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Return on investment of public health interventions:
a systematic review
Rebecca Masters,
1,2
Elspeth Anwar,
2,3,4
Brendan Collins,
2,4
Richard Cookson,
5
Simon Capewell
2
▸Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/jech-
2016-208141).
1
North Wales Local Public
Health Team, Public Health
Wales, Mold, Flintshire, UK
2
Department of Public Health
and Policy, University of
Liverpool, UK
3
Department of Public Health,
Halton Borough Council,
Cheshire, UK
4
Department of Public Health,
Wirral Metropolitan Borough
Council, Merseyside, UK
5
Centre for Health Economics,
University of York, UK
Correspondence to
Rebecca Masters, North Wales
Local Public Health Team,
Public Health Wales, Mold,
Flintshire CH7 1PZ, UK;
Rebecca.Mason@nhs.net
Received 25 July 2016
Accepted 3 February 2017
To cite: Masters R,
Anwar E, Collins B, et al.J
Epidemiol Community Health
Published Online First:
[please include Day Month
Year] doi:10.1136/jech-
2016-208141
ABSTRACT
Background Public sector austerity measures in many
high-income countries mean that public health budgets
are reducing year on year. To help inform the potential
impact of these proposed disinvestments in public
health, we set out to determine the return on investment
(ROI) from a range of existing public health
interventions.
Methods We conducted systematic searches on all
relevant databases (including MEDLINE; EMBASE;
CINAHL; AMED; PubMed, Cochrane and Scopus) to
identify studies that calculated a ROI or cost-benefit ratio
(CBR) for public health interventions in high-income
countries.
Results We identified 2957 titles, and included 52
studies. The median ROI for public health interventions
was 14.3 to 1, and median CBR was 8.3. The median
ROI for all 29 local public health interventions was 4.1
to 1, and median CBR was 10.3. Even larger benefits
were reported in 28 studies analysing nationwide public
health interventions; the median ROI was 27.2, and
median CBR was 17.5.
Conclusions This systematic review suggests that local
and national public health interventions are highly cost-
saving. Cuts to public health budgets in high income
countries therefore represent a false economy, and are
likely to generate billions of pounds of additional costs
to health services and the wider economy.
INTRODUCTION
Benjamin Franklin once famously stated that “an
ounce of prevention is worth a pound of cure”.
Long-term pressures on public sector costs due to
demographic and technological changes and cost
inflation in the caring professions have intensified
following the 2008 global financial crisis. Public
health is often considered a politically soft target
for budget cuts, as recently demonstrated by major
budget reductions in the UK.
1–3
The benefits of population-level public health
expenditure—unlike those of personal healthcare
and social care expenditure—tend to be long term,
mostly accruing after the current politicians and
policymakers have moved on. Though large and
certain at the population level, benefits are also
seen as small and uncertain for individual voters. It
is therefore important to take a hard look at the
cost-effective evidence, and move towards more
rational decision-making in this politically charged
area.
Return on investment (ROI) and cost-benefit
ratio (CBR) are two forms of economic evaluation
that value the financial return, or benefits, of an
intervention against the total costs of its delivery.
The CBR is the benefit divided by the cost, and the
ROI is the benefit minus the cost expressed as a
proportion of the cost, that is, the CBR−1. To help
inform the discussion of proposed cuts to public
health budgets, we set out to determine the ROI
and opportunity cost for a range of public health
interventions at the local and national levels. The
theory underpinning this review is that, because
political backing for public health intervention is
often lacking, many interventions with a high ROI
are not funded. This is because public health inter-
ventions are often opposed by powerful commer-
cial interests, and the health gains for individuals
are often perceived as too small to sway their
voting intentions, despite adding up to large gains
at the population level.
4
METHODS
We conducted a systematic review to examine the
ROI of public health interventions delivered in
high-income countries with universal healthcare.
These included the UK, Western Europe, the USA,
Canada, Japan, Australia and New Zealand.
Search strategy
The authors used Acheson’sdefinition of public
health when considering our search strategy: “The
science and art of promoting and protecting health
and well-being, preventing ill-health and prolong-
ing life through the organised efforts of society”.
