Never too early tackling chronic disease to extend healthy life years

Tackling chronic disease to extend healthy life years A report from the Economist Intelligence Unit Sponsored by Abbott... It identifies best practice initiatives in prevention, early i

Tackling chronic disease

to extend healthy life years

A report from the Economist Intelligence Unit

Sponsored by Abbott

The role of employers: Workplace initiatives to tackle chronic disease 8

2 © The Economist Intelligence Unit Limited 202 © The Economist Intelligence Unit Limited 202

“We are in the age of the old Let’s celebrate,” says Mary Baker, president of the European Brain Council The premise of her statement, especially for Europe, is indisputable The United Nations Population Division reports that life expectancy

in Europe has risen by an average of ten years since 960 and two years in the past decade alone It forecasts that average life spans across Europe will rise from 75 years currently to 82 years by 2050

This is of course good news, but even good news can have a dark side In the case

of Europe’s longevity, the sunny outlook is clouded by the fact that not all those extra years will necessarily be healthy ones The advanced years of many Europeans will be prematurely burdened by the need to cope with one or more chronic

diseases, the incidence of which is climbing alarmingly Moreover, the rising tide

of chronic illness is threatening the viability of Europe’s healthcare systems, which are ill-equipped to cope financially, operationally or strategically with increasing numbers of long-term patients

That said, increased longevity promises opportunities too, as the swelling ranks

of older Europeans represents a largely untapped human resource To raise awareness of those opportunities, the European Union has established the European Innovation Partnership (EIP) on Active and Healthy Ageing, part of

a broader programme aimed at improving co-ordination between the EU and member states to encourage innovation The specific aim of the EIP on Active and Healthy Ageing is to find ways to add an average of two healthy life years for each European by 2020

Like much of the debate around extending healthy life years, the EIP focuses almost exclusively on improving care for Europeans over the age of 65 Yet better care for the aged is only one aspect of ensuring healthy ageing; the other is ensuring that people arrive at old age in a healthy condition in the first place The health practices of people in their 40s and 50s—and much earlier as well—has a

Introduction

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significant impact on their health in their later years Indeed, some health experts suggest that the focus on health should begin at birth, and perhaps even before—

in other words, that it is never too early to start taking steps that result ultimately

in a healthier and longer old age “The strategy for healthy ageing should be a continuum from birth,” says Desmond O’Neill, president of the European Union Geriatric Medicine Society “The challenge is not to take the foot off the pedal.”

This study hopes to make a contribution to European efforts to extend healthy life years by focusing on what can be done well before retirement to increase the odds for healthy longevity The focus is in particular on measures to prevent and manage chronic diseases, since these have the greatest impact on the health of older Europeans The research considers the effects of poor co-ordination among healthcare providers, governments, civil society, private employers and the public

on making the necessary changes to the healthcare system to improve the healthy longevity of both individuals and the system It identifies best practice initiatives

in prevention, early intervention and management of chronic diseases that can contribute to healthy ageing In addition, it highlights effective ways to shift the focus from reactive, hospital-based care of the sick towards a proactive, preventive and patient-centred approach to improving health

4 © The Economist Intelligence Unit Limited 202 © The Economist Intelligence Unit Limited 202

In late 20, with a view towards contributing to the debate surrounding the EU’s European Innovation Partnership on Active and Healthy Ageing, the Economist Intelligence Unit undertook this study of ways to manage the rising tide of chronic disease This research, which was sponsored by Abbott, focuses on tackling chronic disease as one of the chief ways of extending healthy life years in Europe

As an initial step, the Economist Intelligence Unit convened a panel of experts on November 2st in Brussels to discuss the focus of the study This report is based

on the insights gained in that discussion, as well as on extensive desk research and subsequent in-depth interviews with 35 experts in chronic disease and healthy ageing We would like to thank all participants in the expert panel and the interview programme, who are listed in the Appendix

The Economist Intelligence Unit bears sole responsibility for the content of this study The findings and views expressed in the report do not necessarily reflect the views of the sponsor Paul Kielstra was the principal researcher of this study Delia Meth-Cohn and Aviva Freudmann were the authors Conrad Heine, Trevor McFarlane and Stephanie Studer contributed research and interviews

