Author: Beatriz González López-Valcárcel | Professor of Economics at the University of Las Palmas de Gran Canaria (Spain)
Contemporary public health can be understood through three major paradigms that complement and reinforce one another.
The first of these, Health in All Policies (HiAP), became consolidated in Europe in the mid-2000s. Its premise is simple but powerful: health does not depend solely on health policy. Decisions in education, urban planning, employment, or taxation have effects —positive or negative— on population health. For this reason, improving health requires acting on its social determinants, integrating the goal of health into all areas of government.
In parallel, two other closely related approaches have gained increasing prominence: Global Health and One Health.
Global health is based on undeniable evidence: we live in an interconnected world. Infectious agents, as we have seen with SARS-CoV-2 and hantavirus, do not recognize borders. International mobility, trade, and globalization mean that health risks spread rapidly. This requires thinking transnationally: cooperation between countries, coordinated alert systems, and, above all, health equity.
And here an uncomfortable but realistic idea emerges: equity is not only a moral imperative; it is also a self-protection strategy for wealthy countries. As long as pockets of vulnerability exist anywhere on the planet, no one is completely safe. Vaccination against COVID-19 illustrated this clearly: protecting others was, at the same time, protecting ourselves.
But global health is not limited to infectious diseases. There are other forms of “contagion.” One illustrative example is the drug pricing policy promoted in the United States during the Trump administration, which links domestic prices to those of other developed countries by adopting the international reference pricing system (1). Measures of this kind show the extent to which health decisions, even when driven by national agendas, have global consequences. As in the metaphor of the butterfly effect, what happens in one part of the planet can have effects elsewhere.
Moreover, phenomena such as climate change reinforce this global dimension: polluting emissions, biodiversity loss, and environmental degradation do not respect borders. They are externalities that spread and ultimately affect collective health. In this sense, climate change is, at its core, one of the greatest global health challenges of our time.
This is where the third paradigm fully comes into its own. The One Health approach recognizes that human health, animal health, and environmental health are part of the same system. There can be no healthy people on a sick planet. This approach places the environment at the center, as the great global public good, and emphasizes the need for integrated responses to complex threats such as zoonoses, antimicrobial resistance, and the climate crisis.
Health economics is contributing decisively to this transformation. It is increasingly common to incorporate environmental impact into the evaluation of health technologies, and progress is being made toward standardizing the methodology (2,3). It is not only important to relate the cost of a treatment to the quality-adjusted life years (QALYs) it provides, but also to its ecological footprint.
For example, when evaluating certain medicines or anesthetic gases, measurement is beginning to include not only the incremental cost per QALY gained, but also the associated CO₂ emissions. In other words, how many kilograms of carbon are emitted for each unit of health benefit. In addition, methodologies such as multicriteria decision analysis and social return on investment make it possible to integrate clinical, economic, and environmental outcomes within a single framework.
It is worth recalling a basic idea: properly understood responsibility begins with oneself. In this regard, the health sector itself generates around 5% of global greenhouse gas emissions, both directly —such as through the use of anesthetic gases— and indirectly —through energy, manufacturing, and transport of supplies. In this context, we applaud initiatives such as the green hospitals (4) movement, with tens of thousands of centers around the world seeking to reduce the environmental footprint of healthcare.
But the environmental impact of healthcare activity does not end in hospitals. Medicines reach rivers through wastewater, posing risks to ecosystems and human health. In response, a classic economic principle is gaining ground: the polluter pays. The European Union has moved in this direction by requiring Extended Producer Responsibility (5), which obliges the pharmaceutical and cosmetics industries to finance at least 80% of the costs of treating urban wastewater.
In 2019, a statement by the most prestigious economists in the United States was published in The Wall Street Journal (6), including 27 Nobel laureates in Economics, calling for a tax on CO₂ emissions, with the revenue distributed among the population in the form of “carbon dividends.”
Ultimately, the three paradigms —Health in All Policies, Global Health, and One Health— reflect the same evolution: the transition from a view focused exclusively on disease toward an integrated, interdependent, and systemic understanding of health.
And within that framework, every decision —individual, collective, or institutional— matters.
Reference
1. For further details, López-Valcárcel, B. G. (2026). Drug policy in the Trump era: Expected and observed consequences for the United States and Europe. Journal of Healthcare Quality Research, 41(3),1.
2. Williams JTW, Bell KJL, Morton RL, Dieng M. Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review. Value in Health. 2024;27(6):794-804. doi:10.1016/j.jval.2024.02.019
3. Toolan M, Walpole S, Shah K, Kenny J, Jónsson P, Crabb N, et al. Environmental impact assessment in health technology assessment: principles, approaches, and challenges. International Journal of Technology Assessment in Health Care. 2023;39(1):e13. doi:10.1017/S0266462323000041
4. Global Green and Healthy Hospitals [Internet]. [citado 20 de mayo de 2026]. Available from: https://greenhospitals.org/
5. European Parliament, Council of the European Union. Directive (EU) 2024/3019 of the European Parliament and of the Council of 27 November 2024 concerning urban wastewater treatment (recast) (Text with EEA relevance). OJEU-L-2024-81831 [Internet]. 27 November 2024. Available from: http://data.europa.eu/eli/dir/2024/3019/oj
6. Climate Leadership Council [Internet]. [citado 20 de mayo de 2026]. Available from: https://clcouncil.org/
