By Johanna Reidy, Don Matheson & Rhema Vaithianathan*
The global pandemic might have revealed the importance of robust public health infrastructure, but we still have trouble grasping the vital need to invest in it.
An analogy might help. Wellington’s recently opened Transmission Gully motorway shortens journeys from the Kāpiti Coast to the city by up to 15 minutes. First proposed 100 years ago and finally built over the past eight years, the final cost will be at least $1.25 billion. Worth it to some, questionable to others.
But the key value isn’t the infrastructure itself, it’s the time saved. The efficiency and petrol saving on a journey without traffic lights and single lanes will last long after the delays and overspend on the project are forgotten.
Investment in public health has clear parallels with investment in major transport projects. Time saved on a journey is akin to lives saved from a premature end by the kinds of hidden services, like safe drinking water, that are designed to improve, protect and promote the health of the whole population.
But both infrastructure and public health investments can take years before the benefits are realised. Urgent maintenance – filling pot holes or filling hospitals – tends to crowd out strategic investment.
Public health is always the Cinderella of services in a publicly funded health system that delivers personal as well as public services, and is always vulnerable to budget cuts and under-investment.
Sadly, COVID has shown there are no fairy godmothers to step in and wave a magic wand. Globally, the lack of maintenance of public health systems is forecast to cost more than $US12.5 trillion according to the International Monetary Fund.
Positive investments: headlines such as ‘Fully immunised child doesn’t die’ are worthy, but not necessarily newsworthy. Getty Images.
The value of public health
Governments of all political persuasions want healthy populations, they just disagree on how to achieve the goal. Because of this, public health has been consistently undermined.
As the Labour government’s May 19 budget approaches, we need to acknowledge that the massive investment in tackling the pandemic could have been spent earlier to strengthen public health infrastructure.
That said, the question now is how governments can invest to be better prepared for the current and inevitable next public health threat. The shared value of public well-being must be protected by maintaining existing healthcare while investing more in public health.
First and foremost, we need to ensure public health is actually valued and invested in – whether or not there’s a pandemic. The past two years have shown how much New Zealanders are willing to pay, not just to keep themselves healthy, but to keep family, whānau and others safe.
Unfortunately, when all is going well, the true value of public health investment is invisible and unnoticed. Only when there are service failures (for example, the 2016 Havelock North water disaster), controversial health issues (such as raising the age for buying cigarettes), or a global pandemic, does public health become front of mind.
Also, public health’s focus on the whole population rather than on individual cases means it’s not as readily relatable. This lack of an emotional focal point means public health isn’t always uppermost in the minds of decision makers at budget time.
Headlines such as “Fully immunised child doesn’t die”, “Water still drinkable” or “Slight reduction in obesity rates means improved disability-adjusted life years!” are worthy, but not necessarily newsworthy.
Public and personal health
Public health’s long-term view disadvantages it within a three-year election cycle that favours fast outcomes, even if those outcomes are more expensive. It’s easier and quicker to see the impact of treatment than prevention.
Currently, the system is set up to fund personal (individual) health. It’s harder to cut personal healthcare, if only because a real person missing out on surgery or drug therapy makes better headlines.
But a cut to a health promotion budget doesn’t have a face or a name. Public health is simply an easier place to make cuts and is often the first area to lose investment. Historically, it has sometimes had to be ring-fenced to stop it being pillaged to fund other services.
Disinvestment and a focus on personal health occurs even though public health has a better marginal return than personal health – it’s cheaper per person to spend on public health than on personal health.
This is because public health prevents or slows ill health. It’s less costly to tackle the root causes of rheumatic fever, for instance, than to pay for treatment, especially heart valve replacement and long-term care and rehabilitation.
The road to better investment
COVID has highlighted the need for both personal and public health services. The solution is balance, with investment in one reinforcing the other. Without prevention, personal health services would be swamped. Both aim to improve lives, but require different investment approaches.
There are two main things governments can do.
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Adopt investment mechanisms that specifically acknowledge public health will always lose in a popularity contest to personal health, and adjust the budget process accordingly. This means calculating the future benefits of public health investment and redressing the current bias in budget spending.
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Set fixed goals with robust measurement systems to capture short, medium and long-term progress. Allow for flexibility in how those goals are met according to policy priorities and the sociopolitical context. One immediate solution would be to ring-fence long-term public health investment, plus have dedicated strategy and funding, to address the major drivers of ill health – obesity, for example.
It’s time to invest in public health infrastructure as we would with major transport projects. Transmission Gully wasn’t funded by an annual budget allocation in competition with routine maintenance needs. The project’s size, the time-frame for completion and the road’s broader economic benefits all shaped decisions.
Proper investment in services that generate extra years of healthy life and avoid costly cures are surely no less important than the minutes saved on a trip into town.
*Johanna Reidy is Lecturer, Department of Public Health at the University of Otago; Don Matheson is a Professor at Griffith University, and Rhema Vaithianathan is Professor of Economics and Co-Director, Centre for Social Data Analytics, AUT, Auckland University of Technology This article is republished from The Conversation under a Creative Commons license. Read the original article.
