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Background: Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions. Methods: We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries. Results: We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5. Conclusions: This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy.
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Return on investment of public health interventions:
a systematic review
Rebecca Masters,
1,2
Elspeth Anwar,
2,3,4
Brendan Collins,
2,4
Richard Cookson,
5
Simon Capewell
2
Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/jech-
2016-208141).
1
North Wales Local Public
Health Team, Public Health
Wales, Mold, Flintshire, UK
2
Department of Public Health
and Policy, University of
Liverpool, UK
3
Department of Public Health,
Halton Borough Council,
Cheshire, UK
4
Department of Public Health,
Wirral Metropolitan Borough
Council, Merseyside, UK
5
Centre for Health Economics,
University of York, UK
Correspondence to
Rebecca Masters, North Wales
Local Public Health Team,
Public Health Wales, Mold,
Flintshire CH7 1PZ, UK;
Rebecca.Mason@nhs.net
Received 25 July 2016
Accepted 3 February 2017
To cite: Masters R,
Anwar E, Collins B, et al.J
Epidemiol Community Health
Published Online First:
[please include Day Month
Year] doi:10.1136/jech-
2016-208141
ABSTRACT
Background Public sector austerity measures in many
high-income countries mean that public health budgets
are reducing year on year. To help inform the potential
impact of these proposed disinvestments in public
health, we set out to determine the return on investment
(ROI) from a range of existing public health
interventions.
Methods We conducted systematic searches on all
relevant databases (including MEDLINE; EMBASE;
CINAHL; AMED; PubMed, Cochrane and Scopus) to
identify studies that calculated a ROI or cost-benet ratio
(CBR) for public health interventions in high-income
countries.
Results We identied 2957 titles, and included 52
studies. The median ROI for public health interventions
was 14.3 to 1, and median CBR was 8.3. The median
ROI for all 29 local public health interventions was 4.1
to 1, and median CBR was 10.3. Even larger benets
were reported in 28 studies analysing nationwide public
health interventions; the median ROI was 27.2, and
median CBR was 17.5.
Conclusions This systematic review suggests that local
and national public health interventions are highly cost-
saving. Cuts to public health budgets in high income
countries therefore represent a false economy, and are
likely to generate billions of pounds of additional costs
to health services and the wider economy.
INTRODUCTION
Benjamin Franklin once famously stated that an
ounce of prevention is worth a pound of cure.
Long-term pressures on public sector costs due to
demographic and technological changes and cost
ination in the caring professions have intensied
following the 2008 global nancial crisis. Public
health is often considered a politically soft target
for budget cuts, as recently demonstrated by major
budget reductions in the UK.
13
The benets of population-level public health
expenditureunlike those of personal healthcare
and social care expendituretend to be long term,
mostly accruing after the current politicians and
policymakers have moved on. Though large and
certain at the population level, benets are also
seen as small and uncertain for individual voters. It
is therefore important to take a hard look at the
cost-effective evidence, and move towards more
rational decision-making in this politically charged
area.
Return on investment (ROI) and cost-benet
ratio (CBR) are two forms of economic evaluation
that value the nancial return, or benets, of an
intervention against the total costs of its delivery.
The CBR is the benet divided by the cost, and the
ROI is the benet minus the cost expressed as a
proportion of the cost, that is, the CBR1. To help
inform the discussion of proposed cuts to public
health budgets, we set out to determine the ROI
and opportunity cost for a range of public health
interventions at the local and national levels. The
theory underpinning this review is that, because
political backing for public health intervention is
often lacking, many interventions with a high ROI
are not funded. This is because public health inter-
ventions are often opposed by powerful commer-
cial interests, and the health gains for individuals
are often perceived as too small to sway their
voting intentions, despite adding up to large gains
at the population level.
4
METHODS
We conducted a systematic review to examine the
ROI of public health interventions delivered in
high-income countries with universal healthcare.
These included the UK, Western Europe, the USA,
Canada, Japan, Australia and New Zealand.
Search strategy
The authors used Achesonsdenition of public
health when considering our search strategy: The
science and art of promoting and protecting health
and well-being, preventing ill-health and prolong-
ing life through the organised efforts of society.
5
This denition is purposefully broad and the
authors felt that it would incorporate the various
elds of public health. We searched the PubMed,
MEDLINE, Scopus, CINAHL, Cochrane, PsycInfo
and AMED databases using the following search
terms: public health(all elds) AND return on
investmentOR cost benet analysis(title or
abstract). We also hand searched the references of
the included analyses to identify any further
studies. A grey literature search was completed
using Google, yielding three additional results.
Limits were set to publications in the English lan-
guage, and to interventions targeted at humans
(where applicable). Studies with poor generalisabil-
ity to the UK were excluded, including a number
from the USA that may poorly reect UK health-
care systems, structure and demographics.
