Public Health in Austria

Transcription

1 THE LONDON SCHOOL OF ECONOMICS AND POLITICAL SCIENCE HAUPTVERBAND DER ÖSTERREICHISCHEN SOZIALVERSICHERUNGSTRÄGER Public Health in Austria April 2010 Authors: Joy Ladurner, Marlene Gerger, Walter W. Holland and Elias Mossialos Also with: Sherry Merkur, Rachel Irwin and Jürgen Soffried Revised by: Bernhard Güntert, Horst R. Noack and Anita Rieder (Section I) Eleonore Bachinger, Gerhard Fülöp (Section II) Gerlinde Grasser (Section II and III) Werner Bencic and Claudia Habl (Section IV) Martin Sprenger (Section V) London School of Economics and Political Science, LSE Health Please do not cite without consent of the authors. Suggested citation: Ladurner, J., Gerger, M., Holland, W. W., Mossialos, E., Merkur, S., Irwin, R. Soffried, J. (2010). Public Health in Austria. Report for the Main Association of Austrian Social Security Institutions. Vienna: Main Association of Austrian Social Security Institutions. April

2 Foreword Current demographic, medical and economic developments challenge our health care system in an unprecedented way. These changes are not only relevant for the present but also for the decades to come. We are confronted with the difficult task of providing accessible, needs-orientated high quality as well as cost-effective health care to all people. Great endeavours need to be undertaken to promote sustainable health for the entire population. One needs to keep in mind that the health state of disadvantaged population groups is demonstrably more precarious and that health system processes even intensify this situation. All efforts and measures must be independent of income, level of education or professional status. Orientating health policy solely towards the health care sector is too limited. Modern health policy, which is characterised by a public health orientation, combines scientific, organisational and political efforts in order to promote the health of populations or defined population groups and creates health care systems which show a stronger focus on needs-orientation and efficiency. Needs-orientated health care services, quality, effectiveness, efficiency, free access and equitable health services should be in the emphasized when aiming to ensure the optimal level of health care services for the population in the long term. The Main Association of Austrian Social Security Institutions commissioned the London School of Economics and Political Science (LSE) to undertake an analysis of the present status quo of Public Health in Austria, as well as compiling recommendations for further improvement. The present report is intended to highlight areas of Public Health in which Austria still has some catching up to do in order to cope with the challenges lying ahead. We hope that the report leads to a fruitful discussion in Austria. This report, as well as any other studies commissioned by the Main Association of Austrian Social Security Institutions, is available for download at: April

3 Table of contents ABBREVIATIONS... 6 FIGURES... 9 TABLES... 9 ACKNOWLEDGEMENTS ABOUT THE AUTHORS METHODOLOGY INTRODUCTION HISTORY THE GERMANIC EXPERIENCE THE HISTORY OF PUBLIC HEALTH IN DEVELOPED COUNTRIES SCOPE, FUNCTIONS AND RESPONSIBILITIES OF PUBLIC HEALTH STRUCTURE OF PUBLIC HEALTH EDUCATION, TRAINING AND RESEARCH PUBLIC HEALTH IN PRACTICE SELECTED ISSUES AND COUNTRY EXAMPLES Examples of public health practice Selected issues Examples of public health in practice - Selected countries CONCLUSIONS SECTION I: ANALYSIS OF THE AUSTRIAN PUBLIC HEALTH SYSTEM INTRODUCTION AND DEFINITIONS Core functions of public health A brief overview Notions of public health in Austria Experts opinions on the definition and understanding of public health LEGISLATION FUNDING Legislation Resarch and literature Funding of public health related services Overview Funding of selected public health services and activities ORGANISATION AND STRUCTURE, STAKEHOLDERS PUBLIC HEALTH DISCIPLINES, TRAINING AND RESEARCH, KEY FUNCTIONS Public health disciplines Public health training and research structure Functions of public health in Austria CHALLENGES AND PRIORITY AREAS FOR PUBLIC HEALTH IN AUSTRIA Health and disease in Austria Challenges and priority areas for public health based on expert opinion CONCLUSIONS SECTION II: INFORMATION MANAGEMENT AND HEALTH REPORTING SECTION II: INFORMATION MANAGEMENT AND HEALTH REPORTING INTRODUCTION LEGISLATION STAKEHOLDERS HEALTH INFORMATION SYSTEMS DATA PROTECTION DATA SURVEILLANCE AND DATA ANALYSIS HEALTH REPORTING Definitions and targets of health reporting Development of health reporting in Austria April

4 6.3 Infrastructure Producers of health reports Time spans between reporting Contents of reports Influence of international reporting activities Follow-up measures, evaluation and sustainability Success factors for health reporting Ideal health reporting versus current practice in Austria Trends Social insurance s role in health reporting INFECTIOUS DISEASES Legislation on infectious diseases Mandatory reporting of notifiable infectious diseases Surveillance of infectious diseases Early warning systems Outbreak control Reporting and control of infectious diseases in practice REGISTRIES Registries at BIQG Registries at ÖBIG Disease registries Other registries CONCLUSIONS SECTION III: HEALTH TARGETS STARTING POINT AND RESEARCH QUESTION METHODOLOGY Literature review Interviews and qualitative content analysis HEALTH TARGETS A BRIEF THEORETICAL INTRODUCTION STATUS QUO OF HEALTH TARGETS IN AUSTRIA National level Provincial level Local and institutional level CRITICAL SUCCESS FACTORS WHEN USING HEALTH TARGETS THE AUSTRIAN EXPERIENCE Resources Stakeholder involvement Consideration of the Public Health Action Cycle Leadership and political commitment SUMMARY AND DISCUSSION Summary of results Discussion RECOMMENDATIONS FOR DEVELOPING HEALTH TARGETS IN AUSTRIA General recommendations Recommendations for social insurance REFERENCES SECTION IV: ADRESSING DISADVANTAGED AND SPECIAL NEED GROUPS INTRODUCTION IDENTIFICATION OF DISADVANTAGED GROUPS Dimensions and scope of the disadvantaged population Impact of the disadvantage on the health status EQUITY OF ACCESS TO CURATIVE AND PUBLIC HEALTH SERVICES Promoting access to care and healthful lifestyles of disadvantaged groups Equity of access to curative services Equity of access to public health services April

5 2.4 Selected health services for disadvantaged groups POTENTIAL ROLE OF SOCIAL INSURANCE CONCLUSIONS SECTION V: HEALTH PROFESSIONALS AND PUBLIC HEALTH PUBLIC HEALTH PROFESSIONALS IN AUSTRIA Physicians and public health Nurses Midwives Other public health professionals CAPACITY BUILDING IN PUBLIC HEALTH The concept of capacity building Leadership and Commitment Resources Structures, organisational development Networking and partnerships Workforce development Capacity building in social insurance PUBLIC HEALTH RESEARCH CONCLUSIONS SECTION VI: RECOMMENDATIONS I INSTANT RECOMMENDATIONS II GENERAL RECOMMENDATIONS III SPECIFIC RECOMMENDATIONS Section I Analysis of the Austrian public health system Section II Information management and health reporting Section III Health targets Section IV Addressing disadvantaged and special need groups Section V Role of health professionals ANNEX April

6 Abbreviations AGES AHS AIDS aks ASPHER ASVG AURES AUVA AVOS BGBl BGF BIG BIQG BM (in) BMASK BMG formerly BMGFJ formerly BMGF B-VG CDC CAP CME CML COPD CT DALY DFLE DG DLD DRG DSN EAPN EBM ECHIS ECHP ECTS ELGA EU EUGLOREH EUPHA EUPHIX Austrian Agency for Health and Food Safety (Österreichische Agentur für Gesundheit und Ernährungssicherheit) Grammar School (Allgemein Höher Bildende Schule) Acquired Immune Deficiency Syndrome Working Group for Preventative and Social Medicine (Arbeitskreis für Vorsorge- und Sozialmedizin) Association of Schools of Public Health in the European Region General Social Insurance Act (Allgemeines Sozialversicherungsgesetz) Austrian report on antibiotics resistance Austrian Social Insurance for Occupational Risks (Allgemeine Unfallversicherungsanstalt) Working Group Preventative Medicine Salzburg (Arbeitskreis Vorsorgemedizin Salzburg) Federal Law Gazette (Bundesgesetzblatt) Network for Workplace Health Promotion (Netzwerk Betriebliche Gesundheitsförderung) Business Intelligence in the Health Care System (Business Intelligence im Gesundheitswesen) Federal Institute for Quality in the Health Care System (Bundesinstitut für Qualität im Gesundheitswesen) Federal Minister (Bundesminister(in)) Federal Ministry of Labour, Social Affairs and Consumer Protection (Bundesministerium für Arbeit, Soziales und Konsumentenschutz) Federal Ministry of Health (Bundesministerium für Gesundheit) Federal Ministry of Health, Family and Youth (Bundesministerium für Gesundheit, Familie und Jugend) Federal Ministry of Health and Women (Bundesministerium für Gesundheit und Frauen) Federal Constitutional Law (Bundesverfassungsgesetz) Centere for Disease Control Common Agricultural Policy Continuing Medical Education Chronic Myleoid Leukemia Chronic Obstructive Pulmonary Disease Computer Tomograph/Tomography Disability-Adjusted Life Years Disability-Free Life Expectancy Directorate-General Documentation of diagnosis and services (Diagnosen- und Leistungsdokumentation) Diagnosis Related Group Diseases Surveillance Networks European Anti Poverty Network Evidence Based Medicine European Community Health Interview Survey European Community Household Panel European Credit Transfer System points Electronic health record (Elektronische Gesundheitsakte) European Union European Global Report on Health European Public Health Association European Public Health Information System April

7 Eurostat European Statistics EU-SILC European Union - Community Statistics on Income and Living Conditions EWRS Early Warning and Response System FH University of Applied Sciences (Fachhochschule) FGÖ Fund for a Healthy Austria (Fonds Gesundes Österreich) FOKO Calculation of follow-up costs (Folgekostenrechnung) GDP Gross Domestic Product GKK Regional health insurance fund (Gebietskrankenkasse) GÖG Health Austria Ltd. (Gesundheit Östereich GmbH.) GP General Practitioner GmbH/ Ltd. Limited company (Gesellschaft mit beschränkter Haftung) HALE Healthy Life Expectancy HBSC Health Behaviour in School-aged Children HfA Health for All HiAP Health in all Policies HIV Human Immunodeficiency Virus HP Health Promotion HPV Human Papilloma Virus HTA Health Technology Assessment ICD International Classification of Diseases IGP Institute for Health Planning (Institut für Gesundheitsplanung) IHR International Health Regulations IHS Institute for Advanced Studies (Institut für Höhere Studien) ILO International Labour Organization IPF Institute for Pharmaeconomics-Research (Institut für Pharmaökonomische Forschung) IVF In-Vitro Fertilisation KAL Catalogue ambulatory services (Katalog ambulante Leistungen) LBI Ludwig Boltzmann Institute (Ludwig Boltzmann Institut) LBI-HTA Ludwig Boltzmann Institute for Health Technology Assessment LEICON Service/benefits controlling (Leistungscontrolling) LGKK Software for the benefits/services of the regional health insurance funds (Software für die Leistungen der Gebietskrankenkassen) Ltd Limited MPH Master of Public Health MRI Magnetic Resonance Imaging MRSA infections Methicillin-resistant Staphylococcus aureus infections MSc Master of Science NGO Non-Governmental Organisation NHS National Health Service NÖGUS Health and Social Fund of Lower Austria (Niederösterreichischer Gesundheits- und Sozialfonds) OAR Austrian title Oberamtsrat OECD Organisation for Economic Co-operation and Development ÖBIG Austrian Health Institute ( Österreichisches Bundesinstitut für Gesundheitswesen) ÖGD Austrian Public Health Service (Österreichischer Gesundheitsdienst) April

8 ÖGIS ÖGPH PAHO para. PCN PHAC PHAC PSA-test PAP-test/smear PVA REACH-Registry REGIS SARS SI SMART STIs SV SVA TBC TBE TV UK UMIT US VAEB WHO (W)HR WiG Institute WONCA WW Austrian Health Information System (Österreichisches Gesundheitsinformationssystem) Austrian Public Health Association (Österreichische Gesellschaft für Public Health) Pan American Health Organisation Paragraph (in legislation) Permanent Committee of Nurses Public Health Action Cycle Public Health Agency of Canada Prostate-specific antigen test Papanicolaou-test/smear Pension Insurance Institution (Pensionsversicherungsanstalt) Reduction of Atherothrombosis for Continued Health Regional health information system (Regionales Gesundheitsinformationssystem) Severe Acute Respiratory Syndrome Social Insurance Specific (spezifisch), Measurable (messbar), Achievable (realistisch), Relevant (bedeutsam), Time phased (terminiert) Sexually Transmitted Infections Social Insurance (Sozialversicherung) Social Security Institution for Trade and Industry (Sozialversicherungsanstalt der Gewerblichen Wirtschaft) Tuberculosis (Tuberkulose) Tick-Borne Encephalitis (Frühsommer-Meningoenzephalitis, FSME) Television United Kingdom Private University for Health Sciences, Medical Informatics and Technology (Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik) United States Insurance Institution for the Austrian Railway and Mining Industries (Versicherungsanstalt für Eisenbahnen und Bergbau) World Health Organisation Austrian title (wirklicher) Hofrat Vienna Institute for Health Promotion (Wiener Institut für Gesundheitsförderung) World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians - short World Organisation of Family Doctors World War April

9 Figures Figure 1: The main determinants of health Figure 2: Commission on Social Determinants of Health conceptual framework Figure 3: Bodies and institutions involved in public health Figure 4: Life expectancy at birth and at the age of Figure 5: Healthy life expectancy at birth (as % of total life expectancy), 2005 (1) Figure 6: Healthy Life expectancy at age 65 (in years), 2005 (1) Figure 7: Main causes of death standardised death rate, EU-27, 2006 (1) Figure 8: Main causes of death in Austria: development over time Figure 9: Main causes of death 2008 in Austria men and women Figure 10: Infant mortality (per 1,000 life births) Figure 11: Ten leading causes of burden of disease, worldwide, 2004 and Figure 12: Incidence of accidents at work (2005), 1998=100, based on the number of accidents per 100,000 persons employed Figure 13: Smoking cigarettes, cigars or pipe Figure 14: Overweight people, 2003 (1) in % of total population Figure 15: Public Health Action Cycle (Learning Spiral) Figure 16: New South Wales Health Department Capacity Building Framework Tables Table 1: Public health legislation Table 2: Selected health care indicators (per 100,000 inhabitants) Table 3: Registries at GÖG/BIQG Table 4: Registries at GÖG/ÖBIG Table 5: Interview partners Table 6: Status quo of health targets in the provinces (May 2009) Table 7: Overview of the provincial health targets according to target type and Health21-orientation (May 2009) Table 8: Criteria incorporated in the target formulation of the target definition of the provinces (May 2009) Table 9: Number of health targets per topic in each province (May 2009) Table 10: Specialists in social medicine in Austria Table 11: Physicians with a training in occupational medicine in Austria Table 12: School physicians in Austria Table 13: Public health programmes in Austria an overview Table 14: Workforce development in Austrian social insurance institutions (2009) April

10 Acknowledgements Many organisations and individual experts made valuable contributions to the present report. They are subsequently detailed. We are grateful to the Austrian social insurance institutions for commissioning the research project Public Health in Austria as well as for their interest, commitment and dedication towards health policy research. We would like to thank the members of the steering committee, the interviewed experts, the visited organisations and their representatives and the reviewers for their time as well as their numerous and very valuable inputs. Their involvement in the research project is highly appreciated. Every effort was made to accommodate their comments; it was however not always possible to consider all highlighted aspects. Views expressed in the present publication are views of the authors only, not those of insurers or reviewers. Austrian public health experts represented in the steering committee were: Werner Bencic (Regional sickness fund of Upper Austria, Linz), Gottfried Endel (Main Association of Austrian Social Security Institutions, Vienna), Bernhard Güntert (Private University for Health Sciences, Medical Informatics and Technology in Hall in Tyrol, Austrian Public Health Association), Jürgen Pelikan (Emeritus Professor in the Institute of Sociology at the University of Vienna, Key Researcher at the Ludwig Boltzmann Institute Health Promotion Research), Anita Rieder (Deputy Director of the Institute of Social Medicine at the Medical University of Vienna), Martin Sprenger (Associate head of the postgraduate Master of Public Health Programme at the Medical University of Graz), Stefan Spitzbart (Main Association of the Austrian Social Security Institutions) and Nikolaus Patera (External consultant). Experts interviewed in the form of personal interviews (between February and April 2009) and/or in the context of a hearing at the Main Association of Austrian Social Security Institutions (in June 2009) 1 include representatives with the following professional background (interview partners were assured that their names would not be quoted in the report): social insurance, research and teaching (university and other research institutions), professional representations (e.g. physicians, pharmacists), public (health) authorities, patient and self-help organisations, media (print and television) and nonprofit organisations. Three organisations were visited in the form of study visits on 22 and 23 June 2009, including the Federal Ministry of Health, the Austrian Medical Chamber and the Chamber of Pharmacists. The study visit to the Fund for a Healthy Austria was postponed to 6 July Reviewers of individual sections of the report were: Bernhard Güntert (see steering committee), Horst R. Noack (Professor Emeritus in the Institute of Social Medicine and Epidemioloy at the Medical University of Graz, Head of the Master of Public Health programme at the Medical University of Graz) and Anita Rieder (see steering committee), Eleonore Bachinger (Department of Health Planning, City of Vienna), Gerhard Fülöp (Austrian Health Institute, ÖBIG), Gerlinde Grasser (Public Health Information Resarch Unit (PHIRU) at the University of Applied Sciences FH Joanneum), Werner Bencic (see steering committee) and Claudia Habl (Austrian Health Institute, ÖBIG) and Martin Sprenger (see steering committee). Stefan Spitzbart (see steering committee) reviewed the entire report. 1 Partially these individuals were interviewed twice, both by Joy Ladurner between January and April 2009 as well as in the context of a hearing which took place at the Main Association of Austrian Social Security Institutions in June 2009 April

11 About the authors Marlene Gerger is a Junior Research Fellow in the Public Health Unit at the Institute of Health Promotion and Prevention in Graz, Austria. Walter W. Holland is Emeritus Professor of Public Health Medicine, visiting Professor LSE Health at the London School of Economics and Political Science. Joy Ladurner is an independent consultant based in Austria and External Research Associate in the Department of Social Policy at the London School of Economics and Political Science. Elias Mossialos is Brian Abel Smith Professor of Health Policy in the Department of Social Policy at the London School of Economics and Political Science and Director of LSE Health. He is also the Co- Director of the European Observatory on Health Care Systems and Policies. Sherry Merkur is a Research Fellow at the European Observatory on Health Systems and Policies and LSE Health. She is the Deputy Editor of Eurohealth, and teaches in the Department of Social Policy at the London School of Economics and Political Science. Rachel Irwin is a Research Degree Student in the Health Policy Unit at the London School of Hygiene and Tropical Medicine. Juergen Soffried is a Research Officer and Head of the Public Health Unit at the Institute of Health Promotion and Prevention in Graz, Austria. April

12 Methodology Background This publication is the result of a 2-year research project commissioned by the Main Association of Austrian Social Security Institutions (Hauptverband der österreichischen Sozialversicherungsträger), featuring part of a research co-operation between the London School of Economics and Political Science and Austrian social insurance, which has existed since 2004 and so has far involved the completion of 5 research projects (including the present project) 2. Further information on the research co-operation and the publications resulting thereof 3 can be found at: Terms of reference The initial terms of reference were developed by the London School of Economics and Political Science. These were revised and finalised by the steering committee appointed by the Main Association of Social Security Institutions. The final terms of reference are provided in Annex 1. Report structure national and international findings The main report focuses on the Austrian public health situation. International examples of public health structure, functions, etc. are given in chapter 2.7 of the Introduction section of the present report. Timeline The project Public Health in Austria was decided on in October 2007 by the partners of the research co-operation. In January 2008 the first meeting with the steering group took place. Final agreement on the terms of reference was reached by September 2008, which is when the project oficially started. A first draft of the project report was presented in June 2009, a second draft of the project report was presented in December Thereafter last modifications were undertaken based on feedback following a meeting of the internal project group and the steering committee in December 2009 and the inputs provided by the reviewers. The project report was finalised early in 2010 and the final version produced by April In June 2010 the document unterwent additional editing by Susie Stewart, Honory Research Fellow of the University of Glasgow. Organisational structure Internal project group The internal project group was composed of: Josef Probst and Gerald Plankenauer from the Main Association of Austrian Social Security Institutions, Elias Mossialos, Sherry Merkur, Walter W. Holland and Joy Ladurner from the London School of Economics and Political Science and Marlene Gerger from the Institute of Health Promotion and Prevention in Graz, Austria. Contributing authors The following external research associates were consulted in the course of the compilation of selected report sections: Rachel Irwin from the London School of Hygiene and Tropical Medicine (Introduction) and Jürgen Soffried from the Institute of Health Promotion and Prevention (Institut für Gesundheitsförderung und Prävention, IfGP) in Graz, Austria. Marlene Gerger and Jürgen Soffried compiled section III on health targets. Further information on the methodology applied by them is detailed in chapter 2 of section III of the present report. 2 Previous research projects ( ) dealt with the following topics: Pharmaeconomics, performance assessment, reimbursement of physicians and incentive mechanisms and quality in health care systems. 3 The first three reports were published in both German and English; the last two reports were published in English with only the executive summary and the recommendations being translated to German April

13 Steering committee Members of the steering committee were nominated by the Main Association of Austrian Social Security Institutions. They attended project meetings, defined the final terms of reference for the research project, provided guidance and useful feedback and partially acted as reviewers of individual sections of the final report. In the course of the 2-year project the steering group met 4 times (January 2008, April 2008, February 2009 and December 2009). Members of the steering group were informed about project progress by a representative of the internal working group at the Main Association of Austrian Social Security Institutions. Experts A considerable number of Austrian experts were consulted for the present research project. All interview partners were informed in advance that their inputs were anonymous, however their professional background would be stated, e.g. university, social insurance, etc. Experts were consulted in various ways: Firstly, by means of personal interviews conducted by Joy Ladurner in German between February and April Thereby 22 interviews were undertaken, 18 of these in person, 4 were telephone interviews. The choice of experts was co-ordinated with the steering committee. Questionnairs for these expert interviews comprised a set of common questions which were supplemented by several questions defined based on the field of expertise of the respective interview partner. Secondly, by means of a hearing, which took place between 22 and 24 June 2009 in Vienna at the Main Association of Austrian Security Institutions. 24 experts were invited at the beginning of April to attend 20 minute interview sessions, 18 of which were able to come. 3 experts who could not attend the hearing were available for a telephone interview. Experts were selected based on purposive sampling, thereby aiming to include all major stakeholders and experts in the field of public health in Austria. At the hearing interviews were conducted by Walter W. Holland and Elias Mossialos, both in English and German. Interview questions focused on the area/s of expertise of the interview partner. Thirdly, by means of study visits to selected institutions, namely the Federal Ministry of Health (Bundesministerium für Gesundheit), the Austrian Medical Chamber (Österreichische Ärztekammer), the Austrian Chamber of Pharmacists (Österreichische Apothekerkammer) and the Fund for a Healthy Austria (Fonds Gesundes Österreich). The first visit took place on 23 June, the second visit on 24 June. The last study visit was postponed to 6 July 2009 due to conflicting appointments. Interviews undertaken in the course of the first three visits were conducted by Walter W. Holland and Elias Mossialos in both German and English. The interview with the representative of the Fund for a Healthy Austria was conducted by Joy Ladurner and Gerald Plankenauer in German. Literature search and review International literature search (predominantly for chapter 2.7 of the Introduction section) A variety of national and international sources was used including publications of the WHO and the European Observatory on Health Systems and Policies, furthermore official national publications and published standard publications. National literature search The national literature search was undertaken by Joy Ladurner predominantly in 2008 but was updated in 2009 and also 2010 for selected topics. A range of key words from the terms of reference were translated and used as search items in Medline, the internet search engine Google, the legal database RIS (Rechtsinformationssystem) and on a variety of websites of Austrian organisations as well as within their publications (e.g. reports, research papers, etc.). In addition various books and grey literature were consulted. Up to date and relevant search results for the Austrian public health context (in both German and English) were limited which is why a considerable amount of information used for the compilation of the final report is based on expert opinion. April

14 Meetings Several project meetings took place in Vienna, namely in January 2008, April 2008, February 2009, June 2009 and December At the meetings in June and December 2009 interim and final research findings were presented and discussed. To all meetings, apart from the one in June 2009, members of the internal project team the representatives of the steering committee were invited. Further reporting and communication In the course of the project 2 progress reports were prepared by the London School of Economics and Political Science for the Main Association of Austrian Social Security Institutions. These were intended for internal documentation only and were compiled in November 2008 and January Ongoing communication and co-ordination efforts took place within the members of the internal project team. April

15 Introduction 1.1 History Public health was easy to define before the Second World War. Major threats to life were the result of unsanitary conditions, such as a foul water supply and defective or absent sewage or waste disposal, inadequate or overcrowded housing, poor and adulterated food and thus poor nutrition, hazardous work places and little effective clinical care. Public health was then concerned with attempting to rectify these conditions either through legislative policies or through population policies. In order to do this, the malpractices of landlords, employers, the state and others had to be identified, and these had to be persuaded that improvements were essential and could lead to improvements in health status and better life expectancy. At the beginning of the Twentieth Century, many of these ills had been tackled and we no longer had open sewers or child labour. At that time, a new focus for public health also began to be identified, namely the improvement of health, as well as the prevention of disease and death. Thus, public health began to be involved far more actively in health surveillance and in identifying particular groups who need additional help, such as pregnant mothers, infants and small children. In the last 100 years or so, public health has thus become concerned with the organisation of services in order to prevent illness, improve the environment, but also, in the abilities of medical science to prevent, as well as cure disease. We are now involved not only with the control of infectious disease, but also with the control of other conditions which entail not only population or legislative control, but also changes in individual behaviour. Public health must therefore also mean involvement with the local community on two levels. First, public health professionals need to work with representatives of their community to find the best structure for what requires to be done through a reciprocal process of communication and partnership. Second they must also work with and guide those responsible for the planning and provision of those structures and activities which affect the health of a population, for example, housing, water, sewerage, education, employment, transport and clinical services. Only through effective collaboration across many boundaries, can health be maintained and improved. The best working definition of public health to be considered, is the one which was put forward by Acheson in 1988, that public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. 4 The origins of modern public health are in the 19th and 20th Centuries and the state of the current public health - its philosophy, function and structures - cannot be fully understood outside of its historic context. That is, the orientation of modern public health has developed in response to the changing health and social issues, as well as in response to the political context and shifting roles of the state. 1.2 The Germanic experience For the most part, the development of public health in German-speaking countries, including Austria, follows the trajectory experienced by most developed countries, as outlined below. However, there are a few points that warrant mention. Firstly, one of the earliest important figures in the development of modern public health was Johann Peter Frank, a German physician. His nine volume treatise, System einer vollständigen medizinischen Polizey, was a comprehensive examination of various aspects of public health, covering subjects such as sanitation and water supply, sexual health and prostitution, maternal and child health, a school health service, accident prevention and food safety. The first volume was published in 1779, subsequent volumes were released serially until Public Health in England. The Report of the Committee of Inquiry into the future of the Public Health Function (The Acheson Report) London. HMSO April

16 The work is best translated to English as A System of a complete Medical Policy, although as the word Polizey also means police, the title has often been mistranslated as A System of Medical Police, with authoritarian overtones. 5 Although this was not Frank s intention in Germany at the time, authority tended to come from the ruler or adviser to the people and people were likely to conform. Frank s work presented a comprehensive health policy which had much impact upon Germany and other countries with close cultural contact, particularly in Eastern Europe. Secondly, in the late 19th Century, the industrial accident and health insurance schemes were introduced following Bismarck s social policy programme in Germany, which saw the founding of the modern social welfare model. Currently in Austria, the Federal Ministry of Health assumes many of the responsibilities for public health. However, responsibilities are also assumed by other federal ministries, the provinces and municipalities and the social insurance institutions, which are self-administered public corporations. 1.3 The history of public health in developed countries In the era prior to WWII, the main threats to health were unsanitary conditions such as an unsafe water supply, poor food, hazardous workplaces and overcrowded housing. Public health worked to rectify these conditions through legislative and population policies. 6 Then throughout the 20th Century, as health concerns evolved, public health expanded to include the promotion of health and not just the prevention of ill health. Public health also looked at individual behaviours affecting health, not only population-wide issues. It is through an examination of the last two centuries of public health that one can understand how the scope, functions and structure of public health have evolved into the modern era. Late 19th Century During this time the main health problems were caused by poor environmental conditions, including faecal contamination of the water supplies, widespread under nutrition, contamination of food, overcrowded and inadequate housing, and the poor working conditions associated with early industrialisation. This led to a high prevalence of diseases such as tuberculosis, enteric infections, infant mortality and acute respiratory diseases. Occupational health problems were also significant. For example, dangerous working conditions are profiled in works such as Upton Sinclair s novel The Jungle, and his other non-fiction works, which chronicle the exploitation of women and children and include accounts of industrial accidents, such as workers falling into rendering tanks. Early public health action, such as the antipoverty (reform) movement and public health structures, arose in response to this largely though legislative and population policies. These policies addressed the malpractices of landlords, employers and the state, although such reforms were met by opposition from employers and landlords who were concerned with lost profits. This era also saw significant achievements in sanitation and the development of sewerage systems, although this was more notable in Britain than in continental Europe. 7 Pre-WWI era By the end of the 19th Century, many of these issues, particularly poor housing and child labour, had come to the attention of the government and the public, although there remained much to be done. However, the Boer War marked another turning point for public health. The United Kingdom had difficulties finding young men of suitable physical fitness to fight, with just over one-third being turned away due to poor health and poor physical condition. 8 This made it clear that promoting good 5 Holland, W and S. Stewart. Public Health: The vision and the challenge. London: The Nuffield Trust, Holland, W and S. Stewart. ibid. 7 Hamlin, C. The history and development of public health in developed countries. In Oxford Textbook of Public Health. 3 rd Edition. Ed. Detels, R et al. Oxford: Oxford UP, Holland, W and S. Stewart. ibid. April

17 health was needed, as much as the prevention of death and disease. This further led to the increased awareness of child and maternal health, the promotion of health in schools, the adoption of social health insurance and the enactment of public health laws. It also led to public health s more active involvement in health surveillance and in identifying groups with special needs, such as pregnant mothers, infants and small children. This surveillance function was further structured in the period between WWI and WWII. Era between the wars The beginning of this era focused on surveillance, containment and prevention of infectious disease. Typhoid, tuberculosis, smallpox and other infectious diseases continued to plague most of Europe. However, there were significant advances in chemotherapies towards the end of the period. This era also saw a beginning of a decline in childhood illnesses, which had much to do with advances in prevention efforts through increased numbers of children being vaccinated against disease. For example, deaths from measles and whooping cough in Glasgow, Scotland declined from 551 and 621 in 1905 to 4 and 7 in 1954, respectively. 9 Despite the advances towards the end of the 19th Century, issues such as poverty and unsafe housing and work environments persisted and continued to preoccupy public health. Post-war era The post-war era saw a decline in many infectious diseases and an increasing realisation of the burden of chronic disease and accidents. However, diseases such as hepatitis and sexually transmitted infections (STIs) as well as rabies persisted; the latter particularly in post-wwii Germany and Austria. It was also in this period that antibiotics became widespread in their use for the treatment of infectious disease. In part because of the availability of antibiotics, health services began to realise that they could treat disease, not only prevent it. The post-war era also saw a significant expansion in health service provision. Recent and current issues in public health In the recent past and currently, we have seen a continued rise of chronic diseases, many of which are brought on by industrialisation - smog and pollutants, smoking, and sedentary lifestyles that contribute to obesity, cardiovascular diseases, chronic obstructive pulmonary disease, asthma and cancers. 10 Changes in western diets such as increased use of refined sugar, diets high in fats and low in fibre, have also been implicated in the cases of mortality from such conditions as diabetes, and colon cancer. For instance in the United States, 40% of deaths are related to cardiovascular disease, whose risk factors include smoking, poor nutrition, diabetes and obesity. 11 In the WHO Europe Region, noncommunicable diseases account for 86% of deaths and 77% of the disease burden, with cardiovascular diseases alone accounting for more than half of these deaths. 12 However, this is not to say that chronic disease is the only current concern of public health. Other current issues include: multiple-resistant Staphylococcus aureus, or MRSA infections in hospitals, the emergence of HIV, chemical and environmental hazards, food safety, bioterrorism, emerging infectious diseases, and mental health, including violence and suicide. Sexual health issues are also manifest, including those related to abortion, access to contraception, and teenage pregnancies. 9 Chalmers. A.K. and A. Macgregor cited in: Holland, W and S. Stewart. Public Health: The vision and the challenge. London: The Nuffield Trust, A.R. Omran (1971) The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. Milbank Memorial Fund Quarterly. 49: Trends: Overweight and Obesity Trends Among Adults. US Centers for Disease Control and Prevention web site. Available at: (2 January 2009) 12 Fact sheet EURO/03/06. Tackling Europe s major diseases: the challenges and the solutions Copenhagen: WHO, Available at: (accessed 12 January 2009) April

18 Additionally, changing age structures and fertility patterns also affect public health throughout developed countries. In Austria, specifically, since 1992 the average birth rate per woman in has been less than 1.5; on a long term scale, it would be necessary for each woman to bear 2.1 children to maintain the population at its current level. One of the biggest challenges to social and health policy in the coming years will be the greater-than-average increase in the number of elderly and very old people. People over the age of 60 currently total about 1.8 million, and will grow to 2.7 million by the year At the same time, the age-group comprised of those 15 to 59 will shrink. 13 The public health implications of this will likely be an increase in diseases such as blindness and deafness, social isolation, Alzheimer s disease, cancers and cardiovascular diseases and an increasing dependency of this population on care services. However, it should be noted that the impact of the aging population will likely be mitigated by increased migration. Finally, in light of increasing globalisation, public health has become an issue of foreign policy and security. 14 Emerging diseases such as HIV/AIDS and Severe acute respiratory syndrome (SARS) do not recognise national borders. Furthermore, bioterrorism is a present and growing threat as witnessed by the Sarin attacks on the Tokyo subway in 1995 or the post-9/11 anthrax attack in the United States. 1.4 Scope, functions and responsibilities of public health Addressing determinants of health As discussed above, in its first modern conception in the 19 th Century, public health was preoccupied with the direct determinants of health, such as nutrition, environmental and occupational hazards, lifestyle issues, as well as the wider determinants, such as poverty education and housing. Dahlgren and Whitehead 15 use the health determinants model to demonstrate this as in figure 1 below. Figure 1: The main determinants of health Source: Whitehead and Dahlgren (1992) 13 Public Health in Austria. Austrian Embassy web site. Available at: (accessed 12 January 2009) 14 Wyn Owen, J. and O. Roberts. (2005) Globalisation, health and foreign policy: emerging linkages and interests. Globalization and Health. 1: Whitehead M. and G. Dahlgren. Policies and strategies to promote social equity in health. Copenhagen: WHO, April

19 This model takes into account firstly the general socio-economic, cultural and environmental conditions, such as the availability of food, shelter and housing, as well as access to general education, health care services and the economic situation in which those that are able to work can and those unable to do so are supported. It also takes into account individual behavioural factors, such as eating, exercising, smoking and alcohol consumption although it recognises that these are often a product of the wider socioeconomic, cultural and environmental factors. Moreover, it looks at how community and social networks affect one s mental health through social connectedness and support systems. This model acknowledges the influence of demographic and genetic factors on health, as well. To this end, public health must be concerned with the health risks of specific population groups, such as men, women, children, the elderly and ethnic minority populations. Much of modern public health is designed to blame the individual for choosing certain risk behaviours, such as smoking or poor diet, but in fact should acknowledge the wider structural factors that influence decision-making. A similar diagram from the report of the Commission on Social Determinants of Health 16 demonstrates a few of the pathways whereby the wider social-economic environment, one s social position and opportunities affect health (see figure 2 below). Figure 2: Commission on Social Determinants of Health conceptual framework Source: WHO Commission on Social Determinants of Health (2008) Indeed, inequalities in health outcomes are caused by the unequal distribution of power, income, goods, public services and education, as well as by living and working conditions. 17 Assessing both the direct and wider societal and environmental conditions which affect health allow the field of public health to identify areas for intervention and to tackle the roots of health inequities. 16 WHO Commission on Social Determinants of Health. Closing the Gap in a Generation. Geneva: WHO, Available at: (accessed 12 January 2009). 17 Ibid April

20 Scope & responsibilities Major public health problems have tended to recur over the years, sometimes in slightly different guises or with modifications. There are four broad types of problems: 1) Outbreaks of disease caused by infective or toxic agents, e.g. smallpox, typhoid, food poisoning, influenza, radiation and so on. 2) Problems arising from social and environmental issues, such as inadequate housing, unemployment, poverty, abortion, fluoridation of water supply. 3) Behavioural concerns, such as smoking, excessive consumption of alcohol, drug taking and insufficient exercise. 4) Health service issues including the assessment of health care needs and outcomes and the effectiveness and efficiency of particular services. Public health as a discipline must not become directly involved in the management of clinical services, whether in the community or within institutions. Both, because it lacks expertise for this task and because its prime responsibility is to promote health and to prevent and control disease. It must therefore have responsibility for surveillance and for the planning and coordination of measures which promote and maintain health. It needs to be involved in the planning and distribution of clinical services in accordance with measures of need and demand and the assessment of effectiveness. 1.5 Structure of public health Public health is exercised at all levels: central, provincial/regional and local and certain tasks are better accomplished by certain levels of government. In general, many of the tasks carried out by a locality or town may be coordinated by provincial structures, which are then overseen at the national, and sometimes international, level. There must also be processes in place to ensure accountability. That is, if a public health physician at the local level identifies a public health issue, there should be a clear mechanism through which he can report this to the provincial or national level and he should be informed when the issue has been addressed. Moreover, public health must be independent of politics and political influence in its design. Many public health recommendations go against other policies. For instance, in the historical example, factory owners were against reforms to ensure workers safety for fears of lost revenue. Thus, public health must be able to work in the interest of health and not be ignored for monetary or political reasons. This may mean appointing provincial or national public officers who remain in their post regardless of the current government and who can only be removed in cases of gross misconduct, not based on their recommendations. In addition, public health is best carried out by multidisciplinary teams, with individuals undertaking specific responsibilities. There are various models of public health infrastructure which may exist simultaneously within the same country or region. These exist at local, provincial, national and international levels, as shown in figure 3 below. Moreover, public health work occurs outside these official structures, as well. For instance, most public health research takes place within universities and academic centres. April

21 Figure 3: Bodies and institutions involved in public health Bodies & Institutions involved in Public Health World Health Organisation European Commission International Organisations Other UN Bodies International NGOs Public Health Agencies & Services Ministries of Health Public Health Commissions & Committees Sometimes combined National Institutes of Public Health Other Government Ministries Research Institutions & Universities National Level NGOs Local & Regional Public Health Boards and Agencies Local Health Authorities Local Government Local & Community Level NGOs General Practitioners Legend Direct influence (Laws & Mandates) Indirect influence (Recommendations, Funding, Collaboration, etc) Source: Authors own National and local structures Public health efforts must be incorporated into all levels of the health system, from primary care to hospital care. This includes ensuring involvement at the general practitioner (GP) level, via working with regional health bodies, as well as by liaising with physicians associations. For example, in a drive to tackle obesity in 2008, NHS Scotland staff - GPs, nurses, health visitors and pharmacists - were sent guidance to advise their patients on how to incorporate exercise into one s daily routine. To this end, public health must be incorporated into other sectors as well, such as education, social welfare and transport policies. For instance, if GPs are to advise patients on how to incorporate exercise into daily life, the government must provide facilities, such as playgrounds and sporting grounds or promote active transport policies, such as walking and cycling. In terms of creating a healthy environment, local authorities can control traffic patterns and affect road safety and should ensure that housing stock is safe. The incorporation of health into other sectors will be discussed further below. Generally, larger municipalities will have public health boards. In federal or provincial systems, such as Canada or the United States, the states and provinces will also have their own public health structures, which have traditionally focused on communicable disease control, such as vaccination programmes and monitoring outbreaks of notifiable diseases, rather than on health promotion. At a national level, public health efforts take several forms. For instance, Health Japan 21 is a national prevention campaign aimed at strengthening primary prevention, creating an environment conducive to enhancing health, appropriate goal setting and monitoring, and coordination amongst April

22 health bodies. 18 This type of campaign may be organised by the Federal Ministry of Health or public health bodies, such as a national public health agency or service or by a national institute of public health. Examples of public health agencies in North America include the Centers for Disease Control and Prevention (CDC) in the United States and the Public Health Agency of Canada (PHAC). PHAC was established in 2004 to focus on emergency preparedness and response, infectious and chronic disease prevention and control, and injury prevention, and to facilitate coordination amongst federal, provincial and territorial governments. Public health agencies tend to be large bodies concerned with the public health of the nation and coordinate with international bodies such as the WHO. They may also coordinate the work of national disease surveillance and public health laboratories. National authorities also set standards for vaccination schedules, food labelling and food safety, as well as for road and occupational safety. In federal or provincial systems, lower levels of government may also have their own laboratory and surveillance structures. In contrast to large public health agencies, national institutes, such as those seen in Finland and Sweden serve similar purposes to public health agencies, but often have a smaller remit. By its broadest definition, a national institute of public health is a science-based organisation that provides leadership and expertise for a country s efforts to protect and improve health. 19 In most cases these institutes are attached to or affiliated with the country s ministry of health and are linked to other governmental agencies with public health competencies. The main functions of public health institutes are to assess the country s health status, to protect health through surveillance and response and to conduct research to inform policies and programmes. 20 These institutes typically serve to monitor public health, inform policy and coordinate amongst other health and non-health bodies. Most institutes address communicable disease, as well as chronic disease and often focus on the wider determinants of health. They have a national scope of influence and national recognition. Within this broad definition, the actual range of functions and organisational structures of national institutes of public health is vast; there is no explicit definition or criteria for what constitutes a national institute of public health and budgets range from tens of thousands to billions of dollars. 21 Although governments and supranational bodies may do much to promote health, policy decisions often negatively affect health. For instance, the EU subsidises the production of tobacco; this is also within the remit of public health to address these contradictions. Supranational and international structures In addition to institutions, programmes and foundations at the national level, work on chronic disease can also be undertaken at the supranational and international levels. Certain tasks are within the remit of the European Union and the World Health Organization has multiple functions as well. Although under the EU s principle of subsidiarity the responsibility for health policy and the provision of health care is mainly the responsibility of individual Member States, there are instances in which cooperative action is more effective. These are mainly in the realm of health threats that are crossborder or international in nature, such as pandemics and bioterrorism or those that relate to the free movement of goods, services and people. Other tasks for which the EU is responsible include worker s safety, food safety and consumer protection, action on accidents and injury, and addressing health concerns related to climate change. 18 Health Service Bureau. Japanese Ministry of Health, Labour and Welfare web site. Available at: (accessed 14 January 2009). 19 International Association of National Public Health Institutes web site. Available at: (accessed 14 January 2009). 20 Ibid. 21 Binder et al (2008) National Public Health Institutes: Contributing to the Public Good. Journal of Public Health Policy. 29: April

23 The Directorate-General for Health and Consumers (DG Sanco) works in three main areas: public health, consumer affairs and food safety. 22 Other Directorate-Generals whose remit affect health include DG Energy and Transport, which works in road safety and DG Agriculture and Rural Development, which is responsible for overseeing the Common Agricultural Policy (CAP), a policy which has had many negative affects on health, such as subsidising foods with a high fat content. The Research Directorate-General commissions research, with a budget of 6.1 billion for health-related research from The EU s public health competency is limited and other than fines, there is little incentive for Member States to accept health-related recommendations. However, many Member States do want assistance and typically, if work at the EU level fits in with national priorities, it will be accepted by Member States. It is in other areas, such as agriculture, environmental policies, and food and drink labelling the EU has a larger remit. It is partly for this reason that during Finland s EU presidency in 2006, one of the aims was Health in all Policies (HiAP). This served to [establish] coordination mechanisms to ensure that the health dimension is integrated into activities of all Commission services. 24 A large part of this initiative was developing methodologies for health impact assessments to be conducted in an integrated manner throughout all European Commission level activities. These are based on environmental impact assessments and their objective is to evaluate how non-health policies and practices will affect health. 25 Certainly, in practice further developments are necessary, but recognising the impact of other sectors on health is a crucial first step. The WHO also plays an international role in dealing with chronic disease. Specifically, the functions of the WHO Europe Region in dealing with chronic disease prevention are threefold: surveillance, research and recommendations. It provides a coordinating function only to the extent to which it coordinates research and surveillance amongst countries and research institutions, and provides a forum for stakeholders to discuss research and produce recommendations and guidelines for addressing health issues. In contrast to the EU, the WHO has no statutory power. It can provide recommendations and issue policy statements, but has no authority over its Member States. Other actors and sectors Aside from government and international bodies, other actors from civil society to academia play an important role in public health. The United Kingdom has a very active charity sector. Large organisations may run nation-wide campaigns and raise money for both public health and biomedical research, whilst smaller community-based organisations may run local initiatives, such as healthy eating cooking classes or blood-pressure screening. However, rather than providing services, the UK charity sector has had a large role in mobilising public opinion and lobbying the government to change its policy on health-related issues. Also, as mentioned earlier, because other sectors both affect health and are affected by it, the public health sector must liaise with these. For instance, in tackling obesity, public health must work with the transport sector to promote active forms of transport, such as walking and cycling. It must also work with agencies involved with food standards in terms of clear labelling on food. In terms of controlling outbreaks of disease and addressing bioterrorism threats, public health must coordinate with defence and security services. To this end, public health needs appropriate legislative means to achieve its goals in working cross-sectorally. 22 DG Sanco web site. Available at: (accessed 14 January 2009) 23 European Public Health Alliance web site. Available at: (accessed 14 January 2009) 24 Madelin, R. Forward. In Ed. Ståhl, T et al. Health in All Policies: Prospects and Potentials. Helsinki: Ministry of Social Affairs and Health, Available at: (accessed 14 January 2009) 25 Salay, R. and P. Lincoln. (2008) Health impact assessments in the European Union. Lancet. 372 (9641): April

24 Multidisciplinary nature of public health Public health is a multidisciplinary field which requires a wide range of skills and tools. Working within the aforementioned public health structures are specialists with training in a variety of disciplines. These include: epidemiologists, statisticians, economists, physicians, demographers, policy specialists, geneticists, anthropologists, sociologists, ethicists, information systems and computer specialists and many others. Moreover, public health draws upon the tools and methodological approaches of these myriad disciplines. Referring back to the public health domains, we can see examples of multidisciplinary approaches. For example, in health protection, statisticians and epidemiologists gather and analyse data on health threats and diseases, including the use of registries for notifiable diseases and cancer. This data then can inform work on protocols for addressing outbreaks and health emergencies and for designing appropriate treatment and prevention efforts. With regard to health improvement, social scientists work on analysing individual health behaviours and the social and community factors contributing to ill health. In terms of ensuring health service and social care quality, economists measure health interventions in terms of their cost-effectiveness. However, not all specialties are required at all levels. For instance, it may be significantly more cost effective for a laboratory to be based at a regional level, to which local authorities can send specimens, rather than suggesting that each town have its own laboratory. Public health practitioners must be skilled in the handling of outbreaks of disease and the law has to be clear about the responsibilities that they can fulfil to ensure that these responsibilities are accompanied by the necessary powers to act. Training in epidemiology is crucial to this activity. Public health practitioners need to develop the essential links with microbiology and toxicological laboratories, so important in the control of outbreaks, but they must also be appropriately knowledgeable in these disciplines to be able to assess and use this expertise to best effect. Defined responsibilities for this require explicit organisational links and adequate powers to investigate and control any outbreak. For this, relevant methods of disease surveillance, including education, are essential. Public health has key needs in the collection, analysis and dissemination of accurate information. It must have a major role in the design and implementation of appropriate supporting information systems. Expertise is required related to demography, social and environmental data, it is essential for the measurement of utilisation and of outcome, and public health experts must have an understanding of economic principles. It should, however, not be involved in financial, or other purely administrative data, such as those related to manpower. For the effective monitoring of health needs and outcome, the data collected about patients must be linked to individuals and not merely based on events. Methods of record linkage which respect confidentially have been pioneered in Oxford and Scotland as well as in several other European countries such as Sweden and Denmark. 1.6 Education, training and research Effective public health work is underpinned by both a trained public health workforce, as well as an evidence-base for making public health decisions that comes from research. Public health research is typically conducted by institutes and academic centres and many of the governmental bodies collaborate with these bodies to both educate new generations of public health professionals and to conduct research on best practices in public health policies, interventions and programmes. Research must also be encouraged at the local level. To this end, regional and national governments must ensure that local authorities have the capacity to carry out local research and training. As discussed above, public health is a multidisciplinary field, which includes not only clinicians, but also epidemiologists, statisticians and social scientists. In establishing centres for public health training, it is important to involve physicians and physicians associations and bodies from other disciplines. Aside from a grounding in the basic disciplines, public health training should also include a practical element, such as a work placement in a public health agency. For instance, the Faculty of Public Health in the United Kingdom sets out a five-year training plan for those wishing to become public health physicians. Another model is found in the United States, where the American Association of Public Health Schools accredits schools of public health, based on their April

25 course content and examination practices and develops standards for qualifications. What is paramount, regardless of the model, is that public health training is regulated and regularly inspected and includes both academic education and practical experience. One of the major needs for public health practitioners is the ability to communicate with the media, pressure groups and the public, on the concepts of health risk. Thus, it is essential that risk perception and communication is an important part of the role of the public health practitioner and they must be properly educated to fulfil this. This also implies that one of the major tasks of the public health practitioner is diplomacy. In order to be able to persuade others to do what is required. Thus in order to fulfil the role effectively, it is necessary: 1) to be forthright in the advocacy of programmes that improve health and to state clearly and openly the dangers and consequences of some actions, whether they are clinical, environmental or political. 2) for public health practitioners to be able to influence the budget for public health activities and to ensure that long term public health issues are considered on a separate dimension from short term clinical and practical issues. 3) that public health practitioners assume a clearly identifiable role in helping to influence and guide the policies not only of health authorities, but also of schools, environmental agencies, welfare agencies, housing departments, microbiology departments etc. 4) an important component of influencing both individuals and authority, is to prepare an annual report which highlights the problems of public health in a particular locality. This can direct the programme of work and is a positive opportunity to progress it and assess what has happened. 1.7 Public health in practice Selected issues and country examples Examples of public health practice Selected issues The fact that public health is multidisciplinary, affected by many sectors, and tackled in various ways based on its overlapping domains is demonstrated in the following examples. These discuss important considerations in dealing with three specific public health issues. Coronary heart disease Risk factors for coronary heart disease include high blood pressure, obesity, smoking, and a lack of exercise. At a local level, GPs and community pharmacies may run blood pressure screening programmes so that individuals are aware of their blood pressure and subsequent disease risk; individuals with increased risk should then receive follow-up care to treat their blood pressure. Local authorities should also offer smoking cessation services; whilst at the national level, government should implement policies, such as smoking bans and ensure that smoking prevention education occurs in schools. Also, individual behaviours such as diet and exercise are very much constrained by structural issues, such as environment and access to healthy food. Regional and local planning commissions must ensure that sports facilities are available to all and that cost is not a barrier to sport. Moreover, at the national level, the government can set targets for supermarkets to reduce the amount of salt in their prepared foods and explore the option of subsidising the cost of healthy foods, such as fruit and vegetables. Abortion and fertility Abortion and fertility are significant public health issues, particularly in areas which have high abortion rates. The government should ensure appropriate sexual education in schools, and easy access to contraception, such that cost is not a barrier for those unable to afford contraceptive measures. Sexual health clinics should be easily accessible, staff should be supportive, and it should not be difficult or stigmatizing for a woman to utilize these clinics. April

26 Violence Violence includes road accidents, family violence and industrial accidents, all of which may or may not be related to alcohol, drugs and education. Towards achieving the public health goal of reducing road accidents, appropriate alcohol and drugs policies at the national level should be adopted to prevent drink driving, and should be followed up with appropriate education, both in schools and more widely. Preventing family violence is also within the realm of education. For instance, children living in a violent household may not realise that what is happening to them in not right. Additionally, teachers and other educators should be trained to notice signs of abuse and to have a system in place where they can report these to the local authorities and know that these will be addressed. Finally, industrial accidents should be prevented through both a system of worker education and training, which is the responsibility of their employer, and through industrial regulation that is ensured through worksite safety inspections carried out by government authorities Examples of public health in practice - Selected countries 26 In the present chapter examples of public health structure, functions, etc. in selected countries are provided. These include Canada, France, Germany, the United Kingdom and the United States CANADA Canada is a federal state with ten provinces, ranging in population from 130,000 to 10,000,000 and 2 territories. 8 provinces are primarily English speaking. Quebec is primarily French speaking and New Brunswick is bilingual. Although the country is one of the most decentralised federal states, most provinces are demanding, and receiving, greater autonomy. Health status The health status and health problems of the Canadian population are similar to those of other developed countries. Infectious diseases Vaccine preventable diseases are well controlled, consistent with high immunisation rates; around 75 80% of two year olds and 95% of children at school entry have been adequately immunised. Tuberculosis remains a fairly common problem, especially among some immigrant groups and the aboriginal population. There is very little multiple drug resisting tuberculosis. Aids is a problem, requiring appropriate new policies. Chlamydial infection has become the most common sexually transmitted disease while gonorrhea rates are falling rapidly. Hepatitis B is a problem among intravenous drug users and some immigrant groups. Chronic diseases Non-communicable diseases and injuries are the major cause of morbidity and mortality. Cardiovascular diseases comprise about 40% of all deaths, cancer 27%, respiratory diseases 8% and injuries and poisoning about 7%. Leading causes of potential years of life lost before age 75 are ischemic heart disease, motor vehicle injuries, suicide, and lung cancer in males, and breast cancer, motor vehicle injuries, ischemic heart disease and congenital anomalies in females. Mental health Many chronic psychiatric patients who had previously been institutionalised are now homeless on the streets. Canada has a relatively high suicide rate, especially in the aboriginal population. The impact on potential years of life lost is high because young people are especially affected. Although 81% of March Adapted from International Handbook of Public Health, Ed. K. Hurrelmann and U. Laaser. Greenwood Press April

27 adults drink alcohol, only 6% of drinkers drink more than 14 drinks per week. 5% of Canadians report marijuana or hashish and 1% cocaine or crack use during the previous year. Age, gender and social class effects There are the expected health gradients by age as well as substantial inequalities in health by income group. For example, life expectancy is 6.3 years less among males in the lowest income quantile than among those in the highest income quantile. There is a fairly marked geographic gradient in mortality, which is higher in the east and lower in the west. Aboriginals present by far the most notable inequalities in health. Canadian aboriginals are disadvantaged in almost every way education, employment, income, housing and health. Health situation of immigrants and refugees The various waves of immigrants have brought their health problems with them, but these have been fairly quickly controlled. Immigrants have been a major focus for tuberculosis for decades, most recently, among the recent influx of Somalis. About one quarter of immigrants are refugees, many of whom bear the scars of war and torture. Population development The founding peoples of the modern state were French and English but their numbers have been equalled by massive immigration from other European countries and more recently from Asia. The Asian population is relatively young for a developed country, but is aging fairly rapidly. Fertility is below replacement level. Contraception is widely available, and used. Abortion is treated much like any other surgical procedure. Nutritional problems The main nutritional problem is over eating. Despite major improvements, half the population remains sedentary. It is estimated that up to one quarter of all children now live in poverty and under nutrition among these children has become a major concern. Environmental hazards Adverse effects of the environment are confined to occupational groups e.g. lung cancer in uranium miners, injuries in farmers. Air pollution is a concern in the industrial East; it is minor by international standards. Indoor air pollution is increasingly recognised as a problem. Exposure to ultra-violet radiation is increasing with the thinning of the ozone layer. Natural radon levels are high in parts of western Canada and explain a small proportion of lung cancer deaths. The most important pollutant to which Canadians are exposed is tobacco smoke. Provision, utilisation and impact of health services Canadian health services are mainly private, non-governmental. The major professions are selfregulating under the authority of the provincial governments. Most doctors and dentists are independent professionals working alone or in small groups. Community health centres sponsored by community groups care for less than 5% of the population. Most hospitals are owned by charities or municipalities. The provinces own the much reduced chronic psychiatric hospitals and the federal government owns hospitals for the military and for aboriginals. The health care system has always emphasised institutional care but is now moving towards shorter lengths of stay, out-patient care and day surgery. Nearly all births occur in hospitals, many of which are now developing birthing centres to offer a more natural childbirth. Public and private health insurance Because health is primarily a provincial responsibility under the constitution, the National Health Care Programme actually comprises ten provincial programmes and two territorial programmes. It is the dominant feature of the system which is so popular that it is to be regarded as the defining feature of the country. April

