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POLICY BRIEF
HEALTH SYSTEMS AND POLICY ANALYSIS
How can European health
systems support investment
in and the implementation of
population health strategies?
David McDaid, Michael Drummond and
Marc Suhrcke
© World Health Organization 2008 and World Health
Organization, on behalf of the European Observatory
on Health Systems and Policies 2008
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This policy brief, written for
the WHO European
Ministerial Conference on
Health Systems, 25–27 June
2008, Tallinn, Estonia, is one
of the first in what will be a
new series to meet the needs
of policy-makers and health
system managers.
The aim is to develop key
messages to support
evidence-informed policy-
making, and the editors will
continue to strengthen the
series by working with
authors to improve the
consideration given to policy
options and implementation.
Keywords:
DELIVERY OF HEALTH CARE -
trends
HEALTH PROMOTION
HEALTH ECONOMICS
HEALTH POLICY
POLICY MAKING
STRATEGIC PLANNING
EUROPE
Authors
David McDaid, LSE Health and Social Care,
London School of Economics and Political
Science, London, United Kingdom, and European
Observatory on Health Systems and Policies
Michael Drummond, Centre for Health
Economics, University of York, United Kingdom
Marc Suhrcke, Venice Office, WHO Regional
Office for Europe
Contents
Page
Key messages
Executive summary
Policy brief
The case for investing in health
promotion and disease prevention
strategies in Europe 1
Policy options: generating and using
existing evidence on the effectiveness
and cost-effectiveness of population
health strategies 6
Policy options moving forward:
strengthening the evidence base and
examining institutional arrangements 10
Identifying alternative ways of bringing
about change 17
Summary 20
References 22
Editors
WHO Regional Office for
Europe and European
Observatory on Health
Systems and Policies
Editor
Govin Permanand
Associate Editors
Josep Figueras
John Lavis
David McDaid
Elias Mossialos
Managing Editors
Kate Willows
Jonathan North
The authors and editors are
grateful to the reviewers
who commented on this
publication and contributed
their expertise.
ISSN 1997-8073
Key messages
Policy issue and associated policy challenges
• Population health is influenced by a variety of factors, many of which
require action outside the health system.
• The health and socioeconomic costs of the key contributors to poor health
in Europe are substantial. Many of these health problems are avoidable.
• There is a growing body of information not only on the effectiveness but
also on the cost-effectiveness of population health interventions.
• Policy measures to help promote investment in effective interventions need
to focus on improving both the quality and use of evidence across multiple
sectors.
Policy options
• One option to strengthen the evidence base might be to expand the remit
of existing regulatory bodies that assess the cost-effectiveness of health
care technologies.
• A second option in parts of Europe where capacity for evaluation is limited
might be to adapt existing information to the local context to make the
case for investment.
• Various institutional arrangements, including the possibility of a stand-
alone ministry for population health, might help to facilitate coordination
and secure funding for action; other related options include joint budgets
or monetary transfers between sectors.
Facilitating implementation
• When new assessments are conducted, these might begin by focusing on
interventions likely to be highly effective, cost-effective and
noncontroversial. This can help new institutions to establish their presence
and credibility.
• Improving communication between researchers and policy-makers across
sectors can help facilitate change; knowledge brokers might provide a link
between different groups.
• Increasing awareness of the health, non-health and economic effects of
interventions can help to reduce resistance to action outside the health
sector. Health impact assessment may have a role to play in this process.
• Mechanisms to monitor the implementation process across sectors might
Investing in and implementing population health strategies
also help facilitate change; setting explicit measurable targets on
population health objectives might provide further incentives for
stakeholders across sectors to take action.
Policy brief
Executive summary
Poor health in Europe has substantial health and socioeconomic costs. Much of
this burden might be avoided by implementing effective population health
strategies, both within and outside the health system. A broad approach to
promoting population health requires a combination of upstream and
downstream measures. Upstream measures may include measures that, among
other goals, can help promote health, such as fiscal redistribution, improving
the quality of housing and using incentives to encourage students to stay in
school. Downstream measures include health promotion and primary disease
prevention action, often targeting individual behaviour and lifestyle.
To support investment in population health strategies, health systems must be
able to identify not only what works and at what cost but also in what context.
Mechanisms to allow such information to be fed into the policy deliberation
process and also to facilitate the implementation of agreed population health
strategies are then required.
Generating and using existing evidence on the effectiveness and cost-
effectiveness of population health strategies
Using systematic reviews
Systematic reviewing, which seeks to systematically identify and appraise
effectiveness (and other evidence) on a given topic, can be particularly useful in
assessing whether interventions are effective. Collating and, where feasible,
statistically pooling information from studies reduce the probability that one
unrepresentative study would bias the results of any effectiveness analysis.
Information from existing high-quality reviews can also provide rapid
information on the evidence (and evidence gaps) on a particular topic. This may
avoid duplicating time-consuming and costly reviews.
Using economic evaluation
Economic evaluation can also strengthen the case for investing in population
health interventions. Widely used in the health care, environmental and
transport sectors, economic evaluation compares the costs and effects of
alternative courses of action.
Evidence on the cost-effectiveness of population health interventions, while
modest compared with health care evaluation, has grown rapidly, particularly
for screening and vaccinations. Examples of complex cost-effective
interventions in specific settings and contexts include targeted exercise
programmes for older people, measures for controlling tobacco, drugs and
alcohol (including taxation), early-year interventions targeting children and their
Investing in and implementing population health strategies
parents and traffic-calming and transport safety measures. Many interventions
are funded and delivered outside the health system.
Policy options moving forward: strengthening the evidence base
How can countries better use effectiveness and economic evaluation in their
deliberations on population health strategies? Institutional and regulatory
arrangements might include independent agencies to assess evidence; in-house
government agencies; and support for knowledge clearing houses.
Establishing and/or expanding the remit of health technology
assessment agencies
One option might be to expand the remit of existing health technology
assessment agencies. In England, the National Institute for Health and Clinical
Excellence now collates evidence on the effectiveness and cost-effectiveness of
public health interventions. Evaluation includes mental and physical well-being
interventions delivered in the workplace and school-based alcohol education
strategies. It uses a highly formalized process taking up to one year to
complete, which includes opportunities for stakeholder input and formal links
to the policy-making process. It adopts a broader economic perspective than
that used for health care interventions, recognizing effects outside the health
care system.