Study selection and inclusion criteria
We included studies of any design that reported a
ROI of public health interventions delivered in indus-
trialised countries providing universal healthcare.
Masters R, et al.J Epidemiol Community Health 2017;0:18. doi:10.1136/jech-2016-208141 1
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Selection of articles and extraction of data
One investigator (RM) performed the initial screening of the
titles. A second reviewer (EA) independently reviewed the titles
and potentially relevant abstracts. The results were cross-
referenced and any disagreements were discussed with a third
reviewer (BC).
One investigator (RM) led the data extraction and quality
assessment, which was then independently duplicated by EA. A
third reviewer (BC) adjudicated on any disagreements regarding
result details or quality assessment. RM contacted authors for
additional data in three cases, with two responses.
Assessment of methodological quality in included studies
The methodological quality of each included study was assessed
independently by two reviewers (RM and EA) using the
National Institute for Health and Care Excellence (NICE)
quality appraisal checklist for economic evaluations to assess the
quality and external validity of each study.
6
Disagreements in
methodological quality assessments for all the included studies
were resolved by consensus or by recourse to a third member of
the review team (BC).
RESULTS
We identied 2957 potentially relevant titles, after excluding
2559 duplicates. A further 2816 papers were excluded following
title or abstract review. We nally included 52 relevant titles
published over four decades (see online supplementary gure
S1).
Results were stratied by public health specialty (table 1), and
by interventions at a local level (table 2)ornationallevel(table 3).
Results were reported in ve different currencies, as detailed in
tables 2 and 3.
The median ROI for all public health interventions was 14.3,
and the median CBR was 8.3.
The reported ROI and CBRs ranged widely. The ROIs ranged
from 21.27 (inuenza vaccination of healthy workers
7
) to 221
(lead paint control
8
). The CBRs reported ranged from 0.66
(20 mph zones in low-impact areas
9
) to 167 (single measles vac-
cinations
10
). Studies reporting ROIs at the extreme end of the
spectrum tended to be of poorer quality. Studies reporting a
CBR tended to be higher quality.
ROI of public health programmes stratied by specialism
Analysis by specialism revealed that health protection and legis-
lative interventions generally yielded high returns on invest-
ment, often being delivered on a national basis and only
requiring a one-off intervention (such as a vaccination or a new
tax). In contrast, interventions for healthcare public health,
health promotion or wider determinants typically had lower
returns, being often more complex, resource intensive and sus-
tained. Figure 1 provides overviews of the median, maximum
and minimum ROI by specialism, and gure 2 provides an over-
view of the median, maximum and minimum and CBR values
stratied by specialism.
Health protection interventions
Eighteen studies reported a large ROI in relation to health pro-
tection. The ROI median was 34.2, and ranged from 21.3
7
to
221
8
, and the CBR median was 41.8 (range from 1.2
11
to
167
10
).
Health promotion interventions
Fifteen health promotion interventions were reported, 12 ROI
studies and 3 CBR studies. Returns on investment were variable.
The median ROI was 2.2 (range 0.7
12
to 6.2
13
). The median
CBR was much higher at 14.4 (range 2
10
to 29.4
14
).
Legislative interventions
Four studies reported on legislative interventions, with substan-
tial returns. The median ROI was 46.5 (range 38
15
to 55
15
).
The median CBR was 5.8 (range 3
10
to 8.6
16
).
Healthcare public health interventions
Six studies reported ROIs in relation to healthcare public health
interventions. The ROI median was 5.1, and ranged from
1.15
17
to 19.35.
18
No studies reported a CBR.
Wider determinants interventions
Twelve studies reported a return on wider determinants inter-
ventions (for instance, targeted at children or juvenile offen-
ders). The median ROI was 5.6 (range 1.1
19
to 10.8
20
) with a
median CBR of 7.1 (range 0.66
7
to 23.6
21
).
ROI of public health interventions by level
A total of 29 studies reported returns on investment or CBRs in
relation to local public health interventions. The median ROI
was 4.1, and ranged from 0.9
22
to 19.3.
18
The median CBR
was 10.3 (range 0.7
7
to 23.6
19
).
There were 28 studies reporting on national public health
interventions. The median ROI was 27.2 and ranged from
21.3
7
to 221.
8
The median CBR was 17.5 (range 1.2
11
to 167
8
).
Table 1 ROI of public health programmes overall, and stratified by level and specialism
Median ROI ROI range Number of ROI studies Median CBR CBR range Number of CBR studies
Overall 14.3 21.3 to 221 34 8.3 0.7 to 29.4 23
Local level 4.1 0.9 to 19.3 18 10.3 0.9 to 23.6 11
National level 27.2 21.3 to 221 17 17 1.2 to 167. 10
Specialism
Health protection 34.2 0.7 to 221 8 41.8 1.1 to 167 10
Legislation 46.5 38 to 55 2 5.8 3 to 8.6 2
Health promotion 2.2 0.7 to 6.2 12 14.4 2 to 29.4 3
Healthcare public health 5.1 1.1 to 19.3 6 None reported None reported None reported
Wider determinants 5.6 1.1 to 10.8 6 7.1 0.7 to 23.6 6
CBR, cost-benefit ratio; ROI, return on investment.
