Compression of morbidity outcomes key to investment in public health

Abstract

The argument that health-care resources should be rebalanced more in favour of prevention rather than cure has been a constant feature of debate concerning publicly funded health systems across the world. In giving her international perspective for JPH Ann Richardson 1 asks what determines health policy and funding decisions generally, and identifies some of the barriers to greater investment in public health exploring some of the myths and beliefs surrounding public health investment. She cites examples from around the world of the evidence to support large-scale investment in cost-effective public health interventions and programmes to improve health; the Wanless Report in Britain; the National Prevention Health Taskforce Report in Australia and Prevention for a Healthier America in the USA. She argues public health investment in general produces significant gains in worker productivity, reduced absenteeism at work and school and enhanced quality of life as well as medical cost savings. One of the most persuasive arguments she poses, citing research evidence in several countries over different time periods, is for investment in public health to ‘compress’ rather than ‘expand morbidity’ through extending life—the latter is a commonly held belief in government and health policy circles. ‘Compressed morbidity theory’ suggests people live longer, healthier lives with a shorter period of decline and less severe disability in older age, so people live longer with enhanced wellbeing—costing health services less in the long term. As an argument this one feels both sensible and logical until you remember that people are not ‘average’ or all the same and health is determined beyond genetic inheritance and health intervention by family, social and physical environments. 2,3 How and where we live, socialize, work and grow up—the income we earn and education we receive, 4 among other factors, influences the ways the ‘compressed morbidity theory’ of investing in public health plays out. Richardson does not explore inequalities, but it is likely that lack of targeted investment in public health intervention at the lower end of the social gradient is likely to result in ‘expansion of morbidity’ and much higher health service costs in the long run. The evidence base to demonstrate the differential impact of investment in primary public health intervention across all socio-economic groups in society is difficult to create. Indeed, as Richardson points out, there are no easily ‘identifiable victims’ of lack of public health investment. Therefore, we should perhaps be content, as Richardson is not, that the evidence base is a minor rather than major driver of public health policy and investment coming well behind political ideology and belief, at least in Britain. However, her perspective argued coherently in this paper reminds us that all investment in public health should be evidence based and not a leap of blind faith. 5