Viewpoint

Health systems, health, and wealth: a European perspective

Martin McKee, M a r c Suhrcke, Ellen Nolte, Suszy Lessof, Josep Figueras, Antonio Duran, N a t a Menabde

Countries from WHO's European region met in Tallinn,
Estonia in June, 2008, to discuss a new way of thinking
about health systems. For the past three decades, much
of the debate on health care in Europe has been
dominated by cost containment. Informed by detailed
background analyses,''� a 2 year consultation process
poor health was one of several of constraints on economi identified four pathways by
c which health could increas
growth, and second, that the return on investment from e
health interventions was considerable.* However, whethe economic growth. First, hea
r lthy people are more likely t
or not the Commission's conclusions would apply t o

began by asking "what is a health system actually for?" o be employed than those in p
The answer depends on who is asking the question. For high-income countries was unclear. First, the nature o oor health, with less sicknes
some, a health system is a means of redistributing f s

society's resources—from healthy to sick and from rich work differs between countries, with much production in absence, and a lower pro
to poor. For others, it is for commercial opportunity like low-income countries relating to physical labour—such as bability of early retiremen

any other service sector. However, there is widespread in agriculture, mining, or non-mechanised t.
consensus around the goals set out in the 2000 World manu¬ Second, when at work the
Health Report.' These aims are improving health, facturing—whereas in high-income countries much work y are likely to be producti
ensuring responsiveness to legitimate expectations, and is sedentary. Second, in low-income countiies large health ve.

ensuring fairness of financing. gains can be achieved by scaling-up basic interventions, Third, because healthy peop
The participants discussed a model ofrelations between such as immunisation, whereas in high-income countries, le can expect to live for a lo
health systems, health, and wealth, in which each can be in which chronic disorders dominate and necessar ng

mutually supportive, creating the possibility of a virtuous y time, they might invest time
circle of mutually reinforcing relations whereby carefully interventions are complex and multifaceted. and money in their educatio

targeted investments benefit both the health of the Recent analyses of high-income and transition coun¬n,

population and economic growth (figure). In this model tries in Europe,'-� updated for the Tallinn conference,�' itself a driver of economic
health systems are thus seen as a productive sector rather growth. Finally, for the sa
than a drain on resources, forcing reassessment of www.thelancet.com Vol 373 January 24, 2 0 0 9 me
concerns about financial sustainability. We examine each reason, they can save mu
relation in turn. ch for retirement, providi

Generally, increased wealth is associated with improved ng

health. Heightened command over resources allows money for capital investme
individuals and populations to make healthy lifestyle nt. Both reports show muc
choices and to access timely and effective health care. h

Consequently, worldwide, high-income countries have evidence from studies in

increased life expectancies (even if some perform better individuals for the first t
or worse than expected).' wo
Less well-recognised is whether improved health leads to pathways, but, although th
increased wealth. The issue was addressed, at least for e third and fourth pathwa
low-income countries, by the Commission on Macro¬ ys
economics and Health, which demonstrated, first, that have been described in low
-income countries, there was Lancet 2009; 373:349-51

littie evidence for or against these last two pathways in European Observatory on

high-income countries. Health Systems and Policies,

Furthermore, historical studies show that—in addi¬ London School of Hygiene and

tion to known factors such as natural resources and Tropical Medicine, London, UK

openness to trade—gains in health and nutrition in the (Prof M McKee MD, E Nolte PhD);

past two centuries were attributable to a substantial European Observatory on

share of today's economic wealth in high-income Health Systems and Policies,

countries,� and contemporary international comparisons WHO, Regional Office for

show that improvements in health are associated with Europe, Brussels (S Lessof MBA,

increased economic growth.� Other researchers have J Figueras PhD); University of

examined the economic losses attributable to health East Anglia, Norwich, UK

inequalities in Europe, both in terms of the additional (Prof M Suhrcke PhD); WHO,

cost of health care and the wider effect on productivity.' Regional Office for Europe,

If the pre-2007, 25 European Union (EU) governments Copenhagen (N Menabde PhD);

could raise levels of good health in the least well-educated and Técnicas de Salud, Spain

to those of the best educated, they could achieve an (A Duran PhD) 349

estimated 22% reduction in hospital admissions and Correspondence to:

gain €141 billion in productivity (equivalent to 1 • 4% of Prof Martin McKee, London

gross domestic product) every year. School of Hygiene and Tropical

A caveat is, however, required. As the median age of Medicine, Keppel Street,

death increases, the gains to the economy will be London WC1E7HT, UK

martin.mckee@lshtm.ac.uk

Health

systems

Social well-being

Effect on economy

Effect on health outcomes

Figure: Health systems, health, a n d w e a l t h

I Viewpoint

attenuated unless the retirement age is raised and, in resources. Whatwas described as full eng

many countries, the high proportion of the population in agement— which

their 50s who are already outside the labour market is requires the health system to promot
addressed.'" Clearly new models of employment and e health actively
career paths would be needed. rather than merely treating
The contribution of health systems to population health disease—would save
has long been contested, and the view that health care £30 billion (US$48 billion) by 2022-
contributes little is still widely held. Often cited is the work 23, representing
of McKeown" who, writing in the 1960s and 1970s, argued about 40% of the total UK National Heal
that much of the fall in mortality in the previous century th Service (NHS)
was due to improvements in living conditions rather than budget in 2002."
in health care. Although this argument has been One way by which such a scenario co

