by Kim Krisberg
In a little less than a month, public health workers and their community partners in Macomb County, Mich., will set up at the local Babies"R"Us store to offer parents a free child car seat check. The Macomb County Health Department has been organizing such car seat checks for years now, knowing that proper child vehicle restraints can truly mean the difference between mild and severe injuries, or between survival and death.
The car seat check is taking place April 4 in observance of the fourth day of this year's National Public Health Week (NPHW) celebration, which officially runs April 1–7 and is organized by the American Public Health Association (APHA). Bill Ridella, director and health officer for the Macomb County Health Department, said the April 4 event was chosen to coincide with that day's NPHW focus, "Protecting You While You're on the Move"; however, he noted that it also fits in perfectly with this year's overall NPHW theme, "Public Health ROI: Save Lives, Save Money."
That's because according to the Centers for Disease Control and Prevention, proper child safety seats reduce the risk of death in car crashes by 71 percent for infants and 54 percent for children ages 1 to 4. In fact, according to researchers, child safety seats save an average $2,200 in medical spending for an average $52 investment — that's a return on investment (ROI) of $42 for every $1 invested. In Macomb County, after years of collecting data and offering hundreds of individual car seat checks annually, Ridella reports that more than 80 percent of child safety and booster seats inspected were installed improperly — "and we know that correctly installing them does save lives and prevent injury," he told me.
"(This year's NPHW) theme is universal and it's something that public health should be very proud of," Ridella said. "It's so important to stress that whether it's at home, school, work or in the community, public health reaches people everywhere."
Macomb County is planning to hold a number of events during the 2013 NPHW celebration and is one of hundreds of communities nationwide that will be rallying around this year's theme of public health ROI. Kimberly Moore, director of Affiliate Affairs at APHA and lead organizer for NPHW, said this year's theme was chosen because it "underscores the role of public health in our economy and the fact that a strong public health system has implications that go far beyond just the health of a community."
"Public health has such a broad reach and when we invest in strong systems, we can see returns for years to come," Moore told me. "There are challenges. In public health, you may not see the return today or tomorrow, it doesn't come overnight...but if we have a long-term plan to invest in (public health and prevention) and if we're consistent about investing, then we'll see more successful health outcomes at less cost."
Moore noted that measuring ROI in public health can be tricky — "it's different than in the business world where you invest 'X' amount of dollars and get 'X' amount back. That not always the case in public health...we also need to account for improvements in quality of life, the number of lives saved and improvements in the health status of our communities." Indeed, quantifying public health ROI is a challenging endeavor, and related research isn't nearly as prolific as research into the effectiveness of public health interventions on people's health. But it's also a research field that's quickly emerging and one that advocates and researchers say is crucial in an era in which public health must fiercely compete for every penny it gets.
What's the value of public health?
At the University of Kentucky, professor and researcher Glen Mays said he's particularly excited about this year's NPHW theme of public health ROI. Mays is at the forefront of a growing field known as public health services and systems research, which studies the organization, delivery and financing of public health services. The research field is especially relevant to public health ROI as it often zeroes in on how improving efficiencies and effectiveness within public health can help the discipline thrive in a time of dwindling resources.
"I think it's a very important and very timely theme," said Mays, a co-principal investigator at the National Coordinating Center for Public Health Services and Systems Research. "We need to focus attention on the value of public health because historically, the field has struggled with a lack of public and policy recognition of the value that public health provides for society."
The old adage that the work of public health is often invisible, he noted, does public health no favors in the competition for resources.
Unfortunately, Mays told me there isn't "nearly the amount of evidence that is needed and really demanded by policymakers on this issue of (public health) ROI." He said one of the reasons the research is challenging is simply the inherent nature of public health work. For example, we may not see returns on public health investments until far in the future, especially in work targeting chronic disease rates. Mays also noted that because public health activities can have such far-reaching impacts, the health and economic effects are often dispersed among many different populations — "one nutrition program can affect cancer, heart disease, even injury rates...so how you account for all that becomes very challenging." Still, public health ROI can certainly be calculated, Mays said.