Adapting results from existing economic evaluation
Another approach, especially when resources are limited, may be to adapt
information on existing cost-effectiveness studies, such as using the WHO-
CHOICE (Choosing Interventions that are Cost Effective) programme. This
allows a range of interventions, including those for prevention, treatment and
rehabilitation, to be compared in isolation or in combination to determine an
optimal mix of resources within a health care system. The results are presented
in such a way as to determine the probability of an intervention being cost-
effective in low-, medium- and high-resource situations. They can be adapted,
using local information, to specific country contexts.
Reforming institutional arrangements
Institutional structures and governance arrangements can also influence the
success of the implementation of population health interventions. One
possibility, given that funding for population health within health care budgets
can be severely limited, would be to establish a dedicated ministry. Very few
attempts have been made to set up such institutions. One rare example is the
Ministry of Health Promotion in Ontario, Canada, established in June 2005. It is
still too early to judge how effective this model will be; the challenge of
Policy brief
coordinating activities with the health ministry might also mean that public
health becomes more marginalized from mainstream health care policy.
Other alternatives include establishing specific governance structures for
population health within a health ministry, including a ministerial post,
partnership arrangement to encourage intersectoral cooperation at both the
national and local levels and flexible funding structures, including mandatory or
voluntary joint budgets.
Identifying alternative ways of bringing about change
What mechanisms might be available to ensure that population health is on the
agenda of policy-makers in all sectors and at all levels, directing them to be
aware of the health consequences of their decisions and to accept their
responsibilities for health? How can governments provide incentives to
administrative bodies to implement national policy on population health?
Giving priority to the low-hanging fruit
In building the evidence base on population health interventions within a
country, initially picking low-hanging fruit – interventions likely to be highly
effective, cost-effective and noncontroversial – may be prudent. Several health
technology assessment agencies have adopted this policy when they are
becoming established. This can help organizations to establish their presence
and credibility.
Improving the communication between researchers and policy-makers
Researchers and policy-makers often do not speak in a common language and
may distrust each other. Knowledge brokers, individuals who understand
scientific evidence but are comfortable working in a policy-making
environment, may help overcome this problem. They can help translate
academic reports into brief messages relevant to policy-makers and help ensure
that policy-makers commission feasible research. With appropriate training,
staff from international agencies, such as WHO, could potentially act as
knowledge brokers.
Improving the awareness of health effects among policy-makers across
sectors
Awareness of the health effects of policies developed and implemented outside
the health sector may be limited. One way of improving awareness may be
through the formalized use of health impact assessment. This has been used in
several countries, but the extent to which it has facilitated change remains
unclear.
Investing in and implementing population health strategies
Targets, monitoring and evaluation
Investing in systems to monitor and evaluate implementation and measuring
the longer-term effects on population health outcomes can also be helpful.
Joint targets across government departments might be set and progress
towards achievement monitored. Negative publicity arising from failing to
achieve targets may act as a powerful incentive for action.
Policy brief
Policy brief
The case for investing in health promotion and disease prevention
strategies in Europe
Developing a systematic approach to investing in population health strategies
across Europe in its most simple form raises three key issues. First, it requires
assessing key health problems, including their broad socioeconomic
consequences. Second, are effective interventions available to reduce poor
health? How might they compare to alternative potential uses of scarce
resources? What effects will they have on different segments of the population?
Are they suitable for a specific country context? Finally, how can evidence be
used as part of a policy-making process and for facilitating implementation?
The nature of health problems in Europe
Health has been improving across much of the WHO European Region, with
average life expectancy at birth reaching 74.5 years by 2005. This, however,
masks significant variation, with life expectancy ranging from just 65.4 years in
the Russian Federation to 81.6 in Iceland. In general, health status is poorer in
many countries in the central and eastern part of the Region. In 2005, life
expectancy in the 15 countries that were European Union (EU) members before
May 2004 was 79.7 versus 74.0 in the 12 countries joining the EU later and just
67.0 for countries in the Commonwealth of Independent States (1).
Noncommunicable diseases account for 77% of the total disease burden, with
external injuries and poisoning contributing a further 14% and communicable
diseases 9% (Table 1) (2). For men and women, respectively, poor health is
dominated by cardiovascular diseases (men 22.95%, women 22.82%),
neuropsychiatric conditions (men 17.15%, women 22.53%) and cancer (men
11.25%, women 11.63%). Unintentional injuries are also substantial,
accounting for 12.95% of the disease burden for men.
Although the European Region as a whole has many problems in common,
different parts of the region have different needs. Compared with the more
affluent Eur-A countries, the Eur-B and Eur-C countries have much higher rates
of injury and communicable disease. Population health strategies may focus on
different issues in these contexts: such concerns as self-inflicted injuries and
cirrhosis of the liver may be higher priorities.
What are the economic effects of poor health in Europe?
In addition to the profound effect of poor health on individuals and their
families, evidence from such studies (albeit largely from western Europe and
estimated using a variety of methods) suggests that the attributable
1
Investing in and implementing population health strategies
Policy brief
2
Table 1. Burden of disease in the percentage of disability-adjusted life-years (DALYs) by cause, sex and mortality stratum in the
WHO European Region, 2002
Eur-A Eur-B Eur-C European Region
MFBoth
sexes M F Both
sexes M F Both
sexes M F Both
sexes
Total communicable,
maternal, perinatal and
nutritional conditions
4.40 F5.53 4.93 15.34 17.72 16.44 9.24 7.86 8.68 9.14 9.59 9.34
Infectious and
parasitic diseases
1.76 1.68 1.72 5.53 5.28 5.41 5.54 2.95 4.49 4.30 3.09 3.77
Respiratory infections 1.32 1.35 1.33 4.05 4.03 4.04 1.79 1.02 1.48 2.18 1.93 2.07
Perinatal conditions 1.00 0.93 0.97 4.42 3.99 4.22 1.04 1.13 1.08 1.85 1.80 1.83
Nutritional deficiencies 0.32 0.89 0.59 1.34 2.29 1.78 0.88 1.66 1.20 0.81 1.54 1.13
Total noncommunicable
diseases
85.10 89.5 87.18 69.55 76.57 72.29 62.85 81.24 70.29 71.72 83.05 76.73
Neuropsychiatric
conditions
24.18 29.20 26.55 16.41 21.40 18.71 12.25 16.72 14.06 17.15 22.53 19.52
Cardiovascular diseases 18.31 15.71 17.09 22.19 21.10 21.69 26.88 31.08 28.58 22.95 22.82 22.90
3
Investing in and implementing population health strategies
Malignant neoplasms 17.19 15.78 16.53 9.02 8.38 8.72 8.02 9.80 8.74 11.25 11.63 11.42
Respiratory diseases 6.65 6.51 6.59 4.15 4.05 4.10 2.87 3.00 2.93 4.41 4.56 4.48
Sense organ diseases 4.29 5.30 4.77 3.48 5.07 4.21 2.58 4.99 3.56 3.35 5.13 4.14
Digestive diseases 4.92 4.38 4.67 5.30 4.73 5.04 4.93 5.25 5.06 5.02 4.80 4.92
Musculoskeletal diseases 3.20 5.42 4.25 3.10 5.09 4.01 1.94 4.95 3.16 2.63 5.16 3.75
Diabetes mellitus 2.00 2.29 2.14 1.31 1.72 1.50 0.56 1.30 0.86 1.21 1.77 1.46
Total injuries 10.50 4.97 7.89 15.1 5.70 10.77 27.91 10.91 21.03 19.14 7.36 13.93
Unintentional injuries 7.67 3.88 5.88 11.52 4.51 8.29 17.74 7.66 13.66 12.95 5.45 9.63
Intentional injuries 2.83 1.09 2.01 3.59 1.19 2.48 10.17 3.25 7.37 6.19 1.92 4.30
Source:Global burden of disease estimates (2).
