1d. Why Take a Population Health Approach?

Trends in Health Care Costs

One challenge almost always on the mind of a Minister for Health for a province like Ontario is: How will I ever pay for the health care services voters are expecting?

Figure 1 provides a hint at why officials are so worried. In Canada, provincial governments now dedicate approximately well over 40% of their overall budgets to health care. This is up from 30% only 20 years ago. Moreover, one decade from now we may look back and refer to 2018 as the “good old days.”

Unless we can change current trends, health care will consume such a large proportion of the provincial budget that there may not be enough money left over to fund other provincial ministries, programs, and services, such as education, the environment, justice, and social services.

A large reason for the Health Minister’s dilemma is that chronic disease rates are increasing as the population ages. The following diagram (Figure 2), based on data from the World Health Organization, shows the historical and projected deaths from chronic diseases versus communicable diseases and injuries.

As you can see, the number of deaths from chronic disease is predicted to rise to over 50 million per annum by 2030, while the number of deaths attributable to communicable diseases and injuries is predicted to remain relatively stable.

Business Case for Disease Prevention

Given these alarming trends, you may wonder whether public health and those concerned with disease prevention might use this situation to argue for increased emphasis on prevention.

Indeed, governments themselves have understandably called for policy and program developers to outline the so-called business case for new investments. Many have been tempted to argue that disease prevention is justified on the grounds that it will reduce health care costs.

For example, it has been argued that helping people to quit smoking reduces the RELATIVE odds that a person will develop or die from heart disease, cancer, or other diseases that are expensive to treat. However, the reality is that while quitting smoking does improve the relative odds, the change in absolute odds of developing a chronic disease are surprisingly low for young and middle aged adults. For example, despite the fact that heavy smokers are 10 times more likely to develop lung cancer than non-smokers, 5 out of 6 heavy smokers do NOT develop lung cancer². Quitting smoking does not help someone avoid death — it helps postpone it. Since the majority of health care costs occur in the later stages of a person’s life³, quitting smoking may not significantly reduce lifetime health care costs. Reductions in tobacco use or other risk factors really only become economically viable if they ultimately reduce the number of health care providers people require. But they don’t. They just postpone or defer when these services are needed.

As you can see, making a business case for prevention is very difficult.

Consider the larger economic argument. The cold, hard economic facts are in direct conflict with the values of most civilized societies. For example, an infant’s death doesn’t cost our society very much because other than a few health care resources, we haven’t spent much to educate them, protect them, etc.

Infants and young children aren’t the only ones excluded when economics dominate our decisions — it’s also difficult to justify spending resources on anyone over the age of 55. During young and middle adulthood we are generally net producers of economic benefits. However, when we reach age 55, the future health care costs, pension costs, and so on begin to outweigh the average expected economic return. So, once again, I emphasize that it may not be wise to stake the future on public health and disease prevention on an economic justification.

We might however, have more success in arguing, that if our society values health, then public health and various disease prevention strategies might provide a more cost efficient way of achieving this goal. Hence, it is important to distinguish between a case built on cost efficiency, and a true business case.

Humanitarian Case for Disease Prevention

An alternative approach is to argue that public health and disease preventions interventions are justified on humanitarian grounds. Most societies and individuals hold the view that it is better to be well than to be sick. It is better to be alive than dead. And, being alive and well is best of all.

Some public health advocates have argued that health should be entrenched as a fundamental human right and that we should work toward developing a national or international charter enshrining people’s right to health. Such rights have responsibilities, including the notion of distributive justice. We’ll return to this theme later on in the course.

Health is a humanitarian issue. We don’t try to ensure that no one goes hungry because it’s economically viable; we do it on humanitarian grounds. We shouldn’t rely on economics as the primary justification for action on public health. It is first and foremost a matter of humanity.