15 Comments
+1
All government spending, departments and project by project, should go through socio economic cost benefit assessment [(economic+social+environmental benefits)/cost] aimed at maximising wellbeing per capita and the distribution of that wellbeing.
At a department level this would allow an inter-department comparison of the benefits/costs and a rational way of adjusting budgets.
There is much to be spent on infrastructure (vision zero and net zero carbon) in particular aimed at increasing net wellbeing per capita, but there is so much more that needs to be spent on human capital (the health system) given its current state.
In response to Covid19 (for which obesity is a major comorbidity) our public health officials banned sport, shut the gyms and closed playgrounds. And made us all crowd to buy food from Countdown where you have to walk through the 4 rows of sweets, fizzy drink, booze, chips...
They'd ban us from visiting elderly relatives even if you test negative (but allow staff with positive tests to attend), organise the sacking of non-vaxxed through mandates (some of which are now found to be illegal) and imposed internal border controls that didn't work. They even locked us out of our own country while aware there was absolutely no health benefit in doing so.
Our public health sector should not be given more funding until they can justify what they have done.
I don't think any of those were health sector decisions, rather political decisions.
And the choices made matched the general populations' uninformed perspective pretty closely, that is why Labour were voted in with a majority.
Since then we can generally see where the choices were wrong or ridiculous. Perhaps if there was some evidence of an open honest follow up to the mistakes made then we would still be supporting those politicians ahead of the opposition (who frankly made a heap of protests or proposals about the covid19 response that were seen to be rubbish).
I try to keep a level head in politics, however it’s hard to imagine where we would be had National been in power March 2020. Sure, Labour didn’t get everything right but we’re here. Aside from shouting either “we need level 3 NOW!” Or “OPEN THE BORDERS” from the cheap seats, there was absolutely no insightful input from National. In a time of international uncertainty, National played political theatre.
In saying that, my opinion is that the impending health problems will be a combination of a stressed health system causing slightly worse outcomes in all areas of health and the impending mental health “crisis” of the current working class who have had to keep the lights on during a pandemic, and environmental, housing, cost of living crises, low unemployment/higher work loads, and general workplace isolation.
With recession on the horizon and economic uncertainty, anxiety must be through the roof in some cases. Which straw will break the camels back?
Well said. The big conundrum is how on earth do we hope to have enough nurses, police, teachers etc when we've been based for so long on the idea of running up housing debt so we can live beyond our means off costs others will bear.
Wages of these critical workers are now so completely out of kilter with the costs of the false economy we've been driving that it makes no sense for them to stay here when living conditions are simply better elsewhere.
Nursing in particular is considered second class health service and often mistaken for the role of an HCA, and the workload is through the roof. Nurses are told that nursing is a “vocation”, I assume people are unaware that it’s a graduate degree career which provides all forms of assistance and care. Often the work of a hospital nurse exceeds that of your local GP in terms of care, treatment, and prognosis. So why do they get a minimal wage for it? A nurse looking for a work life balance would be silly not to consider Australia given the pay is much higher and the cost of living lower. Who’s left when they leave?
Maybe you misinterpreted my comment, you certainly latched on to the uninteresting part of it and turned it into your calling to dive in.
Can you see anywhere where Labour's decisions were wrong? Or do you wear a different sort of hat that protects you from the idea of nuance. Every politician makes mistakes and voters have been quite willing to accept that in these years of crisis. Some voters turn any mistake into the fuel to promote their opposition, some voters like myself hope to see politicians who admit mistakes or explain themselves when new information appears.
The parent comment seems to me to claim that bad health decisions were made. I'm saying the health sector did damn well, whereas the politicians of NZ got it right for a while but of course the decisions based on simplicity, burying the details or the uncertainty, and sometimes ignoring the expert advice - this has caught up with them.
+1. The analogy and suggestion is pretty good.
The public loves the visibility of a big roading/infrastructure project, the media gets right on board. The idea of a health project that purely directs money to a single vision instead if into the pit of despair that is the sector as a whole has some appeal.
Excellent article, thanks.
Disinvestment and a focus on personal health occurs even though public health has a better marginal return than personal health – it’s cheaper per person to spend on public health than on personal health.
Great point. Amazing how much push back we had from for-profit folk when it came to reducing taxpayer liability for the effects of unhealthy rental homes, for example. Or lobbyists' work pushing against folic acid in bread, despite both these standing to improve health outcomes and reduce healthcare costs.
As long as spending per caputa doesn't increase in inflation adjusted terms I'm happy to try any approach. What I fear is that as our population ages our health spending blows out. We should set a hard cap on healthcare spending to prevent this scenario where healthcare is treated as an unfunded liability.
The blow out is underway already.
The perfect storm of aging pop, new (expensive) treatments for many things, social media (moral highground) pressure to save us all from everything, and raging obesity related issues
Incredibly hard to be rational about affordability and prioritization. Emotional arguments from individual levels quickly drown any conversation.
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