NIHR Signal Public health interventions may offer society a return on investment of £14 for each £1 spent

Published on 18 July 2017

Each £1 invested in public health interventions could offer an average return on investment to the wider health and social care economy of £14.

This systematic review looked at 52 studies where the return on each £1 ranged from -£21.3 to £221. Legislative interventions such as sugar taxes, and health protection interventions such as vaccination programmes, gave the highest returns on investment. Interventions such as anti-stigma campaigns, blood pressure monitoring and early education programmes, provided smaller (but still favourable) returns. National campaigns offered greater returns than local campaigns. Falls prevention provided the quickest return, within 18 months.

These findings apply to high-income countries. There are some limitations to the data, as a variety of calculation techniques were used and the quality of the included studies varied. However, these are unlikely to alter the direction or approximate size of these effects. The study shows how cost-effective public health interventions can be and should inspire future research into how to better implement what is already known.

Public health interventions may offer society a return on investment of £14 for each £1 spent

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Why was this study needed?

Studies assessing public health interventions have generally shown that it makes better financial sense to prevent ill health than to treat it. However, the benefits of population-level public health interventions tend to accrue over the long term, and studies use different economic evaluations to measure costs and benefits, making comparison difficult.

The aim of this review was to compare “return on investment” and “cost-benefit” estimates for a range of public health interventions. The researchers only included studies that had these terms in title or abstract. The definition of public health was broad: “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”. Included interventions ranged from vaccinations, road safety campaigns and taxation, to improved walking and cycling infrastructure, workplace obesity management, falls prevention, and smoking cessation.

This is the first systematic review looking at return on investment from across a broad spectrum of public health interventions at both local and national levels.

What did this study do?

This systematic review included 52 studies (four from the UK) that had calculated either return on investment or cost benefit ratios for public health interventions, published from 1976 to 2015. The interventions were delivered in high-income countries with universal healthcare systems, with the explicit intention of making the results generalisable to the UK.

Results could not be pooled because of the variety of ways in which return on investment was calculated and the variation in intervention type. The quality of the included studies also varied considerably, and the authors reported that publication bias was expected – i.e. that studies with positive results were more likely to be published.

These limitations mean that the results should be interpreted cautiously. However, the size and direction of the potential -savings , although approximate is likely to be as close as possible to what might happen in practice given the variety and complexity of some of these interventions.

What did it find?

  • The median return on investment, averaged across all public health interventions, was 14.3 (from 34 studies). Return on investment ranged from ‑21.3 (influenza vaccination of healthy workers) to 221 (lead paint control).
  • Local level interventions showed on average a lower return on investment than national programmes. The median return was 4.1 (range 0.9 to 19.3, from 18 studies) for local interventions, versus a median return of 27.2 (range ‑21.3 to 221, from 17 studies) for national programmes.
  • Legislative and health protection interventions gave the highest returns on investment. The median return for legislative interventions, such as sugar taxation and child booster seat policies, was 46.5 (range 38 to 55, from two studies), while for health protection programmes, such as vaccination programmes, needle and syringe programmes, and lead paint control, it was 34.2 (range 0.7 to 221, from eight studies).
  • Health promotion, healthcare public health and wider determinants of health interventions gave small returns on investment. For health promotion interventions (e.g. anti-stigma campaigns and family planning services) the median return was 2.2 (range 0.7 to 6.2, from 12 studies), for healthcare public health (e.g. heart failure disease management programmes and blood pressure monitoring) it was 5.1 (range 1.1 to 19.3, from six studies), and for wider determinants of health (e.g. 20mph zones, early education programmes and interventions for juvenile offenders) it was 5.6 (range 1.1 to 10.8, from six studies).

What does current guidance say on this issue?

NICE produces guidance on a range of public health issues. When developing this guidance, economic factors such as return on investment are examined with the evidence about effectiveness of interventions. NICE also provides tools for calculating the return on investment for various interventions to help public health commissioners and decision-makers.

What are the implications?

The authors suggest that cutting public health budgets in the short-term may add substantial costs to health and social care services in years to come. The approach this review took, in comparing different types of public health interventions, might help policy makers in  deciding what to fund and how soon the return could be expected.

The authors do recognise some limitations to this study, including the possibility that studies with positive results might be preferentially reported. The numbers reported should be taken as approximates but if the interventions seem appropriate for an NHS setting then there seems no reason not to test and evaluate them here. The return on investment approach seems a useful tool for estimating the impact of public health interventions and this review should encourage others to use it when evaluating programmes that have been implemented.

Citation and Funding

Masters R, Anwar E, Collins B, et al. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health. 2017;71(8):827-34

One of the authors is supported by the National Institute for Health Research (Senior Research Fellowship, SRF-2013-06-015).

Bibliography

NICE. Return on investment tools. London: National Institute for Health and Care Excellence; 2017.

