Public Health Spending and Population Health

Context

This systematic review synthesizes what is known about the relationship between public health spending and population health outcomes, as well as the pathways that may explain how outcomes vary with spending. It also discusses the limitations of the existing literature and identifies areas in need of future research.

Evidence acquisition

Studies included in this review were retrieved through an iterative process, primarily through key word searches in two literature databases (PubMed and JSTOR) conducted in 2013. All retrieved studies underwent initial and secondary screening. Articles were included if they (1) examined the link between spending and outcomes or (2) explored pathways that mediate the relationship between spending and outcomes.

Evidence synthesis

Seventeen empirical studies and five literature reviews published between 1985 and 2012 were included in this review. Existing evidence suggests that increases in public health spending are associated with improved population health, at least for some outcomes. However, there is little evidence to suggest that increased spending contributes to meaningful reductions in health disparities. Moreover, the pathways through which greater spending translates into better outcomes are not well understood.

Conclusions

Although the complexity of the public health delivery system makes it difficult to demonstrate definitive associations between spending and outcomes, financial investments in public health have the potential to improve community health. Additional research is needed to explore the pathways that mediate this relationship. This research would benefit public health practitioners who need evidence on how to best spend financial resources to achieve better health outcomes.

Introduction

In its 2012 report For the Public’s Health: Investing in a Healthier Future, the IOM recommended substantial increases in federal funding for public health to ensure that governmental public health agencies have the resources to invest in healthier communities.¹ The prevalent assumption underlying this call for action is that greater investment in public health will enable public health agencies to improve their internal processes and performance, thus resulting in better health outcomes for the communities served.2, 3 However, given the complexities of the public health delivery system, empirical study of this hypothesis has been a challenge.⁴ Thus, the link between public health spending and population health outcomes is not yet well understood.4, 5, 6

The objective of this systematic review is to synthesize what is known about the relationship between public health spending and population health outcomes, as well as the pathways that may explain how outcomes vary with spending. More specifically, this review explores (1) the relationship between public health spending and population health outcomes and (2) the pathways that mediate the relationship between public health spending and population health outcomes. The review includes both empirical studies and literature reviews on a variety of population health outcomes, including indicators of mortality, morbidity, and health disparities, and examines the association of these outcomes with indicators of public health spending.

To present a thorough synthesis, the review first presents the current state of knowledge and highlights pertinent findings. It then discusses challenges encountered by those interested in studying the relationship between public health spending and population health outcomes. Finally, it concludes with an overview of additional research necessary to strengthen the evidence on how investments in public health can be utilized to achieve the best possible returns for the health of a community.