5
This definition is purposefully broad and the
authors felt that it would incorporate the various
fields of public health. We searched the PubMed,
MEDLINE, Scopus, CINAHL, Cochrane, PsycInfo
and AMED databases using the following search
terms: ‘public health’(all fields) AND ‘return on
investment’OR ‘cost benefit analysis’(title or
abstract). We also hand searched the references of
the included analyses to identify any further
studies. A grey literature search was completed
using Google, yielding three additional results.
Limits were set to publications in the English lan-
guage, and to interventions targeted at humans
(where applicable). Studies with poor generalisabil-
ity to the UK were excluded, including a number
from the USA that may poorly reflect UK health-
care systems, structure and demographics.
Study selection and inclusion criteria
We included studies of any design that reported a
ROI of public health interventions delivered in indus-
trialised countries providing universal healthcare.
Masters R, et al.J Epidemiol Community Health 2017;0:1–8. doi:10.1136/jech-2016-208141 1
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Selection of articles and extraction of data
One investigator (RM) performed the initial screening of the
titles. A second reviewer (EA) independently reviewed the titles
and potentially relevant abstracts. The results were cross-
referenced and any disagreements were discussed with a third
reviewer (BC).
One investigator (RM) led the data extraction and quality
assessment, which was then independently duplicated by EA. A
third reviewer (BC) adjudicated on any disagreements regarding
result details or quality assessment. RM contacted authors for
additional data in three cases, with two responses.
Assessment of methodological quality in included studies
The methodological quality of each included study was assessed
independently by two reviewers (RM and EA) using the
National Institute for Health and Care Excellence (NICE)
quality appraisal checklist for economic evaluations to assess the
quality and external validity of each study.
6
Disagreements in
methodological quality assessments for all the included studies
were resolved by consensus or by recourse to a third member of
the review team (BC).
RESULTS
We identified 2957 potentially relevant titles, after excluding
2559 duplicates. A further 2816 papers were excluded following
title or abstract review. We finally included 52 relevant titles
published over four decades (see online supplementary figure
S1).
Results were stratified by public health specialty (table 1), and
by interventions at a local level (table 2)ornationallevel(table 3).
Results were reported in five different currencies, as detailed in
tables 2 and 3.
The median ROI for all public health interventions was 14.3,
and the median CBR was 8.3.
The reported ROI and CBRs ranged widely. The ROIs ranged
from –21.27 (influenza vaccination of healthy workers
7
) to 221
(lead paint control
8
). The CBRs reported ranged from 0.66
(20 mph zones in low-impact areas
9
) to 167 (single measles vac-
cinations
10
). Studies reporting ROIs at the extreme end of the
spectrum tended to be of poorer quality. Studies reporting a
CBR tended to be higher quality.
ROI of public health programmes stratified by specialism
Analysis by specialism revealed that health protection and legis-
lative interventions generally yielded high returns on invest-
ment, often being delivered on a national basis and only
requiring a one-off intervention (such as a vaccination or a new
tax). In contrast, interventions for healthcare public health,
health promotion or wider determinants typically had lower
returns, being often more complex, resource intensive and sus-
tained. Figure 1 provides overviews of the median, maximum
and minimum ROI by specialism, and figure 2 provides an over-
view of the median, maximum and minimum and CBR values
stratified by specialism.
Health protection interventions
Eighteen studies reported a large ROI in relation to health pro-
tection. The ROI median was 34.2, and ranged from −21.3
7
to
221
8
, and the CBR median was 41.8 (range from 1.2
11
to
167
10
).
Health promotion interventions
Fifteen health promotion interventions were reported, 12 ROI
studies and 3 CBR studies. Returns on investment were variable.
The median ROI was 2.2 (range 0.7
12
to 6.2
13
). The median
CBR was much higher at 14.4 (range 2
10
to 29.4
14
).
Legislative interventions
Four studies reported on legislative interventions, with substan-
tial returns. The median ROI was 46.5 (range 38
15
to 55
15
).
The median CBR was 5.8 (range 3
10
to 8.6
16
).
Healthcare public health interventions
Six studies reported ROIs in relation to healthcare public health
interventions. The ROI median was 5.1, and ranged from
1.15
17
to 19.35.
18
No studies reported a CBR.
Wider determinants interventions
Twelve studies reported a return on wider determinants inter-
ventions (for instance, targeted at children or juvenile offen-
ders). The median ROI was 5.6 (range 1.1
19
to 10.8
20
) with a
median CBR of 7.1 (range 0.66
7
to 23.6
21
).
