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Innovation for

Prevention and Health

Issue Brief

Critical Issues in Health Care

The Hague Centre for Strategic Studies | September 2013

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Innovation for Prevention and Health

Author Eline Chivot

Introduction In 2003, the co-founder of Seattle’s Institute for Systems Biology (ISB), Leroy Hood, coined the term

‘P4 Medicine’, a systems approach to health and disease.1 It aims to make health care more

Predictive, Preventive, Personalized and Participatory. Advances in genomics and molecular

diagnostics have enabled the development and use of predictive information to prevent diseases. In

case a patient is already subject to a disease, individual genetic information is then used to

personalize treatments.2 The participatory nature of the approach is also important, involving

individuals in managing their own health.3

This Issue Brief takes a closer look at the element of prevention.

1. The need for prevention in health care The developed world will be facing growing health challenges in the near future. Today’s ongoing

trends such as the obesity epidemic, the growing prevalence of certain chronic diseases or increasing

fiscal pressures on our health-care systems are as many symptoms of a need to change the way we

look at and take care of our health. One central element on this pathway to change is the concept of

prevention.

In health care, prevention is an approach aiming at avoiding, but also moderating or disrupting major

dysfunctions (e.g., diseases). Prevention is typically understood as an early intervention that occurs

before the full manifestation of symptoms and through the identification and study of risk and

protective factors. Prevention (of secondary effects, or of other diseases) is also relevant during

disease remission. Prevention can be population-wide, or targeted at a high-risk group of patients. It

is multi-faceted and multidisciplinary by nature. In health care, it targets social determinants such as

social class, environmental influences such as geographical location, lifestyle influences such as

smoking or nutrition, and physiological influences such as cholesterol.4

Health-care services are often and traditionally oriented towards ‘sick care’ (treating acute diseases),

rather than disease prevention and public health programs. The share of health-care expenditures

allocated to prevention remains limited.5 In 2006, prevention represented only 3% of total health

expenditures in OECD countries.6,7 However, it is increasingly gaining ground in the debate on the

future of health and health care. For instance, it has become an important pillar of the US national

health strategy in 2011.8 This section first provides a number of reasons behind the renaissance and

emergence of prevention on health agendas and discussions. It also touches upon the various

concepts defining prevention.

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A response to health challenges in Europe A number of trends and health challenges will likely lead to considerable losses both in terms of

mortality and morbidity burden, and economically.

Chronic diseases remain and will continue to be Europe’s major health challenge. The number of

deaths caused by some of them is projected to increase. For example, in terms of mortality, most

cancers are expected to cause an increasing number of deaths through 2030 – in particular lung,

colorectal, breast and prostate cancers.9 Chronic diseases being rarely cured and lasting longer, they

require different treatments and patient management.

Such diseases are driven by the spread of unhealthy habits and behaviors in Western societies.

Smoking, physical inactivity or the consumption of sugary foods and alcohol have a major influence

on the development of chronic illnesses, including diabetes, cancers or heart diseases, and

multimorbidity, i.e., when a patient suffers from a combination of such diseases. The human and

economic burden of these risk factors is considerable, yet much of it is preventable. Currently, more

than half of the WHO European Region does not get the recommended doses of physical activity, and

according to the WHO, this share is increasing.10 In addition, overweight and obesity have been

increasingly linked to typical Western high-calorie diets. The EU estimates that more than half of the

adult population in the EU is obese (defined as a BMI11>30) or overweight (defined as a BMI>25), and

both these health problems are ranked fifth on the list of leading causes of death in Europe.12

Future health challenges can also be explained by demographic trends that characterize the

developed world. In particular, aging will lead to a greater incidence of diseases, including

neurodegenerative disorders (e.g., Alzheimer’s), but also to more disabilities. For example, according

to the European Commission, the Netherlands is expected to see the share of its population over 65

increase from 15.3% in 2010 to 26.8% in 2050.13 This will require additional investments such as daily

assistance from health-care personnel. Increasing fiscal pressures are likely to weigh on health-care

systems, as life expectancy and the health-care dependent share of the population will go up while

the workforce and thus the share of tax payers will decrease. The current economic context facing

the developed world is expected to render this situation more urgent.

Prevention can be based on the concepts of patient empowerment and self-management (the

participatory element of the ‘P4 medicine’). They entail the increased participation and role of

patients in the process from health to disease. This is expected to lead to a decline in health risk

factors (e.g., smoking).14 Empowering communities and employers to promote wellness strategies

and prevention programs are also recommended.15

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2. The role of innovation in prevention Innovation is a major driver of preventive measures and strategies in health care. Different types

emerge from various industries and sectors: they can be institutional, social, behavioral or cultural,

or technological. In this section, a number of such initiatives supporting the concepts of prevention

are surveyed. It is worth noting here that prevention can be associated with the transformation of

the health-care market into a consumer health-care market, in which the buying initiative originates

from the consumers’ demands. This shift is driven by the increasing use of mobile and web-based

technologies, self-monitoring devices, health tourism, self-care drugs, or functional foods. These are

as many solutions facilitating prevention as well.16

Strategies and policies of prevention There are several ways through which prevention can be efficiently implemented: from prohibition,

taxation, to nudging, and self-management. Grouping these approaches combines individual

responsibility with an impetus for prevention by health-care organizations and the government.