challenged, until around the mid-20th century, health care uld reduce future
contributed very litüe to overall improvements in costs is by reducing morbidity. Ov

population health. However, this is no longer the case in er two decades

not only the more obvious areas such as new ago. Fries'' postulated that the adop
pharmaceuticals and technology, but also in the tion of healthy
development of evidence-based care," and new and more lifestyles would lead to increased longevi
effective ways of organising care, such as the introduction ty and enhanced
of multidisciplinary stroke units or integrated screening periods of good health. Evidence is no
programmes. w emerging that
The effect of these developments has been examined by this improvement is indeed happening,
use of the notion of avoidable mortality, defined as deaths although in part
that should not occur in the presence of timely and because older people are now being ma
effective care (such as deaths from asthma, diabetes, and intained in good

appendicitis, in those younger than a specified age, now health through therapeutic advances, m

typically 75 years)." Research applying this approach to any of which can

industrialised countries consistently shows that such be low cost, especially when generic dru
deaths—about 30% of total mortality in these countries— gs are used.'"
have fallen at a faster rate than overall mortality" and
reduction in particular causes can be linked to the
introduction of corresponding interventions." Yet, even
now, health systems are not all equally successful, with
almost no progress in the U SA in recent years when other
industrialised countries have achieved substantial gains."
The reciprocal relation, from health to health systems,
was the subject of the Wanless report." The report began
with the observation that if everyone was healthy, then the
demand for health care would be lessened. Wanless
developed a series of projections of future health
expenditure in the UK, contingent on adoption of policies
to promote health and achieve the best use of health-care
 A countervailing argument has been that, as the costs
of health care rise with increasing age, enabling people
to live for longer would merely increase the financial
burden on the health-care system. Subsequent work has,
however, demonstrated that increased costs of care are
not due to age per se, but instead to proximity of death,
and that those dying at older ages are actually less
expensive, since they are treated less intensively."
However, the cost of social care should be included,
especially to the extent that it is driven by increasing
rates of cognitive decline. Finally, those working in the
health system can promote improvements in health by
acting as advocates for the inclusion of health in all
policies,™ in sectors as diverse as transport, education,
taxation, and defence.
The ability of a country to invest in health care will
depend on that country's wealth; a country with little
wealth will find it more difficult to invest adequately in
health care. Conversely, a high-income country can
afford to increase investment. Of course, in both cases,
much depends on government priorities. A widely held
view is that health care is what is termed a luxury item,
in that the share of national income devoted to it
increases inexorably as the economy grows (an analogy
is the consumption of designer clothes, which increases
as people become wealthy). This view derives mainly
from cross-sectional studies done in the 1960s, showing
a positive relation between gross national product and
the proportion of it spent on health,�' which raises
350
questions about the value of additional expenditure on
health, with some analysts suggesting that it buys care
rather than cure.�� However, subsequent research has
raised questions about this belief. First, health care does
not behave as a luxury item within countries."
Second, the nature of the observed relation between
health and expenditure on health changes over time.
Third, when combining cross-sectional and time-series
analysis, many different relations can be produced,
some of which support the argument and others refute
it." Thus, although still controversial, and although
there are exceptions, which are rarely publicly funded
(such as cosmetic surgery), the argument that increased
expenditure on health care is essentially an indulgence
is not supported by a careful analysis of the evidence.
A second piece of evidence relates to the return on
investment in health care. A monetary value can be
assigned to a year of life gained. One study, comparing
the growth in health-care expenditure between 1990 and
1998 with the value of years of life gained that were
attributable to health care, showed a substantial positive
return on investment of between 50% and 250%.'
Furthermore, health systems have a role in redistri¬
buting wealth, by providing what are effectively cross-
subsidies to poor people who might otherwise face
catastrophic expenditure in the event of illness." Such
subsidies will benefit low-income workers directly, and
will also provide security to invest their meagre resources
www.thelancetcom Vol 373 January 24,2009
in wealth creation, rather than hoarding to protect their Acknowledgments

families from possible disaster. This viewpoint is a sum m a ry of a report prepared by JF, MM, AD, and

Again, there is a reciprocal relation by which health NM for the W H O European Region Ministerial Conference on Health

systems could contribute to wealth. The presence of Systems, which draws extensively on original research by MM, MS,

health facilities is an important factor in economic and EN.

development of disadvantaged areas, hence the inclusion References

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only a call to spend more on health systems, although in

many cases extra funds will be necessary. Rather, the
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policies and interventions, and strengthening of both
public health and health care, underpinned by a
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persist in many countries.

Finally, health and wealth are means of achieving
societal wellbeing, situated at the centre of the model,
which, in turn, means that policies pursued are equitable
and sustainable and, since Europe is part of a global

system, the gains should not be at the expense of other

parts of the world. WHO sees this model as a historic
opportunity to bring about major change. Yet, this is
only the beginning. The next step will be to deliver on
the commitments that are being made, developing
coordinated policies and establishing systems to monitor
whether they achieve what they promise.
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