Strategies for health services

Quantifying the contribution of healthcare to population health

It is important to recall that healthcare has changed remarkably in a relatively short time. Many new treatments have been shown, in high-quality evaluative research, to be able to prolong life. Examples include effective treatment for hypertension and heart failure, secondary prevention following myocardial infarction and chemotherapy for many childhood cancers. There has also been, in many countries, a revolution in the approach to evidence in making treatment decisions. These changes are part of a long-term trend. Beeson (1980) showed how many treatments advocated in a 1927 edition of a major textbook of medicine were, at the time he was writing, known to be either ineffective or harmful. By the time that the 1975 edition was published there was a major shift to treatments that had been proven to be effective. However, the pace of change has accelerated during the 1980s and 1990s. There has been a much greater willingness to challenge professional judgement where it is not supported by evidence of effectiveness and to question whether clinical performance is optimal. This has led from early pioneers of the medical audit to the enormous expansion of evidence-based healthcare (see below). It encompasses a wide range of activities which together have helped to eliminate many interventions that do not work and have increased the uptake of those that are effective. Thus there is a case that if healthcare had made little contribution to population health during the period that McKeown was looking at, up to the mid-1960s, it may now be doing so. The following section asks whether this has actually happened.

Rutstein et al. (1976) asked an expert panel to identify a list of conditions from which death should not occur in the presence of timely and effective care. These deaths were deemed to be ‘preventable’ although subsequent writers have also used the terms ‘avoidable’ and ‘amenable to medical care’; and were interpreted as a measure of the quality of the healthcare system. This concept was later applied empirically by other researchers, with publication of regional atlases permitting cross-national comparisons. A seminal study by Mackenbach et al. (1988) related changes in deaths from particular causes to the time that various interventions were introduced. By doing so, they were able to show that the impacts of specific treatments were observable as accelerating falls in mortality from the conditions they were intended to treat. They concluded that the healthcare interventions they examined added 2.9 years to life expectancy at birth for men and 3.9 years for women in the Netherlands between 1950 and 1984.

More recently, Nolte and McKee (2004) undertook a systematic review of the evidence that deaths from specific causes of death could be avoided. This enabled them to update the previous lists of ‘avoidable’ causes, taking account of advances in medical knowledge and technology, while extending the upper age limit to 75 years of age. Figure 12.10.1 shows the age standardized death rates in 2003 in a range of industrialized countries.

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Fig. 12.10.1

Age-standardized death rates (0–74 years per 100 000) from conditions amenable to care (2003 or most recent year).

Source: Authors’ calculations using data from the WHO mortality database. Note: Denmark 2001, Italy, Sweden, United States 2002.

A comparison of trends over time in selected European countries showed that reductions in avoidable mortality contributed substantially to increasing life expectancy in Western European countries during the 1980s. They continued to do so during the 1990s, although by then the contribution was greater in southern European countries such as Italy and Spain, suggesting some catching up with their northern neighbours. In contrast, the then communist countries in central and eastern Europe saw little benefit from healthcare during the 1980s but this changed in the 1990s and has continued, with further substantial reductions in avoidable mortality in the first decade of the twenty-first century (Nolte et al. 2004). Finally, a comparison of Russia and the United Kingdom shows how the two countries had very similar rates of avoidable mortality in the mid-1960s, a time when there were relatively few modern pharmaceuticals available in either country. The rate in the United Kingdom then began to fall steadily while they remained steady in Russia, which during the Soviet era never managed to develop a modern pharmaceutical system and where the principles of evidence-based care were essentially unknown (Andreev et al. 2003).

Further evidence that healthcare can impact positively on population health comes from studies of particular causes of death. Beaglehole (1986) estimated that 42 per cent of the decline in deaths from cardiovascular disease in New Zealand between 1974 and 1981 could be attributed to advances in medical care. The long-term decline in mortality from coronary heart disease in the Netherlands between 1969 and 1993 accelerated significantly after 1987, coinciding with the wider availability of interventions such as coronary care units and thrombolysis (Bonneux et al. 1997).

Thus, while there is increasing evidence for a positive impact of healthcare on population health, it is also important not to dismiss Illich’s views entirely. The thalidomide scandal in the 1960s, in which what was thought to be a safe sedative was found later to cause serious limb deformities in the children of mothers who took it while pregnant, confirmed the potential for an effective drug to cause harm to susceptible individuals. Subsequently other apparently safe drugs have been shown to have caused unanticipated long-term side effects. For example, the growing burden of multi-drug resistant tuberculosis is entirely a creation of healthcare, providing a classic example of iatrogenesis. In some countries, the 1990s have seen a marked increase in the rate of resistance among hospital-acquired infections. Rates vary markedly between countries, and there is compelling evidence that they are related to the approach taken to the prescribing of antibiotics. Thus, hospitals and other healthcare facilities in which prescribing is uncontrolled and haphazard represent a threat to the wider population, and not only in the country concerned. Unfortunately, surveillance systems are often weak, even in many industrialized countries. It is easy to forget that, until the early twentieth century, one’s probability of dying was increased by coming into hospital because of the risk of infection and the growth of iatrogenic antibiotic resistance is perhaps one of the greatest challenges facing public health professionals today.