Institutional innovations

Policies that save money and aim to prevent unhealthy habits may be more efficient than medical

interventions and therapies.17 They include prohibitive regulations such as smoking bans in public

places, raising the minimum age for alcohol consumption, or food advertising restrictions, as well as

economic (dis)incentives such as the increased price of cigarettes, or fuel price escalator (i.e.,

increasing duties on fuel) to encourage physical activity.

In addition, using information technology architectures and developments in intervention and

biomedical technology could accelerate the implementation of new processes by public authorities,

such as moving care from hospitals into patient homes.

Behavioral innovations

There are a number of barriers to the successful implementation of disease prevention as a process.

These barriers can be demographic (e.g., educational level), or institutional (e.g., access to care), but

also behavioral, cultural. The latter include languages, social customs, values, norms, traditional

health beliefs, dietary preferences and practices, and communication patterns.18

Prevention could therefore be implemented further by establishing a ‘culture of prevention’

effectively changing values with respect to health. Establishing such a culture would imply a change

within society and transformations at the organizational level. So far, it remains mostly envisioned

through safety and health in the workplace.19 It therefore needs to be expanded to general attitudes

and daily behaviors and, at the organizational level, promoted within the processes of our health-

care systems.

In particular, ‘nudging’, the empowerment of communities and self-management could progressively

and definitively transforming behaviors among populations.

Preventative strategies are intrinsically based on the rationality of patients with respect to – for

example – lifestyle choices. However, appealing to emotions (e.g., as shown in the second section,

with computer games) can prove very efficient in raising awareness, but also in improving emotional

health as part of the objective of prevention. Through the activation of this affective system,

behaviors could be effectively transformed by ‘nudging’ populations, as suggested in a 2011 study.20

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Combined with prohibitive regulations as suggested above, nudging could lead populations to

internalize and adopt healthier behaviors, for example by promoting non-smoking attitudes and

choices through mass media campaigns, by serving drinks in smaller glasses, or by encouraging

physical activity through more visible, attractive and safer cycling lanes in urban areas.

Further, increasing the public understanding of medical science and communicate better on diseases

would facilitate prevention as well as improve medical or health literacy. This implies a larger public

access to more knowledge of the consequences of both their individual behaviors and their use of

health-care systems. New educational tools can help patients make more informed choices of health-

care products, services and options.21 As a result, healthier lifestyle choices and a more responsible

use of health-care services are promoted. Prevention strategies mentioned above – such as nudging

or patient empowerment – can also contribute to changing behaviors on a large scale.

According to a study, the perception of disease prevention remains characterized by traditional

concepts of medical practice. Indeed, the responsibility of individual health would be delegated to

the population, which would make individuals feel guilty and devalued, and “slip into passiveness”.

Investments in research, infrastructure and human resources could be useful in order to modify

attitudes towards prevention and promote it better.22 For example, research into the cost-

effectiveness of preventive screening programs, which are not equally recommended or accessible

across Europe, could lead to their increased integration into health-care delivery.23

Technological innovations Prevention is expected to be facilitated by a number of tools and devices developed in several

sectors, which would make care more affordable and less intrusive. New imaging equipment,

diagnostic devices, wireless devices and in-home care technologies are predicted to become

widespread. This could help in coping with new health challenges such as aging, for example by

developing new tools for in-home care, thereby increasing the independence of elderly.

Pharmaceutical and medical industry

In the pharmaceutical industry, innovation emerges in in-home care products or ‘low-cost’

medication. Generic medicine, self-medication (such as currently customary pregnancy home tests or

drugs for urinary infections) are examples of drugs that would help patients monitor their health –

and would be cheaper to manufacture than those they replace.24

In the medical device (‘medtech’) industry, expectations for future technologies that could create

preventive solutions through 2040 range from diagnostics (for example, blood stream sensors) to

telemedicine (for example, robotic health-care assistants), or from biogerontology (for instance, anti-

aging drugs) to regeneration (with artificial organs), enhanced metabolism and sensory

augmentation.25

Siemens is developing preventive solutions that include early screening for cardiovascular disease, or

computed tomography improving patient experience. These processes form a framework for

personalized medicine with integrating prevention and early detection, diagnostics in vitro and in

vivo (e.g., mammography), and therapy and care (i.e., physical examination).26 Philips is engaged in

wide-ranging R&D to develop new products that are applicable to older consumers, from specialized

lighting options to a range of ‘tele-health’ or home-based care products that facilitate

