Can prevention and promotion save us? Making the case for investing in public health and health promoting interventions in times of crisis David McDaid LSE Health & Social Care & European Observatory on Health Systems and Policies, London School of Economics and Political Science STRENGTHENING HEALTH PROTECTION IN TIMES OF ECONOMIC CRISIS: INCREASING THE EVIDENCE-BASE Science and Technology Options Assessment Unit, European Parliament, February 2013

Structure What do we know about the economic costs of poor health during economic crises? What do we know about the economic case for health promotion and public health? Examples of key areas for action during an economic downturn How can strengthen the evidence base and support implementation across sectors and stakeholders?

Economic downturns have consequences for health which in turn have consequences for the economy

Economic impacts A reduction in over-eating, but also a reduction in diet quality A reduction in alcohol consumption but increased risk of binge drinking with associated harms May be an increased risk of engaging in addictive behaviours May be a deterioration in population mental health – which also increases the risks of physical health problems May be an increased risk of intentional self-harm and suicide in some population groups Longer term consequences of cuts in public health, health care, pre-school care and welfare budgets

Health Inequalities in EU-25 result in: 700,000 deaths per year 1.4% less GDP growth due to reduced labor productivity 9.4% lost GDP (monetary value) 20% health care costs & 15% of total cost of social security benefits Mackenbach et al, 2007 & 2011 Health inequalities impact on economic growth health care expenditure and well-being

Impact of economic crises on mental health Previous crises: increases in unemployment and poverty increase the risk of poor mental health Debt and other financial difficulties have a negative impact on mental health Unemployment and poverty can contribute to depression and increase suicide risk Wahlbeck, Anderson, Basu, McDaid et Stuckler, WHO, 2011

Income inequalities and mental health: 10 years following economic crisis Hong, Knapp & McGuire, World Psychiatry 2011

Number of debts and source of debt impacts on mental health Source: Meltzer, Bebbington, Brugha, Farrell & Jenkins 2012 European Journal of Public Health (Advance Access)

Source: OECD Health Data (2011)

What do we know about economic evaluation of disease prevention and injury prevention and health promotion?

McDaid D, Sassi F, Merkur S (eds) Promoting health, preventing disease: the economic case. McDaid D, Sassi F, Merkur S (eds) Forthcoming Open University Press 2013 Joint European Observatory/OECD initiative on the economics of health promotion and disease prevention Aim: to review the evidence base on the effectiveness and cost-effectiveness of interventions addressing major risk factors for NCDs Methodological and policy implementation issues addressed

Some illustrative examples of actions

Associations of a Mass Rise (>3%) in Unemployment with Age-Standardised Mortality Rates. Source: Suhrcke & Stuckelr 2012 Data are from the World Health Organization European Health for All Database 2008 Edition (HFA-MDB).

Interventions Assessed – Obesity Prevention Health education and health promotion Regulation and fiscal measures Primary-care based interventions Mass media campaigns Fiscal measures (fruit and vegetables and foods high in fat) Physician counselling of individuals at risk School-based interventions Government regulation of food advertising to children Intensive physician and dietician counselling of individuals at risk Worksite interventionsCompulsory food labelling

Cost-effectiveness of Interventions Over Time Sassi 2010

Cost effectiveness of actions to address harmful alcohol consumption Anderson, forthcoming

Economic burden of childrens exposure to hazardous chemicals alongside intervention costs, effectiveness and potential benefits Trasande & Brown, forthcoming

Investing in road safety measures Anderson, McDaid & Park, forthcoming

Net Return on Investment

Active Labour Markets Actions to help people to find employment: include labour market training, special programmes for young people in transition from school to work; programmes to provide or promote employment for people with disabilities. Psychological support for unemployed people to promote mental health and increase re-employment rates. Psychological support for people who lose their jobs as part of redundancy package that employers must provide Each $100 per capita on active labour market programmes reduces by 0.4% the impact of a 1% rise in unemployment on suicide (Stuckler et al 2009)

Debt relief Help to manage debts can improve mental health In Sweden people in high debt granted some debt relief had better mental health (Enforcement Authority of Sweden, 2009) Access to debt management services in England associated with improved general health and optimism and reduced anxiety. (Williams & Sansom 2007) Access to microcredit; not for profit debt support agenci Scope for looking at reform of bankruptcy laws

Family and Parenting Support Programmes Family support programmes – help with costs of raising children, as well as maternity/paternity and parental leave Critical at time when parental mental health may be under pressure Investment in measures to support the well-being of parents and their children can be protective of mental health, with long-term economic gains outweighing short-term costs (McDaid & Park 2011) Each $100 per capita on family support programmes reduces by 0.2% the impact of a 1% rise in unemployment on suicide (Stuckler et al 2009)

The costs and benefits of population wide interventions are often fragmented. This can be a barrier to implementation

Impact of budgetary silos Most of costs of health promoting intervention incurred by education Health Benefits accrue to Health Sector Improved educational performance? So why should education sector invest? Or monetary transfer from health to education

Factors to aid in implementation Define problem / joint benefits of action Identify all cross sectorial stakeholders / actors to be involved Understand what are their priorities and goals – how would joint funding of an initiative add value from their perspectives Vital to highlight non-health benefits; speak non-public health language Sustained effort needed to build cross-sectoral working relationships –Employing co-ordinators (esp where not full integration of budgets) –Co-locate team members to help trust/ working relationships develop A role for performance related financial incentives –Needs common set targets/performance indicators Highlight the economic case for cross-sectoral action

In Summary There is an evidence base on cost effective prevention and health promotion interventions; but need more context specific analysis In economic downturns most immediate impacts on psychological health and wellbeing Cost effective measures to strengthen resilience and protect mental health Also key longer term risks to physical health, particularly if public health budgets seen as easy target But economic costs of avoidable poor health substantial