The case for putting health promotion first

Now should be a good time to live in an industrialised country. Life expectancy is high. Medical advances will continue to lead to new cures and earlier detection. New drugs will alleviate symptoms more effectively than before.

But many of these innovations in "health" are actually expensive cures. A recent Productivity Commission report found that "over the next 40 years, total expenditure on health care is projected to increase from just under 10 per cent of GDP to between 16 and 20 per cent". All industrialised countries are now grappling with soaring health care budgets.

Prevention from sickness in the first place is one obvious way to try and reduce burgeoning health care budgets. Governments in the UK, Switzerland and Germany are examining the economic cost of how much health care costs and the role of prevention. Interestingly, this work has been led in the UK by the Treasury rather than the Department of Health. Sir Derek Wanless, the author of a major review of health spending in the UK published in 2002, suggested three different scenarios for future spending in health, with the most cost-effective - the so-called "fully engaged" scenario - relying on more investment in public health. This was not the recommendation of a group of well-meaning health promotion activists, but the ex-chief of one of the UK’s biggest banks backed by the clout of Treasury.

What prompted the UK Treasury to take an interest in promoting health? When Labour came to power in 1997 it inherited a record number of patients waiting for treatment and a health service which was significantly under-funded in comparison to other European countries. The Chancellor, Gordon Brown, wanted to improve the quality of the NHS and the overall health of the UK population, but the UK press didn’t nickname him "prudence" for nothing because he also wanted to know how much this would cost.

Prevention versus cure: where are we now?

Australian Treasurer Peter Costello is yet to set up a similar investigation although the Productivity Commission has called for a review of the health care system. The need for it is clear. In the 10 years to 2002-03 the health care budget increased by almost 70 per cent in real terms. Australia has more hospital beds per person than other similar countries - about 50 per cent above Canada’s rate, for example, and some states spend almost 70 per cent of their state health expenditure in hospitals.

Yet the OECD - which includes Australia, European countries, Canada, the US and Japan - has estimated 40 to 50 per cent of premature deaths result from preventable behaviours (for example, excess drinking). On average, only 2.8 per cent of total health spending by OECD countries is allocated to public and private health prevention programs. According to the Australian Institute of Health and Welfare, less than 2 per cent of all health expenditure in this country is directed to public health.

There are good reasons for increasing spending on public health. Take obesity. A UK parliamentary report suggests children, for the first time in a century, may have a reduced life expectancy compared with their parents because of obesity. Apart from the inconvenience to individuals of living with related illnesses like diabetes, the report estimates the annual cost of obesity to the UK will be about $AU8-9 billion.

Professor Jay Olshansky from the University of Illinois forecasts life expectancy in the US will decline in the next 50 years as a result of the "obesity epidemic that will creep through all ages like a human tsunami". Director of Public Health in Victoria, Robert Hall, says we already have an obesity "epidemic". Why people are getting fatter is a complex issue, involving everything from the design of our cities through to the food we eat. It might be easier to change nothing and simply treat people as they become obese - but even the most generously funded healthcare system will struggle to cope with an epidemic.

Putting health first: what would it look like?

High-quality hospitals and treatment will always be a fundamental part of any health care system but these facilities are just one part of the overall system. Governments always have to make decisions about how to ration money and there is a strong argument for exploring how much taxpayers’ money could be saved through more emphasis on preventing illness. For example, in Australia the total economic benefit of money spent reducing tobacco use exceeds the capital outlay by at least 50:1. As the current National Tobacco Strategy makes clear: "It is difficult to imagine any other public expenditure providing social returns of this magnitude."

It is difficult for people to automatically make healthy choices when there is a mismatch between the money spent on advertising for potentially unhealthy products versus health-promoting behaviour. People need to be informed to be able to make healthy choices. Ilona Kickbusch, former Director of Health Promotion at the World Health Organisation, argues: "Health systems and health plans are becoming more complex to navigate … every visit to the supermarket demands health choices, every decision to take the car rather than walk has health consequences … living in health and living with disease demand high health literacy."

In England, the King’s Fund is exploring a new type of "local health organisation" that would complement the existing National Health Service (NHS) but focus on "providing individuals with appropriate knowledge and expertise on how to stay well".

Gwendolyn Gray, a senior lecturer in political science at the Australian National University, describes a vision for Australia of a network of primary care centres which would provide "a comprehensive, integrated range of preventive, educational, counselling, caring and social advocacy services as well as conventional medical services".