28 Health care financing Premiums are charged in only two provinces, the remainder support the programme from general revenues and a few charge pay roll taxes to employers. Hospitals are on global budgets based on the previous year s budget plus whatever increment the provincial government offers. Most physicians are paid by fee for service, a few by capitation and perhaps a third are salaried trainees, academics, specialists in pathology, radiology etc. Just over 70% of all health care expenditures are made by governments. Relation between ambulatory and hospital care Neither physicians, nor hospitals, are responsible for the care of defined groups of patients. Large hospitals operate specialised out-patient clinics. Most physicians are private practitioners who apply to hospitals for hospital admitting privileges (being able to admit and treat their patients). Family doctors and general practitioners can obtain such privileges but increasingly do not do so, finding they cannot find the time to visit in-patients. Preventive health care Preventive services are provided both by public health services and by private practitioners. The task force on the preventive health examination has developed excellent practise guidelines for scientifically based preventive medicine but there has been no systematic implementation programme. Rehabilitation services This sector is probably under developed and under funded. Public health services Public health accounts for roughly 3% of health expenditures. This is a mainly provincial responsibility. Federal government is limited to regulation of food and drugs, surveillance of health and disease and policy leadership in health promotion and prevention. In certain provinces, public health services are provided directly by the Ministry of Health through Regional Health Units. Two provinces have local Health Boards, and Quebec assigns community services to Regional Boards and individual services to local community centres, which also provide primary care. Except for the local community service centres, Public Health Services are quite separate from personal health services. Ontario has dealt with the challenge of maintaining standards in a decentralised system by legislating mandatory programmes that all Health Units must provide. The Medical Officer of Health is Chief Executive Officer of the Health Units in most provinces. Because of reluctance to pay adequately, most provinces have difficulty in recruiting public health physicians and many posts are vacant. Major responsibilities include communicable disease control, maternal and child health, environmental health, health promotion and often provision of organised home care. The Canadian Public Health Association with 2,000 members, with its provincial branches, has a strong focus on public health activities and development, holding annual conferences, publishing a journal, advocating for public health and taking on projects for governments. Self-help organisations There are many voluntary organisations, several of which receive some public funding. They are concerned with such matters as Aids policy and they all attempt to influence public services. Accessibility and equity of services Financial barriers to obtaining medical services have been removed although indirect costs remain, for example travel costs. Existence of a single tier of health services means that the rich do not enjoy a deluxe service relative to the poor. There are much larger inequalities in utilisation of uncovered services like dentistry. Rural, or urban mal-distribution of resources limits accessibility, especially in rural and northern areas. Rural areas claim that the closing of many small hospitals has aggravated the problem and rarely accept the idea that a Health Centre can meet their needs. Infrastructure of training and research in public health Undergraduate training in public health is limited mainly to a modest introduction received by medical and nursing students. An exception are the programmes for public health inspectors. There are no April

29 schools of public health functioning under that name but the universities of Toronto and Montreal have well established divisions of community health within their medical schools, offering professional and research degrees. Many other universities offer MSc degrees in epidemiology and related disciplines and a few offer PhD and professional masters degrees. There is a fairly well developed specialty of community medicine, formerly public health and preventive medicine, requiring 5 years of training after obtaining a medical degree. There are 10 training programmes and about 335 specialists, but most provinces are yet to require their medical officers of health to have this certification. The Federal Government s Laboratory Centre for Disease Control offers a 2 year field epidemiology programme providing practical training, mainly to physicians. There is no national institute for public health but the Laboratory Centre for Disease Control has an active research programme in applied epidemiology. Ontario has supported 8 teaching health units based on the concept of a teaching hospital and intended to strengthen teaching, research and practice in public health. Federal, and several provincial, governments support university based research units in health promotion and community health. The Federal Government provides research project funds to academic researchers and, through the Health Promotion Contributions Fund, to community groups. The population health programme of the Canadian Institute for Advanced Research has been active in conceptualising and concentrating on research on the social determinants of health. An attempt to develop public health practice guidelines, parallel to the report of the taskforce on the preventive health check-up, yielded the community health practice guidelines which so far cover 3 interventions: sexually transmitted disease, immunisation and restaurant inspection. Major challenges The major challenge for the health care system is to maintain the level of the service as the economy declines. Preserving the system will require more effective planning and greater emphasis on effectiveness and efficiency of services. The country s historic dependence upon institutional care is becoming less viable as the population ages. A way will have to be found to allocate health care resources in relation to need. At present, health professionals operate where they would like to live and health care dollars follows them. Greater accountability will have to be built into the system, for example by making hospitals and professionals responsible for the care of defined populations/population groups. It is widely believed that responsibility for planning and even for funding health services will be better handled by local communities than by central Administries. Although health services research is fairly strong it must be better linked to services and administration. The vast majority of the inadequate research funding goes to medical research with relatively little going to research on injuries, social factors of health or health services research. Canada has only very recently made any move towards developing national health goals, although several provinces have proceeded to develop goals and objectives. Absence of such goals has probably contributed to the excessive emphasis upon health services as distinct from the broader determinants of health and lack of explicit goals for health services has made planning difficult. Several provinces have developed intersectoral councils in an effort to facilitate intersectoral co-ordination and development of public health policy FRANCE France has a total population of around 57 to 58 million. French citizens benefit from a wide coverage in terms of health services and enjoy, in theory, quasi universal access. Thus cost-containment issues and various question marks about health system efficiency are prominent as in most other countries. Major health problems facing the country (sources of information) Since 1960, national health surveys have provided a description of the morbidity of the French population. Average life expectancy at birth is similar to that of most other western developed countries, almost 80 years. Cardiovascular diseases are the leading cause of death but at a lower rate than in other European countries. In the last 10 years there has been a decrease in alcohol related and atherosclerosis deaths and in traffic accidents. Premature deaths due to accidents and violent deaths including suicide as well as lung cancer and digestive cancers are an important problem as is the emergence of Aids. It is estimated that more than 50% of premature deaths are avoidable; about two April

30 thirds through potential modifications of risk taking behaviours, one third through better health care services and prevention. Mental illnesses are a major problem. Following the same pattern as in most industrialised countries, 3 factors are important contributors to chronic disease: partial control of previously rapidly lethal diseases, increase of life span for chronic diseases and the ageing process of the population with more co morbidities in the late years of life. Organisation, provision, utilisation and impact of health services The Ministry of Health is the leading public authority on health affairs. Medical research is under supervision of the Research Ministry. Health issues and health care services organisation are systematically discussed with the Finance Ministry. The Health Ministry, with the Finance Ministry, play a key role in the control of social security. In France, despite the existence of a national health insurance system, 2 sectors coexist for the organisation of health care delivery. The public sector concerns mostly hospital care, where two thirds of acute care beds are directly managed by the public administration. The private sector is based on liberal practice and serves a larger part of ambulatory care. All health institutions are subject to the control of the state, aimed at improving safety, improving the quality of health care services and adapting them to the changes of technology and needs. Professional organisations have only a secondary say in these matters. Additionally, an unequally enforced central planning system for beds and major equipment is supplemented by the development of a more decentralised and needs oriented approach. The operational management of public health institutions under the new law is now more flexible. Estate control, through its departmental and regional inspections is now performed a posteriori. However, strategic planning, budgeting and physician recruitment are still under a strict a priori control. In public and not for profit institutions, most personnel, including physicians, are paid by salary. Teaching and research are the exclusive domains of the public sector which plays the key role in emergency care and in resource intensive complex treatments but also in long term and psychiatric care. The private sector focuses its activity on surgery and obstetrics, relying mostly on liberal practitioners. The system was not built around public health concerns but represented historically more political imperatives, social progress and professional and or industrial lobbies pressure within a fragmented scene and multiple actors. Public health is now developing a more visible place. This is measurable through the analysis of public health as a professional activity. Professionals, experts and researchers specialised in public health are still few and in many cases are in charge of inspection and control rather then dealing with operational health problems. Among the 160,000 licensed physicians, only 2,755 are qualified in public health. The training system is usually described as poorly structured, but is developing. A leading role is played by the National School of Public Health (Rennes) which depends directly on the Health Ministry. The School performs the initial training for all the public administration health executives. It also offers various continuing education programmes. University public health activities are also being developed and most medical faculties have now created Departments of Public Health with teaching and research. Since 1982 there has been a specific public health track for physicians but it still requires greater emphasis. Despite a rich history in public health, especially in hygiene and control of infectious diseases, France still lacks the critical mass of public health influence that may have positive effects on health care services organisation and impact more clearly on public health. The situation is also reflected by the relatively low volume of public health research and publications, despite the existence of some specialised research units and information production institutions. Recent legislative changes, status improvements and creation of new structures and institutions have led to the emergence of more a public health oriented vision of the health system. Several examples are the creation of the High Committee of Public Health, the national network of public health and specialised agencies. The strengthening of health administration structures and human resources The undertaking of global programmes on perinatal care, anaesthetic safety, emergency care and networks for the care of target groups such as Aids and alcoholism are examples of recent developments. April

31 Major challenges for the health services The main objectives proposed for the coming years by the High Committee of Public Health are derived from 4 major goals: reduce avoidable deaths, reduce avoidable handicaps, improve the quality of life for patients and disabled persons and reduce inequities in health. Specific objectives, which focus on key health problems, representing the main identified priorities in terms of severity, have been developed. Economic impact and feasibility The main targets include the reduction of traffic accidents, domestic accidents, work accidents and cancer prevention. Special attention is being paid to reduce HIV infection. Some health determinants are also considered as key objectives because of their known detrimental impact on health e.g. tobacco and alcohol. The last issue is a great concern, as is environmental health and pollution control. In Paris hospitals, children s consultations for respiratory disease are linked to air pollution in one case out of three. Waste elimination, water control and toxic agent exposure still need to be reduced. Implementation of a stronger public health approach in the French health system is the immediate challenge for France. This requires a mechanism to structure and create a coordinated national public health programme with sufficient resources for a rapid and measurable impact. Special attention needs to be paid to the development of public health in professional practice and the development of training and research. Attention will furthermore need to be paid to evaluation and information system development GERMANY Germany has a population of around 82 million. The birth rate has been declining and, like most countries, the population structure is showing an increase in the proportion of the elderly. Major health problems facing the country Infectious diseases notifiable diseases are in the majority. Immunisation rates could be improved. HIV infections are a very important problem, as is virus hepatitis. Chronic illnesses are becoming an increasing problem with rates of disablement rising in all age groups, particularly amongst the elderly. Mental health is a major problem. Age, gender and social class effects Health and illness correlate in numerous ways with age and gender. Illness and health are linked to social position. Some 6.5 million of Germany s 80+ million inhabitants are from abroad. These show a higher infant mortality and higher mortality rate in all age groups, particularly amongst the young. Nutrition Several diseases are considered to be precipitated by nutrition that may be caused by a deficiency as well as an excess of supply of nutritional elements. The proportion of obese people is increasing, particularly with age. Amongst women aged over 65, 30% can be considered heavily overweight. Environmental hazards In the last 10 to 15 years, there has been an increase in emphasis on environmental and epidemiological hazards and several Chairs for Environmental Health have been created at a variety of universities. There are still, however, few population studies and the research lacks sophistication. Individual studies have been done on chemical solvents, carcinogenic compounds and the effects of climate change and traffic emissions. Provision, utilisation and impact of health services With the implementation of a statutory social insurance system throughout Germany, there is a comprehensive social safety net including statutory health insurance, statutory accident insurance, statutory pension insurance and statutory unemployment insurance. April

32 Organisation of health services There are 3 components of the German health system: 1) ambulatory medical care through private practice 2) inpatient medical care in hospitals 3) public health services There are also of course self-help groups. Private practice plays a decisive role in ambulatory care. Non-profit organisations constitute the central backers for public nursing homes. The government, of course, bears the main responsibility for medical school training and public health officers report to it. Public and private health insurance The German social insurance system is based on legislation formulated towards the end of the nineteenth century. The most significant elements, that are still valid, are the statutory insurance for employees under a certain level of income (those above a certain level can opt out), the right of the insured to benefits, mandatory employer contributions and self governing insurance companies. The relationship between the health care providers, the insured and the insurance organisations is summarised in a social code which consists of ten volumes. Its declared goal is the realisation of social justice and social security. The medical care system is organised in a graded fashion. Privately practising physicians are responsible for primary care these refer to specialists for ambulatory care or to hospitals for inpatient care. Rehabilitation therapy is offered by specialised institutions, both in and out patient. Preventive health care The preventive health care system is subdivided into different areas. Health education in kindergartens and schools is subject to the jurisdiction of the education departments in the individual states. Different organisations on the federal, state and city level are engaged in health education through the public media. They are usually joined at the national level. On the state level, activities on prevention and health promotion are carried out by the central state associations. The health insurance legislation obliges physicians and health insurers to support health promotion and illness prevention. To allow for the early detection of illness, the insured have a right to access screening examinations, which are performed by privately practising physicians, during pregnancy, for infants and for several chronic and benign illnesses among women over 20 years of age and men over 45 years of age. Rehabilitation services The German system of rehabilitation is based on medical, professional and educational rehabilitation. It relies on the support of several institutions: Statutory Pension and Health Insurance, the National Ministry for Labour and the Welfare Offices. Public health services Among the tasks of government with respect to the health care system are the following: 1) National and state specific health administration 2) Health administration of the statutory health and pension insurance companies 3) Public health offices of the states, communes and cities. The German Ministry of Health has responsibilities for health insurance, nursing insurance, medical services of the health insurances, epidemiological statistics, hospital care, illness prevention, health professions, addiction and hygiene, health research, pharmaceutical issues and pharmacies, environmental health issues, nutritional education and other public health issues. There are a variety of different administrative bodies such as the Ministry of Health, the Federal Office for Health Education, the National Office for Vaccines and Serum, the German Institute for Medical Documentation, the Robert Koch Institute for Infectious and Non-infectious Diseases and the Max Von Pettenkofer Institute. The Ministry for Labour and Social Affairs is responsible for pension and April

33 accident insurance. The Ministry for the Environment, Nature Conservation and Nuclear Safety is responsible for health protection in connection with environmental pollution. The Ministry of Education and Research supports several research projects in the field of public health. Federal states have far reaching tasks and responsibilities. They are responsible for the execution of state law, possess judicial authority and have technical supervision over public health. The health departments of the state ministries control not only the public health service but also social insurance. Private practice service, veterinary medicine and food safety surveillance The activities of the states are coordinated by a permanent conference. Industrial inspection boards ensure compliance for occupational protection. In 1991 there were 524 public health offices. The director is a public health physician who has gone through additional training in public health. Physicians that work in public health offices are civil servants and are therefore not subject to dismissal. Currently there are about 5,000 physicians and 1,000 dentists who work in public health offices. Public health officers are responsible for supervision and control of persons and equipment employed in the health professions: prevention and control of infectious disease, supervision of food handling, pharmaceutical and toxic substances, school health promotion, counselling of mothers and children, medical care for patients affected by tuberculosis, sexually transmitted diseases, the handicapped, addicts and the disabled, health education and counselling, promotion of hygiene and sport and medical consultation for public health offices, courts and health insurers. Accessibility and equity Because of the comprehensive social insurance system, essentially all medically necessary services are freely available to all citizens. Infrastructure in training and research in public health Continued education to become a public health physician takes an additional 5 ½ years after the final medical degree is awarded and individuals are allowed to practice medicine. The theoretical part of the training takes 6 months full time study. It is administered by public academies in Dusseldorf, Munich and Schwerin. These academies also offer training programmes leading to a certificate in social medicine for physicians working for the medical services of health insurances, pension funds and rehabilitation clinics. They conduct continuing training for physicians working with adolescents, public health engineers, social workers and social medical assistants. Since 1989, there has been a Master of Public Health degree. The new department for public health at the University of Bielefeld was created and includes 9 areas of research: 1) social epidemiology and health care system design 2) biomedical foundations and population medicine 3) epidemiology and medical statistics 4) prevention and health promotion 5) public health management 6) nursing sciences 7) rehabilitation and social gerontology 8) environmental health 9) social psychiatry At the Technical University in Berlin, an institute for public health sciences, has been established. There are 220 places available for public health students in Germany a year. A university degree in a health related field is an entry requirement for these postgraduate programmes. The University of Magdeburg has established a degree programme in public health promotion. The move has started to make the professional training of nurses more of an academic education and include different programmes in management of nursing. In recent years there has also been a federal April

34 programme for the promotion of public health at 17 universities in 13 German cities. New research structures are created, the aim being to develop high quality and efficient research centres in Germany. In addition to this, in order to improve public health and public health research, a coordinating agency has been established which organises financial support for scientific meetings and symposia, publishes the journal Public Health Forum 4 times a year, and publishes a book as to who is who in public health and also awards a prize every year for the best examination paper in one of the postgraduate programmes in public health. In close cooperation with the scientific associations: German Society of Medical Sociology, German Society of Social Medicine and Prevention and the German Association of Public Health, the coordinating agency plans to establish a system for the evaluation of public health programmes at universities and technical colleges to guarantee a high standard of quality in the education. Major challenges The major challenges that Germany faces are common to most developed countries. Namely, changes in disease pattern, changes in demand by populations, increasing differentials in the development of illness in different social groups, increasing cost of institutional services, problems with personal data and how population health can be improved UNITED KINGDOM The United Kingdom is made up of 4 countries - England, Scotland, Wales and Northern Ireland. The present description will be restricted to the structure and problems of public health in England. There are slight differences between the 4 countries, but it would be more accurate to describe England on its own rather than provide descriptions for the country as a whole. The population of the United Kingdom is about 60 million of whom 50 million live in England. The major health hazards in England are due to cardiovascular disease, cancer, respiratory disease, road accidents, violence and mental illness very similar to those of the other western countries. It is therefore not necessary to describe the precise proportion or details since these have been given already. Infectious diseases play a rather lesser role in being a health problem as in most other western countries. There is a National Health Service which is funded largely from taxation. The basic principle of health care delivery is that all health services are provided for free although co-payments need to be made for drugs, dental services and for ophthalmic services, depending upon the age of the individual patient and their income. There is no bar on private practice and about 12 to 14% of the population is insured privately. Private practice is largely used for elective surgical care. Every member of the population is registered with a general practitioner to whom they have to go if they have a complaint or wish to seek medical care. The general practitioner may provide the care, or will refer the individual to a hospital and specialist services. In England there is a clear split between providers and commissioners with 152 Primary Care Trusts, coterminous with Local Authorities. 168 acute and 73 Mental Health Trusts are responsible for the hospitals and community health services. There are 10 Strategic Health Authority outposts of the Department of Health responsible for strategy and oversights. 122 Hospital Trusts are Foundation Trusts with much greater financial and operational freedom and governed by Boards made up partly of appointed members representing staff and management interests, and partly members elected by patients. These Foundation Trusts are overseen by an independent quango (quasi autonomous non governmental organisations), called Monitor, which is largely responsible for financial oversight. Public Health Public health development in the UK goes back several hundred years and dates back to concern of Local Authorities with the diseases of poverty (e.g.dysentery, erysipelas) in the 19 th Century. The first Medical Officer of Health was appointed in Liverpool around 1850, followed soon after by the appointment of a Medical Officer of Health for London, followed by a Chief Medical Officer to the Local Authority Board, the forerunner of the Ministry of Health. Since the middle of the 19 th Century, each local authority has had a public health department headed by a Medical Officer of Health. In 1974 there was a restructuring of the NHS whereby public health, April

35 which was a function of Local Authority, became a function of the NHS. Since 1974 there has been a series of reorganisations in the structure of public health within the NHS but functions and responsibilities have remained essentially the same. Each Primary Care Trust has a Director of Public Health and a staff of several specialists in public health. Some of these will be medically qualified. The Health Protection Agency, staffed by microbiologists and epidemiologists, is responsible for the control of infectious disease and toxic hazards. Teaching and Research Since the mid 1930 s there has been a development of academic Public Health Departments in all English medical schools which received a particular impetus after the end of World War II. Since 1968, all medical schools have had Departments of Public Health under a variety of different names, such as Epidemiology, Public Health, Public Health Sciences and Community Medicine. These departments are responsible for the teaching of public health to all future doctors who have to pass a final examination in the subject in order to be able to practice Medicine. Public health is also taught in a variety of other academic institutions to non-medical individuals such as nurses, sanitary engineers and so on. There is a National School, The London School of Hygiene and Tropical Medicine, which is one of the institutions responsible for postgraduate training in public health. However, it is important to appreciate that postgraduate training in public health occurs in other university institutions as well, in fact, most universities and medical schools are involved. Research in public health occurs in Research Units funded by the Department of Health, the Medical Research Council or medical charities, by university Departments of Public Health in both universities with Medical Schools, as well as universities with Departments of Health Sciences but not Medicine. In the United Kingdom there is a system of Royal Colleges, which are responsible for the maintenance of professional standards in the subject. For public health there is a Faculty of Public Health, a National Organisation. It is responsible for setting standards and for examination of those intending to take up public health as a specialty. After the basic qualification, whether it be in medicine, in social sciences or in statistics, they have to take a series of courses leading to examination of the component parts of public health i.e. epidemiology, medical statistics and the social sciences in public health. Following this examination, the applicant for a public health post has to undertake further training, usually attached to a service public health department or to an academic department to develop and be responsible for public health activities. Further examination (part 2 of the membership of public health) is then taken, and recognition to be a specialist is acquired after about 4 to 5 years of further education following the initial qualification in medicine or environmental sciences etc. Functions of public health 1) The surveillance of the health of the population centrally and locally. 2) To encourage and develop policies both central and local to promote and maintain health. 3) To ensure that the means are available to evaluate existing health services and to undertake these evaluations. Thus, public health specialists are faced with 4 main types of problems: 1) Outbreaks of disease caused by infective or toxic agents e.g. small pox, typhoid, food poisoning, radiation 2) Problems arising from social and environmental issues, such as inadequate housing, unemployment, poverty, abortion, lack of fluoridation of water supply 3) Behavioural concerns such as smoking, excessive consumption of alcohol, drug taking and insufficient exercise 4) Health service issues including assessment of health care needs and outcomes and the effectiveness and efficiency of particular services. Major problems for the future Major problems are similar to those of other countries, namely the ageing of the population, change in the incidence of disease and the relationships between clinical medicine and public health medicine. April

36 General practitioners are responsible for much health promotion work, usually together with public health departments. A major function in the future is likely to be the development of appropriate programmes for long term continuing care of individuals developing chronic disease such as diabetes, dementia and so on. Manpower There are about 2500 specialists in public health in England; a majority have a medical specialisation UNITED STATES Population and health The population in the United States is more than 260 million. It is one of the most diverse populations on earth and has become increasingly heterogeneous in the twentieth century. Blacks comprise more than 15% of the population. The largest percentage increase however, is among Asian and Pacific islanders. Immigration patterns have dramatically affected ethnic composition. The number of immigrants to the United States from Mexico and Central America has doubled from around 1.65 million to over 3 million now. European immigrants have decreased very considerably. The US population is also characterised by socioeconomic differences among ethnic groups as well as differences in infant mortality rates and life expectancy. In terms of income, 31% of Blacks live below the poverty level, Hispanics are a close second and non-hispanic Whites have the lowest percentage. Percentages below the poverty level have increased for all ethnic groups. Infant mortality rates in the United States decreased until The greater decline occurred amongst the White and Hispanic infants than for Black infants. But this is now changing in that in the deprived ethnic groups, infant mortality rate is beginning to rise. Infectious diseases Advances in public health have vastly reduced the occurrence of infectious disease epidemics and pandemics. The nation s current experience, however, with HIV, as well as other infectious diseases such as Hantavirus and Lyme disease is a sobering reminder that serious microbial threats to health remain. Vaccines are one of the most cost effective means for prevention of infectious diseases. Although there are more than 20 diseases that can be prevented through the use of vaccines, many diseases have no vaccine available. This means that vaccine development is an important consideration for the control of microbial threats to health. Chronic conditions The 10 leading causes of death in the United States are: diseases of the heart, malignant neoplasm, cerebrovascular disease, unintentional injuries, chronic obstructive pulmonary disease, pneumonia and influenza, diabetes, chronic liver disease, atherosclerosis and suicide. Mental health Deinstitutionalisation has been the single most important issue of those in the mental health sphere for the past 3 decades. The most commonly cited statistic used to describe the course of deinstitutionalisation is the yearly count of residential patients in the state and county mental hospitals. In 1955 there were almost 600,000 patients. In the next 3 decades the total has decreased by more than 80%. The major threat to mental health is homelessness. Of all the age related syndromes, perhaps the most age associated one is dementia. Before the mid 1970s, dementia was considered a natural, indeed a normal consequence of aging. Alzheimer s disease was primarily considered a cause of pre senile dementia whereas the so called senile dementia was largely ignored by both the public and medical practitioners. It is now known that Alzheimer s disease affects adults of all ages but only rarely those under the age of 60. The prevalence increases dramatically for each age group over 65. Because of the high percentage of aging, the past decade has seen an increasing awareness that dementia is a problem of immense importance to public health. April

37 Actual causes of death Because of the increasing external non-genetic factors contributing to death, i.e. the actual causes as opposed to the disease based nominal causes of death, Mc Ginnis and his colleagues have estimated that approximately half of all deaths in 1990 could be attributed to the following actual causes: 1) tobacco 19% 2) diet activity patterns 14% 3) alcohol 5% 4) microbial agents 4% 5) toxic agents 3% 6) firearms 2% 7) sexual behaviour 1% 8) motor vehicles 1% 9) illicit use of drugs 1%. Tobacco contributes substantially to deaths from cancer, cardiovascular disease, lung disease, low birth weight and other problems of infancy and births. Dietary factors and activity patterns are associated with cardiovascular disease, cancer and diabetes mellitus. Access to primary health services and poverty Lack of access to a reliable source of primary care when being affected by poverty is also associated with an increased risk of death from a variety of causes. People who are poor have higher mortality rates for heart disease, diabetes mellitus, high blood pressure, lung cancer, neural tube defects, injuries and low birth rates, as well as low survival rates from breast cancer and heart attacks. Prevention - Controlling environmental and nutritional risk factors From the increasing realisation that environmental health factors influence the occurrence of disease, a variety of control measures have been introduced. Such as for example, the Clean Air Act, recycling has become an increasingly attractive option for handling waste, multiplication of an abundant food supply with critical trace nutrients and better methods for determining and improving the nutrient content of foods. As the diseases of nutritional deficiency have diminished, they have been replaced by diseases related to dietary excess and imbalance. 4 of the 10 leading causes of death are associated with over eating as well as the consumption of alcohol. Measures for change In recent years, dissatisfaction with the health care system has become widespread and there are many attempts to improve health insurance coverage and decrease health care costs. (In March 2010 a Bill was, at last passed, increasing health insurance coverage to 95% of the population). Infrastructure of training and research in public health The growing demand for professionals with formal education in public health has led to a substantial expansion in training programmes during the latter half of the last century. In 1958 there were 11 Schools of Public Health in the United States, with the total enrolment of 1,200 students. Towards the end of the last century there were 27 graduate Schools of Public Health with an enrolment of over 13,000 students. About half of these were enrolled in Master of Public Health programmes. Over the years there has been substantial increase in part time students and students enrolled in non-traditional degree programmes as well as the number of physicians graduating with public health degrees. Both public and private universities offer education in public health schools and programmes. All universities rely on federal funds, institutional funds and private gifts. Public health education takes place in all medical schools in the United States and has become increasingly important. The Public Health Service and State and Local Health departments are well established with major institutions such as the National Centres of Disease Control in Atlanta. April

38 Changes in the nature of the nation s health over the last fifty or so years and the increasing difficulty of redirecting programmes in governmental departments, the trend in the United States to downplay the role of public agencies in dealing with major social problems which confront health providers, educators and the public in need of quality health care. This precipitated a crisis in public health, documented in the report by the Institute of Medicine in Traditionally, health departments provided protection against epidemic communicable disease and the health hazards of pregnancy and childhood. As these conditions came under increasing control, with the exception of Aids, a whole new set of problems, mainly the non-communicable diseases replaced them; health departments now redirect their efforts to deal with them. This is undertaken through: 1) Surveillance a system of surveillance of monitoring the health of the population and the factors responsible for it. This is a fundamental public health responsibility and is now being carried out through both the national, federal, and local systems. 2) Behaviour and health health related behaviour evolves in the physical and social circumstances in which people live. Public Health officials however, with few exceptions, have left these matters in the whole hands of social activists. Government health leaders have generally avoided tackling social forces that must be overcome, principally the tobacco and gun industry and segments of the food industry. Some elements of society place priority on achieving profit, for example, by selling guns that facilitate violence, which must be countered by emphasising social responsibility for health. Public health agencies are beginning to take the lead and vigorously seek allies among the media, political and other socially influential groups in developing an effective strategy for achieving patterns of behaviour that favours health. The environment Preventing the spread of microbial infections through water and food has been a central feature of public health from its beginning. That task continues as is evident by the recent outbreaks of water and meat borne disease. But environmental control measures need to be extended to provide protection against a host of toxic chemicals and physical agents that pervade work places, homes and the atmosphere. While basic sanitary engineering and inspections for water and food services survive from the past, more extensive efforts to evaluate and intervene are needed to curtail the hazards of modern industrial life. Availability of personal health services When public health agencies implemented widespread immunisation programmes to benefit the US population, public health departments provided direct services to the economically disadvantaged, as well as oversight of health services to prevent the spread of communicable disease. More recently however, the public health role has been limited to caring for those who cannot afford private sector care. Separate public agencies apart from health departments have often been established to organise and deliver these services for the poor. Three factors however present challenges: 1) The development of many effective medical procedures to safeguard health. 2) The wide variation in access to and quality of personal health services. 3) The growing acceptance of the idea that access to quality medical services is a social right. Special population groups Public health has long focussed its efforts on vulnerable groups of people. Children and adolescents who are victims of family destruction and poverty and the elderly poor currently stand in particular need of quality health care. Ethnic minorities and the homeless suffer from social and economic discrimination and need special attention in public health. April

39 1.8 Conclusions Public health is concerned with health at the population-level, not at the individual level; it is concerned with health services insomuch as the health care service must be properly organised and equipped, but it is not concerned with individual patients. Achieving good health for a community or a nation is accomplished through the organised efforts of society at multiple levels and by multiple actors, from governmental ministries to grass-roots community organisations. The knowledge of changes in health issues facing developed countries over the past two centuries facilitates an understanding of how public health has evolved to tackle these issues and where the field stands today. Throughout its history, public health has addressed the direct and broader material, social and ecological conditions affecting health, such as sanitation and standards of living. Also, in many ways, the concept of controlling infectious disease has been the basis for many of public health structures. Currently, public health is still evolving and adapting in an attempt to control chronic diseases. The short description of public health structures and functions in a number of countries shows the importance of an organisation with responsibility for the delivery of public health services. Public health is concerned with more than the control of communicable diseases in the 21st century. To be effective in the improvement of health status in a country public health attitudes and actions are required at all areas of government at all levels e.g. education, environment, transport, industry, agriculture including health. For this adequately trained individuals are required. Research to investigate both possible new and current hazards must be supported. Information services are also essential. April

40 Section I: Analysis of the Austrian public health system 1 Introduction and definitions Public health is often referred to as the third column of a health system, operating in parallel and in cooperation with the fields of ambulatory care and inpatient care. In the international literature public health is defined as the collective action for sustained population-wide health improvement 27 or the process of mobilizing and engaging local, state, national, and international resources to assure the conditions in which people can be healthy 28 Before entering the Austrian setting and discussing definitions, functions and understanding of public health in Austria, it must be said that definitions of public health used in the international context also display considerable heterogeneity. 1.1 Core functions of public health A brief overview In the international literature various frameworks which were developed to define the core/essential public health functions are described. These include: - the American model - the WHO/Delphi study on essential public health functions - The Pan American Health Organisation (PAHO) Framework - The Australian model - The Essential public health functions for the WHO Western Pacific Region A summary of the different frameworks can be found in a literature review undertaken by the Ontario Public Health Association on the Core Competencies in Public Health the findings of which were presented in March In Austria, the term public health does not have a long tradition; 15 years ago it was hardly known. Only selected individuals, who had usually been trained abroad, could describe corresponding concepts and principles. The terms social medicine (Sozialmedizin) and Öffentlicher Gesundheitsdienst, which is translated in this report as public health service, are still used interchangeably with public health. None of these can however be equated with public health, neither in scope nor in the basic principles. Within a certain community though, the concept of public health is gradually increasingly applied and also understood. Public health in Austria is still at an early stage of development. The understanding of the term, for which in Austria mostly no German translation is used - the term Gesundheitswissenschaften, literally translated as Health Sciences exists in the German literature, is very heterogeneous among health system stakeholders in Austria and even among national experts working in the field of public health. No legal or national definition exists, which hampers the creation of a common ground for discussion and the definition of a uniform strategy. At present only about experts who have actually undergone postgraduate training in Public Health (in Austria or abroad) exist in Austria. 30 For those lacking specialised training, the concept of public health often still seems vague and difficult to define. Due to the lack of an univocal definition of public health existing in Austria, the terms of reference of the present report, which were defined by the steering committee of Austrian Public Health experts 27 Beaglehole R., Bonita, R., Horton, R. et al (2004). Public Health in the new era: improving health through collective action. The Lancet 262, pp Detels, R., MxEwen, J., Beaglehole, R., Tanaka, H. (Eds.) (2004). Oxford Textbook of Public Health (fourth edition). Oxford University Press. New York 29 Accessible at Accessed on 5 May Martin Sprenger (University of Graz). Response to an enquiry of the author April

41 (appointed by the Main Association of Austrian Social Security Institutions), was used as a framework to describe the main functions of public health in Austria. Based on the terms of reference, which determine the structure of this report, public health in Austria is characterised by the following central functions respectively key areas: - Public health services including preventive health services such as e.g. health promotion and prevention but also health care services - Information management and health reporting - Health targets - Public health training and research - Addressing disadvantaged and special need groups In the course of the present study, initially 22 selected Austrian public health experts were interviewed in the form of individual personal interviews by Joy Ladurner. Interview partners were amongst others presented with the following question What are currently, in your opinion, the core areas/functions of public health in Austria? Subsequently responses of the experts are summarised. In June 2009 another series of interviews was undertaken, whereby 18 experts attended a hearing which was organised at the Main Association of Austrian Social Security Institutions in Vienna. Experts were predominantly questioned about matters related to their individual field of expertise. Further details referring to these interviews can be found in the Methodology section at the beginning of the present report. The initially interviewed 22 experts listed a considerable number of public health functions (in Austria), the ones quoted most often being: - Planning (in combination with funding, health reporting and steering) - Health reporting (which was stated to be gradually evolving but still under-developed) - Health care services (at the moment representing the main focus of the Austrian health system which is evident when looking at the distribution of funding, especially at expenses for hospital care) - The public health service (which deals with e.g. infection control, sanitary control or prevention and has a subsidiary function but is in few cases still viewed rather exclusively) - Capacity building (involving education and training) - Health promotion (is developing steadily, showing a focus on the settings: workplace, hospitals and schools) - Prevention (involving immunization and screening) - Health targets (are quoted to be under way but are heterogeneous and not consolidated. No national priorities/plan exist) Other functions listed by experts were usually quoted with restrictions, e.g. by commenting that these were still very weakly developed or only just beginning to be executed in Austria. They included research and evaluation (slow development, lack of funding) or health economics (comparison of costs and benefits, reimbursement, market structure, economic evaluation). Public health functions which were only referred to by few experts were: the consideration of health determinants, consultation of politics, access to care, social inequalities or monitoring (data surveillance, building of an information system to enable monitoring), integrated care, long term care or addressing of risk/lifestyle factors. Further functions quoted by experts, which were however stated to still hardly be applied in Austria but should potentially gain importance in the future, were public relations work (communication and networking) and design/shaping of the health system. Core disciplines which should be involved in public health research and practice are: social sciences, social medicine, sociology, social psychology, health economics, political sciences, anthropology, history, environmental medicine, hygiene, management sciences, health services, demography, April

42 nursing sciences, pharmacology, epidemiology, health statistics, biometry or informatics. 31 The multidisciplinary nature of public health, both in practice and research, is vital. In connection with their responses, several experts added that a great number of small-scale public health activities and initiatives existed, but that these were in many cases not co-ordinated and of a heterogeneous or unknown quality. Analogies used to describe the public health situation in Austria were pieces of a puzzle or rag rug. Furthermore responsibilities, activities and outcomes were argued to lack transparency and missing interdisciplinary activity was criticised. Selected public health functions are described in more detail in chapter 5 of the present section. Before describing the situation of public health in Austria in more depth, a few concepts and definitions are presented. Initially definitions of public health found in legislation, used by Austrian institutions or cited in the literature are presented. Thereafter the understanding of the term public health in Austria, as expressed by a range of experts who were interviewed for the present study, is communicated. 1.2 Notions of public health in Austria The understanding of public health in Austria is fairly heterogeneous, not only generally speaking but also within different levels of the health system or even within individual institutions or departments of institutions. This also seems to apply to social insurance with social insurance funds taking different viewpoints on the subject. Some common elements exist though, which ae recognised among most professionals operating in the field. More information on these can be found in chapter 1.3. The initial terms of reference were developed by the London School of Economics and Political Science. These were revised and finalised by the steering committee appointed by the Main Association of Social Security Institutions. The compilation of the final terms of reference took place between about January 2007 and June/July This information is solely provided with the intention of demonstrating how difficult it was to reach a consensus on the topics covered in and the scope of the study, even among a small number of Austrian public health experts. The following subsections present definitions of public health found in Austrian legislation, institutional documents or Austrian literature Legislation Legislation on public health issues in Austria is fragmented, in some cases outdated and shows several gaps. No legal definition of public health, no own Public Health Act exists in Austria. Several functions and activities of public health are regulated in a range of legal documents which are detailed in chapter 2 of this section. The present subsection only refers to legislation in which the term public health is defined or explained. It is new that public health is explicitly referred to or mentioned in Austrian health legislation. This is the case for the first time in the Agreement based on article 15a of the Federal Constitutional Act which is signed by the Federal Government and the provinces in regular intervals and is, in its current version, valid from 2008 to According to article 11 of the aforementioned agreement, the contracting parties agree to accommodate principles of public health when implementing any measures stipulated in the agreement. Principles listed are: - Acknowledgement of a comprehensive notion of health - Health services research to ensure needs-orientated planning, development and evaluation - Promotion of interdisciplinarity of care or research - Development of health targets - Systematic health reporting 31 Mossialos, E., Allin, S., Ladurner et al Framework Performance Assessment. Report for the Main Association of Austrian Social Security Institutions. Vienna: Main Association of Austrian Social Security Institutions April

43 The list of principles gives a good indication of what public health involves; it does however not represent a formal comprehensive national definition of public health. Furthermore the article does not appear to be known among all experts. Solely two experts mentioned it when being interviewed and asked about definitions for or understanding of public health in Austria. Article 33 of the same agreement defines the funding of cross-national prevention programmes and treatment mechanisms. In article 34 the Federal Government and the provinces agree upon jointly analysing and evaluating the epidemiological impact of current and future preventive measures in the Federal Health Agency and the provincial health funds Institutions In an information folder the Austrian Public Health Association (Österreichische Gesellschaft für Public Health) defines public health as the science and the practice of the promotion of individual and population health, the improvement of the quality of life and the society-orientated system design in the health sector. It furthermore states that Public health must be a multidisciplinary and interdisciplinary science with a strong link to practice and policy The Austrian Public Health Association also writes that whereas public health was previously dominated by topics such as hygiene (water supply or waste collection), a stronger emphasis is nowadays placed on issues such as improved access to health services (mainly through health insurance), prevention or the promotion, maintenance and improvement of health of the broad population and of disadvantaged groups. The Institute of Public Health at the Paracelsus Private Medical University of Salzburg 32 defines Public Health as a societal effort to protect, promote and restore human health. It relates to public health as a problem-orientated and interdisciplinary field of health science, describing the health status of population groups in interaction with medical health care systems. The Medical University of Graz 33 describes public health as a very dynamic and cross-disciplinary field. Two targets of the multidisciplinary and interdisciplinary field of research and practice are listed: Maintaining and promoting the health of the population or of large population group and Further development of the health system in terms of increasing quality of care and efficiency The Center for Public Health at the Medical Universty of Vienna defines public health as a multidisciplinary field combining natural sciences as well social- and cultural sciences. It is argued that public health aims to improve the populations health through health-related initiatives in research, development, education and public relations as well as through consultation of national and international committees. Public health research creates the scientific foundations necessary to achieve these targets 34 The University of Linz 35 states that public health takes a perspective beyond the health sector and considers especially education and environment. Public health is to be understood as a comprehensive approach, as interdisciplinary science with a strong link to practice and involvement of decision makers. It aims to improve the quality of life and promote the health of the society, especially also of disadvantaged groups. Measures therefore are preventive and health promotion measures as well as ensuring demand-orientated access to evidence-based medical, nursing and social care for all individuals Literature In the course of the literature search undertaken for the present study, several definitions of public health were found. The literature search was limited to Austrian literature as the aim was to find out how public health was described in the national environment. 32 Private medical University Paracelsus, Institute of Public Health, accessed at on 5 May Medical university Graz, accessed at on 5 May Medical university Vienna, Center for Public Health, accessed at on 5 May Johannes Keppler Universität Linz, JKU. (no year). Postgraduate study programme. Public Health and Health Systems Management. Brochure. Linz. April

44 In the preface to his Handbook on Public Health 36, the editor Gerhard Polak defines public health as the joint effort of society towards health development and a healthy life of the population. He adds that it stands for frontier crossing and pluralism and strives to ensure the best possible status of health for each individual. Referring to science, Polak defines public health as the science which deals with finding solutions for the question of how, considering existing resources, environmental conditions and genetic circumstances, the best possible health status can be ensured for the largest possible amount of individuals. He furthermore believes public health to be a platform for all players in the health sector:physicians,natural scientists, individuals working in fields related to philosophy, psychologists, sociologists, health economists, jurists, insurers, qualified nurses and employees of the basic health care institutions. Polak emphasises that public health cannot be equated to the Austrian public health service (Österreichischer Gesundheitsdienst, ÖGD). In his article on Modern Public Health, Horst R. Noack 37 writes that the multidiscipline public health, under which he subsumes health science and health care, deals with the scientific exploration of health-related developments and with the political and organisation design of the health system. New versus old public health is described as Public health with a wider perspective vs. just public health medicine. 38 In an article on knowledge and qualifications for public health, Health Noack 39 defines new public health as a comprehensive, interdisciplinary and intersectoral public health system. He continues by stating that the term new public health refers to a complex pattern of health-relevant functions available for all social ranks and to the respective organisational infrastructure. He further distinguishes three main types of public health functions, namely a political function, a scientific function and a management function. According to Bencic and Popper 40 public health stands for an increase in efficiency of health care, the systematic expansion of health promotion and prevention and the exercising of a positive influence on all health determinants across all policy areas. They argue that public health ideas in the Austrian health system could be promoted by integrating public health approaches into the core processes of health care provision. 1.3 Experts opinions on the definition and understanding of public health For the study 22 national experts operating in various fields relevant for public health were interviewed in the form of face to face interviews. They were presented with two questions: 1. How do you define public health? 2. What is, in your opinion, public health in Austria? The aim of these two very similar questions was to find out whether the experts perception of public health in Austria deviated from their formal definition of public health. The first question was targeted at receiving general definitions of public health. It was assumed that the experts view of public health would be strongly influenced by their academic and professional background i.e their expertise, knowledge and experience. The second question was aimed at receiving information and specific details about the understanding of public health in Austria. 36 Polak, G. Das Handbuch Public Health. Theorie und Praxis. Die wichtigsten Public Health Ausbildungsstätten. Springer-Verlag, Vienna Interview with hdr. Gerhard Polak on Public Health, Requirements and Chances Accessed at on 5 May Noack, H. R. (2005). Modern Public Health. Accessed at on 2 May Expert interviews June Noack, H.R. Wissen und Qualifikation für Public Health. Accessed at on 2 May Bencic, W., Popper, H. (2009). Public Health in Kernprozesse der Krankenversorgung einbringen. Soziale Sicherheit März 2009, pp April

45 1.3.1 How do you define public health? Definitions of health and public health depend on the scientific perspective taken, thereby either applying a narrow disease paradigm or employing a wider comprehensive health paradigm (including disease). 41 The definitions of Public Health given by national public health experts, who were interviewed in the course of the present study, show a considerable variation in scope but are at the same time also characterised by the use of several common expressions, terms and concepts. Only few experts quoted definitions taken from the literature. Of these the definition given by Beaglehole et al in their article in the Lancet in 2004 Collective action for sustained population wide health improvement was referred to most often. Other frequently named elements of public health are listed below. These are ranked according to how often they were referred to by experts. Similar principles or characteristics were grouped together. - Maintaining, promoting, improving and restoring individual and population health (that of the entire population and that of certain disadvantaged population groups) - Joint effort involving different levels and fields - the individual, the organisation, the health system, policy, the population and science by means of a participatory approach - Cumulative denomination for different scientific disciplines which try to prevent premature death and early disease such as health care in general, prevention, health promotion, societal aspects and health determinants - Evidence, a scientific basis, appropriate-, need-based services and making best use of existing resources - Cross-sectional-, multidisciplinary. and interdisciplinary (multi-sectoral approach: health in all policies) matter - Systematic and standardised assessment, analyses and detection of interdependencies as well as evaluation and reflection of results using the following tools and/or models: epidemiology, health reporting, health planning, Public Health Action Cycle (PHAC) - Linking theory (research/science) and practice (health system stakeholder activities, policy, action-orientated, policy-orientated discipline, formulation of targets, strategies, measures, etc.), involving a very broad range of art and skills - Addressing inequality: ensuring equal access, affordable health services and fair funding - Current focus on medicine and health care, equating public health and social medicine Items of the first combination of principles were by far quoted most. All experts used the term population or society, most stipulated health improvement, several argued that the effect of health improvement ought to be long-lasting respectively sustainable. This indicates that the definition of Beaglehole is widely used among public health experts in Austria and that the population focus is recognised as a key feature of public health. Different functions of public health were listed by about half of the experts, mostly quoting prevention and health promotion. Several experts pointed out though that it was important not to limit public health to prevention and health promotion. Other disciplines and tools mentioned were epidemiology, health planning and/or health reporting. Principles such as multi-disciplinarity and inter-disciplinarity as well as cross-sectional co-operation when it comes to the topic of health (between resorts/ministries, application of the Health in all policies concept) appear to be attributed a high importance, being mentioned by close to a third of the experts. 41 Noack, H., Kahr-Gottlieb, D. (2005). Introduction: The 2005 conference of the European Public Health Association. About the conference and the conference book. In: Noack, H., kahr-gottlieb, D. (2005) Promoting the Public s Health. EUPHA 2005 Conference Book. Health Promotion Publications. Verlag fuer Gesundheitsfoerderung. Gamburg, pp April

46 It was believed highly relevant to employ adequate methods (e.g. epidemiology) in a systematic way, to collect, assess and analyse data and to evaluate as well as presenting evidence. Public health should show a strong link to practice, demonstrating policy relevance and seeking interaction between experts in research and practice. Selected experts also stated that public health should not display too strong of a focus on medicine and should not be limited to the activities of the public health service (public health authorities in Austria). To conclude this sub-section, a few definitions of interviewed experts are quoted. Public health. is an endeavour of society and its institutions to ensure that health is promoted and improved in accordance with a demand-orientated standard and in line with the definition of the WHO is a multidisciplinary and interdisciplinary science with a strong link to practice and politics can be described as a systematic and epidemiological assessment, the detection of correlations and the reflection of these. is the science and practice of the promotion of individual and societal health, the improvement of the quality of life and the society-orientated design of the health system can be defined using the following catchwords:multidisciplinary,population-orientation i.e. orientation towards population groups, orientation towards health promotion and prevention, responsibility of society for health, participatory action together with those involved/affected is sustained improvement of the society s health under consideration of social inequalities is a cumulative denomination for different scientific disciplines which try to prevent premature death and disease at an early stage through especially prevention. Public health involves an organised networking structure in which different sectors or areas should theoretically co-operate. It is characterised by a population-orientation and does not focus on the individual What is, in your opinion, public health in Austria? The intention behind posing this question was to find out, whether the definition and understanding of public health in Austria, according to the experts opinion, deviated from their general definition of public health and if so in which way. According to experts, the term public health is fairly new to Austria. Related alternative terms or disciplines which were and still are often used synonymously with public health are social medicine, the public health service (Öffentlicher Gesundheitsdienst, ÖGD) and also health care. Based on expert opinion, the field of public health in Austria still maintains a strong traditional focus on medicine (medical prevention) and on the services provided by the public health authorities (e.g. infection control, immunizations, compilation of expert opinions). Several experts argue that equating public health to the activities of the ÖGD is too restrictive and that the ÖGD represents only one important segment i.e. player of public health. The field of public health is currently undergoing considerable change in Austria and is, according to experts, just beginning to develop respectively only gradually in the process of developing. The potential for further development is stated to be significant. In contrast though, experts also argue that many activities are already taking place in Austria which are related to public health but are not denominated or recognised as such. Public health in Austria is a fairly small area with few experts. No clear cut definition exists; depending on the individual asked, the definition obtained may vary considerably. Generalising, different groups of individuals stand out: first those who promote public health development and those who oppose/hinder public health development. Second those who take on a narrow perspective of public health (relating it mostly to the activities of the public health authorities), comparable to Old public health, and those who adapt a broader perspective of public health (including all responsibilities which aim at improving the health of the population), comparable to the concept of April

47 New public health, and third those who promote certain sub-disciplines of public health such as health promotion, prevention or health economics but sometimes do not adapt a whole system view. With regard to framework and structure, public health holds, according to experts, a weak position in the system when compared to other players and fields. Among decision makers knowledge and understanding on the subject of public health are often quite limited. Public health lacks funding (for the establishment of structures, research, training, programmes, etc.), legislation (which is either non existent or in some cases out-dated) and the integration of concepts into institutions and organisations. Very few institutions dealing exclusively with public health issues exist, usually departments or individuals in institutions work on practical public health issues or in public health training and research. Political willpower, targets and prioritisation on all levels of the health system, but especially on the macro level are missing, as well as concerted actions or systematic programmes for implementation. Experts interviewed for the present research project stated that the Austrian landscape of public health activities is comparable to a variegated patchwork of initiatives and projects. Activities are not bundled and stakeholders do not co-operate or communicate enough. Those involved or concerned are not asked to participate when developing or implementing measures. Efforts related to public health are often attached to individuals who show great enthusiasm and dedication to the subject. Activities are mostly short term projects instead of long term programmes and do often not have an impact or sustainable effects. As far as knowledge, research and training are concerned, it was mentioned that several training programmes for public health have been initiated over the past years. This is welcomed by experts and believed to be a positive development. Co-ordination between the programmes is still missing; discussions of involved stakeholders have only recently been initiated. Public health research in Austria is very scarce. This is mostly due to a lack of funding. Expertise and knowledge is partially available (about graduates with an MPH degree exist in Austria), but not always used appropriately or appreciated. Institutions are only slowly reacting to new skills; new jobs/positions have to be created and attractive career paths developed. Many people work in applied public health but few of these have undergone formal training for public health. The data basis necessary for public health activities is not always appropriate and in some parts not sufficient. Some quotes of interviewed experts which were considered highly relevant and provide an appropriate indication of the situation of public health in Austria include: Public health in Austria... is a patchwork of initiatives and projects "is pieces of a mosaic, lacking a systematic programme for implementation is a heterogeneous mingle-mangle of institutions and individuals is driven by individuals is often used synonymously with public health care services involves expert knowledge which has not yet found its way into the structures of all players involves many activities which are not denominated or recognised as being public health activities April

48 2 Legislation The legislation considered most relevant in the context of public health in Austria is listed in the table below. No Public Health Act exists; the term public health is only mentioned literally in one legal document, namely in article 11 of the Agreement according to article 15a of the Federal Constitutional Act. 42 The only legal documents addressing specific public health fields respectively functions are the Health Promotion Act, the draft for the new Federal Act on Health Promotion and Prevention, the Imperial Sanitary Act and the Acts related to infectious diseases and epidemics. Other legislation covers issues relevant for public health amongst covering many other topics. According to experts, legislation related to public health in Austria is frequently characterised by being outdated or non-existent. Gaps are quoted to exist in several areas such as: organisational structures and responsibilities, funding, education, health promotion and prevention structures and management of chronic diseases. The range of legislation presented below regulates issues or refers to topics related to public health functions in Austria. For more information on the understanding of public health in Austria please refer to the previous chapter, chapter 1, of this section. Table 1: Public health legislation English translation German name Abbreviation Federal Ministries Act 1986 Bundesministeriengesetz BMG Imperial Sanitary Act 1870 and the provincial Sanitary Acts Federal Constitutional Act especially article 10 para.12 and article 12, para.1 Agreement between the Federal Government and the provinces according to article 15a of the Federal Constitutional Act Reichssanitätsgesetz Bundesverfassungsgesetz Vereinbarung gemäß Artikel 15a B-VG B-VG Health Reform Act 2005 Gesundheitsreformgesetz 2005 GRG Federal Act on Documentation in the Health Sector Health Promotion Act 1998 Federal Act on Health Promotion and Prevention (draft) General Social Insurance Act as well as the social insurance legislation for other types of social insurance (farmers, self-employed, miners/railwaymen, civil servants, etc.) Bundesgesetz über die Dokumentation im Gesundheitswesen Bundesgesetz über Maßnahmen und Initiativen zur Gesundheitsförderung, -aufklärung und information Bundesgesetz über Gesundheitsförderung und Prävention Allgemeines Sozialversicherungsgesetz und Sondergesetze 15a Vereinbarung DokuG GfG PrävG ASVG B-KUVG GSVG BSVG FSVG Professional legislation, e.g. Physician Act Ärztegesetz ÄrzteG Federal Hospital Act and provincial Hospital Acts Kranken- und Kuranstaltengesetz KAKuG Epidemics Act Epidemiegesetz EpG 42 Excluding a few citations in legislation on public health training courses in which public health is however not referred to more closely or definitions are provided. April

49 Table 1 continued English translation German name Abbreviation AIDS Act AIDS Gesetz AIDSG Tuberculosis Act Tuberkulosegesetz TubG Federal Act on the Statistical Recording of Tumours, Cancer Statistics Act Bundesgesetz über die statistische Erfassung von Geschwulstkrankheiten, Krebsstatistikgesetz KrebstatistikG Act on the Organisation of Schools Schulorganisationsgesetz SchOG Austrian School Education Act Schulunterrichtsgesetz SchUG Austrian Government Programme 2009 Community legislation Source: Author s own illustration Regierungsprogramm Gemeinderecht Subsequently a very brief description of each of the legal documents is provided. The Federal Ministries Act regulates the number of Federal Ministries and the distribution of responsibilities across and within all the ministries. It also details the responsibilities of and the distribution of functions in the Federal Ministry of Health. The Imperial Sanitary Act of 1870 created the first legal foundation for the introduction of a systematic data collection through the health authorities. It regulates the organisation of the Austrian public health service as well as listing the responsibilities of medical health officers and the Supreme Sanitary Council. The Federal Constitutional Act defines the responsibilities of the different health system stakeholders such as the Federal Government, the provinces or the self-governance bodies in the health sector. The Agreement according to article 15a of the Federal Constitutional Act, which was signed by the provinces and the Federal Government, is valid from 2008 to It refers to public health in Article 11 by stating that the contract partners will use principles of public health as guidance when implementing their measures. This involves the following aspects: - Acknowledgement of a comprehensive notion of health - Health services research to ensure needs-orientated planning, development and evaluation - Promotion of interdisciplinarity of care or research - Development of health targets - Systematic health reporting Article 33 of the same agreement regulates the funding of cross-regional prevention programmes and treatment mechanisms. In article 34 the Federal Government and the provinces agree upon jointly analysing and evaluating the epidemiological impact of current and future preventive measures in the Federal Health Agency and the regional health funds. With the enactment of the Health Reform Act 2005, regulations of the Hospital Act, the General Social Insurance Act (and other social insurance legislation), the Federal Act on Documentation in the Health Sector and the Physician Act were amended. The Health Reform Act moreover formed the basis for the implementation of the Health Care Quality Act and the Health Telematics Act. Central aspects of the Act featured the installation of measures to promote integrated care, the co-ordination of planning, steering and funding within the health sector, the initiation of measures to ensure the sustainability of funding of the health sector, the support of prevention and the promotion of quality of care as well as telematics in the health care sector. The Federal Act on Documentation in the Health Sector regulates the documentation of diagnoses and services provided in connection with hospital care and ambulatory care as well as the April