About this research

© The Economist Intelligence Unit Limited 202

The promise of healthy ageing in Europe is

clouded by the rising incidence of chronic

disease These diseases, whose hallmark is

a gradual and long-term deterioration of

function rather than a sudden acute event,

increasingly threaten both the quality of life of

older Europeans and the ability of healthcare

systems to cope with their demands In the

absence of reforms in both the care of individual

patients and the overall design of healthcare

systems themselves, the rising tide of chronic

illness threatens to overwhelm the resources of

healthcare by mid-century, ensuring that ageing

is a burden and not an opportunity for Europe

Most of the work on healthy ageing, including

the European Union’s Innovation Partnership

on Active and Healthy Ageing, focuses on how to

improve care for the aged This study refocuses

attention on getting people to old age in a

healthier condition by looking at what can be

done throughout people’s lives to increase the

odds for healthy longevity Here are some of the

key findings of this research:

l Chronic diseases threaten to overwhelm

Europe’s healthcare system Between 70% and

80% of European healthcare costs are spent on

chronic care, amounting to €700bn in the EU

Chronic diseases account for over 86% of deaths

in the EU

l This scourge is largely preventable Scientists believe that much of the disease burden can be prevented, or at least substantially delayed, through a combination of primary prevention measures, screening and early intervention

l An ounce of prevention is worth a pound of

cure The “four basics” of primary prevention

are already well known: a healthy diet, regular exercise, avoiding tobacco and eschewing excessive alcohol intake

l Prevention also includes early diagnosis and

intervention While primary prevention focuses

on healthy living, secondary prevention (early screening and diagnosis) and tertiary prevention (early intervention to slow the progress of diseases identified) also play important roles in reducing the burden of chronic disease

l It is never too early to tackle chronic diseases such as cardiovascular and respiratory illnesses, Type 2 diabetes, cancer, dementia, kidney and liver diseases, obesity and being overweight

Indeed, healthy practices begun in infancy—and perhaps even earlier, in vitro—can help to forestall the onset of disease

l Care of chronic conditions has distinct

needs compared to acute care, and must be refashioned accordingly To ensure appropriate

care for chronic disease sufferers as well as free

up medical resources for acute-care patients,

Executive summary

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communities and healthcare systems should direct more resources to wellness, prevention and disease management programmes for chronic patients

l Healthcare should be integrated and

patient-centred to the greatest extent possible Integration of medical services and

other services such as mental health, in-home sanitary care, and instruction in self-monitoring and self-care methods are crucial components of creating an integrated, patient-centred chronic care system This is particularly important for patients suffering from more than one chronic disease, who often must co-ordinate their own care among silo-like specialised care providers under the current system

l Healthcare should be devolved as far as

possible down the provider chain As part of

patient-centred healthcare, patients should

be encouraged to do as much as possible for themselves, with appropriate support from a variety of providers—not all of them necessarily specialised doctors Pharmacists, nurses, community workers, home care workers and others can all play a part, and are often in a

better position than doctors and hospitals to provide time-intensive coaching and personal attention to patients

l Employers and health insurers have major

contributions to make in fighting chronic

disease Health and wellness programmes are increasingly being offered by progressive employers as a way to ensure that older workers are able to remain on the job longer Health insurers are also increasingly sponsoring health and wellness programmes as incentives to encourage healthy lifestyles and practices

l Mental healthcare is an important part of the

mix in the prevention and treatment of chronic

illnesses Researchers have found that isolation and loneliness among those whose function is impaired owing to chronic disease aggravates their condition Several promising initiatives aim

at reducing that loneliness through individual case management and personal health coaching

In general, healthcare providers are increasingly incorporating mental health services as part of treatment for chronic-care patients