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Table 2 Return on investment of local public health programmes: specific studies
Reference Intervention Population
Benefit-cost
ratio
Return on
investment Cost perspective
Discount
rate
Time
horizon
Study
quality
Andresen et al
31
Supervised injection facilities IDU population of Vancouver, Canada 5.12 Medical and
societal
3% Lifetime ++
Arrieta et al
18
Home blood pressure monitoring for hypertension diagnosis and
treatment
16 375 participants, USA $7.50$19.35 Insurer 3% 10 years ++
Baker et al
44
Workplace obesity management 890 employees, USA $1$1.17 Medical None 1 year
Beard et al
41
Community-based falls prevention 2000 cases and 1600 matched controls, Australia 20.6 Medical and
societal
8% 18 months ++
Collins
42
Smoking cessation Population of Wirral, UK £1.77 Medical 3.5% 20 years ++
Dopp et al
57
Multisystematic therapy with serious juvenile offenders and their
siblings
305 participants, USA 5.04 Medical and
societal
3% 25 years ++
Goetzel et al
45
Workplace health risk management programme for small
businesses
2458 employees, USA $2.03 Medical and
productivity
No 1 year
Guo et al
59
Improved walking and cycling infrastructure 4674 participants, USA 1.87 Medical 3% 10 years ++
Kleitz et al
21
Multisystematic therapy with serious juvenile offenders 176 participants, USA 9.5123.59 Medical and
societal
3% 13.7 years ++
Kuehl et al
46
Workplace health promotion for fire fighters 1369 fire fighters, USA $4.61 Medical and
insurer
None 7 years
Long et al
47
Health promotion programme for hospital staff 4402 hospital staff, USA $2.87 Employer None 14 years +
Moore et al
52
Medication management for high-risk groups 4500 health plan participants, USA $2 Insurer None 1 year
Medivil et al
60
Speed cameras in urban settings Barcelona, Spain 6.80 Medical and
societal
3% 2 years ++
Nelson et al
39
Water fluoridation Population of Houston, Texas $1.51 Societal 10% 10 years ++
Nyman et al
22
Workplace health promotion 1757 cases and 3619 matched controls,
employer, USA
$0.87 No 2 years +
Ozminkowski et al
51
Workplace health management 25 931 Citibank employees $4.61 Insurer 4% 3.2 years ++
Peters et al
9
20 mph zones in London Population of London, UK 0.662.19 Societal 3.5% 10 years ++
Reynolds et al
20
Intensive early education programme for socioeconomically
deprived families (preschool programme)
1539 participants, USA $10.83 Medical and
societal
3% 20 years ++
Reynolds et al
20
Intensive early education programme for socioeconomically
deprived families (school age programme)
850 participants, USA $3.97 Medical and
societal
3% 20 years ++
Reynolds et al
20
Intensive early education programme for socioeconomically
deprived families (extended intervention)
553 participants, USA $8.24 Medical and
societal
3% 20 years ++
Richard et al
43
Tobacco cessation 805 Medicaid insured tobacco users, USA $2$2.25 Insurer None 1.3 years
Rundell et al
53
Therapeutic services for alcoholism 3034 Oklahoma alcohol service users, USA $1.98 Medical and legal 4% 10 and
22 years
++
Schwartz et al
48
Wellness and disease prevention programme 57 940 health insurance clients, USA $2.02 Insurer None 8 years
Schweinhart et al
56
Preschool education programme for socioeconomically deprived
children
123 preschool children, USA 7.16 Medical and
societal
3% 40 years
Steinbach et al
19
20 mph zones in London Population of London, UK £1.12 Medical None 10 years
Spence et al
54
Outpatient pharmacy services for medication adherence 2957 matched cases and controls, USA $5.97 Medical and
productivity
None 1 year
Van Vonno et al
17
Heart failure disease management 1360 matched cases and controls, USA $1.15 Insurer None 1 year
Wang et al
61
Bike and pedestrian trails 225 351 individual uses of bike and pedestrian
trails over a 1 year period, USA
$2.94 Public health None 10 years
Windsor et al
49
Antinatal stop smoking services 994 pregnant smokers in Alabama, USA 6.7217.18 Medical None 5 years
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Table 3 Return on investment of national public health programmes: specific studies
Reference Intervention Population
Benefit-cost
ratio
Return on
investment Cost perspective Discount rate
Time
horizon
Study
quality
Abelson et al
10
Hib vaccination Australia 1.06 Medical 5% 15 years ++
Abelson et al
10
HIV/AIDS prevention Australia 4 Medical 5% 25 years ++
Abelson et al
10
Measles vaccination Australia 167 Medical 5% 33 years ++