50 documentation of statistics and costing data in hospitals. Despite this Act documentation of privat ambulatory care is still very scarce or in important areas completely missing in Austria. The Austrian Health Promotion Act was enacted in It defines measures and initiatives to ensure the following aims: maintenance, promotion and improvement of the populations health in a holistic sense and for all phases of life, education and information on preventable diseases and on emotional, mental and social factors influencing health. Thereby it draws on the comprehensive definition of health of the WHO as well as the Ottawa Charta of the WHO on health promotion. The responsibility for the implementation of strategies to achieve the above mentioned aims was transferred to the Fund for a Healthy Austria (Fonds Gesundes Österreich, FGÖ). Financial resources are granted from income generated through value added tax; means are distributed based on regulations of the Financial Equalisation Act and amounted to then (in 1998) a 100 million Austrian Shillings, the equivalent of about 7 million Euro. With regard to the strategies, based on the Health Promotion Act, a special focus is to be placed on the following topics respectively population groups: children and adolescents, workplace health promotion, addressing the needs of specific groups such as individuals suffering from chronic diseases, the elderly and pregnant women. Furthermore aspects such as psycho-social health or socio-economic living circumstances are to be taken into consideration. The draft for the Federal Health Promotion and Prevention Act intends to create a common basis for coordinating measures and initiatives for health promotion and prevention. It regulates the support of measures and initiatives of bodies responsible for health promotion and prevention by use of structural and financial means. Responsible bodies are social insurance funds, the Main Association of Austrian Social Security Institutions, the Federal Government, the provinces, the municipalities and communities and Gesundheit Östereich GmbH, GÖG. These can either undertake measures themselves or commission third parties. The Federal Health Agency is in charge of defining targets for health promotion and prevention as well as developing strategies for reaching these targets. A board for health promotion and prevention is to be installed at the Federal Ministry of Health. The draft furthermore lists criteria for the distribution of subsidies and any implications related thereto. The General Social Insurance Act 43 refers to public health functions and services provided by social insurance funds such as for instance those regulated in 116 (ensuring health promotion), 154b (health promotion: obligation to inform the insured about general health risks and the prevention of disease and accidents) or 447h (installation of a fund for preventive health examinations and health promotion at the Main Association of Austrian Social Security Institutions). Professional legislation regulates the education and training of health professionals as well as their duties with regard to continuing education and professional development. Moreover it contains regulations on certain types of professional fields, e.g. that of a medical officer. The Federal Hospital Act regulates the responsibilities for and within hospital care. It describes stakeholder obligations, funding mechanisms and duties related to documentation and qualification requirements. The Hospital Act refers to hospital planning (beds and equipment) etc. being part of the Austrian Health Care Structure Plan or the Regional health care structure plans as well as listing principles to consider in order to promote integrated care. Amongst many others aspects also sanitary control in hospitals/hospital hygiene is regulated by the Act. The Epidemics Act, the AIDS Act and the Tuberculosis Act regulate responsibilities and procedures related to reporting or monitoring of infectious diseases and the course of action to be taken in the event of an infection or disease outbreak. Issues in connection with infectious diseases are described more closely in chapter 7 of section II of the present report. The Cancer Statistics Act of 1969 lists the type of data to be collected by the national cancer registry, namely patient data and data on the type and site of the tumour as well as on disease progression. It specifies the types of diseases which have to be recorded, including all carcinomas, sarcomas, 43 and the other special legislation relevant for further groups of insured such as civil servants, self-employed, farmers, individuals of the railway and mining industry, notaries, etc. April

51 malignant illnesses of the haematopoietic system, the lymph system and the reticuloendothelial system. Reports have to be made on incidence and deaths related to the respective illnesses. The individuals/organisations liable to report are the executive directors/medical directors of hospitals, examination offices of the provincial and local authorities, institutes for pathological anatomy and institutes for forensic medicine. The Act on the Organisation of Schools stipulates the responsibility of schools to promote the health of their students in 2. The Austrian School Education Act lists the duties of school physicians in 66 (1). In the Austrian government programme 2009 various references are made to public health functions such as: occupational health, health in connection with transport policy, health protection with regard to environmental issues, food products, promotion of child- and adolescent health, physical exercise, e-health and the reduction of administration costs. Also the co-ordination of environmental policy with energy-, social-, climate, health-, economic- and regional economic policy is stated as a goal. In the chapter on health the government programme states that the federal government affirms itself to a strong public health system and to ensure high quality medical care for all people in Austria, regardless of their income, age, origin, religion or sex. It is aimed to define national health targets and to pursue an orientation towards living environments and target groups. Other topics referred to are addiction, suicide, preventive health examinations, occupational health promotion, patient interests (waiting times, access to care, case management), patient rights, child and adolescent health, womens health, rehabilitation, quality of care, health professionals, research and teaching, integrated care, planning and steering, palliative care and funding (of health insurance funds and hospitals). European legislation and development on the European/EU-level can have a considerable impact on the situation in Austria. Relevant legislation is not listed at this point though as this would go beyond the scope of the study. April

52 3 Funding According to experts interviewed in the course of this study, the lack of funding for public health is one of the central aspects hindering the further development of this area in Austria. In very few cases do fixed or even legally defined bugdets for public health services exists in Austria. Usually they have to compete for funding with curative services and receive by far less attention, financial and also human resources. When comparing the amount of health expenditure on curative services with the amount spent on services such as prevention or health promotion, it becomes evident that curative services and of these especially hospital services, are dominant in Austria. On the positive side though, it is also evident that the amount of money allocated to public health related services has been increasing over the past, indicating the rising awareness for these services. Whereas expenditure for tertiary and secondary prevention dropped between 1996 and 2001, expenditure for primary prevention increased. The increase in public expenditure on prevention and health promotion can mostly be attributed to the installation and the work of the Fund for a Healthy Austria. In times of economic hardship though, usually measures for health promotion or prevention are cut back first. This is partially also due to the stronger legislation basis for curative services, attributing these a higher priority and attaching them with a greater obligation in terms of service provision. Public health services are at present often provided on a voluntary basis and depend on the economic viability of the funding body. This chapter decribes the situation of funding for public health related services and activities in Austria by detailing the resources allocated to certain institutions and the reimbursement of selected services. 3.1 Legislation Due to the lack of an explicit public health policy the Austrian funding structure is highly fragmented, making it difficult to structure and describe. Relevant legislation in the context of funding of public health services is the: - Finance Equalisation Act (Finanzausgleichsgesetz, FAG) - Federal Finance Act (Bundesfinanzgesetz 2010) - Agreement according to article 15a of the Federal Constitutional Act (Vereinbarung gemäß Artikel 15a Bundesverfassungsgesetz, B-VG) - Austrian Health Promotion Act (Gesundheitsförderungsgesetz, GFG) - Draft of the Federal Health Promotion and Prevention Act (Gesundheitsförderungs- und Präventionsgesetz, GPG) - General Social Insurance Act (Allgemeines Sozialversicherungsgesetz, ASVG) The Financial Equalisation Act (Finanzausgleichsgesetz) regulates the allocation of a yearly sum of 7,250,000 to measures for health promotion, - education and information in 8. This is the budget of the Fund for a Healthy Austria, one of the three subdivisions of Gesundheit Österreich GmbH. Funding issues of the Fund for a Healthy Austria are cross-referenced in the Federal Act on Gesundheit Österreich GmbH in 6. In connection with the generation of funding for the FGÖ the Austrian Health Promotion Act refers to the Constitutional Finance Act and the Finance Equalisation Act. The Federal Health Promotion and Prevention Act (Gesundheitsförderungs- und Präventionsgesetz, GPG) defines guidelines for the allocation of subsidies and regulates subsidies of the Federal Government and the conditions for the use of the subsidies. The General Social Insurance Act regulates which services social insurance has to provide to its insured population and under which conditions these are to be provided. April

53 Article 33 of the Agreement according to article 15a of the Federal Constitutional Act stipulates the funding of cross-regional prevention programmes and treatment measures. The Federal Government and the provinces agree to provide funding of 3.5 million for the promotion of programmes and measures described in the legislation as well as for the funding of further projects and plans undertaken in connection with article 30 para.1 of the same Act (projects and plans of the Federal Health Agency). Subsequently the Federal Health Agency developed a concept for crossregional prevention programmes as well as the directives corresponding with this. An application for funding requires applicants to file their application in accordance with these standards, the guidelines and the directives. The sub-working group public health agreed with both the concept and the directives but still encouraged the development of framework targets for health (see article 11 of the aforementioned law) as these would make priorities explicit. Article 34 of the same agreement states that the Federal Government and the provinces agree to jointly evaluate and analyse the epidemiological outcomes of existing and future prevention measures in the health sector in the Federal Health Agency and the regional health funds. The funding for this measure for 2010 is envisioned in the Federal Finance Act (Bundesfinanzgesetz 2010) which details the income and expenses of the Federal Government on a yearly basis. Other income and expenditure positions (for instance for fighting substance abuse, for the mother-child-pass examination programme or for measures related to food safety, radiation protection or infectious diseases) of the Federal Ministry of Health as well as contributions of the Federal Government to social insurance are also listed in this Act. 3.2 Resarch and literature Barely any research has been undertaken on the subject of public health funding in Austria. Only a handful of references for data exist. Reports on public expenditure on health care prevention and health promotion were published in 2004 and 2001 (based on data from 1996 and 2001 respectively) by the Austrian Health Institute (ÖBIG), commissioned by the then Federal Ministry of Health and Women. As part of the Health care in Transition country report for Austria, which was published in 2006 by the World Health Organization on behalf of the European Observatory on Health Systems and Policies, the Institute for Advanced Studies calculated public health expenditure. Experts interviewed in the course of the study argue that it is very difficult for them to obtain national funding for public health research and that they are therefore forced to apply for external funds (e.g. with the European Union). A national source of funding is for instance the Anniversary fund of the Austrian National Bank (Österreichische Nationalbank) Funding of public health related services Overview In 2007 total health expenditure in Austria amounted to 10.1% of the GDP. Since 2001 it had ranged between 10.1 and 10.4% of GDP. Health expenditure is calculated based on the system of OECD health accounts. 76.4% of total health expenditure was public and 23.6% was private expenditure for health. Based on the same data, health expenditure on prevention and public health services amounted to 455 million in the year The manual for A system of Health Accounts by the OECD defines this expenditure category as collective health care services covering traditional tasks of public health such as health promotion and disease prevention including setting and enforcement of standards. In comparison, 9,272 million were spent on inpatient care and 5,077 million on ambulatory care For further information see (in German), accessed on 8 April Statistics Austria, Health expenditure, accessed at on 26 August 2009 April

54 When, in contrast, health expenditure is calculated based on the system of National Accounts (Volkswirtschaftliche Gesamtrechnung), which follows a different expenditure structure, namely listing expenditure by stakeholder, the current expenditure for prevention and public health services amounted to about 503 in Thereof the Federal Government, the provinces and the communities contributed 217 million (43%) and social insurance funds 211 million (41.9%). The remaining amount was funded privately and to a small extent by NGOs and corporations (other than social health insurance). 46 In 2004 the then Federal Ministry of Health and Women published a report on Public expenditure on health care prevention and health promotion in Austria (based on 2001 data) 47. The authors stated that public expenditure on health care prevention and health promotion amounted to about 6.3% of total health expenditure and to about 9.3% of total public expenditure on health. This is the equivalent of a yearly amount of about 127 per person living in Austria and billion in total. Comparing these figures to 1996 data, this expenditure position has experienced an increase of close to 31%, demonstrating the increase in significance of these services over the years. 48 This rise may also be related to the higher concentration of related activities between 1996 and 2001 such as the enactment of the Health Promotion Act or the installation of the Fund for a Healthy Austria, Fonds Gesundes Österreich, FGÖ. The largest share of the above mentioned billion, an equivalent of 86.7%, was contributed by social insurance, about 7% by the Federal Government, close to 5% by the provinces and 0.8% by the Fund for a Healthy Austria respectively 0.7% by the municipalities. 61% of the social insurance expenditure for health care prevention and health promotion were spent on medical rehabilitation services. 49 In total more than half of the expenditure was for medical rehabilitation services. Expenditure for health care promotion and prevention totalled about million (2.9% of total health expenditure). Compared with 1996, all funding bodies apart from the municipalities had increased the amount of money allocated to health care prevention and health promotion. Most of the funds spent on health promotion and disease prevention services were spent on medical rehabilitation, preventive (periodic) health check-up, measures improving the dental health status of the population, services related to the mother-child pass examination programme and vaccinations. Whereas expenditure for tertiary and secondary prevention dropped between 1996 and 2001, expenditure for primary prevention increased. The increase in public expenditure on prevention and health promotion can mostly be attributed to the installation and the work of the Fund for a Healthy Austria. Another trend described in the 2001 publication of ÖBIG (the Austrian Health Institute) was that administrative bodies tended to source out the provision of health promotion and prevention services to external institutions such as for instance NGOs or Associations. Players operating in the system, for instance the FGÖ, appeared to be able to influence the importance/priority attached to selected topics which as a result received more funding. The Institute for Advanced Studies (Institut für Höhere Studien, IHS) calculated that a share of 18.3% of public health expenditure was allocated to the public health service (e.g. medical officer services, social services, environmental medicine) in 2005, which according to a statement of the 46 Statistics Austria, Health expenditure in Austria. Health expenditure in Austria based on the system of health accounts Results. Accessed at on 26 August Habl, C., Schnabl, E., Vogler, S. et al (2004). Public expenditure for prevention and health promotion in Austria Report commissioned by the Federal Ministry of Health and Women. ÖBIG. Vienna Ibid 49 Habl, C., Schnabl, E., Vogler, S. et al (2004). Public expenditure for prevention and health promotion in Austria Report commissioned by the Federal Ministry of Health and Women. ÖBIG. Vienna April

55 authors, included the expenditure of the provinces for health promotion. This share is stated to be financed by tax revenues Funding of selected public health services and activities The Fund for a Healthy Austria (Fonds Gesundes Östereich, FGÖ), the national competence centre for health promotion, is granted a yearly budget of about 7 million (see chapter 2 on legislation for details) which is to be used for supporting projects on health promotion and primary prevention as well as providing further education on these topics. This is one of the very few cases in which a fixed budget is allocated to a specific public health related service. For further information on the responsibilities of the FGÖ, refer to chapter 4 of this section of the report. In 2008 social health insurance spent 116 million (about 0.84% of its total health insurance expenditure) on measures geared towards early detection of diseases and health promotion and 347 million (about 2.5% of total health insurance expenditure) on measures to strengthen the population s health, prevent disease and provide medical rehabilitation. This reflects an increase of 24 million respectively 7.9% compared to Social health insurance moreover covers one third of the costs of the examinations undertaken as part of mother-child-pass examination programme, a screening programme for pregnant women and their children. Social health insurance funds reimburse their health service providers (physicians) before receiving a two-third refund from the means of the Family Equalisations Fund (FLAF, Familienlastenausgleichsfonds). The provinces are responsible for distributing the mother-child-pass booklets to the different recipients (physicians, health centres, etc.). Social health insurance presents its insured population with the opportunity of undertaking a (yearly) preventive health check-up. Also individuals without health insurance coverage can take advantage of this service; in this case resulting expenses are covered by the Federal Government though. Expenses for the juvenile preventive health check-up, which is offered to the young working population between 15 and 18 years, are shared by social health insurance and the Federal Government (50% each). Vaccinations 52 are no compulsory benefit of social health insurance, the sole exceptions being the vaccination against tick-borne-encephalitis 53 and the vaccination against influenza, the latter however only if the World Health Organisation WHO has declared the influenza a pandemic and the Federal Ministry of Health has ordered the production of the vaccine. 54 Social health insurance also reimburses the costs for influenza vaccinations, rabies or tetanus in cases of administration following exposure. Since January 1998 costs for vaccinations of children (up to the age of 15 years) 55 have been, based on the socalled Children vaccination programme covered jointly by the Federal Government, the provinces and social insurance funds. 56 Thereby the Federal Government pays for 2/3 of the costs, whilst the provinces and social insurance cover 1/6 of the costs each. The provinces moreover pay the 50 IHS HealthEcon 2005 ( in Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies, pp Main Association of Austrian Social Security Institutions (2009). Handbook of Austrian Social Insurance Vienna. Accessed at 52 Also based on Main Association of Austrian Social Security Institutions (2009). Vaccinations A social insurance benefit? Internal document. 8 July Social health insurance funds subsidise these; the height of the subsidy is defined on a yearly basis 54 Regulated in 132c of the General Social Insurance Act Other measures to maintain the health of the population 55 Decisions on which vaccinations to include in the concept are taken jointly and are based on the recommendations of the Supreme Sanitary Council expressed in form the yearly vaccination plan 56 This is based on the socalled Vaccination Concept (Impfkonzept) which was initiated by the then Minister of Health in April

56 physician fees. 57 The Child vaccination concept at present includes the following vaccines: Sixfold immunisation (Diphtheria, tetanus, pertussis, polio, haemophilus infl. B, hepatitis B), Measles-mumpsrubella, hepatitis B, diphtheria-tetanus-polio, diphtheria-tetanus-pertussis, oral vaccination against rotavirus since The conjugated pneumococcal vaccine prevenar is only intended for free of charge use in risk groups (early birth). Costs of vaccinations for adults have to be paid privately; the decision to get vaccinated is considered a matter of individual responsibility. The coverage of costs of health examinations at schools depends on the type of school and can be the responsibility of the Federal Government, the provinces or the municipalities. Most of the provinces have compiled health reports; some of them have already published more than one report over the past years. Recently also other stakeholders such as social insurance or municipalities have engaged in health reporting. The compilation of such reports is frequently commissioned to external consultants or university departments; in a few cases reports are produced in-house. Experts working in the field argue that financial resources dedicated to health reporting can be very limited and thus for instance do not enable them to undertake elaborate data analyses. For further information on health reporting activities, refer to chapter 6 of section II of the present report. Several provinces have gathered experience with the development of health targets. Progress is heterogeneous though. On few occasions the target development process and further actions were supported by scientific backing or characterised by a transparent methodology. Funding and time required for the development and implementation of health targets appears to be frequently underestimated by decision makers. Health targets are discussed in detail in section III of the present report. Over the past years health system stakeholders have started investing in public health capacity building, mostly by promoting workforce development measures and encouraging i.e. supporting their employees to obtain training in public health or a related subject. The Fund for a Healthy Austria for instance provides regular scholarships and insurance funds train a certain number of their employees every year. Without this support some postgraduate programmes could not exist. Organisational structures are only very slowly being adapted and appropriate and challenging positions created for individuals with a corresponding training. Training structures for public health are described in section V of the present report. Investment in public health research is still very low. Both financial as well as adequately qualified human resources are missing and also commitment or leadership is limited. Funding is predominantly provided for short tem activities such as projects, funding for long term programmes or research studies is hardly available. Issues with regard to research are largely dealt with in section V of the report but also briefly summarised in chapter 6 of section I. 57 Federal Ministry of Health, information provided by an expert on the phone, 20 October 2009 April

57 4 Organisation and structure, stakeholders This chapter of the report outlines the organisation and structures of public health in Austria. An overview of the key stakeholders operating in the field of public health is given as well as describing their responsibilities and functions. Before continuing, it is important to be aware of the fact that the responsibility for public health issues in Austria is not limited to one ministry, to a defined individual (such as a minister) holding a specific position or to certain health authorities or institutions operating in the health sector. It is a field in which responsibilities are fragmented and in which all levels of the health system and a great number of health system stakeholders and other stakeholders (occupied for instance with social-, environmental or educational issues) are involved in one or the other way and to which departments, sub-divisions or individual experts of institutions contribute as well as selected experts who are driven by the commitment to a particular topic. Co-operation within the health sector (and even within certain institutions such as e.g. between insurance funds) and across different sectors i.e. a multidimensional approach towards health, involving areas such as social services, environment, education or families, which would be in line with a multisectoral notion of public health, only takes place in few areas and provinces (e.g. in selected administrative districts) and is rarely standardised. The building of co-operations and partnerships is not encouraged and not a standard practice. Within the health sector new measures of co-ordination were introduced as part of the health reform 2005 (on the national level the Federal Health Agency, on the provincial level the Regional Health Platforms); their effectiveness has to still be assessed; first evaluations show promising results. Social insurance partially takes on the role of a communication promoter and initiator or discussions. Summarising, a clearly defined modern public health structure does not exist in Austria, nor is there an overall public health framework, strategy or plan. A national priority setting process has not been initated and national health targets are missing. Austria has no Public Health Ministry and no modern Public Health Act. Public health in Austria is largely not institutionalised (e.g. in terms of an institute department or expert existing for public health) 58 or forms an integral part of organisations. The discipline still lacks an organisational and structural integration, clearly defined responsbilities, targets and strategies as well as a formal legislation basis as legislation is partially outdated or missing. Commitment towards public health by decision makers is still limited and thinking in legislation periods still dominates. Some organisational structures are in place (for instance the public health sub-working group of the Structural Changes working group of the Federal Health Commission (Unterarbeitsgruppe Public health der Bundesgesundheitskommission) or the Science Association of Social Insurance (SV Wissenschaft)) but are often still lacking across all levels of the health system. Responsibilities and potential powers of existing stakeholders are not transparent. Several topic-specific institutions have been established in the past roughly five years (for health promotion, HTA or prevention), but an overall strategy is missing. In Austria two different types of health institutions can be distinguished when it comes to their involvement in the field of public health. The first type of institution is usually focussed on one (or several) selected field(s) of public health, for instance health promotion (e.g. Ludwig Boltzmann Institute for Health Promotion Research, the Vienna Institute for Health Promotion or the Institute for Health Promotion and Prevention in Graz) or HTA (the Ludwig Boltzmann Institute for HTA) whereas the second type, representing the majority of the Austrian institutions or health system stakeholders, are predominantly active in other topical areas i.e. define different core responsibilities and cover public health matters only as one of many topics addressed (Federal Ministry of Health, social insurance, ÖBIG, etc.). 58 An exception is for instance the Fund for a Healthy Austria with ist responsibility for the field of health promotion and primary prevention. April

58 Thereby often no separate deparment or unit for public health but related topics are simply assigned to selected individuals. The subsequent list shows the key stakeholders involved in public health related activities in Austria. On the national level - the National Council (Nationalrat) and the Federal Council (Bundesrat) - the Federal Ministry of Health - Self-governed bodies such as social insurance institutions (Main Association of Austrian Social Security Institutions, national social insurance funds, e.g. for mining and railway workers, for farmers, civil servants or self employed individuals) or professional organisations (e.g. Austrian Medical Chamber) - The Federal Health Agency with the Federal Health Commission and the Federal Health Conference o The Public Health sub-working group of the Structural Changes working group of the Federal Health Commission - Advisory boards: Supreme Health Board and its sub-committees - The Austrian Agency for Health an Food Safety: owned by the Federal Government (represented by the Minister of Health and the Minister of Agriculture, Forestry, Environment and Water management) - Gesundheit Österreich GmbH (Health Austria Ltd.) which is owned by the Federal Government and consists of the sub-divisions Fund for a Healthy Austria (FGÖ), the Austrian Federal Health Institute (ÖBIG) and the Federal Institute for Quality in the Health Care System (BIQG) 59 - Research institutions: universities and universities of applied sciences, selected institutes of the Ludwig Boltzmann Society (e.g. Institute for Health Promotion Research or Institute for Health Technology Assessment), Institute for Health Planning in Upper Austria, Institute for Advanced Studies (IHS) - Others: Austrian Public Health Association, Anti Poverty Network - Planned: National Institute of Public Health On the provincial level - The provincial government, provincial health authorities, provincial health directorate - Regional health insurance funds - Regional offices of professional organisations - Regional health platforms - Advisory boards: regional health boards - Regional research institutions, e.g. the Vienna Institute for Health Promotion (Wiener Gesundheitsförderung, WiG) On the municipal, district and community level - District and community health authorities On various levels of the health system - Medical and other universities, patients and patient representatives, self-help groups, medical officers, NGOs, working groups, health professionals and health care institutions and individual experts Representatives of different institutions state that a co-operation between institutions does take place in the form of projects (target groups, e.g. elderly and specific topics, e.g. mental health), working groups or networks. Few institutionalised or standardised co-ordinating mechanisms exist though FGÖ=Fonds Gesundes Österreich, ÖBIG=Österreichisches Bundesinstitut für Gesundheitswesen, BIQG=Bundesinstitut für Qualität im Gesundheitswesen 60 Expert interviews June 2009 April

59 Subsequently the responsibilities of the individual stakeholders are briefly outlined. The National Council and the Federal Council are responsible for debating and voting upon legislation. Duties of the Federal Ministry of Health are laid out in the Federal Ministries Act. Responsibilities involve for instance: general health policy, protection of the general population s health status, engagement in cross-regional health crisis management, structural policy, planning and funding as well as further development of the health care system, information management, health reporting, health informatics and telematics as well as prevention, overseeing the mother-child-pass examination programme, occupational medicine, hygiene and vaccination services, monitoring and combating infectious diseases, issues related to radiation, supervision and combating of abusive alcohol consumption and narcotics, training and further education of health professionals and food inspection. The Federal Ministry of Health holds an important position in policy making and acts as a supervisory authority: It moreover has a co-ordinating function, bringing together all health system stakeholders. Many duties of the Federal Government listed above are delegated to the provinces or self-governing bodies such as social insurance institutions by means of indirect federal administration. 61 Other ministries such as the Federal Ministry of Education, Arts and Culture, the Federal Ministry of Labour, Social Affairs and Consumer Protection, the Federal Ministry of Agriculture, Forrestry, Environment and Rural Development are also confronted with a range of health-related issues. Cooperation among ministries mostly takes place in form of joint projects instead of stadardised procedures. Social health insurance funds have, by law, various obligations with regard to public health services. According to 116 of the General Social Insurance Act (Allgemeines Sozialversicherungsgesetz, ASVG), social health insurance is responsible for ensuring health promotion (same legal entitlement for insured as preventive services). Social health insurance can also promote public/non-profit institutions assisting the prevention or early detection of disease, the prevention of accidents (apart from work related accidents) and can invest means in researching causes of disease and accidents. A special paragraph on health promotion, 154b, which was enacted in 1992, regulates that health insurance funds have to inform their insured about general health risks and the prevention of disease and accidents (apart from work related accidents). Social health insurance funds can engage in cooperations with other institutions and thereby share costs. The intention behind introducing this paragraph was to promote the role of health insurance in the field of prevention. 62 Based on 447h of the ASVG, a fund for preventive health check-ups (Vorsorgeuntersuchungen) and health promotion has to be installed at the Hauptverband. The fund is financed by money from the Federal Ministry of Finance (Tobacco Tax) and other forms of income. Means of the fund are to be used for the preventive health check-up and for co-ordinated measures of health promotion. The Main Association of Austrian Social Security Institutions has to report to the Federal Ministry of Health on the development of the use of preventive health check-ups. Social insurance has moreover recently initiated a 5-year programme for health promotion and prevention. Social health insurance funds are obliged to provide preventive health check-ups for their insured population and examinations executed as part of the mother-child-pass examination programme. They furthermore offer humangenetic examinations and selected vaccination services. Social insurance funds also engage in accident prevention, the promotion of dental health and occupational health, disease management, promotion of physical activity and healthy nutrition as well as informing about risk factor prevention by e.g encouraging participation in smoking cessation programmes. Settings which are primary targets of health promotion activities are schools ( Healthy Schools project : a joint 61 Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies. 62 HEIdocu part 1, contributions from Günter Flemmich, Helmut Ivansits, Paula Lanske, Doris Lutz, Christa Marischka, Christian Rothmayer, Monika Weißensteiner and Brigitte Wolkersdorfer. Download of part 1 available at download of part 2 available at April

60 project of the Federal Ministry of Education, Arts and Culture, the Federal Ministry of Health and the Main Association of Austrian Social Security Institutions) and workplaces. The creation of public health expertise is promoted within social insurance by supporting the participation of a definite number of employees in post-graduate and other training courses through sponsorships. Another very important and growing field of activity of social insurance is the creation of awareness for the topic of public health and the initiation of discussions by organising events, initiating working groups or defining targets related to this field. The Science Association of Social Insurance 63 SV Wissenschaft, which has been established by all social insurance funds, intends to promote research co-operations in social insurance. Among other activities, research fields have been defined, knowledge on networking acquired, scientific evidence on social insurance positions collected, research-cooperations initiated and events organised. The Austrian Medical Chamber (Österreichische Ärztekammer) is the professional representation organisation of physicians in Austria, representing both employed and freelance (self-employed) physicians. Regional professional organisations exist in each of the nine provinces. Duties of the Austrian Medical Chamber and the regional associations involve amongst others the issuing of statements or suggestions related to any issues affecting physician interests in the health system in general or in connection with education and training or continuing medical education (CME) of physicians. Furthermore they are in charge of monitoring the quality of CME events, of keeping record of registrations and of negotiating contracts with social health insurance funds. In the course of the health reform 2005, which aimed to promote integrated care by reducing the divide between ambulatory and inpatient care (achieving a better co-ordination with regard to planning, steering and funding of the health system), the Federal Health Agency (Bundesgesundheitsagentur) was established on the national level (with the Federal Health Commission (Bundesgesundheitskommission) as an executive body) and Regional Health Funds (Landesgesundheitsfonds) were established on the provincial level (with the Regional Health Platforms (Gesundheitsplattformen) as executive bodies). The Federal Health Conference (Bundesgesundheitskonferenz) was installed as an advisory body of the Federal Health Commission. The Federal Health Agency (Bundesgesundheitsagentur) is responsible for monitoring developments in the health sector, for promoting further development by defining principles (e.g. for planning, budgeting, reimbursement, etc.) and applying steering mechanisms. The Agency is furthermore in charge of defining quality standards which should ensure a better quality of service provision, of devising regulations for uniform documentation and for defining a framework for the management of interfaces between the different sectors of the health system. Its executive body, the Federal Health Commission, is composed of representatives of the Federal Government, the provinces, social insurance and professional organisations/interest groups (physicians, patients, hospitals). 64 In the draft of the Health Promotion and Prevention Act various additional responsibilities of the Federal Health Agency are listed such as the development of targets for health promotion and prevention as well as the definition of strategies to achieve these targets. Furthermore the coordination of new measures with already existing ones and the compilation of a report on the activities undertaken in the areas of health promotion and prevention. The Public Health sub-working group (Unterarbeitsgruppe Public Health) of the Structural Changes working group of the Federal Health Commission (Arbeitsgruppe Strukturveränderungen der Bundesgesundheitskommission) is a group composed of representatives from the following organisations: Federal Ministry of Health (6 persons), provinces/provincial organisations (4), social insurance (3), Vienna Health Promotion Ltd. (1), Health Austria Ltd. (2). The management of the 63 SV Wissenschaft. Accessed at menuid=65117&p_tabid=1 on 9 October Federal Ministry of Health, accessed at on 5 May Article 15 of the Agreement according to article 15a of the Federal Constitutional Act. April

61 working group is taken on by an additional regional representative (from Styria). The working group advises the Federal Health Commission in public health agendas. The Supreme Health Board (Oberster Sanitätsrat) is a medical-scientific body comprised of highly recognised Austrian health experts (physicians of various specialties, pharmacists, psychologists, experts for health planning, financing, nursing, etc.) who are appointed by the federal Minister of Health for a period of three years. Representatives do not receive any remuneration for their work and are bound to confidentiality. The legal basis of the Supreme Health Board is the Imperial Sanitary Act which dates back to Even then the committee took on an advisory and appraising function with regard to questions related to population health. After the Second World War the work of the board focused on maternity and child care, on the reduction of infant mortality and on combating infectious diseases which also included the development of vaccination programmes for children. 65 Today the Supreme Health Board still has the duty to provide the Minister with advice and expert opinions on selected topics. It was reorganised in 2005 and now has 39 members (previously 19). 66 Meetings are held three times a year. Recommendations of the Board are not binding for the Minister. 67 The Supreme Health Board has various subcommittees: the AIDS committee, the vaccination board, the dental committee and the mother-child-pass committee. 68 In 2004 a committee for public health was installed. The sub-committee for Public Health of the Supreme Health Board (Unterarbeitsgruppe Public Health) is composed of members of the Supreme Health Board who volunteer to join the subcommittee. The committee deals with issues related to occupational health and diseases of civilisation as well as with topics which are defined by the committee s members or with enquiries passed on by the Supreme Health Board from the Minister. At present Prof. Michael Kunze, Professor of Social Medicine at the University of Vienna, is in charge of the co-ordination of the Public Health subcommittee. The committee comments on current issues, works on topics of the government programme and on self-defined fields of interest (e.g. health targets, demographic change). 69 In general activities of the Supreme Health Board and the sub-committees are subject to very strict confidentiality regulations. Choice of topics dealt with or decisions taken are not transparent. The Austrian Agency for Health and Food Safety (Österreichische Agentur für Gesundheit und Ernährungssicherheit, AGES, is owned by the Federal Government and fulfils a wide range of responsibilities related to health and food safety. These involve food inspection (to ensure safe and properly labelled food), the promotion of healthy nutrition, veterinary examinations (to ensure protection against animal diseases or zoonoses), the approval of medicinal products and medical devises as well as the prevention and control of infectious diseases. AGES oversees the entire food chain by performing assessments, issuing approvals, giving advice and undertaking research. Gesundheit Österreich GmbH, GÖG (Health Austria Ltd.) was founded on 1 August 2006, based on the Federal Act of the Establishment of Gesundheit Österreich GmbH. 70 It is a national research- and planning institute for the health system, acting as national competence centre for health promotion and is 100% owned by the Federal Government. The organisation comprises three divisions, the Austrian Health Institute (Österreichisches Bundesinstitut für Gesundheitswesen, ÖBIG), the Federal Institute for Quality in the Health Care System (Bundesinstitut für Qualität im Gesundheitswesen, BIQG) and the Fund for a Healthy Austria (Fonds Gesundes Österreich, FGÖ). Their responsibilities are subsequently described in more detail. 65 Marina Hufnagl (BMG). 27 August 2008 (in response to an equiry of the author) 66 Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies. 67 Federal Ministry of Health and Women (2005). Public Health in Austria. Vienna 68 Marina Hufnagl (BMG). 27 August 2008 (in response to an enquiry of the author) 69 Expert interview, 13 March Federal Act of the Establishment of Gesundheit Österreich, download available at April

62 The Austrian Health Institute, ÖBIG 71, provides expertise in various areas such as planning and steering (e.g. development of the Austrian health plan, management of the Austrian Health Information System, ÖGIS and of various registries), health reporting (compilation of provincial health reports and reports on specific topics), training of health professionals (development of curricula), prevention (health promotion and secondary prevention), health economics and evaluation (funding, health systems analysis, HTA and Pharmaeconomics). The Federal Institute for Quality in the Health Care System, BIQG, was founded in the course of the Health Care Reform 2005 and is based on the Federal Act on the Quality of Health Services (Health Care Quality Act) as well as the Federal Act of the Establishment of Gesundheit Österreich GmbH. It has four main operating fields including: patient safety and quality information, quality programmes, outcome quality and quality and effectiveness/health Technology Assessment. 72 The Fund for a Healthy Austria, FGÖ, was founded in 1998 based on the Health Promotion Act (see chapter 2) and constitutes the central body for supporting projects on health promotion and primary prevention as well as providing further education on the aforementioned topics. It defines health promotion in line with the Ottawa Charta of the WHO and pursues the following aims: 73 - Supporting practical and research projects in the field of health promotion and primary prevention (bio-psycho-social wellbeing) as well as participation in international promotion programmes/research projects - Facilitating structural development and - Promoting continuing training and national as well as international networking and co-operating with international associations - Engaging in public relations work in order to raise awareness for the activities of the FGO and for the topic of health promotion The work of FGÖ spans six fields: physical activity, nutrition, mental health, children and adolescents, health promotion at the workplace and elderly people. For 2008 the following priority areas were defined for the work of the FGÖ itself and the decision on supported project was taken including: cardiovascular health, setting district respectively community/city, nursery and school, place of work and business. The working programme for 2009 builds on the work from 2008 and takes it further. Basic principles of social status and gender mainstreaming are constantly taken account of by the Fund. In addition a book of guidance will be available for applicants seeking project support. In 2008/2009 research of the FGÖ focused on the following topics: the contribution of health promotion to a sustainable improvement of the population s health and the reduction of health inequalities, the contribution of health promotion programmes and strategies to establish sustainable structures and comprehensive health policy (health in all policies) and the contribution of capacity building to the population-wide placement of a sustainable health promotion programmes and activities. The FGÖ supports up to a third of the total costs of a practice project. Appropriate evaluation and documentation are mandatory. Projects have to meet defined quality criteria. The Fund for a Healthy Austria defines itself as being responsible for further development and dissemination of research and instruments for health promotion and primary prevention. It is assigned a yearly budget of 7.25 million originating from income generated through sales tax. So far about 725 projects have been supported and documented in a project database. The FGÖ moreover offers materials and courses for further education, organises events and publishes a great deal of information material and reports. It is one of the most important players in the field of health promotion and primary prevention in Austria. Universities and universities of applied science play a crucial role in public health. On the one hand they organise programmes for public health or related disciplines thereby contributing to the formation 71 Website of ÖBIG, accessed at on 3 January BIQG website, accessed at on 5 April FGÖ website, accessed at on 2 January 2009 Expert interview 6 July 2009 (FGÖ) April

63 of national public health expertise and on the other hand they also engage in public health research. Further information can be found in section V of the present report. The Ludwig Boltzmann Institute for Health Promotion Research started its work in March 2008 and places its research focus on the influence exercised by organisations such as schools, hospitals and nursing homes on the health of their employees and users as well as the requirements for the successful implementation of health promotion measures. Furthermore the impact and consequences of these measures are assessed. 74 The Ludwig Boltzmann Institute for Health Technology Assessment defines itself as independent research institution providing scientific evidence to support decisions in favour of an efficient and appropriate use of resources. The five areas covered by the institute are: Evaluation of medical interventions and questions related to evidence based health services research (assessments), scientific supervision of decision-maker networks, Health Technology Assessment in hospitals, scientific decision support of the Federal Ministry of Health, scientific public and public understanding, HTA implementation: development and information on effective steering and policy instruments and international collaborations/hta Best Practice. Systematic work and traceability of findings is considered crucial. The LBI HTA was founded in April The Institute for Advanced Studies (Institut für Höhere Studien, IHS) i.e. its department of health economics is primarily occupied with research in the fields of applied health economics, health systems comparison and health policy. Scientific methods are applied to analyse and assess questions regarding the structure of the health care system. This emphasis was chosen due to the traditional focus of the Institute for Advanced Studies, economic policy. For its educational activities the IHS receives public sponsorship. The area of applied research covers merily the overhead costs, human resources must be funded through projects. The institute barely receives public funding for research. This is only the case for selected projects. 76 The Austrian Public Health Association (Österreichische Gesellschaft für Public Health, ÖGPH) is a non-governmental organisation which brings together both individuals and institutions interested in public health in the form of a scientific community. It promotes interdisciplinary and multidisciplinary collaboration in the field of public health. It was established in the Nineties by a group of enthusiasts who wanted to bring modern public health to Austria. The main objective of the organisation was initially to introduce training programmes and to close the gap public health professionals perceived when returning after undergoing training abroad. 77 Participation in the association, which counts more than 200 members, is based on individual or corporate membership. Members come from a multiprofessional background and involve academics, practitioners and also students. They form working groups, organise meetings and the association publishes a regular newsletter. The association is a member of the European Public Health Association (EUPHA) and was asked to host the 13 th European Congress of the EUPHA in 2005, which was organised in Graz and attracted more than 900 participants from all over the world. 78 The association is furthermore a member of ASPHER (and supports the development of quality standards for post-graduate training programmes in Public Health. Today the Austrian Public Health Association strives to encourage sustainable health orientated structures in society and policy and facilitates networking among experts. Moreover it promotes dialogue between experts and policy makers on specific and current questions and gives statements on any relevant developments in the Austrian health sector. In 2007 it formed four working groups on Public Relations, Screening (International Austrian Screening Committee), Sports and Training as well as a group to develop standards in public health education. Their aims are presented on the 74 Website of the Ludwig Boltzmann Institute for Health Promotion Research, accessed at 5 May Website of the Ludwig Boltzmann Institute for Health Technology Assessment, accessed at 5 May Expert interview 22 June 2009 (IHS) 77 Expert interview 22 June 2009 (ÖGPH) 78 Noack, H., Kahr-Gottlieb, D. (Eds.) Promoting the Public s Health. EUPHA 2005 Conference Book. Health Promotion Publications. Verlag für Gesundheitsförderung. Gamburg April

64 website of the Association at (Working groups/arbeitsgruppen). With respect to decision-making, the association is so far only heard or involved in some provinces, it has however recently also been consulted at a national level. It is planned to establish a National Institute of Public Health. No details are known about the institute yet, only that it will be attached to one of the medical universities (departments/institutes of social medicine) and that its role will be to engage in research and also training activities. Currently departments for social medicine exist at the medical universities of Vienna, Graz and Innsbruck. The one in Vienna is the largest and constitutes a department of the Centre for Public Health 79 The Austrian Anti Poverty Network (Armutskonferenz) is a network of institutions which aims to fight poverty and social exclusion and improve the living conditions of those affected. It unites about 35 members, including welfare organisations, umbrella organisations of social initiatives, church and groups at risk of falling into poverty 80 such as those without work or single parents and acts both on the national and on the level of the provinces. The overall budget of the networt amounts to about 300,000. It is part of the European Anti Poverty Network (EAPN) and is supported by a scientific advisory committee. The Network provides various services: it offers selected social services, engages in lobbying and undertakes research in order to document the status quo and also to find out about developments, future trends and challenges. It moreover performs media work and public relations work to raise awareness and reduce stigma. Another operating field is lobbying for their members whereby ideas and claims for measures are presented to decision makers. On the ministry level the main point of contact of the network is the Ministry of Labour, Social Affairs and Consumer Protection. Inidividual member organisations operate health care institutions such as hospitals, ambulatory clinics (e.g. for individuals without social insurance) and undertake health prevention activities (e.g. in schools and kindergarten) or provide services for homeless or illegal immigrants. 81 On the national level the Federal Ministry of Health is the supreme health authority. In connection with defined public health issues it is, as described above, advised by the Supreme Sanitary Health Board (Oberster Sanitätsrat). On the level of the provinces the local government is in charge and is supported by the provincial health board. Each local government has a health department which is usually headed by a physician, the local health director. Health departments on the district level are headed by a district medical officer. Community health authorities are, amongst a variety of other duties, responsible for undertaking health inspections (audits) on the local level. The Vienna Institue for Health Promotion (Wiener Gesundheitsförderung, WiG) 82 is a non-profit association of the city of Vienna (100% ownership) which was founded in March 2009 and aims to strengthen and further develop existing health promotion activites in Vienna as well as initiating new programmes and processes. It is intended to bring together and concentrate health promotion in Vienna in this institute. The institute is planned to have a total of about 35 employees. It primarily covers topics related to health promotion, but also partially deals with issues of primary prevention, thereby applying a comprehensive definition of health and not being limited to medical prevention. It follows the setting approach as defined by the Ottawa Charta (creation of healthier living environments) and has defined target groups (children, adolescents, eldery people and women and socially disadvantaged individuals in general) and target topics (healthy lifestlye including physical exercise, nutrition, mental health) and pursues not only a health promotion approach orientated towards behaviours but also towards environments. All large projects are complemented by an evaluation concept which is already defined at the beginning of the project. A comprehensive evaluation of the entire institute is planned to take place in the future. 79 The institute of social medicine lists 7 researchers on its website, the department of epidemiology lists 4 researchers on its website. In total the Centre for Public Health has 8 departments (epidemiology, general- and family medicine, ecotoxicology, ethics in medical research, history of medicine, medical psychology, social medicine and environmental hygiene) with about 160 employees listed on its website. 80 Austrian Network against Poverty and Social Exclusion, Accessed 4 September Expert interview 24 June 2009 (Anti Poverty Network) 82 Expert interview 19 August 2009 (Public research institution) April

65 Numerous other NGOs and charities (e.g. Caritas, Diakonie, Hilfswerk, family organisations, etc.) support or facilitate access to curative and public health services for disadvantaged or special need groups, for instance including family carers, individuals at risk of poverty or undocumented migrants/asylum seekers. They furthermore offer information and in some cases counseling services. Medical officers play a central role in the provision of public health services in Austria. They work for regional, district or local health authorities or also for the federal authorities, sometimes being embedded in a multiprofessional team, including for instance, health attendants, biologists, disinfection officers, nurses or hygienists. A medical officer is usually in charge of a population of about 30,000-60,000 inhabitants (Austria has about 300 medical officers). 83 Training consists of a twoyear postgraduate training course which deals with issues such as hygiene, sanitation, epidemiology, toxicology and veterinary inspection. The curriculum of medical officers is at the moment, as part of the reform of the public health service, undergoing revision. For further details on medical officers and the Austrian public health aervice, see section V. School physicians work for schools, usually on a part-time basis, and are responsible for undertaking routine yearly health examinations as well as providing necessary care to the students at all types of schools. In the past and nowadays physicians are still the only health professionals represented in schools. More details on their responsibilites can be found in section V of the present report. Several public health activities (e.g. training or development of curricula for health professionals) take place in the field of nursing. For further information please refer to section V of the report. Various counseling centres exist (e.g. for AIDS, pregnant women, abusive substances) to support the medical health officers in their daily work and to provide services to persons in need on a local/district level. Other public health stakeholders are for instance health working groups such as aks, the Working Group for Prevention and Social Medicine (Vorarlberg), avomed, the Workling Group for Preventive Medicine and Health Promotion (Tyrol), AVOS, the Working Group for Preventive Medicine (Salzburg), Healthy Lower Austria (Lower Austria), PGA, the Association for Prophylactic Health Work (Upper Austria) and Styria Vitalis (Styria), which are joined together in the Forum of Austrian health working groups aksaustria 84. The aks forum is a national co-operation of regional organisations with experience in the field of Public Health, predominantly focussing on health promotion and preventive medicine. It defines itself as contact point for commissioning cross-regional health services. Members are working groups from six different Austrian provinces. 85 The forum aims to enrich the work in the Austrian provinces through cross-regional cooperation and exchange of experience, to prioritise own interests and activities through joint national presence, to offer projects a greater platform for professional implementation and to be an active partner for cross-regional commissioning agents in Austria and the European Union. 83 Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies. 84 Website of the aksaustria, acessed at on 2 January Members listed on the aks website include the Association for Prophylactic Health Activities (Verein für prophylaktische Gesundheitsarbeit, PGA) in Upper Austria, the Working Group for Preventive Health Care Salzburg (Arbeitskreis für Vorsorgemedizin Salzburg, avos), the Working Group for Preventive Medicine Tyrol (Arbeitskreis für Vorsorgemedizin Tirol, AVOMED), the Working Group for Preventive- and Social Medicine Vorarlberg (Arbeitskreis für Vorsorge- und Sozialmedizin Vorarlberg, aks), the Health Forum of Lower Austria (Gesundheitsforum Niederösterreich) and Styria Vitalis from Styria. April

66 5 Public health disciplines, training and research, key functions A brief summary of public health functions was presented in chapter 1.1 of section I. The present chapter initially discusses the application of selected public health disciplines in Austria before having a closer look at certain functions of public health in Austria. Several public health disciplines and functions are discussed in other sections of this report which is why they are not detailed again at this point. Health reporting and control of infectious diseases are covered in section II, health targets are discussed in section III, disadvantaged and special need groups are addressed in section IV and issues related to professionals in public health are the subject of section V. 5.1 Public health disciplines Multidisciplinarity in public health, both practice and research, is vital; Individuals working in the field should ideally have a strong foundation in one of the following disciplines: (medical) statistics, epidemiology, psychology or the social sciences, including (health) economics and management. But also individuals with backgrounds in other fields such as anthropology or history add a beneficial perspective to public health. The awareness for the need of capacity and capacity building in these areas is only emerging very slowly in Austria. Training in certain diciplines is not available (e.g. in epidemiology, health economics), career paths poorly defined and career opportunities limited. Public health in Austria is still a field with a strong medical dominance; individuals with a different background, e.g. in social sciences, nursing or psychology are gradually moving into the field though and acceptance for multidisciplinarity is increasing Epidemiology Austria does not offer any undergraduate or postgraduate training in epidemiology and only disposes of very few recognised epidemiologists who have been trained abroad and usually work either in hospitals or at universities. A department for evidence-based medicine and clinical epidemiology exists at the Danube University in Krems (Lower Austria) which deals with the fields of evaluation, evidence-based information, methods research and systematic reviews and HTA assessments. An institute of Public Health, Medical Decision Making and HTA exists at the Private University for Health Sciences, Medical Informatics and Technology in Hall in Tyrol. The urgency of creating additional structures and resources and training opportunities for epidemiology appears to be barely perceived, especially among policy makers Health economics No specific training opportunities for health economics are offered in Austria. Several research institutions include the term health economics in their name or resarch portfolio. Several economics-, management- or health-related training programmes may include individual lectures on health economics. Eventhough the expression health economics is used quite frequently in Austria, its application and corresponding research outputs are quite limited. Few institutions such as the Institute for Advanced Studies or the Austrian Health Institute ÖBIG actually perform economic analyses and dispose of qualified staff. The need for the formation of experts in health economics is only recognised very slowly. The Karl Landsteiner Institute for Health Economics organises a yearly course for health economics, together with a Hungarian University in Sopron (topics include DRG reimbursement systems in a variety of countries). Other activities of the institute involve research, the organisation of the platform for health economics (sporadic activity in form of lectures) and the provision of April

67 introductory lectures on health economics and health systems for medical students and students of dentistry. 86 Universities of social sciences (offering e.g. studies related to management, business, economics or statistics) have partially taken to offering health related courses and have also initiated programmes on health management or health sciences (see section V for more information on public health training). Several universities offer a couple of hours or days of training on the subject to their students, but no specialised training is available Medical statistics Research in connection with medical statistics and informatics is more widespread and established. The Medical University of Innsbruck has a department for Medical Statistics, Informatics and Health Economics. 87 Its main focus appears to be on biostatistics and medical informatics. Research activities in health economics deal with cost-benefit analyses, the DRG system and funding of health care systems. 88 The Medical University of Vienna has an Insitute for Medical Statistics and a core unit for Medical Statistics and Informatics offering expert knowledge in medical informatics and statistics. At the core unit sections/institutes are avaiable for clinical biometrics, medical statistics, biomedical computersimulation and bioinformatics, medical computer vision, medical expert and knowledgebased systems and medical information and retrieval systems. 89 The Medical University of Graz has an Institute for Medical Informatics, Statistics and Documentation which focuses on image processing in medicine, data protection, clinical bioinformatics, medical information systems, human-computer interaction and usability engineering, telemedicine and ehealth and also knowledge sourcing in medical databases Health technology assessment 90 With regard to the use of HTA Austria can be described as a latecomer. Only few recognised experts exist in the field and a small number of institutions or departments. 91 Austria does not have a national Health Technology Institute and has not implemented a national priority setting process. Experts interviewed in the course of the study do however report some progress and state that HTA is received with greater acceptance nowadays and that findings of assessments are usually considered for further implementation. Also a gradual change from retrospective assessments to prospective planning is visible in Austria. One stakeholder in the field of HTA in Austria is the BIQG 92 subdivision of Gesundheit Österreich GmbH, GÖG, which was founded in 2007 and is responsible for developing a national HTA strategy respectively a national framework for HTA. In 2008 representatives from BIQG developed a strategy together with a working group composed of representatives of the Federal Government, the provinces an social insurance. Some of the aspects of the strategy i.e. the report are already being implemented, others still require further specification. A HTA working group was installed which is in charge of coming up with recommendations for integrating HTA in the decision making structures. 86 Karl Landsteiner Society. Institute for Health Economics. Accessed 3 October Existing since 1968, originally as department for Biostatistics and Documentation, renamed in 2004 to deparment of Medical statistics, informatics and heath economics 88 Department of Medical Statistics, Informatics and Health Economics at the Medical university of Innsbruck. Accessed at on 3 October Core Unit for Medical Statistics and Informativs at the Medical University of Vienna. Accessed at on 3 October Based on expert interviews, 22 June 2009 (HTA, research) 91 For an overview, consult Accessed on 10 April Bundesinstitut für Qualität im Gesundheitswesen = National Institute for Quality in the Health Care System April

68 Another important stakeholder in the field of HTA in Austria is the Ludwig Boltzmann Institute for HTA. The institute disposes of a staff of 12 resarchers and produces about 10 to 12 comprehensive assessments and 10 to 12 rapid assessments a year. These are partially related to public health questions and for instance involve an assessment of the HPV (human papilloma virus) vaccination, of new interventions for hospitals, interventions for chronic backpain, of interoperative radiotherapy, medical devises and equipment or rehabilitation measures. Topics of assessments and research priorities are defined together with partners who provide 40% of the institute s funding. Partners are hospitals, social insurance, the Federal Ministry of Health or universities. Research at the Institute of Public Health, Medical Decision Making and Health Technology Assessment, which lists 33 members of staff on its website, focusses on cardiovascular disease, cancer screening and treatment, infectious diseases, diabetes, neurological disorders and other diseases. 93 The Department for evidence-based medicine and clinical epidemiology at the Danube University in Krems (Lower Austria) deals with the fields of evaluation, evidence-based information, methods research and systematic reviews and HTA assessments. The EBM (Evidence Based Medicine) Review Centre at the University Clinic of Internal Medicine in Graz was established in 2005 and became a Research Unit at the Institute for Medical Informatics, Statistics and Documentation (IMI) in The research centre s aim is to compile overview-papers and untertake meta-analysis on defined medical topics. 94 Furthermore the Main Association of Austrian Social Security Institutions has created a department for Evidence based medicine (Evidenzbasierte wirtschaftliche Gesundheitsversorgung) in HTA experts in Austria generally work either at universities, resarch institutions or on a freelance basis. Experts interviewed in the ourse of the study state that there is a need for a clever priority setting process. International examples and experience should be taken into consideration - good models exist. It is not considered necessary to invent everything newly. 5.2 Public health training and research structure The topic of public health training and research is extensively covered in section V of the report. This chapter includes a brief overview of the main aspects Public health training Training in public health or a related field can be obtained by following different training and career paths which are subsequently summarised. One path is to study medicine and to thereafter specialise in social medicine, occupational medicine or to engage in postgraduate training at one of the universities offering postgraduate training courses in public health or a related field. Austria has three public medical universities which are located in Vienna, Graz and in Innsbruck and one private medical university in Salzburg. Physicians can also enrol in a postgraduate training course for physicians working in the public health service, which is offered at the three medical universities of Vienna, Graz and Innsbruck. Reform of the training course is currently underway. Other training options (school physician, environmental medicine) are available for physicians in the form of diploma courses. Another way is to finish an undergraduate course at university in any subject and to then enrol in a postgraduate public health programme. Individuals can partially also enrol in a postgraduate programme without having an undergraduate degree if they are able to demonstrate a defined amount of working experience (sometimes in a leading position). 93 For further information see the website of the department for evidence-based medicine and clinical epidemiology s website at accessed 8 April Website of the EBM Review Centre, accessed at on 8 April Website of the EWG Department (Evidenzbasierte wirtschaftliche Gesundheitsversorgung), accessed at 58&action=2 on 8 April 2010 April

