Strategic development for effective investments
The COVID-19 pandemic highlighted the vulnerability of our health systems, the burden of chronic diseases and the persistent health inequalities in our societies. Now more than ever, it is important to strategise for health promoting services. There is evidence that these services, delivered within the health system, as well as in partnership with social and other sectors, are effective and offer economic benefits over time (‘best buys’). Primary prevention works and prevention is better than any cure. This entails understanding how, when, and for whom health promoting services work and seek to work and how to finance them.
Planning for strategic opportunities
Those strategising how best to organise services for current and future health challenges can, for instance, make use of the Kingdon model. This model proposes the existence of three non-linear streams in policy-making – problems, policies and politics – which interplay to open so-called “windows of opportunity” for policy decisions and which should coincide in order for policy change to occur. Applying this model can help prepare for change for policy and investment decision-makers, as well as practitioners.
Following this principle, it would be optimal to plan for and adopt a “Health in all Finances” approach at all levels alongside the “Health in all Policies” thinking that is more widely used. This would integrate health promotion strategies with investment strategies within relevant fields and bodies.
We are seeing new dynamics and paradigms towards transition in all systems. These offer new opportunities for change to meet health promotion and health equity goals. They may be grouped for this purpose into four aspects that merit exploration as sound reasons for investments in health promoting services:
- Economic and financial changes affecting fiscal and financial stability and growth;
- Technology developments, including communications and biosciences;
- Demographic changes including migration and ageing;
- Climate and environmental
Together, these are encompassed in the global goals of UN Agenda 2030 and the universal Sustainable Development Goals (SDGs). These present a powerful framework for actions from international organisations, including the WHO and the EU, but also for all local communities, authorities, agencies and States to use as a basis for change.
As these goals and targets receive greater attention towards 2030, it is highly likely that political awareness, policy imperatives, systems priorities and resources will become more focused on them. Because these goals are universal, windows of opportunities can be found almost everywhere. Many of these goals will be accompanied by financial measures and investment opportunities, ranging from research to implementation. Health promoting services, which offer solutions to needs, will be well placed.
For example, the introduction of EC proposals for an integrated European Green Deal, which includes extensive legislation, programmes and investment needs across many health determinants, is highly significant. It will provide platforms for the development of health promoting transformations and services across sectors and systems, including the application of a Just Transition Fund in areas where services are impacted by a transition to sustainable energy sources. It will also include a Farm to Fork Strategy for food systems, which will include provisions and indicators regarding health determinants. This strategy will open new pathways for partnerships, funding and investments, conceivably opening opportunities for further reforms to European agricultural policies and practices in EU programme developments from 2021 to 2027 and beyond.
The EU co-funded research consortium INHERIT, which was coordinated by EuroHealthNet, has produced a wealth of information and recommendations on how to achieve a valuable “Triple Win” of progress on health, equity and sustainability. This includes policy advice and toolkits for local, national and international policymakers; process and analysis models; extensive initiatives and evaluated case studies, which offer substantial bases for evidence, adaptation, scaling up and investment attraction.
Transformation of health systems
The expert group on Health Systems Performance Assessment (HSPA)1 of the European Commission evaluated the transition to integrated care in Europe. The review proposed the following 'building blocks' or 'system levers' for change:
- political support and commitment
- stakeholder engagement
- organisational change
- and collaboration and trust
Making the shift from centralised systems of care to localised, integrated services in communities is challenging, as it involves a fundamental re-configuring of health systems. The shift from curative to preventative care requires a similar shift in perception, direction, and action. There is a clear need to strategise these shifts to enable health promoting services to prepare for the next fifty years.
Strategic goals must be responsive to local contexts, existing barriers and facilitators, as well as to the values held in communities of interest. They must also take into consideration the current health service delivery system, and the financial and political resources available to support change – but as these pages show there are new opportunities now. This again recognises the need for horizontal integration across services and related sectors (for example health and social care).
Investing in sustainable community-based systems
The WHO global strategy on integrated people-centred health services calls for reforms to reorient health services. It is a strategic approach that links societal shifts and sustainability demands with transformative service implementation. This entails shifting away from fragmented supply-oriented models, towards health services that put people and communities at their centre. It surrounds them with responsive services that are coordinated both within and beyond the health sector, irrespective of country setting and development status.
This WHO Europe report on the economic and social impact of health sets out the rationale, evidence, methods and examples to understand the significant potential economic and social impacts and benefits in communities. It seeks to support broader efforts to see health systems as key in promoting equitable and inclusive development, helping to create benefits for the whole community, in particular for those who are often left behind. This approach has great potential for integrated finance and investment planning, sustainable procurement policies and practices, plus wider sustainable development.
