daley D, Whitaker C, Yeo ST, Jones K et al.(2009). Long-term effectiveness of a Anderson P, Møller L, Galea G (2012). Alcohol in the parenting intervention for children at risk of developing European Union: consumption, harm and policy conduct disorder.Br J Psychiatry. 195(4):318–24.
approaches. Copenhagen: WHO Regional Office for Cavill N, Kahlmeier S, Racioppi F (2006). Physical activity and health in Europe: evidence for action. Copenhagen, WHO Regional Office for Europe (http://www.euro.
and-policy-approaches, accessed 5 September 2014).
Bartsch SM, Lopman BA, Hall AJ, Parashar UD, Lee health-in-europe-evidence-for-action, accessed 5 BY(2012). The potential economic value of a human September 2014).
norovirus vaccine for the United States. Vaccine. CDC (2012). Helmet use among motorcyclists who died in crashes and economic cost savings associated with Black R, Victora C, Walker S, Bhutta Z, Christian P, de state motorcycle helmet laws – United States 2008– Onis M, et al. (2013). Maternal and child undernutrition 2010. MMWR Weekly. 61(23):425–430.
and overweight in low-income and middle-income countries. Lancet. 382(9890):427–451.
CDC (2013). Intimate partner violence: consequences [web site]. Atlanta, GA: Centers for Disease Control and Bone A, Nurse J (2010). Health co-benefits of climate change action: how tackling climate change is a "win win win".CHaP Report.16:51–55.
accessed 5 September 2014).
The case for investing in public health CIEH (2008).Good housing leads to good health: a Department of Health (2012). 2003–04 to 2010–11 toolkit for environmental health practitioners. London: programme budgeting data [website]. London: Chartered Institute of Environmental Health (http:// Department of Health (https://www.gov.uk/ programme-budgeting-data, accessed 5 September accessed 12 September 2014).
Clark KA, Biddle AK, Martin SL (2002).A cost–benefit Devine A, Spencer A, Eldridge S, Norman R, Feder G analysis of the Violence Against Women Act of 1994.
(2012). Cost-effectiveness of Identification and Referral Violence Against Women. 8(4):417–428.
to Improve Safety (IRIS), a domestic violence training and support programme for primary care: a modelling Clarke AF, O'Malley A, Woodham A, Barrett B, Byford S study based on a randomised controlled trial. BMJ (2005). Children with complex mental health problems: needs, costs and predictors over one year. J Child Adolescent Health. 10(4):170–178.
Dixon SL, JacobsDE, WilsonJW, AkotoJY, NevinR, Scott Clark C(2012).Window replacement and residential lead Cortes JE, CurnsAT, Tate JE, Cortese MM, Patel MM, paint hazard control 12 years later. Environ Res. 113: Zhou F et al.(2011). Rotavirus vaccine and health care utilization for diarrhea in U.S. children. N Engl J Med. Donaldson LJ, Donaldson RJ (2003). Essential public health, second edition. Abingdon: Radcliffe Publishing.
Coupe VM, van GinkelJ, de MelkerHE, SnijdersPJ, Meijer CJ,BerkhofJ (2009). HPV16/18 vaccination to prevent EEA (2011).Revealing the costs of air pollution from cervical cancer in the Netherlands: model-based cost– industrial facilities in Europe. Copenhagen: European effectiveness. Int J Cancer. 124(4):970–978.
Environment Agency (EEA Technical Report, No.15; Davis A (2011). Essential evidence on a page: No. 76 pollution, accessed 5 September 2014).
– benefits of switch from car to active travel. Bristol: Bristol City Council.
Edwards RT, Neal RD, Linck P, Bruce N, Mullock L, Nelhans N et al.(2011). Enhancing ventilation in homes DEFRA (2013). Protecting and enhancing our urban of children with asthma: cost–effectiveness study and natural environment to improve public health alongside randomised controlled trial. Br J Gen Pract. and wellbeing [website]. London: Department for Environment, Food and Rural Affairs (https://www.gov.
Elder RW, Shults RA, Sleet DA, Nichols JL, Thompson RS, Rajab W et al. (2004). Effectiveness of mass media campaigns for reducing drinking and driving and alcohol-involved crashes: a systematic review. Am J environment, accessed 5 September 2014).
Prev Med 27(1):57–65.
Department of Health (2009). Support related housing: EPA (2011).Regulatory impact analysis for the final incorporating support related housing into your mercury and air toxics standards.Research Triangle efficiency programme. London: Department of Health.