Eur-A: 27 countries in the WHO European Region with very low mortality among both children and adults.
Eur-B: 17 countries in the WHO European Region with low mortality among both children and adults.
Eur-C: 9 countries in the WHO European Region with low mortality among children and high mortality among adults.
socioeconomic effects of poor health are substantial. The most important cause
of poor health, cardiovascular diseases, was estimated to cost more than €168
billion annually in the 25 countries that were EU members in 2005 (EU-25),
with health care systems paying more than 60% of the costs (3). Assessments
of the economic effects of common risk factors for cardiovascular diseases and
other health problems have estimated that illness related to obesity accounts
for between 1.5% and 4.6% of total health care expenditure in France (4),
4.6% in the United Kingdom (5) and 1.9% in Sweden (6).
Depression is a major problem in Europe. The costs of unipolar depression in
the EU-25 countries are estimated at €118 billion annually, with 64% of costs
falling outside the health care system due to high rates of absenteeism and
premature retirement from the labour force (7). This estimate may be
conservative; studies in the United States of America have estimated that the
costs of presenteeism (reduced performance at work) due to depression may be
five times greater than the costs of absenteeism (8).
Alcohol disorders, another key cause of poor health in Europe, have been
conservatively estimated to cost European economies about 1% of gross
domestic product (9). Across the EU-25 countries, even taking account of
alcohol’s preventive effects, they are estimated to cause 115 000 deaths annually
at a cost of €125 billion. Similar to depression, many of these costs fall outside
the health care system and are due to lost productivity, crime and violence (10).
Turning to unintentional and intentional injuries, the costs of road traffic
accidents are estimated to be about 2% of gross domestic product in Europe.
They are the leading cause of hospitalization and death for people younger
than 50 years in the EU, costing €180 billion annually (11). Although data are
sparse, these costs may be even higher in the eastern part of the European
Region because of the higher accident rate. The same might also be said of
self-inflicted intentional injuries. Data from western Europe suggest that each
completed suicide costs society about €2 million (12).
What are the implications for European policy-makers?
Given these socioeconomic effects, a key question for European policy-makers
is the extent to which health systems should help facilitate investment in
policies and strategies intended to help reduce the demands for health care
through effective health promotion and disease prevention activities.
Good evidence indicates that preventive measures delivered within health care
systems, such as vaccinations or statins to tackle cardiovascular diseases, might
substantially reduce avoidable mortality (13–15). Nevertheless, it has long been
recognized that any strategy to promote population health needs to take a
broad perspective involving action within and outside the health system (16).
Policy brief
4
In addition to biological and genetic characteristics, the socioeconomic
environment in which individuals live can substantially affect the risk of
premature mortality and avoidable morbidity (17).
A broad approach to promoting population health could involve a combination
of upstream and downstream measures. Upstream measures may include
measures that, among other goals, can help promote health, such as fiscal
redistribution, improving housing and using incentives to encourage students to
stay in school. Downstream measures include health promotion and primary
disease prevention action, often targeting individual behaviour and lifestyle.
Strategies might, for example, include interventions such as diet and lifestyle
advice programmes, implementing policies to control tobacco and alcohol,
monitoring water and air quality, vaccination campaigns and, for accidents and
injury, legislative, regulatory and other safety measures.
Finding the right balance and facilitating change
So what should the balance be between population health interventions and
health care treatment? Addressing this question in an evidence-informed
manner requires information on both effectiveness and cost-effectiveness.
Funding for evaluating population health interventions is limited compared with
treatment, where licensing and reimbursement mechanisms often ensure
evaluation. Nevertheless, the evidence base to support action, albeit limited, is
growing rapidly (18). Moreover, Suhrcke et al. (19) have shown that better
health may well entail significant broader economic benefits in Europe. How
can the existing evidence base be strengthened and adapted to differing
contexts and linked to the policy-making process?
Another issue to consider is what institutional mechanism and funding
arrangements might best support evidence-informed investment both within
and outside the health system. Funds appropriated for health promotion and
public health appear to be modest relative to their potential to alleviate poor
health, ranging from less than 1% of health care expenditure in Italy and
Denmark to almost 6% in Canada (20). In part, this may reflect the limited
protection and low funding priority for population health activities. One
challenge is to ensure that funds intended for investment in effective
population health interventions do not get diverted to other uses. Another
challenge is to overcome financial silos: institutional and attitudinal barriers that
limit investment in external sectors.
What steps might be taken to help facilitate implementation? Key to this may
be improving the lines of communication between those producing evidence
on what works and at what cost and other stakeholders: not only policy-makers
in health and other sectors such as finance but also other groups such as
5
Investing in and implementing population health strategies
service delivery professionals, the private sector and the general public. This
might involve thinking about how to tailor messages to different audiences.
Disseminating success stories and using incentives such as targets on
population health may also be useful.
Policy options: generating and using existing evidence on the
effectiveness and cost-effectiveness of population health strategies
Using systematic reviews
Some have argued that investment in population health strategies is limited
because of the limited evidence base: randomized controlled trials cannot
always be used to measure effects. We cannot discuss in detail different ways
of generating evidence, but ideally many types of evidence, both quantitative
and qualitative, can inform the policy-making process.
