A New Understanding of Health Policy Is Needed

The current debate on health policy concerns important issues relating to the future provision and financing of our healthcare system. However, it is primarily taking place with the traditional focus on the treatment of illnesses. A broader understanding of healthcare policy is urgently needed for the future. This should increasingly combine prevention and the strengthening of resilience and potential for development as complementary approaches in a holistic health policy approach. This must explicitly include changing challenges against the backdrop of an increasing overuse of our natural resources.

Developments in civilization, technology and the economy over the last few centuries have led to considerable improvements in living standards and therefore also in healthcare. However, these improvements are increasingly being offset by man-made crises. Heatwaves, droughts, flood disasters and the Covid-19 pandemic are making the dangers of overexploiting our natural resources ever clearer. Climate change, the reduction in biodiversity and global environmental pollution are jeopardizing the health of ecosystems and people worldwide.

To name just a few worrying figures: Heat-related mortality in older people has risen by almost 70% in the last 20 years (Romanello et al. 2022). In the heatwave summer of 2022 alone, there were 100,000 additional deaths in Europe (Rahmstorf, 2022). Globally, 5 million deaths per year are related to antimicrobial resistance (Murray et al., 2022) and at least 9 million premature deaths per year are due to environmental pollution (Fuller et al., 2022). At the same time, lifestyle-related diseases are increasing massively: 17 million people aged 30 to 70 alone now die each year from non-communicable diseases (WHO, 2020), many of them due to factors like unhealthy diets, lack of exercise or stress. These developments are not limited to a few regions; they can be observed worldwide and in all income groups.

The above figures clearly show that an understanding of health and health policy that is limited to the acute control of diseases falls short of the mark. In order to grasp the causes of many disease burdens, we need to think and act more broadly. Health is part of the overall environment-health-economy complex. Nevertheless, the perception in society and politics is often not that agricultural policy, transport policy and energy policy - to name just a few examples - are also health policy. There is an urgent need for a rethink towards a systemic approach that considers health issues in all governmental departments and at all levels - in other words, a "health in all policies" approach.

The German Advisory Council on Global Change (WBGU) addressed this topic in its flagship report "Healthy Living on a Healthy Planet", focusing on the fact that human health is inseparable from the well-being of species and ecosystems (WBGU 2023). The discussion about urgent adjustments to the understanding of health is inspired by integrative and transdisciplinary health concepts such as One Health and Planetary Health, which have become increasingly important in recent years. These health concepts are not only leading to a new understanding of the connection between health and global environmental change in the health community, they are also enriching the international debate on sustainable development.
 

What Can Concepts Such as Planetary Health and One Health Achieve?

Both concepts have shaped the scientific and political debate on health and environmental change in recent years. While One Health can look back on a somewhat longer history, there are clear overlaps between the two concepts. The One Health concept emphasizes the interactions between human and animal health from a biomedical perspective. The focus is on the control of infectious diseases and antibiotic resistance as well as the general management of health risks for humans and animals. Planetary health focuses on the entire earth system and the biosphere. The emphasis is on the interrelationships between human health and the Earth's natural systems as well as social, political and economic systems. While ecological determinants used to be understood only as external factors influencing human health, integrative and transdisciplinary health concepts understand human health as closely linked to intact natural resources and the health of other living beings and ecosystems.

Despite their differences, both concepts are extremely valuable for the future debate on health policy reforms. At the same time, competing concepts harbor the risk of losing sight of the topical focus. This is all the more true as there is a whole range of other concepts that emphasize different aspects and have often emerged from different disciplinary backgrounds (e.g. GeoHealth and EcoHealth). For this reason, the WBGU chose not to endorse any of these concepts in its report, but to instead speak of the vision of "healthy living on a healthy planet". This vision implies that an improvement of human health can only be realized by improving many other dimensions of sustainability as well. Its realization is therefore inconceivable without a comprehensive transformation towards sustainability.

The vision of the WBGU, but also of Planetary Health and One Health, thus complement the guiding principle of sustainable development as reflected in various international conventions and goals (Rio Conventions, Paris Agreement, Sustainable Development Goals SDGs, etc.). However, reducing the contribution of the new health concepts to this would fall short of the mark.

Perhaps their most important contribution lies in the accessibility of the topic of health and its connection to the natural environment for each individual. The debate on sustainable development has long been perceived at an individual level as more or less abstract, even though it has been intensively discussed in science and ultimately also in politics and society since the 1990s. The SDGs have helped to reduce this abstractness by formulating concrete goals. The diversity of the aspects addressed by the SDGs has also contributed to sustainability being perceived as more than just climate change and local pollution. In this respect, the SDGs were an important step towards anchoring sustainable development more firmly in people's consciousness.  Nevertheless, the SDGs are often not seen as directly relevant to an individual's own live, especially in high-income countries.

