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12.10 Strategies for health services

12.10 Strategies for health services
Oxford Textbook of Public Health

12.10
Strategies for health services

Martin McKee and Josep Figueras

Introduction
Do health services affect population health?

Quantifying the contribution of health care to population health

Health care and health equity

Health care and health—a synthesis
Why are health systems changing?

Macroeconomic factors

Norms and beliefs

Changing burden of disease

Upward pressure on health care expenditure

The quest for enhanced quality of care

The information society
Emerging themes in health services

The changing relationships between state and market in health care

Reorganizing the system: decentralization, recentralization, and privatization

Enhancing citizens’ rights, choice, and participation
Strategies for health services

Tackling scarcity of resources

Equitable funding of health systems

Optimal allocation of resources

Efficient service delivery
The contribution of public health to health services
Chapter References

Introduction
At the outset it is necessary to ask why public health professionals should be interested in health services, and so set the agenda for this chapter. Those involved in the delivery of health services can have many different objectives. The growing numbers of for-profit chains of health maintenance organizations in the United States seek primarily to increase financial returns to their shareholders. In the European Union, the Amsterdam Treaty has recognized explicitly the contribution of health care to job creation. However, it is the view that health care offers a means of improving the health of a population that provides a justification for public health professionals to become involved in health services. As discussed below, this is leading to a growing recognition in many countries of the positive contribution that public health professionals can make to the organization and delivery of health care.
The content of this chapter follows from these arguments. Public health professionals, with their emphasis on improving population health, have a legitimate role in ensuring that the pursuit of health gain becomes a central objective of health care systems, whatever other objectives may be being pursued by others. To do so, they must promote the equitable use of interventions that are effective and appropriate for the population in question, reduce interventions that are ineffective or harmful, and thus maximize the health gains obtained with the available funding.
Health care systems in many countries are changing, for a variety of reasons (Saltman and Figueras 1997). This brings both opportunities and threats for public health professionals. On the one hand, change offers the possibility to challenge existing arrangements and maximize the contribution of health services to population health. On the other hand, it brings threats as those responsible for health policy seek other objectives, such as the narrow pursuit of profit.
Consequently, this chapter explores the changing nature of health services, the role that public health professionals can play in these processes, and the strategies that they can pursue to enhance health gain and promote equity. It does not seek to provide a description of the many different health services throughout the world or offer a blueprint for those wishing to design the perfect health system (if such a thing is possible). A critical review of texts covering these questions has been published elsewhere (McKee and Figueras 1997).
Before considering these matters, there is one question that must be addressed. This is whether health services actually make a meaningful contribution to population health. The view that they do is not universally accepted, and so before proceeding to examine what is known about how public health professionals can best contribute to the organization and delivery of health services, it is necessary to examine whether there is any evidence that such services actually do any good.
Do health services affect population health?
While most would agree that some interventions, most obviously immunization against diseases such as smallpox, poliomyelitis, and measles, but also some low-technology strategies such as integrated management of childhood illness (Lambrechts et al. 1999), have been remarkably successful in reducing mortality in many parts of the world, there is much less agreement about many other elements of health services.
At the risk of simplification, the debate has become somewhat polarized. If the major determinants of health lie outside the health care sector, is the involvement of public health professionals in the delivery of health care at best an irrelevance and, at worst, a diversion from the more important roles of advocacy and mobilizing intersectoral action (Whitty and Jones 1992)? Or have they a role in ensuring that health care is provided effectively and efficiently, on the basis that this will maximize population health?
A widely held view is that the weight of evidence supports the former position. This is associated most closely with McKeown (1979) who showed how three-quarters of the decline in mortality in England and Wales between 1841 and 1971 had been due to a reduction in deaths from infectious disease and that three-quarters of this reduction had preceded the widespread introduction of immunization or antibiotics. Thus, he argued, the main drivers of improvements in health had been nutrition, environment, and behaviour.
A different, but related, perspective is offered by those who argue that it is unrealistic to expect health care to contribute significantly to population health because so little of it has been adequately evaluated and found to be effective (Chappell 1993).
To others, however, it is not just that health care has little impact on health. Instead, it may actually damage it. This view receives some support from studies that have related health care inputs to outputs. If anything, these have suggested that there is an inverse association, with greater health care resources leading to worse overall health (Cochrane et al. 1978; Scheiber et al. 1993). One possible explanation is that scarce resources are being channelled into health care rather than sectors such as education where they would have a greater, albeit less immediately obvious, impact on health. Another is that health care has a direct and adverse effect on health, a view advanced by Illich (1976), who emphasized patients suffering from the side-effects of prescribed drugs, hospital-acquired infections, poorly performed surgery, and the consequences of following up spurious abnormalities found among increasing numbers of laboratory investigations.
These views have elicited a range of responses. Some physicians have simply dismissed them (Ingelfinger 1977), arguing that they are completely at odds with the everyday experience of clinicians who see the results of the care that they provide. In contrast, others, especially some health economists, have argued that the existing level of health care provision in some countries is excessive (Evans 1994; Lavis and Stoddart 1994) and that politicians should shift expenditure from health care to sectors such as education, housing, and employment (Smith 1994).
However, there is a compromise position which is that, while Illich and McKeown may have been correct in the 1960s and 1970s when they were developing their arguments, the intervening period has seen major changes, with many formerly fatal conditions now susceptible to treatment. Furthermore, many of the criticisms made by Illich concerning unnecessary and inappropriate investigations and treatment have now been addressed by the greater acceptance of evidence-based health care. In this scenario, health care, at least in industrialized countries, is seen, potentially, as one of the major determinants of health of a population and thus worthy of the attention of public health professionals.
Quantifying the contribution of health care to population health
Health care has changed remarkably in a relatively short time. Many new treatments have been introduced that have been shown, in high-quality evaluative research, to be able to prolong life. Examples include effective treatment for hypertension and heart failure, secondary prevention following myocardial infarction, and chemotherapy for many childhood cancers. There has also been, in many countries, a revolution in the approach to evidence in making treatment decisions.
These changes are part of a long-term trend. Beeson (1980) showed how many treatments advocated in a 1927 edition of a major textbook of medicine were, at the time he was writing, known to be either ineffective or harmful. The 1975 edition displayed a major shift to treatments that had been proven to be effective. However, the pace of change has accelerated during the 1980s and 1990s. There has been a much greater willingness to challenge professional judgement where it is not supported by evidence of effectiveness and to question whether clinical performance is optimal. This has led from early pioneers of the medical audit (Lembcke 1947; Neuhauser 1990) to the enormous expansion of evidence-based health care (see below). This encompasses a wide range of activities which together have helped to get rid of many interventions that do not work and have increased the uptake of those that are effective. Thus there is a case that if health care made little contribution to population health in the past, it may now be doing so. The following section asks whether this has actually happened.
Rutstein et al. (1976) addressed this question by asking an expert panel to identify a list of conditions from which death should not occur if appropriate medical care was provided. These deaths were deemed to be ‘preventable’ although subsequent writers have also used the terms ‘avoidable’ and ‘amenable to medical care’. They argued that the decline in such deaths was a measure of the performance of the health care system. This concept has subsequently been adapted by other researchers and used to examine many different countries (Charlton and Velez 1986; Poikolainen and Eskola 1986; McKee and Bewley 1987; Malcolm and Salmond 1993) and in the production of regional atlases permitting cross-national comparisons (Holland 1991; Józan and Prokhorskas 1997).
These studies have consistently found that deaths due to causes amenable to medical care have fallen at a faster rate than other deaths, suggesting that medical care is now contributing to population health. This concept is not, however, without its critics. Carr-Hill et al. (1987) have argued that deaths amenable to medical care include only a small percentage of overall deaths. Furthermore, at a subnational level, there is no clear link with other measures of health care provision.
The first criticism arises largely because the original advocates of this concept adopted the somewhat arbitrary criterion that only deaths occurring under the age of 65 years could be considered amenable. This is inconsistent with life expectancies at birth in the high seventies or low eighties in many industrialized countries. Mackenbach and coworkers (Mackenbach et al. 1988; Mackenbach 1996) addressed this by increasing the age limit to 75 years. By also increasing the number of conditions classed as amenable, they considerably extended the concept of death amenable to medical care. They addressed the second criticism by relating changes in deaths from particular causes to the time that various interventions were introduced. By doing so, they were able to show that the impacts of specific treatments were observable as accelerating falls in mortality from the conditions they were intended to treat. They concluded that the health care interventions they examined added 2.9 years to life expectancy at birth for men in The Netherlands between 1950 and 1984 and 3.9 years for women.
The approach taken by Mackenbach had the advantage of bringing many more conditions under the umbrella of avoidability. However, the chain of events leading to death is complex and there is an advantage in separating those amenable to personal medical interventions from those amenable to wider government health policies. A study from Spain separated conditions amenable to personal medical care, such as tuberculosis, appendicitis, and asthma, that accounted for 11 per cent of all deaths, from conditions amenable to national policies, such as cirrhosis of the liver and motor vehicle accidents, that accounted for 19 per cent of total mortality (Albert et al. 1996). Deaths from causes amenable to personal medical care fell between 1975 and 1990 whereas those amenable to national health policies increased.
Support for this hypothesis also comes from studies of particular causes of death. Beaglehole (1986) estimated that 42 per cent of the decline in deaths from cardiovascular disease in New Zealand between 1974 and 1981 could be attributed to advances in medical care. The long-term decline in mortality from coronary heart disease in The Netherlands between 1969 and 1993 accelerated significantly after 1987 coinciding with the wider availability of interventions such as coronary care units and thrombolysis (Bonneaux et al. 1997). Deaths from testicular cancer in the German Democratic Republic fell following unification with the west and increased access to new treatments (Becker and Boyle 1997), and in childhood leukaemia in Russia where again modern treatments have recently become more widely available (Shkolnikov et al. 1999).
Notwithstanding these findings, it is pertinent to re-examine Illich’s view that modern health care is generally harmful. Clearly some interventions are damaging to health. As the example of albumen, which has long been given to patients with burns and multiple trauma, shows, even treatments that seem intuitively likely to be beneficial may not withstand critical scrutiny (Cochrane Injuries Group Albumen Reviewers 1998). Increasingly, such interventions are being identified and withdrawn but this remains an unfinished agenda.
Health care and health equity
The health impact of health services raises the important issue of equity. When health care had little measurable impact on health, sociodemographic inequalities in access to care may have been of little importance. Indeed, it is arguable that the wealthy, exposed at considerable personal expense to such painful and ineffective treatments as leeches, cupping, and bleeding were actually disadvantaged compared with the poor. The present situation is quite different. If health care does contribute materially to population health, then lack of access to it will exacerbate health inequalities (Arblaster et al. 1996).
There is considerable evidence from many countries that such inequalities exist and that they have an impact on health. This is intuitive in health care systems where there is not universal access to care, such as the United States. For example, American research has found that people living in deprived areas with poor access to care have high rates of hospital admission with chronic medical conditions, such as asthma, heart failure, and diabetes that, if detected and treated early should not require admission to hospital (Bindman et al. 1995). But inequalities are also seen in countries offering universal coverage. In the United Kingdom, women (Petticrew et al. 1993), those from minority ethnic populations (Shaukat et al. 1993), and those living in deprived areas (Ben-Shlomo and Chaturvedi 1995) are all disadvantaged in access to surgical interventions for coronary artery disease. In New Zealand, social class gradients are substantially greater for causes amenable to medical care than other causes of death (Marshall et al. 1993). A study from Helsinki, Finland, found significantly higher death rates from causes amenable to medical care among those in the lowest social class or who were homeless (Poikolanen and Eskola 1995). Equitable access to effective health care becomes a matter of legitimate concern for public health professionals.
The findings discussed above suggest that, contrary to the situation before the 1960s, health services are now making an important contribution to overall improvements in life expectancies in industrialized countries. They may also be contributing to the differences in life expectancy between countries. Rates of treatment with interventions of known effectiveness vary considerably (Mulrow 1995). Even between otherwise similar countries, large differences may exist. Law and Wald (1999) have compared the uptake of secondary prevention among survivors following myocardial infarction in the United Kingdom and France (Table 1).