independence.27

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Wireless health

Other industries are contributing to technological breakthroughs in health care, including innovations

that are not originally related to this sector. One of the most revealing examples is the development

of initiatives that use ‘big data’ in health care. Information about customers of these initiatives can

be collected, registered, and exchanged; users can measure their performance and evaluate their

behaviors with their smart phone applications or other devices.28

Applications

In particular, familiar technologies such as tablets, mobile and web device applications provide

solutions that are transforming the health-care industry. They increasingly support preventive care

and patients in managing their health condition by aggregating data, sending medication reminders,

healthy habit tips and medical bill reminders, tracking blood sugar, blood pressure, pain, counting

calories, etc.29 As anticipated in one study, “Google-types of search engines for medical advice will

emerge, as will software to manage medical expenses, and technology that enables instant home

health-care access, or telemedicine”.30

Mobile Personal Health Records (mPHR) include the so-called apps that enable self-care through the

monitoring of patients’ conditions and potential chronic illnesses. One of Nhumi.com’s innovations, a

software company specialized in clinical data, comprehensively targets and defines diseases through

a 3D-model of the human body.31 Heart diseases are one of the many chronic illnesses that remain

major causes of death: developed by an eponymous Californian start-up,32 the Cardiio App calculates

the user’s heart rate, and can help monitor one’s condition by targeting or preventing complications.

Diabetes is set to become an increasing issue in developed societies: a mobile phone app, mySugr,

helps diabetics manage their level of blood sugar concentration. Another promising example in a

context of increasing allergic diseases33 include 23andMe, or the ‘pollen app’ which identifies both

allergy symptoms and types, the regions with likely pollen release, etc. Customers can adjust their

activities and mobility on this basis. The conditions of an aging populations could become more

efficiently examined by mPHR as well: Control4 by CloseBy Network, a developer of wireless

communications products, combines “sensor technology embedded in the home to monitor the

elderly and alert caregivers to changes in status” or behaviors via cell phones and alerts via email or

text “when specific sensors are triggered”.34

Personalized devices

It is interesting to note the recent shift towards investments that aim to increase independence, such

as equipment personalizing health-care solutions, empowering patients, and providing information

control. These technological solutions support acute and chronic care and give rise to more patient-

friendly innovations. They are also expected to play a role in providing a system for prevention by

adapting treatments to patients’ profiles.35 They support daily health management for both health

individuals or patients in the form of sensor-embedded consumer products such as glucometers or

sleep manager devices aiming to prevent apnea, etc.36 Tools such as the Zeo are particularly relevant

as people suffering from insufficient sleep are exposed to greater disease risks.37 The Zeo, a personal

analysis device, consists of a “wireless headband, bedside display, and email based personalized

coaching program and analytical tools. It identified periods of wake, REM, light, and deep sleep”. The

Zeo produces a daily score relating to the individual’s sleep quantity and quality. Another example is

the Fitbit Tracker, a coaching device clipped to clothing, tracking calories burned, steps taken,

distance travel, sleep quality. It wirelessly synchronizes with a phone or a computer, which

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automatically upload the tracked data to a fitness and nutrition website.38 Dexcom “uses a biosensor

inserted into the skin to continuously monitor blood sugar levels and transmit that data to a mobile

communication device”.39 If used by diabetics, this could help practitioners and caregivers to adjust

insulin doses accordingly.

In a more playful domain, computer games are being developed for their therapeutic effects,40 and

strengthen the relations between stakeholders. For example, ‘Re-mission’ has been developed by

HopeLab (from the Omidyar philanthropic network) for young cancer patients.41 Research has shown

that the game would be effective in supporting health outcomes and behaviors among patients.42

‘Circus Challenge’ was created by neuroscientists from Newcastle University and Limbs Alive (a

company specialized in the rehabilitation of arms and hands) for stroke victims. Halfbrick Studios also

developed ‘Fruit Ninja’ which helps stroke victims through motion controls. Circus Challenge is

available for iPad, PlayStation, Xbox, etc., and could soon include telemonitoring to allow

practitioners watch and support their patients’ progress. Lastly, remote monitoring devices

combined to computer games also aim to prevent people at risk from becoming diabetic. One

example is the digital glucose monitor (DIDGET) that integrates with the Nintendo game console. It

was commercialized by Bayer to ensure patient compliance in diabetes monitoring.43

This further incorporation of technology into people’s lives – which some refer to as the ‘Quantified

Self’ (QS) movement44 – can help in monitoring and improving one’s health daily through gaining self-

knowledge and making better choices. Developers of QS initiatives advocate the democratization of

health care and, as more data becomes available, the acceleration of medical research as additional

positive implications. At the same time, challenges such as the increasing vulnerability to loss, theft

and abuse of personal data, and the growing threat of cyber crime, cannot be underestimated.