© The Economist Intelligence Unit Limited 202

“An ounce of prevention is worth a pound of cure,” wrote

American statesman Benjamin Franklin in the 8th century

Although his dictum was meant to apply to all facets of

life—and not only to medical cures—his wisdom is nowhere

more applicable than in 2st century Europe Today in Europe,

many pounds of cure are being expended to fight chronic

illnesses that in many cases could have been prevented in

the first place

A preventable scourge

Chronic disease is shaping up as a modern-day scourge

According to the European Chronic Disease Alliance, a

coalition of medical professional organisations, over 00

million European citizens—or 40% of the population above

the age of 5—have a chronic disease That proportion rises

progressively through the age ranks, with the result that

Europeans reaching retirement age are more likely than not

to suffer from at least one chronic condition According to the

World Health Organization (WHO), two out of three Europeans

Heading off chronic disease

New approaches to prevention

For Europe’s healthcare systems—and the national budgets that largely support them—this trend also suggests an unhealthy future According to the European Public Health Alliance (EPHA), between 70% and 80% of European healthcare costs are spent on chronic diseases This corresponds to €700bn in the EU, and this figure is expected

to rise in the coming years, according to the EPHA Worldwide, the figures are even more dramatic The World Economic Forum calculates that the global economic impact of the five leading non-communicable diseases (NCDs)—cardiovascular disease, chronic respiratory disease, cancer, diabetes and mental ill-health—could total US$47trn by 2030 (see Chart ) Unless the rising tide of chronic disease is reversed, such costs—which

2010: total 22.8

2030: total 43.4

Doubling the burden by 2030

Chronic disease cost burden, 2010 and 2030 (VSL estimates*)

(US$ tr)

*The VSL approach is used to estimate the economic burden of NCDs in 2010 and to project that burden in 2030 The VSL data are taken to be the value of life of a representative

median-aged member of the corresponding national population Constructing the VSL estimates/projections requires the estimation of DALYs in 2010 and 2030.

Chart 1

14.8

5.1 2.4 High income Upper middle income

Lower middle income Low income

Source: 'The Global Economic Burden of NCDs', World Economic Forum and Harvard School of Public Health, 2011.

0.5

1.0

8 © The Economist Intelligence Unit Limited 202 © The Economist Intelligence Unit Limited 202

include output loss as well as direct healthcare spending—

could have a severe impact on national economies and their

healthcare systems

One of the main reasons healthcare systems around the world

are ill-suited to dealing with chronic disease is that they

were designed to respond to acute, short-term illnesses and

injuries, rather than to prevent and manage the gradual,

long-term deterioration that characterises chronic disease Indeed,

the rising ride of chronic disease represents a sea change in

the type of illnesses affecting people worldwide More than

60% of deaths worldwide are due to NCDs, killing 36 million

people each year, according to the World Economic Forum

Chronic diseases account for over 86% of deaths in the EU,

according to the Chronic Disease Alliance

Astoundingly, scientists believe that much of this scourge

is preventable—or at least can be substantially delayed

According to the WHO and the NCD Alliance, simple measures

that fall under the rubric of “primary prevention”, such as

eating a healthy diet, avoiding tobacco use and excessive

alcohol, and increasing physical activity can prevent 80% of

premature heart disease, 80% of Type 2 diabetes and 40% of all

cancers A recent large longitudinal study in the Netherlands

found that eating a Mediterranean diet, regular exercise, not smoking, and maintaining a healthy weight collectively added

5 years to an average woman’s life span and 8.5 years to an average man’s life span

“These measures are so well known as to be almost banal,” says Professor James Vaupel, founding director of the Max Planck Institute for Demographic Research in Rostock, Germany, and head of its Laboratory of Survival and Longevity “The bottom line is, you are more likely to reach age 80 if you listen to what your mother told you.” But the trend towards healthier living

is weak, at best “People think they need expensive food to have a good diet, but the Mediterranean diet is cheap and smoking costs lots of money,” notes Piet van den Brandt, professor of epidemiology at Maastricht University and author

of the Dutch study A 200 study by the OECD and the European Commission found that over one-half of adults living in the EU are overweight or obese, and that the rate of obesity has more than doubled over the past 20 years (see Chart 2) Similarly, although smoking rates have fallen, smoking is still very much part of the culture in many parts of Europe

Prevention is not only a matter of healthier living Early diagnosis and the right kind of early intervention and disease

Note: Overweight defined as % Body Mass Index 25-29.9; and obesity defined as % Body Mass Index 30+

Source: International Association for the Study of Obesity, 2011

Switzerland Sweden

Spain Slovakia Russia

Poland Italy

Germany France

Finland England

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management—known as secondary and tertiary

prevention—can also make considerable

contributions to reducing mortality from chronic

diseases (For fuller definitions of primary,

secondary and tertiary prevention, please see

box, “Prevention: Three lines of defence”.)