The 2016 Joint Report on fiscal sustainability of health and care systems by the European Commission and the EU Economic Policy Committee and its 2019 updates on country by country situations and prospects form valuable tools of evidence and examples for deciding strategic options for health promoting services where best value can be added.
It specifically states that “In particular, governments should address inefficiencies in hospital care and pharmaceutical spending; invest in health promotion, disease prevention, and primary care; and improve the governance of health systems.”
An important source of strategic information, policy dynamics and associated resource allocation for all EU States is the annual European Semester process. Originally termed the EU economic governance process, it has since been updated significantly and now includes highly significant social, health and environmental sustainability components and objectives.
While national fiscal measures by states offer advantages of scale and impact, regional or local dimensions should also not be overlooked. Localised taxes can provide culturally focused impacts for integrated health promotion and equity initiatives. Similarly, localised incentives for smaller businesses or to address specific problems can be more rapidly effective than complex national negotiations and trade-offs. Of course, avoiding inequities between localities should be avoided.
Fiscal measures in social, economic, environmental or educational spheres can have effective co-benefits for health and equity, making fiscal incentives available along social gradients.
When priorities are established in an integrated framework, new logical opportunities to identify fiscal measures, financing and funding arise. Fiscal measures that respect health and related systems are being considered or applied in many countries and regions.
These measures may affect health promotion directly or indirectly as part of a “toolbox” including:
- specific levies on goods and hypothecation (specific uses) for such levies;
- consumption and environmental taxes and charges
- tax incentives for regions, individuals, businesses and organisations to stimulate and promote wellbeing;
Technological change can be a powerful driver for desirable reorientation towards health promoting services through strategically applying new forms of equitable, ethical and sustainable investments.
One key question to be addressed in planning for new digital health promoting services, or those embracing other technologies including genetic, nano, biosciences and artifical intelligence, is the extent to which mutual understanding of all relevant stakeholders is assured. Often, technology providers complain that health bodies do not appreciate their potential needs or benefits – the so-called commercial “offers and asks”.
However the converse applies that external providers may not fully understand health needs and impacts. This applies when strategically considering investments in policy and practice planning and implementation phases – and of course applies as well to developing all forms of health promoting services, whether introducing emerging technology components or not.
Authorities and investors should structurally involve providers such as health services or experts, as well as the users and potential beneficiaries to develop the best instruments at the best time to find the best solution. The purpose is not only about how to prioritise investments; it is also about how to attract investment.
Digital health literacy is an essential element for the successful transformation of health and care systems, but it is vital to ensure that no-one is left behind. Digitally health literate people can more actively manage personal health and care. This in turn can also have positive effects on the efficiency and sustainability of health systems. Better digital health literacy can lead to enhanced prevention models, better observance of healthier behaviours and improved wellbeing.
Foresight and evaluation
This section on strategy and forward thinking would not be complete without mention of two very broad and vital components:
Most planners of health policy or systems will be familiar with both. However they are not necessarily used most effectively in terms of investment for health promoting services and developments. Foresight and evaluation should not be an afterthought during planning initiatives, but instead can used as a core element to attract investments.
Foresight analyses are increasingly used across policy sectors, including public health. For example on future proofing food systems, which has relevance for health promoting services.
Many countries use foresight techniques in strategic development for public health, including through strategic updates commissioned by public or private bodies. A useful example could be from The Netherlands Institute for Public Health and Environment (RIVM) which regularly produces comprehensive Public Health Foresight Studies (PHFS).
These studies provide insight into the most important societal challenges for public health and health care in the Netherlands. They are commissioned by the Ministry of Health, Welfare and Sport and are used to inform national and local public health policy. Typical aspects of the PHFS methods are a multidisciplinary, participatory and conceptual approach, using a broad definition of health. It is easy to see how more widespread use of such approaches could contribute to the development of more effective health promoting systems and services.
Last but not least, it is important to integrate evaluation as a component of strategic planning and thinking. This is an often-overlooked aspect of programme, policy, practice and project cycles, with evaluations (and some audits) treated as unimportant “tick box exercises” – and metrics or targets too far beyond effect to be meaningful. Conversely, it is then often claimed that evidence of outcomes or effectiveness is not available. When addressing strategic approaches for investment paradigms and new funding sources, these “real time” cycles become essential.
Evaluation cycles need to be to be appropriate for investment purposes. it cannot just be assumed that traditional approaches are sufficient for new methods of funding.
In the graph from the Rainbow Framework, we find an example of how strategic planning and forward-thinking address impact investment in evaluation cycles.
Impact investment aims to create positive social change alongside financial returns, thereby creating blended value. Evaluation and assessing the intended and actual blended value created is an important part of the process.