It is also important to recognize the accumulating evidence of patient harm resulting from medical errors, with one analysis suggesting this could account for as much as 44 000 deaths among Americans each year (Institute of Medicine 2000). Finally, it is salutary to recall that even well-established interventions may be ineffective or even harmful, as in the example of albumin, long given to patients with burns and multiple trauma on the basis, incorrectly, of an intuitive belief that it was likely to be beneficial (Alderson et al. 2004). In this context, it is necessary to consider the specific situation in the countries of the former Soviet Union. Its isolation from international developments during the Soviet era led to the widespread adoption of many entirely ineffective treatments based on various forms of electromagnetic and ionizing radiation, many of which remain in widespread use (McKee 2007).

Healthcare and health equity

The health impact of health services raises the important issue of equity. When healthcare had little measurable impact on health, socio-demographic inequalities in access to care may have been of little importance. Indeed, it is arguable that the wealthy, exposed at considerable personal expense to such painful and ineffective treatments as cupping and bleeding were actually disadvantaged compared with the poor who patiently waited for the inevitable death spared such indignities. The present situation is quite different. If healthcare does contribute materially to population health, then lack of access to it will exacerbate health inequalities (Arblaster et al. 1996).

There is considerable evidence from many countries that such inequalities exist and that they have an impact on health. This is intuitive in healthcare systems where there is not universal access to care, such as the United States. For example, American research has found that people living in deprived areas with poor access to care have high rates of hospital admission with chronic medical conditions, such as asthma, heart failure, and diabetes that, if detected and treated early should not require admission to hospital (Billings et al. 1996). Death rates from many chronic disorders responsive to healthcare are very much higher among African Americans than white Americans (Kunitz & Pesis-Katz 2005), with similar differences in survival from many cancers, reflecting both later presentation (itself a reflection of access to primary care) and lower rates on intervention once a diagnosis has been made (Morris et al. 2006).

Inequalities are, however, also seen in countries offering universal coverage. In the United Kingdom, women, people from minority ethnic populations, older people, and those living in deprived areas are all disadvantaged in access to surgical interventions for coronary artery disease.

Differential access is a factor in the observation that social class gradients are substantially greater for causes amenable to medical care than other causes of death (Marshall et al. 1993).

Inequitable access to care can disadvantage many groups of people other than those listed above (Healy & McKee 2004). Thus, those living in rural areas may be disadvantaged unless specific measures are taken to ensure their access to care. This will often require innovative delivery models, taking advantage of technological developments such as near-patient testing and telemedicine to compensate for the increasing pressure to centralize facilities. Prisoners in many countries receive poor quality care, while disabled people may face structural obstacles in accessing health facilities and obtaining services. At a global level there are enormous inequalities in access to basic, but essential, treatments such as immunization and life-sustaining drugs such as anti-retrovirals and insulin.

This section has highlighted how, unlike the situation prior to the 1970s, healthcare can make a substantial difference to population health. However, as the World Health Organization noted in the Ottawa Charter (World Health Organization 1986), health services are only one of the determinants of health, others being genetic predisposition, individual behaviour and lifestyle, and environmental circumstances (Lalonde 1974), whose importance are recognized in the creation by the World Health Organization, in March 2005, of a Commission on Social Determinants of Health.

Public health professionals must look at the wider picture and take into account these other determinants but it is important that, in taking a broad perspective, they do not lose sight of the contribution that healthcare can make to population health, ensuring that what care is provided is effective and is provided equitably. The remainder of this chapter explores the changing nature of health services, the impact that various policies have, and the role that public health professionals can play in maximizing the health gain that health services can provide.

