IS PREVENTION REALLY BETTER THAN CURE - PARAMETERS OF THE DEBATE AND IMPLICATIONS FOR PROGRAM-EVALUATION DESIGN

The relative contributions of health promotion programs and services t o the improvement of community health is the subject of long-standing debate. Critics of health promotion have argued that it does not save costs, has low cost-effectiveness compared to treatment services, does not attract strong community support and may be inequitable. The argu ments and counter-arguments that form the basis of this debate are can vassed in this paper. This is done by applying these various claims no t to health promotion in isolation, but in comparison with treatment a nd care services. The special problems for health promotion-namely tha t its benefits are often considerably delayed and only uncertainly app ly to a particular individual and are less in demand than services wit h more immediate benefits-are examined. Demand for health promotion an d other programs is considered from a political perspective. The relat ive importance of equity and effectiveness as program goals is an impo rtant consideration for program and service managers, not only for hea lth promotion but all health care programs. To address further these i ssues, evaluation of health promotion programs is urgently needed to e stablish which programs should be expanded or contracted. These evalua tions need to incorporate economic appraisal techniques and to assess program demand and equity. The two latter themes can most appropriatel y occur as part of process and impact evaluation studies. Implications for the evaluation of different types of health promotion programs ar e explored. Even if health promotion programs can be demonstrated to j ustify support on cost, effectiveness and equity grounds, they will fa ce continued political obstacles to their funding.