The imperative for health promotion in universal health coverage

Keeping People Well Vs. Caring for the Sick

Health promotion comprises interventions intended to keep people well, as opposed to interventions designed to improve health once people are sick—essentially curative care. We recognize some overlap between prevention and curative care, but that has little or no effect on our assessment.

The key distinction between “sick care” and promotion of good health has long been recognized.^3–5 Harvey V. Fineberg, President of the Institute of Medicine and former Dean of the Harvard School of Public Health for 13 years, contrasted traditional curative “sick care” and preventive approaches and gave reasons why prevention gets little attention (Box 1).

In curative care, the principal professional responsibility is to the individual patient, whereas in preventive care, focus is often at the population level and entails a responsibility to the entire community. In curative care, solutions involve prescribing medication, performing operations, or delivering other clinical therapies; in prevention, there is a much wider array of possibilities, from changing behavior choices to altering social conditions, in addition to clinical interventions such as immunizations. Ensuring the health of a population is more difficult than delivering health care to an individual.⁶

Health Promotion and Health Care Form Two Arms of the Health System

The 2 major “arms” of the health system over the life of an individual are:

1. Health promotion and disease prevention

2. Personal health care services (mostly curative)

The y-axis in the Figure represents health and illness; the x-axis is our full expected life span. Health care services are in the lower half of the figure, where individual clients who are ill receive personal health care, aiming to recover, as much as possible, their optimal health. Health promotion and disease prevention are in the upper half—generally population-based interventions provided to large numbers of people who are healthy.

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FIGURE

Two Major Arms of the Health System

^a Health promotion activities are considered public goods: goods that are available for the benefit of all, and where the use by one individual does not reduce availability to others. In contrast, with clinical care, the supply is limited by available resources, and provision to one person reduces the quantity available to others. Since public goods are available to all and it is difficult to charge or exclude users, they are undersupplied by private markets, making it essential for governments, or the public sector, to promote health and prevent illness. World Bank. Annual review of development effectiveness 2008: shared global challenges. Washington (DC): World Bank; 2008.

About 85% to 90% of newborns are born healthy (lower in developing countries), and, clearly, one role of the health system is to help keep infants, children, adolescents, and adults in optimal health across their life span. Should an individual become ill, s/he may need medical care including diagnosis and treatment that will lead to her/his recovery and hopefully to optimal health. The more effective and efficient the intervention to maintain health and prevent illness, the less the demand for (often costly) health care. Health promotion has a huge agenda, covering both infectious diseases and the emerging priorities related to NCDIs (Table).

Health Promotion Interventions Are Diverse

The following is a simplified list of health promotion interventions:

• “Medical” such as immunization, well-baby clinics, or the nicotine patch

• Persuasion or direct behavior change, such as mass media to promote breastfeeding

• Policy/regulatory, such as a tobacco tax or speed limits

• Environments and physical structures conducive to health, such as latrines, speed bumps, and standards for food service

The “medical” field of health promotion and disease prevention is being quickly and greatly transformed by the opportunities brought by the dramatic progress in genomic, proteomics, and pharmacogenomics. The potential to anticipate risks and individualize disease prevention and health promotion interventions is undeniable, although many technological and financial barriers still exist, particularly for low- and middle-income countries (LMICs). However, with the rapid progress in laboratory technology, the increased use of these laboratory resources, and the eventual reach of enough computational power, the accuracy, cost, and availability of these tests will no longer be a limitation. While many believe the widespread use of these methods will happen within the next 5 years,⁷ the other areas of health promotion in our simplified list will remain important.

Notice that many of these interventions lie outside the domain of clinical health services. Thus, they often call for diverse interventions, different expertise, and a population-level mindset. Behavior change and policy and legislative expertise are especially crucial.

Mathematical Modeling of Results of Primary Prevention Efforts

Results of mathematical modeling²⁶ of risk factor reduction in apparently healthy people (primary prevention) and risk factor reduction in patients with CHD (secondary prevention) undertaken in England and Wales,²⁷ Europe,²⁸ New Zealand,²⁹ and the United States³⁰ show very powerful effects of primary prevention, equal to or greater than the reduction in deaths achieved by secondary prevention.

England and Wales²⁷:

• CHD mortality has halved since 1981 in the United Kingdom, resulting in 68,230 fewer deaths in 2000.

• Current government initiatives favor risk factor reduction in CHD patients (secondary prevention), but population-based primary prevention might be more powerful.

• Approximately 45,370 fewer CHD deaths were attributable to reductions in smoking, cholesterol, and blood pressure in the whole population.