69 Several Universities of Applied Sciences offer undergraduate training in subjects such as health promotion, health services management, etc. Graduates also work in the public health field. Another way of obtaining a position which is concerned with public health is to demonstrate practical training only, in the form of experience and potentially attendance of conferences, seminars, etc. Public health programmes do not have a long tradition in Austria. The first Austrian Master of Public Health programme started at the University of Graz in autumn In the past years further programmes were initiated at the Johannes Kepler University in Linz (Upper Austria), at the Private University for Health Sciences, Medical Informatics and Technology in Hall in Tyrol (course on Health Management), and at the Medical University of Vienna (Vienna). The curriculum which is taught in Graz is also offered in Schloss Hofen (Vorarlberg), in co-operation with the university of applied sciences in Dornbirn. Various universities (e.g. in Krems and Klagenfurt) and Universities of Applied Sciences (e.g. in Pinkafeld, Steyr or Bad Gleichenberg) followed the trend and initiated programmes containing public health elements, e.g. for health care management, health promotion, hospital management or other related fields. One big problem of public health training, both at Universities and at Universities of Applied Sciences a serious shortage of teachers trained in public health Public health research The topic of public health research is also covered in section V of this report and is therefore only presented in a very short manner at this point of the report. Public health research is limited in Austria due to various reasons. Departments at universities offering public health or related courses are usually very small and employees are mainly occupied with course organisation, teaching and administration. No fixed budgets for research and only few ongoing research co-operations exist in this area, indicating a lack of prioritisation of the topic. Research is often commissioned on demand or following trends; planned research barely exists. Publications frequently report on outcomes of short-term projects; long-term research activities are very rare. Involvement in EU research activities is sometimes hampered because of a shortage of resources respectively the time and effort needed to prepare an application. Research topics are to a great extent influenced by the head of the research institution, by the funding-partners of the respective institute and by external trends and events. Currently research shows a focus on the description of the status quo. 5.3 Functions of public health in Austria This chapter describes a range of functions and applications of public health in Austria, involving health services, social medicine, occupational medicine, the Austrian public health service, health promotion and prevention. Several functions of and tools applied in public health are detailed in other sections of the present report and will therefore not be repeated in this chapter. They involve health reporting (section II), health targets (section III) the addressing of disadvantaged and special need groups (section IV) and training and research (section V) Health care services Health care services in Europe are mostly funded and provided by public entities such as national or social insurance bodies or national, regional or local authorities. In Austria public expenditure on health amounted to 76.9% of total expenditure in Health insurance coverage is widespread throughout Europe; dominant funding mechanisms of health systems are either social insurance, tax 96 Statistics Austria. Health expenditure based on the OECD System of Health Accounts, accessed at on 15 April 2010 April

70 funding or mixed funding systems. Austrian health insurance covered 99% of the population in In addition private health insurance presents an option; its importance varies considerably in different countries, depending on the dominance of public insurance and the extent of the benefits package provided. Health expenditure as % of GDP in Austria is above European average and amounted to 10.5% in Main sources of funding are social insurance, private payments (23.1%) and taxes. 98 Private health insurance only plays a minor role in Austria, mostly acting as supplementary or complementary health insurance and in very few cases as subsitutive health insurance. The main reason for this is the comprehensive coverage of social health insurance and the fairly extensive benefits package. Government relies heavily on delegating regulatory functions and devolution to the provinces, and also to social insurance which is acts based on self-governance. Responsibilities for the funding and provision of services are fragmented which results in incentives to shift costs between the different sectors of service provision, thus limiting continuity of care and patient centredness of care. Demographic changes such as the ageing of the population or the decreasing number of child births confront especially the healthcare sector with considerable challenges as most health services are consumed by the elderly and are paid for by the working population (in the form of taxes or social insurance contributions). Additional trends which can be observed in the health care sector are a rise in patient and provider mobility, an increasing demand for accountability (focus on evidence-based medicine and application of HTA, e.g. economic evaluation, to justify expenditures), the introduction of case- and disease management programmes, the movement towards mixed funding systems, the more frequent use of quality mechanisms and a gradual integration of health promotion and prevention services into health insurance packages (national, social and private insurance). Health care data are either related to the infrastructure and resources provided or to the utilization of these by patients. The number of practising physicians per 100,000 inhabitants shows strong variation in European countries, being highest in Greece (close to 500), Belgium (405 physicians in 2007) and Austria (376 physicians). Methodological differences may apply. 99 Of the roughly 36,000 registered physicians and dentists close to 30% had signed a contract with Austrian social health insurance. 100 Between 1997 and 2005 the number of hospital beds in the EU-27 has decreased by 15%. This is on the one hand due to a shifting of care from in-patient to outpatient care but also the result of a more efficient use of resources. In 2005 an average of curative care beds as well as 60.4 psychiatric beds was available per 100,000 inhabitants in the EU Austria had a total of 267 hospitals and 770 hospital beds per 100,000 inhabitants in The number of in-patient days amounted to 18,569,303. All data quoted in this paragraph is from Main Association of Austrian Social Security Institutions. Social Insurance in Figures. March Accessed at df on 5 April Statistics Austria. Health expenditure based on the OECD System of Health Accounts, accessed at on 15 April European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April Main Association of Austrian Social Security Institutions. Social Insurance in Figures. March Accessed at df on 5 April European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April Main Association of Austrian Social Security Institutions. Social Insurance in Figures. March Accessed at April

71 Austria had 1,233 public pharmacies in 2008, 46 hospital pharmacies and 962 in-house physician pharmacies. 103 Table 2: Selected health care indicators (per 100,000 inhabitants) Social medicine Historically social medicine, Sozialmedizin, was very important to nurture the idea of and give birth to public health. Nowadays in Austria it is a rather theoretically and scientifically orientated medical df on 5 April Ibid April

72 discipline which physicians can specialise in once they have graduated from medical university. 104 It requires a training period of six years to specialise whereby four years involve training in the main (chosen) subject of social medicine and two years are spent training in complementary medical specialties. Austria has three departments of social medicine (at the medical universities of Vienna, Graz and Innsbruck). Training can only be undertaken at university. Currently only one full-time training post for social medicine is listed at the Austrian Medical Chamber. 105 During undergraduate medical studies, social medicine was previously a small examination students took towards the end of their studies. In the new medical curriculum (since 2001/2002) aspects related to public health and social medicine have increased. For further information see chapter of section V. Based on the training regulations for physicians (Ärzteausbildungsordnung), the specialty of social medicine involves the execution of measures to maintain social, physical and mental health and to combat disease, focussing on prevention, diagnostics, treatment and rehabilitation of health impairments, illnesses and behaviour which could be of a societal origin. 106 According to the examination regulation for the examination taken in connection with becoming a specialist of social medicine, social medicine is an independent medical specialty, which deals with interdependencies between health and illness and society. In addition to diseases which are caused or influenced by social aspects, also the impact of health disorders on the social and economic standing of an individual as well as the entire population is assessed. Social medicine furthermore studies societal measures of preventing disease, restoring health and caring for chronically ill and disabled. Methods applied in social medicine are mostly geared towards epidemiology, sociology, economics and psychology. 107 The detailed knowledge and skills which have to be acquired during the training period for social medicine (four years of special training) can be found in the training regulations 108. Other health professionals such as midwives and/or social workers also learn about social medicine during their training. According to the Institute of Social Medicine and Centre of Public Health 109 at the Medical University of Vienna, Social Medicine deals with the interaction of social circumstances, health and disease, as well as being titled the science of and for health policy. Public health is defined on the institute s homepage as the application of social medicine which uses epidemiology as source of information and implements findings from epidemiology in public health programmes with the intention of contributing to the promotion of the population s health. The same definition classifies social medicine as a staff function in the health sector which is in charge of supporting and evaluating the line functions, which are prevention, early detection, therapy and follow-up care. Based on the statement of an Austrian expert for social medicine who was asked to describe the difference between social medicine and public health, the disciplines cannot be separated. When compared to public health, social medicine shows a stronger medical focus. 104 The specialisation of Social Medicine was introduced in Austria in Website of the Austrian Medical Chamber, accessed at usbildstatt%2fsozmed.htm on 4 May 2009 and 5 April Annex 39 of the Physician training regulations (Ärzte-Ausbildungsordnung) 2006, BGBl. II Nr. 286/2006 which came into effect Austrian Medical Chamber (2001). Examination Directive for the medical specialisation of social medicine (Fachspezifische Prüfungsrichtlinie für das Sonderfach Sozialmedizin). Decided by the Examination Commission in November 2001, status 11/2008. Accessed at on 10 May Annex 37 of the physician training regulations (Ärzte-Ausbildungsordnung), BGBl. Nr. 152/1994, amended last through BGBl. Nr. 169/ Homepage of the Institute of Social Medicine and Centre for Public Health, accessed 5 May 2009 April

73 According to Rásky, social medicine and public health deal with nearly identical questions and problems, have however a different background. Social medicine has a medical and public health a multidisciplinary background. 110 Rásky suggests making better use of highly qualified specialists of social medicine, who currently predominantly work in education and research as well as compiling expert opinions, by for instance creating positions in the public health service, in policy consulting and in private research institutions. Also hospitals, private practices or municipalities could benefit from their broad knowledge. Small institutes for social medicine exist at the three medical universities (Vienna, Graz and Innsbruck). These partially still follow fairly conservative structures Occupational medicine Another medical specialty which partly shows overlaps with the field of public health is occupational and work medicine. Detailed information on training in occupational and work medicine can be found in chapter of section V. The speciality of occupational medicine deals with the interdependencies between work, occupation and health with the aim of maintaining and promoting health and the productivity of employees, thereby especially focussing on the detection of health- and productivity related factors in the work environment, the assessment of the impact of these factors on the human being and on working procedures, the development and execution of preventive measures, the clarification of health disturbances with regard to their potentially work-related causes as well as participating in the medical measures taken in the case of work accidents and occupational illnesses including the execution of work promoting rehabilitation The Austrian public health service The public health service (Öffentlicher Gesundheitsdienst, ÖGD) constitutes a very important sub-set of public health in Austria. At the moment responsibilities of the Austrian public health service i.e. of the public health authorities are predominantly based on the Imperial Sanitary Act of 1870 and feature the fulfilment of administrative duties as defined by law. The implementation of these is, by means of indirect federal administration, largely overseen by the provinces (provicial governor, provincial authorities), districts and municipalities. Division of responsibilities with regard to the services provided by the public health authorities is very heterogeneous across the provinces; the basic principles respectively duties are comparable but the execution and the extent of delegation and devolution (to district/community or other authorities) varies considerably in every province, making comparisons very difficult. The public health service in Austria has various competencies. The health authorities of the provinces and municipalities are responsible for the establishment, implementation and supervision of public health services such as health reporting (e.g. compilation of reports based on medicinal statistics), prevention (e.g. approval of funding for prevention projects, vaccinations) reporting and monitoring infectious diseases, issues related to environmental medicine (assessment of environmental compatibility), sanitary inspections (of health care institutions), aspects related to maternity care (e.g. undertaking examinations of mothers to approve of premature maternity leave) and the provision of physician services in schools. 112 Medical officers on all levels also act as consultants, compiling expert opinions on selected subjects. 110 Rásky, É. (1999). Prophete rechts, Prophete links, das Weltkind in der Mitten. Sozialmedizinische Fachärztinnen und ärze im Aufbruch in Polak, G. (Ed.). Das Handbuch Public Health. Theorie und Praxis. Die wichtigsten Public-Health-Ausbildungsstätten. Springer Verlag. Vienna 111 Annex 3 of the physician training regulations (Ärtzinnen-/Ärzte-Ausbildungsordnung) 2006, BGBl. II Nr. 286/ Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies April

74 As part of the health reform 2005, a reform of the Austrian public health service was initiated. One of the main motivations behind the reform was to re-define the core duties of the ÖGD and to create a modern understanding of the Austrian public health service. In 1998 the Federal Ministry of Health had already commissioned the Austrian Health Institute ÖBIG to perform a study on the re-positioning of the ÖGD. Outcomes of the study were not implemented. This resulted in the decision of managing the present reform, which is again headed by ÖBIG, as a process instead of conducting another research study. It was believed that this would promote and facilitate an actual implementation of measures. A first step of the process was to suggest a catalogue of duties to be met by the public health service as well as providing a recommendation of how these could be distributed across the different administrative levels. As an initial output the handbook of public health services was produced by ÖBIG in co-operation with a working group compiled of representatives of the health authorities of the provinces as well as other experts. The handbook forms the base for discussions with the provinces by means of which a consensus on a uniform catalogue of duties of the public health Service should be reached. Thereafter it is planned to firstly define a framework for a training concept for medical officers (working in the public health service/ the public health authorities), based on which new curricula should be developed and secondly to elaborate an own working package for the implementation of the ÖGD reform in the provinces. Authors of the abovementioned handbook 113, which describes the future vision of the Austrian public health service, rather than the present status quo, suggest that the ÖGD is responsible for all matters affecting the health of the population as a whole Health promotion The WHO defined health promotion in the Ottawa Charter for Health Promotion of 1986 as 114 : the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being. This is also the definition referred to by most Austrian experts in the field. For this chapter on health promotion 12 Austrian experts were interviewed. Their responses as well as the reviewed literature form the basis of this chapter. Health promotion is one of the public health functions which are fairly well established in Austria. The field has changed remarkably since the Ottawa Conference in Health promotion in Austria has undergone considerable development over the past decade, especially since the enactment of the Health Promotion Act in 1998 and the creation of the Fund for a Healthy Austria. Still many challenges exist. With regard to legislation, the following regulations are considered the ones most relevant for the Austrian health promotion context: - Austrian Health Promotion Act Draft for the Federal Health Promotion and Prevention Act - Social insurance legislation - Financial Equalisation Act 113 Federal Ministry of Health, Family and Youth (2007). Handbook ÖGD. Basis for discussion. Handbook for the public health service. Vienna. November WHO, Ottawa Charter for Health Promotion, accessed at on 10 May 2009 April

75 For details on legislation, please refer to chapter 2 of section I. The most important stakeholders operating in the field of health promotion are the Federal Ministry of Health, the Fund for a Healthy Austria, social insurance funds, NGOs, associations and charities and research institutions (universities, universities of applied sciences, independent research institutes, e.g. the Ludwig Boltzmann Institute for Health Promotion Research) and regional institutes for health promotion such as the recently founded Vienna Institute for Health Promotion. Moreover networks, e.g. the Network for Workplace Health Promotion (Netzwerk Betriebliche Gesundheitsförderung, BGF), service providers, health authorities on all levels of the health system and special health centres as well as counseling centres, (e.g. for mothers). Details on their responsibilities were described in chapter 4 of this section. Issues related to funding are covered in chapter 2 of this section. Financial resources invested in health promotion are so far still very limited. Eventhough the Fund for a Healthy Austria is one of the few public health institutions with a fixed budget, the budget is still, compared to the importance of the field, small. Past development and current situation of health promotion The Ottawa Charter is often quoted as being the starting point for health promotion activities in Austria. A crucial event for the development of health promotion was the enactment of the Health Promotion Act in 1998 and the establishment of the Fund for a Healthy Austria. With the installation of the first Master programme for public health in 2002 and the subsequent establishment of other undergraduate and postgraduate programmes, which partially place a focus on health promotion, also the required expertise is slowly being formed. At present a significant number of individuals and organisations are involved in health promotion activities, some of which are still struggling to survive. This is due to financial resources still being very limited, when compared to the resources allocated to health care services. The installation of the FGÖ and its work has resulted in the topic of health promotion receiving more attention and also being met by greater understanding, especially among health system stakeholders. The FGÖ used the first decade of its existence to create awareness for health promotion and to initiate a wide range of projects on the different levels of the health system. In addition to this numerous information campaigns, conferences and other events have taken place with the intention of building knowledge, educating and promoting discussion among those involved. As already mentioned above, these years were also used to build human resources and knowledge. The topic of health promotion spread into various settings, the most visible being workplaces, communities, hospitals and schools. Development in connection with health promotion is happening slowly but constantly. Discussions and promises are however not always followed by actions. Initiatives are usually short-term activities which sometimes lack sustainable outcomes or continuity because they are not extended or pursued once the project funding has expired. They partially take place in isolated settings, systematic acquisition of co-operation partners (e.g. schools or companies) is not common practice. Area-wide implementation or involvement does often always take place due to lack of backing or long-term funding. With regard to the different settings for health promotion activities, health promotion at the workplace is the most advanced area, communities and hospitals are doing fairly well and schools still have some catching up to do. This may be because the first mentioned settings already have management structures in place into which health promotion activities can be integrated whereas this is not the case in schools. In addition, the very diverse ownership structures of schools and the large number of actors who are involved make it a difficult environment in which to initiate health promotion activities. Small and medium size companies may lack financial resources to provide health promotion activities and require special attention wheras hospital usually have the advantage of being linked to research and of already being familiar with concepts such as for instance evidence based medicine or clinical pathways Expert interview 1 April 2009 (Research, Health promotion) April

76 All settings experience difficulties because of a lacking legal and structural framework, sometimes concerning missing commitment as well as financial resources. The regional sickness fund of Upper Austria was and is a great promoter of workplace health promotion and also represents the Austrian headquarter of the Network for Workplace Health Promotion. The Ludwig Boltzmann Institute for Health Promotion Research focuses on the settings schools, hospitals, communities, organisation and long term care but also deals with the evaluation of health promotion activities. With regard to schools, the Healthy Schools Project was initiated by the Federal Ministry of Education, Arts and Culture, the then Federal Ministry of Health, Family and Youth (now Federal Ministry of Health) and the Main Association of Austrian Social Security in The final report was published in Social insurance undertakes various health promotion activities. It is involved in workplace health promotion, but also promotes measures related to dental health, smoking cessation, nutrition and physical activity or accident prevention. Recently the topic of health promotion for the Elderly has been taken up. 117 Austria is part of the network Health Promoting Hospitals and the network Healthy Communities. About 30 Austrian cities are part of the WHO Healthy Cities Network. 118 Present and future challenges Health promotion activities in Austria are too short to ensure continuity and sustainable outcomes and lack co-ordination. Initiatives are often isolated which is due to the missing of a joint framework or structure. Another weakness of Austrian health promotion activities is that these do not always follow defined standards or undergo an evaluation. The FGÖ is once more stated as a positive example with regard to good quality assurance and evaluation of projects. The enactment of the Federal Health Promotion and Prevention Act could address some of these points. It is however not clear whether the draft will be approved of. Based on the current draft, the Federal Health Agency will be responsible for defining targets for health promotion and prevention and for developing an overall strategy as well as target-specific strategies for meeting the targets. Definite guidelines are to be drawn up listing the requirements which have to be met in order to receive funding for measures or initiatives. In addition the Federal Health Agency will be in charge of compiling a 3-year report on health promotion and prevention activities taking place in Austria. The Austrian Federal Health Agency will have to install a project database and the Federal Ministry of Health is, based on the draft of the Act, responsible for undertaking a health impact assessment for any federal legislation if this entails a potential significant impact on health. The Health Promotion Act of 1998 was very innovative at the time. The formation of a legal basis for health promotion triggered the establishment of structures and the building of capacity. It will be important to continue this process in the future and to extend these structures and the financial means assigned to health promotion. Health promotion and prevention are still, in comparison to health care services, neglected in Austria. Individuals must be educated and informed, but also incentivised to choose the healthier among different alternatives. Help for self help ought to be encouraged. Structural, legislative and organisational structures will have to be defined in more detail in order to clarify responsibilities. These have to be responsive to the needs of the population. The creation of a common language is required. Projects and measures should be applied area-wide and their sustainability ensured. Any activities must be accompanied by quality assurance (definition of and adherence to standards) and 116 Project website, accessed at on 10 May Conference Ageing Creating opportunities for the potential in December 2009 and conference Health promotion with elderly people, both accessed at 76&action=2&p_pubid=78092#pd on 8 April WHO Health Cities Network: Accessed 2 November 2009 April

77 followed by an evaluation. Funding must, according to experts, be increased to ensure an adequate output and to reduce the imbalance between health promotion and health care. Vulnerable groups should be identified and targeted in the most suitable way. Further expertise should be formed; the different involved sectors (e.g. education, schools) should co-operate closely. Challenging future topics which were explicitly mentioned by epxerts or target groups which should receive special attention were: chronic diseases, obesity, alcohol, smoking, social inequalities children/adolescents and the elderly Prevention Activities related to prevention in Austria show a strong focus on medical prevention. Prevention is a very emotionally discussed topic which is strongly influenced by interest groups and economic interests. In the recent past the focus has shifted from behavioural to setting-orientated prevention. Early detection and prevention of disease Austrian activities for disease prevention or early detection of disease involve the following: - Mother-child-pass examination programme - School health examination - Juvenile health examination - Military health examination - Preventive health cehck-up for the adult population - Health passes for different target groups - Measures to strengthen the populations health, prevent dieases and provide medical rehabilitation - Humangenetic examinations - Vaccinations The mother-child-pass examination programme is a national screening programme which intends to monitor the health of mothers and their children during pregnancy and up to the 62 nd month of the child s life. The programme was launched more than 30 years ago (in 1974) and is planned, implemented and overseen by the Federal Ministry of Health which is advised by the mother-childpass committee, a sub-committee of the Supreme Sanitary Council. The programme pursues the following aims: ensuring basic medical care and prevention for pregnant women and their children; promoting early detection and timely treatment of health risks; and facilitating the monitoring of the development status of children. It involves five examinations of the pregnant woman and nine of the child, ultrasound examinations not yet included. Women receive a mother-child pass which is a booklet documenting all examinations and their results. Together with the booklet they receive an information booklet on pregnancy and childcare as well as a vaccination certificate for their child. All examinations listed in the mother-child pass are free of charge for mothers and their children. Also, women residing in Austria who do not have Austrian nationality or those not covered by social health insurance are entitled to take part in the programme. The examination programme is physician focussed; examinations are predominantly undertaken by gynaecologists. Midwives are not involved in the programme. Advice given to pregnant women in Austria is only partially standardised. Although the Austrian mother-child-pass examination programme has existed for more than 30 years, to date no comprehensive evaluation of the programme has been undertaken. There have only been a few isolated and not standardised attempts at analysis, which have proven to be extremely difficult due to the fact that no complete electronic record of the data exists. No regular revision of the motherchild-pass examination programme is undertaken and little research on outcomes exists. Health examinations of students in schools have to by law be undertaken on a yearly basis. Examinations are performed by school physicians based on the legal obligation of collecting health related information in order to advise teachers; health examinations are not followed up by treatment measures. No evaluation of the benefits of school examinations has been undertaken in Austria so far. The content and structure of the examination is based on the health form of the Federal Ministry of Health which can be found in Annex 2a. Data collected involve data of a general anamnesis such as size, weight, eyesight, hearing, teeth, posture, asthma., The information received from students is supplemented by information collected from the parents see form in Annex 2b. By law the scope of April

78 the examination is limited to the examination of aspects which are associated with participation of students in class, any other forms of examination may be denied by the student. Parents are questioned about: prevalence of diabetes and/or obesity n the family (parents), the infectious diseases which their child has already had, other illnesses the child may have suffered from, operations, regular intake of medication, vaccination for TBE, presence of certain conditions (allergies, asthma, diabetes, frequent, headache and others). Health aspects which are examined by school physicians include hearing, eye sight or the student s supporting apparatus. Dental health is assessed as well as performing a general anamnesis. Finally the physician has to state whether other examinations or referrals are required. In case the school physician detects any irregularity in the results of a student s health examination, he or she is obliged to report these findings to the student respectively the parents of the student. Any further examinations can only be undertaken with the consent of the student. The administration of vaccinations to students at schools is not a duty of school physicians but of the health authorities. The school physician may however be appointed by the authorities to execute the vaccinations. The analysis of data collected through school examinations cannot be used for scientific studies or analysis since there is no legislation basis. Forwarding of data forms is considered problematic because of violation of data protection regulations. 119 The juvenile health check-up is based on 132a of the General Social Insurance Act. It is targeted at young working people between the age of 15 and 18 years and consists of a physical examination, a urine test and health counseling. In the year % of the target population participated in the examination. Participation was highest in Tyrol (88.1%) and lowest in Lower Austria (49.7%). 120 Costs for the examinations are covered by social health insurance funds which receive a partial (50%) refund from the Federal Government. It is planned to evaluate the results of the examinations and to maybe supplement the basic examination with other targeted examinations. 121 All individuals liable to military service are invited to attend a military health examination in the year in which they turn 18. Persons experiencing a gap of more than five years between their last examination and their planned military draft need to repeat the examination. The preventive health check-up is available to individuals age 18 and older and is based on 132b of the General Social Insurance Act. It was introduced in 1974 and is provided through contract partners of social insurance. Ensurees are entitled to a yearly examination 122 ; costs for individuals without insurance are covered by the Federal Government. In the year examinations were performed, of which 871,691 were basic examinations and 116,007 gynaecological examinations. 123 The share of the population taking advantage of the preventive health check-up amounts to about 12% of those entitled. People can go once a year; several examinations are however, depending on the age 119 The forwarding of individual data requires consent of the student respectively his/her parents 120 Main Association of Austrian Social Security Institutions (2009). Handbook of Austrian Social Insurance Vienna. Accessed at on 5 September Main Association of Austrian Social Security Institutions. Accessed at mswindow&p_menuid=533&p_tabid=3 on 5 September Whenever a patient visits a physician for a preventive health check-up two enquiries are performed after the patient has passed his e-card to the physician, one being the confirmation of insurance coverage and the second being whether the insured person has already undertaken a preventive health check-up respectively examination during the past year. For any components of the periodic health examinatio which are only recommended once in a defined time period, the same check is performed in order to see whether they can/should be repeated. 123 Main Association of Austrian Social Security Institutions (2009). Handbook of Austrian Social Insurance Vienna. Accessed at on 4 April 2010 April

79 of the patient, recommended to be undertaken only every 2 or 3 years. Based on data findings, people tend to undergo a preventive health check-up every three years. The basic check-up includes an anamnesis, a medical examination and the consultion of the patient about risk factors related to lifestyle or genetic disposition. The programme includes a basic examination for the entire target population and specific examinations for certain groups of individuals (depending on sex and age). Since 1990 the number of preventive health check-ups performed has more than doubled indicating a greater awareness among the target population. In 2005 the new preventive health check-up 124 was introduced which was aimed at being based on evidence based standards of care only 125. The new programme was developed between 2003 and 2004 by the Main Association of Austrian Social Security Institutions together with a working group composed of representatives of social insurance and the Austrian Medical Chamber. It comprises a mixture of measures of primary prevention 126 and secondary prevention 127 and covers four different target areas: cardio-vascular diseases 128, carcinomas 129, a general area 130 and a field for advanced age 131. New medical components of the examination programme include: a stonger focus on encouraging the change of lifestyle 132, compiling a risk profile for each insured, strenthening the advisory role of the pyhsician, screening for colon cancer for people older than 50 years 133, more attention on testing of hearing and vision for individuals older than 65 years and a screening for peridontal diseases. 134 As part of the preventive health check-up, women can take advantage of a gynaecological examination. A PAP smear can be performed for women older than 19 years, the execution of a mammography involves: undertaking a family anamnesis, the examination itself and medical counseling. The examination is offered to women from the age of 40 years and can be performed as part of the preventive health examination every 2 years. Organisational innovations included the introduction of a call-recall system which was aimed specifically at identifying disadvantaged groups and individuals with special needs as well as the application of quality assurances measures and the execution of an evaluation. In May 2007 the first dispatch took place. Originally it was planned to identify risk groups four times a year and that every insurance fund could join the dispatch. Because of a low response rate, campaigns were interrupted in 2008 and the decision was taken to send out only two invitations in The evaluation of data originating from the preventive health check-up was delayed due to unresolved issues with regard to data protection and data confidentiality. The installation of a pseudonymisation unit 135 at the Main Association of Austrian Social Security Institutions in 2008 enabled the evaluation 124 Based on information provided by the Main Association of Austrian Social Security Institutions 125 Internationally recognised criteria and guidelines were consulted (e.g. from the U.S.A. and from the U.K.) and adapted to the Austrian situation 126 Screening for risk factors and support for reducing personal risk factors 127 early detection of diseases: therapeutic measures to limit or prevent the progression of disease or complications associated with it 128 Cardiovascular risk anamnesis, BMI, smoking, alcohol, type 2 diabetes, arterial blook pressure, hyperlipidemia, Gamma-GT, triglyceride: younger than 40 years: every 3 years, after that every 2 years 129 Carcinoma risk anamnesis, PAP smear, melanoma screening: younger than 40 years: every 3 years, after that every 2 years. Mammography: for women older than 40 years every 2 years 130 Peridotal diseases, glaucoma: younger than 40 years: every 3 years, after that: every 2 years 131 Impaired hearing, impaired vision: for individuals older than 65 years every 2 years 132 Assessing BMI, total cholesterol and HDL-cholesterol, advice on physical activity: younger than 40 years: every 3 years, after that every 2 years 133 Haemocult test, colonoscopy: yearly haemocult test, colonoscopy for patients older than 50 years every 10 years. 134 Main Association of Austrian Social Security Institutions (2005). New Health Examination, Information document. Vienna Accessed at on 7 September The social insurance number/code of an individual is replaced by a psydonym which makes it possible to follow an insured person s patient history without violating data protection regulations. April

80 of the examination results; The Main Association of Austrian Social Security Institutions and the Austrian Medical Chamber agreed on an evaluation of the data between October 2008 and October This is currently undertaken by the insurance fund of the railway and mining industry. A mammography, colonoscopy and screening for cervical cancer (PAP smear) can be undertaken as part of social insurance s preventive health check-up. Mammographies are offered to women of the age of 40 (every 2 years), PAP smears to women older than 19 years (every 3 years and for women of the age of 40 and older every 2 years), haemocult tests yearly for men and women of the age of 50 and older and colonoscopy to the same target group, but every 10 years. Screening for melanomas is offered as part of the preventive health check-up to individuals younger than 40 years (every 3 years) and to individuals of the age of 40 and older (every 2 years). Screening for prostate cancer is not part of the preventive health examination but can be performed by physicians under certain circumstances. 137 Screening for peridontal disease and glaucomas is part of the preventive health check-up for individuals younger than 40 years: every 3 years, after that every 2 years. Screening for impaired hearing and vision is also included in the preventive health check-up for individuals older than 65 years (every 2 years). Advice on physical activity should be provided to patients younger than 40 years every 3 years and after that every 2 years. With regard to quality standards for screening, physicians performing preventive health check-ups have to follow the directives on the execution and evaluation of the examination (Durchführungsbestimmungen) of the Main Association of Austrian Social Security Institutions. These contain administrative details and partially also list definite requirements for the provision of certain services. 138 For colonoscopies a quality certificate has been developed by the Hauptverband together with the Austrian Society of Gastroenterology and Hepatology. Several initiatives have been undertaken to improve the quality of PAP smears (at the Hauptverband, the Vienna sickness fund) and a working group has been created at the Federal Ministry of Health. Supplies provided by social insurance to gynaecologists in practices (spatulas) have been modified based on the study/project results and expert recommendations thus ensuring improved quality of outcomes. Mammography screening is currently also undertaken in the form of various pilot projects in different Austrian provinces. Standards and concepts applied by the provinces are not the same, making a direct comparison of the outcomes impossible. At the time of the present study the data basis for screening at ÖBIG/GÖG did not enable an evaluation of outcomes. It is e.g. not possible to assess the number of cases/deaths avoided. Austria is only just at the start of the process of introducing screening programmes. Present screening activities taking place in Austria are still to a large extent not systematic, respectively not based on systematic and strategic planning and mostly involve opportunistic screening. Evidence-based 136 Specifications for the evaluation are listed in the directives for the execution and evaluation of the preventive health cechk-up ( 12) 137 The patient voices justified personal concern and is older than 50 years or older than 45 years with a hereditary predisposition. Further requirements for reimbursement may be specified in the reimbursement catalogues of the different health insurance funds. 138 A final consultation has to be undertaken following the anamnesis and all examinations (15 minutes) For PAPsmears a cytological test has to be performed The medical specialists entitled to perform the different parts of the preventive health check-up are listed Preventive health check-ups have to take place at different times than regular practice hours Documentation has to be performed electronically, patients are entitled to receive a physician letter or a print out of the examination report Physicians are obliged to inform the patient about all examination/test results Regulations concerning the call-recall system: individuals younger than 40 years are invited every 3 years and individuals older than 40 years every 2 years. Reimbursement of services provided to individuals without insurance coverage (refund from the Federal Government) Evaluation and reporting duties April

81 screening does in most cases not exist, however considerable efforts have been made in this direction when implementing the revised preventive health check-up in Even the parties involved do not always share the same opinion with regard to who has to be screened (population), what has to be screened (parameters), when it should be screened (at what age) and how often screenings should take place (intervals). Reaching an agreement on basic features of screening programmes has proven very difficult (e.g. in the case of mammography screening). Several initiatives for mammography screening have however been started in Austria in the recent past. Patient representatives argue that lack of objective information and transparent quality standards lead to uncertainty and fear among patients. They furthermore state that patients do not receive sufficient information on the impact screening may have and any potential adverse effects. Between 2005 and 2007 health passes for various population groups were developed, for the population 6plus, for young people/adolescents (from 8 th level of education), for the population 18plus, the population older than 40 years and the population 60plus and 75plus. These passes were geared to the school health examination, the juvenile health examination respectively the new Preventive health check-ups and were intended to encourage continuity of care (improving comparability of results documented in the pass), as well as increasing the awareness for health in general. Together with the pass, individuals received an information brochure (including information on diseases, lifestyle and risk factors) and an international certificate of vaccination. On the national level health passes are not distributed any more. This is acccording to the Federal Ministry of Health, because they were not taken up by the population and not strongly promoted by physicians. It has been discussed to distribute the service-booklet separately from the monitoring booklet of the passes. Health passes had previously also been introduced in various provinces (by the provinces and the regional medical associations) such as for instance Vienna (2001) or Lower Austria (2000), the intention being to synthesize existing documents and health-related information, e.g. on blood group, vaccinations, allergies or emergency contacts in one document. It is not known to what extent these are still used. Social health insurance measures to strengthen population health and disease prevention Measures to strengthen the health of the population involve convalescent stays in the country side or in a sanatorium/health resort. These can be reimbursed by health insurance funds depending on their financial capabilities. Measures to prevent disease are voluntary benefits and include health education, caring for youth and newborns, measures to prevent widespread diseases and tooth decay and the reimbursement of certain transportation costs. According to social insurance, measures to strengthen people s health are intended to strengthen the role of health insurance in the field of prevention by reducing risk fators for health in veryday life and at the workplace. Measures to maintain the health of the population Measures to maintain the health of the population reimbursed by social health insurance involve preventive humangenetic examinations (genetic family counseling, prenatal diagnosis, zytogenetic examinations) 139, vaccinations and any other measures to maintain the health of the population. Every year the vaccination committee of the Supreme Sanitary Council defines the vaccination plan for Austria which lists the vaccinations recommended for infants and toddlers, for school children and adults. Vaccinations 140 are no compulsory benefit of Austrian social health insurance, the sole exceptions being the vaccination against tick-borne-encephalitis 141 and the vaccination of influenza, the latter 139 Individuals to whom this may concern are defined in the directive BGBl. 274/1981. Accessed at on 4 October Also based on Main Association of Austrian Social Security Institutions (2009). Vaccinations A social insurance benefit? Internal document. 8. July April

82 however only if the World Health Organisation WHO has declared the influenza a pandemic and the Federal Ministry of Health has ordered the production of the vaccine. 142 Social health insurance also reimburses the costs for influenza vaccinations, rabies or tetanus in cases of administration following exposure. Since January 1998 costs for vaccinations of children (up to the age of 15 years) 143 have been, based on the socalled Children Vaccination Programme, covered jointly by the Federal Government, the provinces and social insurance funds. 144 Thereby the Federal Government pays for 2/3 of the costs, whilst the provinces and social insurance cover 1/6 of the costs each. The provinces moreover pay the physician fees. 145 The Child Vaccination Programme at present includes the following vaccines: Sixfold immunisation (Diphtheria, tetanus, pertussis, polio, haemophilus infl. B, hepatitis B), Measlesmumps-rubella, hepatitis B, diphtheria-tetanus-polio, diphtheria-tetanus-pertussis, oral vaccination against rotavirus since The conjugated pneumococcal vaccine prevenar is only intended for free of charge use in risk groups (early birth). Costs for vaccinations for adults have to be paid privately; the decision to get vaccinated is considered a matter of individual responsibility. Vaccination status and vaccination rates of the entire population are not systematically documented or analysed in Austria. The Federal Ministry of Health documents vaccination rates for vaccinations executed as part of the vaccination programme mentioned above. Time trends do not exist but it is, based on the statement of a Ministry representative, planned to document these in the future. Regional health authorities also collect some data on vaccination rates. Individual provinces or institutions in Austria may dispose of data (e.g. in Styria). Information on vaccination rates is available here and there but it is rarely made transparent as to how these were materialised. According to Kreidl et al the official estimate of the average measles vaccine coverage with at least one dose of the birth cohorts 1997 to 2007 was 84%. 146 No data were available on the age group specific measles seroprevalence of the Austrian population. 147 Vaccination of children for certain diseases is in several cases not undertaken due to uncertainty of parents and and has resulted in outbreaks, e.g. an outbreak of measles in 2008 in Salzburg, spreading also to Upper Austria and Bavaria and an outbreak in rubella early in 2009, mostly concentrated on Styria. The Austrian vaccination plan lists the duties of the physician with regard to informing the patient (or his/her parents) about any issues relevant to the vaccination. Every year up to 400,000 people contract influenza during an average influenza season and up to 6,000 of these die because of complications. The uptake of influenza vaccinations appears to be low even though significant efforts are put into advertising. In autumn usually immunizations campains for influenza are undertaken, offering vaccinations at a lower price and trying to motivate people to be vaccinated. In the past years the vaccination rate of the population amounted to about 18%, among health professionals it was even lower, namely 17%. In 2007 about 12% of the population were vaccinated, of the population older 141 Social health insurance funds subsidise these; the height of the subsidy is defined on a yearly basis 142 Regulated in 132c of the General Social Insurance Act Other measures to maintain the health of the population 143 Decisions on which vaccinations to include in the concept are taken jointly and are based on the recommendations of the Supreme Sanitary Council expressed in form the yearly vaccination plan 144 This is based on the socalled Vaccination Concept (Impfkonzept) which was initiated by the then Minister of Health in Federal Ministry of Health, information provided by an expert on the phone, 20 October Kreidl, P., Muscat, M. (2008). Mission Report Measles outbreak in Austria Risk assessment in advance of the EURO 2008 football championship April Accessed at in July Hanratty, B. et al. (2000). 'UK measles outbreak in non-immune anthroposophic communities: the implications for the elimination of measles from Europe.' Epidemiology and Infection 125, pp April

83 than 65 years 37% had been vaccinated. According to an expert, this is related to a lack of awareness of the population. 148 The vaccination plan 2009 recommends the administration of influenza vaccinations for defined groups of children and for adults older than 50 years. Based on an analysis investigating the costeffectiveness of influenza vaccinations, public funding of influenza vaccinations for individuals older than 65 is judged to be cost-effecttive. 149 Potential role of social insurance with regard to health promotion and prevention Social health insurance funds currently have a very limited legal obligation to fund services related to health promotion and prevention. Responsibilities for the provision of public health services and amongst these for health promotion and prevention are not clear cut in Austria. Whereas several public health related benefits provided by social health insurance funds are compulsory benefits, most are voluntary benefits, meaning that insured do not have a legal right to obtain these. The exent to which these services are provided depends on the financial situation of the insurance funds and also on its own judgement and the viewpoint it decides to take. Health insurance funds do not share a uniform view on this issue; some health insurance funds are more and others less active in the field of prevention and health promotion. Experts, who were questioned about the potential role of social insurance with regard to health promotion and prevention, argued that the unclear responsibility of social insurance in connection with the provision of services related to health promotion and prevention ought to be changed. It must be evident who is responsible for the provision of which services and what these services entail. Nationally recognised definitions of health promotion and prevention ought to be elaborated. The definition of legislation, structures and funding is essential. The importance and necessity of health promotion and prevention must be acknowledged and priorities respectively targets defined. Social health insurance could, after explicitly defining its responsibilities in the field, take on the role as a promoter and facilitator for health promotion and prevention. It could encourage the revision of databases and the creation of evidence, giving indications on what works and what does not work. Certain services could be included in the benefits catalogue, but these ought to be based on evidence, their execution supported by quality standards and their utilisation linked to incentives. Social health insurance furthermore has the opportunity to, through their wide net of contract partners, reach the population groups which are in greatest need of the services. Whatever responsibilities social health insurance would take on in these areas, it is recommended that insurance funds form co-operations and networks which support them. For services which are provided to the insured population, it should be required to demonstrate scientific evidence showing their benefit. Social insurance could be in charge of quality control with respect to providers meeting defined standards when providing services (training, equipment, etc.) and with regard to the provision of evidence of the beneficial impact services have on the health of the patient. In addition it could encourage the development of standards for education and training as well as the aligning of training programmes. Social health insurance could promote the definition of requirements which have to be met for reimbursement (quality standards, indications, etc.). Experts believe that social insurance could take on a leadership role when it comes to promoting and prioritising certain topics, developing strategies or guidelines and implementing measures. It could engage in research co-operations and/or build up its own research institute. Moreover it could encourage the installation of a cohort study or long-term research activities. This may be easier for the social insurance funds as these are not so strongly influenced by legislation periods. One of the key responsibilities of social health insurance is to inform and educate the insured population. This can lead to empowerment and increased self help as well as appropriate support of e.g. family members. 148 Kunze, U. (2008). 'Austria resistent against Influenza control.' Facharzt 4/2008, pp Stoppacher, A. (2008). Cost-effectiveness analysis of influenza vaccination in Austria. Master thesis. Graz. August April

84 Social insurance should support the further development of databases and execution of data analyses, thereby generating evidence. Social insurance could also promote the systematic introduction of evidence based screening programmes and enter co-operations for the implementation of these Balance of curative and preventive health services The Austrian health system shows a strong imbalance in favour of curative health services. This is for instance reflected in funding, resource allocation and service provision and training structures. With regard to legislation, public health is neglected as responsibilities for service areas are either not clearly defined or existing legislation is partially outdated. Public health is not institutionalised or integrated into existing organisational structures. It does, at present, not have the (financial or human) resources or the structures to grow. Too few qualified individuals exist and public health topics are not promoted in a way health care topics are. Health care organisations and their interest groups dominate the health sector. Research is barley existent which is again due to lack of funding and qualified staff. Training of health professionals in the past only included public health elements to a very minor extent; the topic is gradually being granted a space in the curricula of health professionals. The first (postgraduate) training programme for public health professionals was initiated in 2002; other programmes and undergraduate programmes for health promotion and health management have followed, slowly resulting in the building of public health. The health system is only gradually opening up to the concept of multidisciplinarity, by providing posts for individuals with a variety of professional backgrounds. In terms of funding, a large share of financial resources is allocated to health care services, in comparison to the share which is used for services promoting the population s health. A study which was published in 2004 (based on data of 2001) states that the expenditure for prevention and health promotion in Austria amounted to about 6.3% of total health expenditure i.e. to about 9.3% of public health expenditure in 2001, featuring an equivalent of about 127 per inhabitant per year. 150 Decision makers and stakeholders in many cases lack even a basic understanding of public health. Instead they still pursue a very strong focus on curative health services. With regard to funding and responsibilities, the Austrian health care system shows a considerable fragmentation. This partially motivates behaviour which compromises the quality of care of the patient (e.g. reducing continuity of care, transparency, co-ordination of treatment or medication, communication among providers, etc.). Some of these issues could be addressed by taking a broader view of the system. The situation of patients following discharge from hospitals appears to pose a problem as their needs may not be taken care of in the most effective way (e.g. management of chronic diseases). So far only one disease management programme has been implemented (Diabetes), and this does not operate nation-wide yet. Evaluation results of the related randomized controlled study undertaken in Salzburg should be assessed very carefully before promoting further implementation. Insights gained from this programme should be considered for the planning and implementation of future programmes. Patients suffering from multiple morbidities taking a range of different medications require supervision and periodic revision of the medication taken with regard to their effectiveness and potential drug interactions. The quality of treatment or services provided is often not visible and cannot be judged by patients. Outcomes should be made more transparent and understandable. Any results of major patient surveys assessing patient satisfaction should be discussed with all involved, also the providers of health services. Experts report a lack of patient-orientation as well as health professionals spending little time with the patient or not informing the patient adequately. 150 Habl, C., Schnabl, E., Vogler, S. et al (2004). Öffentliche Ausgaben für Prävention und Gesundheitsförderung in Österreich Commissioned by the Federal Ministry of Health and Women. ÖBIG. Vienna April

85 6 Challenges and priority areas for public health in Austria This chapter of the first section of the report summarises, based on findings in the national and international literature and supplemented by inputs from expert interviews, current and future challenges and priority areas for public health in Austria. Readers are asked to also refer to the individual sections for further information on future challenges with respect to specific topics covered in the report. Before detailing the challenges and priority areas, main indicators for health and disease in Austria as well as risk factors are presented. 6.1 Health and disease in Austria Life expectancy and healthy life expectancy Life expectancy has risen considerably in the past century due to factors such as reductions in infant mortality, increasing living standards, improved lifestyles and better education as well as advances in health care and medicine. Increases are expected to continue in the future, as fell the trend of female and male life expectancies converging (closing of the gender gap). Average life expectancy in Austria was 77.6 years for men in 2008 and 83.0 years for women. Since 1970 the difference between the life expectancy of men and women has decreased. The population in the West of Austria showed a higher average life epectancy than the population living in the East of Austria. Figure 4: Life expectancy at birth and at the age of 60 Source: Statistics Austria (2008). Yearbook of Health Statistics Male life expectancy at birth was situated at 77.1 years in 2006 whereas female life expectancy was 82.6 years. Thereof 80% (61.7 years) for men and 76% (63.2 years) for women are spent in (subjective) good health. The life expectancy of a 65 year old man was 17.2 years (51% of which spent in good health) and life expectancy of a 65 year old woman was 20.5 years (44% of which spent in good health). Between 1978 and 2006 both life expectancy and life expectancy in good health experienced a significant increase. Results for life expectancy spent in good health are based on April

86 surveys and reflect subjective measures. 151 Life expectancy in (subjective) good health was significantly higher for men and women with a higher level of education. 152 Life expectancy has been increasing throughout Europe in the past and strongly contributes towards the ageing of the population. Still considerable variations among the different countries persist. Male life expectancy at birth ranges from 65.3 years in Lithuania to 78.8 years in Sweden or Cyprus and female life expectancy from 76.2 years in Romania to 84.4 years in both Spain and France. Healthy life expectancy (HALE), also called disability-free life expectancy (DFLE), is increasingly used as a health expectancy indicator in addition to life expectancy. HALE represents the average number of years that a person can expect to live in full health respectively free of disability at a specific age (usually at birth or age 65).It combines mortality statistics (objective data from life tables) with data on self-perceived disability (from health surveys), thereby introducing the concept of quality of life. Figure 5: Healthy life expectancy at birth (as % of total life expectancy), 2005 (1) Figure 6: Healthy Life expectancy at age 65 (in years), 2005 (1) 151 Statistics Austria. Healthy life expectancy. Accessed at html on 4 October Statistics Austria, Life expectancy 2006 depending on subjective health status, age and highest level of completed education. Accessed at 5.html on 4 October 2009 April

87 6.1.2 Mortality Mortality in Austria has shown a continuous decrease over the past decades, both for men and for women and across all ages Main causes of death The main causes of death for men and women in Europe (EU-27) in 2006 (1) were cancer, ischaemic heart diseases, accidents, diseases of the nervous system, pneumonia, chronic liver disease, Diabetes mellitus and suicide. Since rates for cardio vascular disease and rates for cancer have decreased since 1970, rates for nervous diseases and Diabetes have increased. Non-communicable diseases, including cardiovascular disease, cancer, mental health problems, diabetes mellitus, chronic respiratory disease and musculoskeletal conditions account for more than 85% of deaths in Europe. 154 Significant gender disparities exist as well as geographic differences in incidence of death. Figure 7: Main causes of death standardised death rate, EU-27, 2006 (1) In Austria the main cause of death remains to be cardiovascular diseas eventhough incidence has decreased considerably over the past decades. In the graph below (figure 8), changes in causes of death over time are displayed. The share of deaths caused by malignant growths has experienced a constant growth during the past decades (36.34% in 2008) whereas the share of deaths due to cardiovascular disease increased steadily until it started declining again in 2001 and thus contributed considerably to an overall increase in life expectancy (43.01% in 2008). The share of deaths due to diseases of the respiratory system has dropped by close to 3% percent points between 1970 and 2008, experiencing the biggest drop between 1970 and 1980 (5.50% in 2008). The share of the population dying from diseases of the digestive system decreased by about 2 percent points between 1970 and 2008 (4.05% in 2008). The share of deaths due to other diseases dropped by more than 3 percent points between 1970 and 1980, then remained more or less stable until about the year 2000 before gradually increasing again after 2001 (15.47% in 2008). 155 The 153 Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 5 October European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April Other deaths include infectious and parasitic diseases - 0.8% of total deaths in 2007, diseases of the blood, dietary- and metabolism-related diseases (especially diabetes mellitus) 5.4% of total deaths (4.2% due to diabetes), mental illnesses 0.9% of total deaths, alcohol abuse - 0.5% of total deaths, drug addiction - 0.3% of total deaths, diseases of the nervous system and the sense organs 2.9% of total deaths. Further causes of death April

88 share of deaths caused by injuries and intoxications 156 has gradually decreased over the past decades, displaying a reduced share by about 2 percent points in 2008 when compared to 1970 (5.62% in 2008). The most frequent cause of death among young people is injuries and intoxications, accounting for about 6 of 10 deaths. These are still the main cause of death in early adolescence before being supassed by malignant growths and cardiovascular diseases. Figure 8: Main causes of death in Austria: development over time 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Injuries and intoxications (Verletzungen und Vergiftungen) V01-Y89 Other diseases (Sonst.Krankheiten) A00-B99,D01- H95,L00-R99 Diseases of the digestive system (Krankheiten der Verdauungsorgane) K00-K93 Diseases of the respiratory system (Krankheiten der Atmungsorgane) J00-J99 Cardio-vascular diseases (Krankheiten des Herz-Kreislaufsystems) I00-I99 Malignant grow th (Bösartige Neubildungen) C00-C97 Source: Statistics Austria, Cause of death statistics, own calculations The following graph shows the shares of deaths (in %) due to the main disease groups for men (left pie chart) and women (right pie chart) for the year About 5 of 10 women die of cardiovascular diseases versus about 4 of 10 men. Women are also more prone to die of other diseases whilst men are far more likely to die of injuries and intoxications and malignant growths than women. Figure 9: Main causes of death 2008 in Austria men and women Translations: Bösartige Neubildungen = Malignant growth, Krankheiten des Herz-Kreislaufsystems=Cardio-vascular diseases, Krankheiten der Atmungsorgane=Diseases of the respiratory system, Krankheiten der Verdauungsorgane=Diseases of the digestive system, Sonstige Krankheiten=Other diseases and verletzungen und Vergiftungen=injuries and intoxications. summarised in the category other causes of death are diseases of the uretogenital tract, congenital malformations and perinatal affections. 156 Including: traffic accidents, falls, intoxications, suicide and self-harm, homicides, manslaughter and deliberate harm of others. April

89 When looking at regional differences, the data for deaths due to malignant growths of 1998/2004 shows a considerably higher incidence in the North-East of Austria, in Vienna and especially Lower Austria, but also in parts of Styria. Mortality rates are lowest in parts of Salzburg, Upper Austria, Carinthia and Lower Austria. 157 The regional distribution of death rates due to cardiovascular diseases shows a clear East-West divide, mortality being much higher in the East, North-East and South-East of Austria, especially in Vienna, Lower Austria and Vienna and also in parts of Styria and Upper Austria than in the West and South-West of Austria, in Vorarlberg, Tyrol, Salzburg and Carinthia Infant mortality Infant mortality in Europe has dropped from almost 28 deaths per 1000 live births in 1965 to 4.7 deaths per life births in Progress in health care services (pre- and postnatal care) as well as better nutrition has contributed significantly to this development. However persistent differences remain across different social groups or provinces. Figure 10: Infant mortality (per 1,000 life births) Over the past 25 years infant mortality in Austria has dropped by more than 2/3. Since 1997 infant mortality is situated below 5.0 deaths per 1,000 live-births (within the first year of life). In 2007 the highest infant mortality rate was documented for Vienna and Lower Austria (5.4 vs. 4.4 deaths of 1,000 live-births), the lowest for Tyrol (2.3 deaths per 1,000 live-births) Morbidity 160 Average length of stay in hospitals has generally dropped in the past and varies strongly depending on the diagnosis. Longest average length of stay was recorded for patients suffering from cancer or circulatory system problems. Countries reporting a long length of stay are Finland, the Czech Republic, Germany and Lithuania wheras France, Cyprus, Malta and Poland have short average length of in-patient stay Statistics Austria. Mortality: Malignant growths 1998/2004 regional districts. Accessed at on 5 September European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 5 October Ibid, based on hospital discharge data 161 European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April April

90 In 2006 the highest number of hospital in-patient discharges among the EU-27 countries was recorded for Austria (exceeding 27,000 per 100,000 inhabitants 162 ) which was followed by Lithuania. The lowest number of discharges was recorded for Malta and Cyprus (below 7,000 per 100,000 inhabitants). According to Eurostat, the most hospital discharges in 2006 were related to diseases of the circulatory system 163 Based on the WHO Global burden of disease report (2004 update) unipolar depressive disorders will rank first with regard to burden of disease (DALYs 164 ) in 2030, followed by ischaemic heart disease and road traffic accidents. 165 Figure 11: Ten leading causes of burden of disease, worldwide, 2004 and 2030 Source: WHO (2008) Global burden of disease report, part 4 COPD=chronic obstructive pulmonary disease, a also includes other non.infectious causes arising in the perinatal period apart from prematurity, low birth weight, burth trauma and asphyxia. Hospital discharge data is Austria is not individual person data but case based data. Day clinic visits are also included in the statistics. Whereas the average length of stay in acute-hospitals has decreased considerably over the past nearly 50 years (from about 25 days in 1960 to about 11 days in 1989 to an average length of stay of roughly 7 days 166 ), the number of cases per 100,000 has more than doubled (about 15,000 in 1960, about 22,000 in 1989 and more than 30,000 cases per 100,000 in 2006, in total 2,538,544 inpatient stays). Average length of inpatient stays in hospitals providing acute care was longest in Vienna (7.8 days) and shortest in Burgenland (5.8 days). The number of in-patient stays is higher for women than men, especially for the over years olds (due to births) and for the 80 year-olds (reflecting the age structure of the population). About half of all discharges from acute hospitals concern patients older than 60 years. 162 National statistics, quoted below, state figures of more than 30,000 cases. 163 European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April Disability adjusted life years one DALY represents the loss of the equivalent of one year of full health 165 WHO (2008). Global burden of disease report update. Accessed at on 4 April Depending on the diagnosis average length of stay varies considerable, e.g. being very short for eye diseases, birth and pregancy related stays and longest for stays in connection with mental and behavioural disorders. In 1997 a new hospital funding system was introduced which has, based on the literature, also influenced the development of the length of stays and the number of admissions April