ROI of public health interventions by level
A total of 29 studies reported returns on investment or CBRs in
relation to local public health interventions. The median ROI
was 4.1, and ranged from −0.9
22
to 19.3.
18
The median CBR
was 10.3 (range −0.7
7
to 23.6
19
).
There were 28 studies reporting on national public health
interventions. The median ROI was 27.2 and ranged from
−21.3
7
to 221.
8
The median CBR was 17.5 (range 1.2
11
to 167
8
).
Table 1 ROI of public health programmes overall, and stratified by level and specialism
Median ROI ROI range Number of ROI studies Median CBR CBR range Number of CBR studies
Overall 14.3 –21.3 to 221 34 8.3 0.7 to 29.4 23
Local level 4.1 0.9 to 19.3 18 10.3 0.9 to 23.6 11
National level 27.2 –21.3 to 221 17 17 1.2 to 167. 10
Specialism
Health protection 34.2 0.7 to 221 8 41.8 1.1 to 167 10
Legislation 46.5 38 to 55 2 5.8 3 to 8.6 2
Health promotion 2.2 0.7 to 6.2 12 14.4 2 to 29.4 3
Healthcare public health 5.1 1.1 to 19.3 6 None reported None reported None reported
Wider determinants 5.6 1.1 to 10.8 6 7.1 0.7 to 23.6 6
CBR, cost-benefit ratio; ROI, return on investment.
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Table 2 Return on investment of local public health programmes: specific studies
Reference Intervention Population
Benefit-cost
ratio
Return on
investment Cost perspective
Discount
rate
Time
horizon
Study
quality
Andresen et al
31
Supervised injection facilities IDU population of Vancouver, Canada 5.12 Medical and
societal
3% Lifetime ++
Arrieta et al
18
Home blood pressure monitoring for hypertension diagnosis and
treatment
16 375 participants, USA $7.50–$19.35 Insurer 3% 10 years ++
Baker et al
44
Workplace obesity management 890 employees, USA $1–$1.17 Medical None 1 year –
Beard et al
41
Community-based falls prevention 2000 cases and 1600 matched controls, Australia 20.6 Medical and
societal
8% 18 months ++
Collins
42
Smoking cessation Population of Wirral, UK £1.77 Medical 3.5% 20 years ++
Dopp et al
57
Multisystematic therapy with serious juvenile offenders and their
siblings
305 participants, USA 5.04 Medical and
societal
3% 25 years ++
Goetzel et al
45
Workplace health risk management programme for small
businesses
2458 employees, USA $2.03 Medical and
productivity
No 1 year –
Guo et al
59
Improved walking and cycling infrastructure 4674 participants, USA 1.87 Medical 3% 10 years ++
Kleitz et al
21
Multisystematic therapy with serious juvenile offenders 176 participants, USA 9.51–23.59 Medical and
societal
3% 13.7 years ++
Kuehl et al
46
Workplace health promotion for fire fighters 1369 fire fighters, USA $4.61 Medical and
insurer
None 7 years –
Long et al
47
Health promotion programme for hospital staff 4402 hospital staff, USA $2.87 Employer None 1–4 years +
Moore et al
52
Medication management for high-risk groups 4500 health plan participants, USA $2 Insurer None 1 year –
Medivil et al
60
Speed cameras in urban settings Barcelona, Spain €6.80 Medical and
societal
3% 2 years ++
Nelson et al
39
Water fluoridation Population of Houston, Texas $1.51 Societal 10% 10 years ++
Nyman et al
22
Workplace health promotion 1757 cases and 3619 matched controls,
employer, USA
$0.87 No 2 years +
Ozminkowski et al
51
Workplace health management 25 931 Citibank employees $4.61 Insurer 4% 3.2 years ++
Peters et al
9
20 mph zones in London Population of London, UK 0.66–2.19 Societal 3.5% 10 years ++
Reynolds et al
20
Intensive early education programme for socioeconomically
deprived families (preschool programme)
1539 participants, USA $10.83 Medical and
societal
3% 20 years ++
Reynolds et al
20
Intensive early education programme for socioeconomically
deprived families (school age programme)
850 participants, USA $3.97 Medical and
societal
3% 20 years ++
Reynolds et al
20
Intensive early education programme for socioeconomically
deprived families (extended intervention)
553 participants, USA $8.24 Medical and
societal
3% 20 years ++
Richard et al
43
Tobacco cessation 805 Medicaid insured tobacco users, USA $2–$2.25 Insurer None 1.3 years –