Experimental studies can help to reduce the chance of bias in specific studies,
but the controlled conditions in which these studies are conducted may mean
that the results are not easily generalized. Qualitative research, for instance, can
help to identify which population health promotion interventions are
acceptable to target population groups.
Systematic reviewing, which seeks to systematically identify and appraise
effectiveness (and other evidence) on a given topic, can be particularly useful in
assessing whether interventions are effective. Collating and, where feasible,
statistically pooling information from several studies reduces the probability that
one unrepresentative study would bias the results of any effectiveness analysis.
Information from existing high-quality reviews can provide policy-makers with a
rapid source of evidence (and evidence gaps) for a particular topic. This may
reduce the need for time-consuming and costly additional reviews and, where
required, limit the scope of any new review, for example, to the time period
after existing reviews.
High-quality reviews are available from several sources, most notably the
Cochrane (health) and Campbell (education, social welfare and crime)
Collaborations, the United States Preventive Services Task Force sponsored by
the United States Agency for Healthcare Research and Quality, and the Task
Force on Community Preventive Services sponsored by the United States
Centers for Disease Control and Prevention (21). The Cochrane Public Health
Collaborative Group is being established. Unlike existing Cochrane reviews,
which focus mainly on interventions targeted at individuals, this group will
focus on “systematic reviews of interventions and programmes, which seek to
address upstream determinants of health, targeted to whole populations or
particular target groups” (22).
Policy brief
6
Policy-makers could specify that information on the findings of existing reviews
be assessed before agreeing to fund any evidence synthesis. If new studies are
required, well-accepted guidelines on design are available to help
commissioners (23). Policy-makers might then focus their attention on
considering whether interventions identified through review need to be
adapted to be implemented in their specific country contexts.
Making use of economic evaluation
Another reason for the modest investment in public health and health-
promoting interventions to date may be the lack of information on the cost-
effectiveness of interventions (24). Although these potential health (and
non-health) benefits may be substantial, economic evaluation can still
strengthen the case for investing in population health interventions.
Any decision to invest in population health interventions needs to consider the
human and infrastructure costs associated with delivery. For instance, is
preventing health problems rather than simply treating the smaller group of
individuals who become ill really more cost-effective? Are there also potential
gains from reducing or delaying the need for consuming future health care
resources and from reducing the external costs to economies resulting from
absenteeism and health-related early retirement from the labour force? What
additional non-health-related benefits, such as improving community cohesion
and educational performance and reducing crime, might be realized (25)?
Systematically using economic evaluation can be one aid to setting priorities
both within and outside health systems. Widely used in the health care,
environmental and transport sectors, economic evaluation can be considered
“the comparative analysis of alternative course of action in terms of both their
costs and consequences” (26–28). It acknowledges that scarcity is an endemic
feature of all societies and implies that investment in one specific public project
will mean a lost opportunity to use these resources for another purpose. Even
in the absence of long-term effectiveness data, economic evaluation can use
modelling techniques to assess the long-term costs and effects and/or identify
the level of effectiveness a strategy would have to achieve to be considered
cost-effective.
If a new intervention is both less costly and more effective than the existing
situation, then the decision is usually straightforward – invest in the new
intervention. If an intervention is both more effective and more costly, then
policy-makers must make a value judgement as to whether it is worthwhile.
The resources and infrastructure available influence this: what may be deemed
cost-effective in Ireland or France may not be in Tajikistan or Georgia.
Economic evaluation should not be used in isolation. Policy-makers need to
7
Investing in and implementing population health strategies
consider other factors. Investment in the most cost-effective intervention might
conflict with other policy goals, such as reducing inequality in health or non-
health outcomes between social groups. Other inputs into deliberation might
include the need to ensure fair access to services and support, the effects on
the local economy of a population health measure, such as the effects of
banning smoking on pubs and restaurants, or local political concerns.
Approaches to economic evaluation
Although existing methods of economic evaluation of population health
interventions are helpful in strengthening the case for investment, applying
them presents practical and methodological challenges (29,30). Guidelines from
health technology assessment bodies tend to recommend the use of cost-utility
analysis, where outcomes are measured in utility: that is, an individual’s
preference for a specific level of health status or a specific health outcome,
such as the quality-adjusted life-year. This approach allows comparisons on
investment decisions within the health system but does not capture the
potential substantial non-health effects of population health interventions.
Alternative approaches are available, but all have limitations. In England, public
health guidance developed by the National Institute for Health and Clinical
Excellence allows the use of cost-consequences analysis as an addendum to
cost-utility analysis. This approach can present a range of natural health and
non-health outcomes, such as heart attacks avoided or a reduction in crime
rates. It is then up to policy-makers to assess which outcome (if any) may be
most important.
Although useful, this approach cannot easily deal with situations in which
health outcomes might only be modest but non-health effects elsewhere might
be more positive. For example, providing breakfast at school free of charge may
only lead to a modest improvement in nutritional intake but may generate
additional effects on social and educational development (31,32).
Cost–benefit analysis may be a solution. Widely used in transport and
environmental appraisal, it measures both costs and benefits in monetary
terms, allowing investment in health to be compared with investment in other
sectors such as education. The value of non-health as well as health gains can
therefore be measured using the same terms, greatly aiding decision-making. A
positive net benefit would merit investment.
The challenges of eliciting accurate monetary values for outcomes and negative
public perceptions of valuing health in monetary terms have limited the use of
cost–benefit analysis. Public health guidance from the National Institute for
Health and Clinical Excellence, however, enables a broader perspective on costs
than the conventional consideration of costs to the health and social care
Policy brief
8
system. It can, for instance, examine the effects of workplace health promotion
programmes on absenteeism and productivity levels.
What is known about the economic case for investment in population health
strategies?
Although the results of economic evaluation need to be interpreted carefully, is
the evidence base actually limited as has been claimed? Although it is modest
compared with that for health care interventions, it has grown rapidly. Several
sources of information can now provide relevant information on cost-
effectiveness. These include traditional economic evaluation databases, such as
the freely available National Health Service (NHS) Economic Evaluation Database
in the United Kingdom and WHO-CHOICE.
