Viewpoint

www.thelancet.com Vol 381 June 22, 2013 2219

Beyond disease burden: towards solution-oriented
population health
Ian Roberts, Rod Jackson
The Global Burden of Disease Study (GBD) 2010 made a
major contribution to population health by igniting a
debate about how best to reduce human suering and
premature death. The timing was impeccable. As gov-
ernments, health agencies, and civil society go into
conclave to elect a successor framework to the Mil lennium
Development Goals (MDGs), the GBD put health high on
the policy agenda. We live in a world of horrendous health
inequalities despite a vast array of eective interventions.
In 2010, healthy life expectancy in men was 30 years in
Haiti but 70 years in Japan.
1
The corresponding gures for
women were 37 years and 72 years, respectively. Never
before has our obligation to reduce suering been
accompanied by such potential to do so.
The challenge for policy makers is to maximise
population health with the resources at their disposal,
taking into account equity and social values. From this
perspective, taxonomies of solutions are more useful than
are taxonomies of disease burden. The important
problems are the ones that we can do something about,
those for which we have eective interventions. Because
of budget limits, a decision to invest in a particular set of
interventions means that we are implicitly deciding not to
invest in others. By prioritising cost-eective inter ventions
we make the most of available resources. However,
budgets are not the only constraint. Because ecosystem
disruption is a major threat to survival, ecological limits
must also be considered.
2,3
Maximisation of health gain
requires a focus on cost and carbon eectiveness.
4
The information we need for allocation decisions is less
about disease burden and more about the costs, benets,
and environmental eect of potential solutions. Priority
setting should be informed by the marginal improvement
in health and the marginal resource intensity of
interventions.
5
Methods to allocate resources within and
between health programmes to optimise population
health within resource constraints are avail able.
6,7
They
allow explicit inclusion of equity concerns, although to be
vague about equity is easier than to be explicit.
Although the GBD authors acknowledge that priority
setting should be guided by the costs and benets of
intervention, this point is largely lost given that their
focus is on disease burden. The GBD challenges us to be
rigorous and clear in our arguments about the criteria
that should guide programming and investment
decisions writes the President of the World Bank.
8