Abelson et al
10
Programmes to reduce rates of coronary heart disease Australia 11 Medical 5% 40 years ++
Abelson et al
10
Programmes to reduce tobacco consumption Australia 2 Medical 5% 40 years ++
Abelson et al
10
Road safety campaigns Australia 3 Medical 5% 40 years ++
Boccalini et al
32
Universal hepatitis B vaccination Italy 2.78 Medical and
societal
3% 20 years ++
Bonin et al
58
Parenting programmes for the prevention of persistent conduct
disorders
England 7.89 Medical and
societal
3.5% 35 years ++
Drummond
11
Needle exchange Australia 1.2 Public health 5% Lifetime ++
Evans-Lacko et al
12
Antistigma social marketing campaign England £0.7 to £1.90 Unclear None 1 year -
Garpenholt et al
38
Hib vaccination Sweden 1.59 Societal 5% 20 years ++
Gortmaker et al
15
Sugar sweetened beverage tax USA $55 Medical 3% 10 years ++
Gortmaker et al
15
Eliminating tax subsidy of nutritionally poor food advertising to
children
USA $38 Medical 3% 10 years ++
Gould
8
Lead paint control USA $17 to $221 Medical and
societal
None Unclear
Holtgrave et al
34
HIV counselling, testing, referral and partner notification services USA 20.09 Societal 6% Lifetime ++
Hutchinson et al
35
Expanded HIV testing USA $1.46 to $2.01 Health sector 3% Lifetime ++
Kwon et al
36
Needle exchange Australia $A1.3 to $A5.5 Health sector 3% Lifetime ++
Lokkerbol et al
55
Telemedicine for depression The
Netherlands
1.45 to 1.76 Medical 1.5% costs, 4%
effects
5 years ++
McGuire et al
14
Family planning services UK 11.09 to 29.39 Medical 6% Lifetime ++
Miller et al
16
Booster seats for 47 years olds USA 8.6 Medical 3% 3 years ++
Nguyen et al
37
Needle exchange USA $3.48 Medical None 1 year +
Nichol et al
7
Influenza vaccination of healthy workers USA $21.27 to +$174.32 Societal 3% 1 year +
Romano et al
40
Folic acid fortification of grain USA 4.3 to 6.1 Human capital 4% Lifetime ++
Trust for America
13
Primary and secondary prevention programmes USA $6.2 Medical 0% 1020 years +
Wang et al
50
Universal school nursing services USA $2.20 Societal None 1 year +
White et al
28
MMR vaccination USA 14 Medical 10% Lifetime ++
Ding et al
30
Hospital-based postpartum influenza vaccination USA $1.7 Medical and
societal
3% 1 year ++
Zhou et al
38
Hib vaccination USA 5.4 Medical and
societal
3% Lifetime ++
Hib, haemophilus influenzae type b; MMR, measles, mumps and rubella.
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DISCUSSION
Our systematic review offers several potentially important
observations
First, even with the most rudimentary economic evaluations, it
was clear that most public health interventions are substantially
cost saving. This conrms our theory that public health inter-
ventions generally offer a considerable ROI. Median ROI was
generally higher than median CBR in all of our key public
health expenditure categories. This was because most studies
only report one of these two measures, and studies that report
ROI tend to have higher estimates. A direct comparison is pos-
sible, by converting between ROI and CBR at the study level
using the simple formula ROI=CBR1.
Second, we demonstrated a public health effectiveness hier-
archy. Public health interventions at a local level averaged an
impressive ROI of 4, meaning that every pound invested yields
a return of £4 plus the original investment back. However,
upstreaminterventions delivered on a national scale generally
achieve even greater returns on investment, particularly legisla-
tion (a 10-fold higher ROI averaging 46).
Third, Benjamin Franklins belief that an ounce of preven-
tion is worth a pound of cureis thus borne out by the
costs-savings demonstrated, particularly when compared with
recent returns for investment in healthcare.
23
It has been esti-
mated that investing an additional £13 000 in the English
National Health Service (NHS) can achieve health benets of
one additional quality-adjusted life year (QALY).
23
When this
health benet is valued in monetary terms at the UK
Department of Healths current rate of £60 000 per QALY,
24
this represents a ROI of 3.16 (£60 000£13 000/£13 000).
Fourth, this systematic review was partly prompted by recent
government cuts to public health budgets in England. We there-
fore focused on public health interventions delivered in other
high-income countries in order to maximise UK relevance. We
can therefore now better estimate the likely opportunity costs of
the proposed cuts in local and national public health budgets.