Park, NC: U.S. Environmental Protection Agency (http:// Department of Health (2010).NHS reference costs accessed 5 September 2014).
2008–2009 [website]. London: Department of Health FOEN (2009). Noise pollution in Switzerland: results of the SonBase national noise monitoring programme. DH_111591, accessed 5 September 2014).
Bern: Federal Office for the Environment. (State of the Environment Series, No. 0907; http://www.bafu.
html?lang=en, accessed 5 September 2014).
The case for investing in public health Ford E, Ajani U, Croft J, Critchley J, Labarthe DR, Kottke Ho KM, Geelhoed E, Gope M, Burrell M, Rao S (2012). TE et al. (2007). Explaining the Decrease in US Deaths An injury awareness education program on outcomes from Coronary Disease, 1980–2000. N Engl J Med. of juvenile justice offenders in Western Australia: an economic analysis. BMC Health Serv Res. 12: 279.
Frenk J, de Ferranti D(2012). Universal health coverage: Home Office (2009).Saving lives. Reducing harm. good health, good economics. Lancet. 380(9845):862– Protecting the public: an action plan for tackling violence 2008–11 – one year on. London: Home Friedli L, Parsonage M (2007). Mental health promotion: uk/20100413151441/http://www.crimereduction.
building an economic case. Belfast: Northern Ireland Association for Mental Health (http://www.chex.
5 September 2014).
documents-of-interest/, accessed 5 September 2014).
Irvine L, Conroy SP, Sach T, Gladman JR, Harwood RH, Kendrick D et al. (2010). Cost–effectiveness of a day Gains A, Nordstrom M, Heydecker B, Shrewsbury hospital falls prevention programme for screened J, Mountain L, Maher M (2005). The national safety community-dwelling older people at high risk of falls. camera programme four year evaluation report. Age Ageing. 39(6):710–716.
London: PA Consulting Group (http://www.eltis.org/ Jarrett J, WoodcockJ, Griffiths UK, ChalabiZ, EdwardsP, accessed 12 September 2014).
Roberts I et al.(2012).Effect of increasing active travel in urban England and Wales on costs to the National GatwoodJ, Meltzer MI, Messonnier M, Ortega-Sanchez Health Service. Lancet. 379(9832):2198–2205.
IR, Balkrishnan R, Prosser LA (2012). Seasonal influenza vaccination of healthy working-age adults: a review of Jit M, YuzbashyanR, SahakyanG, AvagyanT,MosinaL economic evaluations. Drugs. 72(1):35–48.
(2011). The cost–effectiveness of rotavirus vaccination in Armenia. Vaccine. 29(48):9104–9111.
Gillies CL, Lambert PC, Abrams KR, Sutton AJ, Cooper NJ, Hsu RT et al.(2008). Different strategies for screening Juel K, Sørensen J, Brønnum-Hansen H (2008). Risk and prevention of type 2 diabetes in adults: cost factors and public health in Denmark. Scand J Public effectiveness analysis. BMJ. 336(7654):1180–1185.
Health. 36(Suppl 1):11–227.
Gorell RSJ,TootillW(2001). Monitoring local authority Karanikolos M, Mladovsky P,Cylus J, Thomson S, Basu road safety schemes using MOLASSES. Wokingham: S, Stuckler D et al. (2013). Financial crisis, austerity, and Transport Research Laboratory.
health in Europe. Lancet. 381(9874):1323–1331.
Gould E (2009). Childhood lead poisoning: conservative Kelly MP (2012). Public health at National Institute estimates of the social and economic benefits of lead for Health and Clinical Excellence (NICE) from 2012.
hazard control. Environ Health Perspect. 117(7):1162– Perspect Public Health. 132(3):111–113.
Klietz S, BorduinC, Schaeffer C (2010). Cost–benefit Greenspace Scotland (2009).Social return on analysis of multisystemic therapy with serious and investment (SROI) analysis of the Greenlink, a violent juvenile offenders. J Fam Psychol. 24(5):657– partnership project managed by the Central Scotland Forest Trust (CSFT). Stirling: Greenspace Scotland.
Knapp M, McDaid D, Parsonage M (2011). Mental Helweg-Larsen K, Kruse M, Sørensen J, Brønnum- health promotion and prevention: the economic case. Hansen H (2010).The costs of violence-economic and London: Department of Health (http://www2.lse.
personal dimensions of violence against women in Denmark.Copenhagen: National Institute of Public PSSRUfeb2011.pdf, accessed 12 September 2014).
Health, University of Southern Denmark (http://www.
violence-samlet.pdf, accessed 5 September 2014).