Rundell et al
53
Therapeutic services for alcoholism 3034 Oklahoma alcohol service users, USA $1.98 Medical and legal 4% 10 and
22 years
++
Schwartz et al
48
Wellness and disease prevention programme 57 940 health insurance clients, USA $2.02 Insurer None 8 years –
Schweinhart et al
56
Preschool education programme for socioeconomically deprived
children
123 preschool children, USA 7.16 Medical and
societal
3% 40 years –
Steinbach et al
19
20 mph zones in London Population of London, UK £1.12 Medical None 10 years –
Spence et al
54
Outpatient pharmacy services for medication adherence 2957 matched cases and controls, USA $5.97 Medical and
productivity
None 1 year –
Van Vonno et al
17
Heart failure disease management 1360 matched cases and controls, USA $1.15 Insurer None 1 year –
Wang et al
61
Bike and pedestrian trails 225 351 individual uses of bike and pedestrian
trails over a 1 year period, USA
$2.94 Public health None 10 years –
Windsor et al
49
Antinatal stop smoking services 994 pregnant smokers in Alabama, USA 6.72–17.18 Medical None 5 years –
Masters R, et al.J Epidemiol Community Health 2017;0:1–8. doi:10.1136/jech-2016-208141 3
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Table 3 Return on investment of national public health programmes: specific studies
Reference Intervention Population
Benefit-cost
ratio
Return on
investment Cost perspective Discount rate
Time
horizon
Study
quality
Abelson et al
10
Hib vaccination Australia 1.06 Medical 5% 15 years ++
Abelson et al
10
HIV/AIDS prevention Australia 4 Medical 5% 25 years ++
Abelson et al
10
Measles vaccination Australia 167 Medical 5% 33 years ++
Abelson et al
10
Programmes to reduce rates of coronary heart disease Australia 11 Medical 5% 40 years ++
Abelson et al
10
Programmes to reduce tobacco consumption Australia 2 Medical 5% 40 years ++
Abelson et al
10
Road safety campaigns Australia 3 Medical 5% 40 years ++
Boccalini et al
32
Universal hepatitis B vaccination Italy €2.78 Medical and
societal
3% 20 years ++
Bonin et al
58
Parenting programmes for the prevention of persistent conduct
disorders
England 7.89 Medical and
societal
3.5% 35 years ++
Drummond
11
Needle exchange Australia 1.2 Public health 5% Lifetime ++
Evans-Lacko et al
12
Antistigma social marketing campaign England £0.7 to £1.90 Unclear None 1 year -
Garpenholt et al
38
Hib vaccination Sweden 1.59 Societal 5% 20 years ++
Gortmaker et al
15
Sugar sweetened beverage tax USA $55 Medical 3% 10 years ++
Gortmaker et al
15
Eliminating tax subsidy of nutritionally poor food advertising to
children
USA $38 Medical 3% 10 years ++
Gould
8
Lead paint control USA $17 to $221 Medical and
societal
None Unclear −
Holtgrave et al
34
HIV counselling, testing, referral and partner notification services USA 20.09 Societal 6% Lifetime ++
Hutchinson et al
35
Expanded HIV testing USA $1.46 to $2.01 Health sector 3% Lifetime ++
Kwon et al
36
Needle exchange Australia $A1.3 to $A5.5 Health sector 3% Lifetime ++
Lokkerbol et al
55
Telemedicine for depression The
Netherlands
€1.45 to €1.76 Medical 1.5% costs, 4%
effects
5 years ++
McGuire et al
14
Family planning services UK 11.09 to 29.39 Medical 6% Lifetime ++
Miller et al
16
Booster seats for 4–7 years olds USA 8.6 Medical 3% 3 years ++
Nguyen et al
37
Needle exchange USA $3.48 Medical None 1 year +
Nichol et al
7
Influenza vaccination of healthy workers USA −$21.27 to +$174.32 Societal 3% 1 year +
Romano et al
40
Folic acid fortification of grain USA 4.3 to 6.1 Human capital 4% Lifetime ++
Trust for America
13
Primary and secondary prevention programmes USA $6.2 Medical 0% 10–20 years +
Wang et al
50
Universal school nursing services USA $2.20 Societal None 1 year +
White et al
28
MMR vaccination USA 14 Medical 10% Lifetime ++
Ding et al
30
Hospital-based postpartum influenza vaccination USA $1.7 Medical and
societal
3% 1 year ++
Zhou et al
38
Hib vaccination USA 5.4 Medical and
societal
3% Lifetime ++
Hib, haemophilus influenzae type b; MMR, measles, mumps and rubella.
