Financing for Health in All Policies

Abstract

Innovative public health policies that promote health and support the objective of Health in All Policies require innovative approaches in the allocation of resources. This chapter does not advocate any particular system of resource procurement and spending but compares the existing systems and attempts to understand how we can undertake health promoting public policies that do not increase the existing inequities in our societies. This chapter is not about public finance but about the motivation of policy makers and civil servants in charge of public money to support the Health in All Policies approach.

Policy innovations required to achieve ‘Health in All Policies’ upset the traditional ways of bureaucracies and health professionals. They affect the distribution of health and monetary benefits to the population. There is evidence that investing in health yields a two- to threefold return on investment, but those who are required to invest may not be the direct beneficiaries of that investment. Investment in innovative health policies may require a budget reform to allocate resources by missions that cut across institutions (both state and social health insurance (SHI) administrative departments). This might prove more difficult in countries with Bismarckian systems (SHI) where the state administration is traditionally in charge of public health provided by salaried state professionals while the SHI is in charge of health care with fee-for-service professionals. Thus coordination is needed between the two administration departments and their payment mechanisms.

The historical belief that economic growth results in improved health in developed countries has been contradicted by evidence from North America. Increasing income is not enough when the variables of interest for population health are the distribution of income and the social and cultural environment. Should policies target health determinants (or risk factors) one by one with specific policies or population groups? If the latter route is chosen, should measures be tailored to the requirements of specific populations or be universal. Evidence of successful interventions point at the combination of universal and specific measures. Targeting health determinants individually is easier because the tools already exists (monetary incentives, for example) but has so far had limited success on population health. Universal measures benefit the entire population, not those who need it most, but because of this, they tend to gain wider support from the general public. Specific measures which address the demands of those most in need have better face validity, but receive weaker political support. Policy innovation required to implement Health in All Policies seems cut across existing beliefs and bureaucratic domains and integrate interventions from administrative departments both at the national and local level with interventions from private stakeholders. Political involvement at the highest level is necessary to give the initial momentum, but sustainability at the local level requires the participation of local stakeholders in the policy design in addition to recurrent sources of revenues.