Shifting priorities

Although policymakers are well aware of the shift

in the nature of the burden on the healthcare

system, that knowledge has yet to be translated

into an overhaul of the system Funds are still

directed in the same way they have been all

along—to caring for hospital-bound patients,

and to treating diseases after they occur rather

than trying to prevent them from occurring

Much of healthcare spending is still oriented

The medical system has developed a typology

for the wide range of practices covered by

the general term “prevention” Preventive

measures are carried out by both individuals and

healthcare providers, and fall into three general

categories:

l Primary: Primary prevention aims to protect

healthy people from developing a disease in

the first place, through such measures as good

nutrition, regular exercise, avoiding tobacco

and alcohol, and receiving regular medical

check-ups Primary prevention may also extend

to population-wide measures such as improving

air and water quality, mass immunisation, and

strengthening family and community ties to

promote mental health

l Secondary: After risk factors have been

found to be present, and/or signs of an illness

have actually appeared, secondary intervention

consists of screening for illnesses, particularly

when risk factors are present, and early

intervention measures to slow the progress of

the disease while it is still in its early stages

For example, a patient with signs of a heart

condition might take daily low dosages of

aspirin to prevent a first or second heart attack

Alternatively, secondary prevention might consist of an enhanced regimen of screening and monitoring to track the progress of the disease as well as monitor response to therapies and track any required adjustments in dosing

In some cases, drug therapies can be introduced

to delay or slow down development of a disease such as Alzheimer’s

l Tertiary: For patients who already have

illnesses such as diabetes, heart disease, cancer or chronic musculoskeletal pain, tertiary prevention consists of measures to slow down physical deterioration Such measures might include participating in cardiac or stroke rehabilitation programmes, joining chronic pain management groups, or participating in support groups for patients with mental or psychological problems While these measures are technically

no longer strictly preventive—the patient has already been diagnosed with the disease—they

do help to limit the debilitating effects of the illness, and thereby improve quality of life and extend life years in comparative health

Prevention: Three lines of defence

towards single-organ and single-occurrence events—such as heart attacks or acute appendicitis—rather than on the less dramatic long-term deterioration of function associated with chronic disease

As a result, most funds expended in the healthcare system are directed towards solving yesterday’s problems rather than today’s and tomorrow’s problems In particular, vast sums are directed towards fighting diseases when they are close to killing patients rather than earlier in life when they are not immediately life threatening “About 27% of [US] Medicare spend

is in the last year of a patient’s life,” notes Dr Paul Keckley, executive director of the Deloitte Center for Health Solutions “The policy debate is, is it

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better to reinvest those resources in preventative management of chronic disease, or is it better to spend an inordinate amount of resources on end-of-life care.”

Similarly in Europe, the Organisation for Economic Cooperation and Development has determined that only 3% of current health expenditure in Europe is invested in prevention and in public health programmes (see Chart 3) This shows the extent of the difficulty of the shift from curative to preventive investment

And yet for healthcare professionals, the link between early prevention and intervention,

on the one hand, and healthy longevity, on the other, is clear “Every single measure of prevention—say, reducing smoking or obesity

or cholesterol—means that during the ageing period your quality of life will be much better,”

says Bernat Soria, a former minister of health

in the Spanish government Clearly, the healthy longevity of both individuals and healthcare systems would be well served by a reordering of the current spending priorities

Available data on the benefits of early diagnosis and intervention point in the same direction as that on the impact of healthier lifestyles In the case of many chronic diseases, the onset of the disease can be delayed, and its progress slowed,

by secondary and tertiary prevention measures

as well as primary prevention measures

Advances in genomics are helping doctors to identify risk factors, which in turn helps them

to identify vulnerable population groups, as well as population groups likely to respond

to specific treatments Various screening and diagnostic devices are then used to identify individuals at risk or showing early signs

of disease Identifying risk factors and/or biological markers—any protein or other substance in the blood whose concentration can indicate the presence or future onset of a disease—provides a powerful incentive for both patients and doctors to take further action

to prevent the onset of the disease or slow its progress

Prevention: Making a start

Proportion of European health expenditure invested in organised public health and preventionprogrammes, 2008

(%)

Chart 3

Sources: OECD Health Data 2010; Eurostat Statistics Database, 2010.

