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).
The ReThink Health Dynamics Model, developed in the USA, utilises systems thinking and agent-based modelling 1Homer, J., Milstein, B., Hirsch, G. B., & Fisher, E. S. (2016). Combined regional investments could substantially enhance health system performance and be financially affordable. Health Affairs, 35(8), 1435-1443 to enable health planners to envision changes to the health system, see the effects unfold and learn from the results. A model such as this holds promise for designing health promoting services as tool for service delivery and for creating a dialogue with different sectors, service providers, and citizens.2Hirsch, G., Homer, J., Milstein, B., Scherrer, L., Ingersoll, C., Landy, L., & Fisher, E. (2012). ReThink Health Dynamics: Understanding and influencing local health system change. In 30th International Conference of the System Dynamics Society, St. Gallen, Switzerland (Vol. 80).
ReThink Health Dynamics Model
The ReThink Health (RTH) Dynamics Model is a fictive regional health system in a computer. By simulating a health system's respons to changes, it lets leaders see which investments will do the most to save lives, reduce costs, improve quality, enhance equity, and boost productivity. The model can help discover a new path to system transformation. It lets you ask 'what if' questions and get the results instantly to see how various strategies are likely to unfold. With a diverse menu of initiatives and financing options, everyone can test their own ideas and track results across scores of measures. Designed by an award-winning team of MIT-trained system modellers, the RTH Dynamics Model brings together decades of evidence and is regularly updated to reflect the latest research and input from users.
The ReThink Health Dynamics Model, representing a US region (city, county, or larger), simulates changes in population health, health care delivery, health equity, workforce productivity, and health care costs by quarter year increments from 2000 to 2040. This is done within a single, testable framework tied to many sources of empirical data and open to sensitivity analysis. It is a compartmental stock-and-flow structure with causal feedback, built according to the principles of system dynamics.
The model divides the population into ten subgroups by age (youth, working age, seniors), socioeconomic status (advantaged or disadvantaged, based on household income above or below 200 percent of the federal poverty level), and insurance status (yes or no) for youth and those of working age. The model simulates changing health states as they are shaped by unhealthy behaviours, crime, environmental hazards, poverty, lack of insurance, aging, and the quality of care. Together, those drivers affect physical illness (mild and severe), mental illness (treated and untreated), acute clinical episodes (urgent and nonurgent), and deaths.
The model considers financial incentives from different payment schemes (such as fee-for-service versus global payment) along with the program cost and return on investment for each simulated initiative. If an intervention does save health care expenditures, model users might choose to reinvest a fraction of those savings in an effort to sustain or expand the initiatives over time.
The model contains more than twenty options for simulating the likely effects of efforts to alter health risks, health care delivery, provider payment, or program financing. Each strategy can be simulated individually or in combinations. The model rests on data from more than a dozen national sources, along with numerous studies in the literature on health services, health economics, and population health. It can be calibrated to represent a particular region using available local data and small-area estimates.
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;
In 2011, to improve Hungarian health statistics as well as to make some funding available for the health service staff, the Hungarian Minister for Health suggested to introduce a tax on unhealthy food and beverages. The food industry fiercely opposed the tax, and even complained to the European Commission saying that the planned measures would harm the industry. However, the Minister of Health was ready to respond and a working group created to examine the national data on population health delivered strong evidence to support the introduction of a new tax.
The new tax was introduced in September 2011 and included sugar-sweetened beverages, energy drinks, confectionery, salted snacks, condiments, stock cubes, flavoured alcohol and fruit jams. The targeted food product prices rose by an average of 29%. At the same time, sales of taxable products fell by an average of 27%. Overall, the impact assessments concluded that consumers changed their eating habits and tax revenues contributed to the increase of wages for 95,000 health workers.
In addition to the support for the tax from health NGOs and medical staff, teachers in Hungary pushed for the energy drinks to be covered by the tax. They expressed their concerns about the direct correlation between the consumption of energy drinks among pupils and poor behaviour at school.
Initially, the national media was unsupportive of the tax and sided with the industry claiming that the measure was discriminatory. As a response, the public health sector launched several campaigns, organised several conferences and actively engaged with the media to explain the positive impact on health that the tax could bring3 Giles, A., Costigan, D., Graff, H., Stacey, R. & Modi M. (2019). Case study: The Hungarian public health product tax. UK Health Forum http://ukhealthforum.org.uk/wp-content/uploads/2019/01/Hungary.pdf.
The first impact assessment conducted in 2012 showed that around 40% of unhealthy food products manufacturers changed their product formulas either reducing (28%) or eliminating (12%) unhealthy ingredients. At the same time, since the introduction of the tax, legislation had to be reviewed five times to close the loopholes permitting manufacturers to replace taxed ingredients with other tax-exempt unhealthy ingredients.