Organizational innovations In health care, organizational innovation can be associated with the development of new forms of

networked cooperation between health-care organizations, professionals, and patients.45 It is also

reflected within the corporate world, in the implementation of preventive health measures and

alternative work processes, and in the creation of new financial arrangements (PPPs). These

innovations provide solutions that aim to support prevention and could well increasingly provide an

alternative to shrinking governmental health-care expenditure.

New business models

Communities That Care (CTC) is an example of organizational or social innovation implemented by

the University of Washington. It develops a preventative strategy by encouraging communities to use

prevention research and data to implement systems aiming at reducing risk factors such as drug and

alcohol misuse or school age pregnancy. CTC provides manuals, training and tools, and technical

assistance to identify risk factors and target needs.46

New business models in health-care delivery increasingly rely on technologies. Examples include

facilitated user networks for chronic disease prevention and management. Showing the evolution of

established brands towards the integration of technologies, Weight Watchers has developed into an

online coaching program that includes support and advice on helpful habits and smart eating. The

network dLife aims to facilitate the exchange of advice and information among diabetics and their

families.47 These models are expected to move simple procedures from hospitals to homes. Such

innovations supporting preventative measures and self-management of health may render health

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care more affordable, as they deliver care at lower costs and offer alternatives to hospital and

physician practices.

Prevention in the workplace

Firms are increasingly implementing policies using technologies adapted to working environments.

This could help reduce costs by mitigating the effects on aging on workers, thereby extending

working lives with improved productivity.48

Wilkhahn is an example of a company with successful qualification measures, as it was able to “more

than halve its sickness rate from formerly ten to then four percent by means of a systematic

participation-oriented analysis of the stresses and strains of the workplaces and corresponding

comprehensive measures of behavior prevention as well as the prevention of unsafe workplaces”.49

Continental AG had achieved a similar success through ergonomic improvements. BMW is also

adapting to the future evolution of its labor pool, by implementing policies that aim to preserve the

productivity of an aging workforce. Since 2007, BMW has initiated adjustments of limited cost such

as wooden platforms for workers to work on, rather than cement floors, to reduce the impact on

joints; chairs at several workstations, to let workers sit while performing some tasks; magnifying

glasses to help workers see tasks more clearly, etc. As a result, the performance and productivity of

workers increased. A broader plan for demographic change followed in 2011: ‘Today for tomorrow’

was designed “to set new standards in aging-appropriate workplaces” through better health

management and training, as well as new retirement possibilities such as semi-retirement and more

flexible working models.50

Public-Private Partnerships

Due to the increasing costs associated with non-communicable diseases or unhealthy habits and the

diminished capacity of governments to address these, Public-Private Partnerships (PPPs) aiming to

develop prevention are being increasingly created. Traditionally, PPPs seem to focus on preventing

diseases (e.g., sexually transmitted infections and malaria), developing and facilitating access to

vaccines and drugs, and improving health-care services in the developing world.

A number of European PPPs promote initiatives to prevent childhood obesity. For example, the

Directorate General Health and Consumers of the European Commission, several nonprofit

organizations from the public sector have collaborated with Nestlé or Kraft Foods to facilitate

community-based prevention interventions.51 Next to obesity, diabetes are a mounting concern in

the developed world. In the US, the National Diabetes Prevention Program aims to reduce of delay

type 2 diabetes through lifestyle programs (offering coaching services, encouraging physical activity,

etc.).52 It is led by the Centers for Disease control and Prevention (US Department of Health), in

cooperation with partners such as the UnitedHealth Group, a leading health-care company.

PPPs also set up projects in the field of neurodegenerative diseases. The Alzheimer’s Public-Private

Partnership, ‘Solutions Project Office’, was implemented in 2010 within the US Federal Government.

It is based on active collaboration with stakeholders outside the government and provides

prevention and care improvement initiatives.53 In the Netherlands, ParkinsonNet54 was created by

the Radboud University Nijmegen Medical Centre and the Dutch society for Neurology55 to enable

the proximity of care for patients with Parkinson. The initiative is supported by the Dutch national

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Parkinson’s organization56 and different professional groups of caregivers (e.g., physiotherapists,

speech or occupational therapists, in cooperation with nurses and neurologists).

PPPs also focus on cardiovascular diseases, as these remain the biggest killer in the developed world.

The National Salt Reduction Initiative in the US is coordinated by the New York City Health

Department and 85 state and local health departments, as well as national health organizations such

as the Consumers Union or the American Medical Association.57

Other PPPs finance initiatives for cancer research and prevention. New York City programs aiming to

prevent colorectal cancer through screening for vulnerable populations are funded by the New York

Community Trust Cancer. The foundation particularly collaborates with the New York City

Department of Health.58

Health PPPs face implementation challenges, as all PPPs do (e.g., unpredicted increases in demand).