The median ROI for all public health interventions was 14.3, and
the median CBR was 8.3. An ROI of 14.3 implying a cash return
of 1430% would sound too good to be true in the nancial
world. However, public health is different, because decision-
Figure 1 Median, maximum and minimum return on investment values stratied by specialism.
Figure 2 Median, maximum and minimum cost:benet ratios stratied by specialism.
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making is governed by politics rather than markets. Our systematic
review clearly demonstrates that there are big public health invest-
ment opportunities out therethey just need some political will
to implement them. If we take the lower, conservative CBR gure
of 8.3, this would suggest that the opportunity cost of the recent
£200 million cuts to public health funding in England is likely to
be eightfold higher, in the region of £1.6 billion. The UK govern-
mentsefciency savingsthus represent a false economy which
will generate many billions of additional future costs to the ailing
NHS and wider UK economy. The recent UK increases in (avoid-
able) teen pregnancies, sexually transmitted infections, homeless-
ness and suicides are thus predictable and worrying. Do they
represent harbingers of worse to come? Although this study draws
on the experience of the UK public health system, there are impli-
cations for public health systems outside of the UK, which may be
guided towards areas of potential underinvestment, and avoid
harmful cuts in public health budgets.
Previous reviews
Ours may be the rst comprehensive systematic review of
ROI and CBR to include the broad spectrum of public health
interventions. Furthermore, it extends and strengthens earlier,
narrower reviews which consistently highlighted the cost-
effectiveness of selected public health interventions. These
included the Australian Assessing Cost Effectiveness (ACE)
Prevention Study
25
and the Health England Leading Priorities
(HELP) Tool, which ranked several public health interventions
against a set of criteria.
26
NICE appraises and recommends public
health programmes and interventions in England. In 2012, they
reviewed 200 cost-effectiveness estimates used in their guidance.
Many interventions (particularly around smoking cessation) pro-
duced a net cost-saving for the NHS, that is, the intervention was
more effective and cheaper than the comparator.
27
Most inter-
ventions were highly cost-effective with a very low cost per
QALY: 85% were cost-effective at a threshold of £20 000 per
QALY, and 89% at the higher £30 000 threshold, 5% exceeded
£30 000 per QALY and only the nal5%weredominated(ie,
more costly and less effective than the comparator).
27
Health protection interventions
Eighteen studies reported ROI or CBR gures in relation to
health protection interventions.
7810112840
The median ROI
for health protection interventions was very high at 34.2. The
Australian single measles vaccination programme in the 1980s
and 1990s reported the highest CBR, with a CBR of 167:1.
10
The UK now uses the combined Measles, Mumps and Rubella
vaccination that has an excellent ROI of 14:1.
28
Seven studies assessed the prevention, notication, follow-up
and treatment of infectious diseases such as hepatitis B and HIV.
Overall, they demonstrated a consistently high ROI, reecting
the high disease burden of infectious diseases and the huge
benets of prevention.
29
Calculating the ROI of inuenza vaccination of healthy
working adults is challenging, as it is highly sensitive to the ef-
cacy of the seasonal vaccine. Thus, most such studies
730
have
reported a modest twofold ROI overall, but with extreme ROI
values ranging from 21 to +174.
30
Legislative interventions
One paper reported ROI in relation to legislative interventions,
which offered substantial returns on investment, with a median ROI
of 46.5. Furthermore, they are relatively low cost and target behav-
iour at a national level. Introducing a sugar sweetened beverage tax
could save $55 for every single dollar invested
15
in the USA.
Health promotion interventions
The 15 studies analysing health promotion interventions
reported an overall twofold ROI with a more impressive median
CBR of 14.4.
10 13 14 22 4151
Interventions aimed at reducing
rates of falls are able to show one of the swiftest returns on
investment of any of the public health interventions identied
within this study, with a CBR of 20.6 returned within 18
months.
41
Falls prevention interventions by their nature are rela-
tively low cost (structured exercise programmes for those at risk
of falls), and yet their potential impact on demand management
for hospital services is clearly demonstrated. Shifting investment
from secondary care for the treatment of falls to primary pre-
vention would show signicant and swift returns on investment.
Tobacco control interventions
10 42 43
overall reported a
twofold ROIs, which increased when targeted at high-risk
clients such as pregnant women.
42
Such contrasting results
perhaps highlight the complexity of public health interventions.
Healthcare public health interventions
Six studies
17 18 5255
reported healthcare public health results,
offering a substantial median ROI of 5.14. The majority
focused on disease management or medication adherence for
high-risk patients, such as home blood pressure monitoring for
hypertension diagnosis and treatment.
18
Wider determinants interventions
Twelve studies reported results for wider determinants interven-
tions.