A 20154IbidWHO analysis concluded that a fiscal instrument can play an effective role in improving a population's nutrition behaviour. However, the Hungarian tax is not a silver bullet for addressing poor nutrition or a budget shortfall. Healthier products due to product reformulation are a positive consequence of tax avoidance.
A key outcome of the tax was increased nutrition literacy, and improved nutrition behaviour beyond the direct impact of the price increase. Intersectoral action enabled accurate problem definition, development of an appropriate policy solution, and effective implementation. Continuous refinement of legislation after initial enactment was essential for exposing and shutting loopholes, ensuring tax’s effectiveness. 5Giles, A., Costigan, D., Graff, H., Stacey, R. & Modi M. (2019). Case study: The Hungarian public health product tax. UK Health Forum
There are four intended benefits of a sugar tax6Backholer, K., & Martin, J. (2017). Sugar-sweetened beverage tax: the inconvenient truths. Public health nutrition, 20(18), 3225-3227. , they:
- reduce consumption through a price increase and produce subsequent public health benefits;
- generate revenue, that could be reinvested solely into prevention measures;
- emphasise that regular consumption of sugary drinks is not part of a healthy diet; and
- incentivise manufacturers to reformulate products to reduce sugar content.
In terms of research outcomes, the 2017 Healthy Ireland survey showed that 16% of adult population drank sugar sweetened drinks (SSDs) daily. Almost half of 13 year olds consume SSDs at least once per day, while males, young people and those from lower socio-economic groups are the most frequent consumers.
The Institute of Public Health, Ireland was requested by the Department of Health to undertake a Health Impact Assessment (HIA) of the proposed tax. As part of this assessment, a stakeholder engagement event was organised with representatives from a range of sectors, including the health and the food and beverage industries. In addition, a review of current literature and a modelling exercise were also carried out.
The HIA concluded that:
- SSDs are a source of energy intake with little or no nutrient value;
- Price increases tend to decrease demand, but the degree to which this happens is variable;
- There is a positive relationship linking consumption of SSDs to overall energy intake;
- A 10% tax on sugar sweetened beverages could reduce the number of obese adults in Ireland by 10,000. This reduction would be greater in young people and regular consumers.
A public consultation process was also engaged by the Department of Finance in order to determine views in relation to the design, scope and practical implementation issues of the tax. This process received 30 submissions, which are published on the Department of Finance website.
Finally, the Health Research Board commissioned an opinion poll with adults in Ireland on the topic of SSDs. This research revealed that 44% of purchasers would buy SSDs less frequently if the price increased by 10%, while 34% would not change their purchasing behaviour. 40% also stated that they would switch to diet drinks if they were cheaper than SSDs. Women were more likely to respond to this price change than men.
Per the Irish budget for 2018, it was estimated that this tax would generate €30 million by the end of 2018 and €40 million within one full year. In 2018, following its inception in May, the tax produced €16.5 million in revenue. Figures released in July 2019 show that the tax had produced €15.8 million in revenue in 2019 so far. The funds generated through this tax are allocated to general funds as hypothecation (the dedication of a specific tax for a particular expenditure purpose) is not a feature of the Irish tax system.
Early research from the sugar tax in Mexico has had two noteworthy findings:
- The tax on sugar sweetened beverages was associated with reductions in purchases of taxed beverages; 7Colchero, M. A., Popkin, B. M., Rivera, J. A., & Ng, S. W. (2016). Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. bmj, 352, h6704.
- Purchases of untaxed beverage increased 2.1 percent in the first two years following the introduction of the tax.8Colchero, M. A., Rivera-Dommarco, J., Popkin, B. M., & Ng, S. W. (2017). In Mexico, evidence of sustained consumer response two years after implementing a sugar-sweetened beverage tax. Health Affairs, 36(3), 564-571. In Mexico, two years after the introduction of a tax on sugary drinks, households with the fewest resources reduced their purchases of sugary drinks by 11.7%, compared to 7.6% for the general population.
A different type of governmental funding via taxes is the Politique gouvernementale de prevention en santé in Quebec, Canada, which is funded by taxes on tobacco. The government of Quebec has developed an inter-ministerial action plan that aims to increase structured upstream action on social determinants of health (SDOH) to improve health, to decrease the incidence of avoidable health problems, and to reduce health inequalities within the province.
This is a pan-governmental policy and multi-year action plan that binds the commitment of 15 ministries and governmental organisations from various sectors. The policy and action plan foster collaboration, complementarity, synchronisation and coherence of ministry interventions. It consists of concrete ministerial measures designed and operationalised to affect the individual and environmental dimensions that make a population healthy: lifestyle, schooling, land use, housing, income, working conditions, living environments, and organisation of the health and social services systems.
The taxes from tobacco sales are key to funding the prevention plan and none of the revenue from tobacco taxes is directed to the tobacco industry.
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.