For instance, Mays co-authored a study published in 2011 in Health Affairs that examined the relationship between local public health spending and preventable death over a 13-year period. He and co-author Sharla Smith found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. In Washington state, researcher Jeffrey Harris and colleagues recently published a similar study on the ROI of public health-led tobacco prevention efforts. Harris, a health services professor within the University of Washington School of Public Health and director of the school's Health Promotion Research Center, said he and co-authors "really wanted to see whether the program was working the way we thought it was," noting that the tobacco program's funding was under extreme threat from the state legislature.
And the study, published in February in APHA's American Journal of Public Health, found that public health was indeed making a difference. Of the tobacco interventions studied, researchers found that the state health department-led program had the most consistent and biggest effects on heart disease, cerebrovascular disease, respiratory disease and cancer. Over a 10-year period, the state program, which included media and school-based campaigns, a quitline and policy enforcement, was associated with the prevention of nearly 36,000 hospitalizations, saving about $1.5 billion. It also means the program saved more than $5 for each $1 invested.
Despite the findings, which were shared with state lawmakers, the legislature zeroed out funding for the tobacco program in 2011, Harris told me. However, it did restore some of the funding in 2012 after the study was published — "it's one thing to write a paper and another to have it published," Harris noted.
"It shows that policy is an interesting process and cost effectiveness is important but it's just one part of the story," he said.
Harris also said that it isn't fair to expect all public health work to save money. For example, he said, if someone breaks a leg and is taken to the hospital, no one asks if setting the bone saves money. However, fixing that leg does provide significant value to society and to the individual. We have to apply that same framework to public health and prevention, he said. Still, Harris notes that while some might think all prevention saves money, that's not always the case and "we need to be honest about what works and what doesn't."
"Oftentimes, we in public health think 'we do good things so just trust us'...but I don't think policymakers are swayed by that," he said. "Even within the realm of prevention and public health, not all goods are created equal."
But even in a time when cost efficiency seems to reign, public health needn't abandon its foundations, said Peter Jacobson, professor of health law and policy at the University of Michigan School of Public Health. Social justice and efficiency are not mutually exclusive, Jacobson told me, and it's critical that public health practitioners and advocates speak within that framework.
"Let's create a new model where we think about providing better services more efficiently as entirely compatible with the social justice values inherent to public health," he said. "I share the (social justice) goal and it's an important voice to have, but it can't be the voice of mainstream public health, otherwise we won't have any influence. If social justice is a prong detached from economic efficiency, cost effectiveness and cost benefit, I just don't think anyone is going to listen."
In 2008, Jacobson co-authored a study in the American Journal of Public Health that studied the disconnect between health economists and public health workers. In interviewing public health workers, researchers found that they did want to provide decision-makers with better measures of value, but there were many barriers. Among them was a lack of training in conducting such research, plus declining workforce numbers that make it increasingly difficult to squeeze in new analytic tasks. The 2008 study noted: "Aside from the attribution problem, our respondents suggested that understanding public health's intangible values was the most difficult conceptual and measurement challenge they faced. Virtually every respondent maintained that a unique trait of public health was the intangible value that it has."
In response, Jacobson and study colleague Peter Neumann developed a "Framework to Measure the Value of Public Health Services" that was published in 2009 in the Health Services Research journal. The framework covers four main components: external factors, internal health department actions, using appropriate measures and communicating value to policymakers. Jacobson told me that if public health doesn't adapt to a public dialogue that prioritizes value and efficiency, "then we simply cede control to people who have no interest in social justice."
"What we're trying to do is to show public health officials ways of navigating in a new environment," he said.
'This is the gold standard now, whether we like it or not'
Jeff Levi, executive director of Trust for America's Health (TFAH), was fairly blunt about the need to better communicate the value of public health work.