The case for investing in public health Krameddine YI, Demarco D, Hassel R, Silverstone PH Morano R, Pérez F, Brosa M, Pérez Escolano I (2011). (2013). A novel training program for police officers that Análisis de coste-efectividad de la vacunación improves interactions with mentally ill individuals and antineumocócica en España [Cost–effectiveness is cost-effective.Front Psychiatry.4:9.
analysis of pneumococcal vaccination in Spain].Gac Leal J, Luengo-Fernandez R, Gray A, Petersen S, Rayner M (2006). Economic burden of cardiovascular disease Munro JF, Nicholl JP, Brazier JE, Davey R, Cochrane in the enlarged European Union.Eur Heart J. 27:1610– T (2004). Cost effectiveness of a community based exercise programme in over 65 year olds: cluster randomised trial. J Epidemiol Community Health.58: Luengo-Fernandez R, Leal J, Sullivan R (2012).The economic burden of malignant neoplasms in the European Union. Congress of the European Society for NICE (2010). Alcohol-use disorders: preventing harmful Medical Oncology, Vienna, Austria, 22 May.
drinking. London: National Institute for Health and Care Excellence. (NICE public health guidance 24; Mackenbach JP, Meerding WJ, Kunst AE (2011). http://www.nice.org.uk/guidance/PH24, accessed 5 Economic costs of health inequalities in the European September 2014).
Union. J Epidemiol Community Health. 65(5):412–419.
NICHSR (2014).Glossary of frequently encountered Margolis HS, Coleman PJ, Brown RE, Mast EE, Sheingold terms in health economics [website].Bethesda, MD: SH, Arevalo JA (1995). Prevention of hepatitis B virus National Information Center on Health Services transmission by immunization: an economic analysis of Research and Health Care Technology (http://www.nlm.
current recommendations. JAMA 274(15):1201–1208.
14 September 2014).
McCrone P, Dhanasiri S, Patel A, Knapp M, Lawton- Smith S (2008). Paying the price: the cost of mental Nixon J, Parr S, Sanderson D (2006). Anti-social health care in England to 2026. London: The King's behaviour intensive family support projects: an evaluation of six pioneering projects. London: Department for Communities and Local Government.
Merkur S, Sassi F, McDaid D (2013). Promoting health, preventing disease: is there an economic case? Norman R, Spencer A, Eldridge S,FederG (2010). Cost– Copenhagen: WHO Regional Office for Europe (http:// effectiveness of a programme to detect and provide better care for female victims of intimate partner violence. J Health Serv Res Policy. 15(3):143–149.
accessed 4 September 2014).
Nurse J, BasherD, Bone A, Bird W(2010). An ecological approach to promoting population mental health and Mihalopoulos C, Vos T, Pirkis J, Carter R (2012). The well-being–a response to the challenge of climate population cost–effectiveness of interventions change. Perspect Public Health. 130(1):27–33.
designed to prevent childhood depression. Pediatrics. Oddsson K, JohannssonJ., Mladovsky P, Srivastava D, Cylus J, Karanikolos M, of human papilloma virus vaccination in Iceland. Evetovits T, Thomson S et al. (2012). Health policy ActaObstetGynecol Scand. 88(12):1411–1416.
responses to the financial crisis in Europe. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.
OECD (2006). Future budget pressures arising from spending on health and long-term care. OECD Economic Outlook 79:145–156 (http://www.oecd.org/ the-financial-crisis-in-europe, accessed 4 September htm, accessed 4 September 2014).
The case for investing in public health Oldridge NB (2008). Economic burden of physical PMS Unit (2004). Alcohol harm reduction strategy for inactivity: healthcare costs associated with England. London: Prime Minister's Strategy Unit (http:// cardiovascular disease. Eur J CardiovascPrevRehabil. alcohol_misuse.aspx, accessed 5 September 2014).
Orton LC, Lloyd-Williams F, Taylor-Robinson DC, Moonan M, O'Flaherty M, Capewell S (2011). Prioritising PSI (2014). The best buys survey: where to invest in public health: a qualitative study of decision making to global health in 2014. Washington, DC: PSI (http:// reduce health inequalities. BMC Public Health.11:821.
psiimpact.com/the-best-buys-survey/, accessed 5 September 2014).
Pacyna JM, Sundseth K, Pacyna EG, Munthe J, Åström S, Panasiuk D (2008). Socio-economic costs of continuing Puska P, Vartiainen E, Laatikainen T, Jousilahti P, Paavola the status-quo of mercury pollution. Copenhagen: M, editors (2009). The North Karelia Project: from North Nordic Council of Ministers, 2008 (http://www.norden.