Table 1 Uptake of secondary prevention agents among survivors following myocardial infarction in the United Kingdom and France

Boyle et al. (1996) argued that it would be possible to track trends in safer surgery and anaesthesia by means of a study of deaths from a common surgical condition, benign prostatic hypertrophy. They found that deaths had fallen in many countries between 1950 and 1990 the improvements were much greater in Northern Europe and North America than in Central and Eastern Europe and South America. Death rates from childhood cancers for which effective treatments are now available have decreased in most European countries although to a greater extent, and earlier, in Northern Europe than in Southern or Central Europe, arguably reflecting differences in the diffusion of new treatments (Levi et al. 1992).
The division of Europe prior to 1990 offers an opportunity to examine this issue further. The former communist countries of Central and Eastern Europe were relatively isolated from many modern health care developments. Noting that death rates from causes amenable to medical care were higher in these countries than in the west (Bojan et al. 1991; Boys et al. 1991). Velkova et al. (1997) sought to quantify their contribution to the East–West gap in life expectancy. Excluding early neonatal deaths, for which only incomplete data are available, they estimate that amenable causes accounted for 24 per cent of the gap in male life expectancy between birth and the age of 75 years in 1988. The corresponding figure for females was 39 per cent.
International comparisons in this field are intrinsically problematic because of differences in incidence of disease as well as definitional problems. However, these problems have, to a considerable extent, been overcome in a major comparative study of cancer survival in Europe, the Eurocare study. This has found large differences in cancer survival between countries, raising important questions about the organization and funding of cancer services in some countries (Coebergh et al. 1998) (Fig. 1). The implication, for public health professionals, is that international differences provide many natural experiments from which lessons can be drawn (McKee 1998). This process is increasingly being facilitated by initiatives such as the European Observatory on Health Care Systems (Figueras and Saltman 1998).

Fig. 1 Cancer survival in European countries. (Source: Sant et al. 1995).

Health care and health—a synthesis
The previous section showed that there is now considerable evidence that, unlike the situation prior to the 1970s, health care can make a substantial difference to population health. However, as the World Health Organization (WHO) noted in the Ottawa Charter (WHO 1986), health services are only one of the determinants of health, others being genetic predisposition, individual behaviour and lifestyle, and environmental circumstances. Public health professionals must look at the wider picture and take into account these other determinants. But it is important that, in taking a broad perspective, they do not loose sight of the contribution that health care can make to population health, ensuring that what care is provided is effective and is provided equitably. The remainder of this chapter explores the changing nature of health services, the impact that various policies have, and the role that public health professionals can play in maximizing the health gain that health services can provide.
Why are health systems changing?
Health care systems face a range of pressures, from both within and without (Saltman and Figueras 1997). External factors include the macroeconomic climate and the evolving framework of values of the society within which the system is located. Internal factors include the changing pattern of health in the population being served, upward pressures on expenditures arising from ageing populations and technological change, a search for improvements in the quality of health care that is delivered, and the expansion of information technology. These will be considered in turn.
Macroeconomic factors
The configuration of a health system is strongly influenced by its economic environment. While the costs of some inputs into health services reflect local market conditions, such as salaries for health care professionals, others, such as pharmaceuticals and technology, reflect world market prices. Indeed, co-ordinated purchasing policies mean that some products, such as insulin, may actually be substantially cheaper in industrialized than in developing countries. Consequently, the combination of labour, capital, and consumable elements in a health system can be expected to reflect each country’s economic circumstances.
However, these circumstances are not static. During the 1990s, many health care policies had been driven by concerns about national competitiveness in an increasingly global market place. Health care represents a major element of public expenditure, even in those countries where the system is largely privatized such as the United States. High social costs, of which health care is one element, are cited as reasons for transnational corporations to locate production in one country rather than another (Stephens et al. 1999). Simultaneously, the historically high rates of economic growth seen during the 1960s and 1970s have not been sustained in the 1990s.
In addition, some regions have been subject to very specific factors. In Western Europe, the Maastricht criteria for entry to European Monetary Union, with their requirement for reductions in public sector debt, have had a major impact on the political environment within which decisions on public spending are made (Kanavos and McKee 1998). In the countries of Central and Eastern Europe, the collapse of established trading networks in the early 1990s led to deep economic recessions and wide-ranging reforms of the public sector. In the mid-1990s, the countries of Southeast Asia suffered a major economic crisis which has led to substantial changes in health care sector, a shift from private to public care, and the introduction of wide-ranging strategies aimed at cost containment (UNFPA 1998). Many developing countries have been faced by rising levels of debt and externally imposed structural adjustment policies with major implications for health services (Peabody 1996).
The importance of the macroeconomic environment for public health professionals, apart from the obvious need to be aware of the implications of macroeconomic change for population health, is primarily in the extent to which it influences the political decision-making process and, in particular, the allocation of resources to competing sectors. While, in most cases, public health professionals must work within the constraints that this creates, they also have a major role, as advocates for the public’s health, in shaping the debate.
Norms and beliefs
A second set of factors driving change in health care systems relate to the underlying norms and beliefs of the society within which the system is embedded (Contandriopoulos et al. 1998). Health care systems act as mirrors that reflect deeply rooted social and cultural expectations of the population that they serve. Although these norms and beliefs are generated outside the formal structure of the health care system, they play a major role in defining the system’s overall characteristics.
The impact of different norms and beliefs is apparent when comparing the United States, where health care is generally seen as a commodity to be bought and sold, and Europe, where health care is seen predominantly as a social or collective good, in which citizens benefit when an individual receives effective care. The latter model is associated the principle of solidarity, in which there are cross-subsidies between groups and population defined by age, wealth, health status, to enable access to health care to be available.
However, this dichotomy is oversimplified and, in reality, societies have dominant belief systems (Benson 1975). This does not imply that a single view is held by all members of that society; rather, the tension and negotiation that exists between various beliefs and values has some stability. A useful approach to understanding belief systems sees these tensions as grouped around four poles (Habermas 1987): values, understanding of phenomena, definition of jurisdictions and allocation of resources, and logic of regulation. Values include the tensions and trade-offs between equity, individual autonomy, and efficiency (Clark 1988). Understanding of phenomena relate to how concepts such as life, death, sickness, health, and pain are interpreted and thus viewed as relating to the objectives of a health care system (Gillett 1995). Definition of jurisdictions and allocation of resources comprise the perceptions of the role and functions of those working in the health care sector, as well as the allocation of resources between prevention and cure and between health care and broader determinants of health. The logic of regulation relates to how society chooses to regulate the delivery of health care (Contandriopoulos et al. 1998). This may be technocratic, with trained experts guiding the system on the basis of their knowledge and position within the hierarchy, professional self-regulatory, which has the physician, as the best agent of the patient, at the centre of the system, the market-based model, in which regulations reflect supply and demand in a competitive market, or the democratic model, in which the population, either directly or, more often, through elected or appointed representatives, is responsible for setting out the framework for delivery of health care.
Although dominant belief systems have some stability, they are in a state of constant tension as different classes and groups within a society struggle for ascendancy, a phenomenon most clearly seen in the fluctuating electoral success of political parties. In some societies, the process of change will be evolutionary and incremental. In others, as exemplified by the countries in Central and Eastern Europe after the collapse of communism, it will be abrupt.
An understanding of the dominant belief system in a society is important for public health professionals as it contributes to knowledge of why systems are as they are, how they have changed, and the objectives that individuals within the health care system are pursuing. It will also influence the choice of strategies that should be adopted to bring about change.
Changing burden of disease
Although it would be naive to think that the health needs of the population are the only factor driving the configuration of health services, they do play an important role. For example, the public health services in many industrialized countries are a direct result of the global epidemics of cholera in the mid-nineteenth centuries (Davies 1998). Recognition of the infectious nature of tuberculosis led, somewhat controversially, to the creation of sanitoria (Fairchild and Oppenheimer 1998). More recently, the discovery of the agent responsible for hepatitis B and, especially, the emergence of the HIV virus, have both had significant implications for the organization of systems designed to reduce cross-infection in health care facilities.
The burden of disease worldwide is dynamic (Murray and Lopez 1996). One factor is the changing age structure of the population. In many populations the number of old people, and especially the very old, is increasing. This is causing an increase in the frequency of patients with complex multiple pathology. Coupled with a growth in evidence of the effectiveness of organizational interventions, such as stroke units (Stroke Unit Trialists’ Collaboration 1997) and integrated care teams, this will lead to a need for much closer working by different specialists and professional groups, and a consequent breaking down of many established hierarchies.
A second factor leading to changing patterns of disease is changing risk factors. Some of these, such as tobacco consumption, act over long periods, while others, such as alcohol or those leading to some infectious diseases, have consequences that appear almost at once.
In the space available it would be impossible to discuss the many different trends seen worldwide. They include, in industrialized countries, a long-standing decline in stomach cancer, most likely as a result of lower rates of infection with Helicobacter pylori in childhood (Pisani et al. 1997), more recent falls in ischaemic heart disease, mainly as a result of more healthy diets (Vartiainen et al. 1994), and a steady rise in smoking-related cancers among women (Peto et al. 1994). In developing countries falling death rates from some infectious diseases coincide with increases in the ‘diseases of affluence’, such as ischaemic heart disease (Bobadilla et al. 1993). In particular, many smoking-related disease will rise further (Barnum and Greenberg 1993). Many countries have also been severely affected by high levels of HIV infection and AIDS (Over and Piot 1993).
The key message is that the incidence and prevalence of many diseases are changing, creating a pressure for changes in health care systems. Public health professionals have a central role in tracking and predicting these emerging trends, in designing mechanisms that address them, and in supporting the changes in service delivery that are required.
Upward pressure on health care expenditure
Increased health spending constitutes the most important single factor leading to health systems change. At the core of many health care reforms is the need to contain costs. Figure 2 presents a snapshot of the growth of health care expenditure in a number of Western European countries. Several factors have combined in recent decades to exert upward pressure on health spending. These include the ageing of the population, the expansion of coverage and the development of more expensive health technologies combined with increased population expectations.