• Some 36,625 (81%) of these fewer deaths occurred in people without recognized CHD and 8,745 (19%) in CHD patients.

• Compared with secondary prevention, primary prevention achieved a 4-fold larger reduction in deaths.

Europe²⁸: The risk of developing a chronic disease decreased progressively as the number of healthy factors increased, after adjusting for age, sex, educational status, and occupational status.

New Zealand²⁹: In Auckland, approximately half the reduction in CHD mortality rate was attributed to medical therapies and half to reductions in major risk factors.

United States³⁰: There were 745 deaths among the 8,375 people aged 20 years and older who participated in the 1999–2002 U.S. National Health and Nutrition Examination Survey, who were followed through 2006. Deaths were most likely to have occurred among study participants with no healthy behaviors; the more healthy behaviors people had, the lower their risk of being among those who died.

All-Cause Mortality³¹: A 2012 meta-analysis of 15 prospective studies on the combined effects of healthy lifestyle behaviors on all-cause mortality comprised 531,804 people with a mean follow-up of 13.24 years. The meta-analysis found that the more healthy lifestyle behaviors people had, the lower the risk of all-cause mortality. None of the studies included in the meta-analysis were conducted in LMICs; 7 were conducted in Europe, 5 in the United States, 2 in Japan, and 1 in China. Healthy lifestyle was defined as not or never smoking, optimal weight, physically active, a healthy diet, and moderate consumption of alcohol—behaviors relevant to both CHD and NCDs.

The mathematical modeling and meta-analysis confirm the importance, effectiveness, and cost-savings of population-based health promotion and disease prevention programs to facilitate optimal health of large numbers of people across their life span.

Malaysian Health Promotion Board

The Malaysian Health Promotion Board³² is a statutory body in the Ministry of Health established by an Act of Parliament in June 2006. It is governed by an independent body with members from relevant ministries, nongovernmental organizations (NGOs), and health promotion professionals. Its primary role is to define “the health promotion agenda across different sectors and settings,” primarily through building capacity and funding grants.

The priority areas for health promotion are:

• Prevention and control of tobacco and alcohol

• Promotion of healthy lifestyles, including exercise and healthy eating

• Environmental health

• Mental health

• Prevention of cancer, diabetes, cardiovascular disease, and obesity

• Sexual health, including HIV/AIDS

• Research

• Promoting health through sport, cultural, and arts activities

Thai Health Promotion Foundation

ThaiHealth,³⁴ an independent state agency established in 2001, is funded by a 2% tax on tobacco and alcohol, yielding an annual budget of about US$100 million; its Governing Board is chaired by the Prime Minister. ThaiHealth works with multiple partners and funds more than 1,000 projects each year. It is a member and Chair (2010–2012) of the International Network of Health Promotion Foundations that works to enhance the performance, and support the establishment of health promotion foundations based on innovative financing.

A 10-year review of ThaiHealth³⁵ (2001–2011) identified the following achievements and challenges resulting from policy initiatives such as tobacco- and alcohol-free zones; behavior change communication campaigns coordinated with religious, community, and civil society leaders; and creating environments conducive to health.

Global Efforts Against Tobacco

The Framework Convention on Tobacco Control entered into force in 2005, reflecting broad consensus and strong evidence on effective, cost-effective interventions to reduce the massive and growing burden of disease caused by tobacco products.³⁶ Powerful, practical summaries of the evidence and guidance provided by the World Bank,^36,37 WHO,³⁸ and other groups, and committed effective action by Australia, Brazil, Canada, South Africa, Thailand, and other countries, have enabled some countries to:

• Raise taxes to make tobacco products progressively less affordable

• Reduce tobacco product advertising

• Educate people—especially smokers through graphic labeling on cigarette packs—on the risks of use and benefits of quitting

• Reduce exposure to cigarette smoke by ensuring smoke-free public places

• Offer effective support to people who want to quit

The impact of determined, evidence-based antismoking measures is clear. A recent estimate finds that 41 countries that implemented, between 2007 and 2010, at least 1 of 5 key interventions to a level that met WHO criteria, will have reduced the number of smokers by 14.84 million and averted an estimated 7.42 million smoking-attributable deaths (range: 4.6–10.4 million) among smokers alive in 2007.³⁹ There are other concomitant benefits, too—for example, Turkey cut smoking-related hospital admissions by 20% over 8 years.⁴⁰

Global Efforts Promoting Physical Activities

Regular physical activity is important for health. The benefits include weight control; stronger bones and muscles; longer life expectancy; and lower risk of cardiovascular disease, type 2 diabetes, and some cancers.⁴¹

Governments in Brazil, Canada, Chile, Colombia, France, Mexico, the United States, among many others, actively promote physical exercise through “Ciclovia” bicycle programs that are funded primarily by public funds.⁴² In general, Ciclovias use existing streets that are temporarily closed to motorized vehicles during weekends and holidays, although some cities develop special bicycle lanes used throughout the week.⁴³ Cost-benefit ratios of 4 Ciclovia programs were 3.23–4.26 in Bogota, 1.83 in Medellin (both in Colombia); 1.02–1.23 in Guadalajara, Mexico; and 2.32 in San Francisco.⁴⁴ The programs have strong popular support.