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DISCUSSION
Our systematic review offers several potentially important
observations
First, even with the most rudimentary economic evaluations, it
was clear that most public health interventions are substantially
cost saving. This confirms our theory that public health inter-
ventions generally offer a considerable ROI. Median ROI was
generally higher than median CBR in all of our key public
health expenditure categories. This was because most studies
only report one of these two measures, and studies that report
ROI tend to have higher estimates. A direct comparison is pos-
sible, by converting between ROI and CBR at the study level
using the simple formula ROI=CBR−1.
Second, we demonstrated a public health ‘effectiveness hier-
archy’. Public health interventions at a local level averaged an
impressive ROI of 4, meaning that every pound invested yields
a return of £4 plus the original investment back. However,
‘upstream’interventions delivered on a national scale generally
achieve even greater returns on investment, particularly legisla-
tion (a 10-fold higher ROI averaging 46).
Third, Benjamin Franklin’s belief that “an ounce of preven-
tion is worth a pound of cure”is thus borne out by the
costs-savings demonstrated, particularly when compared with
recent returns for investment in healthcare.
23
It has been esti-
mated that investing an additional £13 000 in the English
National Health Service (NHS) can achieve health benefits of
one additional quality-adjusted life year (QALY).
23
When this
health benefit is valued in monetary terms at the UK
Department of Health’s current rate of £60 000 per QALY,
24
this represents a ROI of 3.16 (£60 000−£13 000/£13 000).
Fourth, this systematic review was partly prompted by recent
government cuts to public health budgets in England. We there-
fore focused on public health interventions delivered in other
high-income countries in order to maximise UK relevance. We
can therefore now better estimate the likely opportunity costs of
the proposed cuts in local and national public health budgets.
The median ROI for all public health interventions was 14.3, and
the median CBR was 8.3. An ROI of 14.3 implying a cash return
of 1430% would sound too good to be true in the financial
world. However, public health is different, because decision-
Figure 1 Median, maximum and minimum return on investment values stratified by specialism.
Figure 2 Median, maximum and minimum cost:benefit ratios stratified by specialism.
Masters R, et al.J Epidemiol Community Health 2017;0:1–8. doi:10.1136/jech-2016-208141 5
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making is governed by politics rather than markets. Our systematic
review clearly demonstrates that there are big public health invest-
ment opportunities out there—they just need some political will
to implement them. If we take the lower, conservative CBR figure
of 8.3, this would suggest that the opportunity cost of the recent
£200 million cuts to public health funding in England is likely to
be eightfold higher, in the region of £1.6 billion. The UK govern-
ment’s‘efficiency savings’thus represent a false economy which
will generate many billions of additional future costs to the ailing
NHS and wider UK economy. The recent UK increases in (avoid-
able) teen pregnancies, sexually transmitted infections, homeless-
ness and suicides are thus predictable and worrying. Do they
represent harbingers of worse to come? Although this study draws
on the experience of the UK public health system, there are impli-
cations for public health systems outside of the UK, which may be
guided towards areas of potential underinvestment, and avoid
harmful cuts in public health budgets.
Previous reviews
Ours may be the first comprehensive systematic review of
ROI and CBR to include the broad spectrum of public health
interventions. Furthermore, it extends and strengthens earlier,
narrower reviews which consistently highlighted the cost-
effectiveness of selected public health interventions. These
included the Australian Assessing Cost Effectiveness (ACE)
Prevention Study
25
and the Health England Leading Priorities
(HELP) Tool, which ranked several public health interventions
against a set of criteria.
26
NICE appraises and recommends public
health programmes and interventions in England. In 2012, they
reviewed 200 cost-effectiveness estimates used in their guidance.
Many interventions (particularly around smoking cessation) pro-
duced a net cost-saving for the NHS, that is, the intervention was
more effective and cheaper than the comparator.
