The idea that prevention is necessarily better than cure long ago made its way from adage into the heart of health policy. But it has done so with relatively little hard information about the relative costs of preventing a disease against curing it. Although, in a sensible system, we may sometimes opt legitimately for a more costly option, we should perhaps know more about what we are choosing, and why.
From those arguing for more health dollars to be spent on preventing illness rather than curing it, two arguments are paramount. One is that it costs less, both in terms of suffering for the patient and money for the system. Prevention is, they say, far more effective than curative medicine in extending life.
The other is that only a tiny proportion of the health budget is spent on prevention and an enormous amount spent on hospitals, doctors and drugs to cure people after they get sick. Figures from the Australian Institute of Health and Welfare show that only about 2.8% of government health budgets go to specific prevention programs, such as environmental health, food standards and hygiene, health promotion campaigns. immunisation programs and screening for disease. In 2008-09 the average amount spent from state and federal health budgets on prevention averaged $105.84 per person across the country. Tasmanians, with $121.36, got more than the average. On the face of it, that’s not much.
How valid are these arguments? Well, they are – up to a point. But the situation is more complicated than the very simple arguments presented by those seeking money for their own projects, and the politicians in all parties, and particularly at state level, whom they have convinced of the unanswerable rightness of the cause.
In 1999 the Centers for Disease Control in Atlanta, America’s main public health body, published in one of its journals a list of the ‘ten great public health achievements’ of the 20th century.
This was the list: vaccination; motor vehicle safety; safer workplaces; control of infectious diseases; decline in deaths from coronary heart disease and stroke; safer and healthier foods; healthier mothers and babies; family planning; fluoridation of water supply and recognition of tobacco use as a health hazard.
There is good evidence for the validity of this list. All those things are as important as they ever were. Slacking off on any one of them would have huge public health ramifications. But look again. How many of these items come within the area we regard as public health? How many come within the health portfolio at all? And how many of them are state responsibilities?
Vaccination is mainly funded from Canberra, either by the National Immunisation Program or by the Pharmaceutical Benefits Scheme. The PBS is not counted as a prevention program, even though it spends billions on disease-preventing drugs.
Road safety is largely a state responsibility (despite federal road funding and national vehicle design standards) but does not come under the health portfolio.
Infectious disease control is due to many factors, only a few of which come within state public health area. Antibiotics, except for those dispensed in public hospitals, are federally funded by the PBS. Improved public and personal hygiene is a cultural matter deep within the community. Most of the behaviour-change funding comes from Canberra, as do funding for programs like safe-sex education, needle programs, and so on.
Cardio-vascular health: better diet; a more affluent society that can afford a better lifestyle; rickets and rheumatic fever have all but disappeared. Blood pressure is far better controlled: doctors are treating it and preventing large numbers of heart attacks and strokes. Anti-hypertensives are funded by the federal government and are not a cost to public health budgets at state or federal level. Statins, controlling blood fats including cholesterol, are funded by the PBS. Surgery and post-stroke care have improved massively.
Safer and healthier food. This is perhaps the biggest single formal responsibility of state public health units within health departments but Food Standards Australia New Zealand, which regulates the food industry, is a Commonwealth responsibility.
Healthier mothers and babies. There have been huge reductions in the past 100 years both in infant mortality and in the survival of mothers. Some of the improvement is due to better nutrition and better pre- and post-natal care. Puerperal (or childbed) fever, once a common cause of the death of new mothers, has all but disappeared in the developed world. Women have better knowledge among mothers of how to behave during pregnancy, controlling their use of alcohol, cigarettes and other behaviours which could harm the foetus. Much of this knowledge comes to them from general practitioners, obstetricians and gynaecologists. Death and injury from backyard abortions have disappeared.
Family planning. Smaller families often mean they can afford better lifestyles and better health. Again, there is a limited involvement of public health in securing these changes. Oral contraceptives are on the PBS.
Fluoridation of water supply is a responsibility of water supply authorities and does not come from health budgets.
Tobacco. Advocates often claim the entire credit for reductions in tobacco use but this is a complex area. Public education has been important – but how many people do not know these days about the dangers of smoking? Public health education programs aimed at children have a significant place – but so do schools and parents. Quit programs are of immense value but so are bans on advertising, labelling and point-of-sale regulations, bans on smoking in the workplace and in restaurants and other public areas, and in cars containing children. So is taxation and pricing policy. Nicotine replacement products are on the PBS or are funded by individuals. Most of these are not formal health portfolio responsibilities. Most cost the government almost nothing. Higher taxes actually raise money.
In fact, nobody knows how much is spent on preventing disease by governments, businesses or individuals. The sums have never been done.
Major elements of government expenditure should be guided by knowledge of how well the money is spent. In health, than means working out how much health benefit the community gets for each dollar spent.
The most rigorous and impressive system for doing this is run by the PBS. Clinical trials are mined for data on each drug’s ability to improve health. Those benefits are balanced against the costs – in side-effects, other costs to the health system and the price the drug company wants. Similar calculations are done for new tests and procedures being considered for listing by Medicare.
But for most prevention programs, such calculations cannot be done. The data on which to base a meaningful economic analysis does not exist. Many cost-effectiveness studies have been conducted, for instance, on the value of smoking cessation programs but because it is impossible to measure everything they should measure, the chances of them being valid and useful are remote. The cost of a program is known; the extent to which smoking is reduced can be measured; but it is impossible to separate the effects of the cessation program from the huge array of other factors contributing to someone’s decision to give up cigarettes.
A blinding fog of ignorance and mystery surrounds the decisions being made on disease-prevention funding. Perhaps it is time we started to do the job better.
Martyn Goddard is an independent health policy analyst based in Hobart. His analyses of national and state health systems are here