But these projects may have a fiscal impact on governmental budgets. Other key challenges that can

be expected include unclear regulations, inadequate technical capacity, maintaining the access to

and quality of care, and accountability issues.59

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3. Assessing the costs and benefits of prevention in health care In the face of the challenges previously mentioned, it appears that there is a case for disease

prevention becoming a public health priority. But a number of studies have shown that the potential

of prevention for controlling health-care costs should be carefully evaluated. Some measures are

very efficient. Investing in prevention may save money in some cases, but it may increase medical

spending in others. Much depends on the type of population and intervention.60

Investing in prevention is likely to be economically beneficial when intervention costs are low, or

when getting sick is expected to be and remain costly (as it is the case for dementia care).61 Some

studies indicate that prevention may positively affect productivity levels and lower mortality and

morbidity, thereby reducing demands or cost pressures on health-care systems: healthier people are

more productive than ill ones. And productivity losses associated with the effects of chronic diseases,

such as disability, unplanned absences and increased accidents, are estimated to cost as much as

four times more than the cost of treatment.62

More generally, good health contributes in major ways to people’s wellbeing, which can also

significantly contribute to high economic returns. Therefore, health improvement through

prevention should be increasingly perceived as a value of investment with wider benefits rather than

just an economic return on investment. Focusing on the latter may be the wrong way to think about

prevention. Instead of simply taking into account financial indicators and the sole argument of cost-

effectiveness, the value of good health could be measured through – for instance – participation

indicators, preventive screening and health risk indicators.63

Based on this perspective, Van Ewijk et al.64 present a number of health benefits. First, individual

health benefits include an increased life expectancy (‘quantity’), a better quality of life and improved

labor participation. Health is an important means for people to earn an income and to effectively

participate in society. A healthy population is also a precondition for a functioning civil society – for

instance, through voluntary work and informal care. In addition to individual benefits, better health

leads to external benefits that arise because an individual’s health is also beneficiary to others: at the

most basic level, a healthy individual does not infect others. But collectively, health is an important

condition for a highly educated and productive population.

Beyond the undisputed improvement of health status, economic benefits of prevention for

individuals themselves are also identified. In particular, a 2006 study published in the American

Journal of Public Health shows that except for smoking cures, life extension as a consequence of

preventive interventions would not lead to increasing lifetime medical spending on average, most

notably with respect to obesity, diabetes or hypertension.65 The same study calculates the effects of

prevention on life expectancy gains, revealing that a 51 or 52 year-old patient would live 0.85

additional years after being successfully treated for obesity, 2.05 years for hypertension, and 3.14 for

diabetes. In addition, longer life expectancies may imply long-term care, the ability to live

independently and potentially longer working lives. As a result, innovation in prevention anticipating

and responding to these needs may help maintain physical function and optimize health for the

elderly. This may mitigate the potential negative psychosocial effects of isolation and immobility.

For these reasons, focusing on disease prevention and health promotion deserves more attention in

future health research strategies. This suggests a new way to look at prevention – not only as a

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means to control spending – but also more generally at health, health outcomes and disease

management within health-care systems.

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Conclusion The growing prevalence of health risk factors, demographic trends and fiscal pressures on public

health-care expenditures call for the adoption of health-care systems that would place more

emphasis on the prevention of diseases and the promotion of better population health. Driven by

these health trends and an easier access to new technologies within our societies, an increasing

number of innovative projects and initiatives are directed towards promoting health and preventing

diseases. They range from the realm of new technologies and the health-care industry to the

adoption of new organizational processes and new types of collaboration, as well as a more

comprehensive transformation of values and behaviors toward the meaning of health and disease.

There is consensus that governments spend too much on treatment, and not enough on prevention,

in spite of the relevance of this approach to our societies’ health challenges. At the same time, there

is some evidence that spending more on prevention may not always help in controlling health-care

costs. More research seems necessary to carefully evaluate this issue. And the role of governments

may have to be reassessed: initiatives from communities and the private sector could provide solid

alternatives to finance and promote prevention, and may even manage to upgrade health-care

infrastructure. Shifting the focus to prevention will in any case involve a new perspective on the

definition and meaning of health and individual or shared responsibility.

1 Leroy Hood, “The Emergence of Proactive P4 Medicine: A Revolution in Healthcare”, Institute of Systems

Biology, November 2012, http://www.youtube.com/watch?v=WWxuUIjDUSM. 2 For more information on Personalization, see Issue Brief: “Innovation for Personalized Health Care” (HCSS &

TNO, 2013). 3 Sherri Kirk, “P4 Medicine 101”, The Ohio State University Medical Center: Leaders in Personalized Health Care,