Fig. 2 Total expenditure on health as a percentage of gross domestic product, Western Europe, 1980 and 1997. (Source: OECD 1999).

Ageing populations influence the demands on the health care system, especially as they often coincide with falling birth rates, leading to an increasing dependency ratio. Thus the demands on the system are increasing at a time when the number of people of working age, who are paying for it, is falling. These changes vary greatly between countries. Some, such as Germany and Japan, face substantial challenges while others, such as the United Kingdom, will be somewhat less affected, at least until the middle of the twenty-first century.
Although an ageing population is probably one of the most frequently cited causes of rising health care expenditure, it is necessary to enter a caveat. There is still considerable uncertainty about the extent to which health care costs actually do increase with age.
Fuchs (1984) has argued that the elderly do not incur health care costs simply by being old. Rather it is that, with increasing age, more are in the last year of life, which is the true cause of high costs. This is supported by evidence from American Medicare data, which shows that payments associated with an additional year of death fall as age at death increases (Lubitz et al. 1995) and that the most costly patients are those who die young, possibly because, for a variety of reasons, they are more intensively treated (Scitovsky 1988). However, these studies did not include the cost of social or long-term care, unlike a study conducted in The Netherlands, which found that the total cost of health care rose exponentially with age from 50 to 95 years and over (Meerding et al. 1998).
Clearly, the relationship between ageing and health care costs is complex and depends partly on what is and is not included. In addition, it is at least plausible that the level of general health of the elderly in the future may be different from that of today, as they will have benefited from a lifetime of better nutrition and social conditions. For these reasons, simplistic extrapolations of cross-sectional data to a future population with a longer life expectancy is flawed.
A second factor exerting upward pressure on expenditure in some countries has been expansion of coverage, although the relationship with expenditure is complex, as illustrated by the case of the United States, which has the highest expenditure on health care but the lowest coverage of any industrialized country (Starr 1982; Rothman 1993).
In general, the twentieth century was characterized by an expansion of health care coverage. In 1960, only a few industrialized countries provided universal or near universal coverage through compulsory systems. By 1996, nearly all did. In Europe, for example, only Germany and The Netherlands do not, permitting or requiring the wealthiest segments of the population to opt for private coverage. Chile, under the Pinochet regime, permitted the wealthy to opt out of the Servicio Nacional de Salud (Reichard 1996). This had the effect of fragmenting the previous system and creating deep inequalities and offers a graphic example of the social consequences of reducing coverage. In particular, this approach, although superficially attractive because it appears to be reducing demands on the health care system, has adverse effects because the wealthy typically contribute more than they cost.
However, it is not just through explicit policy decisions that change takes place and the American population is experiencing an insidious process of reduction of benefits packages leading to a steady increase in the number of people without effective health care coverage (Kirkman-Liff 1997).
A third factor is the introduction of new pharmaceuticals and technology. The pace of change in health care is steadily accelerating. Hip replacements have been joined by knees, shoulders, and finger joint replacements. Transplant surgeons have added heart, liver, and pancreas transplants to their initial successes with kidneys. Surgery for peptic ulcer has been largely replaced by long-term treatment with H2-antagonists. AIDS has been transformed from a rapidly progressive fatal disease to one in which increasing numbers of patients are keeping the disease under control with complex cocktails of antiviral therapy. The list is almost endless.
The growth of health care technology is widely held to have contributed substantially to the upward pressure on health care expenditure, for several reasons, although its precise contribution is controversial (Mossialos and Le Grand 1999). New technologies are often more expensive than the ones they replaced. Even where the actual technology is less expensive, it may lead to increased costs as other aspects of the service are reorganized to reflect changing patterns of treatment. The introduction of new treatments may lead to an expansion in the number of individuals with indications for treatment, either because a previously untreatable condition becomes treatable or, as side-effects or contraindications are reduced, the threshold for treatment falls. Finally, the diffusion of technology from tertiary centres, in some cases into primary care, can markedly reduce barriers to access and thus increase uptake.
In response to the increasing use of expensive new technologies, many countries have established health technology assessment facilities and related systems to control the introduction and diffusion of new technology although, in some, fragmentation of decision-making due to the introduction of market-based health sector reforms is making control more difficult.
Finally, consumers have increased their expectations about the services provided by the health care system. As noted above, the development of new and more expensive technologies coupled with the increased access to information by the general public, particularly with the appearance of new means of communication such as the Internet have led people to demand a wider range of services of high quality from health care providers. This factor is exerting a major pressure on health care costs. The role of information technology as a pressure for change in the health services and some of the reform strategies adopted to increase the role of the citizen in decision-making are dealt with below.
Each of these contributors to upward pressure on health care expenditure has implications for public health professionals and not only because of the importance of understanding the forces driving change in health services. The question of how health care costs change with ageing remains unresolved and more epidemiological and health economics research is urgently required. Public health professionals can also contribute to discussions on how health services can be reconfigured to meet the increasingly complex needs of an elderly population with multiple disease processes. Debates about health care coverage raise important questions for those seeking to address health inequalities. And discussions of new health technology require inputs from public health professionals, drawing on skill such as epidemiology and economics, to assess appropriateness and cost-effectiveness.
The quest for enhanced quality of care
Research undertaken in the 1970s and 1980s that drew attention to widespread geographical variations in the use of common procedures (McPherson 1989) gave way to a questioning of clinical judgements of appropriateness of health care interventions, with some authors suggesting that up to 30 per cent of clinical services may be ineffective (Chappell 1993). In conjunction with other work demonstrating large variations in the costs of apparently similar services and in the outcomes achieved, this has led to an emerging emphasis on the effectiveness and efficiency of health care. Increasing research on the effectiveness of interventions is casting doubt on the effectiveness of established treatments and is identifying gaps in knowledge. The International Cochrane Collaboration—an international grouping of researchers working in many countries worldwide, which undertakes systematic reviews of available evidence in the literature, agrees standardized methods, and disseminates information—has played a major part in this process (Chalmers and Altman 1995). Targeted programmes of research to fill these gaps are greatly increasing knowledge of what works and what does not, and in what circumstances. In parallel, work to increase research awareness among health policy-makers means that they are increasingly likely to ask for evidence that proposed innovations will actually achieve what they are intended to do.
While such research provides evidence of what health care interventions can achieve, there is also a growing recognition that this is not always achieved in practice. This has led many countries to introduce systems to assess and improve the quality of clinical care and, in some cases, to make the results of such assessments available to the public.
These developments reflect a change in dominant belief systems, challenging traditional models based on clinical autonomy. They are contributing to a range of changes in health care systems that include not only the elimination of ineffective treatments and adoption of effective ones but also new organizational structures to bring about change. Again, public health professionals have key roles to play because of their skills in health care evaluation and the management of change.
The information society
The 1980s and 1990s have seen an unparalleled revolution in the pace and volume of communication. The speed and storage capacity of computers has increased so that a machine which, a few decades ago, would have filled an entire room will now fit comfortably into a briefcase. Postal deliveries have given way to faxes, which have been supplanted by electronic mail. The Internet has vastly expanded the amount of information available to health professionals, patients, and the general public.
These developments are having profound impacts on the organization of health care, bringing benefits but also risks. E-mail offers scope to reduce delays between referral and treatment and between undergoing tests and receiving results. Telemedicine means that a primary care physician in the remotest corner of the world can have a radiograph or a skin lesion seen by the world expert in the condition in question (Wootton 1996). Patients can search for information on their conditions on the world wide web, drawing on the perspectives not only of physicians but also of other sufferers from their condition. However, those searching the web must be aware of its unregulated nature, publishing views of both Nobel laureates and quacks (Eysenbach et al. 1998; Sandvik 1999). Internet prescribing may offer price savings for some, but it may also circumvent regulatory safeguards designed to reduce risks to patients. Greater access to information on modalities of treatment in other countries, especially via the Internet, is increasing recognition of the wide variations between otherwise similar countries in the diffusion of technology and is fuelling public expectations, which may be difficult to meet.
The communications revolution is also changing the way in which health care is organized. Greater local access to information and to the capacity to analyse it is promoting more localized decision-making. Conversely, cascade fax systems and e-mail provide an opportunity for a more rapid flow of central directives and closer monitoring of subordinate units. The precise effects of the new technology in any particular system are difficult to predict but it is clear that they are changing the relationship between the centre and the periphery in many health care systems.
Emerging themes in health services
This section explores some of the themes that are emerging in the responses to these pressures for change in health services. Evolving norms and beliefs, coupled with the changing macroeconomic environment, have led to a reassessment of the relationship between the state and the market in health care in many countries. Changing beliefs, coupled with developments in information technology are challenging traditional hierarchies, stimulating new ways of organizing health systems, and focusing attention on empowerment of the public and patients’ rights. These themes will be considered in turn.
The changing relationships between state and market in health care
During the 1980s and 1990s, many countries had begun to re-examine the role of the state in the funding and delivery of health care. In those countries in which the state has played a central role, new pluralistic solutions are being explored, with involvement of a range of actors at varying distances from the state. Where the state has played a less central role in the health sector, acting only as a source of regulation between competing private interests, a similar reassessment is taking place.
Before examining these trends in detail, it is important to recognize the limits to generalization. While governments do draw extensively on the experience of others, and many vested interests seek actively to export models of health care reform, it would be quite wrong to see these developments as a process of convergence to some ideal model of a health system. Instead, the situation in each country represents the complex interplay of interest groups and deep-seated cultural beliefs. Nonetheless, some observations are possible (Saltman and Figueras 1997). In some countries where the state traditionally has had a strong role, some functions are being devolved to local government or to statutory agencies at arm’s length from government. Others are being transferred to private ownership. Conversely, in some countries in which the state has played a limited role, governments are now taking greater regulatory responsibility.
This debate is often characterized as a dichotomy between the state and the market but this is a gross oversimplification (Saltman and von Otter 1995). The terms ‘state’ and ‘market’ are often poorly defined and are used interchangeably to include very different mixes of public, quasi-public, statutory-regulated private, private non-profit, and private for-profit bodies. There is widespread agreement that a pure market in health care is unachievable (Roberts 1993), and so, in practice, the term ‘market’ is taken to mean the use of certain market mechanisms such as contracting. These can be applied at several levels (Frenk and Donabedian 1987; Saltman 1994): health care financing, the organizations delivering care, such as hospitals, individual health care professionals, the providers of health care infrastructure, or the provision of support services. Decisions may be taken on the basis of price, quality, or market share. In addition, the limitations of the market in health care have led some governments to introduce market mechanisms while retaining public ownership (Bartlett et al. 1998), sometimes termed quasi- or internal markets.
Although superficially attractive, the introduction of market mechanisms into the health sector creates a series of conceptual and practical difficulties. Conceptually, health care is considered in many societies as a social good, in which the provision of service to each individual is also valuable to the community as a whole, whether because of ideas of self-interest, as in the treatment of dangerous mental illness or contagious disease, or altruism. Such principles have led to the creation of systems to ensure universal coverage and solidarity. In contrast, market incentives are intrinsically based on the assumption that services provided are a commodity, with demand driven by individual preference.
The second difficulty is that the neoclassical concept of a market is based on the relationship between a buyer and a seller. However, health care systems typically comprise a more complex set of relationships involving the patient, various health professionals, a provider institution, and a payer, with health professionals acting as both suppliers of services and agents for the patient (Young and Saltman 1985). Finally, the assumption in neoclassical economic theory that cross-subsidies between different patients are inefficient is incompatible with the social function of the health care system based on solidarity in which there are substantial cross-subsidies between young and old, rich and poor, and healthy and sick.
While some may dismiss these conceptual difficulties as problems that can be resolved given sufficient imagination and determination, a more powerful critique is based on the experience of attempts to implement market mechanisms while at the same time seeking to maintain solidarity and contain costs. They include the failure to design effective systems to adjust for differences in risk of incurring future health care costs of those enrolling in competing health insurance systems, failure to achieve predicted savings after the introduction of competition between providers due to high transaction costs, and costly duplication of facilities to secure a competitive advantage (Saltman and von Otter 1995).
A related issue is the changing approach to state regulation. Traditional ‘command and control’ measures are giving way to market-derived incentive-based arrangements within the public sector. The appropriate balance between regulatory and competitive measures will depend on the objectives being pursued and the context in which they are implemented. Regulation is becoming more sophisticated, with greater recognition of the need to empower rather than constrain and of the scope, with poorly drafted regulations, for perverse incentives. It is most effective where the objectives can be clearly defined and operationalized, while maintaining sufficient flexibility to account for local circumstances. In general, it should focus on outcomes rather than inputs (Saltman and Figueras 1997).
Similarly, competitive measures also should be tailored to the specific objectives being pursued. These measures have been most successful where they have incorporated close monitoring and evaluation as well as a clear legal framework.
Regardless of the approach taken, public health professionals have an important role to play in ensuring that approaches based on either regulation or incentives are used to maximize health gain. Whichever model is employed, the increasing sophistication required from either regulation or use of incentives calls for an enhanced role for government (Kettl 1993).
Reorganizing the system: decentralization, recentralization, and privatization
Decentralization is a key element of health care policy in many countries (Mills et al. 1990). It is seen as a means of empowering those at local level to improve the delivery of services and of involving the population in decisions about priorities.
Decentralization has been defined as the transfer of authority from a high, or national, level to a lower, or subnational, level (Rondinelli 1981). It can take many different forms which, for convenience, can be considered under four headings (Rondinelli 1983) (Table 2).

