It is widely acknowledged that adverse lifestyle behaviours in the population now will place an unsustainable burden on health service resources in the future. It is estimated that the ten leading risk factors for disease are responsible for 77% of deaths and 51% of disability adjusted life years (DALYs) in the UK [1
]. The main contributors to the DALYs experienced in the UK are tobacco, high blood pressure, high cholesterol, high BMI and alcohol, together accounting for 41% of the burden. It has also been estimated that behavioural causes account for nearly 40% of all deaths in the United States [2
]. In contrast it is argued that medical care has a relatively minor role to play in reducing early deaths [3
] and that a broad programme of prevention aimed at changing these behaviours may help to reduce this burden [4
Traditionally, Wales has had an interest in and an emphasis on the economics of public health, that even pre devolution was not reflected in other parts of the United Kingdom. The Heartbeat Wales programme, initiated in 1985 as a national demonstration project for reducing coronary heart disease included economic appraisal [5
], while the economics of health promotion were being considered in Wales before the publication of the Wanless reports that highlighted the need to further develop the evidence base in this area [6
The Review of NHS Funding and Performance, five years after the original Wanless report, stated that the UK has underperformed in terms of potential life years lost for some diseases (ischaemic heart disease, cerebrovascular and respiratory diseases) when compared to other countries [7
]. Furthermore, with the continuing rising trend in obesity, results are worse than even the slow uptake scenario, suggesting that significantly higher levels of funding will be required to provide the level of services outlined in the first Wanless review in 2002. The picture is even starker in Wales, with levels of smoking, obesity and alcohol abuse high relative to other countries within the UK.
The economic case for prevention
Reviews and models that have been carried out suggest that substantial benefits could be realised from systematic prevention efforts [8
]. For example, it has been estimated that a significant proportion of the past reductions in coronary heart disease mortality could be attributed to preventive efforts, with treatment explaining less of the mortality decline than risk factor changes [10
In addition to the public health arguments for Government intervention in public health policy, the case can further be made on economic grounds. Economic theory suggests that governments should intervene in the provision and delivery of goods and services when the market fails to provide an adequate supply of them . In the case of prevention, there are at least three potential sources of market failure [8
Time inconsistent preferences i.e. the preferences of an individual may not be consistent over time. An individual may choose instant gratification over their long-term interests, such that a commitment made in the present to behave in a certain way in the future will be broken when that time in the future comes;
Departures from rationality (particularly in young people). The assumption that people act rationally (defined as maximising their expected utility) is core to economic thinking. However, it is recognised that children and young people in particular often make choices that may not be in their long-term best interests - they make lifestyle choices with a short-term view, even when they are informed of future consequences. This could provide a justification for government intervention, to prevent them from harming themselves; and
imperfect information – government intervention in the provision and production of health information is justifiable as information itself is a public good and is thus likely to be undersupplied by the market.
The above market failures justify an explicit government role in the prevention of lifestyle-related morbidity and mortality [8
Further, the existence of negative externalities, whereby some of the costs of the lifestyle behaviour may be borne by other individuals, may also provide justification for government intervention in this area. Negative externalities may arise for example though exposure to second hand smoke or being a victim of accidents or anti social behaviour caused by alcohol misuse of others. Interventions to tackle these can take the form of awareness campaigns to raise knowledge of the impacts of behaviours on others with a view to changing behaviours (for example raising awareness of the impacts of second hand smoke on children), or more direct regulations to control behaviours to reduce the negative externalities, as has been seen with the regulations on smoking in public places.
Making the economic case for prevention, however, has not always been easy. This paper discusses the different types of ‘economic’ arguments that have been put forward and outlines the role that economics can play in making decisions about public health spending. The intention of this paper is to add to discussion surrounding appropriate use of economic arguments to support public health initiatives and is not intended to give a definitive answer. A systematic approach to identifying literature to inform the paper was taken - although a full systematic review was not performed – to capture the range of viewpoints portrayed within the literature, to supplement views obtained as a result of our experience in Wales.