Physic Ventures, Special Edition 2012, http://www.physicventures.com/files/p4_medicine_101.pdf. 4 Ruth Puttick, Innovations in Prevention, NESTA, October 2012,

http://www.nesta.org.uk/library/documents/InnovationsinPrevention.pdf. 5 Ruth Puttick, Innovations in Prevention, NESTA, October 2012,

http://www.nesta.org.uk/library/documents/InnovationsinPrevention.pdf. 6 ‘Prevention’ in this sentence refers to vaccination programs, public health campaigns on nutrition, physical

activity, alcohol abuse and smoking – as defined by the OECD. 7 OECD, “Health spending in Europe falls for the first time in decades”, November 16, 2012,

http://www.oecd.org/newsroom/healthspendingineuropefallsforthefirsttimeindecades.htm. 8 US Department of Health and Human Services, “Obama Administration releases National Prevention

Strategy”, News Release, June 16, 2011, http://www.hhs.gov/news/press/2011pres/06/20110616a.html. 9 International Agency for Research on Cancer, “GLOBOCAN 2008”, 2008, http://globocan.iarc.fr/.

10 WHO Europe, “Physical activity, Facts & Figures: 10 key facts on physical activity in the WHO European

Region”, http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/physical-activity/facts-and-figures/10-key-facts-on-physical-activity-in-the-who-european-region. 11

According to the WHO, the Body Mass Index (BMI) “is a simple index of weight-for-height that is commonly used to classify underweight, overweight and obesity in adults”. According to the BMI International Classification of adult underweight, overweight and obesity, a BMI superior to 25 means an individual is overweight, and a BMI superior to 30 corresponds to obesity. 12

World Health Organization, “Obesity and Overweight”, Fact Sheet N°311, May 2012, http://www.who.int/mediacentre/factsheets/fs311/en/. 13

The 2012 Aging Report: Economic and Budgetary Projections for the EU-27 Member states (2010-2060) (European Commission, Economic and Financial Affairs, 2012), http://ec.europa.eu/economy_finance/publications/european_economy/2012/pdf/ee-2012-2_en.pdf. 14

European Commission, Special Issue on Healthcare: Healthy Ageing and the Future of Public Healthcare Systems, 2009, http://ec.europa.eu/research/social-sciences/pdf/efmn-special-issue-on-healthcare_en.pdf.

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Association of Schools of Public Health, “Creating a Culture of Wellness: Building Health Care Reform on Prevention and Public Health”, ASPH Policy Brief, Executive Summary, 2009, http://www.asph.org/UserFiles/Prevention-and-Public-Health-Strategies-for-HC-Reform-asph-policy-paper2009.pdf. 16

Tekes and Finpro, The Consumer Healthcare Market: A New Booming Market to Conquer, White Paper, 2008, http://194.100.159.181/NR/rdonlyres/EBFC77D5-EA58-4C43-BBD1-96C999BE371B/11352/WPConsumerHealthcareMarket97.pdf. 17

Steven H. Woolf et al., The Economic Argument for Disease Prevention: Distinguishing Between Value and Savings, Prevention Policy Paper Commissioned by Partnership for Prevention, National Commission on Prevention Priorities (NCPP), United States, February 2009, http://www.prevent.org/data/files/initiatives/economicargumentfordiseaseprevention.pdf. 18

Robert M. Huff and Michael V. Kline, “Chapter 1: Health Promotion in the Context of Culture”, in Huff and Kline, Health Promotion in Multicultural Populations, SAGE Publications, 2008, http://www.sagepub.com/upm-data/23214_Chapter_1.pdf. 19

Finnish Institute of Occupational Health, KOSHA, INRS and the International Social Security Association’s Special Commission on Prevention, “International Symposium on Culture of prevention – future approaches”, September 25-27, 2013, Helsinki Congress Paasitorni, Finland, http://www.ttl.fi/en/international/conferences/culture_of_prevention/Documents/fa_culture_of_prevention.pdf 20

Theresa M. Marteau, Martin Roland and Michael P. Kelly, “Judging nudging: can nudging improve population health?”, British Medical Journal, January 29, 2011, Vol.342, pp. 263-265, http://kie.vse.cz/wp-content/uploads/Marteau-et-al-2011.pdf. 21

Zsuzsanna Jakab, WHO Regional Director for Europe, “Patient Empowerment in the European Region - A Call for Joint Action” (presented at the First European Conference on Patient Empowerment, Copenhagen, April 11, 2012), http://www.euro.who.int/__data/assets/pdf_file/0016/162232/RDs-Opening-speech-Patient-Empowerment.pdf. 22

Tais Rocha Figueira et al., “Women’s perceptions and practices regarding prevention and health promotion in primary healthcare”, Revista de Saude Publica, 2009, Vol. 43, N°6, http://www.scielo.br/pdf/rsp/v43n6/en_04.pdf. 23

European Observatory on Health Systems and Policies, “Screening in Europe”, Policy Brief, 2006, http://www.euro.who.int/__data/assets/pdf_file/0007/108961/E88698.pdf. 24