"We like to believe that we do God's work and calculating dollars can make people uncomfortable," Levi told me. "There's definitely a fear and I get it — that if something turns out not to have a positive return on investment, then it becomes harder to justify. ...But I think we need to be willing to say that even though (a public health activity) might not have a cash return, it has value for other reasons. Policymakers are not stupid and they know when we're fudging."
Of course, collecting data on public health ROI is quite challenging, Levi said, noting a dearth in funding for such research as well as inconsistent definitions of what exactly public health value is and how to measure it. TFAH itself is no stranger to such research. In 2008, the nonprofit released an oft-cited report on the cost savings related to investments in disease prevention. The report found that an investment of $10 per person per year in proven community-based efforts that increase physical activity, improve nutrition and prevent tobacco use could save the nation more than $16 billion annually within five years — that's an ROI of $5.60 for $1 invested. In fact, Levi said that one of the reasons for passage of the Prevention and Public Health Fund, the landmark funding stream included in the Affordable Care Act, was that advocates were able to show the potential for ROI.
"I think the biggest challenge (public health) faces is operating in a world in which any program is expected to show some kind of ROI and the challenge is how we frame that definition and how we define value," he said. "This is the gold standard now, whether we like it or not."
In North Carolina, Greg Randolph and his colleagues at the Center for Public Health Quality are helping public health agencies nationwide improve the quality of their services, which he said can have a direct impact on outcomes and ROI. In fact, every time the center engages in a project with a health department, it also conducts an ROI analysis to capture the benefits of the project to both internal efficiencies and community health. For example, Randolph told me the center had worked on a project to increase hospital referrals to a state tobacco quitline. The project was indeed able to increase referrals and so by using previous research on quitlines and related cessation rates, center staff was able to calculate a beneficial ROI.
Randolph, who serves as the center's director and is also an associate professor of pediatrics and public health at the University of North Carolina-Chapel Hill, said the ROI analysis not only helps public health workers in justifying current funds, but in leveraging new funding and creating new partnerships. For instance, he said that if public health can prove that its work has financial and health benefits for patients, hospitals may be more willing to collaborate on, or even fund, public health activities.
Randolph also told me that if you'd asked him just a few years ago if public health ROI research was that important, he probably would have said "no." Now, he hopes it's research the public health field truly begins to embrace.
"When you start doing these analyses, they may seem foreign and people may be leery about it...but we've found that it really does resonate," he said. "I think it's really very important to the future of public health."
In today's funding climate, "policymakers are looking wherever they can for efficiencies and trying to divert from what's not working to what works...we need to prove that (public health) can deliver and that we are worthy and good stewards of the taxpayer dollars we're receiving," said Emily Holubowich, executive director of the Coalition for Health Funding. Of course, proving public health's impact doesn't always come down to dollars and cents, she said, it's also about saving lives and improving health. Holubowich did note that public health is caught in a bit of a catch-22 situation: In other words, who is going to fund public health ROI research if not the government and yet it's the government that wants such ROI research to justify spending levels.
One way around that conundrum may be shifting part of the dialogue, she said. Plus, she said that everyone is coming into congressional offices these days talking about ROI — "there's so much noise in the ROI space right now, we're starting to get drowned out." Holubowich called on public health workers to talk about immediate ROI impact, such as the effect that a public health program has on individuals and families, the everyday effect on people's lives.
"Tell the story of real people in your community, focus on personal stories," she said. "In terms of ROI, we need to think more immediately because that's the psyche of members of Congress."
Back at APHA, NPHW organizer Moore hopes this year's NPHW participants will share local, real-world examples of how public health is changing people's lives. Just one successful story can make a difference, she said.
"Connect the numbers and data to real-life situations," Moore said. "A story gives meaning."
To learn more about the upcoming National Public Health Week celebration, its five daily themes, how to take part or to download a free toolkit with tips on how to get started in your community, visit www.nphw.org.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.