Macroeconomic factors

Health systems are influenced strongly by their economic environments. One is the nature of the market within which resources are procured. In general, the costs of some inputs into health services have tended to reflect local market conditions, such as salaries for healthcare professionals. Others, such as pharmaceuticals and technology, have tended to reflect world market prices although, in practice, the situation is not quite so simple. Thus, the cost of employing health professionals will reflect the market within which they function. Those in countries where few speak one of the major international languages may still be operating in what is essentially a national market, allowing salaries to remain low. Conversely, where most speak a language such as English, French, or Spanish, health workers operate increasingly in a global market, so that healthcare providers must pay high salaries if they are to retain them. The inability to do so has contributed to the emigration of vast numbers of health professionals from low-income countries. In the case of pharmaceuticals, the price paid in a low-income country may actually be several times higher than in a developed one because of the fragmentation of the purchasing function and multiple mark-ups along the supply chain (Mossialos et al. 2004). The different costs of inputs will shape the pattern of care that is provided.

A second consideration relates to the resources available for healthcare. There are two issues to be considered. The first is the overall state of the economy. The second is the share of the economy devoted to health.

Clearly, the healthcare system is likely to come under pressure during an economic crisis. Examples include events in some Latin American countries in the 1980s and 1990s, in the countries of the former Soviet Union in the years following 1991 or, in many low-income countries, in the face of externally imposed structural adjustment policies. The effects may be seen in death rates from treatable conditions. Thus, deaths from diabetes among young people increased many times in the former Soviet Union during the early 1990s (Telishevka et al. 2001) while child mortality has increased in countries facing structural adjustment.

These circumstances are, however, unusual and economic swings are typically much less severe. Yet, they still impact on the health system. An economic downturn, especially where it leads to long-term unemployment, will increase demand for many elements of healthcare at a time when financial resources are scarce, although, paradoxically, death rates from cardiovascular disease, traffic injuries, and cirrhosis increase during an economic boom.

The share of the economy devoted to healthcare is, inevitably, the result of the interplay between market forces and political choices. Regardless of the funding system in place, governments in all industrialized and middle-income countries play an important role in determining how much will be spent. This is easiest in countries where healthcare is financed from taxation but governments in countries with social insurance systems are usually partners to negotiations on contribution levels, salaries, or pharmaceutical prices, simply because of the important macroeconomic implications. Even in a country such as the United States, where the role of the government in healthcare is often considered to be minimal, almost 50 per cent of the population have their healthcare paid from government funds.

The way in which healthcare expenditure is viewed has changed over the past decade. During the 1980s and 1990s it was often regarded as a drain on the economy, with high social costs damaging national competitiveness. In particular, the cost of healthcare was sometimes cited as a reason for trans-national corporations to relocate production in a country where the costs were less (Stephens et al. 1999). This was exacerbated in some places by specific factors. In the mid-1990s, the countries of Southeast Asia suffered a major economic crisis. However, countries responded in different ways, providing a valuable natural public health experiment. Thailand and Indonesia followed advice from the World Bank to cut back on public expenditure while Malaysia did not (Hopkins 2006). There was a short- lived but detectable increase in mortality in the first two countries but not in Malaysia, highlighting the importance of maintaining social safety nets at times of economic crisis.

More recently, there are signs of a change of direction in the prevalent thinking. Research, initially in low-income countries (World Health Organization and Commission on Macroeconomics and Health 2001), but later confirmed in high-income countries (Suhrcke et al. 2006), has highlighted the contribution of good health to economic growth, with better health leading to greater wages, higher labour force participation, higher savings, and greater investment in one’s own education.

Historical improvements in health and nutrition have contributed substantially to the favourable economic status of today’s advanced industrialized countries (Fogel 1994). People who are healthy are more likely to remain in the workforce, where they are more productive. They are likely to save more, increasing the resources available for capital investment, and to invest in their own skills. Furthermore, there is a growing recognition that investment in timely care can reduce the frequency of complications, which are much more expensive to treat (Billings et al. 1996). One example of this new thinking is the Wanless Report (Wanless 2001), commissioned by the United Kingdom Treasury. This report showed how investment in better health now would lead to a substantial reduction in expenditure in the future.

While, in most cases, public health professionals must work within the constraints imposed by the macroeconomic context in which they find themselves, they also have a major role, as advocates for the public’s health, in shaping the debate, arguing for sustained investment in health on the basis of its contribution to future economic growth.

Norms and beliefs

A second set of factors driving change in healthcare systems relate to the underlying norms and beliefs of the society within which the system is embedded (Contandriopoulos et al. 1998). Healthcare systems act as mirrors reflecting deeply rooted social and cultural expectations of the population that they serve. Although these norms and beliefs are generated outside the formal structure of the healthcare system, they play a major role in defining the system’s overall characteristics.

The impact of different norms and beliefs is apparent when comparing the United States, where healthcare is generally seen as a commodity to be bought and sold, and Europe, where healthcare is seen predominantly as a social or collective good, in which citizens benefit when an individual receives effective care (McKee 2002).