James C. Robinson and Mark D. Smith, “Cost-Reducing Innovation In Health Care”, Health Affairs, September 2008, Vol. 27, N°5, pp. 1353-1356, http://content.healthaffairs.org/content/27/5/1353.full. 25

Envisioning Technology, “Envisioning the Future of Health Technology”, Visualization Exercise, September 2012, http://envisioningtech.com/envisioning-the-future-of-health.png. 26

Siemens Corporate Website, “Demographic Change and Robotics: I, Butler”, http://www.siemens.com/innovation/apps/pof_microsite/_pof-fall-2010/_html_en/i-butler.html. 27

The Economist Intelligence Unit, A Silver Opportunity? Rising longevity and its implications for business, 2011, p. 15. Philips, Corporate website, Resident Safety Products, http://philipsseniorliving.com/content/life-safety-products/life.jsp. 28

Cees Wevers and Govert Gijsbers, “Innoveren voor Gezondheid: Technologische en Sociale Vernieuwing in Preventie en Zorg”, Uitgave naar aanleiding van symposium ‘Innoveren voor Gezondheid’, HCSS & TNO, 2013, p. 38. 29

Ibid. See also (for other examples): http://www.deloitte.com/view/en_US/us/Industries/health-care-providers/center-for-health-solutions/disruptive-innovations/index.htm. 30

The Cambridge Monitoring Group, The Future World of Healthcare, 2008, http://www.monitorinnovation.com/downloads/Future_of_Healthcare.pdf. 31

Social Innovation Europe, “Showcasing the Latest Innovations, Health Care Goes Digital”, November 19, 2012, http://www.socialinnovationeurope.eu/magazine/design-and-technology/articles-reports/showcasing-latest-innovations-health-care-goes. Full article available at http://www.health2news.com/2012/11/15/unleashing-the-synergies-of-patients-physicians-and-data-health-2-0-europe-showcased-the-latest-innovations-as-health-care-goes-digital/. 32

Ernst & Young, Pulse of the Industry: Medical technology report, 2012, http://www.ey.com/Publication/vwLUAssets/Pulse_medical_technology_report_2012/$FILE/Pulse_medical_technology_report_2012.pdf.

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33

European Federation of Allergy and Airways Diseases Patients Associations, http://www.efanet.org/wp-content/uploads/2012/12/EFA-Position-Paper-to-Save-Pollen-Info-and-Forecast-for-Europe.pdf. 34

The Deloitte Center for Health Solutions, “The Mobile Personal Health Record: Technology-Enabled Self-Care: Barriers and opportunities to accelerate use”, Issue Brief, 2010. 35 For more information on Personalization, see Issue Brief: “Innovation for Personalized Health Care” (HCSS &

TNO, 2013). 36

Ernst & Young, Pulse of the Industry: Medical technology report, 2012, http://www.ey.com/Publication/vwLUAssets/Pulse_medical_technology_report_2012/$FILE/Pulse_medical_technology_report_2012.pdf. 37

Division of Sleep Medicine at Harvard Medical School, Healthy Sleep: Consequences of Insufficient Sleep”, http://healthysleep.med.harvard.edu/healthy/matters/consequences. 38

PricewaterhouseCoopers’ Health Research Institute, Healthcare Unwired: New business models delivering care anywhere, 2010, p. 5, http://download.pwc.com/ie/pubs/2010_healthcare_unwired_new_business_models_delivering_care_anywhere_nov.pdf. 39

The Deloitte Center for Health Solutions, “The Mobile Personal Health Record: Technology-Enabled Self-Care: Barriers and opportunities to accelerate use”. 40

Science News, “Video Games Help Patients and Health Care Providers”, ScienceDaily, September 19, 2012, http://www.sciencedaily.com/releases/2012/09/120919142006.htm. 41

HopeLab, “Innovative Solutions: Re-Mission”, http://www.hopelab.org/innovative-solutions/re-mission%E2%84%A2/. 42

HopeLab, “Our Research: Re-Mission Outcomes Study”, http://www.hopelab.org/our-research/re-mission-outcomes-study/. 43

PricewaterhouseCoopers’ Health Research Institute, Healthcare Unwired: New business models delivering care anywhere, 2010, p. 5, http://download.pwc.com/ie/pubs/2010_healthcare_unwired_new_business_models_delivering_care_anywhere_nov.pdf. 44

Cees Wevers and Govert Gijsbers, “Innoveren voor Gezondheid: Technologische en Sociale Vernieuwing in Preventie en Zorg”, p. 38. 45

EURAM, Rotterdam School of Management, Erasmus University, “Social Innovation in Health Care”, June 2012, http://euram2012.nl/userfiles/file/5_%20Social%20Innovation%20in%20Health%20Care.pdf. 46

Ruth Puttick, Innovations in Prevention, NESTA, October 2012, http://www.nesta.org.uk/library/documents/InnovationsinPrevention.pdf. 47