91 Principle diagnosis of discharge (after inpatient stay) in 2006 were diseases related to cancer (14.4%), cardiovascular diseases (12%), injuries and intoxications (10.2%), diseases related to the sceleton, muscles and connective tissue (10,0%) and diseases of the digestive system (9.3%). For women the three principle discharge diagnoses were: diseases related to cancer, diseases of the musculosceletal system and connective tissue and cardiovascular diseases, for men principle discharge diagnoses were diseases related to cancer, cardiovascular diseases and injuries and intoxications. Between 2001 and 2006 in-patient stays related to the following diagnoses showed a significant increase: diseases of the nervous system (22.6%), diseases of the digestive system (21.2%), diseases related to cancer (20.5%), diseases related to the musculosceletal system and the connective tissue (19.5%) and diseases of the eye and the adnexa (17.7%). Most performed operations in 2006 were operations concerning the uveal tract, the lense, cornea or visual nerve (7.9%), operations concerning the distal femoral or knee joint (7.6%), operations related to pregnancy and birth (7.3%), operations in connection with the skin, dermal appendage or subcutitis (6.9%), operations of the uterus (5.8%). Conservative treatment provided most often was physiotherapy and CT/MRI diagnostics. In 2005 fewer new cases of cancer were reported than in 2004 but the incidence was 6.3% higher than Men were affected slightly more often (52.8%) than women (47.2%) in 2005; between 1996 and 2005 new cases among men increased by 11.1% and decreased by 1.3% among women. Age standardised rates have fallen for both men and women since The age-standardised risk of falling ill with cancer was 1.4 times as high for men as it was for women. Men most often contract prostate cancer whereas women contract breast cancer. The risk to fall ill with lung cancer has increased considerably for women and strongly decreased for men over the past decade, colorectal cancer is, eventhough rates have dropped over the past 10 years, the second most frequent location of cancer among women and the third most frequent among men. Cases of stomach cancer are decreasing for both men and women. Age-standardised incidence rates for cancer of the cervix dropped by 22% between 1996 and Regional age-standardised incidence for new cases related to cancer was highest in Carinthia and Tyrol and lowest in Upper Austria and Salzburg. In 2005 about a third of all tumours was diagnosed when the tumour was still limited to one organ, a fifth was diagnosed after the tumour had already developed regional metastasis and another 11% were diagnosed in a disseminated tumour stage. In the 19 th and the early 20 th century an epidemiological transition from communicable to noncommunicable diseases could be witnessed. Deaths from infectious diseases have dropped since 1960 but still remain an important issue in Europe dur to high rates of HIV infection in various countries, the continuing threat from other, mainly epidepic-prone, communicable diseases and the emergence of new disease. Tuberculosis or hepatitis shows a higher incidence in Eastern European countries than in Central or Western European countries. In Austria reporting of infectious diseases is the duty of the Federal Ministry of Health and the health authorities of the provinces. In 2007 cases reported most often were cases related to bacterial food poisoning 167 followed by scarlet fever, infectious hepatitis and sexually transmitted diseases. 560 new cases of Tuberculosis were reported in 2007; numbers have been decreasing since For more information on the reporting of infectious diseases see section II, chapter 7. The number of people being infected with hepatitis has decreased since In cases of hepatitis C were reported (per 100,000), 8 cases of hepatitis B and 1.4 cases of hepatitis A. (56.9% cases hepatitis C, 36.3% hepatatis B and 6.4% hepatitis A.) In individuals were infected with AIDS. Of these 78.1% were men. Only 34.0% of the infections were related to homosexual contacts, 22% were connected to heterosexual contacts, 16% to intravenous drug abuse and for 26% the cause of infection was not known. Women are more likely to be infected with AIDS through heterosexual contacts and intraveneous drug abuse. 167 In most cases related to Campylobacter or Salmonellosis April

92 In ,096 road accidents involving bodily injury occurred. As a result 53,902 individuals were injured of which 691 died. After a decrease in causalities in the past (after 2003) this has lead to a new inccrease. About 2/3 of the causalities were due to car accidents, 18% were due to single-lane motor vehicles and about 10% were cyclists. More than half of the causalities and three quarters of those killed were men. Sick days have been decreasing since 1985 and have slighly increased again in Average duration of sick leaves of employed persons and workers was 12 days in 2007, with 12.6 days for men and 11.4 days for women. The number of days increased with age for both sexes. Most sick days occurred in the construction sector, followed by public administration, national defence and social insurance, the fewest in the teaching sector. Reasons for sick leaves reported most often in 2007 were diseases of the respiratory system (31.9%), diseases related to the musculosceletal system and the connecting tissue (14.5%) and gastric diseases (10.2%). According to the European Agency for Safety and Health at Work work-related causes result in over 150,000 deaths a year. The number of fatal accidents at work has dropped by 24% in the EU-27 between 1998 and Increases in fatal work accidents in the before mentioned period were registered in Lithuania (33% increase), Sweden (31% increase) and Slovenia (28% increase) and Ireland (17% increase), whereas an especially high decline was observed in Greece, Malta and France (at least half the incidence). Fatal accidents occurred most often in the construction sector, in agriculture and the transportation sector. Occupational accidents affect by far more men than women which is mainly due to men being over-represented in higher risk occupations. 168 Figure 12: Incidence of accidents at work (2005), 1998=100, based on the number of accidents per 100,000 persons employed In Austria 119,847 accidents occurred at work (198 of these were fatal) in 2007, as well as 12,580 travel accidents (67 of these were fatal) and 1,590 occupational illnesses (73 of these were fatal). Recognised work accidents (without travel accidents) have decreased by more than a third since In the course of the military health examination (year of birth 1987) 73.7% of those examined were found to be suitable. A disease was diagnosed with more than 2/3 of those examined, 21% showed anomalies of the sceleton, muscles and connective tissue, 11.1% displayed endocrinological dietrelated or metabolic diseases, about 10% were diagnosed with a mental illness, 9.7% with an injury or intoxication and 9.6% had a disease of the respiratory system. Those not suitable to serve in the army were in most cases not fit because of mental illness (25.1%), congenital disorders (11.3%) or defects related to ears, hearing or mastoid process (9.8%). 168 European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April April

93 Diseases which lead to the awarding of a disability pension most often in 2007 were diseases of the sceleton, the muscles and the connective tissue (32.6%), mental illnesses (28.7%) and cardiovascular diseases (12.3%) Health of Austrian school children 170 Based on the HBSC survey 2005/2006, which was conducted in March 2006 among 11-, 13- and 15- year old students (subjective views), 43% of all students describe their health status as excellent. About 50% of the boys do so whereas only 36.2% of the girls choose this answer. 37.5% of the students quote that they regularly suffer from physical or mental discomfort. This applies to about half of the girls and about a third of the boys. 14.5% of the students have a medically diagnosed chronic illness or a disability and 40.5% of the students were injured so badly in the past 12 months that they required medical treatment. 35% of the students believe that they are too fat, especially amongst girls this is a frequent phenomenon (42.8%) but also close to a third of the boys believe this. 12.2% of the students are overweight or obese. With regard to physical activity not even 20% of the students quote that they are physically active on seven days of the week. During school days about 2.3 hours are spent sitting in front of the TV, when students do not have to attend school this reaches 3.3 hours. Also computer games and game consoles are used to a considerable extent, 1.4 hours per school day and 2.3 hours on days off school. 20.8% of the students state that they eat fruit, 35.2% that they eat vegetables at the most once a week. Only about a third eats fruit on a daily basis and even less, namely about 16.2% eat vegetables every day. Yet about a fifth eat sweets or drink lemonade containing sugar every day. 35% of the students have smoked (11-year olds: 8.4%, 15-year olds: 64.6%), half of these went beyond trying. 7.6% of the students smoke every day, about 20% of 15-year old boys and girls). Close to 15% of the students consume alcohol on a regular basis (15-year old boys: 41.2% and 15-year old girls 32.3%), 12.1% of the students stated that they had been drunk at least once in the past 30 days (31.8% of the boys and 26% of the girls aged 15). Nearly 60% of the students were involved in bullying during the past months, 19.2% as victims, 17.6% as culprit and 22.4% as both). The socio-economic situation of a family has an influence on both the health status and the health behaviour of a child. Children and adolescents from families that were better off appeared to be healtier than children and adolescents from families that were not so well off. Those of the first group however showed a greater risk of being a culprit in bullying or drunk. Another factor which proved to exercise an influence on the health and health behaviour of the target group was family composition. Children and adolescents from single parent families had, when compared to families with both parents a lower probability of being healthy. Adolescents from families with stepfamilies displayed a higher risk of getting drunk or smoking. Also the school environment was important for the health and health behaviour of the students. Children and adolescents who had a good relationship with their fellow-students and teachers had a higher probability of being healthy. Equally they showed a lower risk of being involved in bullying attacks, of smoking or drinking Risk factors Risk factors covered in this chapter include smoking, physical activity, nutrition, obesity and alcohol. Risk factors such as poverty, low level of income, low level of education or a migration background are covered in detail in section IV of the report. The prevalence of chronic diseases is increasing in all European countries. Major risk factors for chronic disease are tobacco consumption, alcohol consumption, unhealthy diet, overweight and obesity as well as physical inactivity. 169 Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 5 October Dür, W., Griebler, R. (2007). The health of Austrian school students in their living conditions. Results of the WHO-HBSC Survey Commissioned by the Federal Ministry of Health, Family and Youth. Vienna April

94 Smoking Tobacco is the single largest cause of preventable death and accounts for 650,000 deaths every year in the EU. It is estimated that the economic loss caused by smoking resulted in more than 100 billion Euros in the year The percentage of daily smokers in the EU-27 ranges between 16.4 and 36.3% of the total population, amounting to an average of 26.5%. 171 The highest proportion of daily smokers can be found in Greece (35%), Bulgaria (31%) and Latvia (30%) wheras the lowest proportions were recorded for Slovenia (17%), Sweden (18%) and Finland (19%). 172 Especially the proportion of young women (15-24 years) has increased considerably in the past years. Figure 13: Smoking cigarettes, cigars or pipe Source: European Commission. Eurobarometer Survey on Tobacco (2009) Also in Austria smoking features the single largest cause of avoidable death. Current legislation on smoking features a compromise and is, when compared to measures taken in other European countries, very light. In the Eurobarometer survey on Tobacco Austrians were found to be amongst those least supportive of implementing smoking restrictions in public places (together with the Czechs and Dutch). They also showed one of the lowest shares of being totally in favour of regulating smoking in restaurants (only 38%). Smoking in restaurants appears to be by far more accepted than smoking in offices and indoor work places. 173 Advertising of tobacco products is, following EU legislation, with very few exceptions not allowed in Austria. Eventhough many of the interviewed experts quoted smoking as one of the main public health topics of the present and future, measures undertaken to reduce smoking and passive smoking appear to be strongly influenced by emotions and interest groups. According to the Eurobarometer Survey 2009, about 26% of the Austrian population older than 15 years smoke. Based on a survey commissioned by the Federal Ministry of Health in 2004 even a share 171 Website of the European Commission. Health/Tobacco/Policy, accessed at on 4 April European Commission (2009). Flash Eurobarometer.Survey on Tobacco Analytical report. Requested by the Directorate General Health and Consumers. March Accessed at on 5 November European Commission (2009). Flash Eurobarometer.Survey on Tobacco Analytical report. requested by the Directorate General Health and Consumers. March Accessed at on 5 November 2009 April

95 of 40 to 50% of the population is quoted to be smokers. Of these 19% were severely dependent on nicotine and 13% smoked up to a packet of cigarettes a day. 174 Whereas the share of men smoking has experienced a decrease over the past decades (from about 39% of the male population the 1970s to about 27% in 2006/ ), the share of women smoking has increased in the past (from about 10% of the female population in the 1970s to about 19% of the female population). 176 Young people start smoking at a very early age. 60% of the year-olds smoked in the past year and 13% of these are strong smokers. 177 When experts were questioned about their views on smoking policies in Austria, many of them openly declared their incomprehension about national policies. They were not certain about the reasons for the liberal smoking policies, arguing that lobbying could play an important role (restaurant owners, individual groups) and that politicians probably worried about losing votes if they took a clear standing against smoking. The topic was intented to be part of a television campaign but postponed, as it was not considered to be a good moment to discuss the topic. Some people believed that the decision to smoke or not smoke was a matter of personal choice. The awareness for the health of others does not apper to be very big. It also seems that in a small country like Austria individual experts can dominate certain topics and have a strong influence on decision makers. Various services are offered to encourage people to stop smoking. Social health insurance funds offer inpatient and ambulatory smoking cessation programmes. Together with the provinces and the Federal Ministry of Health they have started the smoker s telephone, a national initiative whereby people receive information and counseling on topics related to smoking by means of a hotline and online. 178 Apart from these services, a national strategy or nation-wide comparable services for smoking cessation are still lacking. A range of advisory centres and contact points can be found across Austria which are run by the provinces, the local health centres, the health insurance funds, hospitals or other institutions. Alcohol Europe is the continent with the highest alcohol consumption (measured in litres of pure alcohol). 3-8% of all global deaths were related to alcohol in Alcohol furthermore features one of the major preventable causes of disease, accounting for 4-6% of the global burden of disease and injury. Both deaths and diseases attributable to alcohol show a great regional variation. Gender and socio-economic status are the most relevant factors in alcohol consumption. Alcohol has an especially pronounced detrimental effect on unintentional injuries, cardiovascular diseases, cancer, cirrhosis of the liver and intentional injuries. Worldwide men consume more alcohol than women. 179 Alcohol consumption and abuse is a matter which should be taken very seriously in Austria. The negative effects on health adhering to excessive alcohol consumption can be considered as one of the main health risks in Austria. Even though the total number of those misusing alcohol as well as the daily amount of alcohol consumed by the adult population have decreased over the past 30 years, certain population subgroups (women and teenagers) show an increase in consumption Federal Ministry of Health, accessed at on 5 September Based on the national health survey 2006/ Statistics Austria. Accessed at on 4 September Federal Ministry of Health. Accessed at on 5 September Smoker s telephone (Rauchertelefon). Website: Rehm, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon, Y., Patra, J. (2009). 'Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 373, pp BMGF (2005). Public Health in Austria. Vienna. December 2005 April

96 About 10% of the Austrian population suffer from alcoholism at some point in their life. This applies to about 14% of the men and 6% of the women. In 2005 Austrians aged years consumed an average of 12.6 litres of pure alcohol per year, an equivalent of about 27.2 grams per day. Alcoholics account for about a third of this amount. 181 About 16% of the population can be classified as alcohol abusers, who are defined by either suffering from alcoholism or by exercising problematic alcohol consumption (10.6% vs. 5%). Those suffering from alcoholism (5% of the total population) represent about 7.5% of the male and about 2.5% of the female population. In absolute terms this amounts to about 340,000 individuals. In the past an alcohol emancipation of women has taken place which is characterised by more women drinking and abusing alcohol. 182 Teenagers experiment with alcohol at the age of 13 (boys) vs. 15 (girls) or sometimes even earlier. About 8% of the 13-year-olds and about 37% of the 15-year-olds drink alcohol regularly (at least once a week). 183 Alcohol can cause a variety of damages to health and result in certain diseases. Alcohol consumption can potentially lead to or, together with other factors, trigger the development of fatty liver, diabetes mellitus type II, pancreatitis, certain types of carcinomas, kidney damage, cardiomyopathy, circulatory disturbances, hypertension and liver cirrhosis. In addition the consumption of alcohol during pregnancy can increase the risk of miscarriage or halt development of unborn children. 184 Other illnesses which may be related to alcohol consumption are depression, sleeping problems, anxiety, etc. Rather than stating the mortality in connection with alcohol, the life years lost due to alcohol consumption provide a more reliable estimate of the scope of the problem. It is estimated that the average reduction in life expectancy of persons abusing alcohol (about 10% of the Austrian population suffer from alcoholism at some point in their life) is situated at 17 years for men and 20 years for women. The average reduction of life expectancy of all Austrians in connection with alcohol amounts to 1 to 3 years. 185 In ,578 alcohol induced accidents occurred, in the course of which 3,564 individuals were injured and 56 killed. On average about 100 fatalities per year are related to acute alcohol intoxication. In addition about 8,000 alcoholics die as a consequence of their illness. The population is informed about the health risks and potential detrimental consequences of alcohol consumption and -abuse through various media including the internet, brochures, television-and radio spots as well as information events. Providers of health services, especially general practitioners are encouraged to talk to their patients about the health risks related to alcohol 181 Uhl, A. et al. (2005). Nationwide representative survey on substance use (Österreichweite Repräsentativerhebung zu Substanzgebrauch). BMGFJ. Wien., Uhl et al. (2007). Handbook Alcohol Austria.Vienna. in Centre for Addiction Prevention (Fachstelle für Suchtprävention) (2008) Alkohol. Accessed on 4 November BMGF (2007). The not quite normal consumption of alcohol and its consequences for health (Der ganz»normale«alhoholkonsum und seine gesundheitlichen Folgen). 2nd edition.vienna. Accessed at on 2 September 2009 VIVID Addiction prevention, Centre for Addiction Prevention (Fachstelle für Suchtprävention). Accessed at on 4 September Dür, Griebler (2007). Health of Austrian school students in the context of their living conditions (Die Gesundheit der Österreichischen SchülerInnen im Lebenszusammenhang). Results of the WHO-HBSC Survey Ministry of Social Security and Generations (no year given) Early detection of health-related consequences of the normal consumption of alcohol (Früherkennung der gesundheitlichen Folgen des normalen Alkoholkonsums). Vienna. Accessed at on 4 September Federal Ministry of Health (2008). Alcohol. Handbook Alcohol Austria. Figures Data Facts Trends. Accessed at -_version_ pdf on 4 September 2009 April

97 consumption and to promote preventive actions. In the course of the preventive health check-up an own form on alcohol has to be filled out by the patient. Institutions dealing with the treatment of alcohol-related illnesses and offering consultation-services are ambulatory and inpatient institutions as well as self-help groups. But even in the presence of information campaigns and a range of other measures, the topic of alcohol abuse continues to be inflicted with stigma and shame (people do not talk about it) and also with ignorance (trivialization and supression of problems). Physical activity 186 Based on findings of the Austrian health survey 2006/2007, 60% of the men and 49% of the women older than 15 years undertake physical exercise at least once a week. A third of all men and close to a quarter of all women exercises at least three times a week. Physical activity decreases with advanced age and is especially pronounced for men and women between the ages of 60 to 75. Women of nearly all age groups undertake less physical activity than men. Based on results of the ÖSES.pal07 study the average PAL (physical activity level) of Austrian adults was situated at WHO recommends a level of at least 1.7. The level of physical activity was influenced by the age, level of education, profession, time spent sitting and smoking habits. Women showed by far lower levels of physical activity. Considerably more men had professions involving physical activity. Smokers and individuals who spent a lot of time sitting also displayed lower levels of physical activity. Nutrition 187 All population groups apart from children consume too much fat especially in the form of fatty acids. Individuals of all age groups consume sufficient protein, whereas they consume too few carbonhydrates and fibres. Cholesterol levels are lower than recommended for children but above the recommended levels for elderly people, adult men and pregnant women. Austrians consume less folic acid, calcium and vitamine D than the recommended levels (all age groups), but too high levels of sodium. Factors influencing dietary habits were smoking, body weight, satisfaction with weight, frequency of eating and attitude towards eating. With regard to the consumption habits of the Austrian population, the consumption of breadstuff, vegetables and fish has increased but is still lower than the recommended levels. Women between 18 and 65 years appear to consume the recommended amounts of fruit and vegetables. Women of all age groups consume more fruit and vegetables than men. Especially children consume by far too little fruit and vegetables. Average consumption of fat is too high, young people and children eat too many sweets. Individuals of all age groups drink more than the recommended daily levels of fluid intake by favourably drinking tap water. Overweight and Obesity Obesity is a serious public health problem and features a considerable risk factor with regard to death and disability. In the past decade large increases in obesity rates were witnessed in all EU-Member States. About 50% of the EU-population is overweight or obese, with especially high proportions in England or Germany (61% respectively 59.7%) and lowest shares in Italy and France (less than 40% 186 Statistics Austria. Austrian health survey 2006/2007. Physical activity during leisure time. Accessed at ml on 5 September Elmadfa, I. (2009). Austrian Nutrition Report Institute of Nutrition Sciences of the University of Vienna. Commissioned by the Austrian Federal Ministry of Health. March Accessed at cht_n.pdf on 5 November 2009 April

98 of the population). The increase in obesity rates has been especially pronounced in Central and Eastern European countries. 188 Figure 14: Overweight people, 2003 (1) in % of total population More than half of the Austrian population is overweight, of these 43% are overweight and 12% are obese. Fewer women tend to be overweight (29%) but more women are obsese (13%) than men. In all age groups the share of overweight men is bigger than the share of overweight women. The highest share of overweight men and women can be found among the population of the age group (53% of the men and 41% of the women). About 20% of the same popluation group are obese % of students between the age of 6 and 15 years are overweight and 8% of these are obese. The distribution of overweight and obese population shows an East-West divide. 6.2 Challenges and priority areas for public health based on expert opinion In the second part of this chapter current and future challenges and priority areas for public health in Austria as perceived by experts are presented. Interviewed experts were confronted with two questions: - What are the main problems and what are future challenges for public health in Austria? 190 and - If you were a decision maker in the health sector, which issues would you consider being of the highest priority to change i.e. promote? 191 The chapter is structured accordingly, first describing general (long or short term) challenges in connection with public health in Austria and then going into more detail by listing the short term priority areas which should be addressed in the near future Challenges Challenges were grouped into various categories: - Structures, framework and integration 188 European Communities (2009). European Commission. Eurostat statistical books. Europe in figures. Eurostat yearbook Accessed at EN.PDF on 3 April Statistics Austria, Body Mass Index (BMI), Accessed at ml on 8 November Responses of 19 experts were incorporated into this chapter 191 Ibid April

99 - Capacity building - Research - Specific topics which should be addressed in the future Structures, framework and integration The understanding of public health is in general fairly heterogeneous in Austria; it is however characterised by some common elements which are recognised among most professionals operating in the field of public health. For the definition of measures and activities and for better communication in general it would be essential to achieve a common basic understanding of the elements and features of public health. This would require existing legislation to be revised and new legislation to be drawn up. Public health ought to be institutionalised by either creating a new institution for public health (mostly taking on a co-ordinating function) or by installing a new position for an individual representing the area. In order to make this possible, adequate funding must be available and a strategy defined (including planning, target definition, forecasting, resource distribution, etc.). According to experts, the topic of public health should receive more attention which could for instance be achieved through activities such as lobbying, political engineering, social marketing or other steps to increase awareness among stakeholders on all levels of the health system. Responsibilities of players in the system should be defined very clearly; participation of concerned stakeholders, individuals and the population should be encouraged. The integration of public health services and health care needs to be promoted, thereby potentially aiming at achieving a greater balance between the two areas. As far as integration is concerned it is not only important to promote the integration and co-ordination of various sub-disciplines of public health such as health planning, health reporting, etc. but also to integrate public health concepts into all health system issues, ranging from the micro level to the macro level, an overall target being to move towards the (at least stepwise or partial) realisation of the Health in All Policies concept. Public health should become an integral part of health system organisations. Social matters and health care are traditionally separated in Austria and handled by different ministries, as a consequence making it very difficult to define strategies for Public Health measures for topcis affecting both ministries such as e.g. poverty, long-term care, social exclusion, etc. The lack of co-operation of health and social services is furthermore visible in the area of aftercare, specifically when a patient is discharged from a hospital and in many cases not receive adequate guidance in order to cope with everyday life again. Standardised communication and co-ordination structures are lacking. Capacity building After World War II a considerable resistence against any public health ideas was present in Austria. A new start was made in the 60s and 70s, meaning that Austria, in comparison to other European countries, was a latecomer in the field of public health. Now Austria should aim at producing a critical mass of public health professionals operating on all levels of the health system in order to advance further. 192 The concept of multidisciplinary practice (teams consisting of doctors, nurses, dieticians, physiotherapists, etc.) should be applied more widely. Skills of public health need to be brought into other sectors such as environment, social services or education. Basic principles of public health should be part of the training curricula of all health professionals, maybe in a different degree of intensity. Principles must furthermore be conveyed to decision-makers on all levels of the health system as these currently only in few cases demonstrate an understanding of public health. Experts should be urged to promote capacity building which requires assigning adequate resources, ensuring favourable structures and creating the formation of sufficient qualified resources. 192 Expert interviews, June 2009 (University, Research) April

100 Training should correspond to the needs of the individual (e.g. level of the health system, position, etc.) in order to ensure the greatest applicability. Communication and exchange of knowledge is frequently taking place in an unstructured way and is not standardised. Best practice examples are often not shared or communicated, resulting in isolated initiatives and the use of unneccesary resources because the wheel is re-invented. The establishment of networks, the search for external expertise and the building of co-operations is essential, as it is neither possible nor sensible for every organisation to do everything themselves. A co-ordinated and concerted course of action is required. Showing a strong commitment to public health and taking on leadership for certain topics is crucial to promote their success. Networking between different stakeholders on the national level (e.g. co-operations between stakeholders operating in any area related to health, education, social services or environment) partially works well on a project basis. Implementation of follow-up measures can however be problematic as it takes long until agreement is reached and resources are mobilised. The needs of all those involved should be assessed in order to react to and incorporate these adequately (e.g. the needs of patients need to be known to develop projects for them). Research No national research strategy for public health exists in Austria. Funding for research is very hard to obtain, limiting research development severely. Also the strict data protection regulations and the difficult access to data in Austria pose a considerable barrier to research. For several areas no data exist, meaning resources involved are usually based on estimates. This is for instance the case with data on homeless people or illegal immigrants. Research on needs i.e. needs analysis is largely missing, resulting in sub-optimal allocation of resources. Experts believe it to be important to initiate several model projects and longitudinal studies (lasting for several years) as these are more likely to show a long lasting impact than short projects which at present dominate the public health environment in Austria. Public health activities should lead to a greater evidence base. Too few adequately trained researchers exist, especially epidemiologists. Staff involved in the provision of postgraduate public health training is usually so occupied with organisational issues that hardly any time remains for research. Initiatives should be evaluated and assessed with respect to their benefit. The development of methods should be encouraged and forecasting i.e. the visualisation of future trends promoted. Research careers are at present not very attractive for young people and university graduates. They are often not well paid and are perceived as boring by doctors when compared with clinical work. Specific topics which should be addressed Topics which should, according to experts, receive special attention in the future are: inequality, lifestyle (risk) factors, especially smoking, increasing the health awareness of people, health promotion for children/adolescents, management of co-morbidities or chronic diseases by for instance promoting integrated care, e-health, mental health, demographic change and its influence of health and long-term care. Based on expert opinion, the following health problems are considered the main public health problems in Austria: cardio-vascular diseases, chronic diseases, health problems related to the musculoskeletal system, mental health problems (suicide, depression), smoking, obesity, lack of physical exercise, alcohol and inadequate nutrition. Furthermore challenges for life and health of modernisation such as economic crisis and climate change feature important public health problems, potentially resulting in a rise in diseases related to poverty, unemployment and stress respectively leading to water or food shortages, flooding, storms or migration. April

101 6.2.2 Priority areas The list below reflects the priority areas listed by a range of experts questioned in the course of this project. These priority areas are very similar to i.e. partially overlap with the challenges presented in the previous section. At this point it was however tried to rank the priority areas based on the times how often they were referred to. Structural changes - Funding for Public Health: definition of budgets, allocation of financial resources - Definition of a national public health infrastructure - Integration of health care/health services and public health (re-distribution of resources, networking/dialogue co-ordination across and between professions, encouraging participation of those involved, promotion of the health in all policies concept) - Creation of public and political awareness - Clearly voiced commitment towards public health - Definition of health targets, priorities, strategies and measures - Reduction of double structures/over-provision of services - Move from interest-dominated and supply orientated structure to needs-based structure - Needs-orientated and just reimbursement, use of incentive mechanisms - Orientation towards health determinants - Reduction of inequality Legislation - Revision of legislation for public health, creation of new legislation (e.g. for public health training, chronic diseases) - Revision of legislation on data protection Capacity building - Educating of decision makers - Ensuring political commitment and will - Building of new public health capacity (reaching a critical mass) - Integrating public health elements into the training of health professionals - Paying more attendion to quality of qualification in the public health sector - Encouraging multidisciplinarity Research - Allocating financial resources to research - Promoting basic research and interdisciplinary research - Financing of longitudinal studies - Shift from project-dominated research to sustainable programmes and studies, covering greater areas (communities, provinces) - Propose a research programme in public health. A resarch grant is needed whch is marked for at lease 5-10 years, a critical mass of money. - Create a good decision base for decision-makers - Promote research on needs, identify groups at risk - Creating evidence and evaluating measures (HTA, Health impact assessment, etc.) Data - Creation of a conceptual framework behind data collection, data processing and use of data - Improvement of the data situation: creation of a database adequate for scientific research and for health policy work (planning, development of diseases, etc.) - Revision of the legislation on data protection. Data should be made available for research institutions. Public health focusses on the population, not the individual, thus analysis on an aggregated level are of a primary interest. - Initiation of periodic surveys, the current health survey could be undertaken more often than every 10 years - Revision of the effectiveness of existing registries April

102 Other - Raising the health awareness of the population which appears to be quite low - Increasing the interest for prevention, prophylaxis and health promotion. The curative system in Austria is very well established and accepted, but not sufficient resources are geared towards Public health fields. For most of the priority areas listed above a critical mass of these is important as well as the urgent need for monitoring health systems by the use of indicators for life or health changes in the context of economic, social and political developments. In general there is a big need to co-operate within the EU, especially with neighbouring countries and to learn from other European countries. Public health is a global field of action but emphasis naturally needs to be placed on efforts targeted at the regional and European level. April

103 7. Conclusions The field of public health is currently undergoing considerable change in Austria and is, according to experts, just beginning to develop respectively only gradually in the process of developing. The term Public Health does not have a long tradition; it was hardly known 15 years ago. Today it is frequently used but in many cases the underlying understanding and knowledge varies considerably. One of the core problems of public health in Austria is based on a language problem. No accepted German translation for the term public health exists in Austria. Usually the English term is used, sometimes without knowing what it actually involves. On the one hand aspects or activitites are denominated as being public health relevant even if this is not the case and on the other hand aspects or activities, which are clearly relevant for public health, are not denominated as such. The lack of a nationally recognised definition and the missig agreement on the basic functions of public health result in confusion and contribute to the slow development of a common ground for discussion and the definition of a uniform strategy as well as hindering the development of public health in general. For those not disposing of specialised training, the concept of public health often still appears vague and difficult to grasp. Legislation on issues relevant for public health is fragmented, in some cases outdated and shows several gaps. No modern national Public Health Act or public health institution exists; the establishment of the latter is currently discussed though. Responsibilities for public health functions are fragmented and distibuted across a variety of institutions, departments and individuals. Awareness for the need of trans-sectoral co-operation (e.g between the health care and the social sector) with regard to health matters is still somewhat limited but increasing. The Austrian health system shows a strong focus on curative measures which is reflected by the allocation of funds and the reimbursement schemes (for health service providers) which do not incentivise providers to provide e.g. health promotion or preventive services. Social health insurance funds in Austria only have a limited legal responsibility to provide public health services; individual insurance funds handle this issue in different ways. Concepts such as prevention or health promotion have gained considerable ground over the past years. Two important achievements in this context have been firstly the enactment of the Austrian Health Promotion Act in 1998 and, as a consequence thereof, the foundation of the Fund for a Healthy Austria (Fonds Gesundes Österreich, FGÖ), the major institution responsible for the higher awareness for the topic as well as the increase in health promotion activities, and secondly the revision of the preventive health check-up examination (which is provided by contract physicians of Austrian social health insurance) in 2003 and 2004, resulting in the introduction of the new health examination concept in Due to economic pressure, but also to other national or international developments, disciplines such as evidence-based medicine, health technology assessment, health economics and quality management have received more attention in Austria in the past years. Evaluation does however still not feature a standard practice. This is problematic because good practice may not be made known or published, but also because some initiatives are started without there being sufficient supporting evidence. Promising projects are discontinued respectively not implemented in a sustainable form because of either their positive effect not being proven i.e. transparent or because of a general lack of funding. For those involved this can obviously be very frustrating. The lack of evaluation is to some degree also related to limited data availibility or due of the restricted use which can be made of existing data. Access to data as well as the linking of databases and data analysis in general can be complicated because of strict data protection regulations. Furthermore gaps in data e.g. epidemiological data exist which hampers the creation of a basis for sound decision making. Financial resources for research are, based on the statements of experts interviewed in the course of the study, scarce and difficult to obtain, thus also reducing the chances of attracting highly qualified individuals to engage in research. April

104 The public health community in Austria is very heterogenous and career paths are not clearly defined yet. Many professionals working in the field dispose of medical training, but also individuals with other (non-medical) backgrounds are gradually entering the area of public health. Various training paths are followed. The training acquired thereby is not necessarily reflected in the responsibilities or in the reimbursement structure of the professional in question. The development of a public health workforce has been promoted in the recent past (e.g. by selected provinces, the FGÖ or social insurance funds), receiving a special impetus when national public health programmes were established at various Austrian universities. Other aspects of capacity building, such as for instance organisational development or the formation of networks and partnerships, are still lagging behind though. Several experts interviewed in the course of the present study stated that the increasing number of public health professionals in Austria was already noticeable respectively made an impact. With regard to health outcomes, Austria has been experiencing a constant increase in life expectancy over the past decades. Infant mortality has dropped by ore than 2/3 over the past 25 years. Main causes of death remain to be cardiovascular diseases eventhough a major decrease has been registered in the past, thus contributing to an increase in life expectancy. In contrast the share of deaths due to cancer has increased. Principle diagnosis of discharge (after inpatient stay) in 2006 were diseases related to cancer (14.4%), cardiovascular diseases (12%), injuries and intoxications (10.2%), diseases related to the sceleton, muscles and connective tissue (10,0%) and diseases of the digestive system (9.3%). Smoking, alcohol abuse and weight problems present significant future challenges for Austria. Smoking is decreasing among the male population but has increased among women, especially young women. Smoking policies are, when compared to other European countries, not very strict in Austria. Alcohol is a matter which should be taken very seriously in Austria. Eventhough the total number of those misusing alcohol as well as the daily amount of alcohol consumed by the adult population have decreased over the past 30 years, certain population subgroups (women and teenagers) show an increase in consumption. 193 More than half of the Austrian population is overweight, of these 43% are overweight and 12% are obese. 193 BMGF (2005). Public Health in Austria. Vienna. December 2005 April

105 Section II: Information management and health reporting Introduction Information respectively a comprehensive, up to date and reliable data basis are crucial components of any health system. The systematic collection of data, which should be revised and adapted regularly, forms the basis of research, analysis and reporting which again are essential foundations for health planning (of structures and resources), further analysis and data assessment, health forecasting, the monitoring of trends, the definition of targets and the evaluation of these at a later point in time. Data collection procedures and processing mechanisms have changed significantly over time as well as the focus of data collection, which has been extended from mostly documenting data on infectious diseases, mortality and services provided to in a first step also documenting morbidity and health system related information. In the recent past public health aspects such as determinants of health (e.g. demographic or environmental factors) are being discussed more and more when assessing health data. By doing so, different health risks of population groups can be calculated and needs addressed in a more appropriate way. Implementation of public health orientated concepts in practice is however slow. Yet the situation with regard to health data does overall not look too bright in Austria. No national information strategy or framework exists which defines information needs, reasons for collecting data and intended use of data. A large variety of data is collected but it is not always clear as to whether this is relevant, sufficient and whether the quality of data is good. Reports in many cases do not appear to be followed-up in a standardised way; further analyses and detailed assessments of comprehensive health reports are undertaken on few occasions. The picture described above may not appear too positive, therefore it must be added that promising steps are being made, e.g with respect to health reporting activities but also with regard to a greater consideration of the Public Health Action Cycle in general. Health reporting has a long history in the UK and US, going back to the 19 th century. In Austria health reporting activities started in the 70s and 80s, initially in the form of activity reporting by public health authorities (based on the Imperial Sanitary Act). Health reporting, in a more modern form, as it is now understood internationally, is a fairly recent discipline in Austria (first developments taking place in 1994). It appears that it is still not used up to its potential; only few disease registries exist and the execution of extensive representative health surveys or large-scale research studies are a very rare exception. Decision-makers are often not trained to understand or consider public health issues and are only gradually incorporating existing knowledge and evidence-based findings into their decision making processes. Financial resources and adequately qualified professionals for data collection, processing, analysis and interpretation thereof are lacking. Austria can furthermore not look back on a long history of epidemiological research but has only lately started to shown a beginning interest in this area. Research is, based on experts (health reporting), strongly influenced by the pharmaceutical industry which is reflected in the research areas covered. Experts describe the national data situation with regard to epidemiological data as not satisfactory, stating that this has a negative impact on both research and health policy. 194 Data collected for inpatient care are influenced by aspects of the reimbursement system whereas no adequate documentation of diagnoses exists for the ambulatory setting (physicians in practices). 195 On the national level little data are collected on children or immigrants. A survey which is undertaken on a regular basis (every 4 years) is the WHO Health Behaviour in School-aged Children (HBSC) Survey. It is conducted by the Ludwig Boltzmann Institute for Health Promotion Research. 196 The Austrian health survey 2006/2007 also contains information on immigrants (see specifically the 194 Expert interviews June 2009 (Research, University) 195 Expert interview June 2009 (Research) 196 Contact information for the HBSC survey in Austria: April

106 special evaluation on socio-economic determinants of health 197 ). Only few registries (see chapter 8 of this section) exist and these are predominantly based on regional/provincial, local or individual initiatives (e.g. applied in several hospitals). Systematic screenings take place in few cases and appear not to be based upon the latest research findings i.e. scientific standards. Since 2006 Austria refers to international guidelines, which are for instance applied in the form of EU guidelines in several projects for mammography screening. The programme of the preventive health check, which was introduced in 1974 was revised in 2005, the intention behind the revision being to create an evidence-based examination programme. Legislation and regulations on the use of data, data protection and data confidentiality are strict in Austria, making the linking of data sets and data analysis in general very difficult and partially even impossible. Public health research is still quite under-developed in Austria. This is due to various reasons, primarily though to a lack of prioritisation and political dedication as well as missing institutionalised responsibility with respect to the topic which is for instance reflected in a lack of capacity building in this area (the formation of financial and human resources). At present it is not possible to do a PhD in public health at any Austrian university. Little data on objective health status are available; the same applies to data on outcomes and also on the quality of health services. Examples for the publication of quality data are for instance: the Austrian Hospital compass (Österreichischer Spitalskompass) 198 and the Rehabilitation compass (Österreichischer Rehabilitationskompass) 199, which include information on structural quality and on (minimum) frequencies. Transparency in connection with data on health outcomes and transparency of data in general has so far not been promoted. Evaluation of projects and other activities or measures does not appear to be part of the Austrian culture and is not encouraged. This may change through the Federal Institute for Quality in the Health Care System (Bundesinstitut für Qualität im Gesundheitswesen, BIQG) which was founded in July 2007 and covers quality registries and outcome quality as one of its core working areas For the present report a literature review was undertaken during which it became evident that the body of literature describing the Austrian public health context is on the one hand not very large and that on the other hand many of the publications date back to the Nineties or the beginning of the 21 st century. The information provided in these publications is not necessarily outdated though, as the situation has in some cases remained more or less unchanged. A very comprehensive and concise description of the health data situation in Austria was given by Rásky in She summarises an extensive range of then existing health data sources, assesses the data s relevance and suggests measures for improvement. According to Rásky s assessment, the Austrian health data landscape showed a strong disease focus in 2001 and health aspects were barely considered. Data were, according to the author, not comparable and fragmented, socio-economic, psycho-social and ecological factors were neglected, the same applied to topics such as adolescents, gender or health promotion. Systematic data collection was uncommon, critical data analysis and discussion only found in few occasions and statistics (especially those of health authorities) still placed an emphasis on disease rather than health. Rásky also commented that no comprehensive representative surveys or longitudinal research studies were undertaken which were considered essential for capturing the health status of the population. 197 Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the then Federal Ministry of Health, Family and Youth. Vienna Austrian Hospital Compass Accessible at Austrian Rehabilitation Compass, Accessible at Other fields of work are: quality reports and health information, quality of processes and structures and quality and efficacy/health Technology Assessment 201 Rásky, È. (2001). Health data situation in Austria (Die Datenlage zur Gesundheit in Österreich) in Rásky,È., Freidl, W. (2001). Health reporting in Austria. Appraisal and results of a regional survey (Gesundheitsberichterstattung in Österreich. Bestandsaufnahme und Ergebnisse eines regionalen Surveys.) Report series Health sciences. Linz April

107 The author argues that the tendency of neglecting health and health promotion aspects in the past, in favour of aspects related to disease and health care has lead to resources being mostly allocated to health care services, thus favouring costly medical solutions over health promotion and prevention measures. The situation Rásky describes in the report remains, with regard to many aspects, unchanged today. Austria s health data situation is still mostly disease orientated, data analyses or health reporting are only exercised by a small but growing group of experts, national reports are frequently not followed up in a standardised way or used up to their potential, qualified human resources are still missing and several decision makers and professionals in the health sector only have a vague idea of what public health is or does. However, also several very positive developments have taken place in the past eight years such as the execution of the first national health survey based on the European Community Health Interview Survey ECHIS. Several questions of the Microcensus 1991 have been included in the Austrian health survey 2006/2007 and are comparable across time. The survey is planned to be undertaken every 10 years (by the national statistics institute, Statistics Austria); whereby a shorter interval would be favoured by a range of experts. Furthermore positive developments with regard to health reporting can be observed e.g. in Vienna, Styria or Carinthia as well as the installation of various health data tools or the expansion of the Austrian health information system, ÖGIS. Also training programmes which have been initiated in the past years have resulted in a steady increase of qualified individuals. April

108 1. Legislation Nearly any legislation relevant for the health sector contains regulations on data collection, documentation or reporting. The legislation listed below and partially described in more detail thereafter is considered most relevant in the context of this section of the report. The main stakeholders respectively providers of health data in Austria are referred to in the consecutive subsection. European and international regulations are not included in the list, are however relevant for the Austrian context. - Imperial Sanitary Act (Reichssanitätsgesetz 1870) - Federal Act on Documentation in the Health Sector (Bundesgesetz über die Dokumentation im Gesundheitswesen) - Hospital Act (Kranken- und Kuranstaltengesetz) - Professional Legislation (e.g. Physician Act, Ärztegesetz) - Agreement according to article 15a of the Federal Constitutional Act (Vereinbarung gemäß Artikel 15a Bundes-Verfassungsgesetz) - General Social Insurance Act (Allgemeines Sozialversicherungsgesetz) Health Reform Act 2005 (Gesundheitsreformgesetz 2005) including amendments of various laws (e.g. the Hospital Act, social insurance legislation or the Documentation Act) and the new Federal Act of the Quality of Health Services as well as the Health Telematics Act - Cancer Statistics Act (Bundesgesetz über die statistische Erfassung von Geschwulstkrankheiten, Krebsstatistikgesetz) - Resolution E 103/XVII. GP of of the National Council (national health report) - Population Register (Melderegister) The Imperial Sanitary Act dates back to 1870 and describes the Austrian public health service. It is closely linked to the Act on the Political Authorities which outlines the organisation and responsibilities of the public authorities on the different administrative levels (national, cities, provinces, districts). The Imperial Sanitary Act obliges the health authorities of the provinces to, based on the health statistics collected by them, produce activity reports. Legislation has in the mean time been amended in several provinces (Styria, Vienna) resulting in the reduction of the duties of the provincial health authority with regard to health reporting. Eventhough no legal basis for health reporting exists in Styria the provincial health authority still commisions the compilation of a health report; in Vienna health reporting was made the responsibility of an own department of the Magistrate of Vienna. 203 The health report for the National Council is based on a resolution of the National Council dating back to in which it demanded the Minister of Health to present a health report every three years. It is new that public health is explicitly referred to and mentioned in Austrian health legislation. This is the case for the first time in the Agreement based on article 15a of the Federal Constitutional Act which is signed by the Federal Government and the provinces in regular intervals and is, in its current version, valid from 2008 to According to article 11 of the agreement, the contracting parties agree to accommodate principles of public health when implementing any measures stipulated in the agreement, one of these principles being systematic health reporting. Others listed are the acknowledgement of a comprehensive notion of health, the undertaking of health services research to ensure needs-orientated planning, development and evaluation, the promotion of interdisciplinarity of care or research, another the development of health targets. 202 As well as the other social insurance laws 203 Bachinger, E., Grasser, G. (2009). Capacity Building for Health reporting. in: J. Kuhn & J.Böcke (eds).: Administered health. Contributions to the political relevance of health reporting. Concepts of health reporting at the centre of discussion (Verwaltete Gesundheit. Beiträge zur politischen Relevanz der Gesundheitsberichterstattung. Konzepte der Gesundheitsberichterstattung in der Diskussion). Frankfurt: Mabuse. 204 Resolution E 103/XVII. GP of April

109 Article 6 of the same agreement regulates reporting on quality in the health care sector (responsibilities, process). Article 28 defines that hospitals receiving funding from the regional health funds, have to report diagnoses and services to both a pseudonymisation unit and the regional health funds. The Federal Health Agency is in charge of any decisions related to the pseudonymisation unit. Article 37 strives to ensure and promote further development of documentation. The documentationand information system which can be accessed by social insurance and the regional health funds should be extended. The same article also forms the legal basis for the installation of a pseudonymisation unit at the Hauptverband. The unit is intended to promote data transparency across various areas of the health sector, ensure data protection and encourage use of the data for joint monitoring, steering, planning and financing in the health care sector. Another document referring to health reporting is the Handbook ÖGD Neu 205 which was developed in the course of a project dealing with the re-organisation of the training of physicians working in the public health authorities (medical officers) on various levels of the health system (national, regional/provincial and community level). Before redefining the curriculum the authors outlined what the future field of work of the aforementioned professionals could entail. The project is described in Section 1 of this report. Authors of the handbook authors recommend that health reporting (epidemiology and health reporting) should be one of nine fields of responsibility (core duties) of the Austrian public health service. They propose the assignment of this duty to the public health service by arguing that the public health service incorporates the necessary independence from individual interest and takes on a population-orientated perspective. They furthermore stipulate that a modern public health service, in the form as they suggest it, requires profound and comprehensive epidemiological information in order to detect trends, make connections, plan resources and give recommendations. Sub-responsibilities pertaining to the field of health reporting would, according to their suggestion, be: monitoring the populations health status and factors having an impact on health, identification of further factors, ensuring the collection and provision of necessary data, ensuring the assessment and analysis of the collected data, providing data- and knowledge orientated political consulting and ensuring the publication of health data and recommendations. In their report they incorporate current trends in health reporting such as action-orientated reporting and health-orientated reporting. For this scenario to be realised, the authors acknowledge that new legislation would have to be created. The recommendation on health reporting, which was developed by the platform for health reporting in 2007, is another document which plays an important role for the development of health reporting in Austria. More details on it can be found in the following section. 205 Federal Ministry of Health, Family and Youth (2007). Handbook ÖGD. Handbook for the Public Health Service, ÖGD. Vienna. November April

110 2. Stakeholders A large number of institutions and organisations on various levels of the health system (national, regional/provincial, community, institutional) collect information relevant for the health sector. It is impossible to detail all of them in this section and to describe the data they collect as well as their responsibilities in a comprehensive way. Therefore only an overview of those considered most important is provided. The list was developed by the author and complemented by adding inputs originating from expert interviews. A good overview is provided in Rásky and Freidl (2001) 206. Data collection and reporting activities are frequently based on legal obligations and concern infectious diseases, health service utilisation, mortality and morbidity (diagnosis related data on inpatient care), data on health system structure (institutions, beds, health professionals/providers, equipment, etc.) or costing data. Assessment and documentation of health outcomes, health determinants and economic aspects of health or health targets is only slowly increasing. Below stakeholders considered most important with regard to data collection are listed: - Statistics Austria (National statistics institute) - Social insurance (Main Association of Austrian Social Insurance Institutions and the individual social insurance funds: health insurance, accident insurance/worker s compensation, pension insurance) - Federal Ministry of Health (BMG) - Federal Ministry of Labour, Social Affairs and Consumer Protection (BMASK) - Regional/provincial and local/district health authorities (health department/public health service) - Health service providers (hospitals: discharge data, physicians: billing and prescribing data, etc.) - Professional organisations (Austrian Medical Chamber, Chamber of Pharmacists, etc.) - The Austrian Agency for Health and Food Safety (AGES) Others: research institutions, universities, private insurance companies, NGOs Statistics Austria has a legal obligation to collect and report certain data. It documents mortality by keeping the cause of death statistics and fertility by keeping the birth statistics. It is furthermore responsible for publishing data on inpatient care, based on the medical and administrative hospital data it receives from the Federal Ministry of Health, as well as on selected social insurance information. Statistics Austria oversees the national cancer registry and is contracted by the Federal Ministry of Health to execute the national health survey. Data originating of the latter are publicly available free of charge. Results are presented in the form of reports. Statistics Austria also calculates Austrian expenditure on health based on the OECD system of health accounts. Data on infectious diseases is reported to Statistics Austria by the Federal Ministry of Health. Statistics Austria furthermore reports data to the EU, EUROSTAT, the WHO and the OECD. In general Statistics Austria operates in a very transparent manner. Data or any results of further analysis are published in reports which are in most cases, similar to any other information relevant for data collection (e.g. questionnairs) available through their website in the form of an electronically downloadable file or can alternatively be ordered by post, which usually involves a charge. The Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) collects structural data on health providers and health institutions (e.g. hospitals) as well as recording cases of infectious diseases. The Ministry has delegated several documentation duties to other institution such as AGES (Agency for Health and Food Safety) or GÖG/ÖBIG (Health Austria, Austrian Health Institute) 206 Rásky, È. (2001). Health data situation in Austria (Die Datenlage zur Gesundheit in Österreich) in Rásky,È., Freidl, W. (2001). Health reporting in Austria. Appraisal and results of a regional survey (Gesundheitsberichterstattung in Österreich. Bestandsaufnahme und Ergebnisse eines regionalen Surveys.) Report series Health sciences. Linz AGES website. English introduction. Accessed at on 3 May 2009 April

111 The Federal Ministry of Labour, Social Affairs and Consumer Protection (Bundesministerium für Arbeit, Soziales und Konsumentenschutz, BMASK) records and publishes data on topics such as longterm care, social assistance or on issues related to handicapped people. Social insurance funds collect data on their insured population (basic indicators, contributions), on health care provision (contract providers) and utilisation (billing data of providers: physician visits, services provided, prescriptions issued, etc.), on work accidents and occupational illnesses, on sick leaves and on pensions and disability. Professional organisations i.e. representations (e.g. Medical Associations) record a wide range of data on their members (registration, professional status (working in a hospital, in a practice, giving expert opinions, etc.), training, competences, location, membership fees, etc). Hospitals report their administrative data (human resources, costing data, beds, machines, etc) and their service data (discharge data: diagnoses, examinations performed, etc.) to the regional health fund which forwards it to the Federal Ministry of Health which then passes it on to the national statistics office, Statistics Austria. Responsibilities of public health authorities (regional/provincial and district health authorities) vary greatly throughout Austria. With regard to documentation and reporting they, in general, document the services provided by them as well as recording infectious diseases. Statistics offices of the provinces (Landesstatistik) collect demographic data on the population in their respective province. ÖBIG, the Austrian Health Institute, is one of the three divisions 208 of the Health Austria Ltd. (Gesundheit Österreich GmbH, GÖG), which is owned to a 100% by the Federal Government. ÖBIG plays a major role when it comes to health information management and reporting. It oversees the Austrian health information system ÖGIS (which is described later on), produces reports on numerous topics and keeps several registries (e.g. registration of objections against organ donation, in-vitrofertilisation registry, registry for medicinal products, haemovigilance registry). For further information on registries see chapter 8 of this section. BIQG, the Federal Institute for Quality in the Health Care System (Bundesinstitut für Qualität im Gesundheitswesen), is another division of Health Austria Ltd. and is responsible for the following areas related to information management: basic groundwork with regard to health reporting, health information for the public, patient safety, national quality guidelines, outcome quality and HTA. Most institutions report data to international organisations such as the WHO, the European Commission, EUROSTAT or the OECD as well as supporting international surveys and studies (e.g. Eurobarometer, EU-SILC, health promoting hospitals, HSBC, etc). Other data collected within the health system are for instance data on school examinations (which are recorded but not analysed in a standardised way), on traffic accidents (Board for Traffic Safety, Kuratorium für Verkehrssicherheit) or on air pollutants (Federal Authority for Environment, Umweltbundesamt). As part of projects a number of additional data collections are performed. Registries are in some cases overseen by GÖG/ÖBIG, in other cases they are kept by medical societies or other institutions. The topic of registries is discussed later on in this section (chapter 8). Data collection is only in part routine data collection. Data are, on several occasions, collected but not published or used for data analysis. This for instance applies to the data collected in the course of school examinations). Reasons for this are primarily issues related to data protection, but also lacking prioritisation and culture of data analysis as well as to a certain extent lack of resources. The range of different stakeholders involved i.e. the high degree of fragmentation when it comes to responsibility, which is for instance the case with schools, exacerbates the situation. The scope of certain data may be difficult to estimate as they do not enter any official statistics (e.g. private services which are paid for out-of pocket and for which insurees do not claim a refund from their social health insurance fund). 208 The other two divisions are: BIQG (Federal Institute for Quality in the Health Care System/Bundesinstitut für Qualität im Gesundheitswesen) and FGÖ (Fund for a Healthy Austria/Fonds Gesundes Österreich) April

112 3. Health information systems The Austrian Health Institute (ÖBIG) created the national health information system ÖGIS (Österreichisches Gesundheitsinformationssystem) about 15 years ago. Many of the stakeholders described in chapter 2 feed their data into the system. ÖBIG s intention is to create a database spanning the entire health system. Several selected indicators of the information system are publicly accessible via the interface REGIS (Regional health information system, Regionales Gesundheitsinformationsystem), in which data is provided in pre-defined queries, e.g. in the form of cartographic images. Data or images cannot be downloaded or used for further analysis. REGIS appears to be a good starting point but further development is encouraged. The situation regarding health information systems on the regional level is very heterogeneous. Several provinces have already established health information systems, others are in the process of doing so (e.g. Styria, Tyrol, Lower Austria or Carinthia). According to an Austrian health reporting expert, ÖGIS is, with regard to its composition/content orientated towards the European Public Health Information System EUPHIX April

113 4. Data protection Legislation and regulations on the use of data, data protection and data confidentiality are, partially because of historical reasons, fairly strict in Austria, making it difficult or even impossible to access data for research and data analysis. Public health authorities, universities and other research institutions encounter considerable barriers when trying to access or use data. Use of individual patient data generally requires obtaining the consent of the individual which poses a huge barrier. Partially data can be analysed anonymously. This however has the disadvantage that patient pathways cannot be followed over time. Experts hope that the situation may improve with the introduction of the electronic health record (Elektronische Gesundheitsakte, ELGA) or may be facilitated through the pseudonymization of data, undertaken by e.g. social insurance. Through the installation of a psyeudonymisation unit at the Main Association of Austrian Social Security Institutions in 2008, the pseudonymisation of social insurance data is now possible. Thereby the social insurance number/code of an individual is replaced by a psydonym which makes it possible to follow an insured person s patient history without violating data protection regulations.this system is currently used for the evaluation of data of the preventive health check-up. The only professional group which, based on interviews, appears to be completely in favour of the existing data protection sitution, is the medical profession i.e. their representative organisations. Before existing data protection regulations are questioned or modifyed it is initially important to know the data requirements of the users as well as specifying data collection needs (which data is collected, which data is actually used, e.g. for analysis and in which way?). April

114 5. Data surveillance and data analysis Surveillance describes the act of systematic observation or the monitoring the health of the population and the factors responsible for it. Few institutions in Austria undertake data analysis or perform assessments of health data. No real disease surveillance systems exist in Austria, apart from for infectious diseases. Several registries exist (see chapter 8), it was though not possible to look into all of these for the present study. The National Statisics Institute Statistics Austria collects, in accordance with its legal responsibiltiy, data and publishes a variety of standardised reports. Linking of data happens for some health data (e.g. by linking data on the incidence of disease, the utilisation of health services or other aspects of health services with age, sex, provinces, income or education) on occasions (e.g. health survey) but is generally very difficult because different data sets can frequently not be linked. If commissioned to do so, experts from Statistics Austria perform further analyses on the collected data but this is not a regular procedure and not one of their responsibilities. Reports or data published by Statistics Austria do not appear to be used or followed up in a standardised way. Eventhough new reports are presented to a large audience, e.g. in the form of a press conference, actual interest in the data for further analysis or action is fairly low among the main system stakeholders. Data collected by Statistics Austria is partially requested by universities or other research institutions which then perform more detailed analyses. In addition to the reports published by Statistics Austria, comprehensive reports have been compiled by university representatives on various disease related topics such as for instance diabetes or osteoporosis. The use of findings of such reports and the implementation of consecutive measures is not transparent. Also health reports, which have been published by several provinces and other players in the health system (see chapter 7 of this section) experience difficulties when it comes to putting findings into practice. Impetus for disease surveillance and disease spread comes from universities and other research institutions rather than from public authorities. 210 In summary, health data and health reports do not appear to be used to their full potential or followedup in a standardised way, thus not making the most effective use of them. Institutions with a reputation in data analysis, health system analysis and/or health technology assessment (not necessarily exclusively but also in the health sector) in Austria involve the Institute for Advanced Studies (Institut für Höhrere Studien, IHS), the Institute for Pharmaeconomics-Research (Institut für Pharmaökonomische Forschung, IPF), the Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) or the Austrian Health Institute, division ÖBIG (Gesundheit Österreich, Österreichisches Bundesinstitut für Gesundheitswesen, GÖG/ÖBIG), The Public Health Information Resarch Unit (PHIRU) at the University of Applied Sciences FH Joanneum as well as some of the health insurance funds or selected university departments. Research at the IHS focuses on applied health system analysis and health economics, research at the IPF on Pharmaeconomics, research at the LBI-HTA on health technology assessment and research at the GÖG/ÖBIG on health system and health services research. Institutes and departments in the field of health promotion undertaking data analysis are the Ludwig Boltzmann Institute for Health Promotion Research (Ludwig Boltzmann Institut für Health Promotion Research), the Institute for Health Promotion and Prevention (Institut für Gesundheitsförderung und Prävention, IfGP), the Department for Evidence-based Medicine and Epidemiology at the Danube University Krems and Styria vitalis. Moreover several private consultants offer services in this area. Resarch and data analysis also takes place at university departments of social medicine, epidemiology, environmental medicine and medicinal statistics at the medical universities of Vienna, Graz and Innsbruck. Furthermore universities for social sciences have in several cases installed departments for health, public health, health care management, etc. (e.g. University of Klagenfurt, 210 Expert interview, 22 June 2009 (Research) April

