How can European health systems support investment in and the implementation of population health strategies?

    Publication year: 2008

    Key messagesPolicy issue and associated policy challenges• Population health is influenced by a variety of factors, many of whichrequire action outside the health system.• The health and socioeconomic costs of the key contributors to poor healthin Europe are substantial. Many of these health problems are avoidable.• There is a growing body of information not only on the effectiveness butalso on the cost-effectiveness of population health interventions.• Policy measures to help promote investment in effective interventions needto focus on improving both the quality and use of evidence across multiplesectors.Policy options• One option to strengthen the evidence base might be to expand the remitof existing regulatory bodies that assess the cost-effectiveness of healthcare technologies.• A second option in parts of Europe where capacity for evaluation is limitedmight be to adapt existing information to the local context to make thecase for investment.• Various institutional arrangements, including the possibility of a standaloneministry for population health, might help to facilitate coordinationand secure funding for action; other related options include joint budgetsor monetary transfers between sectors.Facilitating implementation• When new assessments are conducted, these might begin by focusing oninterventions likely to be highly effective, cost-effective andnoncontroversial. This can help new institutions to establish their presenceand credibility.• Improving communication between researchers and policy-makers acrosssectors can help facilitate change; knowledge brokers might provide a linkbetween different groups.• Increasing awareness of the health, non-health and economic effects ofinterventions can help to reduce resistance to action outside the healthsector. Health impact assessment may have a role to play in this process.• Mechanisms to monitor the implementation process across sectors mightInvesting in and implementing population health strategiesalso help facilitate change; setting explicit measurable targets onpopulation health objectives might provide further incentives forstakeholders across sectors to take action.Executive summaryPoor health in Europe has substantial health and socioeconomic costs. Much ofthis burden might be avoided by implementing effective population healthstrategies, both within and outside the health system. A broad approach topromoting population health requires a combination of upstream anddownstream measures. Upstream measures may include measures that, amongother goals, can help promote health, such as fiscal redistribution, improvingthe quality of housing and using incentives to encourage students to stay inschool. Downstream measures include health promotion and primary diseaseprevention action, often targeting individual behaviour and lifestyle.To support investment in population health strategies, health systems must beable to identify not only what works and at what cost but also in what context.Mechanisms to allow such information to be fed into the policy deliberationprocess and also to facilitate the implementation of agreed population healthstrategies are then required.Generating and using existing evidence on the effectiveness and costeffectivenessof population health strategiesUsing systematic reviewsSystematic reviewing, which seeks to systematically identify and appraiseeffectiveness (and other evidence) on a given topic, can be particularly useful inassessing whether interventions are effective. Collating and, where feasible,statistically pooling information from studies reduce the probability that oneunrepresentative study would bias the results of any effectiveness analysis.Information from existing high-quality reviews can also provide rapidinformation on the evidence (and evidence gaps) on a particular topic. This mayavoid duplicating time-consuming and costly reviews.Using economic evaluationEconomic evaluation can also strengthen the case for investing in populationhealth interventions. Widely used in the health care, environmental andtransport sectors, economic evaluation compares the costs and effects ofalternative courses of action.Evidence on the cost-effectiveness of population health interventions, whilemodest compared with health care evaluation, has grown rapidly, particularlyfor screening and vaccinations. Examples of complex cost-effectiveinterventions in specific settings and contexts include targeted exerciseprogrammes for older people, measures for controlling tobacco, drugs andalcohol (including taxation), early-year interventions targeting children and theirInvesting in and implementing population health strategiesparents and traffic-calming and transport safety measures. Many interventionsare funded and delivered outside the health system.

    Policy options moving forward:

    strengthening the evidence baseHow can countries better use effectiveness and economic evaluation in theirdeliberations on population health strategies? Institutional and regulatoryarrangements might include independent agencies to assess evidence; in-housegovernment agencies; and support for knowledge clearing houses.Establishing and/or expanding the remit of health technologyassessment agenciesOne option might be to expand the remit of existing health technologyassessment agencies. In England, the National Institute for Health and ClinicalExcellence now collates evidence on the effectiveness and cost-effectiveness ofpublic health interventions. Evaluation includes mental and physical well-beinginterventions delivered in the workplace and school-based alcohol educationstrategies. It uses a highly formalized process taking up to one year tocomplete, which includes opportunities for stakeholder input and formal linksto the policy-making process. It adopts a broader economic perspective thanthat used for health care interventions, recognizing effects outside the healthcare system.Adapting results from existing economic evaluationAnother approach, especially when resources are limited, may be to adaptinformation on existing cost-effectiveness studies, such as using the WHOCHOICE(Choosing Interventions that are Cost Effective) programme. Thisallows a range of interventions, including those for prevention, treatment andrehabilitation, to be compared in isolation or in combination to determine anoptimal mix of resources within a health care system. The results are presentedin such a way as to determine the probability of an intervention being costeffectivein low-, medium- and high-resource situations. They can be adapted,using local information, to specific country contexts.Reforming institutional arrangementsInstitutional structures and governance arrangements can also influence thesuccess of the implementation of population health interventions. Onepossibility, given that funding for population health within health care budgetscan be severely limited, would be to establish a dedicated ministry. Very fewattempts have been made to set up such institutions. One rare example is theMinistry of Health Promotion in Ontario, Canada, established in June 2005. It isstill too early to judge how effective this model will be; the challenge ofPolicy briefcoordinating activities with the health ministry might also mean that publichealth becomes more marginalized from mainstream health care policy.Other alternatives include establishing specific governance structures forpopulation health within a health ministry, including a ministerial post,partnership arrangement to encourage intersectoral cooperation at both thenational and local levels and flexible funding structures, including mandatory orvoluntary joint budgets.Identifying alternative ways of bringing about changeWhat mechanisms might be available to ensure that population health is on theagenda of policy-makers in all sectors and at all levels, directing them to beaware of the health consequences of their decisions and to accept theirresponsibilities for health? How can governments provide incentives toadministrative bodies to implement national policy on population health?Giving priority to the low-hanging fruitIn building the evidence base on population health interventions within acountry, initially picking low-hanging fruit – interventions likely to be highlyeffective, cost-effective and noncontroversial – may be prudent. Several healthtechnology assessment agencies have adopted this policy when they arebecoming established. This can help organizations to establish their presenceand credibility.Improving the communication between researchers and policy-makersResearchers and policy-makers often do not speak in a common language andmay distrust each other. Knowledge brokers, individuals who understandscientific evidence but are comfortable working in a policy-makingenvironment, may help overcome this problem. They can help translateacademic reports into brief messages relevant to policy-makers and help ensurethat policy-makers commission feasible research. With appropriate training,staff from international agencies, such as WHO, could potentially act asknowledge brokers.Improving the awareness of health effects among policy-makers acrosssectorsAwareness of the health effects of policies developed and implemented outsidethe health sector may be limited. One way of improving awareness may bethrough the formalized use of health impact assessment. This has been used inseveral countries, but the extent to which it has facilitated change remainsunclear.Investing in and implementing population health strategiesTargets, monitoring and evaluationInvesting in systems to monitor and evaluate implementation and measuringthe longer-term effects on population health outcomes can also be helpful.Joint targets across government departments might be set and progresstowards achievement monitored. Negative publicity arising from failing toachieve targets may act as a powerful incentive for action.