The literature has been reviewed several times (33,34). One review (18)
identified more than 1700 evaluations, most in the past 10 years. More than
60% were vaccination and screening interventions that could largely be
delivered within health care systems. This may reflect the relative ease in
quantifying resource use, cost and short-term outcomes in terms of true
positive cases detected or successful immunization conducted. In the longer
term, modelling has also been used to assess their lifetime benefits. Although
vaccinations tend to be cost-effective in broad terms, many evaluations are still
conservative, not taking account of the benefits of herd immunity or the value
of reduced anxiety from having a lower risk of contracting a disease (35). This is
particularly important given the increase in the cost of new-generation vaccines
compared with traditional low-cost vaccines.
More complex interventions have been evaluated less frequently. Examples of
cost-effective interventions in specific settings and contexts include targeted
physical activity programmes for older people, measures to control tobacco,
drugs and alcohol and financial incentives and educational measures to
promote nutritional change. One review of measures for cardiovascular diseases
(36) indicated a substantive body of evidence on clinical preventive measures,
primarily lipid-lowering drugs, but much less in the way of more upstream
health-promoting interventions. Another review on promoting mental well-
being and preventing mental health problems found the most compelling
evidence to lie with early-year interventions targeting children and their
parents, some measures aimed at primary prevention of depression and suicide
prevention strategies (37).
A consistent theme in all of these evaluations is that many interventions are
funded and delivered outside the health system. This is particularly true for
interventions to reduce accidents and injuries, many of which are highly cost-
effective. For example, in New Zealand, which has many road traffic crashes,
enforcement measures delivered by the police and transport sector-funded
9
Investing in and implementing population health strategies
advertising campaigns against drink-driving, speeding and mandatory use of
seat-belts all appear to be highly cost-effective in reducing the number and
severity of crashes (38).
Assessments of workplace-based health promotion programmes, particularly in
the United States, where many employers pay for the health care costs of their
employees, are also common (39). Schemes shown to be cost-effective include
physical exercise programmes, lifestyle advice, workplace health screening
programmes and enhanced care management for people identified as having
depression or stress problems (40).
Policy options moving forward: strengthening the evidence base and
examining institutional arrangements
These reviews indicate that an economic case can be made for investment in
many population health interventions across settings. Investing additional
resources may improve the quality of life much more than many health care
interventions. Moreover, there are often substantial benefits outside the health
sector. The rapid expansion of the evidence base in recent years and the
growing interest of policy-makers reflect the importance of the economic case
for public health, including health promotion. How can countries use more
economic evaluation in their deliberations on population health strategies?
Institutional and regulatory arrangements might include independent agencies
to assess evidence, in-house government agencies and support for knowledge
clearing houses.
Establishing and/or expanding the remit of health technology
assessment agencies
One of these potential options might be to expand the remit of existing
institutional mechanisms to assess the costs and effectiveness of health
technologies. So far these have focused on drugs, medical technologies and
surgical techniques. This situation is beginning to change, most evident being
the experience of the National Institute for Health and Clinical Excellence in
England1(41).
Operating as an independent authority, the National Institute for Health and
Clinical Excellence originally focused solely on interventions within the health
care system but, since 2005, has expanded its remit to collate evidence on the
effectiveness and cost-effectiveness, including optimum delivery methods, of
public health interventions. This includes interventions delivered and funded
Policy brief
10
1Although the remit of the National Institute for Health and Clinical Excellence for health
technologies covers England and Wales, public health guidance only applies to England.
outside the health system; evaluations include assessments of mental and
physical well-being interventions delivered in the workplace and school-based
alcohol education strategies.
A highly formalized process taking 9–12 months has been developed with two
types of public health-related guidance issued (Box 1). Public health
intervention guidance focuses on local clearly circumscribed actions that aim to
reduce the risk of developing a disease or condition or help in promoting or
maintaining a healthy lifestyle. Interventions are normally led by public health
professionals and target specific populations, communities or individuals, such
as advice on exercise given in primary care settings. A second type of guidance
relates to public health programmes. These are often a multi-agency and
multifaceted package of policies, services and interventions. They involve a suite
of activities that may be topic-, setting- or population-based and may involve
changes to organizational infrastructure. Topics covered include smoking
cessation in the workplace and community engagement and community
development to promote health.
11
Investing in and implementing population health strategies
Box 1. Independent assessment agency: the role of the National Institute for
Health and Clinical Excellence in public health
The National Institute for Health and Clinical Excellence produces guidance on promoting
health and preventing ill health for people working in the NHS, local authorities and the
wider public and voluntary sector. Guidance covers specific interventions and broader
programmes and may be reviewed and updated (usually after three years).
Stakeholder views and experiences are actively sought throughout the development
process to ensure that recommendations in guidance are realistic and appropriate.
Recommendations may be made at the population, community, organizational, group,
family or individual level. They can cover both downstream issues (such as lifestyles) and
upstream issues concerned with the wider determinants of health (such as housing and the
environment).
Reviews of evidence on effectiveness and cost-effectiveness are commissioned and assessed
according to well-defined criteria and then graded. Various types of evidence, both
qualitative and quantitative, are considered.
For interventions, an expert Public Health Interventions Advisory Committee considers
evidence; draft recommendations are then made; field testing is undertaken and guidance
developed including amended recommendations; and the guidance is then published on
the National Institute for Health and Clinical Excellence web site.
For programme development guidance, a committee meets five or six times over nine
months to review effectiveness and economic evidence. Draft recommendations are then
subject to stakeholder consultation and field-tested with barriers and facilitators to
implementation identified. Recommendations are then amended, and the guidance is
finally published on the web site.
Policy brief
12
Limitations remain in this process. Although a broader economic perspective is
used, evidence from economic evaluation that uses cost–benefit analysis may
still not be incorporated into economic models built as part of the evaluation.
Even the recommendations of the National Institute for Health and Clinical
Excellence are not always implemented despite the clear links to the policy-
making process. It is too early to judge the impact of this public health
programme, but some insight can be obtained from the experience of the
health technology and clinical practice guidelines of the National Institute for
Health and Clinical Excellence. Even though such guidance is mandatory for the
NHS, only about half of NHS local commissioners were adhering to this (42).
For public health assessment, many of the recommendations are aimed at
stakeholders outside the health system who have no obligation to follow the
guidance. Although such stakeholders are involved in the consultation process,
further ongoing communication to help facilitate implementation is required.
