No quality health care without strong public health
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* Trevor Hancock

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/189/46/E1435/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/189/46/E1435/F1)

Public health is in the same business as the rest of the health care system: saving lives and reducing suffering. But it does so by intervening before — rather than after — the onset of disease or injury. Public health is an important contributor to quality health care, as we can see if we consider the “Triple Aim” of the Institute for Healthcare Improvement, a well-recognized set of goals for the health care system.

The first of the triple aims is to improve the health of populations, which is precisely the objective of public health. Its focus is on improving health in the population as a whole rather than through one-on-one care. This often proves to be more cost-effective. A recent systematic review of the return on investment of public health interventions found that local and national public health interventions were highly cost-saving. Its authors concluded that cutting public health budgets in high-income countries represents a false economy, as the cuts will likely result in billions in additional costs to health services.

The second aim is to improve the patient’s experience of care. Surely, the best patient experience is to never be a patient, by never having the disease in the first place? Prevention should be seen as the first step in disease management and a key marker for quality health care. Public health approaches that focus on equity and cultural safety can also contribute to quality.

The final aim is to reduce the per-capita cost of health care. This can be approached in four main ways: reduce the burden of disease, improve self-care so fewer people seek care, improve the efficiency and effectiveness of care services, or reduce services. Of these, surely, the best and most appealing is the first? Reducing the burden of disease — which includes reducing the excess burden of disease attributable to inequalities in health — is the business of public health.

So it’s not surprising that Canada’s ministers of health issued a Declaration on Prevention and Promotion in 2010, emphasizing that promoting health and preventing disease, disability and injury are priorities to ensure sustainability of the health system. They called for a better balance between prevention and treatment.

At a time when governments and health authorities are struggling to contain health care costs, amid general concerns about the financial sustainability of the health care system, one would think that the rest of the health care system would be interested in a strong public health system. Yet experts in public health have felt compelled to decry the undermining of public health federally and in many of Canada’s provinces and health authorities, describing recent policy actions as placing public health “under siege” or “under attack.”

We have seen public health downgraded within governments and health authorities, through breaking up of public health units; sidelining of medical officers of health, including erosion of their independence and ability to speak out; declining funding and role confusion, leading to diversion of scarce public health resources into primary and community care.

Indeed, some public health experts are questioning whether public health even belongs within health authorities, given ongoing erosion of its capacity. These concerns were reinforced in a recent *CMAJ* commentary by Canada’s provincial and territorial chief medical officers of health, which implored health ministers to revive the national prevention agenda.

Given the potential contribution of public health to improve the health of the population, reduce the burden of disease and resultant burden of care, and thus contribute to the financial sustainability of the health care system, undermining public health is in nobody’s interest.

It is time that Canada’s ministers of health and the health authorities they direct live up to their 2010 commitment to strike a better balance between prevention and treatment.

*Dr. Trevor Hancock is an internationally recognized public health physician. He was one of the creators of the global Healthy Cities and Communities movement, and he cofounded both the Canadian Association of Physicians for the Environment and the Canadian Coalition for Green Health Care. He’s a senior editor for the* Canadian Journal of Public Health*, on the editorial board of* Cities & Health *and a columnist for a daily newspaper in Victoria, BC. The Canadian Public Health Association recently recognized his outstanding contributions in the broad field of public health with the R.D. Defries Award.*