13.

THE WAY FORWARD

Acronyms

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 rather than on the individual, and involves efforts by all government sectors and levels. 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 a disease when this is still reversible. Many countries have developed national public health strategies, accompanied by 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 several countries. 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 whether the programmes would be valuable and complementary to current practice in the member states. 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 runs from 2003-2008, and aims at: improving information and knowledge for the development of public health, enhancing the capability of responding rapidly and in a coordinated fashion to threats to health, and promoting health and preventing 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.

In addition, the European Commission, in collaboration with its Member States have produced - mainly as Council Conclusions or Recommendations - strategic Documents to control specific diseases or health determinants.

Public health spending 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, such as Austria (from 1.3% total health spending in 1995 to 2% in 2004), and the Netherlands (from 2.8% in 1990 to 5% in 2004). Very low levels of funding are seen in most countries, with public health and prevention accounting for about 0.5% of total health spending in Denmark and 0.6% in Italy, to 4.9% in the Netherlands and 3.9% in Finland. However, where data exist, some countries have shown an increasing proportion of funding allocated to public health e.g. Austria, Finland, France, the Netherlands, Slovakia and Spain. It is important to exercise caution when interpreting public health expenditure data as 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 costs for some activities, in particular occupational health programmes, may fall on private enterprises.

A very interesting approach has been developed in the UK with the recent inclusion of the cost effectiveness evaluation of public health interventions 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 the 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.