Global Efforts Against Obesity

Brazil, Chile, Colombia, Costa Rica, and Peru⁴⁵ have passed laws that focus on improving healthy food choices offered to children, generally in schools. Some countries control the advertising of food in schools, regulate food labeling, and limit advertising especially on television.

Brazil's approach to promoting healthy food in schools includes setting nutrition standards and requiring that 30% of food in school meal programs be locally grown or manufactured and 70% be unprocessed.⁴⁵

Peru has implemented nutritional education in schools, information campaigns by the education and health ministries, monitoring nutrition, overweight, and obesity among children and adolescents, healthy food in school kiosks or cafeterias, more physical activity, and controls on advertising aimed at children and adolescents younger than 16 years.

In Mexico, one of the most obese nations according to a United Nations report,⁴⁶ legislators approved an 8% tax on soft drinks and high-calorie foods such as fried foods and sweets.⁴⁷ Mexican lawmakers are also requiring 30 minutes of daily physical education classes in schools.⁴⁸

Global Efforts Promoting Healthy Settings: Cities, Municipalities, Communities

“Healthy Settings” is a strategy supported by WHO to implement intersectoral health promotion partnerships including local governments to create environments conducive to health.⁴⁹ “Healthy Cities,” among the best-known and largest of the settings approaches launched in the 1980s, is defined as a city that is:

continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.⁵¹

The movement is considered a success. Thousands of cities around the world are implementing Healthy Cities partnerships, generally involving distal interventions, such as community organization and social development, organizational and infrastructure development, and policy development. The focus of this collaborative action often includes bike lanes and safe public space for walking and other physical exercise, better public transport, smoke-free public spaces and other pollution reduction, and healthy and affordable housing. Evaluations of the Healthy Cities project in Europe found that an appropriate mix of distal interventions for health provides a broad and sustainable effect on population health, whereas proximal interventions (for example, health and patient education, health care) yield focused health gains (often disease, gender, and age-group specific) at relatively high cost.^51,52

Low Spending on Prevention and Public Health

To a degree, the shortfalls mentioned above reflect low spending for health promotion. A recent report⁵⁹ analyzes trends in prevention and public health (PPH) expenditures from 2005–2010 in 16 African countries with National Health Accounts (NHAs).† (The 16 countries are: Benin, Burkina Faso, Botswana, Côte d'Ivoire, Democratic Republic of the Congo, Ethiopia, Kenya, Liberia, Mozambique, Malawi, Namibia, Nigeria, Rwanda, Senegal, Tanzania, and Zambia.)

Across the 16 countries, PPH expenditures per capita vary from US$4 in Burkina Faso to US$64 in Botswana. In 13 of the 16 countries, spending for curative care accounts for the largest percentage of total health expenditures (THE); in 9 countries, PPH services are the second largest expenditure. Expenditures for prevention of NCDs account for less than 3% of THE in every country. Only 9 countries provide data on how PPH expenditures are spent: most goes for prevention of communicable diseases, and about 10% is classified as “other.”

Data on the financing agents of PPH, defined as institutions or entities that channel funds provided by financing sources to pay for, or purchase, health services,⁶⁰ are available in 13 countries. In 4 countries, the primary financing agent managing PPH expenditures is the government, in another 8 it is NGOs (both local and international) and donors.

Data on providers of PPH services are available in 8 of the 16 countries. In 6 countries, providers of PPH programs received a majority (45% to 96%) of PPH expenditures, while in 2 countries the majority of PPH expenditures are used by ambulatory care providers.

Ministry of Health policy and decision-makers in the African Region recognize the importance of implementing health promotion programs to “foster actions that enhance physical, social and emotional well-being.”⁵³ To achieve this important goal, the countries also recognize they need undergraduate and graduate educational programs and highly specialized personnel. Yet the National Health Accounts indicate low per capita spending for PPH for NCDs by LMICs, compounding future challenges for health systems to maintain their populations in optimal health.