Accurate assessment of the global, regional, and country
health situation and trends is critical for evidence-based
decision making for public health writes the WHO
Director-General.
9
These views can be challenged.
Accurate data for disease burden are not essential to set
priorities and it is not necessary to accurately count how
many people have died prematurely to prevent premature
death. A preoccupation with dis ease burden could move
resources from highly cost-eective solutions to less cost-
eective ones, reducing health gain. The best way to
improve population health is to think less about the
problem, disease burden, and more about the solution
cost-eective and carbon-eective interventions.
A solution-oriented approach should also be taken for
research investment. In deciding what research to fund,
funding bodies should consider the costs of the research
in relation to the expected value of the information that it
will provide.
10
Although the expected benets of
information increase with the size of the population
whose choice of intervention can be informed by
additional evidence, traditional measures such as
incidence and prevalence (in the case of chronic diseases)
are needed rather than summary estimates of disease
burden. Often there is only a tenuous link between
research questions and the decision problems faced by
policy makers aiming to maximise health. Starting with a
comprehensive decision model and examining the extent
to which reduction of uncertainty in model parameters
would aect decision making would be a more appropriate
framework for research funding than would a simple
relation with disease burden.
Investment in health without monitoring the return on
the investment and without holding the recipients of
health funding accountable would be foolish. Although
repeated assessment of burden would allow comparisons
to be made between populations and over time, because
mortality and morbidity are multicausal, any changes in
burden are di cult to attribute to actions taken by the
health sector. A given health system might achieve the
best possible population health given its budget, but
disease burden could increase because of changes in
other causes of disease (eg, changing food supply or
climatic conditions). Similarly, a system might provide
substandard care while disease burden falls. Even in
high-income countries the correlation between qual ity of
care and mortality is low.
11
A solution-oriented approach to monitoring and
accountability has many advantages. For example, early
administration of tranexamic acid to bleeding trauma
patients reduces the risk of bleeding to death by about a
third.
12,13
The treatment is highly cost eective in all
countries irrespective of income level.
14
Because the
causal link between tranexamic acid and mortality is
established, we can monitor whether trauma patients
receive the drug. Such monitoring is easier than
monitoring trauma case-fatality, for which case-mix
Lancet 2013; 381: 221921
Published Online
March 11, 2013
http://dx.doi.org/10.1016/
S0140-6736(13)60602-9
London School of Hygiene and
Tropical Medicine, London, UK
(Prof I Roberts MD); and School
of Population Health,
University of Auckland,
Auckland, New Zealand
(Prof R Jackson PhD)
Correspondence to:
Prof Ian Roberts, London School
of Hygiene and Tropical
Medicine, London WC1E 7HT, UK
ian.roberts@lshtm.ac.uk
Viewpoint
2220 www.thelancet.com Vol 381 June 22, 2013
dierences necessitate scrupulous risk adjustment. Even
if trauma mortality is low and patients are not being
treated, we can infer that it would lower still if they were.
Health services have more control over process than
outcome and so are better able to do something about
process. Process measures stimulate action from all
health services with potential for improvement, not
only those with poor outcomes, avoiding stigma.
15
For
example, some UK hospitals fail to give tranexamic acid,
whereas some hospitals in India do. On this dimension,
some Indian hospitals provide better care than do UK
hospitals. Of note, there is no direct link between the
potential to benet from tranexamic acid and any
particular disease burden category: some tra c injury
victims can benet, as can some victims of violence and
some patients with falls. Similar arguments apply to
policy interventions. We know that smoking is common
and causes poor health and early death, so we implement
non-smoking policies and smoking cessation inter-
ventions. Although monitoring the ongoing smoking
burden is an (indirect) method by which to estimate the
eectiveness of policy and other interventions, to monitor
the degree of implementation of processes that have been
shown to improve cessation rates is more useful.
Although disease seems an obvious enemy and disease
burden a worthy adversary, the notion of disease is also a
slippery one. According to Rose there is no disease that
you either have or dont haveexcept perhaps sudden
death and rabies. All other diseases you either have a
little or a lot of.
16
In non-communicable diseases,
medical care decision making is moving away from
diagnosis towards prognosis and treatment. Because
most of us have some cardiovascular disease, the role of
the health worker is to predict the individuals risk of
future adverse health events and to oer treatment to
those for whom the treatment benets exceed the harms,
taking into account costs and patient preferences.
17
The traditional notion of disease has been useful
because it allowed doctors to dichotomise the population
into those at high and low risk of adverse health
outcomes. Having diagnosed disease, they can focus on
the high-risk group, the group that they call patients, and
forget about the others. Making diagnoses enables them
to allocate resources more easily. Diagnosis of disease
typically involves placing people into binary categories on
the basis of a somewhat arbitrary threshold on a
continuous sale.
18
For example, people with a fasting
blood glucose greater than 69 mmol/L are called
diabetics and when they die it might be said that diabetes
is the cause of death. However, this arbitrary dichotomy
does not reect biology and ignores other predictors of
poor health outcomes such as smoking, blood pressure,
and cholesterol levels.
18
Indeed, many people without
diabetes with only moderately raised blood glucose
concentrations but high levels of other vascular risk
factors will be at greater risk than will many patients
diagnosed with diabetes.
Disease would be a useful construct if risk prediction
was univariate but it seldom is, with most ill-health
related to complex long-term disorders. The increasing
use of prognostic models that take several factors into
account limits the use of disease labels. Disease burden
cannot be used to monitor trends and set priorities
(even if this approach were appropriate) when diseases
change position in disease burden rankings because of
changing labelling conventions. Some current diseases
(hypertension, type 2 diabetes, obesity) might largely
disappear as they come to be accepted as continuous risk
(causal) factors for vascular and metabolic disorders. It
would be a pity if public health professionals adopted a
disease focus just as medical care moves away from it.
The idea of disease as a link in a causal multifactorial
chain does not only apply to non-communicable disease.
For example, a man dies after a road tra c injury.
Although the injury itself is clearly part of the chain of
causation, it might also include road design factors, poor
safety enforcement, excessive speed, driver fatigue,
depression, or drunkenness, and the absence of eective
trauma care. Moreover, upstream of these proximal
causes are ecological, social, and economic factors such
as fossil fuel energy policies, land use planning, and oil
prices. To say that death was caused by road tra c injury
is to select one link from a long chain.
Much premature death and suering can be prevented
by tackling its causes. Removal of upstream (distal)
causes is often more cost eective than is removal of
proximal medical causes, because upstream causes bring
about a plethora of downstream suerings. Several years
ago one of us was invited to lead a series in The Lancet on
road tra c injury. The oer was declined on the basis
that a narrow focus on road tra c injury neglected other
important health eects of transportation fossil fuel
energy use. Instead, the London School of Hygiene and
Tropical Medicine assembled a team of researchers to
estimate the health eects of climate change mitigation
strategies.
19
The team showed that limiting car use and
increasing walking and cycling would reduce heart
disease, stroke, breast cancer, dementia, and depression,
and reduce the carbon emissions that threaten the
integrity of the ecosystems on which life depends.
20

These benets would bring large cost savings to health
services.
21
Restriction of livestock production to reduce
methane emissions would reduce the amount of
cardiotoxic saturated fat owing into the food system.
22

Tackling of upstream causes is also likely to be more
sustainable than is tackling of proximal causes, and
because we have no choice other than to address the
threats to the viability of our ecosystems, alignment of
health and sustainability objectives makes tackling of
upstream causes more cost eective since we only have
to consider the additional cost of the health interventions.
Nevertheless, some medicines are highly cost eective,
although the chem ical industry that many depend on is
highly carbon intensive.
23
A solution-based approach to
Viewpoint
www.thelancet.com Vol 381 June 22, 2013 2221
better health would prioritise the most cost-eective and
least carbon-intensive interventions, whether upstream
or downstream.
A solution orientation means reduction of premature
death and suering through a concerted focus on
removal or modication of causes, in the most e cient
and sustainable way. It means monitoring the upstream
ecological, economic, and social determinants of health,
setting targets, and holding governments to account for
reductions in hazards. It also means monitoring and
management of the implementation of cost-eective and
carbon-eective downstream interventions and holding
health services to account for their implementation.
Action will be required in all countries. The focus of
population health decision making would be on nding
the most appropriate package of policies and health
services in view of the constraints of environment,
cost, and equity. Research should be oriented towards
provision of accurate data for the cost and carbon
eective ness of sustainable interventions and on
optimum allocation to maximise population health. The
best way to tackle problems is through a resolute focus
on solutions.
Contributors
IR drafted the paper. RJ contributed to several subsequent drafts.
Conicts of interest
We declare that we have no conicts of interest.
Acknowledgments
We thank Liam Smeeth, Zaid Chalabi, Anne Mills, Carine Ronsmans,
Richard Smith, Claire McKenna, Haleema Shakur, David Prieto,
Daniela Manno, and Katharine Ker for helpful feedback on the ideas
presented in this Viewpoint.
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