A final limitation is that the system developed by the National Institute for
Health and Clinical Excellence is not feasible in all European settings. Not only
does it require an annual budget (for all activities) of £35 million per year to
commission reviews, but it also relies on the goodwill of unpaid technical
experts and other stakeholders to provide input to the appraisal process. The
United Kingdom is fortunate to have significant capacity to undertake
systematic reviews, develop models of cost-effectiveness and set up technical
oversight committees. Where such capacity is limited, alternative institutional
models may be required.
Adapting results from existing evidence on economic evaluation: the
case of WHO-CHOICE
One alternative may be to try and adapt the results of specific evaluations from
the National Institute for Health and Clinical Excellence and health technology
assessment bodies to other countries and settings. However, such
generalizations are not always easy, particularly for public health interventions
and given that the resources and institutional capacity within countries vary
tremendously. Although tools and guidance are nevertheless being developed
for this purpose, none has focused on the highly context-specific nature of
many health-promoting interventions (43).
A pragmatic approach may be to adapt the information on cost-effectiveness
reported as part of the WHO-CHOICE programme. This has the advantage,
compared with more narrow evaluations conducted by the National Institute for
Health and Clinical Excellence and other health technology assessment bodies,
of adopting a sectoral approach to economic evaluation: “that all alternative
uses of resources are evaluated in a single exercise, with an explicit resource
constraint” (44). This allows a range of interventions, including those for
disease prevention, treatment and rehabilitation, to be compared in isolation or
in combination to determine an optimal mix of resources within a health care
system. They are compared with both the situation in which nothing is currently
done and with current practice. The results presented project the probability of
an intervention being cost-effective in low-, medium- or high-resource
situations and can be adapted to consider scaling up existing resources.
WHO-CHOICE has built a database of information on the cost-effectiveness of
interventions for several years to tackle some of the leading aspects of the
global burden of disease. This has been combined with a model designed to
estimate the effects of a disease and/or interventions on different populations.
Further, the resource data needed to implement interventions are collected
using a standardized tool. The results are presented for WHO subregions, but
they can be adapted to specific country contexts, such as interventions for
alcohol- and tobacco-related problems in Estonia (Box 2).
13
Investing in and implementing population health strategies
Box 2. Using generalized cost-effectiveness analysis to assess the case for
investing in alcohol and tobacco control policies in Estonia
The objective of the analysis was to assess the population-level costs, effects and cost-
effectiveness of various alcohol and tobacco control strategies in Estonia. Local data on
health behaviour and the prevalence of health risks were taken from a major postal survey
in Estonia, mortality data were obtained from Statistics Estonia and morbidity data from a
review of scientific literature.
Local data on the costs of delivering interventions were calculated. Interventions for alcohol
included excise taxes; reduced access to retail outlets; a comprehensive advertising ban;
roadside breath-testing; and brief interventions involving counselling by a primary care
doctor. Interventions for tobacco included excise taxes; a comprehensive advertising ban;
controls on smoking in public indoor locations; and nicotine replacement therapy.
A local group of experts discussed and contextualized interventions to Estonia’s situation.
The annual costs of implementing legislative and fiscal measures were much lower than
brief therapy and nicotine replacement therapy. Increased excise taxes were most cost-
effective: €49 and €14 per DALY averted for alcohol and tobacco consumption
respectively. The incremental costs per DALY averted by advertising bans were €85 and
€19, respectively. The incremental costs per DALY averted of a comprehensive combination
of interventions for alcohol and tobacco control were €457 and €238, respectively.
Data from the WHO Commission on Macroeconomics and Health suggest that all
interventions with cost per DALY averted of less than EEK 90 454 (€5780) are cost-
effective in Estonia.
Source: Lai et al. (45).
Reforming institutional arrangements to help facilitate the
implementation of cost-effective population health strategies
Successful implementation of population health interventions can also be
influenced by the institutional structures and governance arrangements in
countries. Questions that might be considered include the extent to which the
health system should be responsible for directly providing population health
services or how might it collaborate with other sectors to support investment in
such areas as transport, employment and education.
Dedicated ministry for population health
Since funding for health promotion and public health within health care
budgets can be severely limited, one policy option to guarantee funding would
be to establish a dedicated ministry entirely distinct from the health ministry.
There have been very few attempts to set up such an institution. One rare
example is the Ministry of Health Promotion in Ontario, Canada, created in
June 2005 (Box 3). This is entirely separate from the provincial Ministry of
Health, although this retains responsibility for many more medically oriented
public health functions such as vaccination.
It is still too early to judge how effective this model will be in facilitating
investment in effective population health strategies, including success in
developing partnerships and collaborating across sectors. Whether it can also
help to direct funds to more upstream population-wide measures to tackle
some of the socioeconomic risk factors for poor health is also difficult to judge,
Policy brief
14
Box 3. The Ministry of Health Promotion in Ontario, Canada
The remit of the Ministry of Health Promotion is to develop comprehensive strategies that
include chronic disease prevention, physical activity, participation in sports, injury
prevention and mental wellness in an integrated approach to overall good health. It
recognizes that complex factors such as education, housing, employment and the
environment all influence health and that a partnership approach involving these and other
stakeholders, both in the public and private sectors, is required. Total expenditure by the
Ministry in 2007/2008 was estimated to be CAN$ 380 million (€235 million) or almost
CAN$ 30 (€18.50) per capita.
Key priorities include: implementing a province-wide smoke-free strategy; promoting well-
being by encouraging participation in sport and physical activities; coordinating initiatives
to prevent illness and injury; and improved health outcomes by supporting the public
health system (46). As part of this final priority, the Ministry finances 75% of four
mandatory health programmes (25% municipal co-financing): chronic disease prevention;
children’s health; reproductive health; and injury prevention (including substance abuse
prevention).
as the initial priority areas of the Ministry of Health Promotion appear to focus
largely on interventions to influence individual behaviour.
One risk may be the challenge of coordinating activities with the Ministry of
Health; public health might become more marginalized from mainstream health
care policy. Arguing for increased allocation of funds may also be more difficult;
earmarking might set the funding below the level that might optimally benefit
population health. Careful assessment of population health needs might help
ensure that funding is commensurate with population health priorities.
Alternative institutional structures
One more modest alternative may be to ensure that a health ministry has
specific governance structures for population health. This might include a junior
ministerial post for public health, such as in Ireland and Sweden, and Scotland
has a Minister for Health and Wellbeing.
