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Return on investment of public health interventions: a systematic review
  1. Rebecca Masters1,2,
  2. Elspeth Anwar2,3,4,
  3. Brendan Collins2,4,
  4. Richard Cookson5,
  5. Simon Capewell2
  1. 1 North Wales Local Public Health Team, Public Health Wales, Mold, Flintshire, UK
  2. 2 Department of Public Health and Policy, University of Liverpool, UK
  3. 3 Department of Public Health, Halton Borough Council, Cheshire, UK
  4. 4 Department of Public Health, Wirral Metropolitan Borough Council, Merseyside, UK
  5. 5 Centre for Health Economics, University of York, UK
  1. Correspondence to Rebecca Masters, North Wales Local Public Health Team, Public Health Wales, Mold, Flintshire CH7 1PZ, UK; Rebecca.Mason{at}


Background Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions.

Methods We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries.

Results We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5.

Conclusions This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy.

  • Health inequalities
  • Economic evaluation

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Contributors RM drafted the paper, conducted the literature search, assessed the methodological quality of included studies and conducted the analysis. EA independently conducted the systematic review and assessed the methodological quality of the included studies. BC adjudicated in any disagreements in the methodological quality assessments, provided health economics advice and assisted with the data analysis. RC provided expert health economics advice and support throughout, and made significant contributions to the analysis and manuscript. SC devised the concept, supervised the project, provided expert public health advice and support throughout, and made significant contributions to the analysis and manuscript. All authors made substantial contributions to the analysis and manuscript, including final approval.

  • Funding RC is supported by the National Institute for Health Research (Senior Research Fellowship, SRF-2013-06-015).

  • Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.