Co-ordinating prevention.

A major reason why the balance between pronouncements on prevention and action is tipped so much towards the former is that, in most countries, responsibility for prevention is fragmented and vaguely defined. If an effective and efficient national prevention policy is to come about, then it is important that overall responsibility be placed in the hands of a single agency, and for that agency to recognise that priorities in prevention must be a function of costs as well as benefits. The first task of such an agency will be to sort out the fundamental objectives of public policy by clarifying what is meant by prevention and specifying the rationale for government intervention and hence the sorts of prevention which should be the responsibility of the public sector. Given this, national expenditure on prevention from any source which contributes to government prevention strategy can be identified and expressed in the form of a programme budget showing the proportions of total prevention expenditure going to each of the defined programme areas (environment, occupational health and safety, screening, health promotion, etc.). This framework gives a broad overview of the existing situation and by forcing consideration of benefit valuation in any decision to alter the balance of expenditure between programmes, ought to lead to a more rational prevention strategy than would result from a focus on individual programmes in isolation. Moreover, through an emphasis on costs and benefits, the overseers of prevention policy will be better placed to consider the relative efficiency of existing policies--since all share the common objective of reducing future morbidity and mortality. Finally, consideration will also need to be given to issues of equity. The approach described, illustrated by the case of the United Kingdom, will, if adopted, increase the likelihood that a rational and sensible national prevention policy will emerge.