The global pandemic might have revealed the importance of robust public health infrastructure, but we still have trouble grasping the vital need to invest in it.
An analogy might help. Wellington's recently opened Transmission Gully motorway shortens journeys from the Kāpiti Coast to the city by up to 15 minutes. First proposed 100 years ago and finally built over the past eight years, the final cost will be at least $1.25 billion. Worth it to some, questionable to others.
But the key value isn't the infrastructure itself, it's the time saved. The efficiency and petrol saving on a journey without traffic lights and single lanes will last long after the delays and overspend on the project are forgotten.
Investment in public health has clear parallels with investment in major transport projects. Time saved on a journey is akin to lives saved from a premature end by the kinds of hidden services, like safe drinking water, that are designed to improve, protect and promote the health of the whole population.
But both infrastructure and public health investments can take years before the benefits are realised. Urgent maintenance – filling potholes or filling hospitals – tends to crowd out strategic investment.
Public health is always the Cinderella of services in a publicly funded health system that delivers personal as well as public services, and is always vulnerable to budget cuts and under-investment.
Sadly, Covid has shown there are no fairy godmothers to step in and wave a magic wand. Globally, the lack of maintenance of public health systems is forecast to cost more than $US12.5 trillion according to the International Monetary Fund.
The value of public health
Governments of all political persuasions want healthy populations, they just disagree on how to achieve the goal. Because of this, public health has been consistently undermined.
As the Labour Government's May 19 Budget approaches, we need to acknowledge that the massive investment in tackling the pandemic could have been spent earlier to strengthen public health infrastructure.
That said, the question now is how governments can invest to be better prepared for the current and inevitable next public health threat. The shared value of public wellbeing must be protected by maintaining existing healthcare while investing more in public health.
First and foremost, we need to ensure public health is actually valued and invested in – whether or not there's a pandemic. The past two years have shown how much New Zealanders are willing to pay, not just to keep themselves healthy, but to keep family, whānau and others safe.
Unfortunately, when all is going well, the true value of public health investment is invisible and unnoticed. Only when there are service failures (for example, the 2016 Havelock North water disaster), controversial health issues (such as raising the age for buying cigarettes), or a global pandemic, does public health become front of mind.
Also, public health's focus on the whole population rather than on individual cases means it's not as readily relatable. This lack of an emotional focal point means public health isn't always uppermost in the minds of decision makers at budget time.
Headlines such as "Fully immunised child doesn't die", "Water still drinkable" or "Slight reduction in obesity rates means improved disability-adjusted life years!" are worthy, but not necessarily newsworthy.
Public and personal health
Public health's long-term view disadvantages it within a three-year election cycle that favours fast outcomes, even if those outcomes are more expensive. It's easier and quicker to see the impact of treatment than prevention.
Currently, the system is set up to fund personal (individual) health. It's harder to cut personal healthcare, if only because a real person missing out on surgery or drug therapy makes better headlines.
But a cut to a health promotion budget doesn't have a face or a name. Public health is simply an easier place to make cuts and is often the first area to lose investment. Historically, it has sometimes had to be ring-fenced to stop it being pillaged to fund other services.
Disinvestment and a focus on personal health occurs even though public health has a better marginal return than personal health – it's cheaper per person to spend on public health than on personal health.
This is because public health prevents or slows ill health. It's less costly to tackle the root causes of rheumatic fever, for instance, than to pay for treatment, especially heart valve replacement and long-term care and rehabilitation.
The road to better investment
Covid has highlighted the need for both personal and public health services. The solution is balance, with investment in one reinforcing the other. Without prevention, personal health services would be swamped. Both aim to improve lives, but require different investment approaches.
There are two main things governments can do.
1. Adopt investment mechanisms that specifically acknowledge public health will always lose in a popularity contest to personal health, and adjust the budget process accordingly. This means calculating the future benefits of public health investment and redressing the current bias in budget spending.
2. Set fixed goals with robust measurement systems to capture short, medium and long-term progress. Allow for flexibility in how those goals are met according to policy priorities and the sociopolitical context. One immediate solution would be to ring-fence long-term public health investment, plus have dedicated strategy and funding, to address the major drivers of ill health – obesity, for example.
It's time to invest in public health infrastructure as we would with major transport projects. Transmission Gully wasn't funded by an annual budget allocation in competition with routine maintenance needs. The project's size, the time-frame for completion and the road's broader economic benefits all shaped decisions.
Proper investment in services that generate extra years of healthy life and avoid costly cures are surely no less important than the minutes saved on a trip into town.