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

2.7 2.7 2.4

2.3 2.12.0 1.81.6 1.6 1.4 1.4 0.7 0.7

© The Economist Intelligence Unit Limited 202

“The latest statistics from the International

Diabetes Federation show that 50% of people

with diabetes do not know that they have it,”

notes Dr Maha Taysir Barakat, medical director

at the Imperial College London Diabetes Centre

in Abu Dhabi “The challenge is how to increase

the chance that those who don’t know they have

diabetes will take the test and go to a health

provider who can help them The sooner you

start managing someone with diabetes, the

better the long-term outcome That will have an

impact on extending healthy lives.”

From diagnosis to treatment

There is also promising clinical work under way

to identify the biological markers—such as the

build-up of plaques and tangles in the brain—

that point to the likely future development

of Alzheimer’s disease, the principal form

of dementia Many doctors argue that early

screening to determine if such markers are

present can lead to a regimen of exercises, diet

changes and possible drug therapies, which

together can delay the onset of the disease and

slow its progress once it appears Researchers

are also trying to develop a clearer view on

what biological markers, and especially in what

concentrations, would prove the effectiveness of

different therapies in fighting the disease

Similarly, clinicians generally believe that

measuring certain biological markers in the

blood or urine can identify patients at risk of

kidney diseases, can detect diseases in the

earliest stages, and through early detection

can be treated effectively A clinical trial,

published in the Clinical Journal of the American

Society of Nephrology Studies in 2007, showed

promising results in terms of lower death and

hospitalisation rates after participation in

an early intervention programme The trial

compared results obtained for around ,000

hemodialysis patients enrolled in such a

programme, and another ,000 patients in a

control group By the end of one year, the death

rate of early-intervention patients was around 43%, compared with 56% for the control group

of long-term hemodialysis patients Within the first 90 days, the mortality rate for participants

in the early intervention programme was 20%, compared with 39% for the control group

“Screening is a very good idea for renal disease, because when we are effective, we are very effective,” says Johannes Mann, professor

of medicine and head of the Department of Nephrology, Hypertension and Rheumatology

at Schwabing General Hospital in Germany

“Screening is especially effective when we prevent people from going on to dialysis I see no negative aspects to screening for kidney disease

For other diseases, the case can be different

There has been a long debate about prostate cancer, for example, where you might be able to recognise the disease earlier but not necessarily change its course.”

Improving the links between diagnosis and treatment is crucial if preventive healthcare is

to be effective Among other things, it would provide a needed incentive to shift resources from treating the sick to preventing illness

However, this process is not simple In particular, there is a thicket of conflicting scientific studies

on the costs and benefits associated with screening and early intervention For example, mammography to detect breast cancer in women—once considered an obvious health measure—has fallen into controversy Some respectable research institutes have found an unexpectedly strong probability that, in some populations, mammography could yield false positives or highlight pre-cancers unlikely

to become full-fledged cancers, but which nonetheless lead to interventions These studies suggest that, for the populations in question,

if a highly sensitive test is used, the probability

of a false positive may exceed the likelihood of finding real cancers and saving lives—in effect saying that, statistically, the costs of the test exceeds its benefits in such cases

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The same questions have been raised in screening and early intervention for respiratory and for cardiovascular illnesses To ensure they detect as many real cases as possible, clinicians may use

a highly sensitive measurement, which may also yield some false positives “The classic example

is asthma: we tend to diagnose twice as many asthmatics as those that actually have asthma,”

says Mr Keckley of the Deloitte Centre for Health Solutions “So we are not particularly good at doing these things There are some great studies that show that our primary care system is failing

to adequately apply the evidence to diagnostics.”