910121921 5661
Public health interventions addressing
wider determinants also averaged a vefold ROI. Several studies
assessed effectiveness of early years interventions, particularly
those targeted at juvenile offenders, or those deemed to be at
risk of future offending. Although much of this literature is
from the USA
20 21 56 57
emerging UK evidence demonstrates
similar returns to society and the wider economy.
58
The benets
of early years interventions thus extend far beyond health, with
participants reporting improvements in literacy, job prospects
and earnings (hence savings to the criminal justice system,
increased taxation of higher earnings, etc).
This also highlights the cross-sector ow problem: cost-
effective public health programmes may not be commissioned if
decision-makers are only looking through a narrow health lens.
STRENGTHS
We describe a carefully conducted systematic review. Although
the precision of application of ROI calculations varies widely,
even the most rudimentary analyses consistently suggest that
most public health interventions are substantially cost-saving.
LIMITATIONS
Several limitations should be considered. First, the difculty of
dening what constitutes a public health intervention, particu-
larly those focused on wider determinants. We purposefully cast
the net wide to achieve a broad systematic review. Further ana-
lysis of particular topic areas might now be benecial.
Second, publication bias appears likely, and even some pub-
lished studies may have been missed. Such studies are inevitably
scattered across a wide eld of journals and some economic
studies may only be available via organisational websites.
However, we did search the grey literature and we did identify
almost 3000 total studiesa reassuringly high number.
Third, we did not conduct a formal meta-analysis because of the
very inconsistent manner in which ROI was calculated, with differing
cost perspectives, time horizons and discount rates. Discount rates
6 Masters R, et al.J Epidemiol Community Health 2017;0:18. doi:10.1136/jech-2016-208141
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ranged from 0% to 10%. A high discount rate disadvantages public
health interventions that have a long payback time.
62
Conversely, a
1 year time horizon may offer too short a time frame.
Fourth, the generalisability of the interventions conducted from
one country to the next will vary. Participants in US studies may
poorly reect UK demographics and vice versa. Furthermore,
some studies focused on vaccination practices that are no longer
employed in a number of countries (eg, single measles and haemo-
philus inuenzae type b vaccinations). Similarly, the majority of
workplace health promotion initiatives come from the USA,
where employers who pay for employeeshealthcare will have an
additional nancial incentive to promote the health of their
workforce.
Fifth, the quality of the economic evaluations varied consider-
ably. Practice has clearly improved substantially since the 1970s,
with recent evaluations employing more sophisticated modelling
techniques. Designing such studies can be challenging as public
health interventions are often complex and multifactorial, and it
can be difcult to isolate an effect size even within a randomised
controlled trial. Some of the published literature may therefore
systematically overestimate or underestimate the ROI of inter-
ventions, and hence the need for more research.
Unanswered questions and future research
There is a clear need for further high-quality economic evalua-
tions of public health interventions, which include a range of
discount rates and robust sensitivity analyses.
Implications for clinicians and policymakers
Overall, the results of our systematic review clearly demonstrate
that public health interventions are cost-saving, both to health ser-
vices as well as the wider economy. Furthermore, some are very
rapid: falls prevention interventions reported substantial returns
within 612 months.
41
One might reasonably expect equally rapid
returns for preventive interventions such as immunisation, health-
care, smoking cessation and nutrition.
63
Although attempting to
quantify returns within a short timescale can be challenging, even
larger returns on investment were seen over a 1020 years time
horizon.
10 15 17 32 58
This has signicant implications for policy-
makers, who often work to a much shorter time horizon (typically
35 years). We suggest that Public Health England, NICE and
other advisory bodies therefore need to routinely emphasise that
public health interventions can offer surprisingly rapid returns,
which may increase further over the longer term.
CONCLUSIONS
This systematic review suggests that local public health interven-
tions are cost-saving, and offer substantial returns on invest-
ment, nationwide programmes even more so.
The cuts to public health budgets therefore represent a false
economy. They are likely to generate billions of pounds of add-
itional costs to the health services and wider economy.
What is already known on this subject
It is well known that it is nancially preferable for healthcare
systems to aim to prevent ill health rather than to subsequently
treat it. A number of studies have calculated the return on
investment for individual prevention interventions; however, no
systematic review has spanned the breadth of public health.
What this study adds
This systematic review demonstrates a median return on
investment of public health interventions of 14:1. Thus, for
every £1 invested in public health, £14 will subsequently be
returned to the wider health and social care economy.
Furthermore, this review categorises the return on investment
according to the public health specialty and local versus
national levels of intervention. It suggests that cuts to public
health services are short sighted and represent a false economy,
with substantial opportunity costs.
Acknowledgements The authors would like to thank Knowsley Metropolitan
Borough Council Public Health Team, and Tracy Owen from the North West
Commissioning Support Unit FADE Evidence Knowledge Centre, for their support in
the development of this review.
