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".

Information is important and there is a valuable role for social marketing campaigns. But, as data on health and deprivation consistently highlights, access to nutritious and affordable food, rewarding jobs, decent housing, and parks and other places where people can enjoy outdoor recreation are also fundamental to improving health. This will take more than a few punchy TV advertisements. "Health goes with wealth", and deprived areas are often without the facilities, services and jobs that make for good health.

Dr Hall argues that the capacity of individuals to lead healthy lives is determined by their socio-economic and cultural circumstances and that these must be "addressed directly". All government departments need to understand the role they have in contributing to the health and wellbeing of all of the population. There also needs to be better integration between different levels of government.

The Department of Human Services is currently working with local councils on a Health Impact Assessment developmental program to help understand the health implications of decisions made locally. VicHealth’s work on promoting the role of urban planning in improving health is another example of the cross-departmental links that can lead to governments taking action to help individuals make healthier choices.

There needs to be more evidence of "what works", both for medical treatments and public health interventions. This will be important as the proportion of public money spent on health continues to rise.

Current barriers to promoting health

The Federal Government itself acknowledges "when it comes to saving money on health, prevention can certainly be better than cure". So why is there such a mismatch in health spending? Decades of experience in trying to increase the role for promoting health points to a number of answers.

Intervention versus individual choice

Suggesting what people should eat or how they should exercise can quickly lead to accusations of a "nanny state" where individuals are pressured into living in a certain way. There is a presumption that governments have little room to manoeuvre when it comes to promoting healthy lifestyle choices.

However, research in the UK on consumer attitudes to health suggests that individuals are not concerned about being involved in decisions about health spending. Niall Dickson, Chief Executive of the King’s Fund, which carried out the research, points out that people "did not oppose government intervention and the 'nanny state' debate. What most people want is a sensitive balance between encouragement, enabling, exhortation and enforcement".

Media watch

An awkward dance happens between the media and government where both accuse the other of failing to make more progress on airing public health debates. The media sees itself as reporting what the public wants to know, while government believes it is at the mercy of a press that won’t report news that isn’t headline grabbing.

Former federal health minister Michael Wooldridge argues if there isn’t a clearly identifiable victim to a health story - "which is the case in most of public health" - then it is "very hard to get any media". Nor is the vision, so essential for television, as compelling for public health. There are no dramatic shots of doctors running along corridors and ambulance helicopters ferrying patients to hospital.

Powerful interests

Developed countries abolished many debilitating illnesses through public health measures like sanitation and medical interventions like immunisation. But now other diseases plague these affluent countries, largely as a consequence of lifestyle. The current economic system doesn’t necessarily promote a healthier lifestyle. The things that make us unhealthy and inactive (fast food and cars, for example) sell far better than those that make us active and healthy, and it’s for this reason that VicHealth CEO Rob Moodie describes obesity as a "market success".

Within this system it is the industries that are focused on curing illness, rather than promoting health, which benefit. Many of these are powerful interests that will fiercely resist changes to the present healthcare system because they could lose profits and influence.

Political cycles

Promoting health through prevention strategies takes time. Former Cancer Council Victoria director Dr Nigel Gray had to present his case for a hypothecated tax on tobacco to eight health ministers before he found one who was sympathetic. Government ministers are unlikely to even notice policies that can’t demonstrate some kind of outcome within their political lifetime.

Right isn’t always might

Professor Wooldridge argues "in many cases public health advocates feel so passionately about the correctness of their cause that they just can’t understand why others can’t see the justice of their case". Past experience of promoting public health suggests that evidence, while important, is not enough. According to Dr Moodie, the skills required in public health today are more than the traditional specialist areas such as epidemiology and sociology. "Public health advocates also need to be able to work within existing political and economic systems, and understand how decisions are made and how to influence this decision making," he says.

Promoting health in the future

Australia’s current health care system is, according to the Productivity Commission, "beset by widespread and growing problems". One commentator argues "so much of the debate is about the funding of health services through Medicare when the real problem is a health delivery system which is badly out of date".

Dr Hall believes, while the Victorian State Treasury hasn’t yet followed the path of the UK, the economic case for reviewing the allocation of health funding to prevention is "on the agenda". Dr Moodie argues it is time for public health advocates to "invade the Treasury" and to highlight the potential returns of spending more on promoting health. Otherwise, it may take a full-blown health spending crisis before the benefits of spending more on prevention and less on cure become obvious.