27
Most inter-
ventions were highly cost-effective with a very low cost per
QALY: 85% were cost-effective at a threshold of £20 000 per
QALY, and 89% at the higher £30 000 threshold, 5% exceeded
£30 000 per QALY and only the final5%weredominated(ie,
more costly and less effective than the comparator).
27
Health protection interventions
Eighteen studies reported ROI or CBR figures in relation to
health protection interventions.
78101128–40
The median ROI
for health protection interventions was very high at 34.2. The
Australian single measles vaccination programme in the 1980s
and 1990s reported the highest CBR, with a CBR of 167:1.
10
The UK now uses the combined Measles, Mumps and Rubella
vaccination that has an excellent ROI of 14:1.
28
Seven studies assessed the prevention, notification, follow-up
and treatment of infectious diseases such as hepatitis B and HIV.
Overall, they demonstrated a consistently high ROI, reflecting
the high disease burden of infectious diseases and the huge
benefits of prevention.
29
Calculating the ROI of influenza vaccination of healthy
working adults is challenging, as it is highly sensitive to the effi-
cacy of the seasonal vaccine. Thus, most such studies
730
have
reported a modest twofold ROI overall, but with extreme ROI
values ranging from −21 to +174.
30
Legislative interventions
One paper reported ROI in relation to legislative interventions,
which offered substantial returns on investment, with a median ROI
of 46.5. Furthermore, they are relatively low cost and target behav-
iour at a national level. Introducing a sugar sweetened beverage tax
could save $55 for every single dollar invested
15
in the USA.
Health promotion interventions
The 15 studies analysing health promotion interventions
reported an overall twofold ROI with a more impressive median
CBR of 14.4.
10 13 14 22 41–51
Interventions aimed at reducing
rates of falls are able to show one of the swiftest returns on
investment of any of the public health interventions identified
within this study, with a CBR of 20.6 returned within 18
months.
41
Falls prevention interventions by their nature are rela-
tively low cost (structured exercise programmes for those at risk
of falls), and yet their potential impact on demand management
for hospital services is clearly demonstrated. Shifting investment
from secondary care for the treatment of falls to primary pre-
vention would show significant and swift returns on investment.
Tobacco control interventions
10 42 43
overall reported a
twofold ROIs, which increased when targeted at high-risk
clients such as pregnant women.
42
Such contrasting results
perhaps highlight the complexity of public health interventions.
Healthcare public health interventions
Six studies
17 18 52–55
reported healthcare public health results,
offering a substantial median ROI of 5.14. The majority
focused on disease management or medication adherence for
high-risk patients, such as home blood pressure monitoring for
hypertension diagnosis and treatment.
18
Wider determinants interventions
Twelve studies reported results for wider determinants interven-
tions.
9101219–21 56–61
Public health interventions addressing
wider determinants also averaged a fivefold ROI. Several studies
assessed effectiveness of early years interventions, particularly
those targeted at juvenile offenders, or those deemed to be at
risk of future offending. Although much of this literature is
from the USA
20 21 56 57
emerging UK evidence demonstrates
similar returns to society and the wider economy.
58
The benefits
of early years interventions thus extend far beyond health, with
participants reporting improvements in literacy, job prospects
and earnings (hence savings to the criminal justice system,
increased taxation of higher earnings, etc).
This also highlights the ‘cross-sector flow problem’: cost-
effective public health programmes may not be commissioned if
decision-makers are only looking through a narrow health lens.
STRENGTHS
We describe a carefully conducted systematic review. Although
the precision of application of ROI calculations varies widely,
even the most rudimentary analyses consistently suggest that
most public health interventions are substantially cost-saving.
LIMITATIONS
Several limitations should be considered. First, the difficulty of
defining what constitutes a ‘public health intervention’, particu-
larly those focused on wider determinants. We purposefully cast
the net wide to achieve a broad systematic review. Further ana-
lysis of particular topic areas might now be beneficial.
Second, publication bias appears likely, and even some pub-
lished studies may have been missed. Such studies are inevitably
scattered across a wide field of journals and some economic
studies may only be available via organisational websites.
However, we did search the grey literature and we did identify
almost 3000 total studies—a reassuringly high number.
Third, we did not conduct a formal meta-analysis because of the
very inconsistent manner in which ROI was calculated, with differing
cost perspectives, time horizons and discount rates. Discount rates
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ranged from 0% to 10%. A high discount rate disadvantages public
health interventions that have a long payback time.