Why was this study needed?

Studies assessing public health interventions have generally shown that it makes better financial sense to prevent ill health than to treat it. However, the benefits of population-level public health interventions tend to accrue over the long term, and studies use different economic evaluations to measure costs and benefits, making comparison difficult.

The aim of this review was to compare “return on investment” and “cost-benefit” estimates for a range of public health interventions. The researchers only included studies that had these terms in title or abstract. The definition of public health was broad: “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”. Included interventions ranged from vaccinations, road safety campaigns and taxation, to improved walking and cycling infrastructure, workplace obesity management, falls prevention, and smoking cessation.

This is the first systematic review looking at return on investment from across a broad spectrum of public health interventions at both local and national levels.

What did this study do?

This systematic review included 52 studies (four from the UK) that had calculated either return on investment or cost benefit ratios for public health interventions, published from 1976 to 2015. The interventions were delivered in high-income countries with universal healthcare systems, with the explicit intention of making the results generalisable to the UK.

Results could not be pooled because of the variety of ways in which return on investment was calculated and the variation in intervention type. The quality of the included studies also varied considerably, and the authors reported that publication bias was expected – i.e. that studies with positive results were more likely to be published.

These limitations mean that the results should be interpreted cautiously. However, the size and direction of the potential -savings , although approximate is likely to be as close as possible to what might happen in practice given the variety and complexity of some of these interventions.

What did it find?

  • The median return on investment, averaged across all public health interventions, was 14.3 (from 34 studies). Return on investment ranged from ‑21.3 (influenza vaccination of healthy workers) to 221 (lead paint control).
  • Local level interventions showed on average a lower return on investment than national programmes. The median return was 4.1 (range 0.9 to 19.3, from 18 studies) for local interventions, versus a median return of 27.2 (range ‑21.3 to 221, from 17 studies) for national programmes.
  • Legislative and health protection interventions gave the highest returns on investment. The median return for legislative interventions, such as sugar taxation and child booster seat policies, was 46.5 (range 38 to 55, from two studies), while for health protection programmes, such as vaccination programmes, needle and syringe programmes, and lead paint control, it was 34.2 (range 0.7 to 221, from eight studies).
  • Health promotion, healthcare public health and wider determinants of health interventions gave small returns on investment. For health promotion interventions (e.g. anti-stigma campaigns and family planning services) the median return was 2.2 (range 0.7 to 6.2, from 12 studies), for healthcare public health (e.g. heart failure disease management programmes and blood pressure monitoring) it was 5.1 (range 1.1 to 19.3, from six studies), and for wider determinants of health (e.g. 20mph zones, early education programmes and interventions for juvenile offenders) it was 5.6 (range 1.1 to 10.8, from six studies).

What does current guidance say on this issue?

NICE produces guidance on a range of public health issues. When developing this guidance, economic factors such as return on investment are examined with the evidence about effectiveness of interventions. NICE also provides tools for calculating the return on investment for various interventions to help public health commissioners and decision-makers.

What are the implications?

The authors suggest that cutting public health budgets in the short-term may add substantial costs to health and social care services in years to come. The approach this review took, in comparing different types of public health interventions, might help policy makers in  deciding what to fund and how soon the return could be expected.

The authors do recognise some limitations to this study, including the possibility that studies with positive results might be preferentially reported. The numbers reported should be taken as approximates but if the interventions seem appropriate for an NHS setting then there seems no reason not to test and evaluate them here. The return on investment approach seems a useful tool for estimating the impact of public health interventions and this review should encourage others to use it when evaluating programmes that have been implemented.

Citation and Funding

Masters R, Anwar E, Collins B, et al. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health. 2017;71(8):827-34

One of the authors is supported by the National Institute for Health Research (Senior Research Fellowship, SRF-2013-06-015).

Bibliography

NICE. Return on investment tools. London: National Institute for Health and Care Excellence; 2017.

Return on investment of public health interventions: a systematic review

Published on 31 March 2017

Masters, R.,Anwar, E.,Collins, B.,Cookson, R.,Capewell, S.

J Epidemiol Community Health , 2017

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.

Expert commentary

Public health commissioning is now largely based in non-health settings. A common question posed by lay people in these situations is what value is likely from a choice of spending options? However, once beyond preventing risk and managing early signs of disease, the answer is often unclear. This paper goes some way to inform us on the relative return on investment from a wider range of interventions.

In these days of localism, the authors find that the largest impacts come from national interventions, and the more centralised health protection functions, partly because they are regularly studied. Further evidence on the health improvement and wider determinants is sorely needed, but even now the emerging work indicates respectable returns.

This needs to be stated widely in the light of budget retrenchments, in order to avoid lost opportunities for our future health. 

Professor Yvonne Doyle, Director for London, Public Health England

Categories

  •   Commissioning, Public Health