Table 2 Typology of decentralization

Decentralization has become attractive because of disillusionment with the perceived failings of large centralized, bureaucratic institutions. These include inefficiency, lack of responsiveness, and failure to innovate. Decentralized institutions are seen to have several advantages. Those working in them are better equipped to identify changing circumstances and needs, and thus can respond more flexibly. They can be more innovative than centralized institutions and they can generate higher morale, more commitment, and greater productivity. Decentralization can also facilitate enhanced partnerships with the local population, thus increasing the democratic input into policy-making.
However, decentralization can have negative effects. These include fragmentation of services, loss of critical mass in central government functions, inequity, political manipulation to favour particular interests or stakeholders, and a weakening of the public sector (Collins and Green 1994).
Borgenhammer (1993) has identified certain social and cultural conditions that are necessary for successful decentralization. These include adequate local administrative and managerial capacity, ideological certainty in implementation of tasks, and readiness to accept several interpretations of a particular problem. Thus organizations undertaking decentralization must engage in a process of articulation of their mission, create internal cultures around core values, and establish mechanisms to monitor results (Osborne and Gaebler 1993).
Privatization requires separate consideration as it is fundamentally different, in several important aspects, from other types of decentralization. Its advocates argue that it brings benefits from the introduction of economic incentives for greater efficiency and higher quality in the management of health care (Cabinet Office 1999). It is also attractive to some governments as a means of enticing private capital into the health sector, thus reducing demands on scarce public funds. Finally, the ability of governments to resist private sector involvement is being eroded by a series of international trade and development policies. The International Monetary Fund and World Bank have made private finance for public infrastructure a requirement for many structural adjustment loans (Gaffney et al. 1999b) and the World Trade Organization’s Government Procurement Agreement requires public contracts in many countries to be opened to international competition (Thornton 1999).
However, these perceived benefits of privatization are being challenged by a growing body of evidence derived from experience of greater private sector involvement (Bennett 1992). Private competitive insurers have powerful financial incentives to engage in adverse selection on the basis of individual risk, thus undermining solidarity (Saltman and von Otter 1987). They can also go bankrupt, leaving governments as the insurer of last resort.
The suggested benefits of using private capital to build health care facilities have been examined in most detail in the United Kingdom, where the Private Finance Initiative enables consortia of private firms build and run hospitals. The National Health Service then pays an annual charge rather than having to find the initial cost of building. It is now clear that, as the consortia must secure financial returns consistent with those obtainable in other sections of the economy, the long-term cost is much greater than if the previous public sector procurement approach been adopted, despite highly creative accounting by those who have sought to justify the policy (Gaffney et al. 1999a). Other suggested benefits, such as transfer of risk to the private sector, have proved illusory because of creative wording of contracts.
A related issue, of greater relevance in those systems that are already highly pluralistic such as the United States, is the growth in for-profit health care chains at the expense of the non-profit sector. Health care is one of the most rapidly expanding sectors on the New York Stock Exchange. There is growing evidence that the increasing profits from this sector are accompanied by quality of care that is significantly lower than in the non-profit sector with, for example, lower rates of primary and secondary prevention activities (Himmelstein et al. 1999).
Three broad findings emerge from the debate on decentralization. The first is whether the advantages of decentralization outweigh the disadvantages, such as fragmented and duplicated services and high transaction costs, an issue that must be resolved on a case-by-case basis. Secondly, a policy of decentralization requires a series of measures to create an appropriate framework, including development of a shared vision and a means of monitoring outcomes. Thirdly, the suggestion that privatization is simply another form of decentralization and that, in practice, it is unimportant who provides the service, does not withstand scrutiny.
Enhancing citizens’ rights, choice, and participation
A third theme emerging from the debate on health care systems is that of patient empowerment. This is fuelled by changing norms about the role of professional authority and expert judgement and, increasingly, greater access to information via media such as the Internet. Following in the path set by some well-educated vocal groups, patients in many countries are increasingly demanding a choice of who treats them, where, and how.
Enhanced patient participation can take many different forms and, in a given country, the debate will reflect the dominant belief system. One model involves taking the collective views of the public into account by means of increased participation in the policy-making process, thus making health care professionals and the health system more accountable. This view is commonly associated with the view that health care is a public good. A second model, which is more commonly associated with the view of health care as a commodity, focuses on enhanced individual patient participation. In some countries, a third model has emerged as part of the debate on rationing health care. Here, participation by the public involves being asked their views on priorities for health care. This is different from the first model in that the agenda is set by others and the role of the public is responsive rather than proactive. Finally, Saltman (1994) has proposed a democratic-political model in which patient choice is enhanced and used as a mechanism whereby individuals can exert more influence over what happens to them inside a publicly operating system.
These models can be placed on a continuum that moves from the least to the most empowered position for an individual patient. Beginning with moral persuasion, or the right to ask to be heard, it continues through legal remedies, patient selection of funder or provider, democratic control over finance and commission of services, to patient choice of treatment modality. In this typology, empowerment is signified by the degree of individual leverage by the patient over specific service delivery decisions.
While there is a general tendency in many countries to increase the participation of patients in health care systems, this is raising some complicated issues, bringing both challenges and opportunities for public health professionals (Saltman and Figueras 1997). One is whether choice is equally important in all health care decisions. In some circumstances, such as maternity care, many patients may be willing to invest the time and energy into collecting the information acquired to make an informed choice. This may not be so in other areas. The development of mechanisms for participation must take this into account. A related issue is that of the complexity of the information required to make judgement about quality of health care. Several countries have sought to inform the public by means of publication of rankings of outcomes by hospital or physician. However, these are subject to substantial methodological limitations and also provided scope for opportunistic behaviour, either to exclude patients and higher risk or to manipulate the data that are presented. Public health professionals, by virtue of their expertise in evaluating health care, have a role to play in addressing these problems. Finally, enhancing choice risks increasing health inequalities as those with the greatest command over resources will be most able to exercise choice. For these reasons, the concept of choice is a complicated one in the context of health care and it should not be assumed that policies that enhance it are inevitably desirable.
Strategies for health services
It is impossible in the space available to provide a comprehensive overview of every strategy that might be employed to enhance the performance of health services. Instead, a few areas have been selected on the basis of the contribution that public health professionals can make to them. Although there are many possible ways of categorizing strategies for health services, such as the objectives they seek to achieve (e.g. equity, effectiveness, or efficiency), what element of the health system they affect (e.g. funding, allocation of finance, or delivery of services), or which health sector actors they involve (e.g. the patient, third-party insurer, third-party purchaser, or service provider), this section draws on a taxonomy developed by Saltman and Figueras (1997) that combined these approaches. Evidence on the impact of different policy interventions is brought together into four broad categories. The first category includes strategies that address resource scarcity, which here includes the process of setting priorities for health care. The second category relates to health care funding, here focusing on the issue of equity and, specifically, the tension between competition and solidarity. The third category includes strategies designed to achieve a more effective allocation of resources, here including assessment of health care need and purchasing and contracting for health care. The final category includes strategies designed to achieve more cost-effective and higher-quality care, including achieving the optimal balance between the different levels of health care (primary, secondary, and tertiary), enhancing the quality of care, and reorienting the curative sector towards prevention.
Tackling scarcity of resources
Upward pressure on health care costs in the face of limited resources confronts governments with two options. One is to increase the resources for health care by shifting funds from other areas of public sector expenditure or by increasing taxation or social insurance contributions. The second is to seek to control health care expenditure by pursuing strategies that influence either the demand for or the supply of health care. Strategies that act on supply of health services include reducing the number of health care professionals or facilities, setting global budgets for providers (Schwartz et al. 1996), giving professionals incentives to reduce the amount of care provided, and reducing access to care (Abel-Smith et al. 1995).
Strategies acting on demand include priority setting to ration access to certain services, the use of cost-sharing, incentives to encourage greater private expenditure, such as tax concessions, and the right to opt out of the statutory system. Each of these measures seeks to reduce demand by shifting some portion of health care costs to the individual.
Each of these approaches has been discussed elsewhere (Abel-Smith et al. 1995; Mossialos and Le Grand 1999). Here only one approach, that of setting priorities, is considered as it is the one in which public health professionals have played the greatest role.
Setting priorities
Throughout the 1990s, many countries have addressed the issue of explicit rationing of publicly funded health care, in part as a result of the developments described above that have given the state a greater role in the health care system but also as a result of upward pressures on costs. The debate has been lengthy and complex (New 1997), with many different views. Perhaps the only issue where there is a degree of unanimity is that, in all health care systems, some form of rationing has always taken place although, in most cases, this was implicit, inextricably linked to clinical judgement. Beyond this, the consensus breaks down as illustrated by the situation in the United Kingdom where there has been a fundamental disagreement between politicians and others about even the choice of the terms ‘rationing’ or ‘priority setting’ as a means of describing the process (Klein 1998).
In this debate, some commentators have argued that rationing should not be necessary if either sufficient funding was made available, typically by redirecting it from other areas of public expenditure or raising taxes, or by ensuring that available resources are used more efficiently. However, others have argued that the continuing upward pressure on health care costs has made explicit rationing of effective care necessary. For these commentators, the key issue is transparency.
Concerns about the affordability of health care have led, in several countries, to initiatives that examine priority setting on a more systematic and explicit basis (Abel-Smith et al. 1995). These processes have brought together a wide range of individuals, including public health professionals, managers, politicians, economists, and philosophers.
Explicit setting of priorities involves making decisions at different levels within the health care system, ranging from the overall funding of health care to the treatments available to individual patients (Klein 1993). If explicit priority setting is to be undertaken, a co-ordinated, strategic approach is most effective to integrate decision-making at these different levels (Saltman and Figueras 1997). An example is provided by The Netherlands, where a national debate on a package of essential care has been combined with investment in technology assessment, the development of practice guidelines, and the establishment of criteria to control waiting lists.
Decisions may lead to blanket exclusions of interventions or of condition–intervention combinations, as in the approach taken in Oregon in the United States, or production of guidelines, as has been done in New Zealand (National Advisory Committee 1992) and by the National Institute of Clinical Excellence in the United Kingdom (Smith 1999).
The experience of Oregon has been especially interesting because of the technical and ethical issues it has raised (Oregon Health Services Commission 1991). It was designed to create a list of condition–intervention pairs, ranked on the basis of cost–benefit, with a cut-off point based on available resources below which combinations would not be funded. The idea was that this would maximize the return on resources invested in health care. However, the process was extremely problematic when it became clear that many of the data required were unavailable and some results were quite counterintuitive—for example, appendicectomy was rated lower than cosmetic dentistry. The process also raised important ethical questions as the exercise was confined to poor women and children in the Medicaid programme and services denied to them would remain available to others.
An alternative approach was used in The Netherlands. There the Dunning Committee (Dunning 1992) proposed four criteria that any intervention to be funded from social insurance should meet (Fig. 3). These were necessity, effectiveness, efficiency, and whether the condition is a matter of individual rather than community responsibility. As a result of this process, it was recommended that services such as dentistry for adults, homeopathic treatment, in vitro fertilization, and physiotherapy for sports injuries should be excluded.

Fig. 3 Dutch criteria for inclusion within social insurance package. (Source: Dunning 1992).

From this debate has emerged a recognition that the priority-setting process must include government, providers, the public, and patients, as well as evidence on health needs and on the cost and effectiveness of available interventions (Fig. 4) (Ham 1993). Priority setting cannot be reduced to a technical exercise and should be combined with a thorough public debate about the choices to be made. This is seen in the approach taken in Sweden (McKee and Figueras 1996), which focused on the need to reach a shared view of the ethical basis on which priorities should be set. This rejected a narrow economic approach and gave priority to the treatment of life-threatening conditions. It also emphasized the importance of social solidarity.