Societies thus have dominant belief systems (Benson 1975). This does not imply that a single view is held by all members of that society; rather, the tension and negotiation that exist between various beliefs and values have some stability. A useful approach to understanding belief systems sees these tensions as grouped around four poles (Habermas 1987): Values, understanding of phenomena, definition of jurisdictions and allocation of resources, and logic of regulation. Values include tensions and trade-offs between equity, individual autonomy, and efficiency (Clark 1998). Understanding of phenomena relates to how concepts such as life, death, sickness, health, and pain are interpreted and thus viewed as relating to the objectives of a healthcare (Gillett 1995). Definition of jurisdictions and allocation of resources comprise the perceptions of the role and functions of those responsible for and working in the healthcare sector, as well as the allocation of resources between prevention and cure and between healthcare and broader determinants of health. The logic of regulation relates to how society chooses to regulate the delivery of healthcare (Contandriopoulos et al. 1998). This may be technocratic, with trained experts guiding the system on the basis of their knowledge and position within the hierarchy; professional self-regulatory, which has the physician, as the best agent of the patient, at the centre of the system; the market-based model, in which regulations reflect supply and demand in a competitive market; or the democratic model, in which the population, either directly or, more often, through elected or appointed representatives, is responsible for setting out the framework for delivery of healthcare.

Although dominant belief systems have some stability, they are in a state of constant tension as different classes and groups within society struggle for ascendancy, a phenomenon most clearly seen in the fluctuating electoral success of political parties. In some societies, the process of change will be evolutionary and incremental. In others, as exemplified by the countries in Central and Eastern Europe after the collapse of communism, it will be abrupt. An understanding of the dominant belief system in a society is important for public health professionals as it contributes to knowledge of why systems are as they are, how they have changed, and the objectives that individuals within the healthcare system are pursuing. It will also influence the choice of strategies that should be adopted to bring about change.

Changing burden of disease

Although it would be naive to think that the health needs of the population are the only factor driving the configuration of health services, they do play an important role. For example, the creation of public health services in many industrialized countries was a direct result of the global epidemics of cholera in the mid-nineteenth centuries. Recognition of the infectious nature of tuberculosis led, somewhat controversially, to the creation of sanatoria in rural areas. As the need for surgery for tuberculosis declined, thoracic surgeons turned first to undertaking mitral valvotomies for rheumatic heart disease, and then to more advanced forms of cardiac surgery, explaining why some world-famous cardiac surgical hospitals are currently situated on their own in open countryside. More recently, the discovery of the agent responsible for hepatitis B and, especially, the emergence of the HIV virus, have both had significant implications for the organization of systems designed to reduce cross-infection in healthcare facilities, and in the latter case, the approaches taken to issues of patient consent and confidentiality.

The burden of disease worldwide is dynamic (Mathers & Loncar 2006). One factor is the changing age structure of the population. In many populations, the number of old people, and especially the very old, is increasing. This is something to be celebrated, especially as there is growing evidence that it is associated with compression of morbidity, so that people are living even longer in good health. Yet, when coupled with the ability to maintain people with chronic diseases in good health, this is leading to a situation wherein there are many more people with multiple chronic diseases (McKee & Nolte 2004). This will be perhaps the greatest challenge to health systems in the twenty-first century. Yet traditionally, health services have been based on a model of individual self-limiting illnesses in which a patient is attended to by a single health professional. This model is inappropriate in a situation where a patient must navigate a complex maze of health facilities and health professionals. In such circumstances, the patient (or his or her carer, where the patient has cognitive impairment) may be the only person who has a comprehensive view of the total package of care.

Recognition of these challenges has led to the development of new models of care, especially in the United States where, as already noted, outcomes of chronic disease are poor. One of the best known, the Chronic Care Model, illustrates many of the issues related to these new models of care (Wagner et al. 1999). Most other models are variations on the same theme. The Chronic Care Model comprises four interacting system components: Self- management support, delivery system design, decision support and clinical information systems. Evaluations have linked individual components to improvements in some process or outcome measures, such as perceived quality of care, patient outcomes, pathways to care, and reduced cost (Tsai et al. 2005). However it is less clear whether this is a consequence of applying the model as a whole, or whether the same benefits can be achieved using only some of the components (Bodenheimer et al. 2002). The message to emerge from this body of work is that appropriate care for the growing number of people with multiple chronic disorders requires systems that empower patients and help them to navigate through a complex system, secure in the knowledge that the care available is co-ordinated and based on evidence of effectiveness.

