Is it possible to make prevention and reduce health spending?
Increasing physical activity would improve the health of the Country, would reduce health spending, it would give new opportunities to work and maybe a small step forward in the field of security. Is it so difficult?
In 2016, the estimated Italian Public Health spending will reach 113.2 billion euro, 1.9% increase if compared to 2015. In 2012 it was 111 billion, equivalent to 7% of GDP (about 1,867 euro per year per inhabitant). Health expenditure is growing but, news of these days, in Italy the average duration of life, even if only slightly, is coming down.
Does it mean that, despite the huge professional and financial commitment, the resources are badly or not adequately employed, or is it just the result of the increase in costs? In any case, although much lower than that of other major European countries, it is necessary to find new ways to reduce health care spending.
The linear cuts made until now were strongly, and rightly, disputed because they do not guarantee an improvement of health; indeed, they are likely to worsen the resulting further increase in costs. It is, in fact, necessary to start a path to appropriateness, but this cannot be just a term; we need a strategy shared with health stakeholders.
The great effort that Public Health is doing, however, is aimed primarily at those who are already ill and thus require appropriate care; it is therefore difficult to reduce the spending commitment. The Italian Parliament is facing with an important institutional dilemma: on the one hand, the right to health, enshrined in the Constitution, and the consequent decision to provide free (or almost) healthcare; on the other, the imperative to contain expenses that tend to rise, even for the progressive aging of the population, which erodes great resources that could be allocated to the Social State and/or other productive investments.
Prevention is certainly the best way to rationalize spending and thus reduce it; but we all know that proper prevention can give long-term results, although it certainly leads to a substantial savings, at present risks only to be a cost; and resources seem exhausted.
It is, therefore, necessary to decide whether to run after the disease trying to patch the most damage created by it, spending as little as possible or, rather, do some investment, perhaps in new technologies, especially diagnostics, to reduce the occurrence of disease.
Or, more simply, to try to get less sick.
It is not a utopia. It is possible to get less sick thus reducing health spending. Let's see how.
Physical inactivity is a health risk, because it produces 2 million deaths / year worldwide. In particular, physical inactivity favors the 10-16% of cases of breast cancer, colon cancer and diabetes and 22% of heart attacks.
Regular physical activity is thus critical for prevention.
The health benefits brought by the change in lifestyle habits are proven by a 25-year study in which it was shown that the change in lifestyle has reduced deaths from cardiovascular disease (-68%), stroke (-73% ), cancer (-44%).
A more active lifestyle would lead to the prevention of at least 2 million premature deaths and 20 million DALYs (Disability-Adjusted Life Year) in the world.
For five diseases it has been proven the relationship between physical activity and health benefits: cardiovascular disease, stroke, colon cancer, type II breast cancer and diabetes. An expanded list of diseases caused by sedentary lifestyle includes: overweight, obesity, diabetes type II, cardiovascular disorders (heart attack, myocardial infarction, stroke, heart failure, high blood pressure, venous insufficiency), osteoporosis, arthritis, increased blood cholesterol and triglyceride levels, colon and breast cancer. All diseases that, once arisen, tend to become chronic and must be kept under constant health control and appropriate care.
It was calculated that increasing only by 1% of the number of active people, the save in health care spending would be 80 million euro per year.
The main consequence of physical inactivity is overweight and later obesity. In particular, the central type obesity, with the accumulation of fat in internal organs, is associated with an increased incidence of complications: metabolic (diabetes and / or intolerance to carbohydrates, dyslipidemia, hyperuricemia), cardiovascular (blood pressure, heart disease and ischemic heart failure), systemic (arthritis, colon cancer, respiratory failure, cholelithiasis, etc.).
About 50% of obese children over 6 years become obese at adult age in comparison (10%) of non-obese children at the same age. In obese adolescents, this percentage rises to 70% and above 80% if one parent is obese.
In Italy, 33.1% of the population is overweight (41% of men and 25.7% women), and 9.7% is obese. Although the latest figures are mildly encouraging, the levels of overweight and obesity in childhood remain high.
The phenomenon is more widespread in the South (Abruzzo, Molise, Campania, Puglia and Basilicata regions cover more than 40% of the sample), where some eating habits and poor perception of the phenomenon are a problem. Out of 46,492 children from 2,623 classes of third grade, 22.1% of children aged 8-9 years are overweight compared to 23.2% in 2008/09 (-1.1%) and 10.2% in condition of obesity, compared with 12% in 2008/09 (- 1.8%).
The presence of obesity in adolescence is predictive of a greater development of cardiovascular events in adulthood, although in this age of life a normal body weight has reached. Children between 6 and 11 years with overweight problems are one million one hundred thousand. 12% are obese, while 24% are overweight: more than one in three children, therefore, has a weight higher than it should have for his age.
How did we come to this?
School medicine and military medicine have been virtually dismantled, with serious impairment of prevention. The early detection of many diseases slows the onset of complications and contributes greatly to improving the quality of life; an example among all: diabetes, which affects a large number of people with increasing costs.
