Public Health as a Public Good
Before I start today’s note, a quick comment on President Obama’s executive action this week aimed at curbing gun violence in this country. It is heartening to see this step, even as it falls far short of much needed comprehensive firearm legislation. The President has been, over the past year, a consistent and clear voice on the need to mitigate the scourge of gun violence in the United States. That is encouraging. It remains on the public health community to continue making the case clearly and unequivocally that firearm violence is a preventable epidemic, requiring concerted policy action involving all branches of government, national and local.
Moving on to today’s topic. The classic understanding of a public good in economics, building on Paul Samuelson’s 1954 work, is a good that is non-excludable and non-rivalrous, where no one can be excluded from its use and where the use by one does not diminish the availability of the good to others. Classic examples of public goods include air, water, parks, and national security. This original definition posits public goods as a “product (i.e. a good or service) of which anyone can consume as much as desired without reducing the amount available for others.” A public good, then, becomes the opposite of a private good, which is “any product for which consumption by one person reduces the amount available for others, at least until more is produced.” When using these definitions, a public good is not automatically connected to the public sector, nor is a private good automatically connected to the private sector.
This early conception has been much debated and modified over time. In The Affluent Society, John Kenneth Galbraith suggests that public goods are “things [that] do not lend themselves to [market] production, purchase, and sale. They must be provided for everyone if they are to be provided for anyone, and they must be paid for collectively or they cannot be had at all.” In a thoughtful challenge to these established definitions, June Sekera offers an instrumental definition of public goods with three elements: “Public goods are goods and services that are supplied through non-market, public production. I.e., they are: a. created through collective choice, b. paid for collectively, and c. supplied without charge (or below cost) to recipients.” Marc Wuyts adds a helpful coda suggesting that “public goods are socially defined and constructed according to what is perceived as a ‘public need,’ rather than containing certain inherent characteristics of non-excludability and non-rivalry.”
From a classic economic perspective, the production of public goods can lead to a market failure, an imbalance that manifests when a free market economy does not achieve results efficient for the whole economy. Such failure is mainly attributed to the free rider problem, where individuals choose to receive the benefits of a public good without contributing to the payment of the costs of producing those benefits. For this reason, public goods are often supplied by governments rather than private companies and paid for collectively. In her book Why Democracy Needs Public Goods, Angela Kallhoff argues that public goods contribute to the generation of civil society by creating conditions that help citizens identify with a larger community of equal citizenship. Moreover, she suggests that social justice, engendered by fairness inherent in the availability of public goods, contributes to robust democracies. Kallhoff does not argue that the state should provide public goods, but suggests that groups (e.g. non-governmental organizations or actors with private resources) can provide public goods if they ensure open access.
Health generally is not considered a public good, because non-paying individuals (for health insurance, healthy food, etc.) may not be able to achieve good health. Efforts to introduce universal health coverage in all countries will move healthcare closer towards being a public good. The adoption of social insurance systems or other publicly financed health insurance, where all citizens are insured and can utilize healthcare services regardless of whether they can afford it or not, suggests that insured health services then become non-excludable and non-rivalrous, better approximating a public good.
I would argue that public health is a prime example of a public good, and this notion helps us to understand the true contribution of public health to society.
First, building on the classical definition of public goods, public health is a collective property that depends principally on the conditions that create public health (i.e. the structural, social, and political forces that produce health of populations) rather than on any individual action. These conditions are features of social structures that are not owned and not buyable by individuals. Salutogenic urban environments seek to be both non-excludable and non-rivalrous; so do policies that incentivize healthier foods and efforts to minimize pollution. As well articulated in Global Public Goods for Health, the provision of public health is inextricably linked to government action and other classic public goods. Therefore, the conditions that promote the health of the public are classic public goods, even if an increasingly assertive ownership society may threaten some of that. Knowledge (for example, on health risks), technology, policy, and health systems have many properties of considered public goods— but, as Smith argues, modern health technologies are “increasingly patented and thus made artificially excludable.” Likewise, health systems, absent public financing, are not affordable to many.
Second, public health, the health of the collective, represents a classic example of shared gain from a shared good. As David Woodward and Richard Smith argue, even though a person (or group of people) is the primary beneficiary of his/her (or the entity’s) health, public health, as is amply illustrated by examples of herd immunity or the protection from adverse health behaviors by salutogenic group behavior, represents a collective benefit from which no one is excluded. For example, no one can be excluded from the benefit of infectious disease reduction, and one person benefiting certainly does not prevent others from benefiting as well.
Third, as the world rapidly globalizes, the interdependence of our health on the health of those in other countries, as underscored by the Ebola and SARS epidemics, suggests that notions of nation-specific public goods are quaint and that that the provision of public health is dependent on global public goods that may require universal solutions. For example, no country can be excluded from benefitting from a reduction in carbon dioxide emissions.
Fourth, a core element of public health has always been, and should continue to be, health equity—the opportunity for all to live in conditions that promote health, minimizing inter-group health differences. This is synchronous with a conception of public goods whereby access to a positive resource is not limited by individual circumstance. Public health is then both a good and an opportunity for access to other goods that contribute to the perhaps mythical, but nearly universally aspirational, “level playing field.”
Why does all of this matter? I go back to the suggestion, more than 20 years old, that public goods are socially defined and a matter of perceived public need. It is then incumbent upon us to make it clear that the core elements of public health are indeed global public goods that manifest collectively, benefit all of us, are interdependent with other public goods, and are essential for a healthy workforce and healthy consumers who can propel the production and consumption of private goods. That positions us well to agitate for collectively investing in conditions and promoting policies that make people healthy, thus creating population health. It also points strongly to the need for cross-sectoral investment in public health and creates the way for multiple actors to invest resources in the social, physical, and economic circumstances that shape the health of populations.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Acknowledgement: I am grateful for the contributions of professor Margaret Kruk, MD, MPH, Laura Sampson and Salma MH Abdalla MBBS, to this Dean’s Note, and to Catherine Ettman for conversations that stimulated it.