There are, however, many other ways in which the burden of disease is changing that have implications for health services. To a considerable extent this reflects changing risk factors. It is increasingly likely that the epidemic of tobacco-related disease will be seen as a transient phenomenon of the twentieth and early twenty-first century, at least in industrialized countries. Other changes are a result of a general improvement in living conditions, such as the long-standing decline in stomach cancer, reflecting falling rates of infection with Helicobacter pylori in childhood. Still others are more complex. Death rates from cardiovascular disease have fallen by about 50 per cent in many industrialized countries over the past three decades, reflecting a combination of lower rates of smoking, improved diet (in part a result of global trade), and improved understanding of risk factors. Yet, not all changes are so encouraging. A combination of energy-rich diets and reduced levels of exercise are leading to a rapid increase in obesity in many countries, with an accompanying rise in the prevalence of type II diabetes. Finally, successes against some infectious diseases, such as measles, contrast with failures with others, exemplified by increasing rates of HIV infection and drug-resistant bacteria in many places.

The key message for public health professionals is that they have a central role in tracking and predicting these emerging trends, in designing mechanisms that address them, and in supporting the changes in service delivery that are required.

Upward pressure on healthcare expenditure

The debate on the future of health systems often seems to be dominated by discussion of the cost of providing care. This is an issue that is surrounded by a great deal of mythology. For example, the observation that healthcare costs increase with age is often used to support the argument that an ageing population will render the provision of universal healthcare unsustainable. However, it is now clear that age per se does not increase costs but rather proximity to death (McGrail et al. 2000). In fact, in the United States, Medicare data show that payments associated with an additional year of death fall as age at death increases (Lubitz et al. 1995) and that the most costly patients are those who die young, possibly because, for a variety of reasons, they are more intensively treated. An ageing population will, however, incur increased costs for social care, largely reflecting the effects of cognitive decline (Meerding et al. 1998). However, when looking to the future it is necessary to take account of evidence that tomorrow’s elderly population is likely to be considerably healthier than today’s, as they will have benefited from a lifetime of better nutrition and social conditions. This is known as compression of morbidity (Fries 2003). For these reasons, simplistic extrapolation of cross-sectional cost data to a future population with a longer life expectancy is flawed.

The changing composition of the population does, however, have one important consequence. In many countries ageing populations are coinciding with falling birth rates, leading to an increasing old-age dependency ratio (ratio of people 65 and over to those aged 15–64). These changes vary greatly between countries. Some countries, such as Germany and Japan, face substantial challenges while others, such as the United Kingdom, will be somewhat less affected, at least until the middle of the twenty-first century. This development, taken with the evidence of compression of morbidity noted above, is leading several countries to explore the possibility of raising the retirement age as a means of addressing what would otherwise be a shrinking share of the population in working ages. Projections indicate that a relatively small increase in retirement age, coupled with efforts to increase the participation in the workforce of people over 50, would overcome many of the anticipated problems.

Another area where there appears to be considerable misunderstanding relates to the oft-quoted statement that healthcare costs inevitably rise at a faster rate than the economy, or in economic terms, that healthcare is a luxury good. This is often linked to a view, usually implicit, that it is legitimate to restrict health expenditure because the additional expenditure is not yielding proportionate health gains. However, cost estimates are only as good as the underlying data and models used. Thus, Parkin and colleagues have shown it is possible to derive widely differing figures for the elasticity of health spending on national income in industrialized countries, depending on whether exchange rates or purchasing power parities are used and on how the model is specified (Parkin et al. 1987). Furthermore, analyses inside countries consistently indicate that healthcare is not a luxury good.

A third issue is the introduction of new pharmaceuticals and technology. The pace of change in healthcare is steadily accelerating. The growth of healthcare technology is widely held to have contributed substantially to the upward pressure on healthcare expenditure, for several reasons, although its precise contribution is controversial (Mossialos & Le Grand 1999). New technologies can be more expensive than the ones they replaced. Even where the actual technology is less expensive, it may lead to increased costs as other aspects of the service are reorganized to reflect changing patterns of treatment. The introduction of new treatments may lead to an expansion in the number of individuals with indications for treatment, either because a previously untreatable condition becomes treatable or, as side-effects or contraindications are reduced, the threshold for treatment falls. Finally, the diffusion of technology from tertiary centres, in some cases into primary care, can markedly reduce barriers to access and thus increase uptake. In response to the increasing use of expensive new technologies, many countries have established health technology assessment programmes and related systems to control introduction and diffusion. One example is the United Kingdom’s National Institute for Health and Clinical Excellence, which looks beyond specific technologies to evaluate a wide range of health interventions. It assesses evidence of cost-effectiveness, typically recommending the adoption of interventions where the cost of an additional quality-adjusted life year gained is under about £30 000 (E44 000). It also identifies gaps in the available research. While some of its decisions not to recommend interventions or products have attracted considerable controversy, it has also been credited with increasing the uptake of innovations of proven effectiveness.