In contrast, the health-related consequences of human intervention in nature can be felt by everyone directly and in their own environment. The aforementioned heatwaves, droughts and flood disasters are not limited to other countries. They can be observed directly in everyday life and their frequency is increasing. The discussion surrounding the Covid-19 pandemic in particular has raised the awareness of the scientifically proven consequences of the interaction between the environment and humans (Wu, 2021; Gibb et al., 2020): The risk of pandemics is promoted by human interventions in nature.

What has long been perceived primarily as scientific forecasts and scenarios is now taking shape right on our own doorstep. Given the existential importance of health, the attention that the topic is currently receiving is a unique opportunity to drive the transformation towards sustainability. Planetary Health and One Health can play an important role in this.
 

What Does This Mean in Economic Terms?

The economic take on climate change, biodiversity conservation and environmental pollution is often viewed with a certain degree of skepticism. This applies to the public as well as to many scientific debates. The "economization" of the use of our natural resources is not seen as an opportunity, but as a threat.

As is often the case in life, both perspectives contain a share of truth. Hardly any economist will deny that attempts to quantify the diversity of ecosystem services in monetary terms cannot reflect all the consequences of human intervention. And even with regard to the consequences that are quantified in scientific studies, there are considerable uncertainties. Nevertheless, the estimates can be helpful in the political discourse on Planetary Health and One Health in order to convince politicians of the usefulness of measures. Just a few examples:

The costs of non-communicable diseases are estimated to amount to 30 trillion US dollars globally in the years 2011-2030 (Bloom et al., 2011). These costs could be massively reduced through a range of policy measures. This basically concerns all areas of human life, from people’s diets to the organization of work, but also the healthcare systems themselves.

A stronger focus on prevention and health promotion, for example, would bring massive benefits for poorer countries in particular (WHO, 2022b). According to Watkins et al. (2022), additional investments of USD 18 billion per year would generate a net economic benefit of USD 2.7 trillion in all low- and middle-income countries combined by the end of this decade.

However, it is not only in low- and middle-income countries that direct disease control, rather than prevention and health promotion, is the focus of health policy interest. According to the OECD (2021), spending on prevention in OECD countries currently only accounts for 2.7% of total spending in healthcare systems. In Germany, too, the current remuneration systems for healthcare services show that prevention is not the focus. Accordingly, the remuneration of advisory activities and discussions on health promotion and prevention is relatively low (Osterloh, 2022). At the same time, the predominant focus on curative measures can increase the much discussed cost pressure on healthcare systems when incentives aligned to these curative measures lead to overuse, underuse and/or misuse of health services (German Medical Association, 2022).

Healthcare systems also generate pollution themselves and are quite resource incentives. Energy and water consumption, medical waste and the use of toxic chemicals jeopardize the health of the planet with corresponding health consequences for people.

However, prevention and health promotion go far beyond the health sector and encompass both behavioral and structural prevention. Measures aimed at influencing people's behavior fall under behavioral prevention (e.g. information provision and health education), while addressing living conditions and contexts (e.g. environmental protection measures, occupational health and safety, social standards) is subsumed under structural prevention. Only both types of prevention together can give rise to a sustainable and economically efficient strategy in the context of health promotion.

Studies show, for example, the great leverage effect that can be achieved through both behavioral and structural prevention in the area of mobility. The WHO estimates that physical inactivity and lack of exercise lead to global healthcare costs of USD 27 billion per year (WHO, 2022a). For the food sector, in turn, externalized health costs are estimated at USD 11 trillion (Hendriks et al. 2021). In comparison, the market value of the food produced is estimated at USD 9 trillion.

In many cases, we do not lack the principal knowledge about how behavioral and structural prevention could be implemented. However, a greater awareness of the costs incurred at both macroeconomic and individual level can help to overcome obstacles to their implementation.
 

Conclusion

Planetary Health and One Health have great potential to contribute to overcoming the health crisis facing people and nature. The German government's Global Health Strategy from 2020 and the EU's Global Health Strategy from 2022 show that this is also being recognized at a political level. There was even a focus on health for the first time at the UN Climate Change Conference in 2023. However, the transformative potential of these approaches needs to be promoted through appropriate communication, education and research initiatives, both at home and globally. There is still a great need for action here.

Published under the title “Es braucht ein neues Verständnis von Gesundheitspolitik“, Makronom, February 5, 2024.