Fig. 4 Inputs into explicit priority setting. (After Ham 1993).

Ultimately, while public health professionals have an important role in providing the evidence on which any debate on priority setting must be based and on examining the consequences of any decisions for equity, priority setting in a publicly funded system is the responsibility of politicians. Decision-making inevitably involves trade-offs between objectives as a balance is sought among universal coverage, comprehensiveness of services, equity, efficiency, cost containment, and broader social values.
Equitable funding of health systems
As Whitehead (1988) has shown, access to services is a key element of strategies designed to reduce health inequalities. Throughout the twentieth century the steady expansion of coverage in many countries has served to improve access to health care for those in greatest need. This has been associated with the growth of the principle of solidarity (Esping-Anderson 1990). As noted earlier, solidarity is based on ‘risk pooling’ in which those who remain healthy provide financial support for those who become sick and use health care services. In a system based on solidarity, individual financial contributions are related to ability to pay and are not dependent on the individual’s health status.
At present, however, certain developments threaten to undermine the principle of solidarity. One is the pressure from advocates of market-based policies to establish competition among health care insurers. A second is the development of information technology and, increasingly, the use of genetic profiling, enabling individual risks to be predicted more accurately and permitting exclusion or higher premiums for those at greatest risk, although this is raising enormous technical and ethical issues (Low et al. 1998). A third is the failure, by some governments, to collect sufficient taxes or social insurance contributions from the wealthy to fund the system. This has several causes. One is the prevailing global neoliberal agenda that argues that, for countries to attract inward investment and employment, they must reduce taxes. A second cause, which is especially problematic in, but not exclusive to, developing and middle income countries, is widespread tax avoidance by the wealthy. This is also an increasingly important issue in some industrialized countries as the Internet makes off-shore tax havens accessible to the middle classes.
Each of these issues has important implications for equity and thus for public health professionals. The third is beyond the scope of this chapter, but the first and second, which are linked in that competitive insurers have a strong incentive to identify the risks attached to those they accept, are relevant as public health professionals may have to work with such competitive systems. Furthermore, some of the issues that emerge have a wider relevance in, for example, systems in which there is competition between bodies that include both purchasing and provision of care, such as primary care groups in the United Kingdom (Goodwin et al. 1998).
Solidarity and competition
Competition between health insurers (whether private or public) tends to erode solidarity in health care financing, since health insurers seek to select good risks (Rothschild and Stiglitz 1976). In the absence of regulation, older people and those with pre-existing illness or even a strong family history of illness are either excluded from coverage or charged higher premiums. As noted above, advances in information technology and genetics are making this ever easier although this is raising enormous ethical issues (Danziger 1996). For example, should an insurer be permitted to know an individual’s HIV status?
Two responses are open to policy-makers. One is mandatory open enrolment, so that insurers are unable to refuse coverage to an individual. This is typically linked to some regulation about the level of contributions, such as community ratings. The second is the use of risk-adjustment schemes that redistribute the health insurance system’s revenue among competing health insurers on the basis of the risk profile of those enrolling with each insurer.
While these responses might work in theory, they are much more problematic in practice. Apparently open enrolment can be distorted in many subtle ways by targeting promotional activities or manipulating access so that insurers tend to ‘cream skim’ (de Roo 1995). Risk pooling requires development of valid formulas, which have proved elusive (van den Ven et al. 1994), with several systems relying purely on crude measures such as age.
If politicians choose to introduce competitive markets in health care financing, despite a widespread consensus from health economists and others that such initiatives are fraught with danger, public health professionals have an important role in monitoring and responding to any effects on equity. Maintaining solidarity in health care financing while introducing competition among insurers is an ambitious and difficult undertaking. The ‘safety-net’ for solidarity has to be designed very carefully, and such an undertaking requires experienced supervision of health care markets. Moreover, several crucial questions have not yet been answered. Whether competition among insurers really leads to more efficient and more effective health care has yet to be demonstrated (Chinitz et al. 1998), not least because of the need for expensive regulatory and risk adjustment systems, as has the question of whether mechanisms seeking to combine solidarity with competition can succeed.
Optimal allocation of resources
Upward pressure on costs and an increasing willingness of politicians, managers, and the public to challenge established patterns of care have placed an increased emphasis on the optimal allocation of scarce health care resources. Several strategies are available to health policy-makers. These include ensuring that the health services provided reflect the health needs of the population that they serve, enhance the efficiency with which services are delivered, and reduce the cost of key inputs such as pharmaceuticals and technology. Public health professionals can play an important role in both the assessment of health needs and, increasingly, in the process of intelligent purchasing of health care so as to maximize health gain for a given set of inputs.
Assessing need for health care
In this context, need is defined as the ability to benefit from health care. As such it is differentiated from demand, which arises when someone with a need for care expresses it. The relationship between need and demand is mediated by differing illness behaviours. Although it may seem obvious, it is also distinct from use of health care (Fig. 5). In reality, however, these two concepts are often confused, as when increased uptake of a widely advertised, but ineffective, intervention is described as need, or conversely where low uptake of an effective, but inaccessible, intervention is described as an absence of need (Stevens and Gabbay 1991).

Fig. 5 Relationship between need, demand, and use. (Source: Stevens and Gabbay 1991).

Interest in the assessment of health care needs has arisen from the recognition that, left to itself, the pattern of a health service will frequently reflect only partially the health needs of the population that it is serving, and often those whose needs are greatest will receive least (Hart 1971). Instead, other factors come into play, such as the specialist interests of individual physicians, the structure of financial incentives, and the ease of interacting with different groups of patients. Consequently, services for articulate, wealthy, and well-educated patients with interesting conditions are likely to be supplied at the expense of those with low literacy who have unpleasant or uninteresting disease and who are uncooperative.
In practice, four types of needs assessment have been described: epidemiological, comparative, corporate, and pragmatic (Stevens and Raftery 1994). Epidemiologically assessed need involves selecting an intervention, such as a surgical procedure, defining indications for its use, operationalizing these into a survey instrument, and measuring the number of individuals in a population with those indications. Clearly, this is only possible for some conditions, typically surgical procedures where there is a straightforward means of identifying those with clinical indications. Examples include studies of the need for hip replacement (Wilcock 1979) and for prostatectomy (Sanderson et al. 1997).
Comparative need is defined as existing where the population of one area has a lower uptake of a particular intervention than that of another area, after adjustment for any differences in age or other population characteristics. While overcoming many of the technical difficulties involved in epidemiological assessment of need, it makes the assumption that the intervention rate in the area where it is higher is the correct one and fails to take account of either differences in disease prevalence rates or of previous treatment.
Corporate assessment of need is defined as a process whereby expert judgement is assembled to decide on either an appropriate level or configuration of services. Ideally, some system of formal consensus development would be used (Murphy et al. 1998) but clearly this approach risks legitimizing existing patterns of care that may have little rational basis.