Fourth, consumers have increased their expectations about the services provided by the healthcare system, in some cases encouraged by governments. As noted above, the development of new and more expensive technologies coupled with the increased access to information via the Internet have led people to demand a wider range of services of high quality from healthcare providers, an issue dealt with in more detail below.

Each of these issues has implications for public health professionals. Public health professionals must contribute to the process of anticipating future health needs. This requires an understanding of the relationship over time between a change in exposure and its corresponding outcome. This may be very short, as was seen following the collapse of the USSR where rapid fluctuations in mortality were driven by large-scale changes in alcohol consumption (Shkolnikov et al. 2001). In contrast, there is a delay of many years between an increase in smoking in a population and the development of many tobacco-related diseases. It is, however, important to recognize that relationships may be asymmetrical, with reductions in exposure leading to rapid declines in disease or death.

Public health professionals must also contribute to discussions on how health services can be reconfigured to meet the increasingly complex needs of the elderly population with multiple disease processes, as well as how to invest effectively in prevention so as to extend the years that people live in good health. Discussions about new health technology require inputs from public health professionals, drawing on skills such as epidemiology and economics, to assess appropriateness and cost-effectiveness. However, it is also important to stress that attention to these issues may lead to a conclusion that there is a need for greater expenditure on healthcare, as was the case in the United Kingdom, where the Wanless Report demonstrated how the National Health Service was underperforming because of long-term underinvestment (Wanless 2001).

The quest for enhanced quality of care

Research undertaken in the 1970s and 1980s drew attention to widespread geographical variations in the use of common procedures (McPherson 1989) and led to a questioning of clinical judgements about the appropriateness of healthcare interventions. The International Cochrane Collaboration has played a major part in this process by highlighting the extent to which much care that was provided was ineffective, while effective interventions were not adopted widely (Chalmers & Altman 1995). Similar findings have emerged from the health technology assessment activities discussed above. More recently, there has been growing attention to patient safety, in the light of research showing unacceptably high levels of patient injury and death due to clinical errors (Institute of Medicine 2000).

These developments reflect a change in dominant belief systems, challenging traditional models based on clinical autonomy. They are contributing to a range of changes in healthcare systems that include not only the elimination of ineffective treatments and adoption of effective ones but also new organizational structures to bring about change. Again, public health professionals have key roles to play because of their skills in healthcare evaluation and the management of change. Strategies to ensure quality of care are discussed in more detail below.

The information society

The 1980s and 1990s have seen an unparalleled revolution in the pace and volume of communication. This brings both challenges and opportunities for health systems, discussed in more detail in Chapter 5.3 (Web-based public health information dissemination and evaluation).

Tackling scarcity of resources

Upward pressures on healthcare costs in the face of limited resources confront governments with two interconnected options. One is to increase the resources for healthcare by shifting funds from other areas of public sector expenditure or by increasing taxation, social insurance contributions, or direct payments. The second is to seek to control healthcare expenditure by pursuing strategies that influence either the demand for or the supply of healthcare. Strategies that act on supply of health services include reducing the number of healthcare professionals or facilities, setting global budgets for providers, giving professionals incentives to reduce the amount of care provided, and reducing access to care (Abel-Smith et al. 1995).

Strategies acting on demand include priority setting to ration access to certain services, the use of cost-sharing, incentives to encourage greater private expenditure, such as tax concessions, and the right to opt out of the statutory system.

Each of these measures seeks to reduce demand by shifting some portion of healthcare costs to the individual. They have all been discussed elsewhere (Mossialos & Le Grand 1999) and here only one approach, that of setting priorities, is considered as it is the one in which public health professionals have played the greatest role.

During the 1990s, many countries addressed the issue of explicit rationing of publicly funded healthcare. The debate has been lengthy and complex, with many different views. Perhaps the only issue where there is a degree of unanimity is that, in all healthcare systems, some form of rationing has always taken place although, in most cases, this was implicit, inextricably linked to clinical judgement. Beyond this, the consensus breaks down as illustrated by the situation in the United Kingdom where there was fundamental disagreement between politicians and others about even the choice of the terms ‘rationing’ or ‘priority setting’ as a means of describing the process.

In this debate, some commentators have argued that rationing should not be necessary if either sufficient funding was made available typically by redirecting it from other areas of public expenditure or raising taxes or by ensuring that available resources are used more efficiently. However, others have argued that the continuing upward pressure on healthcare costs has made explicit rationing of effective care necessary. For these commentators, the key issue is transparency.

Concerns about the affordability of healthcare have led, in several countries, to initiatives that examine priority setting on a more systematic and explicit basis. These processes have brought together a wide range of individuals, including public health professionals, managers, politicians, economists and philosophers.

