"Where Would You Put the Money?"

By David A. Kindig, MD, PhD

As regular readers know, I’ve been arguing consistently for the need for a regular, sustainable revenue stream to support population health improvement. However, I’ve not directly addressed the question of how these dollars should be allocated. As one of the authors of the important Evans-Stoddart population field model said in their 2003 AJPH article (Consuming Research, Producing Policy?), “redirecting resources means redirecting someone’s income…most students of population health cannot confidently answer the question…well, where would you put the money?” 

Why is this so? Can’t we simply link the huge variation in health outcomes we see across states and communities to financial and non-financial policy investments over time?  Why have we not simply estimated community level, per capita policy and programmatic investment in each health factor area (health behaviors, clinical care, social and economic factors, and the physical environment) to derive a base level of investment needed to achieve health benchmarks?

There has been some limited national and state level research and policy analysis on this question. The Trust for America’s Health (TFAH) estimated in 2008 that that investing $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking could save the country more than $16 billion annually within five years. In 2009, Kim and Jennings found that at the state level more generous education spending, progressive tax systems, and more lenient welfare program rules help to improve population health. However, the magnitudes of the effects were quite small, most likely because using the state as the unit of analysis masks much of the important variation in both outcomes and investments at more local levels.   

We have suggested that since communities have different outcomes and determinants profiles, locally tailored “policy packages” might be an effective and efficient approach. These packages could be driven by the strength and breadth of local investments affecting the multiple determinants of health. Unfortunately, we are not aware of any national or state data sets that could inform development of such investment recommendations. The relevant financial data from the multiple local, state and federal public and private funding sources does not exist or is not standardized in ways to allow policy-relevant comparisons that would be useful to public and private policy makers. But I strongly believe that making real progress in this area will require that we systematize and standardize collection of these data.

In the meantime, we should rely heavily on currently available compass points. The County Health Rankings encourage comparison of health factor areas with national benchmarks. Everyone needs access to healthcare services, and the TFAH guidelines for prevention investments are useful. Many local public health departments are inadequately funded for their critical work. There is a strong evidence base that investing in early childhood and other education programs has efficient long term pay off in terms of health outcomes. And a strong argument can be made for resources to support the work of emerging multisectoral super-integrators that can play a critical role in identifying and harnessing resources.

We must start with what we have, by continuing to rely on existing tools and resources. But we must also move beyond these, to advocate for and insist on development of state-of-the-art surveillance systems to promote evidence-informed investment and stewardship of our limited and extremely valuable population health resources. 

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.

Comments

[Joanne Lynn]

Community authority and management may be most important in altering the social conditions and prevention activities to promote health ---AND in the complex services needed for persons with serious, persistent, and progressive disabilities, mostly associated with aging. Both populations basically have to "make do" with the services that their community makes available. The populations "in the middle" with an acute or non-disabling chronic illness, if they have resources and interest, can examine the marketplace locally and at a distance and make choices. I wonder whether it is important to link the very sick and those who could be well - or whether they need different integrators and advocates, and a different set of community-based managers.