The limitations of these approaches has led to the development of what has been described as the pragmatic approach to assessment of need (Stevens and Raftery 1994). This draws on data from a variety of sources. Information on the epidemiology of the condition in question is summarized, the range of possible interventions is defined, and evidence for the effectiveness of each one is summarized. Finally, an optimal model of care, taking into account the characteristics of the particular health care system and the dominant belief system, is generated. This approach accepts that there are gaps in the available evidence but takes the view that this should not preclude acting on what is available.
Each of these approaches requires a considerable amount of resources and, especially in developing and middle-income countries, they will often be inappropriate. An alternative model, rapid appraisal, offers certain advantages in such circumstances (Rikkin 1992). This is a multidisciplinary approach that incorporates flexibility and innovation and which draws extensively on the views of the local community. It is quick, as its name indicates, and it emphasizes timely insights and ‘best bets’ rather than final truths. It involves using key informants to build up a community health profile. This approach has also been used to enhance community involvement in developed countries (Ong et al. 1991).
Assessment of need for health care, using whichever of these models is most appropriate, is a prerequisite for optimal allocation of resources.
Intelligent purchasing
In an increasing number of countries intelligent purchasing is seen as an instrument to implement health policy objectives, including ensuring that health services closely reflect the health needs of the population that they serve (Øvretveit 1995). Purchasing acts as a co-ordinating mechanism that offers an alternative to a traditional command-and-control approach. Its essential characteristic is that it separates purchasers from providers but binds each party by means of contracts to explicit commitments, with creation of the economic motivation to fulfil these commitments.
The growth of purchasing health care is a result of the changing role of the state and the market described previously. Contracts have always been a feature of health care systems based on social insurance systems, with complex institutional structures developed to represent health insurers and physicians in negotiations over payment schedules. Governments have often played some role in these discussions, typically to ensure cost containment and preservation of solidarity. However, both insurers and governments are increasingly using contracts as a means of reorientating the focus of health services, to ensure that they reflect health needs and provide cost-effective care.
In contrast, in most tax-based systems, relationships between health authorities and providers have traditionally been based on hierarchies. This is also changing as policy-makers seek new ways of influencing provider behaviour, based on a clearer identification of the objectives of the health system, including explicit priority setting, while, at the same time, seeking ways of decentralizing decision-making (Ham 1997).
In systems based on private insurance, similar changes are taking place. Instead of simply reimbursing costs incurred retrospectively, insurers are introducing what is described as managed care, in which entitlements are defined in advance and treatment patterns are closely scrutinized (Corrigan et al. 1997).
From a public health perspective, interest in purchasing relates to whether or not it can achieve health gain and promote equity. Whether it does so will depend on both the objectives being pursued and on the quality of the contracting process. Contracts bring many potential benefits but also some risks.
For purchasing to promote health gain it must be based on an assessment of health needs coupled with a strong focus on the cost-effectiveness of clinical interventions and the organizational context within which they are delivered. Conversely, if, as seems increasingly to be the case in some American managed care systems, it is based primarily on cost-saving, it will reduce health gain.
Contracts can support equity if, through needs assessment, they take explicit account of vulnerable and disadvantaged groups as well as underserved communities. From this perspective, purchasers represent the interests of their populations, allocating resources and purchasing services in accordance with their needs. However, purchasing also carries the risk of undermining equity if providers are able to underemphasize or phase out services that are less profitable, rather than simply less efficient.
Purchasing also offers a means for enhancing participation by the population in the organization of health care, thus increasing the accountability of governments and the medical profession and making health policy more relevant to the needs and priorities of society.
In some countries, especially where public health professionals have played a central role in the contracting process, it has been possible to use contracts to develop intersectoral responses to health problems or to reorient health care providers so that they integrate prevention with curative care. The opportunities for doing so are discussed in more detail below.
Implementation of an intelligent purchasing system is a complex process requiring a high level of skills and well-developed information systems. At a minimum, information is required on patient flow, cost, and utilization information across specialties or diagnostic groups, and demographic and risk groups. It is important that expectations of what can be achieved are realistic (McKee and Clarke 1995). Medical care is extremely complex. Diagnostic labels are often imprecise and clouded by a degree of legitimate uncertainty. Decisions on clinical management incorporate values and beliefs relating to factors such as attitude to risk and the utility placed on different health states. Contracts must incorporate sufficient flexibility and reflect the views of all those concerned if they are to retain any credibility.
Purchasing also involves transaction costs to cover activities such as needs assessment, performance analysis, negotiating, and monitoring. A substantial increase in quality and efficiency is required to justify these additional costs. Increasingly, purchasers and providers are entering into long-term contractual relationships that reduce transaction costs (Rosen and McKee 1995).
If transaction costs can be minimized without compromising the pursuit of the objectives of equity and health gain, intelligent purchasing can provide a formidable instrument to promote population health.
Efficient service delivery
The increasing use of intelligent purchasing is focusing the attention of public health professionals on the delivery of health care. Evaluative research is highlighting the extent of use of treatments that are unsupported by evidence of effectiveness and the importance of appropriate organizational structures and cultures in the provision of high-quality care. This section examines three areas in which public health professionals can play an important role: the design of systems that ensure that patients are managed at the level of the health care system that is most appropriate, the creation of mechanisms that identify and promote high-quality clinical care, and the reorientation of curative services towards prevention.
Shifting interfaces
Health services are typically organized on different levels, reflecting the need to balance two competing objectives. On the one hand, dispersion permits easy access to those facilities in which most people receive care and where they can obtain an initial contact with the system. On the other hand, concentration of specialized resources required by relatively small numbers of patients optimizes scarce resources, with potential gains in effectiveness and efficiency, although the relationships are complex and often counterintuitive (Ferguson et al. 1997). Movement between the various levels (primary, secondary, tertiary, and community care) typically involves passage across an interface that is governed by rules of varying degrees of formality. Examples include referral to hospital by a primary care physician or discharge from an acute hospital to a long-stay facility.
The nature of these interfaces is steadily changing in the face of the new circumstances discussed above. Upward pressure on costs is causing policy-makers to ensure that patients are treated in the most cost-effective settings. Changing patterns of disease, coupled with evolving patient beliefs about the nature of health care, are challenging established ways of delivering care. New technologies in fields such as imaging, diagnosis, surgery, pharmaceuticals, and information are having a substantial impact on clinical practice. Health care professionals are developing new and different sets of skills (Coulter 1995).
These changes involve a process of substitution, by which there has been a continual regrouping of resources across care settings to exploit the best available solutions. This can take many forms. One typology differentiates three kinds of substitution: moving the location of care, introducing new technologies, and shifting the mix of staff and skills (Warner 1996). Examples include substituting hospital care with home care (e.g. hospital at home schemes and domiciliary renal dialysis) or with primary care (e.g. undertaking minor surgical procedures or the enhanced management of chronic diseases such as diabetes or asthma in primary care) (Fig. 6).