Explicit setting of priorities involves making decisions at different levels within the healthcare system, ranging from the overall funders of healthcare to the treatments available to individual patients. If explicit priority setting is to be undertaken, a co-ordinated, strategic approach is most effective to integrate decision-making at these different levels.

Decisions may lead to blanket exclusions of intervention, or of condition–intervention combinations, as in the approach taken in Oregon in the United States, or production of guidelines, such as those developed by the National Institute of Health and Clinical Excellence in the United Kingdom. The experience of Oregon was especially interesting because of the technical and ethical issues it raised (Oregon Health Services Commission 1991). It was designed to create a list of condition intervention pairs, ranked on the basis of cost-benefit, with a cut-off point based on available resources below which combinations would not be funded. The idea was that this would maximize the return on resources invested in healthcare. However, the process was extremely problematic when it became clear that many of the data required were unavailable and some results were quite counterintuitive—for example, appendectomy was rated lower than cosmetic dentistry.

An alternative approach was used in the Netherlands. There the Dunning Committee (Dunning 1992) proposed four criteria that an intervention to be funded from social health insurance should meet. These were necessity, effectiveness, efficiency, and whether treating the condition should be a matter of individual rather than community responsibility. As a result of this process, it was recommended that services such as dentistry for adults, homeopathic treatment, in vitro fertilization and physiotherapy for sports injuries should be excluded.

This debate has created a recognition that the priority-setting process must include government, providers, the public and patients, as well as evidence on health needs and on the cost and effectiveness of available interventions (Ham 1993). Priority setting cannot be reduced to a technical exercise and should be combined with a thorough public debate about the values underpinning the choices to be made. This is seen in the approach taken in Sweden (McKee & Figueras 1996), which focused on the need to reach a shared view of the ethical basis on which priorities should be set. This rejected a narrow economic approach and gave priority to the treatment of life-threatening conditions. It also emphasized the importance of social solidarity.

Ultimately, while public health professionals have an important role in providing the evidence on which any debate on priority setting must be based and on examining the consequences of any decisions for equity, priority setting in a publicly funded system is the responsibility of politicians. Decision-making inevitably involves trade-offs between objectives as a balance is sought among universal coverage, comprehensiveness of services, equity, efficiency, cost-containment, and broader social values. However, it is also important to note that, despite enormous efforts being devoted to the setting of priorities, it has been extremely difficult for any health system ostensibly providing universal coverage to exclude any treatments except for a few on the margin, such as cosmetic surgery.

Equitable funding of health systems

Whitehead (1988) has shown how access to services is a key element of strategies designed to reduce health inequalities. Throughout the twentieth century the steady expansion of coverage in many countries has served to improve access to healthcare for those in greatest need, based on the principle of solidarity, in which individual financial contributions are related to ability to pay and are not dependent on the individual’s health status.

At present, however, certain developments threaten to undermine the principle of solidarity. One is the pressure from advocates of market-based policies to establish competition among healthcare insurers. A second is the development of information technology and, increasingly, the use of genetic profiling, enabling individual risks to be predicted more accurately and permitting exclusion or higher premiums for those at greatest risk, although this is raising enormous technical and ethical issues. A third is the failure, by some governments, to collect sufficient taxes or social insurance contributions from the wealthy to fund the system. This has several causes. One is a neo-liberal agenda that argues that, for countries to attract inward investment and employment, they must reduce taxes. A second cause, which is especially problematic in, but not exclusive to, low- and middle-income countries, is widespread tax avoidance by the wealthy.

Each of these issues has important implications for equity and thus for public health professionals. The third is beyond the scope of this chapter, but the first and second, which are linked in that competitive insurers have a strong incentive to identify the risks attached to those they accept, are relevant as public health professionals may have to work with such competitive systems.

Competition between health insurers (whether private or public) tends to erode solidarity in healthcare financing, since health insurers seek to select good risks. In the absence of regulation, older people and those with pre-existing illness or even a strong family history of illness are either excluded from coverage or charged higher premiums. As noted above, advances in information technology and genetics are making this ever easier, although this is raising enormous ethical issues. For example, should an insurer be permitted to know an individual’s genotype?

Two responses are open to policy-makers. One is mandatory open enrolment, so that insurers are unable to refuse coverage to an individual. This is typically linked to regulation of the level of contributions, such as community ratings. The second is the use of risk-adjustment schemes that redistribute the health insurance system’s revenue among competing health insurers on the basis of the risk profile of those enrolling with each insurer.