Contributors RM drafted the paper, conducted the literature search, assessed the
methodological quality of included studies and conducted the analysis. EA
independently conducted the systematic review and assessed the methodological
quality of the included studies. BC adjudicated in any disagreements in the
methodological quality assessments, provided health economics advice and assisted
with the data analysis. RC provided expert health economics advice and support
throughout, and made signicant contributions to the analysis and manuscript. SC
devised the concept, supervised the project, provided expert public health advice
and support throughout, and made signicant contributions to the analysis and
manuscript. All authors made substantial contributions to the analysis and
manuscript, including nal approval.
Funding RC is supported by the National Institute for Health Research (Senior
Research Fellowship, SRF-2013-06-015).
Disclaimer The views expressed in this publication are those of the authors and
not necessarily those of the NHS, the National Institute for Health Research or the
Department of Health.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
terms of the Creative Commons Attribution (CC BY 4.0) license, which permits
others to distribute, remix, adapt and build upon this work, for commercial use,
provided the original work is properly cited. See: http://creativecommons.org/licenses/
by/4.0/
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interventions: a systematic review
Return on investment of public health
Simon Capewell
Rebecca Masters, Elspeth Anwar, Brendan Collins, Richard Cookson and
published online March 29, 2017J Epidemiol Community Health
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Many public health interventions are extremely good value for money. So why has it often proven difficult to obtain political backing for apparently common-sense public health interventions such as sewage treatment, vaccinations, or cigarette taxes? The authors use economic models of public choice, supported by plenty of examples, to explain how powerful interests groups, voting arrangements, and politicians or bureaucrats who pursue their own objectives, have shaped public health priority setting. They show that it may be perfectly rational for policy makers to accommodate these constraints in their decisions, even if it implies departing from welfare maximizing solutions.
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Home blood pressure (BP) monitoring has been shown to be more effective than clinic BP monitoring for diagnosing and treating hypertension. However, reimbursement of home BP monitoring is uncommon in the United States because of a lack of evidence that it is cost beneficial for insurers. We develop a decision-analytic model, which we use to conduct a cost-benefit analysis from the perspective of the insurer. Model inputs are derived from the 2008 to 2011 claims data of a private health insurer in the United States, from 2009 to 2010 National Health and the Nutrition Examination Survey data, and from published meta-analyses. The model simulates the transitions among health states from initial physician visit to hypertension diagnosis, to treatment, to hypertension-related cardiovascular diseases, and patient death or resignation from the plan. We use the model to estimate cost-benefit ratios and both short- and long-run return on investment for home BP monitoring compared with clinic BP monitoring. Our results suggest that reimbursement of home BP monitoring is cost beneficial from an insurer's perspective for diagnosing and treating hypertension. Depending on the insurance plan and age group categories considered, estimated net savings associated with the use of home BP monitoring range from $33 to $166 per member in the first year and from $415 to $1364 in the long run (10 years). Return on investment ranges from $0.85 to $3.75 per dollar invested in the first year and from $7.50 to $19.34 per dollar invested in the long run.
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To examine whether increasing investment in needle/syringe exchange programs (NSPs) in the US would be cost-effective for HIV prevention, we modeled HIV incidence in hypothetical cases with higher NSP syringe supply than current levels, and estimated number of infections averted, cost per infection averted, treatment costs saved, and financial return on investment. We modified Pinkerton's model, which was an adaptation of Kaplan's simplified needle circulation theory model, to compare different syringe supply levels, account for syringes from non-NSP sources, and reflect reduction in syringe sharing and contamination. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion.