62
Conversely, a
1 year time horizon may offer too short a time frame.
Fourth, the generalisability of the interventions conducted from
one country to the next will vary. Participants in US studies may
poorly reflect UK demographics and vice versa. Furthermore,
some studies focused on vaccination practices that are no longer
employed in a number of countries (eg, single measles and haemo-
philus influenzae type b vaccinations). Similarly, the majority of
workplace health promotion initiatives come from the USA,
where employers who pay for employees’healthcare will have an
additional financial incentive to promote the health of their
workforce.
Fifth, the quality of the economic evaluations varied consider-
ably. Practice has clearly improved substantially since the 1970s,
with recent evaluations employing more sophisticated modelling
techniques. Designing such studies can be challenging as public
health interventions are often complex and multifactorial, and it
can be difficult to isolate an effect size even within a randomised
controlled trial. Some of the published literature may therefore
systematically overestimate or underestimate the ROI of inter-
ventions, and hence the need for more research.
Unanswered questions and future research
There is a clear need for further high-quality economic evalua-
tions of public health interventions, which include a range of
discount rates and robust sensitivity analyses.
Implications for clinicians and policymakers
Overall, the results of our systematic review clearly demonstrate
that public health interventions are cost-saving, both to health ser-
vices as well as the wider economy. Furthermore, some are very
rapid: falls prevention interventions reported substantial returns
within 6–12 months.
41
One might reasonably expect equally rapid
returns for preventive interventions such as immunisation, health-
care, smoking cessation and nutrition.
63
Although attempting to
quantify returns within a short timescale can be challenging, even
larger returns on investment were seen over a 10–20 years time
horizon.
10 15 17 32 58
This has significant implications for policy-
makers, who often work to a much shorter time horizon (typically
3–5 years). We suggest that Public Health England, NICE and
other advisory bodies therefore need to routinely emphasise that
public health interventions can offer surprisingly rapid returns,
which may increase further over the longer term.
CONCLUSIONS
This systematic review suggests that local public health interven-
tions are cost-saving, and offer substantial returns on invest-
ment, nationwide programmes even more so.
The cuts to public health budgets therefore represent a false
economy. They are likely to generate billions of pounds of add-
itional costs to the health services and wider economy.
What is already known on this subject
It is well known that it is financially preferable for healthcare
systems to aim to prevent ill health rather than to subsequently
treat it. A number of studies have calculated the return on
investment for individual prevention interventions; however, no
systematic review has spanned the breadth of public health.
What this study adds
This systematic review demonstrates a median return on
investment of public health interventions of ∼14:1. Thus, for
every £1 invested in public health, £14 will subsequently be
returned to the wider health and social care economy.
Furthermore, this review categorises the return on investment
according to the public health specialty and local versus
national levels of intervention. It suggests that cuts to public
health services are short sighted and represent a false economy,
with substantial opportunity costs.
Acknowledgements The authors would like to thank Knowsley Metropolitan
Borough Council Public Health Team, and Tracy Owen from the North West
Commissioning Support Unit FADE Evidence Knowledge Centre, for their support in
the development of this review.
Contributors RM drafted the paper, conducted the literature search, assessed the
methodological quality of included studies and conducted the analysis. EA
independently conducted the systematic review and assessed the methodological
quality of the included studies. BC adjudicated in any disagreements in the
methodological quality assessments, provided health economics advice and assisted
with the data analysis. RC provided expert health economics advice and support
throughout, and made significant contributions to the analysis and manuscript. SC
devised the concept, supervised the project, provided expert public health advice
and support throughout, and made significant contributions to the analysis and
manuscript. All authors made substantial contributions to the analysis and
manuscript, including final approval.
Funding RC is supported by the National Institute for Health Research (Senior
Research Fellowship, SRF-2013-06-015).
Disclaimer The views expressed in this publication are those of the authors and
not necessarily those of the NHS, the National Institute for Health Research or the
Department of Health.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
terms of the Creative Commons Attribution (CC BY 4.0) license, which permits
others to distribute, remix, adapt and build upon this work, for commercial use,
provided the original work is properly cited. See: http://creativecommons.org/licenses/
by/4.0/
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interventions: a systematic review
Return on investment of public health
Simon Capewell
Rebecca Masters, Elspeth Anwar, Brendan Collins, Richard Cookson and
published online March 29, 2017J Epidemiol Community Health
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