Another option might be a cross-department mechanism to coordinate
activities, perhaps coordinated by the finance ministry or the office of the prime
minister or president. In Denmark, for example, the Ministry of the Interior and
Health and 10 other ministries were involved in developing the national public
health policy for 2002–2010 (47,48).
Partnership arrangements between sectors can also be facilitated at the local
area level. Many interventions or policies may be intrinsically area based (such
as ensuring equitable access to good quality education, housing and public
transport). Area-based partnerships may be attractive because they allow for
local involvement and ownership, which in turn can help facilitate cooperation
and implementation. Examples of cooperation across sectors can be found in
several countries, such as between local primary care trusts and local municipal
authorities in England.
Promoting flexible funding
Another key challenge is overcoming budgetary barriers in making the case for
investment in population health interventions. Allocative efficiency, how
available resources are distributed to best meet the health needs of the
population, will be affected if coordination and collaboration are poor or
moving funds between the health and non-health sectors is difficult. Many
population health interventions that generate substantial health gains are
delivered outside the health sector. For instance, increasingly robust evidence
indicates that interventions targeting children both in the first years of life and
at school can be highly effective in reducing the risk of poor physical and
mental health in later life (37). In some countries, one challenge may be to
persuade the education ministry to invest in school-based health promotion
interventions that appear to solely benefit the health sector.
15
Investing in and implementing population health strategies
How might public policy-makers overcome these barriers? Mechanisms that
promote flexible funding may help create incentives for sectors to implement
population health strategies. One approach may be using mandatory or
voluntary joint budgets between health and non-health sectors for some
services, such as school-based health promotion services. Evaluation of
experience with pooled budgets for population health-specific services remains
limited, but examples of joint budgeting in other areas can be identified (Box 4).
An alternative to joint budgeting might be a mechanism for the intersectoral
transfer of funds to compensate a sector that does not directly benefit from the
intervention but would be responsible for delivery. Using this approach as long
as there is an overall net benefit, whether in the health or non-health sectors,
monetary compensation could be used to facilitate investment (51). To date,
such an approach has not been used in practice; the success of any mechanism
in determining the level of financial compensation required remains to be seen.
Determining the health and non-health benefits of interventions might also be
helpful. Where information can be conveyed illustrating benefits to both health
and other sectors, compensation may not be needed. For example, a reduction
in child obesity might be linked to a demonstrable improvement in classroom
concentration or educational attainment from a school-based health
intervention. Emphasizing these multiple benefits might help persuade other
funders to invest in preventive measures to help minimize future avoidable costs
Policy brief
16
Box 4. Joint budgeting across sectors in Sweden
In Sweden, experiments in pooling funds between health, social services and sickness
insurance budgets have been developing since the mid-1990s. These arrangements were
set up in response to the growing problem of long-term absence from the labour market
because of workplace-induced health problems. They recognized that several service
providers would need to provide the mix of services to get individuals back into
employment and that these individuals risked falling through the cracks between different
services and budget holders (49).
Under the 1994 SOCSAM scheme, which involved collaboration with social services, up to
5% of the budgets for social services and sickness insurance could be pooled with a
matching contribution from health services to help reintegrate individuals into employment.
A national evaluation suggested that this joint budgeting arrangement helped to improve
interdisciplinary coordination and collaboration. It also allowed co-location of personnel
from different sectors and joint political steering of the initiative, which in turn helped
overcome the reluctance of sectors to invest in initiatives when the impact is likely to be felt
elsewhere (50). Following evaluation, permanent legislation came into force in 2004.
they might have to bear. For instance, some European private health insurance
companies now fund employee assistance programmes to promote workplace
health (52).
Identifying alternative ways of bringing about change
Another key issue is the implementation process. What mechanisms are
available to ensure that population health is indeed “on the agenda of policy-
makers in all sectors and at all levels, directing them to be aware of the health
consequences of their decisions and to accept their responsibilities for health”
(16)? How can governments provide incentives to administrative bodies to
implement national policy on population health?
Giving priority to the low-hanging fruit
Beginning by picking low-hanging fruit may be prudent in building up the
evidence base on population health interventions. This means interventions
likely to be highly effective, cost-effective and noncontroversial. Several health
technology assessment agencies adopted this policy when they were becoming
established. This can help organizations to establish their presence and
credibility. They can begin to build up relationships with a range of stakeholders
while providing strong evidence on topics on which agreement is broad that
action would be beneficial. The National Institute for Health and Clinical
Excellence, when producing its first guidance on public health interventions,
chose to look at smoking-cessation interventions for which the evidence and
the case for intervention were strong.
Improving communication between researchers and policy-makers
Another issue is how to improve communication between researchers and
policy-makers (53). This is not simply a matter of ensuring that the latest
evidence reaches policy-makers. Passively disseminating guidelines and
information on population health interventions is insufficient to facilitate
change. It requires multiple and ongoing exchange between different
stakeholders. Moreover, messages need to be actionable and tailored in
language accessible to different target audiences. Change can take time; rarely
will knowledge lead to immediate change. Typically, stakeholders gradually
become more aware and amenable to new ideas.
Unfortunately, researchers and policy-makers often do not speak a common
language. Moreover, these two communities may have a mutual sense of
distrust (54). One way to overcome this problem may be through involving
knowledge brokers: individuals who understand scientific evidence but are
comfortable working in a policy-making environment (55). They can help to
17
Investing in and implementing population health strategies
translate academic reports into brief messages relevant to policy and help to
ensure that policy-makers commission feasible research. Evaluation remains
limited (56), although examples of policy change can be identified, again
illustrating that the pace of change can be slow due to the need for iterative
dialogue (57).
With appropriate training, staff from international agencies, such as WHO,
could potentially act as effective knowledge brokers. For instance, the European
Observatory on Health Systems and Policies might also play a role, providing a
vehicle to bring senior policy-makers and researchers together to debate issues
through a process of policy dialogue and to provide advice and support on
implementation at the local level. Other international networks, perhaps
including the European Network for Health Technology Assessment if sustained,
might in future expand their remit to commission, undertake and share
systematic reviews of the effectiveness and cost-effectiveness of various
strategies to meet the needs of countries where capacity is limited.
Targeting messages to policy-makers across a range of sectors
Awareness of the health consequences of policies developed and implemented
outside the health sector may be limited. Surveys of civil servants in Canada and
New Zealand indicate a desire for practical information on effective population
health interventions (58,59). The civil servants lacked knowledge despite the
publication of major policy documents on the socioeconomic determinants of ill
health and promoting population health.