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Background: Poor medication adherence among patients with chronic diseases can result in complications and increased health care expenditures. An outpatient pharmacy clinical service (OPCS) program targeted nonadherent diabetes mellitus (DM) and/or coronary artery disease (CAD) patients with hemoglobin A1c (HbA1c) and/or low-density lipoprotein cholesterol (LDL-C) outside clinical goals. Pharmacists engaged identified patients with a face-to-face B-SMART consult, a consultation methodology to identify Barriers to medication adherence, work on Solutions to identified barriers, Motivate patients, recommend Adherence tools, reinforce the pharmacist-patient Relationship, and Triage if needed, to other services such as health education to improve outcomes. Objectives: To (a) assess rates of medication adherence and clinical outcomes in the OPCS program compared with usual care in an integrated health care system and (b) estimate return-on-investment (ROI) from this intervention. Methods: This retrospective cohort study used data from the Kaiser Permanente Southern California region to identify patients who received OPCS consultations and usual care patients from March 2009 through December 2010, with 1 year of follow-up from the initial consult (index date). Four patients from usual care were matched to each patient in the OPCS program and were assigned the same index date as the matching OPCS patient. Additional selection criteria were applied after matching. All patients were required to have a medication possession ratio (MPR) of less than 0.80 for their diabetes or dyslipidemia oral medications 1 year prior to the index date, indicating lower adherence to the prescribed therapy. Diabetic patients or dyslipidemic patients had to have a HbA1c or LDL-C lab result outside of clinical goals prior to the index date to be included in the study, respectively. Adherence outcomes as well as clinical outcomes were measured 12 months after the index date using chi-square tests for differences in percentages and t-tests for differences in means. The ROI was based on a cost-avoidance model that compared the cost of the OPCS program with the cost savings gained through reduced hospitalizations and emergency department (ED) visits. The diabetes and dyslipidemia cohorts were combined for the ROI analysis. Results: Demographic and clinical characteristics at baseline were similar between the OPCS group (n = 1,480) and usual care group (n = 1,477). Among patients with diabetes, a higher percentage in the OPCS group than in the usual care group were adherent with their diabetes medications (53.5% vs. 37.4%, P = 0.001). There was no significant difference in average MPR between groups. However, patients in the OPCS group had a greater increase in mean MPR (0.19 vs. 0.15, P = 0.024); were less likely to discontinue taking their diabetes medications (11.7% vs. 35.5%, P = 0.001); and were more likely to have a timely first fill after the index date (34.8% vs. 12.9%, P = 0.001). The average number of days to the first fill after the index date was significantly shorter for the OPCS group (79.3 vs. 156.3, P = 0.001). Regarding clinical outcomes, patients with diabetes in the OPCS group had a lower mean HbA1c (8.48 vs. 8.80, P = 0.024) and a greater reduction in HbA1c (-1.25 vs. -0.75, P = 0.001) than in the usual care group. They were also less likely to have an ED visit (1.67% vs. 4.21%, P = 0.040), but there was no significant difference in the percentage of patients with a hospital admission. Among patients with dyslipidemia, the mean MPR was significantly lower for the OPCS group than the usual care group (0.70 vs. 0.74, P = 0.003). There were no significant differences in the percentage of adherent patients or the change in mean MPR from baseline. However, the OPCS group was significantly less likely to discontinue dyslipidemia medications (21.1% vs. 35.4%, P less than 0.001) and more likely to have a timely fill (28.3% vs. 15.1%, P less than 0.001). The average days to first fill after the index date was 106.9 for the OPCS group, compared with 162.6 for the usual care group (P less than 0.001). The OPCS group had a lower mean LDL-C (105.1 vs. 110.4, P = 0.001) and a greater reduction in LDL-C (-30.5 vs. -22.4, P = 0.001) than the usual care group. There were no significant differences in the percentage of patients with an ED visit or a hospital admission. In terms of ROI, assuming that 58% of hospitalizations and 8.5% of ED visits incurred in the usual care group were avoidable, approximately $5.79 could be saved for every dollar spent on the OPCS program. Conclusion: By engaging nonadherent patients to restart their DM or lipid medications during a face-to-face consult, the OPCS pharmacist was able to influence and improve medication adherence and clinical outcomes, particularly among patients with diabetes. A positive ROI was demonstrated.
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Importance In recent years, across the United States, many school districts have cut on-site delivery of health services by eliminating or reducing services provided by qualified school nurses. Providing cost-benefit information will help policy makers and decision makers better understand the value of school nursing services.Objective To conduct a case study of the Massachusetts Essential School Health Services (ESHS) program to demonstrate the cost-benefit of school health services delivered by full-time registered nurses.Design, Setting, and Participants Standard cost-benefit analysis methods were used to estimate the costs and benefits of the ESHS program compared with a scenario involving no school nursing service. Data from the ESHS program report and other published studies were used. A total of 477 163 students in 933 Massachusetts ESHS schools in 78 school districts received school health services during the 2009-2010 school year.Interventions School health services provided by full-time registered nurses.Main Outcomes and Measures Costs of nurse staffing and medical supplies incurred by 78 ESHS districts during the 2009-2010 school year were measured as program costs. Program benefits were measured as savings in medical procedure costs, teachers’ productivity loss costs associated with addressing student health issues, and parents’ productivity loss costs associated with student early dismissal and medication administration. Net benefits and benefit-cost ratio were calculated. All costs and benefits were in 2009 US dollars.Results During the 2009-2010 school year, at a cost of $79.0 million, the ESHS program prevented an estimated $20.0 million in medical care costs, $28.1 million in parents’ productivity loss, and $129.1 million in teachers’ productivity loss. As a result, the program generated a net benefit of $98.2 million to society. For every dollar invested in the program, society would gain $2.20. Eighty-nine percent of simulation trials resulted in a net benefit.Conclusions and Relevance The results of this study demonstrated that school nursing services provided in the Massachusetts ESHS schools were a cost-beneficial investment of public money, warranting careful consideration by policy makers and decision makers when resource allocation decisions are made about school nursing positions.