115 Private University for Health Sciences, Medical Informatics and Technology in Hall in Tyrol, UMIT, University of Vienna, etc). A considerable amount of patient data is collected by hospitals which use this for clinical research and scientific publications. Health insurance funds have, in the past, focussed data analyses on expenditures (billing/reimbursement of contract providers); research on health technology assessment or health care provision and utilisation is gradually increasing. In the past decade, the Main Association of Austrian Social Security Institutions and several insurance funds have created powerful tools for data comparison and analysis (e.g. FOKO, LGKK, BIG, KAL, LEICON, META-HONO 211 ). These are primarily still used for monitoring the behaviour or providers and the insured population but are increasingly also applied for undertaking analysis or research. Other institutes collecting and analysing data for health reporting are detailed later on in this section. 211 FOKO=Calculation of follow-up costs (Folgekosten), LGKK=Software for the benefits/services of the regional health insurance funds (Gebietskrankenkassen=GKK), BIG=Buiness Intelligence in the health care sector (Business Intelligence im Gesundheitswesen), KAL=Catalogue of ambulatory services (Katalog ambulanter Leistungen), LEICON=Service/benefits controlling (Leistungscontrolling), META-HONO=meta reimbursement catalogue (Metahonorarordnung) April

116 6. Health reporting Modern health reporting as it is now, does, as already indicated above, not have a long tradition in Austria. First health reporting activities took place as early as the 70s, based on the Imperial Sanitary Act, and had the form of activity reports. In 1994 the first modern health report was produced in Vienna. Based on a study of the Austrian Health Institute (ÖBIG) of 1998, which aimed to capture health reporting activities at the time, only few provinces had started publishing health reports, namely Vienna, Styria and Upper Austria. Eventhough the Imperial Sanitary Act created the first legal foundation for the introduction of a systematic data collection through the health authorities in 1870, thus obliging the authorities to publish health reports, this was, as deailed before, previously executed by them in the form of activity reports rather than in the form of health reports. Health reporting is usually based on data of existing data pools because the collection of additional data would involve considerable time and financial resources. 212 One of the first information systems developed in this area in Austria during the Nineties was the Austrian Health Information System ÖGIS (Österreichisches Gesundheitsinformationssystem) which enables analyses of selected health related questions which will be elaborated later on in this section. 6.1 Definitions and targets of health reporting Below various targets of health reporting are listed, originating either from international literature or Austrian publications. Targets quoted by experts, who were interviewed in the course of the study, are also listed before a brief summary concludes this subsection. Based on Kellerhof (1998) 213, health reporting efforts are aimed at improving the health status of the population and the health care situation for the population. The Vienna Health Report of lists, based on this definition, various sub-goals: - Making public health measures more targeted by providing decision makers in the fields of policy, administration and health services with the relevant data to create, plan and steer policies. - Motivating decision makers and citizens to place increasing emphasis on health. - Providing citizens with factual and relevant information on the state of health of the population and its main determinants. Health reporting should not only be the basis of decision-making for health planning, health policy making and health promotion measures but should reach a very heterogeneous group of users originating from all sorts of specialties, disciplines and professional fields as well as reaching the general public. 215 GÖG/ÖBIG, the Austrian Health Institute, states on its website that health reports document and analyse the health status of the population of a defined regional entity, being a community, region, province or entire state, the type and scope of institutions of inpatient- and outpatient care as well as factors determining the health status of the population such as environmental and behavioural factors. It argues that the aim of health reporting is to spot deficits, to elaborate measures for improving the 212 Meggeneder, O. (1996). Statistics as basis for health reporting. Data on the health status of employed people (Statistiken als Grundlage zur Gesundheits-berichterstattung. Daten der Sozialversicherung zur gesundheitlichen Verfassung der ArbeitnehmerInnen) in Grossmann, R. (Hrsg). Health promotion and public health. Developing public health through organisations. Facultas-Universitätsverlag.Vienna Quoted by Bachinger, E. at her presentation given at the 11th Austrian Health Promotion Conference How healthy is Austria on 4 May 2009 in Innsbruck, Austria. Organised by GÖG/FGÖ 214 Bachinger, E. (2004). Vienna Health Reports Magistrate of the City of Vienna. Department of socialand health planning as well as Finance Management Health Reporting. Vienna. Accessed at on 15 April Bachinger, E. (2009). Vienna Health Report 2004 and outlook on the health report Presentation given at the 11th Austrian Health Promotion Conference How healthy is Austria on 4 May 2009 in Innsbruck, Austria. Organised by GÖG/FGÖ. April

117 situation as well as to assess these measures with regard to their effectiveness and efficiency. It concludes by defining health reporting as a permanent process which ought to take place on the national, regional and community level. The Public Health Information Resarch Unit (PHIRU) at the University of Applied Sciences FH Joanneum states that Health reporting consists of various products and measures aimed at both creating knowledge and awareness of public health problems and their determinants among different population groups, as well as recommending possible solutions. The target groups of such reports are decision makers (also those in the tourism field) in a position to contribute to improvements in the public s health, as well as the affected population in general. Health reporting is carried out at the national, regional and communal levels, and can have various thematic emphasis, such as fitness, women s health, or tourism. Completion of health reports at regular intervals can serve a monitoring function and provide the requisite information for strategic health policy planning. Compiling health reports involves collection, collation, analysis and epidemiological interpretation of routine data, and data from health surveys. Qualitative methods are also employed, such as document analysis, systematic literature research and expert interviews. Based on these data, interrelationships can be identified and recommendations can be made for health policy measures and programmes to improve the health of the population. 216 Eva Ràsky defines health reporting as the periodic, comprehensive and understandable analysis of data relevant to the health of the population in her report of She argues that it features a complex approach which is intended to improve the infrastructure and instruments of data collection and analysis. Health reporting is action-orientated and therefore offers the basis necessary for the formulation of effective and efficient interventions. She also states the ideal case in which the results of health reporting are communicated to those affected or links are made between different data sets. 217 Experts interviewed in the course of the present study stated the following aims of health reports respectively of health reporting: - Information of the public and the expert community about the status quo and about future trends regarding the structure of the health sector and health care - Provision of modern and comprehensive reports containing up to date information which are suitable for (international) comparison and benchmarking and suitable for a heterogeneous target group (not too scientific, but still demanding in terms of their content and presentation) - Support of further development and monitoring of health targets - Periodic assessment of achievements, the result of which forms the basis for the definition of follow-up measures - Explaining health system aspects and correlations as well as promoting the detection of problems, deficiencies or deviations - Constituting the basis for planning of public health and health promotion measures - Facilitating the assessment of the potential and the limitations of available data, followed by the definition of measures to improve the data basis and the use of data, methodology applied, definitions used, etc. Summing up, health reports have a great variety of aims they strive to meet. They should not only provide information but provide it in a user- and action-orientated way, facilitating and promoting implementation of follow-up measures. Reports ought to be the basis for planning and policy-making 216 Information folder of the PHIRU at the University of Applied Sciences FH Joanneum 217 Rásky, È. (2001). Health data situation in Austria (Die Datenlage zur Gesundheit in Österreich) in Rásky,È., Freidl, W. (2001). Health reporting in Austria. Appraisal and results of a regional survey (Gesundheitsberichterstattung in Österreich. Bestandsaufnahme und Ergebnisse eines regionalen Surveys.) Report series Health sciences. Linz April

118 in the health care sector and also across sectors. Describing the status quo with regard to selected indicators, assessing the current situation and deducting targets and measures to meet these targets are equally aims of health reports. They must meet certain scientific standards but at the same time be readable and understandable for a very heterogeneous audience. Health reports should inform decision makers in the system and provide them with the relevant knowledge for their decisions. They should also present recommendations and give guidance for future action. 6.2 Development of health reporting in Austria Public health authorities of the provinces are, based on the Imperial Sanitary Act, which dates back to 1870, responsible for producing yearly reports containing medicinal statistics (documenting their activities). In most Austrian provinces, the Imperial Sanitary Act is still the only legal basis for health reporting. Due to a lacking legal obligation to produce health reports, efforts related to reporting are frequently based on the initiative of regional politicians, leading civil servants (representatives of health authorities) or other individuals. Health reporting activities corresponding to the WHO idea of health reporting started in Austria in the late Nineties; first health reports in the modern sense were produced on the regional level by the provinces of Vienna, Styria and Upper Austria since the mid 1990s. Other provinces followed. Initial reports tended to place a strong focus on disease, health care infrastructure, health care services and utilization. The intention of those involved in the production of the reports has always been that health reports are used as a strategic tool providing the basis for planning and decision making. Reports have though rarely resulted in visible and sustained action. The commitment to initiate follow-up measures after publication still appears to be low as reports rarely contain health targets or are evaluated after a defined time period. In general the priority attributed to health reporting and the financial resources dedicated to the field are limited. Some stakeholders may appreciate reports as a personal political marketing tool rather than valuing it as basis for strategic health planning and decision making. With regard to the topics covered in the reports, topics such as health (vs. disease), health determinants, prevention, health promotion and social inequality have received more interest lately. In 2004 the first national health report was published by the Federal Ministry of Health (produced by the Austrian Health Institute, ÖBIG). 218 Most experts interviewed in the course of the present study however refrain from defining this report as a health report corresponding to current understanding of health reports. Today nearly all provinces have published at least one health report. Some have recently updated their reports. In addition, a few communities have started to produce health reports. A range of special reports (on any level of the health system) has been compiled, usually targeting a defined illness or population group. Topics covered involve for instance mental health, men s/women s health, adolescents and children or chronic illnesses. The second national report is planned to be published in 2009 or In addition to producing the national report and several regional reports, ÖBIG is also commissioned by the Federal Ministry of Health to compile the highly standardised political health report for the National Council (Nationalrat), which has to be presented to the National Council every three years. Health reports in Austria can only be compared with each other to a very limited extent due to their diverging aims (those of the commissioning agency), their heterogeneous availability and use of available resources, the time frame covered, their data and methodologies applied (e.g. weighting), structure and contents. To counteract this and to strive towards a certain degree of harmonization, the Platform for Health Reporting was founded on the national level by GÖG/ÖBIG in The platform brings together experts and representatives of institutions operating in the field of health reporting (e.g. representatives of the Federal Ministry of Health, Statistics Austria, the Gesundheit Österreich GmbH. and the health authorities of the provinces) and meets twice a year. In 2007 it developed a recommendation for health reporting which is aimed at promoting the comparability, 218 ÖBIG (2004). Health and Disease in Austria. Health Report Austria Commissioned by the then Federal Ministry of Health and Women. Accessed at on 28 March 2010 April

119 uniformity and targeted application of health reports in Austria as well as encouraging the execution of health reporting by following a cycle of steps (comparable to the Public Health Action Cycle) 219. Partially methodology has been defined more closely and has undergone harmonisation. Experts welcome the development of an Austrian framework on health reporting, are however reluctant to acknowledge its contribution to the current reporting landscape. The recommendation was only published a couple of years ago and it will still take some time until all stakeholders know of it and engage in the process of further development. 6.3 Infrastructure Resources for health reporting and health surveys are, as already mentioned before, very scarce in Austria. Resources include financial resources as well as know-how and human capacity. The existence of a fixed budget for health reporting is a rare exception. Austria only has very few adequately trained and experienced experts; posts specifically for health reporting or health statistics barely exist within the public health structure (exceptions: Vienna and Upper Austria), resulting in the contracting-out of these areas. The number of appropriately qualified persons is gradually increasing due to a number of public health orientated training courses coming into existence in the past years. Prioritization of the topic and commitment is lacking on all levels of the health system. Reports are not actively used by decision makers in practice. This may be due to the fact that reports are not analytical enough, the contents is sometimes not understandable for somebody without prior knowledge of public health and epidemiology and that they do not include precise and compact summaries or conclusions and recommendations (for solutions). Another aspect is that decisions in Austria have in the past not always been taken on basis of factual information but rather on political grounds and negotiations. 6.4 Producers of health reports Health reports in Austria are promoted, commissioned and produced on various levels of the health system. Their significance and success strongly depends on the initiative of the commissioning agency or on the initiative of politicians or senior level civil servants, who initiate the discussion or commissioned the compilation of the report. To a certain extent they may use the health report as a marketing tool for their own interests and position. Regional/provincial public health authorities are, in most Austrian provinces, obliged by law to publish medicinal reports which usually present statistics on the services their have provided. Health reports in Austria are produced on the national, regional/provincial and recently also on the community level. The national health reports (2004, 2009) and the (political) report to the National Council are compiled by GÖG/ÖBIG. Several provinces have contracted GÖG/ÖBIG to produce their reports (for the first time in and for recent updates). This applies to for instance Burgenland, Salzburg, Tyrol, Vorarlberg and Lower Austria. Some experts argue that GÖG/ÖBIG is taking on a monopoly-like position when it comes to health reporting. Producers of national reports are also the Federal Ministry of Work, Social Affairs and Consumer Protection (Bundesministerium für Arbeit, Soziales und Konsumentenschutz, BMASK), Statistics Austria (results of health surveys) or NGOs (e.g. Anti-Poverty Network). Another institution which made a contribution towards national health reporting is Austrian social insurance when it presented a first pilot report in In the future social insurance however plans to refrain from producing own reports and instead to contribute to existing reports respectively reports published by other stakeholders. Health system reports or analytical reports are for instance published by the Institute for Advanced Studies (e.g. HiT Healthcare in transition report, European Observatory on Health Systems and Policies). Further regional/provincial health reports have been compiled in-house by experts in the health authorities of the provinces (e.g. Vienna, in some cases Styria), based on a co-operation between 219 For a definition see for example (The Public Health Action Cycle as starting point for evidence-based Public Health), Accessed on 28 March 2010 April

120 experts in the health authorities of the provinces and research institutions (e.g. Styria or Carinthia: Public Health Information Research Unit (PHIRU) at the University of Applied Sciences, FH Joanneum) or have been produced by research institutions or university departments (e.g. in Carinthia or special reports (e.g. Austrian Diabetes report 2004 which was produced by the association Altern mit Zukunft). In Upper Austria the Institute for Health Planning (Institut für Gesundheitsplanung, IGP) was founded which operates based on a partnership (joint funding) between the province of Upper Austria, the cities of Linz and Wels, the regional sickness fund and the Medical Chamber of Upper Austria. The institute produces regional and also community health reports as well as detailed reports on special topics. GÖG/ÖBIG has listed health reports existing in Austria (published in the year 2000 or later) on its website Time spans between reporting Several provinces have so far only published one health report; most provinces have published two or more. Vienna has a longer history of and more experience with reporting, previously publishing yearly reports. When it comes to the time span covered by the report respectively the gap between two reports, experts consulted recommend a period of about five years as this time span would capture the major events but also give time for change to take place and room for evaluation. In between publications, monitoring ought to take place and selected updates could be undertaken. 6.6 Contents of reports Health reports can either be general reports or special reports. The first cover basic indicators and show a strong epidemiological focus, the second address specifically chosen topics/issues (subjectrelated reports) or report on population groups/sections (target group-related reports). 221 Additional features or components adding to health reports may be the results of health surveys or data analysis. Initially health reports contained mostly data on the utilisation i.e. consumption of health services, thus rather featuring utilization reports or disease reports. At a later stage epidemiological information was added and recently also health determinants, health behaviour or in few cases health targets are included in reports. However experts believe that health reporting in Austria is still not part of a cycle but features an isolated procedure. Follow-up evaluation and re-assessment respectively adjustment are missing in most cases. According to experts the national health survey undertaken by Statistics Austria features a valuable contribution to health reporting. Within Austria, Viennese health reports have a very high standing and are frequently quoted by experts as benchmark. Few reports include health targets and even fewer recommendations for measures or an evaluation of past targets or measures. This is to some extent based on missing basic epidemiological data such as important registries and statistics. Other relevant aspects are the lack of political willpower and commitment as well as the fact that planning- and decision making structures follow legislation terms, resulting in politicians being reluctant to allocate a considerable amount of resources to measures which may show positive outcomes in only about 10 to 20 years, thereby most likely benefiting another politician then themselves. 6.7 Influence of international reporting activities Examples for reports or guidelines influencing national health reporting activities on the international level are WHO reports, on the European level EUGLOREH, the European Global Report on Health 222. Another example is the Dutch RIVM reports 223. Several countries are considered 220 GÖG website. Accessed at on 9 October 2009, ne1=64&set_z_arbeitsbereiche_ebene2=9999&set_z_arbeitsbereiche_ebene3=9999, accessed 6 May The distinction between subject-related and group-related reports was taken from Bachinger (2002) April

121 to be forerunners in the field of health reporting, involving the UK, Germany (e.g. Bielefeld, Nordrhein-Westfalen), France, Italy (South Tyrol) or the Scandinavian countries. Indicators used are for instance based on the Health for All Targets (HfA 21) of the WHO or on the ECHIM project (European Community Health Indicator Monitoring) Follow-up measures, evaluation and sustainability Reports in Austria in few cases include an assessment or evaluation of the achievements made since the previous report. This is due to various aspects, one being the lack of a strategy and health targets respectively the lack of commitment towards these. Several provinces have defined health targets but do not publish them publicly in their health reports. This is probably because politicians or other stakeholders do not want the targets to involve too much of a commitment for them and because this would oblige them to assess whether targets were met or not, exposing them more to discussion and potential criticism. Targets are, in addition, not always quantifiable and thus target achievement can be difficult to measure. Usually health reports in Austria provide a very good and comprehensive description of the status quo but are not part of an overall framework process, strategy or action cycle. Use of the health report depends largely on the contracting agencies interest, the understanding of the contents and thus of the implications as well as the political situation and potential reactions to the findings. Austrian experts interviewed in the course of the study were asked how a sustainable impact of health reports could be ensured or promoted. The experts responses are summarised below. They partially overlap with the success factors described in the subsequent chapter. - Health reporting should be attached a higher priority: this ought to be visible in funding, capacity/resources, building of know how, embedding it in the organisational structures as well as using the report for follow-up activities such as planning, strategy development, etc. - Responsibilities and roles in connection with health reporting need to be clearly defined and transparent - Health reporting activities should be backed by a legislation base - A consensus on basic features of the report should be found: content, methodology used, time period covered. It is recommended to allow for a certain degree of flexibility and creativity though - A common understanding of the concept of health reporting should be reached - Expectations of all actors involved in health reporting should be made transparent and result in health reports being more tairlored to meet the needs of their users - Stakeholder and expert involvement during the compilation of the report should be promoted to improve personal identification with the report and commitment to it when it comes to implementing follow-up actions - Health reporting should be part of a cycle involving: clear and quantifiable targets, conclusions, recommendations, follow-up measures, identification of weaknesses/problem areas, analysis and evaluation - Inter-sectoral and integrated health reporting activities should be promoted - Health reports and activities connected to these should be communicated and marketed appropriately, thereby aiming to increase public awareness and discussion 6.9 Success factors for health reporting Experts consulted in the course of the study suggested various factors which could promote the successful compilation and use of health reports. Responses were grouped into the following categories: Content, Resources/Capacity, Commitment/Backing, Communication/User orientation and Effectiveness, evaluation April

122 Content - Co-ordination and alignment of content if reports have a larger number of contributing authors - Health and disease should be subject of reporting, not disease only - Health determinants ought to be included - Making a distinction between regular i.e. returning topics and special topics, the latter of which are carefully chosen in terms of deciding on the best time/moment to address them - The reporting time should 5 to 10 years, 1 year is too short, sensible samples can be found more easily for 5 years. Resources, capacities - Availability of financial resources - Time frame for compilation should be adequate/realistic - Good knowledge of the expert scene to know who to involve in which way - Commissioning agent should dispose over a certain degree of knowledge of public health to understand, interpret and take forward results Commitment, backing - Prioritization of health reporting, dedication and commitment - Health reporting should be a continuous, long-term activity and independent from political decision making schedules and agendas - All stakeholders (professionals, organisations) should be involved in developing and compiling the report to increase acceptance (e.g. in the form of an expert board) - Backing of the report and the results by the contracting agent Communication, user orientation - Reports should reflect the needs of their audience: some may be political, others action-orientated - Reports should be understandable but demanding. Layout and design, presentation and language are key features - Providing a long and a short version of a report is considered a good idea. The long version should not be too long (maximum of pages) - Between two subsequent reports a brief upate or monitoring report could be published - Good cooperation with contributing institutions (Statistics Austria, regional/provincial statistics authority, social insurance, etc.) is crucial - The general public should be involved (beyond responding to surveys) - Presentation in the Internet and the production of an executive summary in English could promote dissemination Effectiveness and evaluation - A minimal consensus on the contents and the methods could promote comparability (guidance) - Reports should be commissioned on a regular basis, thus reducing the arbitrariness of decision makers to receive certain resuls - Success must be defined and measureable - Careful and adequate interpretation of data - Authors should draw conclusions and give recommendations. They are the experts, not the readers - Future trends, plans and targets should be included in the report - Health reports should include measures, targets and an evaluation of previous targets - Following-up of use made of reports and impact 6.10 Ideal health reporting versus current practice in Austria This chapter was compiled based on the information provided by an expert working in the field of health reporting in Austria. It contrasts ideal conditions for health reporting with current practice in Austria. Information provided may not be applicable to all provinces in Austria as practices in health reporting are subject to variation (organisational structure, scope, resources allocated, etc.). Health reporting should ideally - provide appropriate information on the health status and condition of the population and the most relevant determinants April

123 - be an important, knowledge-based and indispensable foundation for health planning decisions, health policy targets and health promotion measures related to national and regional health politics - represent a valuable source of knowledge for a very heterogeneous target group (including health professionals, health policy makers and health economists) - promote topics relevant for improving the health of the population - contribute to raising the awareness of the population and ideally motivate them to engage in more sensible and responsible health behaviour - meet the numerous requirements concerning health reporting 225 aimed at different target groups and topical areas by means of a an interdisciplinary team equipped with adequate human resources as well as sustainable and calculable economic resourses Experts in health reporting should ideally - align the contents of health reporting with the current requirements of health policy, thereby being in direct contact with the decision makers - act as professional advisors of decision makers At present health reporting activities in Austria are however characterised by - appropriate information being provided but being very rarely used as basis for decision making by the responsible health politicians - significant discrepancy between the existence of elaborate and detailed reports and the lack of interest and use of these reports by decision makers - lack of training, technical knowledge and obvious information deficits of decision makers with regard to basic public health principles - little appreciation of the work of health reporting experts by decision makers (especially by those without a basic understanding or training in public health) - excessive demands towards decision makers and their advisors who usually dispose of a political rather than a technical orientation - frequent changes of decision makers and top representatives (in many cases also resulting in a change of their advisors) - being attached with a low value within Austria - lack of awareness of the possibilities offered by and the significance of health reporting on the policy level - health reporting experts and health policy makers not being equal partners (in terms of background knowledge and understanding) - missing prioritisation - lack of resources, featuring barely any employed positions dedicated entirely/mostly to health reporting, small budgets, missing organisational structures, etc Trends Various developments are currently taking place in Austria with regard to health reporting. This section summarises the main visible and discussed future trends and is based on the responses of experts on the one hand and presentations given at a health promotion conference organised by the FGÖ on 4 May in Innsbruck, Austria. 225 With the primary fields: demography, epidemiology, health planning, health economics, health promotion, social affairs, development of health targets and indicators, elaboration of and execution or commissioning of periodic health surveys, execution of special assessments April

124 Health reporting is a topic which has received greater attention in the recent past. Resources are however still very limited (see later on). Developments on the international and the EU level promote developments in Austria, e.g. by demanding certain data and reports. One visible trend is the one towards harmonization and comparability of reports, a movement which is especially driven by the platform of health reporting at GÖG/ÖBIG. The process involves the definition of core indicators, of the contents and structure as well as the data classification and methodological issues. Even though a certain degree of harmonisation appears to be welcomed, several experts still voiced the concern that extensive uniformity could potentially undermine individual creativity and variety of health reports as well as neglecting any special needs of decision makers (e.g. placing a focus on a certain topic because this is related to a regional/provincial health target). According to a health reporting expert 226, representatives of the provinces fear that future standards for health reporting will be too restrictive. It will be difficult to achieve an agreement in the platform, which obviously requires consent of all involved stakeholders respectively representatives. Another development is increased communication and networking among the health reporting community which is for instance visible in the installation of the platform for health reporting at ÖBIG as well as the increased number of presentations related to the topic at conferences in 2009, thereby involving the gathering of and exchange among the respective community. Experts in the field demand that health reports should aim for a stronger action-orientation and feature a basis for health policy making. This implies that health reports have to be explicit with regard to the conclusions made and the recommendations given and easily understood by key decision makers. This also entails the advice that health reports ought to incorporate targets and suggestions for measures to be taken following the assessment of the current situation. At present the slogan Daten für Taten which means Data for action is used very frequently in Austria in the aforementioned context. Sometimes however decision makers choose to not promote this development because they fear that it will entail political consequences such as for instance increased pressure, the obligation to meet targets or to perform in line with measures defined in the reports. Experts also believe that health reporting should be part of a process, in analogy to that outlined in the public health action cycle, involving steps such as an assessment, action and evaluation before reinitiating the process. Lately the discussion of attributing health determinants more attention in health reports has evolved. This coincides with the criticism of health reports being too disease-orientated instead of being healthorientated. Two future trends are integrated i.e. inter-sectoral health reporting. Austria has, with very few exceptions 227, no experience in inter-sectoral health activities, which is why international experience with this topic is currently eyed and assessed very carefully (e.g. Germany). Another trend is health reporting on the level of communities/districts. Only a small number of reports exist for this level of the health system, e.g. for the cities of Linz and Wels in Upper Austria or for the community of Schwechat in Lower Austria. Reports published in Austria in the future will be both general reports as well as special reports. Unfortunately not only positive things are taking place but also draw-backs and surprising developments can be observed such as the cutting back of resources of highly recognized and wellestablished health reporting entities. Such developments increase frustration among those affected, leaving them behind asking why have we worked so hard over the past years?. They also, to a certain extent, reflect the political priority health reporting has in Austria. 226 Telephone enquiry (expert for health reporting) on 18 December See for instance the National Report on Strategies for Social Protection and Social Inclusion by the then Ministry of Social Affairs and Consumer Protection (now Federal Ministry of Labour, Social Affairs and Consumer Protection) which was published in 2008 or the final report of the Healthy Schools Project undertaken jointly by the Ministry of Education, Arts and Culture, the Ministry of Health and social insurance April

125 Resources for health reporting were and generally still are very limited. The topic does not feature an integral part of the health policy agenda. Currently health reporting in Austria is based on the activities of a small group of very motivated and dedicated experts who are, on occasion, backed up by decision makers/politicians. The restricted and heterogeneous understanding of public health and epidemiology exacerbates the implementation of population orientated health measures such as health reporting. This applies to all levels of the health system. Gradual changes can be observed in the form of capacity building or awareness events of e.g. social insurance. The culture of decision making based on data, facts and on evidence rather than being the outcome of negotiations which may be biased through political or interest-group involvement, is progressing very slowly in Austria. A great variety of data exist in Austria. Their adequacy for health reporting is however not always ensured. In addition some areas show large data gaps. Hardly any large-scale population surveys are undertaken Social insurance s role in health reporting One of the demands voiced repeatedly by experts in the Austrian health care system is that responsibilities should be made very clear and based on who can contribute best in which way. Several experts argued that not all stakeholders within the health system should compile their own reports but instead encourage co-operations such as for instance the one established in the province of Upper Austria. When experts were asked to state which role social insurance could play in health reporting, several suggestions were made which are subsequently listed. Social insurance could: - make social insurance data (especially data on outpatient care) available for various health reports - make its own data more suitable for health reporting - improve the situation of health data and data quality in general - assist the pseudonymisation of health data - analyse and assess own data (thereby also looking at other aspects than reimbursement) - grant access to its data for further analysis - promote the definition and implementation of health targets - assist the creation of a decision making basis with regard to strategic planning in the health sector - be an opinion leader, build up public pressure and create awareness to promote certain topics - promote the use of health reporting in general - make a contribution towards supporting a stronger public health perspective - promote awareness for and demand the use of evidence-based and knowledge-based decisionmaking (basing its own decisions on a strong health reporting foundation) - present and communicate itself as a consumer-orientated-institution by ensuring the provision of high quality and evidence based care (value for money) - assess the needs of its insured population - facilitate access to certain population groups for health surveys (e.g. migrants) through its contract partners - report to its insured on a regular basis (based on their needs and wishes) The interest in the data of social insurance is considerable among other health system stakeholders. Experts would like to see social insurance as an active partner in health reporting activities, thereby granting access to its data and feeding into existing health reports. Social insurance could furthermore, as one of the most powerful stakeholders in the health system, take on the role of a promoter and opinion leader. April

126 7. Infectious diseases Like in other countries in Western Europe, infectious diseases have experienced a loss of importance over the past decades in Austria. Changes were both a reduction in morbidity and mortality. In the recent years however the number of deaths associated with certain infectious diseases has been rising again. Factors contributing to this development are assumed to be, amongst others, the increased mobility of the population as well as the opening of the boarders. 228 In % of all deaths in Austria (564 persons) occurred due to infectious diseases. In 2007 cases of infectious diseases reported most often were cases related to bacterial food poisoning, followed by scarlet fever, infectious hepatitis and sexually transmitted diseases. Reports on bacterial food poisoning increased noticeably between 1990 and 2004 before decreasing again. The majority of reports are related to campylobacter (73.7 per 100,000) or salmonellae (43.2 per 100,000). Reports on animal bites (animals potentially having rabies) reached a peak in 1980 (6,572 cases) and have decreased since. In cases per 100,000 were reported. In this context also statistics of notifiable diseases should be consulted, which show by far lower values for this group, presumably only including the actually verified cases i.e. those which actually received further treatment following an animal bite. The highest number of reports on scarlet fever was made in 1965 (10,706 cases). Since then reports continuously decreased and have ranged between about 1,500 and 2,200 cases per year after Tuberculosis has, also on an international level, received more attention lately. Reported cases of sterile TBC have decreased between 1960 and 1985, a short increase took place in 1990 before falling again in Since 1994 the number of reports has dropped. In new cases were reported, of which 526 concerned pulmonary tuberculosis (6.3 per 100,000) and 34 (0.4 cases per 100,000) were related to extrapulmonary tuberculosis. The highest numbers of cases were reported in Vienna, Lower Austria and Upper Austria. The number of people being infected with hepatitis has decreased since In cases of hepatitis C were reported (per 100,000), 8 cases of hepatitis B and 1.4 cases of hepatitis A. (56.9% casess: hepatitis C, 36.3% hepatatis B and 6.4% hepatitis A.) In individuals were infected with AIDS. Of these 78.1% were men. Only 34.0% of these infections were related to homosexual contacts, 22% were related to heterosexual contacts, 16% to intravenous drug abuse and for 26% the cause of infection was not known. Women are more likely to be infected with AIDS through heterosexual contacts and intraveneous drug abuse. 229 Reporting, monitoring and prevention of infectious diseases in Austria is regulated by law and is under the supervision and responsibility of the Federal Ministry of Health, the public health service (Öffentlicher Gesundheitsdienst) including the district administration authorities (health authorities) and the health boards in the provinces (Landessanitätsrat), the Supreme Sanitary Council as an advisory body on the national level and the Food and Health Safety Agency, AGES. The Federal Ministry of Health (BMG) regularly publishes a report on infectious diseases which aims to provide information on the epidemiology of selected infectious diseases as well as displaying trends of infections over time and reporting on their regional distribution. It moreover contains a description of the organisation and quality of surveillance-systems in Austria, gives an overview of national and international activities and presents a concept for the yearly reporting of infectious diseases. 228 Then Federal Ministry of Health, Family and Youth (2007). Report on infectious diseases Vienna, accessed on 18 July Download available at ankheitenbericht_cms _kopie_von_gbik_06.pdf (reporting term ) 229 Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 5 October 2009 April

127 Measures to monitor infectious diseases involve surveillance and reporting. When performed effectively, these facilitate and enable a rapid detection and the immediate initiation of appropriate counter actions to combat infectious diseases. 7.1 Legislation on infectious diseases The handling of epidemics and infectious diseases in Austria is regulated in the Epidemics Act as well as the directive on notifiable transmittable diseases, published in Selected infectious diseases such as aids, tuberculosis, sexually transmitted diseases or zoonosis or avian flu 230, are regulated more closely in individual laws. Other legislation relevant in this context is the Bacillus Excretor Act 231 or the Rat Act Mandatory reporting of notifiable infectious diseases General legislation Epidemics Act (Epidemiegsetz) The Epidemics Act defines the diseases which have to be reported, who is responsible for reporting cases and who reports have to be made to. Fast spreading and transmittable diseases which may potentially result in severe medical conditions are subject to statutory notification. According to the Epidemics Act ( 1), certain cases of infectious diseases have to be reported to the responsible District Commission (Bezirksverwaltungsbehörde) corresponding to the residence of the patient within a time period of 24 hours. For some diseases not only actually diagnosed cases but also suspected cases are to be reported. With regards to subacute spongiform encephalopathy, only deaths are to be reported. The duty to report rests with the attending health professional, e.g. the physician, nurse or midwife. In hospitals the medical director or head of the involved department is in charge of undertaking the report to the health authorities. Reporting responsibilities are regulated in 3 of the Epidemics Act. The district commission or magistrate overseeing the area in which the ill person lives or the deceased person lived is the responsible authority to which reports have to be submitted. Notifiable diseases listed in the act are: leprosy, cholera, bacterial food poisoning, brucellosis, anthrax, infection with the influenza virus A/H5N1 or any other avian flu virus, SARS, measles, psittacosis, diphtheria, typhus, TBE (tick-borne encephalitis), yellow fever, bacterial meningitis, transmittable spinal meningitis, meningococcal sepsis, streptococcus pneumoniae, haemophilus, hepatitis A-G, pertussis, transmittable poliomyelitis, trachoma, legionnaires disease, paratyphus, plague, pox, glanders, recurrent fever, malaria, dysentery, scarlet fever, deaths related to subacute spongiform encephalopathy (Creuzfeldt-Jacob-Disease, Gerstmann-Sträußel-Scheinker), Echinococcus granulosus and echinococcus multilocularis, trichinosis, rabbit fever, childbed fever, rabies, tuberculosis caused by mycobacteria bovis and viral haemorrhagic fever (Ebola, Lassa, Marburg, Krim-Kongo, etc.). The Minister of Health is entitled to modify the list of notifiable diseases. 230 Ordinance on Avian Flu (Geflügelpestverordnung, BGBl. II Nr. 309/2007) 231 Bazillenausscheidergesetz (BazillenausscheiderG, BGBl 131/1964) 232 Rat Act (RattenG, BGBl 68/1925) 233 HEIdocu, contributions from Günter Flemmich, Helmut Ivansits, Paula Lanske, Doris Lutz, Christa Marischka, Christian Rothmayer, Monika Weißensteiner and Brigitte Wolkersdorfer. Download of part 1 available at download of part 2 available at Epidemics Act (EpidemieG 1950, BGBl. Nr. 186/1950, Verordnung betreffend anzeigepflichtige übertragbare Krankheiten 2004, BGBl. II 254/2004) April

128 7.2.2 Disease related legislation 235 The following brief sections list and summarise legislation related to specific notifiable diseases. Aids Act (Aidsgesetz) 236 Individuals diagnosed with AIDS (evidence of an HIV infection (or an indicator disease according to the directive Vo BGBl. No. 35/1994) have to be reported to the Federal Ministry of Health within a week of diagnosis. This equally applies to any deaths for which it was determined that the deceased had AIDS at the moment of death. Reports are to be made in written form and patient data are anonymised. The supreme sanitary council has a topic-related sub-committee, the Aids-commission. Sexually Transmitted Diseases Act (Geschlechtskrankheitengesetz) 1945 Sexually transmitted diseases requiring reporting to the District Commission are gonorrhoea, syphilis, chancroid and lymphogranuloma iniguale. The prerequisite for these diseases to be reported is that a further spread of the disease is feared. Reporting also involves the naming of patients who are not willing to undergo treatment or reject medical observation. Tuberculosis Act (Tuberkulosegesetz) Cases in which individuals have been diagnosed with tuberculosis or deaths caused by tuberculosis have to be reported to the health authorities (District Commission) within 3 days. According to 5 (1) and 11 of the Act, the District Commission reports individual anonymous cases and deaths directly to the Federal Ministry of Health. Zoonosis Act (Zoonosengesetz) 238 The Zoonosis Act regulates the reporting of cases of Zoonosis as well as the procedures to be followed in the case of a food-related breakout. 7.3 Surveillance of infectious diseases In case a notifiable disease is suspected or identified, certain measures have to be taken. These are regulated in 6 of the Epidemics Act and involve measures to prevent the infection of others with the respective disease as well as measures to combat the disease. They comprise the adequate documentation of the case as well as the public communication/proclaiming of it and, if deemed necessary, the isolation of the respective person, the disinfection of any items or facilities which may be infectious as well as the prohibition to access public facilities (e.g. school, kindergarten, etc.). Other actions are the monitoring of infected individuals, the closure of institutions, e.g. schools or businesses and the cancellation of major events involving the gathering of many people. The handling of infected dead bodies is regulated in 13 of the Epidemics Act. Anybody failing to report a notifiable disease is subject to an administrative penalty. Surveillance systems Surveillance of the epidemiological development of infectious diseases over time is facilitated through mandatory reporting. Changes in reporting practices have to thereby be taken into account. Surveillance systems for infectious diseases distinguish between illnesses for which an EU casedefinition exists (e.g. tuberculosis) and those for which this is not the case (e.g. Hepatitis C). The reporting procedure of infected cases is regulated in the Epidemics Act respectively, if available, the legislation applicable to the above mentioned selected illnesses. 235 Then Ministry of Health, Family and Youth (BMGFJ), Notifiable infectious diseases in Austria, accessed at ichtige_uebertragbare_krankheiten_neu.pdf on 28 July AIDS Act/AIDS-Gesetz 1993 (AidsG, BGBl. 728 idgf) 237 Tuberculosis Act/Tuberkulosegesetz (TuberkuloseG, BGBl. Nr. 127/1968 idgf) 238 Zoonosis Act/Zoonosen-Gesetz (ZoonosenG, BGBl. I 128/2005 idgf) April

129 Reports of infectious diseases are usually made to the District Commission (Bezirkshauptmannschaft) within a time period defined in the relevant legislation. Consequently the District Commission reports the case to the public health authority of the province (Landessanitätsdirektion) which thereafter notifies the Federal Ministry of Health in an anonymous form and in regular intervals (monthly reports). This usually results in a time lag until information is available on a provincial and national level. Only individuals suffering from AIDS have to be reported directly to the Ministry. In addition to the cases which are reported through these channels, further reports may be made by laboratories. Inpatient cases are documented by the hospitals (Documentation of diagnosis and services, Diagnosen- und Leistungsdokumentation, DLD). The latter involves significant delays in reporting (2-3 years) and may entail inaccuracies with respect to data quality. A special information system was created for influenza-illnesses. National reference centres are also involved in reporting: They undertake defined tests for laboratories and report cases to the District Commission. Detailed flowcharts outlining the reporting processes of both cases can be found in the yearly report on infectious diseases of the Federal Ministry of Health (see 2006 report, page 8). Central aspects influencing the quality of surveillance systems are the quality and validity of the data reported and the speed of reporting. Especially the latter is a precondition for the early detection of outbreaks and epidemics as well as for the rapid initiation of counter measures. The application of clear, uniform and unambiguous definitions (e.g. of disease cases) is key for efficient and meaningful reporting. Continuous evaluation of the surveillance systems is necessary which is currently undertaken by following the standard protocols of the WHO and the CDC (Centre for Diseases Control in Atlanta). Disease outbreaks occurring on the provincial level can only be detected by the sanitary authority of the respective province because it obtains information for the entire region i.e. province. Data on the district level is collected by the District Commissions. National outbreaks can be detected either by the Federal Ministry of Health or by the reference centres which have access to national data. Central (national) reporting register for infectious diseases 239 The then Federal Ministry of Health, Family and Youth (now Federal Ministry of Health) commissioned a feasibility study to assess the installation of an electronic reporting system detailing individual cases of infectious diseases. Cases would be based on clear case definitions. Objectives of such a system were to create a data record for each individual, to avoid multiple reporting as well as to enable the documentation of disease progression. Furthermore it was supposed to act as an up to date early warning system. 240 In May 2008 the National Council took the unanimous decision to create a national registry for infectious diseases (e.g. measles, rubella, scarlet fever, diphtheria, malaria and yellow fever). The Epidemics Act serves as a legal basis of the registry and was amended accordingly (see 4). Such a registry aims at preventing the spreading of before mentioned diseases in an efficient way. Another central objective is to facilitate a fast response to a potential disease outbreak. Coordination and communication among the provinces and involved players should be promoted. The database should be accessible for authorities responsible for handling infectious diseases and situated in the Federal Ministry of Health. Reported data includes patient data, data on disease development and -progression as well as any other potentially relevant information (e.g. vaccinations, travelling, contact persons). Data protection issues should be handled in accordance with the existing regulations and should receive special attention. 239 Federal Ministry of Health, Family and Youth, accessed at on 1 August 2008 Der Standard, 14 May 2008 Infektionen: künftige Datenspeicherung. Accessed at on 1 August Ministry of Health, Family and Youth (BMGFJ), Notifiable infectious diseases in Austria, accessed at ichtige_uebertragbare_krankheiten_neu.pdf on 28 July 2008 April

130 7.4 Early warning systems European Union (EU) On the EU level, the EWRS, the Early Warning and Response System and the DSN, the Diseases Surveillance Networks were established in the late Nineties. The EWRS is a network of 24/7 contact points nominated by the national Ministries of Health. Their duty is to inform each other about incidents related to infectious diseases potentially affecting other EU-member countries. The head office for public medical services at the Federal Ministry of Health in Austria serves as the EWRS contact point, thus overseeing and ensuring the relevance of the information fed into the system. In order to ensure comparable reports of the different countries case definitions for the different diseases were developed. These mostly require individual based reporting. Following the terrorist attacks in 2001, the Health Security Committee and the Bioterrorism Task Force as well as the Rapid Alert System for Biological and Chemical Alerts and Threats were established in Luxembourg. In 2005 the European Centre for Disease Prevention and Control (Europäisches Zentrum für Krankheitsvorbeugung und kontrolle) was founded. World Health Organisation (WHO) Another fundamental source to be quoted with regards to the field of epidemics are the International Health Regulations (IHR) of the WHO (Internationale Gesundheitsvorschriften), which were adopted in 2005 and regulate the cooperation of WHO member states in case of the occurrence of transnational epidemics. 241 Early Warning Austria In response to the installation of the EWRS on the EU level, a national warning system was created. It features a mailing list including all sanitary authorities of the provinces, reference centres and other relevant organisations. 7.5 Outbreak control Austrian alarm plan for smallpox Smallpox has been declared as eradicated by the WHO in Through the use of Anthrax in the recent past in the course of terrorist attacks, the fear of an epidemic has resurfaced. Austria has therefore defined clear procedures and competences which should enable the fast and competent initiation of necessary actions if required. Austrian influenza pandemic plan Work on the Austrian influenza pandemic plan was initiated in 2003, a report was published through the then Federal Ministry of Health and Women (now Federal Ministry of Health) in This was motivated by the WHO s elaboration of a framework for an influenza pandemic plan in 1999 as well as its revision in 2005 and the by the WHO encouraging the member states to develop national plans. They were equally asked to ensure a sufficient stock of medicines and vaccines for the aforementioned event. The potential outbreak of an influenza epidemic received special attention during the spreading on the avian flu H5N1 in South East Asia and was at the time of the compilation of the present report again at the focus of interest with the spreading of the influenza virus A/H1N Reporting and control of infectious diseases in practice 242 Existing legislation and regulations regarding outbreaks of disease and disease surveillance appear to create problems when executed in practice. Responsibilities are not always entirely clear (reporting in the context of the Epidemics Act, the Veneral Diseases Act and the Tuberculosis Act), leading to delays in the investigation of or the reaction to outbreaks and thus to inefficiencies. 241 For further information see Based on consultations with experts, June 2009 (Public authorities) April

131 As mentioned before, certain cases of infectious diseases have to (based on the Epidemics Act, the Sexually Transmitted Diseases Act and the Tuberculosis Act) be reported to the District Commission (Bezirksverwaltungsbehörde) corresponding to the residence of the patient. Eventhough legislation clearly refers to the district commission overseeing the area in which the patient resides, discussions commonly take place because many of the 99 different district councils believe that only the district commission where the patient has his or her principle residence is in charge (which may be hundereds of kilometres away from where the patient is staying at the time of the infection. Decision making processes are especially problematic if more than one district/more than one province is affected. One of the main problems of the Epidemics Act is that at present only those infectious diseases have to be reported which are listed in the Act in a taxative way. This creates difficulties when new i.e. unknown diseases occur as medical officers may believe that they are, with reference to the Epidemics Act, only legitimised to act in case the respective disease is already subject to reporting (in the list). If however a cluster of deaths with an unknown infection genesis occurs, the medical officer is not entitled to investigate as the unknown infectious disease is not listed in the Epidemics Act. A significant amount of data is, due to contradictory interpretation of the reporting obligation by the 99 district commissions, useless. Uncertainties with regard to reporting exist, are for instance Norovirus infections subject to compulsory reporting in Austria? Some district commissions may confirm this whilst others may argue that no or only if Norovirus infections have definitely resulted in viral food poisoning. The word Noroviruses is not mentioned in the Epidemics Act, in which reference is made only to viral food poisoning. The question whether Noroviruses have to be reported can, due to the heterogenous handling among district commissions, lead to frustration of medical officers. Irregularities like the one just described results in for instance 535 cases of Noroviruses being reported in Upper Austria in 2008 (according to the Federal Ministry of Health) whereas only 1 case has been reported for Vienna. Another difficult case is the reporting of animal bites (by animals with rabies or which are suspected of potentially having rabies) for which, in a country like Austria, which as it is actually free of terrestrial rabies, in reality no or only sporadic reports should be made. However the Federal Ministry of Health reported a total of 2,320 cases in It appears that some physicians wrongly consider all animal bites as being subject to mandatory reporting, which results in irrelevant data. The statistics of notifiable infectious diseases reported only 344 cases in Austria. These are presumably those who actually received further treatment following an animal bite. The situation for mandatory reporting of invasive bacterial diseases (meningitis, sepsis) is equally problematic. In cases of staphyloccocus aureus sepsis were reported by the Federal Ministry of Health; in the AURES report 243 which is also published by the Ministry though more than 1,700 cases are documented. Based on the yearly report of 2008, 7 cases of botulism occurred in Austria; in reality physicians reported clostridium difficile infections (which are subject to mandatory reporting in Germany but not in Austria in 2008) and physicians recorded the reports among the infections which had the most similar name, namely clostridium botulinum. It is furthermore not always clear for the attending physician whether he or she is obliged to report a case. Uncertainties with respect to reporting have a negative impact on the reliability and the quality of the reported data. Mandatory reporting obligations in connection with sexually transmitted diseases also cause problems for reporting physicians and are subject to unclear regulations, thus resulting in reported cases which are far beyond reality. Based on the Sexually Transmitted Diseases Act the attending physician is only obliged to report cases for which a spreading of the disease is to be feared or for which the infected person rejects treatment with antibiotics. Very few cases exist in Austria in which patients with an 243 Austrian report on antibiotics resistance. For further information see April

132 infection reject treatment with antibiotics and would therefore have to be reported. However the Federal Ministry of Health has documented 821 cases of gonorrhoea in its yearly report of In reality thousands of cases occurred which are though usually only subject to limited mandatory reporting (see conditions tated above). The fact that Vienna reported 707 cases and Lower Austria, which is comparable in size reported only 13 cases of gonorrhoea, indicates the poor quality of this data. A clear line of responsibility for the clarification of food-borne disease outbreaks which are districtcrossing is only defined in the Zoonosis Act This is done by nomination of the provincial govenor as person to be in charge. The provinces are not mentioned in any other legislation which has the consequence that duties, which, in other countries, are administered by a national public health institue, are either neglected (see above given elaborations on the quality of reported data) or dealt with directly by the Federal Ministry of Health. A problem experienced in practice is that medical officers and other non-medical professionals in the field do in many cases not dispose over adequate training or qualifications for outbreak investigation and handling. This is because no training options for these professionals exist in the Austrian system. In the light of the above listed uncertainties and problems, present legislation ought to be assessed and revised to ensure efficient procedures and well defined responsibilities of involved stakeholders. April

133 8 Registries For the present study an Internet search 244 was performed to find out which registries exist in Austria. The situation is heterogeneous and intransparent; various disease registries and a range of other registries were found which are detailed in this chapter. Many of these are overseen by the Health Austria Ltd., either by the Austrian Institute for Quality in the Health Care System (Bundesinstitut für Qualität im Gesundheitswesen, BIQG) or the Austrian Health Institute (Österreichisches Bundesinstitut im Gesundheitswesen, ÖBIG) which intend to limit further diversity by e.g. improving comparability and, to a certain extent, developing standards. Others are managed by medical societies, groups of hospitals, university departments, the national statistics office or other institutions. It was not possible to have a detailed look at all of the registries listed below which is why only basic information is provided in order to give the reader an idea of the data collected. Further details can be found at The only national registry in Austria is the National Cancer Registry. All other registries listed in the subsequent chapters are based on regional, local or individual initiatives (e.g. being applied solely in selected hospitals). This means that they are to a great extent not representative with regard to making statements on prevalence. At the same time the quality of the registries is heterogeneous and has usually not been evaluated. Further assessment is necessary. 8.1 Registries at BIQG Registries at BIQG (the Federal Institut for Quality in the Health Care System/Bundesinstitut für Qualität im Gesundheitswesen) are, to a large extent, quality registries measuring quality indicators for a range of medical specialties. Based on selected indicators it is aimed to assess the present situation and to identify opportunities for quality improvement, especially in process and outcome quality but also in patient satisfaction. Current procedures should be optimised both for the provider and the patient. BIQG co-operates with medical societies and health service providers (hospitals). Data collected are for instance data on treatment processes, transportation management, waiting times, infection rates or complications. Data are collected, analysed and interpreted in co-operation with the corresponding medical societies. Results are passed on to the services providers in the form of benchmarking reports. These are then expected to use the provided information to define potential areas of quality improvement and initiate processes to improve their performance. Success thereof is evaluated in the next assessment. Table 3: Registries at GÖG/BIQG Registry Adult heart surgery registry Pacemaker- and ICD registry Hip endoprosthesis registry Content/Status quo Evaluation of treatment results of the nine heart surgery centres in Austria Medicinal product vigilance, documentation of acute problems, product performance and durability of the different products Currently in roll-out phase, analysis of outcomes and development in connection with choice of implants, operation methods, operation management. Assessment of treatment quality and outcomes, early warning system for defected products 244 Internet search by using the internet search machine Google. Consultation of the websites of various health system stakeholders April

134 Table 3 continued Registry Registry for quality assurance in surgery Austrian stroke unit registry Registry for quality assurance in child cardiology Source: GÖG Website, accessed at Registries at ÖBIG Content/Status quo Re-operation rates within the first 14 days following the operation Process indicators, transportation times Outcomes of treatment in child cardiology Registries at ÖBIG (Austrian Health Institute/Österreichisches Bundesinstitut für Gesundheitswesen) are mostly registers which were installed based on legal provisions. They either either for administrative purposes (medicinal products, organ donations), for vigilance (transfusions) or for the documentation of outcome quality in specific cases (e.g. for in-vitro fertilisation). Registries overseen by the Austrian Health Institute are listed in the table below. Table 4: Registries at GÖG/ÖBIG Registry Objection registry against organ donation Registry for medicinal products In-vitro fertilisation registry Haemovigilance registry Source: GÖG Website, accessed at Disease registries Content/Status quo Individuals who do not wish to donate their organs Registration of all individuals and companies with an office in Austria who/which are responsible for marketing medicinal products for the first time in the European economic region or those having a testing- and supervision office in Austria Outcome of IVF attempts Adverse events and reactions in the transfusion chain (testing, processing, transport, administration) Only a small number of disease registries were found in the course of the search. The National Cancer Registry at Statistics Austria is an epidemiological cancer registry which includes data on the incidence of cancer cases. Estimates of prevalence and survival rates can be calculated by matching the incidence statistics with the cause of death statistics. Regional cancer registries are located in the provinces of Tyrol, Carinthia, Salzburg and Vorarlberg. The birth registry is managed by the Institute of Clinical Epidemiology in Innsbruck and documents defined quality parameters in the fields of gynaecology and obstetrics. Hospitals of different provinces report their data to the registry. In the course of an amendment of the Epidemics Act, a national registry for notifiable infectious diseases (e.g. for measles, rubella, scarlet fever, diphtheria, malaria and yellow fever) was created at the Federal Ministry of Health. Recorded data include name, environment relevant for the infection, disease history and disease progression. Bodies responsible for preventing the spread of infectious diseases have direct access to the register. See chapter 7.3 of this section for further details. The Bronchus carcinoma (primary malign tumours of the lung and the pleura) registry is located at BIQG and collects diagnosis and treatment relevant data for lung- or pleura cancer patients. The April

135 registry is currently still in a pilot phase. It is aimed to improve the process- and the outcome quality, based on diagnosis and therapy. The Austrian osteoporosis registry contains data from patients of six Austrian hospitals. Indicators documented are prevalence, length of stay and data relevant to treatment provided. The registry for chronic myleoid leukemia (CML registry) is an application provided by the Austrian society for Heamatology and Oncology which documents patient data as well as diagnosis and treatment data on chronic myleoid leukemia. The Austrian Acromegaly registry is a project of the Austrian Society for Endocrinology and Metabolism. The Austrian Haemophilia registry is a registry which was created based on the initiative of the Haemophilia Society and providers of services for heamophilia. It is aimed at doumenting treatment success, adverse effects and data relevant for research. The registry for cardiac and vascular atherothrombotic diseases, REACH-Register, (Reduction of Atherothrombosis for Continued Health) is a registry which aims to identify risk factors for atherothrombosis and to prevent future strokes or heart attacks. 245 Data recorded are patient data, health status and treatment of patients with a risk of atherotrombosis. The Institute of Clinical Epidemiology in Innsbruck (Tyrol), which operates a number of registries and among these also the above mentioned cancer registry also manages a registry for diabetes which collects data on the patient, on a potential migration background, on diagnosis, aspects related to the family of the patient (family anamnesis), on complications and medical check-ups. 8.4 Other registries Further registries found in the course of the search were the following: - Other registries of the Institute of Clinical Epidemiology in Innsbruck: Prosthesis registry - Austrian stem cell transplantation registry - Austrian registry for bone marrow and stem cell donations registry - Styria abnormalities registry - Endoprosthesis registry - Gene analysis registry, gene therapy registry, registry of interlaboratory tests - General registry of residents at the Federal Ministry of Internal Affairs - Percutane transluminal coronary angioplasty registry - Central registry of radiation sources 245 See for instance Wascher, T.C., Aichner, F., Sourij, H., Topakian, R., Huber, K., Kvas, E. (2007). ' The Reducation of Atherothrombosis for Continued Health- (REACH-) Register : Basisdaten der österreichischen Population. Austrian Journal of Cardiology 14 (3-4), pp , Accessed at on 28 March 2010 April