Physical activity is important for the prevention of many diseases and to improve the conditions of sick people. "Exercise is medicine" is the new address for prevention and therapy.
The boys also benefit of the sport activity for their psychological maturation.
In addition, there are the damage from poor nutrition, alcohol dependence and the overuse of pharmacologically active substances, misuse of drugs, even those permitted.
It is therefore necessary to increase the quantity / quality of time devoted to physical activity, both at school and outside school, but above all, it is vital the dissemination of knowledge of the problem.
A widespread information / training, along with a sport and proper medical supervision into every type of school, would lead to a sharp reduction in public spending, much higher than the 80 million of which we have just spoken, with an almost negligible investment.
The ideal would be to set up in School a course of education to health, with the principles of nutrition and physical activity, in order to improve the lifestyles and reduce health spending through health education, proper nutrition and sports activities. 1-2 hours a week would be enough to communicate to children, and indirectly their families and the families of the future, what are the criteria for a healthy life.
It is, however, necessary to have suitably qualified teachers for the treatment and dissemination of health prevention principles of proper nutrition and the correct approach to sports activities. A specific training should be therefore held in the University. Health education cannot be done by the science teachers or those of motor sciences, alone; they must have a physician specially trained to coordinate, perhaps in co-presence, the interventions.
We must start a comprehensive training: school teachers, family physicians, those involved in physical training and athletics, sports administrators. One might ask, why sports managers? Because are needed sports managers who are not motivated only obtaining the results, but they do of sport a means to improving public health, as described below.
How to increase the number of practicing physical activity? We should promote agreements between schools and sports facilities (whereas schools do not already have) belonging to municipalities, sports clubs, for two / three hours in the afternoon, for all the kids of middle school at least and high school, asking to families a minimum contribution, such as 20 euro per month in order to perform physical activities at a low cost.
If we imagine to gather in a sports facility 100 boys, whose families paying 20 euro, with the 2,000 euro resulting it can be payd a qualified instructor who would follow them for the two / three hours, leading them to a controlled physical activity. As with all sports, kids should undergo a preliminary medical examination, which would identify any eventual disease.
So, in a very simple way, it would reduce obesity and the diseases related to it, it would improve the course of many diseases, it would increase employment and you could have a very large sports lever, at almost null cost.
Someone might object: but if some students do not want to exercise? No problem, they would also go to the fields, where they will attend the activities of others. Sooner or later they will be convinced to do it too.
I mentioned the sports administrators. It is fundamental a preparation of adequate university level also for those who want to pursue a sports manager career. At all levels. The ideal sports manager must have some knowledge in several fields, from the biomedical one to the technical, training, rehabilitation, but also legal and economic, psychology of sport and sports communication, plant and equipment. Not always it is enough to have been an athlete, even if of high level, to be a good sports manager.
For the younger generation, which should be addressed at a proper sports culture, the presence of instructors and managers who have a clear knowledge of what they do and of the human material they have in their hands.
As an example, some time ago it was proposed that it should not be necessary the license to coach amateur teams, to save money. But we know how important a coach in a team, his role as an educator and controller; according to the proposal, it could be anyone. But with what kind of results?
In the concept of global education it must also be considered the possible positive effects towards public safety, in that many criminal organizations are using sports centers for the sale of illegal products and for money laundering.
The illicit is favored by underdevelopment and ignorance.
The institution, in each sports center from the smallest to the largest organization, of the certified quality of the manager and / or trainers, would constitute not only a guarantee for the public to have quality instructors, but also the possibility of fully "tracking" the system, by limiting the range of action of criminal organizations.
Obviously, in universities or in hospitals, should be developed specific routes for either the sports fitness, or recovery from diseases as well as for the diagnosis and treatment of diseases related to the sport.
The problem of physical activity, however, does not invest only the children but also the elderly. The exercise is a powerful stimulus for the production of GH and, on the other hand, aging and obesity are associated with a reduction in the production of GH. But then, is obesity which is growing old or aging that makes you fat?
The infiltration of fat is a natural part of the aging process. As we become old, our muscles gradually begin to shrink, burning fewer calories. When we lose muscle tissue, we burn less fat and start to add fat to our structure.
Therefore, if it is physiological that the fatty tissue replaces the muscle during the age, it is essential to keep active the muscular system, to delay the process and avoid the excess of fat accumulation.
In short: increasing physical activity would improve the health of the Country, would reduce health spending, would give new opportunities of employment and maybe also a small step forward in the field of security.
Is it so difficult?
Prof. Roberto Verna
Professor of Clinical Pathology
Director of the Center for Medicine and Sport Management
Sapienza University of Rome, Department of Experimental Medicine
Past President of the Italian Society of Clinical Pathology and Laboratory Medicine - SIPMeL
iPresident, World Association of Societies of Pathology and Laboratory Medicine
and the WHO Representative
President, World Pathology Foundation
Prof. Roberto Verna