11.2.2. Public health services

Public health can be defined as the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society. It differs from health services in its focus on the population and not on the individual, and involves efforts by all sectors and levels of government. Primary prevention aims at reducing or removing the cause of a disease or illness, while secondary prevention seeks to identify individuals at an early stage of the disease, when this is still reversible.

Many countries have developed national public health strategies, inclusive of a set of goals to be achieved. The strategies differ, reflecting the national context and political choices, but they also have much in common, for example the widespread emphasis on tackling inequalities in health. Comprehensive policies to reduce social inequalities in health can be seen in England, Sweden, and at local level in the Netherlands (Judge et al 2006). The concept of health strategies has echoes at international level. In the EU, following the Maastricht Treaty in 1992, eight priority areas were identified for community action programmes based on the burden of the disease, its socioeconomic impact, the degree to which it is amenable to preventive action, and on the fact whether the programmes would be valuable and complementary to current practice in the member states (Merkel and Hübel, 1999). These priority areas were identified as: health promotion, cancer, AIDS, drug dependence, health monitoring, injuries, rare diseases and pollution-related diseases. The latest of the EU’s multi-annual public health programmes ran from 2003 to 2008, and aimed at improving information and knowledge for the development of public health, enhance the capability of responding rapidly and in a coordinated fashion to threats to health, and promote health and prevent disease by addressing health determinants across all policies and activities. The programme’s implementation is overseen by the European Commission’s Public Health Executive Agency.

No country has a systematic procedure for making decisions affecting public health, or setting priorities among different public health interventions. One exception may be in the UK with the recent inclusion of public health intervention cost effectiveness evaluation in the remit of the National Institute of Health and Clinical Excellence. The methodology used for making decisions and setting priorities in public health typically relate to population health status, epidemiological data, burden of disease and, at times, scope for prevention. Also important in this process, however less documented, are political negotiations, pressure from interest groups and informal processes (Allin et al 2004).

Spending on public health is extremely difficult to accurately measure and compare across countries. The data suggest that, despite increased attention at policy level and development of national policies, there has been an increase in funding only in some countries, e.g. Austria (from 1.6% total health spending in 1995 to 2% in 2005), and the Netherlands (from 3.5% to 4.7%) (OECD Health data 2007). Very low levels of funding are seen in most countries, with public health and prevention accounting for about 0.7% in Italy, to 4.7% in the Netherlands and 3.9% in Finland. Spending on prevention included a wide range of programmes such as vaccination programmes and public health campaigns on alcohol abuse and smoking. It is important to exercise caution when interpreting public health expenditure data: some public health programmes may not be accounted for, such as those related to GP practice; public health activities may be coordinated or funded by other ministries e.g. social and environmental sectors; and the costs for some activities, in particular occupational health programmes, may fall on private enterprises.

Several European governments have moved mental health problems up on their political agenda, and are showing signs of tackling the stigma, discrimination and health threats associated to mental illness. However, spending on mental health varies widely across Europe. Only five countries spend at least 10% of their health budget on mental health, with the lowest levels of under 2.5% and 3% in CEE countries (McDaid et al, 2005).

A common limitation in the area of public health policy in Europe is the relative lack of evidence to support policy decisions and evaluate the effectiveness of programmes. More research is needed to evaluate the effectiveness and cost-effectiveness of public health interventions. Commentators have argued that it is important to move beyond the ‘black box’ that describes the current thinking of economic evaluation in the area of public health, and that the mechanisms of economic appraisal can and should be applied to public health to better inform policy makers (Kelly et al, 2005). One of the exceptions to the above limitations is screening. In terms of mental health, while the evidence base on the availability of cost effective pharmaceutical and psycho-social treatments continues to grow, there are substantial gaps in our knowledge on the prevalence of mental health disorders.