136 9 Conclusions A large variety of data is collected by different stakeholders in Austria but an overall national strategy or framework for information management does not exist. It is moreover not always clear as to whether data collected are relevant and sufficient and whether the quality of the data is good. According to experts gaps in data collection exist with regards to data on children, immigrants or diagnoses for ambulatory services. The assessment of data needs and the actual practical use of data as well as the identification of gaps in reporting are important and should be undertaken periodically. Data protection regulations in Austria are very strict, making the linking of selected datasets and the undertaking of certain data analysis difficult. This aspect has to be taken into consideration when assessing data sources. The focus of data collection is slowly changing in Austria, shifting from collecting data mostly based on legal obligations (e.g. data on mortality or activity related data) to also collecting data on processes, health determinants, outcomes and quality. Data analysis is still scarce though, which is partially related to the fact that evaluation of activities has so far not featured a standard practice. In the mean time it is becoming more and more important to provide evidence on the effectiveness of measures to ensure their funding respectively their sustainability. Data on health status is collected in the course of the national health survey which is undertaken every 10 years. Experts argue that a more frequent data collection would be beneficial. The interest in health reporting and data analysis appears to be emerging only gradually; experts interviewed in the course of the study stated that the actual reaction to or the practical use of published reports as tools for health planning, forecasting or decision making by health system stakeholders was often only limited. University representatives and other researchers are claimed to request and use data for further analysis. Factors contributing to this situation are, amongst others, the lack of a legislation base for health reporting (the Imperial Sanitary Act does not always apply), the fairly small group of professionals qualified to compile health reports or to perform health economical and other data analyses as well as the still limited awareness for the need of these activities among decision makers, resulting in the insufficient allocation of resources to these areas. Another aspect which potentially limits the actual use of health reports could be the readability of present reports, which are partially quite technical and also very comprehensive (many pages). The closer orientation towards user s needs, the use of new media to promote awareness regarding the publication of new or updated reports (e.g. via the Internet or ) as well as the inclusion of summaries and tables, graphs, etc. to facilitate reading and understanding could potentially increase the use made of the reports. Most provinces in Austria have published at least one health report and are in many cases either plannning to or already in the process of publishing a second one. Producers of reports are ÖBIG, other research institutions or university departments (e.g. JOANNEUM Research), freelance researchers or in-house reporting units (e.g. Vienna). Interpretation and further application of findings can also be hampered by decision makers, who sometimes do not dispose of an understanding of public health. Also health reports may not always be designed and compiled in the most appropriate form to meet the needs of the users/readers. Direct comparison of health reports is difficult due to lack of homogenous regulations for reporting. Recommendations respecively guidelines have been developed by the platform for health reporting (at ÖBIG) in 2007 and are gradually spreading across Austria. Health reporting should feature an integral part of political advisory work which is currently rather an exception. Health targets or priority areas are in several cases included in the reports; the announcement of explicit measures is rare which obviously reduces actual commitment to the report. A favourable development is the higher transparency in connection with health reporting, which is reflected in most reports being published in the Internet and thereby being made widely accessible. Methods applied for health reporting or the definition of health targets are however not treated in an open way. Another promising initiative is the co-operation of different stakeholders in the process of April

137 compiling a report, which is for instance employed in Upper Austria, where the regional sickness fund, the province of Upper Austria, the regional physician association and the two cities of Linz and Wels co-operate. Concepts such as evidence based medicine and health technology assessment are gaining ground in Austria, leading to a greater importance of sound data bases and solid data analysis. This change is for instance visible when looking at the decisions taken in connection with the reimbursement of services by social health insurance or other funding agents. Social insurance could take on a range of functions in connection with health reporting, involving contributing its data, pseudonymisation of data, promoting an improvement of the quality of data or generally encouraging the compilation and use of health reports. Trends in health reporting are the production of integrated health reports and of intersectoral health reports as well as community health reporting. Legislation and regulations on outbreaks of disease and disease surveillance appear to partially create problems when executed in practice. Responsibilities are not always entirely clear (reporting in the context of the Epidemics Act, the Venereal Diseases Act and the Tuberculosis Act) and can result in delays in the investigation of or the reaction to outbreaks and thus to inefficiencies. In connection with the Epidemics Act one central problem is that at present only those infectious diseases have to be reported which are listed in the Act in a taxative way. Because of this regulation uncertainties in reporting arise if a new or unknown disease occurs. Unclear reporting regulations or standards result in data reports and statistics not being comparable, across countries or even provinces. Another difficulty arising in thís context is that medical officers and other non-medical professionals who report potential cases frequently do not dispose of adequate training or qualifications for outbreak investigation and handling. April

138 Section III: Health Targets Starting point and research question Already in 1984 the member states of the World Health Organisation s European Region (WHO Europe) agreed to the framework-concept Health for All (HFA), then defining 38 health targets for the national, regional/provincial and local level. 247 Currently seven of nine provinces (Länder) in Austria are pursuing or are momentarily in the process of developing health targets. On the national level, the agreement according to article 15a of the Federal Constitutional Law (Art. 15a B-VG), as well as the Government Programme for stipulate that national framework-targets for health for Austria have to be defined by latest This section of the project report describes the present situation of health targets in Austria and intends to provide recommendations and suggestions for the development and implementation of health targets. It examines the following central research question: Which aspects should be considered for a successful development and implementation of health targets? Chapter 3 of this section contains a brief introduction to health targets and chapter 4 details the status quo of health targets in Austria. Qualitative interviews and a literature research were performed to answer the aforementioned research question. The outcome of these is presented in chapter 5 and summarised in chapter 6. Chapter 7 gives recommendations and suggestions for initial steps for the use and implementation of health targets in Austria in general and in social insurance in particular. 246 Authors of this section: Marlene Gerger and Jürgen Soffried 247 cp. WHO, 2005, p. 10 et seq. 248 cp. BGBL No. 105/2008, p. 11 April

139 2. Methodology 2.1 Literature review The report incorporates German standard works such as for instance The Public health book by Schwartz et al. (2003) or Health Policy by Rosenbrock and Gerlinger (2006), as well as considering research papers of universities and universities of applied sciences and the World Health Organization (WHO) publication on the Health for All Framework. For the depiction of the current situation with regard to the use of health targets among other resources reports, statements or documents of projects were collected by means of an Internet research or through personal enquiries to health system players or interview partners. 2.2 Interviews 249 and qualitative content analysis To answer the central research question (see chapter 1 Starting point and research question ), the literature search was complemented by 15 expert interviews which were undertaken with a field manual and were conducted in German. Interviews were followed-up by performing a qualitative content analysis. Besides containing questions relating to the already mentioned research question, the expert interviews also involved questions on performed or planned processes related to the development and implementation of health targets. The field manual, which was sent to interview partners in advance, before the interviews, can be found in Annex 3. It was supplemented with keywords so that information, which was hopefully retrieved by asking certain questions, would not be forgotten and so that a uniform procedure for the execution of the interviews could be ensured. Interviews took place in the period between 27 January and 23 February 2009 and were largely undertaken by telephone whilst simultaneously recording them with a digital Dictaphone. Three interviews with a total of five interview partners were face to face interviews. With exception of a group interview with three persons, all interviews were individual interviews. When choosing interview partners, it was aimed at finding at least one representative of the national level and one of each province, representing the provincial level, who was either currently responsible for health targets or would be involved in the process related to health targets in the future. Experts in the provinces were contacted through the health departments which provided the contact information of the responsible person. In order to find representatives on the national level the Main Association of Austrian Social Security Institutions (Hauptverband der österreichischen Sozialversicherungsträger), the Federal Ministry of Health, the Austrian Health Institute (Österreichisches Bundesinstitut im Gesundheitswesen, ÖBIG) and the Institute for Advanced Studies (Institut für Höhere Studien, IHS) were contacted. In response to the enquiry directed towards the Federal Ministry of Health a representative of the sub-working group Public health of the Federal Health Commission (Bundesgesundheits-kommission), Ms. Peinhaupt, was nominated who had already agreed to be an interview partner for the province of Styria. Upon contacting a representative of the IHS, who had, together with other researchers of the same institution, produced the report Health targets and - indicators as steering instrument of social insurance in 2004 and asking whether he/she was available for an interview, the representative referred to the report and refrained from giving an interview. Table 5 displays the interview partners interviewed for the present section of the study report. The 15 experts agreed to their names being published in the report. Ten experts stated in the interview that they were directly involved in the development or implementation of health targets, one person described his role as consultant and four persons defined themselves as observers. In the province of Styria a regional network of the Austrian Public Health Association (Österreichische Gesellschaft für Public Health, ÖPH) could be taken advantage of to interview five experts. 249 Employing a field manual April

140 Table 5: Interview partners National Level Federal Ministry of Health - Hauptverband Mag. Stefan Spitzbart Health Promotion and Prevention unit Member of the sub-working group Public health of the Structural Changes working group of the Federal Health Commission (Bundesgesundheitskommission) Interview on 17 February 2009 IHS - ÖBIG DI Petra Winkler Interview on 17 February 2009 Provincial Level Burgenland Carinthia Lower Austria Upper Austria Salzburg Styria WHR DR. in med. Claudia Krischka Province of Burgenland Head of division for Health and Sports Interview on 5 February 2009 Ass.-Prof. Dipl.-Kfm. Dr. Guido Offermanns University of Klagenfurt Department of Public Business Administration Interview on 10 February 2009 Hon. Prof. (FH) Dr. Bernhard Rupp, MBA Chamber of Labour of Lower Austria Health care and Employee Protection unit Interview on 17 February 2009 Mag. Markus Peböck Institute for Health Planning Managing director Interview on 13 February 2009 HR Dr. med. Christoph König Province of Salzburg Regional health director Interview on 6 February 2009 Dr. Thomas Amegah, MAS (ÖGD) Regional authority of the government of Styria Department 8B Health care (Regional health directorate) Group interview on 27 January 2009 Mag. a Gerlinde Grasser, MScPH University of Applied Sciences FH JOANNEUM Competence Centre for Health Reporting Group interview on 27 January 2009 Mag. a Ines Krenn, MPH Styria vitalis Coordination of public health Agendas in Styria Group interview on 27 January 2009 Mag. a Karin Reis-Klingspiegl Styria vitalis Managing director Interview on 12 Februar 2009 Mag. a Christa Peinhaupt Health Fund Styria and member of the sub-working group Public health of the Structural Changes working group of the Federal Health Commission (Bundesgesundheitskommission) Interview on 3 February 2009 April

141 Table 5 (continued): Interview partners Provincial Level (continued) Tyrol Vorarlberg Vienna Total OAR Dr. Franz Katzgraber Regional authority of the government of Tyrol Regional health directorate Interview on 10 February 2009 Dr. Günter Diem MD aks Working Group for Prevention and Social Medicine Ltd Prevention Managing Director Interview on 11 February 2009 Dennis Beck City of Vienna Restructuring of the Vienna Health Promotion unit Interview on 23 February Persons Upon completion of the interviews, texts (responses) were paraphrased; paraphrased passages classified and assigned headings, corresponding to the questions of the field manual. Thereafter the processed material was forwarded to all interview partners who, if required, made some changes, and cleared the documents. This ensured, in the form of a validation, that the paraphrased material reflected the facts as presented by the interview partner. Information retrieved from the interviews was used to describe the status quo of health targets in the provinces. Content analysis of the information assisted the answering of the research question. The respective approach is subsequently described more in detail. 250 a) Description of processes related to and the status quo of health targets in the provinces (Länder) Responses to the following questions are categorised according to provinces in chapter 4.2, which contains a description of the status quo of health targets on the provincial level. What is the current situation with regard to the topic of health targets in the area which you overlook respectively in which you operate (province, national level)? Is the use of health targets in the planning stage, the development stage, the implementation stage or already in the evaluation stage? Which were the motivating factors respectively the moments triggering the development of health targets? (Respectively: What are, from your point of view, motivating factors respectively triggers for developing health targets in Austria?) How did you proceed respectively how do you proceed when developing health targets? (What has to be paid special attention to?) In case data from the interviews were incorporated into the report, an according reference was provided. b) Answering the research question To answer the research question Which aspects should be considered for a successful development and implementation of health targets? interview partners were asked the questions listed below: 250 Questions in both black and grey font correspond to those asked in the expert interviews and listed in the field manual. Only responses to questions in the black font are presented in the respective chapter, if questions are in a grey font this means that they are discussed in another chapter. April

142 (How did you proceed respectively how do you proceed when developing health targets?) What has to be paid special attention to? (catch words: success factors and barriers) What needs to be done in order to make sure that health targets do not remain a singular event but are seen as an entrance point into the Public Health Action Cycle and what needs to be done to ensure that the cycle continues? Results of the interviews are presented in chapter 5. The structuring of the content of the paraphrased passages was undertaken by using a method of Mayring (2003). After several cycles of the content analysis, finally the categories of success factors listed below were defined and specified by attributes. For definitions of each category, refer to chapter 5. Resources o Financial, time, human (quantitative) o Structural o Public health Expertise Stakeholder involvement o Networking and partnerships o Participation o Transparency Consideration of the Public Health Action Cycle Leadership und political Commitment Within these dimensions another categorisation of the responses of the interview partners was undertaken, namely a categorisation corresponding to the four phases of the Public Health Action Cycle (see chapter 3) problem definition, formulation of strategy, implementation and evaluation. The outcome was summarised and supplemented by representative literal quotations. These were based on the paraphrasing; a verbatim transcription was created ex post. c) Recommendations for social insurance Responses to the question Which homework does social insurance have to make in order to enter the target development process well prepared? were integrated into chapter 5. Results of the interviews as well as verbatim text passages were cited in the form of a code. To facilitate this, interviews were randomly assigned letters and numbers, standing for the page number of the paraphrased text passage in the transcript. As the transcriptions of interviews contain an exact time specification, decoding of the material is feasible. In addition the number of statements assigned to each category as well as the number of interviews in which each of the statements was made was recorded (whereby the group interview with the three interview partners was interpreted as one interview). The subjectivity entailed with matching the text passages to the dimensions as well as the interpretation of the results must be acknowledged. Codes were not used in the process descriptions of the provinces (chapter 4.2). Instead the name of the expert was cited. Because of usually only one person being interviewed per province and interview partners names being listed in table one, decoding would have been possible in the process description section, resulting in a loss of anonymity in the entire document. Experts agreed to the content of the process description for their respective province as well as to the citation of their name. By this way the anonymity could be protected in the other chapters. April

143 3. Health targets A brief theoretical introduction Health policy should strive to maximise the health status of the entire population of a state. 251 This is a principle also affirmed by all member states of the World Health Organisation in 1998: We, the Member States of the World Health Organization (WHO), reaffirm our commitment to the principle enunciated in its Constitution that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being; in doing so, we affirm the dignity and worth of every person, and the equal rights, equal duties and shared responsibilities of all for health. 252 This is however not always consistent with reality, because only too often health policy is foiled by political targets which are based in fiscal, industrial, regional economic or labour issues. 253 and are dominated by the highly diverse interests of the actors as well as the striving for power in the political system. 254 For this reasons health policy should be understood in analytical 255 terms as the sum of organised efforts taking an influence on the health of individuals or social groups irrespective of their outcome, whether they promote, maintain or reconstitute health or solely ease individual and social consequences of illness. 256 The Public Health Action Cycle (PHAC) (see figure 15), which also formed the basis of the qualitative content analysis (results in chapter 5), represents a model for such a concerted strategy in health policy. Figure 15: Public Health Action Cycle (Learning Spiral) Policy Formulation Assessment Assurance Evaluation Source: National Academy of Sciences/Institute of Medicine (1988), cited by Rosenbrock & Gerlinger, 2006, S. 25 The phases of the PHAC, which can be understood as a recurrent learning spiral, underlie the following order: 1. Assessment phase: In this phase, the problem is defined and needs/demand are/is made transparent, e.g. through the compilation of a health report. 2. Policy Formulation phase: Based on the problem definition, TARGETS are formulated and a strategy developed to reach these targets. 3. Assurance phase: This phase involves the implementation and the safe-guarding of the planned interventions. 4. Evaluation phase: To make effects and impacts transparent, the implementation phase has to be followed by an evaluation, e.g. in the form of another health report and the evaluation of target achievement cp. Rosenbrock &Gerlinger, 2006, p WHO, 1998, p Geene, 2000, p cp. Rosenbrock & Gerlinger, 2006, p In the original in italic font 256 Rosenbrock & Gerlinger, 2006, p cp. Rosenbrock & Gerlinger, 2006, p. 25 April

144 According to this, health targets should be defined in the second phase, after performing a precise baseline analysis and should be viewed as part of an overall process, in which the definition of targets is followed by an implementation and an evaluation. Health targets should in this context be understood as binding definition of priorities in health policy. 258 Health targets in line with the broad public health approach of social determinants are formulated by the WHO in the Health for All (HFA) concept. The history of this concept dates back more than 30 years to the conference in Alma-Ata in At that point the concept was aimed at ensuring the best possible level of health for the population by the year Member states have been urged to consider this strategy on both the national and the regional level for over three decades. In 1984 the HFA framework concept was supplemented by WHO Europe with a set of 38 targets as well as an action plan promoting its regional implementation and 65 indicators for assessment. WHO evaluates the regional progress of the HFA concept at intervals of three years. This resulted in a revision of the concept, the outcome of which was presented as Health21 in The 21 targets of the concept consider the diverse developments taking place in the European region. Health21 also features a concept which strives to achieve improvements of the level of health and the protection of health as well as a reduction of health risks. 259 A detailed list of the targets can be found in Annex 4. The publication of the Health21-concept concludes with the following words: Whether one is a government minister, city mayor, company director, community leader, parent or individual, HEALTH21 can help develop action strategies that will result in more democratic, socially responsible and sustainable development. Health is a powerful political platform 260. In reference to the use of health targets for the implementation of this framework-concept, the evaluation report of 2005 of the WHO draws the following disillusioning, but also motivating conclusions: Target-setting has been a traditional approach in the European Region s Health for All policy formulation. Recently, however, there has been a consensus that establishing common targets for all countries in the Region can often be artificial, unfair or simply uninspiring. It does not take into account significant differences in Member States public health and economic development. Nonetheless, setting targets can be an important exercise at national and sometimes subnational levels. National targets can be an excellent implementation and guidance tool, as well as a means for a country to articulate its degree of ambition. And if all stakeholders are involved, the formulation of national health targets can help ensure their joint co-operation in health policy Schwartz, Kickbusch & Wismar, 2003, p cp. WHO, 2005, p WHO, 1998, book cover 261 WHO, 2005, p. 4 et seq. April

145 4. Status quo of health targets in Austria Target 21 of the WHO Health21 framework concept (see Annex 4) states: By the year 2010, all member states should have and be implementing policies for health for all at country, regional and local levels, supported by appropriate institutional infrastructures, managerial processes and innovative leadership. 262 Subsequently the status quo of the achievement of this target in Austria is presented, thereby placing a special focus on the national and the provincial level. 4.1 National level On 10 November 2003, at the Austrian Health Conference, the previous Minister of Health, BM Maria Rauch-Kallat, presented Health Targets 2010, which were to be followed by an elaboration of reform measures in the areas of Finance, Health Promotion, Quality Assurance, Innovations and Structures. Attendees of the conference were invited to participate in health dialogues on Health Promotion, Quality Assurance, Public health Food safety and other topics. 263 In a report by Hofmarcher, Kraus and Riedel (2004) the presented targets are judged to be not geared to the health status. 264 In the course of the conference Federal Minister of Health Rauch-Kallat drew the following conclusions: In terms of the intended change in paradigm Novel health thinking means a clear preference for health promotion, health insurance instead of sickness insurance, health centre instead of hospital Despite this commitment, a report was published in 2005 by the Central Auditing Authority, the Österreichischer Rechnungshof, which attested the then Federal Ministry of Health and Women (BMGF) the following performance: Health Promotion was a priority target of the government programme of 2003 and part of the Health Targets 2010 of the BMGF. The Rechnungshof criticised the lack of an overall strategy. It advised the BMGF to coordinate measures for health promotion in a better way. A concerted medium-term concept for health promotion ought to be devised together with other funding agents. Regular evaluations should be undertaken. 267 On the 26th of July 2006 only a few weeks before the election of the National Council in October the Federal Minister of Health Rauch-Kallat presented ten health targets themed World Health Champion by 2010 (for an excerpt from the archive of the Journal Österreich refer to Annex 5). 268 In the press review of the Hauptverband the following is mentioned in this context: As sensible as these targets may be, as vague are they when looking more closely. 269 The elaboration process of these presented targets is not transparent. There is however no indication that the target definition was preceded by a broad and comprehensive process involving a wellgrounded needs assessment or multi-sectoral stakeholder involvement. It appears that, due to time pressure, political interests were favoured over a systematic and well-grounded course of action. The targets of the summer of 2006 were published on a website (amounting to costs of about 120,000). The campaign, which was planned to last until 2010, was cancelled though without undergoing an evaluation as early as autumn 2006, following the new formation of government. 270 A statement of the then BMGFJ (Ministry of Health, Family and Youth) of September 2008 in which the current situation regarding health targets in Austria was addressed (see Annex 6), refers primarily to the Strategic Report on Social Protection and Social Integration for the years , which also looks into the topic of health (download available at Moreover the currently 262 WHO, 1999, p cp. FGÖ, 2003, p Hofmarcher, Kraus & Riedel, 2004, p Comment of the translator: in German the word hospital literally translated means house for the sick 266 FGÖ, 2003, p Central Auditing Authority, Der Rechnungshof, 2005, p cp. HVB, accessed on ibidem 270 See Central Auditing Authority, Der Rechnungshof, 2009, p.63 April

146 valid agreement based on article 15a of the Federal Constitutional Act (valid from 2008 to 2013) is quoted, in which firstly the development of framework-targets for health is explicitly stipulated in article 11, item 5 and which secondly reflects the overall strategy. 271 The report also refers to the Health Promotion Act and to existing claims on mental health on the EU-level. Based on this information, no explicit national health targets exist for Austria at present, neither is a national Health21 strategy pursued. An indication of a plan to develop such targets is the reference in the already mentioned agreement according to article 15a B-VG 272 and the Government Programme of the XXIV legislation period 273. Specific external impetus for the use of health targets was given to the federal government for instance by the Hauptverband in the form of various reports such as e.g. in the report Health targets and indicators as steering instrument of social health insurance 274 published in 2004, in the Health Report 2005 of social health insurance 275 or in the report 10 To-Dos Potential course of action for the development of national respectively provincial health targets in Austria 276, which was published in The first report provides an overview of the international experience with using health targets. By publishing the report Health report 2005 of social health insurance, the Hauptverband aimed to show the contribution social insurance could, based on existing data, make to Austrian health reporting, as a basis for the development of health targets. Both reports suggest an exemplary catalogue of targets for Austria. ÖBIG, the Federal Health Institute, also recommended to link health reporting in Austria with health targets. 277 The necessity of health targets is furthermore pointed out in the publication Assessment approach of the realisation of the health reform , the call for their development is also voiced by other platforms of social insurance, such as for instance by SHI-Research 279 or the Public health-expert group. 280 In summary, Austrian health policy is currently characterised by different players pursuing varied aims in a range of topic areas. A uniform and binding overall strategy in terms of the WHO strategy Health21 is not yet pursued in Austria. In order to respond to the claims expressed by the different levels as well as those listed in the agreement according to article 15a of the Federal Constitutional Act and the Government Programme for , a corresponding process for the development of Austrian health targets should be initiated as well as consecutively getting a process started to define an Austrian public health strategy which is in terms with the Health21 strategy. Chapter 7 contains recommendations for the initial steps towards the development of health targets on the national level. The Strategic report on social protection and social integration could be interpreted as a first step towards a cooperation spanning different ministries and sectors. The report was published by the Federal Ministry of Labour, Social Affairs and Consumer Protection; it also contains data on health related issues though. 4.2 Provincial level As already mentioned in chapter 2 Methodology, this chapter incorporates information of the interviews undertaken for the present study. Because provincial statements are given and usually only one person was interviewed per province, the anonymity of the person could not be ensured by using a code. Interview partners agreed to open citation of their names. Other sources were visualised in the usual way. For detailed listing of the information given in tables 7 to 9 as well as for a description of the process, readers are asked to refer to Annex 7 (a-e) Health targets are already employed as an instrument respectively as part of the Public Health Action Cycle by most provinces. Table 6 shows whether health targets have been developed and, if this is the 271 BGBL Nr. 105/ cp. BGBL Nr. 205/2008, p cp. republic of Austria, 2008, p cp. Hofmarcher, Kraus & Riedel, cp. HVB, cp. Mair, Peböck & Soffried, cp. GÖG, accessed on cp. Herber, 2007, p cp. SI-Research, 2008, p. 5, accessed on cp. Spitzbart & Plankenauer, 2009 April

147 case, when this took place. The current status in the cycle assessment of demand development implementation evaluation is also stated. As can be seen in table 6, the process of the health-targetformulation has already taken place in five of nine provinces. Upper Austria took on the precursor role in 2000 when it started defining the first health targets; in 2002 the provinces Lower Austria and Tyrol followed suit. Afterwards Salzburg defined health targets in 2004 and Styria in Tyrol has already passed through the entire PHAC once and is at present experiencing the implementation phase for the second time. The provinces of Lower Austria, Salzburg, Upper Austria and Styria are in the implementation phase for the first time whereby Upper Austria and Lower Austria have in parallel, initiated the second target development process. Burgenland and Carinthia are in the phase of target formulation. Drafts already exist in both of the provinces and are planned to be politically fixed before the end of In each of these provinces, the publication of a provincial health report was the impetus for the beginning of the process. Table 6: Status quo of health targets in the provinces (May 2009) Province Yes/No Health targets defined Since (year) Status quo (phase of PHAC) Burgenland Yes (draft) Planned for 2009 First target process: target development Carinthia Yes (draft) Planned for 2009 First target process: target development Lower Austria Yes 2002 (targets defined) 2004 (resolution of the provincial government*) Planned for 2009 Upper Austria Yes 2000 (targets defined) 2006 (target amendet) Planned for 2010 First target process: implementation Second target process: target development First target process: implementation and evaluation Second target process: target development Salzburg Yes 2004 (targets defined) First target process: implementation Styria Yes 2007 (targets defined) First target process: implementation Tyrol Yes** 2002 (targets defined) First target process: completed Vorarlberg No - - Vienna No (targets defined) Second target process : implementation * 2004: Resolution of the provincial government on the regional development concept, containing goals and objectives; 2006: Resolution of the provincial government on the targets of objective 3 (see Annex 7e) **Tyrol has no explicitly formulated health targets but measures have been integrated into the health reports which implicitly are seen as health targets. Source: Authors own illustration, based on expert interviews; Office of the provincial government of Salzburg, 2008, pp. 81; Office of the provincial of Tyrol, 2008, pp As can be observed in table 7, the province of Upper Austria has, corresponding to the types of targets (for definitions see Annex 7, the highest number of defined targets, which also reflect 15 WHO targets. Three provinces each have defined goals, objectives and targets. Lower Austria has in principle, just like Upper Austria and Salzburg, defined 10 goals, but has furthermore also defined 12 additional goals, specifically for objective 3. Upper Austria has defined a SMART target (for a definition of SMART see chapter 5.3) for each of the defined goals. In Salzburg targets were defined for each of the ten goals, of which though only two targets were formulated SMARTly. Styria and Tyrol settled on three goals. Both provinces did not employ a SMART target formulation in public documents; with exception of one target in Tyrol which indirectly, through making reference to the corresponding WHO target, meets the SMART criteria. In general the target areas of the Health21 concept are incorporated in the target formulation of the provinces, the number of WHO-topics which have been incorporated into the provincial targets spans from five to 15. April

148 Table 7: Overview of the provincial health targets according to target type and Health21- orientation (May 2009) Province Types of targets Goals Objectives SMART targets Health21- targets Lower Austria Upper Austria Salzburg Styria Tyrol Source: Authors own illustration, see Annex 7 for details If explicit time dimensions are included in the target definition, these can, as described in table 8, reach up to 20 years. The published concepts of the provinces Lower Austria, Upper Austria and Styria include specific measures respectively suggestions for measures for each target. The health report of the province Tyrol partially contains measures. Financial and/or human resources required for implementation are not mentioned in any of the official target-concepts. Four of the five mentioned provinces list indicators; solely the document of Styria does not do so (this is however envisioned). Upper Austria has supplemented the largest proportion of health targets (as share of total targets) with specific indicators (e.g. share of non-smokers) and target values (e.g. increase by 15 %). Table 8: Criteria incorporated in the target formulation of the target definition of the provinces (May 2009) Province Time Measures Yes/No Resources Yes/No Indicators Yes/No Lower Austria Yes No 22x Yes 11x No 2x Partially Upper Austria Yes No 7x Yes 1x No 2x Partially Salzburg 2x x No No No 2x Yes 4x No 4x Partially Styria No Yes No No Tyrol No 6x Yes 6x No No 2x Yes 8x No 2x Partially Source: Authors own illustration, see Annex 7 for details Table 9 lists the priority topics which have been integrated into the existing health target programmes and shows how many targets were defined for a specific topic in each province. It is important to be aware of the fact that the illustration is not exhaustive as only primary listed topics were considered. Also topic areas covered in the measures were not taken account of (for a detailed elaboration, refer to Annex 7). Addiction and Health promotion are the topics represented most often in the targets defined by the provinces, with 15 targets each. The topic Health system was also referenced to many times; of the 13 targets however 10 alone are in the programme of Lower Austria. The topics for which targets have been defined in all five provinces are Addiction, Prevention and Dental health. Aspects of health promotion have been fixed in Tyrol, but not in the form of a primary target formulation. The increased consideration of socially disadvantaged groups is, in principle, an integral part of all programmes, only Tyrol has defined an own target for this topic though. In Lower Austria, based on April

149 the number of targets, the measured focus is placed on the topic Health system, in Styria this purely quantitative focus rests on Health promotion. Table 9: Number of health targets per topic in each province (May 2009) Topics Lower Austia Upper Austria Salzburg Styria Tyrol TOTAL Adiposity 1 1 Muscoskeletal system 2 2 Education - Capacity Building - Further development of the supply of education Diabetes mellitus Long term care 1 1 Health promotion (HP) - Occupational HP - HP in Schools - Healthy cities, communities - Health promoting life style Health system - Structure - Cooperations - Health care - Data collection Prevention - Preventative health check up - Mother-child examinations - Vaccinations Cardiovascular system Cancer Psycho-social health Socially disadvantaged 1 1 Addiction - Alcohol - Tobacco - Drugs Healthy environment 1 1 Accident prevention Dental health Source: Authors own illustration, for details see Annex 7 The impetus for the process of formulating health targets in the provinces always came from the health department (of the provincial government); procedures chosen were however varied, as described subsequently. The following elaborations feature the status of February The first draft of health targets in Burgenland was developed by the health directorate of the province (Landessanitätsdirektion) in cooperation with the regional sickness fund of Burgenland, based on the two health reports produced by ÖBIG in 2002 and It was intended to send this draft to different health system stakeholders in February 2009, together with an invitation to a round table to discuss the present draft and, if required, adapt it. A binding decision of the health platform (Gesundheitsplattform) is aspired as well as a public declaration in a press conference and on the homepage of the province and/or the stakeholders. It is planned to evaluate targets on a yearly basis and report the results to the health platform Krischka, expert interview on 5 February 2009 April

150 The health resort in Carinthia commissioned the University of Klagenfurt to develop targets. The duration of the project was initially limited to one and a half years. Due to political circumstances the time frame was extended. A project group was installed containing representatives of the health sector as well as representatives of other political sectors. A steering group was installed for feedback reasons. At the beginning of the target development process it was tried to create a common understanding of public health, Health in All Policies and Health Impact Assessment. A comprehensive study describing the situation in Austria and Germany as well as covering programmes going beyond the pathogenetic approach, was performed (a publication is planned). Based on the outcome of the aforementioned study, which was also presented to the project group, health targets were developed jointly following a systematic process which was overseen and provided with a scientific input by the university. The resulting draft was put up for political discussion in spring It is aimed to obtain a clearing of the provincial parliament. 282 The most detailed description of the methods applied in the process of developing provincial health targets was available for the province of Carinthia. This information on methodology was added to the report in the form of an annex, namely Annex 8. Health targets of the province of Lower Austria were developed in 2002 by the health resort and were cleared by the provincial government in Thereafter NÖGUS (Health and Social Fund for Lower Austria, Niederösterreichischer Gesundheits und Sozialfonds) was entrusted with further coordination. Working groups were installed for each of the ten defined targets, which prepared detailed information on the individual targets. Results were presented to the provincial government. Subsequently the working groups, with exception of the working group for occupational health promotion, were dissolved. The working group for occupational health promotion was transformed into a constant platform for occupational health promotion. Currently the periodic evaluation of the health targets is being discussed. 283 Based on the first health report of Upper Austria in the year 2000 the regional sickness fund of Upper Austria promoted the installation of a working group which defined ten health targets for Upper Austria. At the end of 2002 the Institute for Health Planning (Institut für Gesundheitsplanung, IGP) was established for the further coordination required in the context of health reporting activities and health targets. The Health Conference of Upper Austria was founded as an advisory board in It is composed of a fixed range of participants of about 50 persons. Working groups for nearly all health targets were installed and put in charge of defining measures. After about one year results could be presented and implementation initiated. The first evaluation in 2005 showed that targets were only partially achieved. This was, to a certain extent, due to the fact that the adherence to the time frame which had been defined in 2000 was not realistic any more. As a consequence changes were made. For the next health targets 2010, which are defined together with representatives of the Health Conference, a time horizon of two years (December 2008 to December 2010) is envisioned. The IGP compiled working papers on 21 targets (mostly adopting the Health21 targets of the WHO) which were complemented by epidemiological data. Potential and already existing strategies in Upper Austria were also included in these documents by the IGP. Results were presented to the Health Conference in December 2008 and its feedback requested by February Thereafter it is planned to process and incorporate this feedback. Targets as well as evaluation criteria and a rough strategy should be presented at the health conference in December The further plan of action is only just being developed. 284 In Salzburg the health directorate of the province (Landessanitätsdirektion) was put in charge of developing targets. The organisational project management for the implementation of these targets was assigned to the Working Group Preventative Medicine Salzburg (Arbeitskreis Vorsorgemedizin Salzburg, AVOS), which delivers progress reports to the provincial government twice a year. The 282 Offermanns, expert interview on 10 February Rupp, expert interview on 17 February Peböck, expert interview on 13 February 2009 April

151 medical-professional responsibility remained with the medical project managers. In addition project teams and a steering group were installed. 285 In Styria the health fund of Styria (Gesundheitsfonds) commissioned the University of Applied Sciences, FH JOANNEUM with the development of targets. A period of half a year was granted to the university to come up with targets. The FH JOANNEUM applied the following methodology: Description of the demand, based on health reports as well as the epidemiological literature (mostly literature referring to the population of Styria) Collection and documentation of existing health promotion measures Assessment of the target areas using the following criteria: public health relevance of the topic, efficacy of the interventions, target-group orientation, cost-benefit ratio, acceptance and use of resources Development of recommendations for measures based on a literature review (structured according to the levels: region, setting and individual) Definition of actors and policy areas Definition of quality indicators for the implementation of the measures Development of a method for evaluating and monitoring the implementation, based on the Swiss modell of outcome classification and on a review of international sets of indicators for public health surveillance/health reporting. An expert board composed of health system stakeholders, as well as a steering group contributed to the development. As a result of the process, a final report on the scientific foundations of the health targets was compiled. Targets were presented to the public at provincial conferences and the Health Conference 2007 of Styria. A resolution of the health platform exists in which the health fund commissions the implementation of the health targets, emphasising Physical exercise and nutrition. For this purpose a guideline will be elaborated and published, containing specific measures related to behaviour- and condition-orientated prevention as well as indicators. Styria vitalis was entrusted with the implementation. 286 Tyrol has not defined independent health targets but regards the integrated suggestions for measures presented in the two health reports produced by ÖBIG in 2002 and 2007 as its health targets. Measures were defined by the health directorate of the province (Landessanitätsdirektion), were finalised by an internal working group and agreed upon with the policy makers. Implementation takes place through the definition of priorities. Evaluation will be undertaken through the health reports which are published every five years Local and institutional level Because a detailed description of existing health targets for this level (e.g. of cities, communities, institutions or associations) would go beyond the scope of the present study, it is not included into the report. 285 König, expert interview on 6 February Amegah, Grasser, Krenn, expert interview on 27 January 2009; Reis-Klingspiegl, expert interview on 12 February 2009; Peinhaupt, expert interview on 3 February 2009; Grasser, Personal receipt via on 14 August 2009; Peinhaupt, Personal receipt via on 02 September Katzgraber, expert interview on 10 February 2009 April

152 5. Critical success factors when using health targets The Austrian experience This chapter describes the critical success factors for the use of health targets, based on the statements made by experts during interviews undertaken in the course of this study and their experience gathered on health targets in Austria. Factors described below are a result of the qualitative content analysis of the interviews undertaken with a field manual. The ranking of factors reflects the number of statements made by interview partners with reference to each category (in descending order). Definitions for an unambiguous understanding of terms used precede each of the following sub-sections. The content of the interviews is summarised using the categories presented in Chapter 2.2 b and is substantiated solely in abstracts by representative text passages of the interviews, as the provision of further details would go beyond the scope of the chapter i.e. section (as defined by the terms of reference). 5.1 Resources A resource is a means to act or to initiate a procedure. A resource can be a material or an immaterial good. 288 The success factor category resources, was referred to in each of the 13 interviews. In total 86 statements of experts could be assigned to this factor, which therefore featured the indicator with the largest number of statements. Subsequently financial, time and human resources were bundled together in a cluster including a total of 38 statements from 12 interviews. Human resources are, in this context, only to be interpreted in a quantitative way. The qualitative dimension of human resources is taken into account by the sub-category Public health expertise which was assigned the same amount of statements (24 in 11 interviews) as the third sub-category structural resources (24 in 8 interviews). a) Financial, time and human resources Experts reported problems related to resource availability arising as early as in the target development phase. 289 Reasons for problems are, based on the interviews, too tight budgets 290, in combination with understaffing or time lags. 291 With regard to the aspect of time resources, internal bottlenecks were listed as well as the definition of too short periods for target formulation. Time schedules in politics, which depended on legislation periods, are perceived as obstacles by experts, especially if success of health target implementation is already expected to become visible within the same period. As a consequence, the time period allocated for the target definition is too short. But even with implementation being independent of legislation periods, experts mentioned that time lags occurred due to political re-staffing or long lasting political coordination processes. It seems important in this context to enter the process of target definition based on the following understanding: ( ) the time which is needed in case it takes a little longer, has still to be seen as an intervention, it is not wasted ( ) and if this is not understood, ( ), we will not arrive where we need to go. 292 Experts therefore advise to ensure an adequate amount of financial, time and human resources for the process of target formulation in general as well as safeguarding that sufficient resources are available for follow-up processes related to implementation or evaluation. One expert 293 for instance promotes the idea of creating an adequate financing mechanism, analogous to that of the Fund for a Healthy Austria (Fonds Gesundes Österreich), to guarantee a stable funding base for national health targets Troschke & Haas, 2009, S H 2-3, F 4, C 3, E H 2-3, E H E K H 2-3, M 2-3, F 4, A 2, C 3, E 3-4, G 3, K 3 April

153 In the implementation phase the issue of resources and of funding is considered as the central question. 295 On the one hand good planning is definitely necessary and on the other hand it is also required to have the resources for an implementation on the different levels. 296 Interview partners state that, in practice, too tight budgets can result in an implicit prioritisation of targets or even to targets not being pursued at all. Another experience voiced by experts was, that a smaller number of targets had a higher chance of being implemented. It was recommended to use financial resources to create incentive mechanisms for stakeholders with the aim of promoting implementation. The financial basis should be supported by politics; current support is though, according to the judgement of experts, not always satisfactory. They thereby mostly point out problems associated with the generation of funding for the fields of prevention and health promotion whereas criticising that cash does still flow into medical fields which are not supported by a strong body of scientific evidence or lack proven sustainability. Additional funds must therefore be obtained among others from the Fund for a Healthy Austria (Fonds Gesundes Österreich) or the European Union. Experts interpret the high demand for funding needed to establish new structures (e.g. Public health institute) as barrier. Patience appears, according to expert opinion, to be an indispensable attribute one should dispose of when entering an implementation process. This is for instance relevant in connection with the dependency on developments taking place on the national level. As long as a process is under way this should be interpreted as progress, even if only a policy of small steps 297 is possible. A course of action, which is orientated towards legislation periods, ought to be avoided. 298 b) Structural In connection with the second phase of the Public Health Action Cycle policy formulation the complexity and fragmentation of the Austrian health system are referred to as a challenge. With regard to the development of targets, it was seen as a success factor if a clear definition of responsibilities and structures were already in place. The sub-working group for public health of the Federal Health Commission (Unter-Arbeitsgruppe Public Health der Bundesgesundheitskommission) is believed to be an important structural resource for the envisioned development of national health targets (see agreement according to article 15a of the Federal Constitutional Act and Government Programme for ). Experts reported that, in the course of the process of target development, restructuring was taking place within various institutions. This may have, on the one hand, been related to the health target process itself (e.g. re-allocation of human resources). On the other hand the process was also influenced by restructuring mechanisms which were undertaken for other reasons, having an impact in the form of both a strengthening of structures (e.g. increase in human resources) as well as a weakening i.e. a cutting down of structures (e.g. reduction of responsibilities). 299 In connection with structural resources, conflicts of interest were also referred to as a problem, if structural resources depended on one stakeholder or were located directly with this stakeholder. The following example is related to the stakeholder social insurance and its potential conflicts of interest: What we would need in addition, supplementary to social insurance, which has to play a very important role as the health insurer of our population, is that we have an independent institute, to assist social insurance with evidence-based medicine and other techniques, which, in the best case, is not subject to directives or external influences. Well I would really hope for an independent institute which acts as an advisory agent for the Federal Government, the provinces and social insurance. Social insurance will, by no stretch of the imagination, manage to get rid of the image, that it also pursues its own economic interests and does not only act in the best interest of the people. Well, social insurance will not be able to free itself of this problem of credibility by itself. 300 Experts referred to the use of existing local and regional/provincial structures, initiatives or projects as being a crucial success factor for implementation because it does not work, if one tries to 295 J L E C 3, B 2-3, E 3-4, J 2, D 2, K 2-3, L 2, A M 2-3, F 4, A 2, L A 3 April

154 somehow steer it centrally, Austria is too heterogeneous, it can only work on the provincial level. 301 It was seen as an advantage if on the one hand responsibilities were already clearly defined and if on the other hand, in the best case, both human and financial resources were ensured. An inter-sectoral implementation requires the openness to the integration of a broad group of stakeholders. It was judged as beneficial if individual strategies and plans of these stakeholders were orientated towards the health targets. It was moreover believed to be important to not try something on a small-scale basis ( ) and that was it, but to immediately look where I can start at this point, at which existing structures, so that I can immediately reach a greater breadth. 302 Not only structures on higher levels are referred to at this point but predominantly the use of regional and decentralised resources. Through this interventions can achieve a stronger orientation towards target groups and obtain greater acceptance. A lot of convincing is necessary for the creation of new structures because in the moment, in which new structures are created, they are, once again, afraid that a lot of money 303, 304 is involved. c) Public health expertise Two interview partners reported on benefits resulting from the integration of public health expertise into the needs assessment phase, thereby explicitly mentioning the involvement of public health experts for health reporting. 305 Interview partners believe that the lack of public health knowledge among decision makers and health system players currently presents a barrier for the efforts to define health targets, which may for instance be reflected in the form of not perceived need for health targets. However also statements were made that, a constantly increasing understanding of public health is perceived among the players in the health system, independently of the health target process. Several provinces have involved public health experts in the health target process. It is advised that these experts should amongst others take on the task of creating a common basis. 306 This means that all stakeholders who are involved have a certain professional know how; that they understand what public health is; what it means if something like that should be implemented and then really gone through with. But this is of course already a postulation, which is not too small 307 but appears to be relevant for the further progression. The integration of expert knowledge into the process is furthermore deemed to be necessary for the processing of the target content following the latest research findings. 308 Based on the statements of the experts, a broad capacity building in public health as well as a concentration of public health knowledge in the form of public health institutes as a coordinatingand contact point in terms of an own intervention resulting from the health targets should not be forgotten during target implementation. Statements made in this context were: It is important ( ) that knowledge is brought to the communities. What is health? etc. has to be brought into the policy areas. ( ) Knowledge development and parallel to it implementation. 309 One should ( ) for sure also invest into capacity building. We need more people who understand what it is about, from all levels. 310 It can be concluded from this that one aim is to broaden the public health knowledge of political players of all levels (Federal Government to communities) whereas another aim is to achieve a certain degree of empowerment of the population when it comes to the topic of health K J K C 3, B 2-3, J 2, K 2-3, L H 2, F F E H 2, M 2, F 3-4, A 2, I 2, E 3-4, G 2, L F K F 4, B 2-3, C 3, E 3, K 2-3 April

155 Several interviewed experts reported a negative experience with social insurance in connection with public health expertise and expressed concern towards social insurance taking on an active role in this matter. Based on my judgement, social insurance suffers from partially having not-experts, who get involved with a topic based on crash course or personal enthusiasm, but then cannot reason some things in a good way. 312 At the same time specific expectations were voiced towards social insurance, namely expectations related to capacity building, to social insurance s participation in the development of health targets or with regard to the implementation of a public health strategy. Those who wish to seriously be involved in the discussion should be equipped with public health expertise. This means: additional training; ensuring that as many people as possible, who should deal with the topic, have the knowledge. This is very important in order to participate properly in the discussion Stakeholder involvement A Stakeholder is a person, group of persons or organisation who/which is actively involved in the project or influenced by the project s progression or outcome. who/which can, should the need arise, influence the project s progression or outcome. 314 In connection with health targets these stakeholders include policy makers, practitoners and researchers. The following list of stakeholders does not claim to be exhaustive: Representatives of all policy areas which can exert an influence on the social determinants of health Representatives operating on different levels of administration respectively reimbursement in the form of public means (Federal Government, provinces, cities, communities as well as social insurance) Service providers (e.g. health professionals) Service recipients Research experts as well as The interested Public The term project is, in this context, not limited to the process of target development only but refers to the entire Public Health Action Cycle (PHAC). The critical success factor category stakeholder involvement in the health target process has the sub-categories networking and partnerships respectively participation. These terms are defined and distinguished from each other as follows: Networking is defined as a linking of different professions (units) with all their specific abilities to a, for all participants, beneficial network 315 The term partnership is based on the subsequent definition: ( ) a target-orientated relationship between two independent enterprises pursuing joint targets, pursue bilateral benefits and are aware of their high mutual dependence. 316 According to that, these terms are understood in such a way that the cooperation is based on a long-term strategic direction, which was, in the content analysis, used as decisive aspect for distinguishing them from participation. Nutbeam defines participation, in connection with health promotion, as follows: People have to be at the centre of health promotion action and decision-making processes for them to be 312 A E Angermeier, 2005, p Niemeier, 2009, p Heinrich, 2004, p. 81 April

156 effective. 317 In the present section participation is however understood as a selective and shortterm involvement of stakeholders, thereby being used to distinguish between this form of stakeholder involvement and networking and partnerships. Another category which was defined is the category transparency. Transparency should on the one hand be a requirement when involving stakeholders, but then it is also a consequence thereof. It is based on the following understanding: transparency does thereby naturally not mean that everybody must know everything and may know everything. Transparency does however mean clarify about confidentiality, protection of trust and information obligations and information flows. This also applies to the documentation of the entire process. 318 In the context of the present content analysis, it is understood as the transparency of the entire health target process (planning, definition, implementtation and evaluation) and the outcome thereof as well as the motivation to enter a PHAC for all stakeholders. The motivation, which is defined as the willingness to act 319 describes, in the present context, the inner disposition to employ health targets. Stakeholder involvement constitutes, with a total of 70 statements, the category with the second largest number of statements. Like the factor resources it was referred to in all interviews. For the experts long term collaboration appears to be the most important aspect in this situation, receiving a total of 40 statements in 12 interviews. In contrast, selected involvement of stakeholders was only assigned 9 statements in 6 interviews. The sub-category transparency received 21 statements which were made in 8 interviews. a) Networking and partnerships Due to the fact that experts made the highest number of statements with reference to the critical success factor category stakeholder involvement (in terms of a long-term collaboration) in the phase of policy formulation, this factor is seen as the most essential success factor when defining health targets. Experts made a statement corresponding hereto in 11 of 13 interviews. Based on the opinion of the experts interviewed, health targets ought to be developed in close cooperation with politics in order to be realisable. On this level a broadly defined involvement of stakeholders in the development of health targets in terms of the WHO Health in all policies - strategy is recommended. The isolated development of health targets in the health resort only is described as an obstacle. However also the following statement was made in this context: Of course close cooperation with politics is important, it is however not always easy. 320 Given the variety of different actors in the health area and the fragmentation of the Austrian system, this statement appears to be comprehensible, should however not be understood in such a way that a broad involvement can therefore be omitted. Experts do not perceive any practical collaboration taking place between sectors respectively overarching collaboration of political parties in everyday life. This exacerbates the respective process. Exemplary, the lack of cooperation between health promotion and prevention on the one hand and the medical field on the other hand has been reported on several times. By involving all relevant policy areas, state institutions and decentralised institutions, as it were representatives of all those holding an interest in the good health, experts expect chances for the inter-sectoral implementation of and the identification with health targets to be good. If one has established trust, if it is clear what all of it actually means, what one is doing, then it works. 321 It is deducted that the establishment of trust represents a significant requirement for the development of health targets and is primarily achieved through the entering of partnerships and the intense cultivation of these. Experts hold certain expectations towards social insurance: If social insurance can participate actively in the process then the same applies to social insurance as to all others. One needs 317 Nutbeam 1998, p Freigang, 2007, p Der Brockhaus, 2002, p F F 3 April

157 to grant oneself some time for the development of health targets and needs to engage in the process in an as participation-orientated way as possible. 322 It is best to exclude political competitiveness and fears of any kind from the process. For experts, the building of trust in collaborations also stands for the creation of a culture, which involves everybody accepting that each participating person is an expert in his or her field. Those responsible for the process should dispose of very good moderation skills as well as exhibiting expert knowledge (public health expertise, see 5.1 c) and understanding the structures, motivators and working techniques of the involved stakeholders. Based on the situation that many provinces have already developed health targets, experts stated it to be indispensable to involve regional/provincial representatives in a process to develop national targets and to consider already existing health targets. The term framework-targets for health which is used in the agreement according to article 15a of the Federal Constitutional Act, appears to suggest such a course of action. 323 There is this decision on implementation which was taken by the provincial government and this would actually also mean that inter-sectoral activities take place. Based on my personal perception, this has not gone much further than the health department. ( ) Experience made in practice is: Even if departments have the same political orientation it is naive to believe that collaboration is automatically easy. 324 Eventhough it is evident that an inter-sectoral implementation entails many obstacles and problems, it is still believed to be an essential requirement. Responding to the question of what should be done to bring all stakeholders on board, experts for instance stated that: Creation of awareness, good cooperation and networking and then also a good, coordinated project management. And the political will. 325 In addition it was argued that stakeholders should be able to relate to topics of interventions and that there should be a perceivable benefit for stakeholders. 326 b) Participation With reference to the development of health targets, the involvement of stakeholders in form of selected participation was quoted less often by experts than the long-term collaboration with stakeholders in terms of networks or partnerships. Anybody interested in the topic should however at least receive the opportunity to incorporate his/her perspective my means of consultation of stakeholders. 327 c) Transparency Transparency is created in the phase of formulating health targets by ( ) as broad as possible involvement of individuals, meaning organisations, stakeholders in the process, that it becomes transparent for all those participating what happens in which time period, where can I take part in, who takes decisions, where can one get information and that individuals reach a same level 328 It is recognisable from this statement that transparency is on the one hand created by the actual involvement of stakeholders, on the other hand though transparency of processes and outcomes have to be actively demanded as a requirement to ensure a good basis for collaboration. If work packages delegated to stakeholders are for instance not clearly defined, this can result in unrealisable target formulations and losses in quality. Due to this reason, interviewed experts recommend that the motivation to develop health targets must be transparent for all those involved in the process: I believe that it begins with the question What was the motivation?. ( ) My personal conviction is that politicians do not know what they should do. Politicians would like to achieve certain things such as being liked, spending money well and winning the elections again. At certain times they believe that selected topics are well suited for 322 E H 3, M 2, F 3, I 2, C 3, E 3-4, J 2, D 2, L 2, K 3, G G L G 2-3, K 2, J 2, L 2, B H 3, F 3, E 3-4, G 3, M 2, A E 4 April

158 this ( ). 329 This statement shows the conflict between the partypolitical and the topicpolitical motivation and the motivation of public health experts to develop health targets. As already mentioned in chapter 5.1 financial, time and human resources, party-politically motivated planning in legislation periods is not considered beneficial for long term activities. It is therefore advised that politicians declare their motivation for the development of health targets right at the beginning of the process in a transparent way as well as stating what should happen with the final outcome report and by when what should be achieved. Experts explicitly referred to different types of motivators, for which several examples are subsequently given: Health targets instead of disease targets Naturally it would be ideal if ( ) health targets and not disease targets were developed. 330 Statements like this one document that the main motivation behind health targets should be the striving for an optimum of health. According to this experts recommended the orientation towards the Health21 targets (Annex 4), even if simultaneously evaluation of these is viewed to be problematic. Evidence-based, research based and innovative power of health targets I do believe that research findings should be viewed, so that one tries to incorporate these accordingly; that one does not limit oneself by the status quo and that one tries to be innovative and includes things which are evidence based, to ( ) give a new impetus to the system. 331 Reorienting health services I believe that there is currently really too little money to offer services we are offering at present still in the long run. Some experts say that we will crash by the end of 2010 and that this will result in services being cut down. Faced with this scenario, the players simply have the opinion that we cannot afford new structures like health promotion and prevention but that we will have to change existing structures. 332 Statements like this make the impact of restricted availability of resources on the development of health targets and especially on their implementation clear a fact which again should be made transparent in the process. 333 With regard to the creation of transparency through media involvement during the phase of implementation, the following experience was reported: If ( ) marketing is via radio and television we experience this is a very immediate way, meaning that the attention of the people is very strongly activated and as a consequence participation also increases immediately. 334 The same expert also reported on competition existing in the media environment and describes it as being hindering. 335 A uniform transfer of information respectively broad marketing for health targets could not be reported on everywhere: There is a platform decision ( ), but I always have the feeling that they are hardly communicated. Based on my perception it is still a circle of insiders. I would ( ) say everywhere Folks, health targets exist, ( ). But I do not get the impression, ( ) that many people are really aware of this. 336 Experts consider it important that the population, which should ultimately be affected by the health targets, should not only personally be able to perceive the interventions but should also already be informed about targets and the plans for their implementation. 5.3 Consideration of the Public Health Action Cycle The Public Health Action Cycle is described in chapter 3 of the present project report section. Statements of experts generated in the course of expert interviews were assigned to the success factor category Consideration of the PHAC firstly if these refer to a SMART target definition. The acronym SMART stands for Specific, Measurable, Achievable, Relevant and Time phased E M F G M 2, I 2, E 3-4, F 3-4, C 3, J 2, G B ibidem 336 G cp. Voland, 2008, p. 5 April