Karelia to national action. Helsinki: National Institute for Health and Welfare (http://www.thl.fi/thl-client/ 5 September 2014).
accessed 4 September 2014).
Perez K, Mari-Dell'Olmo M, Tobias A,BorrellC (2007). Reducing road traffic injuries: effectiveness of speed Racioppi F, Eriksson L, Tingvall C, Villaveces A (2004). cameras in an urban setting.Am J Public Health. Preventing road traffic injury: a public health perspective for Europe. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/en/ Petrou S, Cooper P, Murray L, Davidson LL (2006). Cost– effectiveness of a preventive counseling and support a-public-health-perspective-for-europe, accessed 4 package for postnatal depression. Int J Technol Assess September 2014).
Health Care. 22(4):443–453.
Reeves A, BasuS, McKeeM, MeissnerC,StucklerD(2013). Phillips C J, Humphreys I, Kendrick D, Stewart J, Hayes Does investment in the health sector promote or M, Nish L et al.(2011). Preventing bath water scalds: inhibit economic growth? Global Health. 9: 43.
a cost–effectiveness analysis of introducing bath thermostatic mixer valves in social housing. InjPrev Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J (2009). Global burden of disease and injury and economic cost attributable Pichery C, Bellanger M, Zmirou-Navier D, Glorennec to alcohol use and alcohol-use disorders. Lancet. P, Hartemann P, Grandjean P (2011). Childhood lead exposure in France: benefit estimation and partial cost– benefit analysis of lead hazard control. Environ Health. Sachs JD (2012). Achieving universal health coverage in low-income settings. Lancet 380(9845):944–947.
Pitkala KH, Routasalo P, Kautianinen H, Tilvis RS (2009). Sassi F. (2010). Fighting down obesity. OECD Observer. Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, accessed 5 September 2014).
controlled trial. J Gerontol A BiolSci Med Sci. Savedoff WD, de FerrantiD, Smith AL, Fan V (2012). Political and economic aspects of the transition to Pitt M (2008). The Pitt Review – learning lessons universal health coverage. Lancet. 380(9845):924–932.
from the 2007 summer flood. London: The Cabinet Schuetz CA, AlperinP, GudaS, van HerickA, CariouB, EddyD et al. (2013). A standardized vascular disease uk/pittreview/thepittreview/final_report.html, accessed health check in Europe: a cost–effectiveness analysis.
12 Sepcember 2014).
PLoS One. 8(7):e66454.
The case for investing in public health Scuffham PA, West PA (2002). Economic evaluation of Van't Veer-Tazelaar P, Smit F, van Hout H, van Oppen strategies for the control and management of influenza P, van der Horst H, Beekman A et al.(2010). Cost– in Europe. Vaccine. 20(19–20):2562–2578.
effectiveness of a stepped care intervention to prevent depression and anxiety in late life: randomized trial. Br J Shafey O, Eriksen M, Ross H, MacKay J (2009). The Tobacco Atlas, 3rd edition. Atlanta, GA: American Cancer Society, 2009, p. 42.
Viscusi WK, Hersch J (2008). The mortality cost to smokers. J Health Econ. 27(4):943–958.
Shafi S, Parks J,GentilelloL (2008). Cost benefits of reduction in motor vehicle injuries with a nationwide Voelker R (1999). Fighting the flu. JAMA. 281(2):123.
speed limit of 65 miles per hour (mph). J Trauma. Walsh JL, Senn TE, Carey MP (2013). Longitudinal associations between health behaviors and mental Stark CG (2006).The economic burden of cancer in health in low-income adults. TranslBehav Med. Europe.Eur J Hosp Pharm SciPract. 12:53–56.
Suhrcke M, Pillas D, Selai C (2007). Economic aspects Wang PS, Simon GE, Avorn J, Azocar F, Ludman of mental health in children and adolescents. EJ, McCulloch J et al. (2007). Telephone screening, Copenhagen: WHO Regional Office for Europe (http:// outreach, and care management for depressed workers and impact on clinical and work productivity outcomes. accessed 5 September 2014).
Wanless D (2002). Securing our future health: taking a long-term view. London: The Public Enquiry Unit, HM Toloo GS, Fitzgerald G, Aitken P, VerrallK, Tong S (2013).
Are heat warning systems effective? Environ Health. 12: files/images/Wanless.pdf, accessed 5 September 2014).
