The Public's Health: Can We Promote Public Health and Generate Return on Our Investment? | Public Health Post

It is widely recognized that the United States spends far more on health, or perhaps more accurately, on medical care than any other country on earth. This leads to a considerable amount of hand-wringing, and also some well-considered ideas about how we can spend our medicine dollars better. While most thinking about how we may best spend our health dollars features, at heart, some scenario of greater spending on prevention, our health spending remains resolutely curative. Of the $3.3 trillion spent on health in 2016, only about 2% of that was spent on classic public health activities such as disease monitoring and surveillance.

We might suggest that this is misaligned with what we really want for our own and our children’s lives. To put it more prosaically, wouldn’t we rather never develop Alzheimer’s than receive treatment for our Alzheimer’s once we get it? Few people ever express a preference for cure over prevention. 
But leaving aside what we might prefer, perhaps we spend more on cure than we do on promoting health because prevention and keeping people healthy are too expensive. That would be a robust argument for spending less in this area since, after all, we all recognize that all spending is zero sum and we have to make choices about what to spend money on.
But is it true that keeping us healthy is too expensive? An analysis set out to assess the return on investment for high-income countries that adopt efforts to improve health. The authors conducted a systematic review of nearly 3,000 papers. They found that the median return on investment for public health interventions was 14 to 1, that is, for every dollar invested, it yields the same dollar back and another 14. They found that the more these interventions were established at the wider, national level, the higher the return, rising up to about 40 to 1 for the best investments. What are these interventions? They include, among other efforts, vaccination programs, taxes on sugar sweetened beverages, building better cities to reduce falls, and early youth interventions to limit teenage pregnancy and delinquency. In other words, classic efforts that create healthier worlds and promote the public’s health.
If we could improve the public’s health and improve our bottom line by investing in what are sometimes called “upstream” efforts, then why do we not do this? Inertia, we suspect, plays a big role here, and a longstanding mismatch in this country between what we value in health and what we do about it. 

Michael Stein & Sandro Galea