Jason Hwang, and Clayton M. Christensen, “Disruptive Innovation in Health Care Delivery: A Framework for Business-Model Innovation”, Health Affairs, Vol. 27, N° 5, 2008, http://content.healthaffairs.org/content/27/5/1329.full.pdf+html. 48

Joel Shalowitz, “Financing Chronic Care Seminar: Chronic Vs. Acute Care, Introduction and Macro View”, 2005, www.soa.org/library/monographs/ ./chronic ./m-hb05-1_viii.aspx. 49

Frerich Frerichs and Mirko Sporket, Employment and Labour Market Policies for an Ageing Workforce and Initiatives at the Workplace. National Overview Report: Germany (European Foundation for the Improvement of Living and Working Conditions, 2007), http://www.eurofound.europa.eu/pubdocs/2007/056/en/1/ef07056en.pdf. 50

The Economist Intelligence Unit, A Silver Opportunity? Rising Longevity and Its Implications for Business, p. 11. 51

Vivica, I. Kraak and Mary Story, “A Public Health Perspective on Healthy Lifestyles and Public-Private Partnerships for Global Childhood Obesity Prevention”, Journal of the American Dietetic Association, February 2010, Figure 1, page 194, http://www.unscn.org/layout/modules/news/documents/Kraak%20and%20Story_JADA_2010_110%282%29192-200.pdf. 52

Centers for Disease Controland Prevention, “The National Diabetes Prevention Program”, http://www.cdc.gov/diabetes/prevention/. 53

The Alzheimer’s Study Group, A National Alzheimer’s Strategic Plan, 2009, http://www.alz.org/documents/national/report_asg_alzplan.pdf. 54

ParkinsonNet, website: http://www.parkinsonnet.nl/welcome/initiative-and-support. 55

Nederlandse Vereniging voor Neurologie, Nederlandse Werkgroep voor Bewegingsstoornissen. 56

Parkinson Vereniging.

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57

New York City Department of Health and Mental Hygiene, “National Salt Reduction Initiative”, 2010, http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml. 58

Fund for Public Health in New York (FPHNY), “Programs: prevent and Detect Cancers”, http://fphny.org/topics/prevent-and-detect-cancer. See also: Len McNally and Rachael N. Pine, “Partnering to Advance Public Health: A Foundation Supports Public Programs”, Grant Watch Report, Project HOPE – The People-to-People Health Foundation, Inc., Health Affairs, Vol. 28, N°2, March/April 2009, http://fphny.org/UserFiles/File/HealthAffairs.pdf. 59

International Finance Corporation (IFC), World Bank Group, “Handshake”, IFC’s quarterly journal on public-private partnerships, Issue 3, October 2011, http://www.ifc.org/wps/wcm/connect/19d4fe8048fbf76e87abef28c8cbc78b/Handshake_Issue_3.pdf?MOD=AJPERES. See also IFC, World Bank Group, “Issues in PPPs for Health Care”, IFC Advisory Services, PPPI Conference, June 2007, http://www.pppinharyana.gov.in/ppp/sectorwise-presentation/Health.pdf. 60

Joshua T. Cohen, Peter J. Neumann, and Milton C. Weinstein, “Does Preventive Care Save Money? Health Economics and Presidential Candidates”, The New England Journal of Medicine, N°358, pp. 661-663, February 14, 2008, http://www.nejm.org/doi/full/10.1056/NEJMp0708558; Janet Adamy, “Prevention Efforts Provide No Panacea on Health Costs”, Wall Street Journal, June 12, 2009, http://online.wsj.com/article/SB124476182985608115.html; Louise B. Russell, “Prevention Will Reduce Medical Costs: A Persistent Myth”, Health Care Cost Monitor, The Hastings Center, 2009, http://healthcarecostmonitor.thehastingscenter.org/louiserussell/a-persistent-myth/. 61

Ruth Puttick, Innovations in Prevention, NESTA, October 2012, http://www.nesta.org.uk/library/documents/InnovationsinPrevention.pdf. 62

World Economic Forum, Global Risks 2010, 2011, p. 25, http://www3.weforum.org/docs/WEF_GlobalRisks_Report_2010.pdf. 63

Ronald Loeppke, “The value of health and the power of prevention”, International Journal of Workplace, Health Management, Vol. 1, N° 2, 2008, pp. 95-108, Emerald Group Publishing Limited, http://www.acoem.org/uploadedFiles/Healthy_Workplaces_Now/Value%20of%20Health-Power%20of%20Prevention.pdf. 64

C. van Ewijk, A. van der Horst, and P. Besseling, “Gezondheid loont: Tussen keuze en solidariteit”, Den Haag: Centraal Planbureau, 2013. 65

Dana P. Goldman et al., “The Benefits of Risk Factor Prevention in Americans Aged 51 Years and Older”, American Journal of Public Health, Vol. 99, N°11, November 2009, pp. 2096-2101, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759785/.