Health system sustainability : new perspectives from macroeconomics and ecological economics

Background: Traditionally, discussions of the “sustainability” of health care systems have largely been economic in nature, centring on whether societies can “afford” to fund the ever-growing array of health technologies potentially available to them. Climate change and a range of other environmental problems are now recognised as posing increasingly grave threats to human health. Meanwhile, understanding of the scale of the environmental damage caused by health care systems has expanded rapidly in recent years, as have demands that health care systems address the challenge of ecological sustainability. Meanwhile, global economic growth has remained historically low over the last decade; many see the need for profound transformations of economic systems at national and global level if humanity is to avoid environmental catastrophe. This PhD thesis, entitled “Health System Sustainability: new perspectives from macroeconomics and ecological economics”, examines the interface between economic and environmental sustainability in health care. Aims: The aims of the research program reported in this thesis were as follows: i) to investigate the likely economic implications for health systems of the Anthropocene and the ecological crisis; ii) to apply concepts and frameworks from ecological economics to health and health care; and iii) to explore how the discipline of health economics and some of its key tools may need to adjust in response to the growing importance of environmental sustainability in health care systems and policy. Methods: To achieve these research aims, a variety of methods have been used in the research program reported in this thesis. The approaches used have included extensive literature reviews, presentation and statistical analysis of comparative international data, scenario analysis, modelling of the incorporation of negative environmental externalities into healthcare costs and cost-effectiveness analyses, and the development of a variety of theoretical and conceptual frameworks. Thesis outline: The thesis has been structured into three main sections. Section I explores the macroeconomics of health and health care in the Anthropocene era: • Chapter 2 reviews the post-Global Financial Crisis economics literature on economic growth and “post-growth” economics, and investigates the consequences for health care systems and health economics. • Chapter 3 reviews the ecological macroeconomics literature, and uses scenario analysis to examine the likely consequences for health systems of three post-growth economic scenarios (a “steady state” economy, voluntary degrowth – a planned reduction in the material scale of the economy, and involuntary degrowth – an unplanned reduction in the material scale and complexity of the economy). • Chapter 4 reviews and synthesises the literature on decoupling economic growth from ecological impacts, and considers the challenges facing healthcare systems in responding to a world of ecological limits and absolute decoupling. Section II focuses on investigating the application of ecological economics to health and health care: • Chapter 5 reviews the ecological economics and global health literature to apply an ecological economics perspective to global health challenges. It develops a transdisciplinary research agenda for collaboration between health researchers and ecological economists. • Chapter 6 reviews literature on overdiagnosis, overtreatment and overconsumption, with a particular focus on evidence from health economics, behavioural economics and ecological economics on the drivers of overuse in health care. • Chapter 7 reviews the evidence on the scale and harms of health care overuse and on the environmental impacts of health care. It develops a conceptual framework through which to consider the overconsumption of health care and its joint harms to human health and the natural environment. Section III explores the integration of key concepts and analytical techniques from health economics with those of ecological economics: • Chapter 8 considers questions of optimal scale, overconsumption and diminishing marginal returns to health care expenditure, using segmented regression to analyse international comparative data on health outcomes and expenditure. • Chapter 9 reviews and synthesises literature on economic evaluation, the environmental impacts of health care, and the valuation of negative environmental impacts, and tests the feasibility of incorporating environmental harms into the economic evaluation of health care. Conclusion: Health care systems in most high income countries have faced low rates of economic growth since the Global Financial Crisis, if not before. This period has shown the damage to health and health care systems caused by economic austerity measures, and the negative impacts of financialisation and rentier power in health. However, the absence of strong growth has also emphasised the growing importance of public health expenditure in protecting health in both high and low income countries. As economies worldwide seek to pivot to “green growth” to avoid catastrophic climate outcomes, health care systems will come under intense pressure to improve their environmental sustainability – yet little or no work on the economics of a health care sustainability transition yet exists. If “green growth” fails to achieve absolute and sufficient decoupling of economic activity from environmental impacts, more stringent “post-growth” models will be required. “Steady state” or “degrowth” economies would be more challenging for health care systems, placing health care in more direct competition with other sectors for scarce energy and natural resources, requiring ever more emphasis on technical and allocative efficiency. However, they would also offer great opportunities to improve population health by reducing harmful overconsumption in many sectors. Health care systems need also to develop much more resilient institutions that can maintain essential functionality during conditions of economic or environmental crisis or collapse. Reducing the overconsumption of health care is vital to the future of health systems in all scenarios. Overuse, overdiagnosis and overtreatment have multiple causes and drivers, which require multifaceted policy responses at all levels. This research highlights the joint harms to human health and the environment caused by health care overuse, and shows that health care is a powerful example of overconsumption and uneconomic growth. Globally, this research shows that health care expenditure demonstrates sharply diminishing marginal returns at high levels of spending, even while large improvements in health could be realised by increasing spending in low income nations. Economic evaluation in health care needs urgently to incorporate the sector’s negative environmental impacts. This research demonstrates the feasibility of incorporating negative environmental externalities as a cost within economic evaluation. More broadly, Health Technology Assessment processes need not only to encompass environmental impacts, but guard more effectively against indication creep and subsequent overuse of interventions