Fig. 6 Health and social care substitution. (Source: Warner 1996).

From a public health perspective, substitution brings the potential of both benefits and risks. Potential benefits include increased patient satisfaction, improved clinical outcomes, greater efficiency, and more appropriate management of certain diseases. Risks include fragmentation of services, loss of specialized skills, increased costs, and wasteful duplication of expensive technology. Each case must be assessed on its merits as initiatives that have seemed intuitively better than what they replaced have often, on detailed evaluation, failed to live up to the initial expectations (Hensher et al. 1996).
Effective substitution policies require co-ordination, with clear strategic objectives. A system-wide perspective is necessary to identify unintended consequences for other services (Checkland and Scholes 1990). Too often substitution involves simply changing the location, without an appropriate shift in skills and technology or without a reallocation of resources.
However, substitution offers a valuable tool to public health professionals to make services more accessible and appropriate to the population and to ensure that care is provided as cost-effectively as possible.
Improving outcomes
As noted above, former deference to medical judgement about how to deliver health care is giving way in the face of wide variations in how physicians actually provide care (McPherson 1989). The view expressed by the editor of The Lancet in 1951, that central guidance on clinical care should be rejected because of the harm that it would do to the sense of personal responsibility of the physician (Fox 1951), is no longer tenable.
Variations in clinical practice have many causes, the most important being clinical uncertainty about the most appropriate treatment in any given circumstance (Anderson and Mooney 1990). Studies of treatment pattern reveal both overtreatment, where patients receive treatments that are ineffective, and undertreatment, where those who would benefit are denied effective treatment. This has led to four related questions. Firstly, which treatments can be expected to produce improved health outcomes? Secondly, does a treatment that has been shown to be efficacious in evaluative research achieve the intended objective in routine clinical practice (Britton et al. 1999)? Thirdly, why are treatments of known effectiveness not used in circumstances where they would achieve health improvement? Finally, how does one change professional behaviour so as to ensure that the most effective, efficient, and humane treatments are provided (Freemantle 1996)? Together, these questions contribute to the quest for what is termed evidence-based health care.
Evidence-based health care includes a wide range of activities that have, as their common goal, the improvement of the outcome of health care. This ‘outcomes movement’ (Relman 1988) in its most developed form encompasses defining prioritized research questions, systematic reviews of available evidence on the corresponding topics, development of a research agenda to fill gaps in the knowledge, support to create a research infrastructure, and dissemination and implementation of the research findings in practice (Peckham 1991).
These activities draw on a multidisciplinary approach, with an emphasis on timeliness, relevance to the needs of the users, and the importance of changing policy and practice. Many countries have mechanisms to address some or all of these tasks. One example is the establishment of organizations for health technology assessment. These typically undertake the early identification of emerging technologies, synthesis of available evidence, and commissioning of needed research. A detailed listing of organizations involved in these activities has been assembled elsewhere (University of York 1999).
The synthesis and dissemination of research-based evidence is at the core of these approaches to assuring the quality of clinical care. It is, however, also necessary to establish mechanisms to ensure that the available evidence is used by practitioners. These constitute what are usually described as quality assurance activities (Black 1992).
Three aspects of quality assurance are important. The first is that it is a continuous process, involving repeated cycles of setting standards, introducing change to meet those standards, and review of the results of change. The second is the existence of different types of quality measure (Donabedian 1966). Measures of structure relate to inputs such as facilities and the availability of trained staff. Measures of process include adherence to agreed good practice. Measures of outcome assess the extent to which the objectives of treatment are achieved. A third aspect involves the differentiation of internal and external approaches to quality assurance.
Quality assurance activities often deal with structures and processes of care rather than outcomes. Ideally, the focus would be on outcomes, but outcomes are typically more difficult to measure and may only become apparent long after the intervention took place. Some outcomes may also be rare and the sample size required to detect a deviation from what is expected may be very large. For example, Mant and Hicks (1995) have shown, on the basis of knowledge of effective treatment for myocardial infarction, that, in a comparison of two typical hospitals, it would take 73 years of data to detect a significant 3 per cent reduction in mortality whereas the corresponding difference in process measures, relating to uptake of treatments, would emerge after only 4 months. Where process or structure measures are used there should be evidence that they correlate with a good outcome. Measures based on structure can be of some value, based on the assumption that high-quality care cannot be provided in the absence of basic prerequisites, such as adequately trained staff, but this is a necessary rather than a sufficient measure and should normally be supplemented by measures of either process or outcome.
Internal and external forms of quality assurance have quite different characteristics. In the former, the activity is conducted by those undertaking the clinical activities concerned, such as the physicians in a hospital. They are responsible for setting standards and implementing change. This has the advantage of fostering a sense of ownership and is less open to opportunistic manipulation of results. However, it does require a culture in which it is accepted that clinical practice should be open to examination by one’s peers. Professional bodies have often played a major role in promoting this approach.
External quality assurance involves a body outside the health care facility examining measures of quality. This typically focuses on structure, largely because this is so much easier to measure than process or outcome. A typical example is hospital accreditation (Scrivens 1997). Accreditation is especially important for countries seeking to establish a mix of private and public health services, as it offers a means of reassurance that all facilities meet an agreed minimum level of quality.
Perhaps the greatest challenge facing those seeking to improve the quality of health care is how to change clinical behaviour. An increasing volume of research on this topic is being brought together by the work of the Cochrane Collaboration on Effective Professional Practice. This has examined behavioural, financial, and organizational approaches to changing practice. It has shown how many traditional approaches, such as conferences and short educational events, are of little value (Thomson et al. 1997). Educational outreach visits have a small effect, and financial and organizational initiatives, such as the introduction of copayments, tend to reduce appropriate and inappropriate care to a similar extent. The most successful strategies involve combing a range of behavioural approaches, such as audit and feedback, production of guidelines, and, where appropriate, computer-generated reminders. However, the main conclusion of this research is that change is very difficult and requires carefully targeted sustained action.
Public health professionals have played a key role in the development of evidence-based health care, although its elements, from research through dissemination to implementation, are in place in only a few countries. Often the focus of health policy discussion remains focused on issues of financing and organization. The difficulties involved in integrating evidence-based health care with health sector reform should not be underestimated, although there is considerable scope for international co-operation, which is already well established through the Cochrane Collaboration.
Health services as a setting for promoting health
Public health professionals have a particularly important role in promoting the reorientation of health services to address the broader determinants of health. Health services are important settings in which it is possible actively to promote health through primary preventive strategies. Health professionals have an important role as opinion formers, both in individual patient encounters and, among the wider public, as respected advocates for healthy public policies (Chapman and Lupton 1994). Conversely, contradictory images, such as physicians and nurses smoking while they advise their patients to quit (Audet 1994), can do much to undermine public health messages.
Relatively simple approaches can often be very effective. One of every 37 patients given brief advice by a physician to stop smoking can be expected to quit, with those at most risk of smoking-related diseases most susceptible (Silagy and Ketteridge 1998). Women who receive brief advice on smoking during pregnancy are almost twice as likely to stop smoking than those who do not (Dolan-Mullen 1994), with a corresponding reduction in low-birth-weight babies. Brief interventions by a variety of health professionals have also been found to be effective in reducing problem drinking among men (Kahan et al. 1995). Such interventions are substantially more cost-effective than other strategies (Plans-Rubrio 1998; Meenan et al. 1998) (Table 3).