Civil servants working in finance were much less likely to be swayed by the
health effects of policies than by their economic effects. Conversely, civil
servants in health and other sectors did not appreciate the importance of
examining the economic effects of policies. Highlighting macroeconomic
benefits can provide potential opportunities to support investment across
sectors in population health strategies.
Another way of improving awareness may be formalizing the use of health
impact assessment of policy interventions across sectors. For instance, civil
servants might be required to consider the health effects of a new airport
runway, traffic-calming measures or economic regeneration. Equally, policy-
makers developing population health policies might prudently assess the key
non-health effects of these policies.
Health impact assessment has been used in several high-income European
countries, mainly at the local level. Nevertheless, the extent to which it has
facilitated policy change remains unclear. One review of the effectiveness of
health impact assessment (60) suggests that a barrier to success may be that
health impact assessment proponents lack understanding of non-health sector
Policy brief
18
issues, and a key factor for success may be ensuring good links with decision-
makers, institutionalizing the health impact assessment process with decision-
making organizations, given the absence of a commonly agreed standard for
health impact assessment.
Targets, monitoring and evaluation
Investing in systems to monitor and evaluate implementation and measuring
the longer-term impact on population health outcomes can also be helpful. The
explicit use of benchmarks or targets related to population health is one
approach. Joint targets across government departments might be set and
progress towards achievement monitored. Negative publicity from failing to
achieve targets may serve as a powerful incentive for action.
In England, for instance, the Ministry of Finance conducted a cross-cutting
review on inequality in health involving 18 government departments and
agencies. This led to a national programme for action that included 12 headline
indicators and 82 commitments across departments to tackle inequality in
health and promote good health (61) (Box 5).
Evaluation of the impact of targets remains limited. They are only likely to make
a difference if they are concrete enough to be measured and realistic enough to
19
Investing in and implementing population health strategies
Box 5. Interdepartmental headline indicators to tackle inequality in health in
England
Death rates from the big killers – cancer and heart disease
Rate of conception among people younger than 18 years
Road crash casualty rates in disadvantaged communities
Numbers of primary care professionals
Uptake of influenza vaccination
Smoking among people performing manual work and among pregnant women
Educational attainment
Consumption of fruit and vegetables
Proportion in non-decent housing
Physical education and school sport
Children in poverty
Homeless families living in temporary accommodation
be achieved within a specific time frame (62). The use of targets in Europe thus
far appears to have been aspirational or to stimulate debate rather than to
ensure implementation of population health policy (48).
In Sweden, when 11 public health objectives focusing on the determinants of
health were published in 2003, they were not explicit enough to be measured;
moreover, no time frame was set for achieving them (63). The need for
intersectoral action might have made it politically difficult to achieve consensus
on more specific targets. Thirty-eight detailed indicators subsequently
developed by the Swedish National Institute of Public Health, the body charged
with monitoring progress towards achieving the objectives, may help address
this issue.
Summary
The health and socioeconomic costs of the disease burden in Europe are
substantial. Much of this burden might be avoided by implementing effective
population health strategies. Moreover, a growing body of information
suggests that many of these interventions would be considered highly cost-
effective in many jurisdictions. Nevertheless, investment in population health
strategies appears modest.
Health promotion strategies should include upstream actions that target risk
factors for poor health; most of these actions are likely to be funded and
delivered outside the health care system. It is important to make better use of
existing systematic reviews of evidence and to invest resources to build on this,
in particular by looking at how to improve what is known about the effects of
upstream interventions. Economic evaluation, comparing the health and non-
health gains of interventions with the resources needed to deliver them, can
help strengthen the case for investment.
One way of strengthening the evidence base may be to expand the remit of
existing bodies carrying out health technology assessment. This approach will
not be feasible in all settings and highly depends on local research capacity.
Alternative approaches may include working with international partners to
adapt the results of existing evaluations to specific country contexts.
Various governance arrangements might help to ensure that resources are
allocated to population health and that actions are coordinated across sectors.
Options include a stand-alone ministry for population health, interdepartmental
working bodies and mechanisms to allow partnership working and joint
budgeting.
Investing in measures to strengthen the evidence base on effective and cost-
effective measures for population health alone is unlikely to lead to change.
Policy brief
20
Measures to improve effective implementation include improved
communication between researchers and policy-makers and awareness-raising
measures on the health effects of all policies. Tools such as health impact
assessment might have a role to play. Mechanisms to monitor implementation
across sectors might help to facilitate change; explicit measurable targets across
sectors on population health objectives would provide additional incentives for
action.
21
Investing in and implementing population health strategies
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Policy brief
26
This publication is part of the joint policy brief series of the Health
Evidence Network and the European Observatory on Health Systems
and Policies. Aimed primarily at policy-makers who want actionable
messages, the series addresses questions relating to: whether and
why something is an issue, what is known about the likely
consequences of adopting particular strategies for addressing the
issue and how, taking due account of considerations relating to
policy implementation, these strategies can be combined into viable
policy options.
Building on the Network’s synthesis reports and the Observatory’s
policy briefs, this series is grounded in a rigorous review and
appraisal of the available research evidence and an assessment of its
relevance for European contexts. The policy briefs do not aim to
provide ideal models or recommended approaches. But, by
synthesizing key research evidence and interpreting it for its
relevance to policy, the series aims to deliver messages on potential
policy options.
The Health Evidence Network (HEN) of the WHO Regional Office
for Europe is a trustworthy source of evidence for policy-makers in
the 53 Member States in the WHO European Region. HEN provides
timely answers to questions on policy issues in public health, health
care and health systems through evidence-based reports or policy
briefs, summaries or notes, and easy access to evidence and
information from a number of web sites, databases and documents
on its web site (http://www.euro.who.int/hen).
The European Observatory on Health Systems and Policies is a
partnership that supports and promotes evidence-based health
policy-making through comprehensive and rigorous analysis of health
systems in the European Region. It brings together a wide range of
policy-makers, academics and practitioners to analyse trends in
health reform, drawing on experience from across Europe to
illuminate policy issues. The Observatory’s products are available on
its web site (http://www.euro.who.int/observatory).
World Health Organization
Regional Office for Europe
Scherfigsvej 8,
DK-2100 Copenhagen Ø,
Denmark
Tel.: +45 39 17 17 17.
Fax: +45 39 17 18 18.
E-mail: postmaster@euro.who.int
Web site: www.euro.who.int
ISSN 1997-8073