While these responses might work in theory, they are much more problematic in practice. Apparently open enrolment can be distorted in many subtle ways by targeting promotional activities or manipulating access so that insurers tend to ‘cream skim’. Risk pooling requires development of valid formulas, which have proved elusive, with several systems relying purely on crude measures such as age.

If politicians choose to introduce competitive markets in healthcare financing, despite a widespread consensus from health economists and others that such initiatives are fraught with danger, public health professionals have an important role in monitoring and responding to any effects on equity. Maintaining solidarity in healthcare financing while introducing competition among insurers is an ambitious and difficult undertaking. The ‘safety-net’ for solidarity has to be designed very carefully, and such an undertaking requires experienced supervision of healthcare markets. Moreover, several crucial questions have not yet been answered. Whether competition among insurers really leads to more efficient and more effective healthcare has yet to be demonstrated (Chinitz et al. 1998), not least because of the need for expensive regulatory and risk adjustment systems, as has the question of whether mechanisms seeking to combine solidarity with competition can succeed.

Optimal allocation of resources

Upward pressure on costs and an increasing willingness of politicians, managers and the public to challenge established patterns of care have placed an increased emphasis on the optimal allocation of scarce healthcare resources. Several interconnected strategies are available to health policy-makers. These include ensuring that the health services provided reflect the health needs of the population that they serve, enhance the efficiency with which services are delivered, and control the cost of key inputs such as pharmaceuticals and technology. Public health professionals can play an important role in both the assessment of health needs and, increasingly, in the process of intelligent purchasing of healthcare so as to maximize health gain for a given set of inputs.

Efficient and effective service delivery

The increasing use of intelligent purchasing is focusing the attention of public health professionals on the delivery of healthcare. Evaluative research has highlighted the extent of use of treatments that are unsupported by evidence of effectiveness and the importance of appropriate organizational structures and cultures in the provision of high-quality care. This section examines three areas in which public health professionals can play an important role: The design of systems that ensure that patients are managed at the level of the healthcare system that is most appropriate, the creation of mechanisms that identify and promote high-quality clinical care, and the reorientation of curative services towards prevention.

Health services as a setting for promoting health

Public health professionals have a particularly important role in promoting the reorientation of health services to address the broader determinants of health. Health services are important settings in which it is possible actively to promote health through primary preventive strategies. Health professionals have an important role as opinion formers, both in individual patient encounters and, among the wider public, as respected advocates for healthy public policies (Chapman & Lupton 1994). Conversely, contradictory images, such as physicians and nurses smoking while they advise their patients to quit, can do much to undermine public health messages.

Relatively simple approaches, such as brief interventions by health professionals, can often be very effective. Yet it is not sufficient to assume that such approaches are always going to be effective, and, as with treatment interventions, each must be assessed individually. For example, while advising patients to take more exercise or eat more nutritious food may seem intuitively beneficial, there is little evidence that it is effective. There is no evidence that attempts to reduce the risk of coronary heart disease through multiple risk factor interventions have an impact on either total or coronary heart disease mortality (Ebrahim & Smith 1997), and fiscal and legislative measures seem more appropriate.

Many people come into contact with healthcare facilities, either as patients or staff. This provides an important opportunity to demonstrate support for health-promoting policies by means of an ethos based on healthy lifestyles. Most obviously, it is no longer acceptable for healthcare facilities to permit smoking on their premises (McKee et al. 2003). Ideally, smokers should be seen several weeks before admission and supported with advice and nicotine replacement therapy (Moller et al. 2002). In contrast, failure to ban smoking provides an implicit message that health promotion is simply not taken seriously and the obvious conflict between the culture of the organization and the advice given to patients will make behavioural change more difficult.

There is, however, much more that can be done to create a healthy environment. For example, patients and staff should be able to choose healthy diets. The provision of cycle parks, gyms, and showers will encourage staff to cycle to work. Many of these ideas have been brought together in the WHO’s Health-Promoting Hospitals project, which seeks to increase participation in health-promoting activities by patients, staff, and others outside the hospital, as well as improving communication and reorienting hospitals towards health promotion.

Finally, the contribution that health services can make to health by employing people should not be ignored. The adverse health effects of unemployment are well recognized (Bartley 1994), in particular the impact of job insecurity and anticipation of unemployment (Ferrie et al. 1995). Health services have always been labour intensive. Healthcare reforms in many countries have led to substantial reductions in staff numbers, either through redundancy or, in some countries, transfers to private sector agencies where levels of pay and conditions of service are substantially worse. While reducing the direct costs to the health service, such policies often increase overall government expenditure through increased social costs. However, some governments are recognizing the role of health services as a source of employment, as illustrated by the use of the European Union’s structural funds to support investment in healthcare infrastructure.