Table 3 Cost per life-year gained from interventions to reduce cardiovascular disease: Spain, 1998

There is also some evidence to support a more proactive preventive role for health professionals in some areas. Assessment of elderly people by health professionals trained to identify risk factors is associated with a 20 per cent reduction in falls (Gillespie et al. 1998). However, this may simply require engagement in a process of patient empowerment. An enhanced process of self-management of asthma, involving self-monitoring and self-adjustment of medication, led to a fall of up to 50 per cent in hospital admission, unscheduled physician visits, and days off work or school (Gibson et al. 1998).
It is not sufficient to assume that such approaches are always going to be effective, and, as with treatment interventions, each must be assessed individually. For example, while advising patients to take more exercise or eat more nutritious food may seem intuitively beneficial, there is little evidence that it is effective (US Preventive Services Task Force 1996). There is no evidence that attempts to reduce the risk of coronary heart disease through multiple risk factor interventions have an impact on either total or coronary heart disease mortality (Ebrahim and Davey Smith 1997), and fiscal and legislative measures seem more appropriate.
However, it is important to recognize that interventions set in the health care sector may risk exacerbating health inequalities, especially where migrant workers and illegal immigrants are excluded from the formal health care system.
Many people come into contact with health care facilities, either as patients or staff. This provides an important opportunity to demonstrate support for health-promoting policies by means of an ethos based on healthy lifestyles. This includes bans on smoking, highlighting the importance of environmental tobacco smoke (Catford and Nutbeam 1983), and provision of cycle parks, gyms, and showers, so encouraging exercise, and ensuring that catering facilities provide healthy dietary choices (Clarkson and Nutbeam 1991). This approach forms one element of the WHO’s Health-Promoting Hospitals project. This seeks to increase participation in health-promoting activities by patients, staff, and others outside the hospital, as well as improving communication and reorienting hospitals towards health promotion (WHO 1999). In contrast, failure to ban smoking or to promote healthy eating choices gives an implicit message that health promotion is not taken seriously. The obvious conflict between the culture of the organization and the advice given to patients will make behavioural change more difficult.
Finally, the contribution that health services can make to health by employing people should not be ignored. The adverse health effects of unemployment are well recognized (Bartley 1994), in particular the impact of job insecurity and anticipation of unemployment (Ferrie et al. 1995). Health services have always been labour intensive. Health care reforms in many countries have led to substantial reductions in staff numbers, either through redundancy or, in some countries, transfers to private sector agencies where levels of pay and conditions of service are substantially worse. While reducing the direct costs to the health service, such policies often increase overall government expenditure through increased social costs. However, some governments are recognizing the role of health services as a source of employment, as illustrated by the European Union’s Amsterdam Special Action Programme, in which 10 billion Euros are being invested in job-creating projects, including health care (European Investment Bank 1999).
Health services as a threat to public health—the growth of antibiotic resistance
While, most commonly, public health professionals will focus on the issues raised in the preceding sections, one other issue requires specific attention. In some countries, the 1990s have seen a marked increase in the rate of resistance among hospital-acquired infections. Rates vary markedly between countries (Gruneberg and Felmingham 1996) and there is compelling evidence that they are related to the approach taken to the prescribing of antibiotics. Thus, hospitals and other health care facilities in which prescribing is uncontrolled and haphazard represent a threat to the wider population, and not only in the country concerned. Unfortunately, surveillance systems are often weak, even in many industrialized countries (Desenclos 1993).
The growth of iatrogenic antibiotic resistance creates a major challenge for public health professionals who must work in association with their clinical colleagues to change clinical behaviour (Frimodt-Møller 1998).
The contribution of public health to health services
This chapter began by showing how health care can no longer be regarded as peripheral to attempts to improve the health of populations. Notwithstanding the importance of tackling the wider determinants of health, modern clinical care offers new opportunities to reduce mortality and improve quality of life. Health care is also taking on a greater importance as evidence emerges of how differential access can increase health inequalities.
Health services are changing, bringing new opportunities for public health to increase its impact in this process by reorienting health services towards the maximization of health gain (McKee and Bojan 1998). However, if public health professionals are to take full advantage of these new opportunities they will need to have a thorough understanding of the contextual as well as the internal health sector pressures that are driving the health services change.
This chapter has highlighted the main health service themes that are emerging in response to these pressures for change. In particular, there is a changing relationship between the roles of the state and the market in health care with the introduction of a series of market incentives at different levels of the health system. However, the evidence does not lend support to a radical shift in the roles of state and market but to an incremental change leading to a more balanced model which retains key features of both approaches (Figueras et al. 1998). In fact the introduction of the market in health care has required not less government activity, but different activity including strategic planning, monitoring, and regulation. Two accompanying trends, partially reflecting the changing role of the state, have been decentralization of responsibility to lower levels within the public sector and an increasing role for the citizen and patient in various health service strategies including the development of patient rights legislation, increased patient choice of provider, and citizen participation in decision-making.
These three themes underlie many of the specific policies adopted at the different levels of health services and outlined above under a series of strategies to address cost containment, increase solidarity and sustainability of funding, achieve a more effective allocation of resources according to health need, and improve the efficiency in health service delivery. These various strategies can be summarized through a conceptual shorthand suggested by Saltman and Figueras (1998) which may help to better summarize the contributions of public health into the health services. This approach compresses the various categories into two traditional economic parameters: policy interventions instituted on the demand side as against those instituted on the supply side of the health care system.
The demand side incorporates all strategies that influence funding of the health care system and more specifically the relationships between the consumer and the third-party payers. A number of health system strategies have concentrated on the demand side by introducing measures shifting costs to the patient, such as cost-sharing arrangements or limiting the public package of care, and by introducing market competition incentives among third-party insurers. Many of these have led to equity problems. The role of public health here is twofold: first to ensure that solidarity of the health system is not harmed by these measures which tend to reduce access and coverage particularly for the most vulnerable groups in our society, and second to shift the policy-makers’ agenda from these individual patient-based demand policies towards strategies dealing with aggregate population-based demand. Indeed, the latter is very much at the core of public health role.
The introduction of effective health promotion and primary prevention strategies should ultimately reduce the total demand for health care services and health care costs. However, the difficulties in measuring health promotion in terms of cost-effectiveness so that it can be compared with health services interventions, has meant that health promotion has not played a central role in health reform agenda. Public health professionals need to strive to develop more and better ways to evaluate health promotion that satisfy the needs of policy-makers, managers, and clinicians so the full potential of health promotion can be realized (McKee and Bojan 1998).
The supply side includes strategies forming a continuum that moves from the allocation of health resources to the delivery of health services. In the area of allocation these include efforts to change provider behaviour through the introduction of contracting within public operated health systems along the development of performance-based payment systems for providers. In the delivery area some of the key strategies include the introduction of quality-oriented strategies, the integration and substitution of services across the hospital and primary health care sectors, and the reorganization of health care providers in various types of public firms with more managerial independence and finance tied to production. In many instances, these reforms have met with considerable success (Saltman and Figueras 1998), but the extent of their success will depend on the availability of series of skills traditionally linked to the public health profession. These include assessing the health needs of the population, evaluating and monitoring interventions, assessing health outcomes, and reorienting health care delivery so that the focus is on prevention as well as cure (McKee and Bojan 1998).
Health services have an important contribution to play in improving the health status of populations. This chapter has identified mechanisms through which public health can have a major role in maximizing the health gain obtained from the health services, but much will depend on the ability of the public health profession to adapt and bring its portfolio of tools and skills to bear on rapidly changing health services.
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