Health promotion and the state

22 World Health • SOth Year, No. 3, Moy- June 1997 Health promotion and· the state Alfons Schroer & Ute Westerhoff Only three years after the Ottawa Charter was drawn up, the government committed the health insurance schemes to carrying out measures that would actively promote better health. ealth promotion is essential to achieving "health for all" . In Germany the idea of health promotion gained popularity very quickly for several reasons. There was political pressure to solve the growing problem of financing the German health system, the general public was showing increasing interest in health, and people were becoming critical of the traditional biomedical approach to ill-health which looked primarily at symptoms rather than root causes. Traditional health education aimed at preventing and dealing with medically defined risk factors and illnesses. At the same time, this approach ignored the way that living conditions influence health and how behaviour can support health. Today's health promotion strate- gies go beyond the prevention of medical risks. They build on exist- ing resources, ensure people 's par- ticipation, and aim to modify lifestyles and living conditions. The Ottawa Charter which emerged from the first International Conference on Health Promotion in 1986 was discussed intensively in what was then the Federal Republic of Germany, and steps were taken to adapt the concept of health promo- tion to the health system at different levels and in both public and non- public institutions. Three groups proved to be the main players in this field: the public health authorities, the adult educa- tion centres and the statutory health insurance schemes. The public health authorities adopted health promotion as one of their responsi- bilities following a federal confer- ence of health ministers in 1991. They took on the role of motivators and coordinators for health promo- tion in the different regions of the country, and regional health promo- tion teams were formed with staff of both public and non-public institu- tions. Also at regional level, the adult education centres were faced with a growing demand for health education and as early as 1985 drew up an outline plan that took a very broad view of health. Insurance covers early diagnosis Statutory health insurance is part of the German social security system along with pension schemes, acci- dent insurance and unemployment insurance. About 90% of the popula- tion is covered, the main purpose being to guarantee health care and provide a replacement for income in case of illness. Benefits are granted · independently of a person 's income. Originally the benefits were mostly reimbursement of costs incurred after the start of an illness, but this changed after 1971 when payment of the costs of measures for early diagnosis of illness was added to the list of benefits. Company health insurance schemes, which had been very active in the field of prevention, developed projects to reduce drug and alcohol dependence and heart disease. Health promotion becomes statutory Only three years after the Ottawa Charter was drawn up, the govern- ment committed the health insurance A clothing factory in Germany, where health insurance schemes must provide information on health schemes to caiTying out measures risks and haw to avoid them . Photo Still Pictures/H. Schwarzbach © that would actively promote better World Health • SOth Year, No. 3, Moy-June 1997 Changing shifts at a car-building plant. As male workers may not be easily reached by health messages, company health promotion is of particular importance. Photo Still Pictures/H. Schwarzbach © health. The Health Reform Law of 1989 laid down that health insurance schemes should inform insured persons about health risks and how to avoid them. Statutory health insurance schemes had developed a variety of health promotion activities even before they were required to do so by Jaw. These included: • using their own journals and brochures, as well as the local media, to inform people about health topics and give them advice about keeping healthy; • organizing courses, seminars, meetings and campaigns covering healthy lifestyles; • reimbursing costs of health screenings for a number of condi- tions; • sponsoring projects on special health topics or for special target groups; • encouraging self-help groups and company initiatives for health promotion. In 1994 a ministry of health study showed that about 8% of the popula- tion had taken advantage of the insurance schemes' health promotion offers. The users were primarily women of middle age with higher- than-average educational background and concern for health. Company health promotion Male workers can be difficult to reach with health messages, which is why company health promotion is so important. Some companies operate company health insurance schemes, and other schemes focus on a partic- ular region or profession; these are good at reaching specific target groups with health promotion. Company health insurance schemes use the following methods to iden- tify health promotion needs: • The "company health report" combines the health insurance scheme's data on absences due to sickness (duration, frequency, cause) with the company's own data, in order to see if any part of the enterprise has an increased health risk. • Working groups on health bring together representatives of em- ployers and employees with company health experts. • Surveys are carried out among employees in selected parts of the enterprise to analyse stress that they may be subject to in their area of work. • "Health promotion groups" get employees involved in analysing the causes of work-related ill- nesses and suggesting improve- ments. • Employees are screened for signs of illness or stress, where appro- priate. 23 • As problems are identified, measures are taken to prevent work-related illness by reducing avoidable strains and stresses. Recently, because of the increasing costs of the health system, the gov- ernment passed a law which had a dramatic impact on the health pro- motion and disease prevention efforts of the German health insur- ance schemes. The new law reduced health insurance premiums, which are paid partially by the employer and partially by the employee. Under this law, the health insurance schemes are no longer allowed to finance measures for healthy persons equally out of both parts of the premium. This change stemmed in part from criticism that the health insurance schemes had not effec- tively used the chances they were given, and in part from the feeling that the benefits of health promotion are felt only in the long term and are non-specific. From this year, insur- ance schemes may finance health promotion measures only from the share of the premium paid by the insured person. On the other hand, the health insurance schemes are committed to cooperate with the employers' federations in the field of prevention of work-related diseases and to inform them of any findings on correlation between illnesses and working conditions. The health promotion measures of health insurance schemes are considered by the insured as services or benefits provided in return for the premium paid. Some measures - such as those that promote the reduc- tion of high blood pressure or cho- lesterol level by changing eating habits - can even be regarded as an alternative to symptom-oriented therapy. As a consequence the health insurance schemes have become competitors with other potential suppliers in the health system. • Or Alfons Schroer is Head of the Health Department, Federation of Company Health Insurance Schemes, Kronprinzenslr. 6, 45128 Essen, Germany, and Ms Ute Westerhoff works in the same department.