Blanket screening does not just carry the potential danger of adding unnecessary costs

to healthcare systems, it also carries the risk

of creating psychological risks to the people it

is trying to help Joep Perk, cardiologist and professor of health sciences, and chairman of the Joint European Societies’ Task Force for Cardiovascular Prevention in Clinical Practice, points to a programme to screen men over 65 for abdominal disease “The psychological effect has not been sufficiently studied In much of our screening work we do not pay enough attention

to the unrest that we create in people,” he says

“I am a national co-ordinator for cardiovascular disease prevention, and it is part of my duty

to speak to doctors about their prevention methods One once said to me about screening,

‘I do not want to make healthy people sick!’

This is the reverse side of the coin It needs more attention.”

While these concerns over how best to implement screening require attention, the overall case for pursuing prevention over cure is clear and urgent Scientists have concluded that most chronic disease is preventable, or at least can

be held at bay for much longer than it is today

Yet for such knowledge and clinical insights to

be translated into a reorienting of spending priorities towards prevention, policymakers must be persuaded of the overall applicability

of the selected clinical trials, which would point

towards a solid economic case for redirecting funds from treatment to prevention The absence

of hard data linking specific prevention measures

to reduced incidence of specific diseases is slowing the process of acting on that knowledge

to change spending priorities and overhaul an outmoded healthcare system

Changing this state of affairs requires three things

First, public health officials need to measure systematically the returns on investment

of various health prevention measures, particularly for more expensive screening and early intervention programmes Walter Ricciardi, president of the European Public Health Association, believes that his profession

is partly to blame for the lack of evidence-based medical care so far “Before, public health people said, ‘prevention is beautiful, let’s do it,’ but did not look at the costs and benefits,” he says

“It is possible for prevention programmes to generate significant savings, but certain ones might also be costly and yield little benefit The problem is that too often evidence is simply not collected either way.” Professor Ricciardi believes that these programmes need to be able

to demonstrate value so that policymakers can decide whether to adopt them (Please see box,

“From sickness to health: Abu Dhabi’s radical refocusing initiative” for an innovative attempt to collect this evidence systematically and translate

it into a new healthcare financing model.)

Second, healthcare policymakers need to move away from talking broadly about prevention, screening or treatment for chronic diseases and start taking a more differentiated and focused view of the efficacy of specific measures for preventing or delaying the onset of specific diseases, for specific groups of people, and identifying those who are most likely to benefit and those who are likely to be non-responders

Ironically, the successful push for recognising chronic disease management as a separate focus

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for healthcare in Europe is now creating an

obstacle for its better diagnosis and prevention

“EU policy does not include any disease-specific

policies except for cancer This is a huge barrier

for cardiovascular disease,” says Sophie O’Kelly,

head of European affairs for the European Society

of Cardiology and a founder of the Chronic

Disease Alliance Diseases are bundled together

as ‘chronic disease’–“which is a start, but it’s

Abu Dhabi may be best known in healthcare

circles for its alarmingly high and rising rates

of obesity and diabetes—and for having lots

of money to throw at the problem But the

emirate is actually testing one of the first

total-population action plans on chronic disease,

built around screening, planning and action

The Weqaya prevention programme was

launched in 2008 by a group of international

health experts within the emirate’s

government Weqaya began with a simple

5-minute opt-out screen for cardiovascular risks

This covered 95% of the population in its first

few years and in 20 moved into the second

screening round (screening will be repeated at

least every three years, more often for those at

the highest risk) Each screened person receives

an individual report, which outlines in a simple

traffic light form the main risk areas, like high

blood pressure and high body mass index, and

a set of personalised actions, from diet changes

and exercise, for example, to visiting the doctor

to receive therapy

“Now we’ve started the second round of

screening, we can start to assess trends

across the population and over time, plus see

what really works in our population,” says

Oliver Harrison, Director of Public Health and

Policy at the Government of Abu Dhabi One

big success was to get people with problems

going to see doctors “In the first round of

screening we found that one-third of people

with diabetes didn’t know they had it, one-half

with hypertension and two-thirds with high

cholesterol Assessing Weqaya overall, we’ve

seen a 40% improvement in blood glucose levels and a 45% improvement in lipids, plus the costs

of the programme are very modest—less than US$20 per person per year.”

