The Wanless report and decision-making in public health

Abstract

The 2004 Wanless report expressed disappointment with the substantial gap that exists between evidence and policy in public health, emphasizing in particular the importance of evidence to make the economic argument for investing in public health. 1 The report recommended setting quantified national objectives for all important determinants of health for the medium and long term. Furthermore, it highlighted the need to develop an evidence base on the cost-effectiveness of existing interventions that could inform future developments. To inform the Wanless report, we were commissioned to review the public health decision-making processes in eight industrialized countries: Australia, Canada, Denmark, Finland, France, Germany, the Netherlands and Sweden. 2 As expected, significant differences in the organization of public health were found among these countries. These differences can be largely attributed to: differing challenges to population health; the political and historical context of public health decision-making, for example in the relative emphasis placed on individual and collective actions; the extent of centralization or decentralization of government; the extent of pluralism in policy-making; the role of nongovernmental organizations; and the important, but less well-documented role of informal mechanisms and interest groups in the policy process. Furthermore, there were significant differences in the reported level of spending on public health as a proportion of total health expenditure across countries, as reported by the OECD, ranging from 1.4 per cent in Australia to 7.3 per cent in Canada. 3 However, these differences must be interpreted in the light of the challenges of defining the boundaries of public health with its multiplicity of funding sources. Despite these differences, some common features emerge. Goals are typically aspirational. They often include issues such as tackling inequalities in health and reducing tobacco consumption. There is, however, little evidence of the use of the quantitative targets for public health that have characterized policy in the United Kingdom. An exception is Finland, where a government resolution on health included specific, measurable targets for the period 2001–2016. 4 The Dutch strategy to reduce socioeconomic inequalities in health also included quantified targets. 5 Although there is growing awareness of the need to develop a system for evaluating public health programmes, remarkably few policies have been subject to an evaluation of effectiveness and even fewer have been examined for cost-effectiveness. For example, the Netherlands is the only country among those examined that had a systematic, research-based approach to public health policy, in this case focussed on socio-economic inequalities in health. 5 This is, however, changing as countries are formulating new national strategies and initiating new evaluations of current interventions. Among the eight countries reviewed, only in Australia has cost-effectiveness analysis (CEA) been undertaken to a significant extent. The Australian Ministry of Health and Ageing assessed the economic return on investment of past public health programmes to reduce road injuries, HIV/AIDS, coronary heart disease, measles and tobacco consumption. 6 In each case, they estimated the costs and health benefits attributed to the programmes, total return to society of investment in these programmes and more narrowly, savings to government. This research found that investments in all five areas yielded a substantial net benefit from a societal perspective. However, these evaluations were ad hoc and not part of a national programme to systematically and continually evaluate programmes. Similar cost-effectiveness evaluations have been conducted in the United Kingdom, however, they remain peripheral to the policy-making process. There are many reasons why the use of economic evaluation in public health is limited. One is that the evaluation of complex interventions such as for public health issues is intrinsically difficult. 7 In clinical medicine, evaluation has largely been limited to single interventions, such as drugs or medical devices, in highly controlled circumstances that often have limited generalizability. In the field of public health, the time taken to implement a project, coupled with the frequently long lag period before an outcome might be detected, means that by the time results are available the intervention has already moved on. There is also the