WHO (2003).WHO Framework Convention on Tobacco Trasande L, Landrigan P J, Schechter C (2005). Public Control. Geneva: World Health Organization (http:// health and economic consequences of methyl mercury www.who.int/fctc/text_download/en/, accessed 12 toxicity to the developing brain. Environ Health September 2014).
WHO (2011a).From burden to "best buys": reducing Trust for Public Land (2008). How much value does the economic impact of non-communicable diseases the city of Philadelphia receive from its park and in low- and middle-income countries. Geneva: World recreation system? Philadelphia: Trust for Public Land Economic Forum (http://apps.who.int/medicinedocs/ and Philadelphia Parks Alliance (http://cloud.tpl.org/ en/d/Js18804en/, accessed 2 September 2014).
pubs/ccpe_PhilaParkValueReport.pdf, accessed 12 September 2014).
WHO (2011b).First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease TU Dresden (2012). The true costs of automobility: Control (Moscow, 28–29 April 2011): discussion external costs of cars: overview on existing estimates paper: prevention and control of NCDs: priorities for in EU-27. Dresden: Technische Universität Dresden investment. Geneva: World Health Organization (http:// prevent_ncds.pdf, accessed 29September 2014).
accessed 12 March 2013).
WHO (2012a).Health 2020: the European policy for University of Oxford (2009).Smoking costs NHS health and well-being [website]. Copenhagen: WHO over £5 billion a year [website].Oxford: University Regional Office for Europe (http://www.euro.who.
of Oxford (http://www.ox.ac.uk/media/news_ stories/2009/090609_1.html, accessed 5 September european-policy-for-health-and-well-being, accessed 4 September 2014).
The case for investing in public health WHO (2012b).European Action Plan for Strengthening WHO (2014b).Health statistics and information systems Public Health Capacities and Services.Copenhagen: [website].Geneva: World Health Organization (http:// WHO Regional Office for Europe (http://www.euro.who.
metrics_daly/en/, accessed 29 September 2014).
Windle G, Hughes D, Linck P, Russell I, MorganR,Woods accessed 4 September 2014).
R et al. (2008). Public health interventions to promote mental well-being in people aged 65 and over: WHO (2013a).Oslo conference on health systems and a systematic review of effectiveness and cost– the economic crisis [website]. Copenhagen: WHO effectiveness. London: National Institute for Health and Regional Office for Europe (http://www.euro.who.
Care Excellence (http://www.nice.org.uk/guidance/ crisis, accessed 2 September 2014).
accessed 12 September 2014).
WHO (2013b).Seven key reasons why immunization Withrow D, Alter DA (2011). The economic burden of must remain a priority.Copenhagen: WHO Regional obesity worldwide: a systematic review of the direct Office for Europe (http://www.euro.who.int/en/health- costs of obesity. Obes Rev. 12(2):131–141.
Wright A, Lloyd-Davies A, Williams S, Ellis R, Strike P accessed 12 September 2014).
(2005). Individual active treatment combined with group exercise for acute and subacute low back pain. WHO (2013c).Health impact assessment: glossary of terms used [website]. Geneva: World Health Zechmeister I, Blasio BF, Garnett G, Neilson AR, index1.html, accessed 14 September 2014).
Siebert U (2009).Cost–effectiveness analysis of human papillomavirus-vaccination programs to prevent WHO (2014a).Global health expenditure database cervical cancer in Austria. Vaccine. 27(37):5133–5141.
[online database]. Geneva: World Health Organization accessed 4 September 2014).
The case for investing in public health 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 for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.
Assuring sustainable organizational structures and financing The 10 Essential Public Health Operations (EPHOs) 2012 1. Surveillance of population health and well-being
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Assuring a sufficient and competent public health workforce 8. Assuring sustainable organizational structures and financing
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Implications of the Varying Permeability Model for Reverse Dive Profiles Department of Physics and Astronomy University of Hawaii Honolulu, Hawaii 96822 561 Keystone Ave. Reno, Nevada 89503 Comprehensive Design Architects/Engineers 3054 Enterprise Drive State College, Pennsylvania 16801 Presented at the

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FULL PAPER International Journal of Recent Trends in Engineering, Vol 2, No. 1, November 2009 EVISTA – Interactive Visual Clustering System K. Thangavel1, P. Alagambigai2 1 Department of Computer Science, Periyar University, Salem, Tamilnadu, India Email: drktvelu@yahoo.com 2 Department of Computer Applications, Easwari Engineering College, Chennai, Tamilnadu, India