With all health data collected and stored in a universal health database (again developed in-house), Abu Dhabi is now taking the individual results and bundling anonymised data for target groups, such as employers and local governments Bundled data help to set local priorities and to measure the level of impact

This form of benchmarking can be used to identify (and praise) best practice which can be disseminated, and identify those who are not putting in the effort Of course, the data can also be aggregated to the population-level to project the level of demand for health services, and strengthen the case for policy interventions such as tobacco control and improving the walkability of Abu Dhabi

Dr Harrison also plans to use the data to revolutionise healthcare financing—an issue even in oil-rich Abu Dhabi as chronic diseases skyrocket along with costs By calculating the expected cost of disease over the next decade, based on the measured risk factors, Abu Dhabi

is planning to reimburse disease management companies directly for improvements in measured health over time “This allows us to transfer risk with a new financing model,” he says “We have geared the numbers so the more

we pay for health, the more we save on future health spend.”

From sickness to health: Abu Dhabi’s radical

refocusing initiative

not enough It makes it difficult in turn for EU member states to adopt specific prevention strategies to address cardiovascular disease.”

Third, healthcare officials will need to find a way of overcoming the problem of short-term costs versus long-term benefits Investing in prevention requires waiting a decade or two

to determine the effect of measures and enjoy

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the benefits in lower healthcare costs “We have elections every four years, but medical complications [in the absence of prevention] will appear in 5 to 20 years,” notes Dr Soria “So today’s politicians will not pay the future price for poor prevention measures.”

Changing incentives

In the case of the medical system, incentives are

at the core of the short-term bias Despite the rising tide of chronic illnesses, the incentives for practitioners are still to treat the sick rather than keep them out of the system

Healthcare in Europe developed as a sickness system rather than a health system, and this

is where, generally speaking, it remains “It’s

a global phenomenon—the urgent crowds out the important,” says Derek Yach, senior vice-president of global health and agricultural policy for US-based Pepsi-Cola “Prevention is always sacrificed in face of the curative load in front

of people.”

In the absence of comprehensive evidence linking preventive measures to significantly retarded rates of chronic disease development and therefore lower future costs for healthcare,

“the prevention case often sounds vague and fluffy—but there are specific actions with big positive outcomes,” Mr Yach says “Part of the problem is that we lump many types of actions under the term ‘prevention’ But some of these are done within the health service by doctors and nurses, such as screening and vaccination; then others are population-wide measures such as tobacco taxes, marketing controls, and efforts to reduce salt intake, and for these you need broad-based partnerships.”

This broad approach was articulated 25 years ago in the intergovernmental Ottawa Charter for Health Promotion, which concluded that, for change to occur, “healthy choices need

to be the easy choices—for individuals, for healthcare providers, and for a wide range

of other stakeholders who have an impact on public health.”

Putting that insight into practice means a broader reconfiguration of incentives—one that goes well beyond the healthcare system “The real thing we need to crack is how to move the non-communicable diseases discussion outside

of the healthcare sector, as no one single sector alone will be able to address its complexity,” says

Dr Jané-Llopis, head of healthcare programmes

at the World Economic Forum “We need to align the incentives currently in place for healthy living For example, subsidies for agriculture should incentivise crops that are beneficial for health; incentives should be aligned to promote walking Unless we work this out between government, industry and individuals, there is no way we will manage to change our behaviours.”

“It has to come from the whole of society to make

it work,” notes Ms O’Kelly of the European Society

of Cardiology “If you just have a campaign to promote fruit and vegetables, but still have advertising for chocolate bars, one will offset the other What is needed is comprehensive, consistent and cross-sectoral co-operation, as recommended by our prevention experts.”

In addition to joining up the dots to promote what is healthy, researchers are finding that peer support is far more effective than education and proscription in getting people to change behaviour Generally, Professor Ricciardi says,

“The approach has been to say ‘smoking is dangerous’, ‘drinking alcohol is dangerous’, but few interventions have understood the psychology behind those behaviours.” In contrast, simple reinforcement of healthy choices, given by an observer or peer group, makes behavioural change much more likely

Much of the evidence of this in Europe comes from the Nordic countries, where smaller and more homogenous populations make such personalised, community-based interventions easier than in larger, more heterogeneous populations The most famous example comes from the Karelia region in Finland, which dramatically reduced its high rate of heart