159 Secondly statements were assigned to this category if they referred to the problem definition, which forms the starting point of target formulation, or if they alluded to the implementation or evaluation of health targets. This therefore represents a consideration of all aspects of the Public Health Action Cycle (assessment, policy formulation, assurance and evaluation). Given that the PHAC is understood as a learning spiral, this category also includes statements on the use of experience or lessons learned which are defined as the sum of findings and insights. 338 The success factor Consideration of the Public Health Action Cycle occupies, with a total of 43 statements, the third place among all categories and was referred to in 11 interviews. We have to equip these targets with measures, with responsibility for measures, with adequate resources, that means financial as well as human resources and then also achieving and evaluating the targets regularly. 339 Experts recommend taking the PHAC into account in the target formulation phase by already defining measures, responsibilities and resources for the implementation and the evaluation phase. In order to define needs-oriented and measurable targets, experts believe health reports to be a primary step in the problem definition phase. They therefore recommend that the structure and content of health reports is coordinated with the direction respectively the motivation of health targets. One expert 340 argues that it is feasible to define targets separately for the normative, strategic and operative level. 341 Experts furthermore consider it sensible to incorporate the experience of other provinces and countries and the experience acquired in connection with previous processes when planning the course of action in terms of a continuous improvement process. 342 The realisation of a coordination office with corresponding project management skills as well as clearly defined responsibilities are, based on the statements of experts, promoting factors which should already be considered in the target formulation phase. 343 Although experts were of the opinion that evaluable targets feature an important aspect, they simultaneously reported on obstacles in this context such as for instance the reluctance of politicians to present outcomes of evaluation or to define indicators. The following core statements reflect reported experience and opinions: ( )This is where acceptance of prevention fails again and again. Results are actually known at a very late stage because it is not possible to provide the evidence for success for a very, very long time. Even though everybody theoretically knows that it yields something, it is impossible to convey this to the extent that it is for instance reflected in the government programme. ( ) Therefore also currently little money is spent on health promotion and prevention, also because actually nobody can quantify the success. 344 I believe that in times of crisis the health of each individual will naturally still be the thing most important to him or her, but we will have difficulties to find means in the economy and in the policy area, because it is necessary, especially with regard to prevention and health promotion, to think in long-terms ( ). If we for instance think about chronic diseases such as Diabetes or cardiovascular diseases, for which we really have to already intervene during infancy and have to aim at creating an awareness for health at that point in time in order to not have even more people suffering from Diabetes 30 years from now. Politics and also the economy only on rare occasion are capable of following and thinking in such long and sustainable intervals; barely anybody manages to do this. These are our great challenges, namely funding and the fact that the degree of suffering one is 338 Der Brockhaus, 2002, p M F H 2-3, M 2-3, F 3-4, I 2, C 3, B 2, G 2, K 2, L 2, D M 2, L 2, H 2, C A 2, D 2, B B 2 April

160 confronted with is rarely so high that financing happens automatically. One always has to put an incredible amount of effort into convincing. 345 What we would need is the understanding that no results of evaluations should be demanded from health promotion and prevention which normal medicine does not provide either. We do for instance also not know the outcome of an orthopaedic specialist working in a private practice. Suddenly a return of investment of 1:3 is demanded and that everything pays off and becomes more reasonable. This means finally distancing oneself from this nonsense in public discussion. 346 In order to still live up to the claim for evaluable targets and to make achievements in health promotion and prevention transparent it was promoted ( ) to build a cohort for health reporting ( ). 347 Thereby achievements could be made transparent Leadership and political commitment Commitment expresses an obligation to act 349. In the present context political commitment is defined as the compulsory political integration of targets. The following are characteristics of leadership: Firstly leaders do not simply lead by instruction but by conviction, motivation and delegation of responsibility. They identify challenges and achieve approval of their vision. Secondly leaders do not solely develop individual accomplishment, but create a comprehensive involvement of their entire team 350 Both criteria are, due to their interdependency, were clustered in one category. In the interviews 39 statements were found in 12 interviews which could be assigned to this category of success factors. With regard to the target development process, experts were convinced that, in connection with the assumption of the leadership role, which is generally taken on by the health department, it is important to understand that a Top-Down-Process alone has small chances of implementation. Exactly because of this, different players have to be involved; to be sure that an as broad a basis as possible basis is created for it. If it contains something which people believe, understand and also want ( ). And this also means that it is not possible to say afterwards, that it will not be included because it does not look good. 351 Leadership does as a consequence not mean that findings of others are, due to partypolitical considerations, altered at the end of the process, but that the process which was implemented on a broad basis, is actively supported, to be amid of it and to decide on the direction but still to accept the expert opinion of the stakeholders and to work towards a result which received as large as possible approval. As far as political commitment is concerned, experts believe it to be essential that a clear assignment with precise allocation of resources is fixed, both across political parties and legislation periods, ideally by law: Politics has to be supportive and define the strategies, provide certain resources, so that the implementation of targets can work. 352 Experience related to this context was reported in the following way: In addition the member of the provincial government responsible for health ( ) has achieved to withdraw it from party politics and that provincial health targets were approved of in a meeting of the provincial government. Thereby the targets became official targets. 353 To achieve such a commitment, political will 354 was stated as a requirement. Experts report that they already sense a positive impact of the integration of the intention to develop framework-targets in the agreement according to article 15a of the Federal Constitutional Law K A G A 2, B 2-3, K 2, G 3, H 2, I 2, D Ammon, 2006, p Zellweger, 2004, p E H A L E 3-4, H 3, I 2, M 3, F 4, A 2, B 3, G 2-3, D 2, K 3, L 2 April

161 In connection with the political will and the commitment, which is equally reflected in the allocation of resources, experts clearly address social insurance: The social insurance funds do not have any money, they are badly in deficit. Well one actually cannot burden them with prevention, if one does not grant them certain means to do this or does not change the legislation base. 356 This means: Also for social insurance a clear legal appointment is needed and a clear authorization capacity, that money can be spent and incentives created ( ). What we would need is a clear commitment, clear legislation and a clear allocation of budgets as well as instructions on what these should be used for. 357 Experts voiced clear expectations towards social insurance. On the one hand it is expected that social insurance speaks as a whole with one voice and assumes a clear position: Social insurance funds should not develop invidual concepts! Because at the moment a little bit of a trend can be observed that every social insurance fund believes that it has to contribute something individually to a development. And this is, at least from my point of view, cumbersome. 358 One should have a very clear idea of what one would like to achieve in this field, also in the field of health promotion. I consider it important that social insurance does this as a whole. 359 On the other hand there is hope that social insurance can, as a constant stakeholder, counter the thinking i.e. planning in legislation periods: Social insurance should put its shoulder to the wheel! Social insurance of all stakeholders is a body which is not bound to legislation periods and could therefore also, when it comes to health targets, promote the idea of not thinking i.e. planning in legislation periods. 360 The installation of a professional structure by means of project management is stated to be a success factor for e.g. the implementation of health targets. A concerted course of action should be taken. Political leadership could, according to expert recommendation, be supported by a neutral coordination- and networking unit. Politicians should throughout the entire process as well as during the phase of implementation understand their role as achiever 361 and not only as facilitator 362. Implementation is believed to be largely dependent on the support of and the decisions taken by politicians. The extent of this support is, based on expert opinion, dependent on the explosiveness of the topic. Several interview partners described support for the generation of resources being based on the prior existence of integrated health targets. Interview partners however frequently perceive politicians as being too weak to achieve noticeable accomplishments in the process of implementation. One expert made the following statement: In theory I believe that targets can be found, but in practice we can see in Bavaria and Austria that we do not get very far, even with regard to the easy topic of smoking because politicians are simply too weak and because we are lacking an expert discussion, which is taken seriously by the public. It is difficult. Many health targets are related to lifestyle and 363, 364 who enjoys taking it on with the population? Here I locate certain political weaknesses. 356 B A E C4 360 E G ibidem 363 A K 2, B 2, C 3, A 2, G 2-3, D 2, L 2, E 4 April

162 6. Summary and discussion 6.1 Summary of results Section III, Health Targets, of the present public health report aimed to identify and present critical success factors for the practical use of health targets. First a short theoretical introduction on health targets was given. After an overview of the status quo of the use of health targets in Austria, which was based on 15 expert interviews (these were performed using a field manual and followed up by a qualitative content analysis) critical success factors for the implementation of a health target development process were generated. These are subsequently listed and then summarised. They define the most relevant fields of action. chapter 7 contains recommendations for fields of action i.e. initial steps towards formulating health targets. List of critical success factors Resource allocation o Ensuring sufficient financial, human and time resources o Make use of existing structural resources and, if necessary, establish new structures o Integrate and build public health expertise Broad involvement of stakeholders o Establish long-term relationships for collaboration in terms of networking and partnerships o Facilitate selective involvement of a broad range of anybody interested in terms of participation o Create transparency with regard to processes, outcomes and motivation for all stakeholders Consider all phases of the Public Health Action Cycle right from the beginning Assume leadership for the entire process and obtain broad political commitment Description of the success factors i.e. fields of action Resource allocation Without the necessary financial, human and time resources a successful implementation of a health target process seems highly unlikely. Experts mentioned the success factor resources most often in their statements which emphasises its great significance. According to experts, sufficient resources are to be ensured in every phase of the PHAC. Ideally resources for the planning of the strategy and measures, the implementation and evaluation should already be planned for in the phase of target development. Based on expert opinion building on existing regional/provincial structures is another critical factor facilitating the implementation of target-group oriented and sustainable interventions. Health targets can however also be used to establish new, innovative institutions such as public health institutes, whereby this requires the consideration of an appropriate resource generation mechanism. All phases of the PHAC require a profound knowledge in public health. Therefore an integration of public health expertise is advised. The development and implementation of health targets should also be used to extend the public health know how in terms of capacity building. Broad involvement of stakeholders In addition to the question of resources, experts attribute a very high importance to a broad involvement of stakeholders. To ensure inter-disciplinarity and inter-sectorality both when developing and also when implementing the health targets, not only broad selected participation is indispensable but even more so the establishment of long-standing collaboration of policy, research and practice through networking and the establishment of partnerships. Transparency for the stakeholders is already to a certain extent created by involving them in the process itself; transparency should however on the other hand also be actively promoted for involved stakeholders, especially when considering the motivation of those commissioning/initiating the process, Even if a broad involvement of stakeholders entails a considerable amount of challenges and difficulties, resulting from unavoidable conflicts of April

163 interest, it seems indispensable for the legitimating of health targets. Experts stated that this process can be supported by the creation of a homogenous knowledge base in public health as well as by the clarification of joint aims respectively motivation to develop health targets. This is finally reflected in the direction of health targets. A general orientation towards the Health21 targets is, from the public health viewpoint, to be aspired. Public Health Action Cycle Health targets should be understood as part of a perpetual cycle in which the phases of the Public Health Action Cycle (problem definition, formulation of strategy, implementation and evaluation) are constantly repeated. This aspect should already be considered when developing health targets. With regard to the evaluation of targets, an as accurate as possible formulation of health targets was recommended by experts, which can however only be undertaken based on a problem definition (e.g. through health reports). Because the PHAC is understood as a learning spiral, also experience gathered in other countries should be considered, as this may possibly give supportive stimulus for the own process. In case the PHAC has already been run through once, it is advised to reflect findings and experience and to consider lessons learned in the following process. Leadership and commitment Leadership, which is, at this point, defined as the internal promotion and support of a process and its external representation, is usually taken on by a representative of the political level. Thereby it should be avoided to favour party-political and/or personal interests (e.g. re-election, thinking in legislation periods) over the actual public health perspective aim (= a healthier population). A basic understanding of public health among decision makers could counteract this. The motivation for developing health targets should be made transparent beforehand. Decisions taken on and the will of the political level are decisive for the success or failure of the process. Therefore obtaining a broad political commitment in the form of a compulsory integration through a compulsory resolution of the entire federal government should be aspired. Findings presented here correspond to various findings described in the Austrian literature 365, which is referred to for obtaining a further and detailed interaction with success factors. 6.2 Discussion Subsequently the strength and weaknesses of the approach applied in this section are discussed more in detail. The results of this section are based on expert interviews. With reference to the literature review it should be acknowledged that no systematic literature review was performed. Literature was identified following the snowball method respectively the berry picking method. The literature search focussed entirely on information related to theoretical concepts on health targets as well as on information describing the situation of health targets in Austria in order to report on the status quo in Austria. It should be pointed out that very few sources documenting development processes for already existing health targets exist so far which is why it was necessary to draw on expert statements. Because no systematic literature review on the success factors relevant for development of health targets was undertaken, results and recommendations are based exclusively on expert interviews. As far as the expert interviews are concerned, it is welcomed that at least one person could be identified as interview partner for each province. On the other hand neither the perspective of the Federal Ministry of Health nor that of the Institute for Advanced Studies could be taken account of because interview partners were not available. It is not possible to judge the impact this circumstance has on the findings. It is furthermore critically assessed that five interview partners from Styria were interviewed in contrast to only interviewing one person each of the remaining provinces. The execution of the interviews was moreover subject to differences. One interview with three participants was undertaken as a group interview whereas the other interviews were performed as individual 365 Soffried, 2006; Mair, Peböck & Soffried, 2007; Mair, 2007; Spitzbart, 2007 April

164 interviews. Moreover interviews were largely telephone interviews, with the exeption of three personal interviews. Each of these aspects can be assessed critically with regard to its potential impact on the findings. Based on the outcomes of the interviews being very homogeneous, it is assumed that the applied approach was acceptable. With regard to the success factors reported by the experts, the statements made were consistent respectively complemented each other instead of being contrary. A special asset which should be mentioned is that for each province which already had existing health targets in place or which was in the process of developing health targets individuals could be found as interviewpartners who were i.e. are directly involved in the process. In connection with the execution of the interview a very open discussion culture was experienced. A transcription of the interview was forwarded to the respective expert to ensure that what he or she said had been documented in an adequate way. The organisation of the interviews as well as co-operation with the interview partners worked smoothly. Based on the fact that information on the development of regional/provincial health targets is very rarely publicly accessible, the generation of information by execution of interviews using a field manual is judged as appropriate, functional and an asset. As already mentioned in chapter 2.2, interview partners had the opportunity of adapting the exact wording of the description of the process followed in the own province. Depicted development processes of each province therefore feature texts which have undergone censoring and quality assurance by regional/provincial experts. The ciriticism of potentially presenting a biased respectively incomplete description of the processes should be acknowledged in this context. The same problem would have however arisen had one used published reports only. Against the background of political systems and structures being highly diverse and the limited amount of resources available to the authors of the present section, the execution of interviews with exclusively Austrian experts is judged as appropriate to develop recommendations for the development of health targes for Austria. Findings of the present section complement the existing literature; a comparable survey documenting the Austrian situation is not known. When comparing the results of the present section with other Austrian literature 366, which partially also takes account of international perspectives, analogies are evident. The methodology applied is considered adequate for answering the predefined questions, whereby no claim is made that the section of the report is complete. 366 Soffried, 2006; Mair, Peböck & Soffried, 2007; Mair, 2007; Spitzbart, 2007 April

165 7. Recommendations for developing health targets in Austria The development of health targets features an important step in the political and societal process of attributing the good health a higher priority. Research of determinants of health has taught us, that main influencing factors of health lie beyond the health care system or the individual. The concept health in all policies (HiAP), which was presented in the course of the Finish EUpresidency in 2006, takes this matter into account and describes the intersectoral responsibility and necessity of the co-operation of different policy areas with the intention of promoting all our health. The Whole of government approach offers the tool to implement the HiAP concept. Among others, the existence of a clear vision for health as well as an elaborate health policy including health targets, represent a main prerequisite for the success of this approach. Based on the fields of action defined in chapter 6, the following two chapters (7.1 and 7.2) present recommendations for aspects which are considered especially relevant for the process of developing national health targets in Austria. It is explicitly emphasised at this point that the recommendations focus on the target development process, neither on the implementation of measures nor on the evaluation of health targets. 7.1 General recommendations a) Ensuring sufficient resources As far as a time frame is concerned, it is recommended (by the authors) to envision a time period of about two to three years (for example 2010 to 2012) for the definition of national health targets. The target development process should be initiated as soon as possible to firstly ensure a comprehensive and concerted process and to secondly enable the consideration of the targets in the next agreement according to article 15a of the Federal Constitutional Act, which will most likely come into force in The intention should therefore be to finalise national framework targets before the negotiations for the new formulation of the agreement according to article 15a of the Federal Constitutional Law commence. For the complex process of defining national health targets it is advised to establish a project-office which is firstly equipped with skills and experience in the management of complex projects and secondly with public health skills. The individuals in charge of the management of the process should be entirely devoted to this task. At the same time the members of this office should not be part of the stakeholders who co-operate in the form of working groups to develop the contents of the health targets, to ensure that these can operate without being subject to any conflict of interest. The existing structure of the Federal Health Agency (Bundesgesundheitsagentur) could act as a commissioning agent, a (project-) steering committee could be nominated from the members of the Federal Health Commission (Bundesgesundheitskommission). The development of national framework health targets necessitates the definition of an according budget. The budget must definitely include funding for human resources and also for the structural and operative means required by the office. Other budget positions depend on the process structure. Funding for the organisation of regular work meetings, for communication between the partners involved in the development process, for services provided by the members of the working groups (based on the assumption that services to fulfil working packages are provided between the working group meetings) as well as means for the selective and event-based acquisition of expertise (from outside of the working groups) must be planned for. Equally resources for acquiring a usable database and for the competent interpretation of the data as well as funding for the participation of stakeholders (consultation processes, public discussion fora) and resources for the organisation of a transparent process (homepage, media campaign, press conferences) should be provided. b) Integration of public health expertise When integrating public health expertise in the process of formulating health targets generally three options are available. An indispensable requirement is that the office is equipped with public health know how. Furthermore public health experts need to be represented amongst the range of experts nominated for the working groups. Another option would be the installation of a scientific April

166 committee, respectively the consultation of external scientific support for the process. International experiece and expertise can be used for this task. Public health know how is not only required in the phase of target development but for any stage of the Public Health Action Cycle (health reporting; investigation of health determinants; interpretation of epidemiological data; assessment of the benefits of measures, development of indicators; design and execution of evaluation etc.) and should therefore definitely be used right from the beginning. c) Broad involvement of stakeholders Whilst the office would oversee the management of the target development process (including consultation process, measures to ensure transparency), the working groups would develop the contents of the Austrian framework targets for health. Thereby it is supported by the office. The working groups reflect the long-standing partnership of policy representatives, representatives of public institutions and of experts from research and practice. On a political level, the involvement of all parties represented in the national parliament is to be aspired; the intention thereof being that a consensus can be achieved among all parties, which would promote the sustainability of such targets. Due to the federal structure of Austria, it must be ensured that both provinces and the Federal Government are represented in the working groups. On the level of the public institutions the ministries, social insurance, the chambers, the trade unions, Health Austria Ltd., Statistics Austria and many more institutions should be represented. Experts from various areas of activity (public and private education and research institutions, NGOs, local representatives and patient representatives) as well as public health experts complete the working group. To achieve the best possible stakeholder involvement, parties who are not represented in the long-term working group should receive the option of contributing by means of selective consultations. It should be ensured that the broad public i.e. the entire population of Austria has the opportunity to comment and discuss. Participation could be promoted and facilitated through measures such as the installation of an interactive homepage, public events, a concomitant media campaign and publications. These initiatives could at the same time improve transparency for all those involved and interested. d) Assigning the leadership role and broad political commitment The individual who takes on the role of an internal motivator and an external representative has to be chosen very carefully. This chairperson heads the office and makes sure that specifications of the process are met. At the same time he or she should safeguard that the process has a positive external connotation as well as promoting active participation within the opportunities available. To fulfil this function, the person in question requires both a high acceptance among stakeholders, profound knowledge of the matter, sufficient time and a strong intrinsic motivation. To ensure continuity the assignment of this role should take place independently of legislation periods. To achieve a high political commitment, an inclusion of the health targets in the agreement according to article 15a of the Federal Constitutional Law should be aspired. Thereby the contents of targets as well as the funding and responsibilities attached to the targets should be clearly defined. 7.2 Recommendations for social insurance a) Involvement as a long-term partner Social insurance is a significant stakeholder in the Austrian health care system and needs to therefore be involved in the development of national framework targets for health i.e. should actively demand to be involved in the process. Involvement of social insurance should due to its importance in any rate be executed in the form of a long-term partnership. Referring to the general recommendations this means that social insurance should, as public body, be part of the working group which is entrusted with the development of the contents of the health targets (see chapter 7.1 c). b) Human resource development and organisational development in the area of public health To take a constructive role in the development of health targets, social insurance requires public health expertise. Being part of the traditional curative health care structure, the fields of action in connection April

167 with areas such as health promotion and prevention are at present fairly underdeveloped in social insurance. Individuals with an explicit training in public health 367 can nowadays be found in ten out of 16 social insurance funds (including the Hauptverband survey 2009). The recently taken decision to strike a new path for the professional qualification of employees in the field of public health should be pursued as a human resource strategy for the whole of social insurance. Thereby special attention should be placed on not only training experts working on or being hired for operative tasks but also on conveying public health knowledge to the decision makers i.e. the strategic management. Decision makers can benefit through public health expertise or own internal public health experts within social insurance with regard to strategic management by for instance involving public health experts in existing social insurance committees or by co-operating with decision makers in the form of specific projects/working groups. c) Generation of financial resources Adequate resources need to be arranged for the building of public health know how (mentioned in section b) by means of human resource development and organisational development. Social insurance should have significantly more resources at its disposal; for general public health agendas (e.g. databased problem definition, assessment of demand, quality management, planning of services, health economic assessment of interventions, increased information of insurees, etc.) as well as for the specific action areas of health promotion and prevention to provide quality assured services corresponding to the demand of the insurees. Such resources could ideally be earmarked to limit any competition with the field of health care when distributing them. d) Assuming leadership When being involved in the process of developing national framework targets for health, it is essential that social insurance assumes a clear position which is supported by all insurance funds. This means that a joint strategy must be found, which is made transparent in a corresponding social insurance position paper. The attitude of expectation, that social insurance may assume the role of a constant stakeholder, counteracting the way of thinking and planning in legislation periods, shows considerable potential. Social insurance could, in case it manages to assume leadership in this process, establish itself as an active and constitutive health policy force. e) Creating commitment In the presence of a strong political will, an optimum of commitment could be reached. Social insurance is called upon to reach agreement and create commitment towards health promotion and prevention within social insurance and to thereby contribute to the creation of a corresponding national commitment for these fields of action. Favourable general conditions for health promotion, prevention and public health in the form of clearly formulated legal responsibilities and the creation of earmarked funding can be achieved, if the aforementioned topics are situated at the very top of the political agenda. Social insurance could assume a leading role in this process. f) Taking on a role in the entire Public Health Action Cycle Social insurance should not only, as described earlier on, assume an active role in the target development process, but also in the implementation of the targets. Social insurance equally represents an important player in the phases of problem definition and evaluation in which health reports are attributed special significance. Social insurance already holds a considerable amount of data and could in the future assume an even more important role as a provider of data for health reporting. This potential has been recognised before and described in the Health report of social health insurance Individuals have either already completed their training or are currently undergoing training 368 HVB, 2005 April

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170 Soffried, J. (2006): Die Entwicklung nationaler Gesundheitsziele in Kanada und Schweden. Empirische Untersuchung der Motivationen nationale Gesundheitsziele zu entwickeln sowie der Erfolgsfaktoren der Zielfindungsprozesse in Kanada und Schweden. Master s-arbeit zur Erlangung des akademischen Grades Master of Public Health. Medizinische Universität Graz, Universitätslehrgang Public Health. Graz. Spitzbart, C. M. (2007): Kriterien zur Entwicklung von Gesundheitszielen auf regionaler Ebene am Beispiel des Bundeslandes Oberösterreich. Diplomarbeit zur Erlangung des akademischen Grades einer Magistra (FH) für wirtschaftswissenschaftliche Berufe. FH Joanneum, Fachhochschul- Studiengang Gesundheitsmanagement im Tourismus. Spitzbart, S., Plankenauer, G. (2009): Ansatzpunkte zum Auf- und Ausbau von Public Health in der österreichischen Sozialversicherung. Hauptverband der österreichischen Sozialversicherungsträger. Vienna. SV-Wissenschaft (2008): Resümee ExpertInnengespräch SV Wissenschaft, 20. Juni 2008 Gesundheitsförderung (in der SV): Projekte und was nun? DB/MMDB134610_Res%c3%bcmee%20ExpertInnengespr%c3%a4ch%20SV%20Wissenschaft.p df, Accessed on Troschke, B. von, Haas, B. (2009): Vertriebscoaching. Von der Führungskraft zum Coach. Gabler Verlag, Wiesbaden. Voland. S. (2008): Projektmanagement als Hilfsmittel des Zielkostenmanagements (Target Costing). GRIN Verlag, Munich. WHO Europe (1998): Health21 health for all in the 21st century. An introduction. European Health for All Series, No. 5. Copenhagen. WHO Europe (1999): Health21. The health for all policy framework for the WHO European Region, European Health for All Series, No. 6. Copenhagen. WHO Europa (2005): Das Rahmenkonzept Gesundheit für alle für die Europäische Region der WHO. Aktualisierung Europäische Schriftenreihe Gesundheit für alle, Nr. 7. Kopenhagen. Zellweger, H. (2004): Leadership by Soft Skills. Checklisten für den Führungsalltag. Gabler Verlag, Wiesbaden. April

171 Section IV: Adressing disadvantaged and special need groups Introduction A society is judged by how it deals with its disadvantaged and special need groups. It therefore has a moral and ethical responsibility towards these people. Apart from ethical matters, addressing inequalities can result in economic growth and thus potentially lead to better health as well as reduced cost of illness; however also the opposite can occur. Economic growth can (e.g. by a widening of income gaps) provoke greater inequalities and also inequity. Developments need to therefore be monitored very closely. Health inequalities and health related inequity are highly relevant issues with regard to a variety of policy areas, not only health policy (keyword Health in all policies ). Determinants of health are manifold and their impact on the access to, the utilisation of and ultimately the health status of individuals or their health outcomes such as life expectancy, morbidity and mortality is complex. Also education, living and working conditions, economic and social status, family composition, etc. influence health to a considerable extent. These inter-relationships make a broader approach towards dealing with health inequalities and health inequity necessary, whereby measures do not take place in an isolated way and are focussed on the the health care system only, but also involve stakeholders of any other relevant policy areas. This section of the report identifies various disadvantaged groups, discusses their health status (subjective health status, morbidity, mortality) and health-related behaviour, looking into the underlying causes of ill health, as well as dealing with equity of access to services. Ideas on how to promote the health of disadvantaged groups are presented as well as listing special health services for these groups in need in Austria. The chapter concludes by outlining the potential role of social insurance with respect to disadvantaged groups. It is essential to view the understanding of disadvantage in relative terms (e.g. income vs. household size), instead of assessing or expressing it in absolute terms, as well as assessing it in connection with the respective context. Even indicators which may seem measurable and obvious such as income have to be assessed and interpreted in relative terms. Definitions need to moreover be adaptable to changing surroundings and circumstances but should at the same time remain comparable over time. The identification of disadvantaged groups can be extremely complicated as data may not exist and the concerned individuals or population groups sometimes do not come forward or are not organised in groups representing their interests. Some do not have a voice of their own and need others to speak for them. These include for instance children, mentally ill, illegal immigrants or in some cases elderly people. Also barriers to care exist which make it more difficult for individuals to obtain the services they need or prevent them from getting them altogether. Barriers are for instance financial, geographical, language, cultural, knowledge or health system barriers (lack of coverage, limited availability of services, restricted opening hours, waiting times, administrative barriers, lack of disabled access/support measures for disabled). Members of vulnerable groups are often strongly burdened with coping with their everyday life and in some cases with actually surviving, thus limiting them in their commitment to other areas of their life such as their health. Individuals generally have a different perception of health, suffering and pain. They may attribute a higher or lower value to it or simply take it for granted. Differing perceptions of health and disease can also be based on cultural background, beliefs or value sytems. As far as the development and implementation of measures for disadvantaged groups is concerned, these are further complicated by responsibilities for these groups being diffuse, especially on the level of decision makers. Often no specific contact person exists or involved institutions or bodies do not co-operate in a systematic or standardised way. Research, which links data on health status with sociodemographic and socioeconomic aspects, is limited in Austria. A couple of comprehensive reports exist as well as several research papers. Data April

172 availability also strongly depends on the disadvantaged group in question, and is, for instance, better for marginal groups like homeless as compared to the average poor. Experts dealing with the topic of how the health status or health outcomes of individuals can be affected by socioeconomic and sociodemographic characteristics are few in Austria. More research is required on the health status and health-related behaviour of disadvantaged groups; to promote early intervention, to facilitate access to the services needed and to target those most vulnerable and in greatest need. Addressing disadvantaged and special need groups is, as already mentioned in the beginning of this section, a cross-sectoral topic, involving aspects such as health, social welfare, integration, housing/living conditions, education, gender, environmental or labour market issues. This means that a variety of stakeholders is affected; Standardised mechanisms for co-ordination, communication and involvement are required. In Austria it is difficult to link epidemiological data (mortality, incidence of disease) or data on the utilisation of health services with socioeconomic data. Information on ethnicity in connection with the demand or the use of health and social services hardly exists or is not collected at all. Little research is available on how the socioeconomic situation of Austrian citizens or other aspects of their lives influence their health status, life expectancy, morbidity or mortality and vice versa. Sometimes proxies are used to describe the socioeconomic situation such as affiliation to a certain social class (income, education, profession, etc). More information on life expectancy, mortality, morbidity and health behaviour can be found in chapter 7 of section I of the present report. April

173 1 Identification of disadvantaged groups In their first report on social inequality and health published in 2001, Pochobradsky et al. concluded that income has a significant impact on the health status of individuals, potentially influencing their morbidity and mortality, that however also aspects such as personal risk factors (disability, gender, lifestyle), factors regarding the provision of health services and aspects related to employment, living conditions and other circumstances are very important in this context. 369 Based on the findings of the studies consulted for and presented in this section, various disadvantaged individuals and population groups were identified. These are subsequently listed. Some overlap among these may exist. Individuals or population groups are those: - being at risk of or threatened by poverty - having a low level of income - having a low level of education - seeking work i.e. being (long-term) unemployed - in atypical working arrangements - without insurance coverage - with a migration background, and thereof especially undocumented/illigal immigrants and asylum seekers - in need of special assistance or protection such as certain groups of particularly vulnerable children or elderly Other disadvantaged groups include homeless, disabled and sometimes also over-burdened individuals such as single parents or family carers. 370 Differences in health status and health behaviour can also be related to gender or age. Other members of the population at risk of poverty and consequently also at a higher risk of experiencing a poorer health condition, are families with many children. Some of the aforementioned individuals or groups may have a different cultural understanding and appreciation of health and illness. Information on the scope respectively the dimension of each of the population groups listed above is provided in the next chapter (1.1); their health status and health behaviour are discussed in chapter 1.2 and chapter Dimensions and scope of the disadvantaged population This first sub-section of chapter 1 tries to capture the dimensions and scope of the population confronted with a certain disadvantage and is structured according to the disadvantages listed in the beginning of the chapter Poverty and low level of income About 13% of the Austrian popluation (more than one million people) are at risk of poverty. 371 The share of the population affected by poverty has experienced a slight increase during the last decade. Low income, proverty and social exclusion are mutidimensional problems and highly complex. On the 369 Pochobradsky, E., Habl, C., Schleicher, B., Hlava, A. (2002). Social inequality and health care. Study commissioned by the Federal Ministry of Health and Women. Vienna % of all people in need of long-term care are cared for by family members at home. 371 Statistics Austria (2009). Income, Poverty and Living Conditions. Results of EU-SILC April

174 European level social cohesion indicators have been developed to monitor these matters more effectively. 372 Groups of the population, who are subject to the highest risk of poverty are: pensioners in single households, unemployed, individuals with a low level of formal education, households with many children, single parents and migrants. 373 In all European countries average income of migrant workers is lower than that of nationals. This is related to the fact that migrants tend to be over-represented in sectors characterised by low wages as well as in unskilled job positions. According to the results of the analysis of the EU-SILC 374 data, households with individuals with a migrant background, with individuals relying on social benefits as a main income, with individuals experiencing long-term unemployment or with disabled individuals (of a working age) are at the highest risk of poverty. 375 Based on data presented in the Eurostat yearbook 2009 (2006, age 18 and over), the population group showing the highest at-risk-of-povery rate 376 (EU-25) after social transfers, when classifying the population according to their activity status 377, is the unemployed population (41% of these are at risk of poverty). 16% of the retired population were stated to be at risk-of-poverty whereas 8% of the employed persons were at risk of poverty. Of the total population 15% were stated as being at risk of poverty. 378 On the European level (EU-25, 2006), the household types at highest risk of poverty after social transfers, are single parents with dependent children, adults older than 65 years living alone, single females, two adults with three or more dependent children and adults younger than 64 living alone Low level of education Between 1971 and 2008 the share of the population with only compulsory education in Austria decreased from 62% to about 27%. Just in the past eight years this population group has shrunk by about 8%. Persons with university education have quintupled since 1971, rising from 2.1% to 10.2% of the population. The population group with an apprenticeship has remained more or less stable since 1991, comprising about one third of the population For further information see for example: Council of Europe, Social Policy, Social Cohesion Development Strategy at accessed 2 November 2009 or European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg 373 ÖGPP Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December SILC = Community Statistics on Income and Living Conditions, Erhebung durch die järhlich Informationen über die Lebensbedingungen der Privathaushalte in der Europäischen Union gesammelt werden. Für nähere Informationen siehe ÖGPP Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December risk-of-poverty rate is defined as the share of persons with an equivalised disposable income that is below the at risk-of-poverty threshold, set at 60 % of the national median equivalised disposable income. Th is rate may be expressed before or after social transfers, with the difference measuring the hypothetical impact of national social transfers in reducing poverty risk. Retirement and survivor s pensions are counted as income before transfers and not as social transfers. 377 Self-assessed most frequent activity status 378 For definitions and further information please refer to: European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg. Data for 2006 (1) 379 European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg 380 Statistics Austria. Accessed at on 4 October Based on data of the population census and the Microcensus April

175 The level of education of the Austrian population has increased considerably over the past 30 years. 84.1% of the population between 20 and 24 years had a level of education going beyond compulsory education. 381 Findings of the population census 2001 show that individuals with a university (tertiary) education tend to cluster in urban areas, especially in the Austrian provincial capitals. 382 The proportion of the populaton with compulsory education is highest in the South-Eastern part of Styria, the South of Burgenland, the North-West of Lower Austria and the North of Upper Austria. 383 Young individuals (25-34 years) with only compulsory education are concentrated in urban areas wheras older people with only compulsory education tend to live in rural areas. 384 Migrants living in Austria are in many cases at risk of poverty. This is in part because of their low level of formal education, which is especially applicable to migrants from Turkey (74% of these have only compulsory education) or from countries of the former Yugoslavian Republic (39% of these have only compulsory education. In contrast, migrants from EU25 countries have a high level of education 385, those from Western-European countries even have a significantly higher level of education than Austrian nationals. 386 Based on the report on Employment and working conditions of migrant workers, published in 2007 by the European Foundation for the Improvement of Living and Working Conditions 387, factors hindering labour market opportunities of migrant workers in Austria are the existence of fewer opportunities for training, work related mobility and self-development as well as language barriers. Sometimes skills and qualifications of the migrant worker s home country are not recognised in Austria Unemployment Data on unemployment is subject to frequent change and depends considerably on the economic situation of a country. In January 2010 Austria registered 402,000 unemployed (including 79,000 in training courses), amounting to an unemployment rate of 8.9% 388. The share of long-term unemployed (one year or longer without employment) comprised 2.6% of the officially registered 323,000 unemployed. 389 Based on data from Eurostat 2006 (first quarter), migrant workers make up about 10.3% of the total labour force. The rate of economic activity of non-nationals from EU25 countries in Austria, which was situated at 76.5%, was higher than the economic activity rate of nationals (72.7%) whereas the economic activity rate of non-eu25 citizens (64.8%) was below the rate of the nationals. The unemployment rate of nationals in 2009 was situated at 4.6%, wheras that of non-nationals from EU25 was 8.5% and that of non-eu25 citizens was 15.8% Atypical working arrangements Atypical working arrangements (part-time work, holding more than one job, freelance work, personnel leasing or contract for services work) are increasing. Public policy has partially reacted to this 381 Statistics Austria (2009). Education in figures 2007/08. Key indicators and analyses. Vienna Statistics Austria. Based on data of the population census Accessed at on 4 October Statistics Austria. Based on data of the population census Accessed at: rzelle_ pdf 384 Statistics Austria (2009). Education in figures 2007/08. Key indicators and analyses. Vienna ÖGPP Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December Statistics Austria (2009). Education in figures 2007/08. Key indicators and analyses. Vienna European Foundation for the Improvement of Living and Working Conditions 2007: Employment and working conditions of migrant workers According to the Austrian definition. Using the Eurostat calculations the unemployment rate as of January 2010 is situated at 5.4% 389 Public Employment Service Austria, Arbeitsmarktservice (AMS), accessed at on 3 March 2010 April

176 development by including different types of employment into the statutory social insurance scheme The increase in atypical working arrangements is seen across many economic sectors but shows a higher concentration in sectors such as agriculture, trade, tourism or health services. Atypical working arrangements usually affect women more than men and are also more prevalent among individuals with lower qualifications. Another factor leading to the deterioration of employment conditions can be economically unfaviourable conditions which lead some companies to either reduce their staff or to modify employment conditions in order to contain ancillary labour costs (e.g. by changing employment contracts to contracts for services or freelance working arrangement or by reducing the number of employees or the number of hours these work). Compared to other European countries (EU-27), the share of women in part-time employment is quite high in Austria and only topped by the Netherlands, Switzerland, Germany, Norway and the UK. The share of men working part-time is still comparably low, being highest in the Netherlands, Norway and Switzerland. 392 These circumstances are obviously very closely linked to family policy issues (maternal leave, child benefits, child care facilities, etc). In Austria migrant workers are more often employed by means of temporary contracts than nationals. This is related to the large number of migrants working as seasonal workers. Part time work generally shows a higher prevalence among women, especially among migrant women. 393 Moreover migrant workers appear to work irregular hours or overtime more often than nationals Lack of insurance coverage About 98.8% of the Austrian population are covered by statutory social health insurance. 394 Some of those who are not covered have chosen to take out voluntary social health insurance, others have decided to voluntarily opt out of the system (this is only possible for a small group of individuals). Further details on insurance coverage are provided in section 2 of this chapter. At the end of June 2003 up to 3.1% of the Austrian resident population of the age of 15 years and older was not covered by social health insurance. 395 Of these 0.7% had taken out substitutive private insurance (opting-out cases) and 2.4% were without any (registered) entitlement to services in case of illness. 396 Data for children are not known. 397 According to statistics of the Main Association of 390 Fink, M., Riesenfelder, A., Tálos, E. (2001). Final Report. Atypical Working conditions. Co-operation of L&R Sozialforschung/social research and the Institute of State- and Politital Sciences of the University of Vienna. 6 December Vienna. 391 ÖGPP Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg 393 OECD data, referred to in European Foundation for the Improvement of Living and Working Conditions 2007: Employment and working conditions of migrant workers Main Association of Austrian Social Security Institutions (2009). Social insurance in figures. Accessed at df on 3 June Fuchs, M, et al. (2003). Quantitative and qualitative assessment and analysis of individuals not covered by health insurance in Austria, Final report October 2003, Report commissioned by the Federal Ministry of Health and Women. 396 Maximum values 397 Fuchs, M, et al. (2003). Quantitative and qualitative assessment and analysis of individuals not covered by health insurance in Austria, Final report October 2003, Report commissioned by the Federal Ministry of Health and Women. April

177 Austrian social security institutions this share has dropped after 2003 (to 1.2% respectively 100,000 individuals in 2008). 398 Austria has a statutory social health insurance system which bases insurance coverage and insurance status on employment or other (e.g. regional) criteria. Employed as well as self-employed, whose income exceeds a defined limit, are subject to compulsory social insurance. Pensioners, unemployed (entitled to unemployment benefits), individuals receiving child benefits and war veterans are also included in the system. Dependent children and certain other individuals living in the same household are also incured. The vast majority of individuals cannot choose their health insurance fund. Based on the findings of the study by Fuchs et al., which was commissioned in the course of the National Action Plan to Combat Poverty and Social Exclusion , measures to extend social insurance coverage were defined in 2004 such as ensuring basic coverage for foreigners in need of assistance (asylum seekers). Social health insurance coverage will be extended to recipients of social welfare benefits as a consequence of the introduction of a general minimum collateral, which is planned to happen in September The legislation basis for the minimum collateral is the agreement according to article 15a of the Federal Constitutional Act. A lack of insurance coverage should in principal be met by the social welfare systems of the provinces. Health services can be accessed if recipients meet defined criteria (e.g. 3 years of residency). 400 Individuals without insurance are mainly unemployed (without entitlement to unemployed benefits 401 ), illegal/undocumented immigrants or refugees/asylum seekers. Lack of insurance also affects individuals working part-time with a monthly income below a defined threshold (liable to insurance registration) who do not take out voluntary insurance, women loosing their insurance coverage as a dependent following divorce, children who loose their insurance coverage as a dependent due to their advanced age (usually older than 27 years) 402 or individuals who, for reasons of shame, do not claim social welfare benefits and thereby forgo their entitlement to social insurance coverage. Another visible trend changing the insurance landscape is the rise of atypical working arrangements (referred to in the previous sub-section). Some of these individuals do not reach the income limit for statutory insurance but may however not take out voluntary insurance because they cannot afford paying the contributions. Several individuals without insurance coverage are not insured because of a lack of information, e.g. not taking waiting periods into consideration, not being aware that they will loose their insurance coverage following divorce or at a certain age (students). Some people are without insurance because they experience severe difficulties when it comes to organising their lives, e.g. due to a personal crisis, drug abuse or mental illness Fuchs, M. (2009). Not insured persons in Austria: empiric findings and methods of resolution (Nicht krankenversicherte Personen in Österreich: empirische Erkenntnisse und Lösungsansätze). Journal of Austrian Social insurance Soziale Sicherheit. June 2009, pp Ibid Federal Ministry of Labour, Social Affairs and Consumer Protection, Homepage, Frequently asked questions, accessed at on 15 February Ibid 401 According to Fuchs (2009) this affected 212,000 registered unemployed individuals in 2008 and on average about 9.6% of the unemployed population. Some of these individuals may be entitled to insurance as a dependent. 402 This mostly affects students. Based on Fuchs (2009). 0.4% of the respondents of a survey on students and social issues undertaken in 2006 stated that they were not covered by social health insurance. 403 Fuchs, M. (2009). Not insured persons in Austria: empiric findings and methods of resolution (Nicht krankenversicherte Personen in Österreich: empirische Erkenntnisse und Lösungsansätze). Journal of Austrian Social insurance Soziale Sicherheit. June 2009, pp April

178 According to the Austrian Poverty Network, all of those lacking social health insurance coverage have a low income. 2/3 of these are without insurance coverage for the first time whereas 1/3 has experienced this situation before. 404 Individuals without insurance coverage tend to more often be men than women. 405 Non-nationals are over-represented among the population without insurance coverage. 406 Based on national reports, 109,000 migrant workers were employed full-time in undeclared jobs in 2002, compared with nationals in the same situation. 407 Areas of work in which this is common are: agriculture, tourism, catering, construction work, household services, health care, childcare and cleaning Migration background 409 Migration is influenced by a range of factors, including economic, political and social aspects. Austria has one of the biggest non-national populations in the EU25. In the past Austria has experienced considerable growth with respect to the amount of foreign citizens residing within the country. This was largely due to more people from outside the EU-25 countries coming to Austria. According to data from Eurostat 2006 (first quarter), the share of non-nationals from EU25 countries 410 of the total population in Austria amounts to 2.8%, the share of non-eu25 citizens to 7% and the share of nonnationals in total to 9.8%. The largest group of individuals without Austrian citizenship residing in Austria is from one of the countries of the former Yugoslavian Republic (about 37%); Turkish citizens represent the second largest group (about 14%). 411 Migrants are a population group especially threatened by poverty. In total 27% of all people at risk of poverty live in a household with a migration background. 412 About 3.1% of the Austrian population are individuals born in Austria who have parents with a migration background Asylum seekers, undocumented immigrants Based on an estimate made in an Austrian study, in 2002 there were judged to be about 80, ,000 persons residing illegally in Austria Document Not-insured (Nichtversicherung) of the Poverty Network, Reference to a study of the European Centre for Social Welfare Policy and Research (Europäisches Zentrum für Wohlfahrtspolitik und Sozialforschung) 405 Showing a strong representation of the men aged years 406 Fuchs, M, et al. (2003). Quantitative and qualitative assessment and analysis of individuals not covered by health insurance in Austria, Final report October 2003, Report commissioned by the Federal Ministry of Health and Women. 407 European Foundation for the Improvement of Living and Working Conditions 2007: Employment and working conditions of migrant workers ÖGPP - Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December For international definitions of terms (e.g. migration, immigrant, asylum seeker, refugee see for instance: European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg, Chapter 3, pp. 163ff. 410 All Member states apart from Bulgaria and Romania, which joined the EU on 1 January Forschungs- und Beratungsstelle Arbeitswelt (2007). Undocumented Worker Transitions. Austria. Country Report. Work Package 2. July 2007., p.3. Accessed at on 2 October ÖGPP - Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December Statistics Austria (2009). Education in figures 2007/08. Key indicators and analyses. Vienna Federal Ministry of Health and Women (2003). Quantitative and qualitative assessment and analysis of individuals not covered by health insurance in Austria, Final report. April

179 Illegal immigration is difficult to measure but is an important issue in Austria. In 2006 the Austrian Alien Police reported 63,971 cases of undocumented migrant presence as well as documenting 17,100 cases of organised human smuggling. 415 In comparison to other European countries (EU-27), Austria shows one of the highest numbers of asylum applications (persons) and is only topped by Sweden, France, the United Kingdom, Greece and Germany). According to Eurostat data, the number of applications (persons) has dropped from a high of 39,355 in 2002 to 22,460 in 2005 and to 11,920 in Based on another source fewer, namely 36,990 applications for asylum were registered in The positive execution of asylum applications varies considerably with respect to the country of origin of the asylum seeker, the applications from Russian nationals (Chechens) being accepted far more often than for instance those from individuals from India or Nigeria. No offcial data exist. 417 According to Eurostat, 41.4% of asylum decisions (from the total number of decisions) experienced rejections in 2007 (37.9% in 2006). 418 A considerable number of citizens from Turkey and the successor states of the former Yugoslavian Republic have come to live in Austria, whereas numerous citizens of other nationalities (e.g. nationals of India, Bangladesh, China, Bulgaria, Romania or African countries) use Austria as a transit country when heading to other countries in Western Europe Children and young people In 2009 the share of children in Austria (0-14 years) was 15.1 %. 421 About 250,000 children and young people in Austria are either at risk of or threatened by poverty. 422 Risk factors of child poverty are: having a migration background, living in a family with one working parent only or in a household with more than two children as well as living in a city. To have both parents working appears to be a protective factor, single parent families are more likely to be at risk of poverty. Other risk factors are parents who are unemployed or parents with a low level of education ( inheriting level of education ). Children in poor families tend to live in small flats or poor housing conditions, which places an additional burden on them. 423 Other children in need of special attention or protection, apart from those affected by poverty or those with a migration background, are children of families in which one or both parents are ill 415 ÖGPP - Austrian Society for Policy Consultation and Development (Österreichische Geselleschaft für Politikberatung und Politikentwicklung) (2008). 2nd Report on Poverty and Wealth for Austria (2. Armuts- und Reichtumsbericht für Österreich).Vienna. December European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg 417 Forschungs- und Beratungsstelle Arbeitswelt (2007). Undocumented Worker Transitions. Austria. Country Report. Work Package 2. July 2007., p.3. Accessed at on 2 October European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg 419 European Foundation for the Improvement of Living and Working Conditions 2007: Employment and working conditions of migrant workers IOM International Organization for Migration, EMN National Contact Point Austria within the European Migration Networt (2005). Illegal Immigration in Austria. A survey of recent Austrian migration research. Vienna Accessed at on 2 September Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 23 March Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the Federal Ministry of Health, Family and Youth. Vienna Network Childrens Rights Austria. Accessed at on 9 October 2009 based on Till-Tentschert, U., Vana, I. (Eds.) (2009). Growing up in poverty. Empirical findings on poverty of children and young people in Austria. University of Vienna. Institute of Sociology Vienna. March Download available at soziologiesem._2008.pdf April

180 (mental or physical illness), or children of families which are subject to poor housing conditions or domestic violence, etc Elderly The largest share of the Austrian population is, like in all other European countries, made up by the population aged 25 to 49 years (37.6% in 2007). The share of the population between 50 and 64 years amounted to 17.6%, the share of the population between 65 and 79 years to 12.4% and the share of the population of 80 years and older to 4.5%. 424 Based on national statistics for the year 2008, about a fifth of the Austrian population is 60 years and older. The share of the population older than 75 years is increasing rapidly. 425 According to the population prognosis of Statistics Austria (2009), the share of indivudals older than 65 years in Austria will increase from 17.4% to 28% in Findings of EU-SILC 2006 show that 28% of pensioners living in single households are at the risk of poverty. The share of old people is highest in the provinces of Burgenland, Carinthia, Styria and Lower Austria and lower in the Western provinces of Austria Gender aspects Gender medicine has gradually moved into the focus of attention, showing that men or women may be more affected by certain conditions, may be more prone to develop certain diseases or may display different a behaviour when accessing and utilising health services. About 51.4% of the Austrian population were women in Whereas men are overrepresented in younger and middle age groups, the share of women increases above the age of 50 years and becomes noticeably dominant for the age group of the over 90 year olds. The larger share of elderly women is due to differences in life expectancy and a consequence of the Second World War Impact of the disadvantage on the health status Subsequently potential consequences of the before listed disadvantages experienced by certain individuals or population groups on the health status and health behaviour, and, where available, on the mortality and morbidity of these, are described. Readers will notice a certain degree of overlap among the different groups; this cannot be avoided due to the multidimensional nature of the risk factors of poor health. With regard to employment, a reverse causality exists due to the fact that on the one hand certain employment conditions, lack of employment or poverty can lead to the development of health problems and that on the other hand also poor health can result in reduced chances for professional development, loss of employment and ultimately poverty. Equally there is a strong dependence between the level of education and the level of income with a higher level of education usually resulting in a higher level of income. As both factors, income and education, have a strong effect on health, the impact of a low level of education combined with a low level of income or poverty, can result in an even higher probability and more pronounced scope of health problems. 424 European Communities (2009). Europe in Figures. Eurostat yearbook Luxembourg 425 Statistics Austria (2009). Demographic Yearbook Accessed at on 23 March Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 23 March Statistics Austria (2009). Demographic Yearbook Accessed at on 23 March 2010 April

181 Poverty or low income furthermore influences the living conditions of individuals. Those with a low income may have to in addition put up with worse living conditions (less space, more noise, dampness, darkness, unpopular location, etc.) which can have a significant impact on their health status Poverty, low level of income Poverty and deprivation can affect individuals in a variety of different ways, including impacts on their living conditions, their social contacts or their consumption habits. Poverty can also result in individuals showing a higher prevalence of certain health problems. Mortality Findings in Austrian research show a correlation between the socio-economic status of a person and the mortality due to cancer. It is stronger for some types of cancer (lung cancer) whereas no significant relationship could be determined for e.g. prostate cancer. Morbidity Individuals threatened by poverty more frequently report a subjectively lower health status and more often show signs of chronic illness (23% respectively 17% of the total population). This group of people equally shows a larger tendency towards experiencing health problems such as obesity, depression or headache. Smoking behaviour and the amount of physical exercise undertaken by individuals do not show a strong correlation with the level of income of the individuals questioned in the course of the Austrian health survey. Women who are at risk of poverty, display a higher risk of having diabetes or high blood pressure. 428 Health status, health behaviour According to the Income, Poverty and Living Conditions report of Statistics Austria which analyses data from EU-SILC 2007, about 10% of the population living below the poverty level do not feel well respectively 12% feel strongly restricted by disability. The report by Statistics Austria on Socio-demographic and socio-economic determinants of health, which was published in 2008 and is based on the national health survey, confirms this, reporting that people with a lower level of income quote their health status as very good or good less often than people with a higher level of income Low level of education A low level of education influences the perceived health status of indivudals and their morbidity as well as their utilisation of health care services. Morbidity 429 Findings from the Austrian health survey show that individuals disposing over a lower level of education (compulsory education) report more cases of chronic diseases and pain than individuals with a level of education higher than compulsory education. Men with a lower level of education report suffering from arthosis, arthtitis and rheumatisms of the joints as well as back problems more often than men with a higher level of education. Among women falling ill with cancer of the cervix, the proportion of those with compulsory education is considerably higher than the proportion of those with a university degree. With regard to breast cancer it is surprisingly enough the other way round. 430 Diabetes is more prevalent among 428 Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the Federal Ministry of Health, Family and Youth. Vienna Ibid 430 BMGF (2003) in Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. April

182 women with a lower level of education (3 times higher risk), as is the probability of suffering from considerable pain. Indivduals with a lower level of education experience allergies less often than those with a higher level of education. Health status, health behaviour Based on the health survey undertaken by Statistics Austria, individuals with a higher education judge their health status as being better than those whith a lower level of education. 431 Findings of EU-SILC 2007 confirm that individuals with a higher level of education tended to rate their subjective health status better than individuals with a lower level of education (compulsory education). More education increases disability free life expectancy. Individuals with a higher level of education engage in risky behaviour less often (smoking, unhealthy diet, physical activity). 432 In general, smoking is increasing among women, especially amongst young women with a low level of education Unemployment Mortality and Morbidity For provinces with a high share of unemployed women, a high incidence of cancer of the urinary and the sexual organs was found as well as an above average mortality due to cerebro-vascular disease. 434 A study conducted by the Medical University of Vienna has proven that long term unemployment has psychological implications on health (increased prevalence of depression) as well as influencing physical health. Stress levels and weight appear to increase during unemployment. 435 Health status, health behaviour Results of EU-SILC confirm these findings. About three quarters of people looking for work for less than 6 months report their health status to be very good whereas only 49% of long-term unemployed chose this category. Results of the health survey undertaken by Statistics Austria 436 confirm these findings, showing unemployment has a strong impact on the subjective health status of individuals. Unemployed individuals report their subjective health status as being very good or good far less often than working individuals. Results of the Micro-census of 1999 show that unemployed women do less to maintain their health than working women (placing less importance on healthy nutrition, health promoting exercise, physical exercise, etc.).working and unemployed men did not show such a large difference. Unemployed experience chronic diseases more often, which especially applies to anxiety and depression. Unemployed women tend to be obese more often and also more likely to smoke Atypical working arrangements Atypical working arrangements have a strong impact on the amount of old age insurance an insuree receives and may also be problematic with regard to health insurance, in case individuals are either not 431 Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the Federal Ministry of Health, Family and Youth. Vienna Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the Federal Ministry of Health, Family and Youth. Vienna Schleicher, Hlava (2003) in Habl (2008) and BMGFJ/Statistics Austria Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 435 Egger et al. (2006) in Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 436 Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the Federal Ministry of Health, Family and Youth. Vienna April

183 registered for social insurance by their employers, work on an informal basis or have no insurance entitlement for any other reason. In the past social insurance has aimed to extend insurance coverage to as many members of the Austrian population as possible. In the course of doing so, idividuals working in atypical working arrangements (e.g. freelance workers, self-employed without a business licence, individuals working on a part-time basis) have to a large extent also been included in the statutory social insurance scheme. Changes in working arrangements, which may be accompanied by greater instability for the individual, have, among other developments in the labour market, also lead to households with one or even two earners suddenly finding themselves at risk of poverty. The phenonmenon of working poor 437 is increasing in Austria Lack of insurance coverage Very little data exists on the health status and health behaviour of individuals without social insurance coverage in Austria. According to a study by Fuchs et al in 2003 differences in subjective health status reported by insured and not insured were not significantly. 438 A more recent publication, also by Fuchs, reports that especially those individuals who do not have any entitlement to health services (based either on social health insurance or social welfare systems) are endangered to experience severe under-consumption. These individuals may ignore health problems and only seek assistance when symptoms are severe. Based on expert opinion uninsured individuals are more likely to suffer from a poorer health status, characterised by mental health problems, alcohol abuse or social deprivation Migration background Morbidity Based on Pochobradsky et al., lacking language skills and lack of awareness of the Austrian health care system result in migrants accessing health services late, which can lead to a higher prevalence of chronic conditions among members of this population group. Significantly more women with a migrant background suffer from chonic diseases (diabetes, high blood pressure) and pain than women without a migrant background. The share of workers who feel affected by poor health conditions at their workplace is documented to be higher amongst migrants (37%) than among nationals (16%). Whereas the percentage of Austrian workers who felt especially affected by accidents and injury risks was 13% among Austrian workers, it was considerably higher among migrant workers, being situated at 30%. 440 Health status, health behaviour Findings of the Austrian health survey performed by Statistics Austria show a strong correlation between a lower subjective health status and a migration background. Especially migrant women report their health status to be very good or good less often than individuals with no migration background. 437 Based on Statistics Austria defined as individuals between 20 and 64 years of age who dispose over a household income which is situated below the poverty threshold. 438 Fuchs, M, et al. (2003). Quantitative and qualitative assessment and analysis of individuals not covered by health insurance in Austria, Final report October 2003, Report commissioned by the Federal Ministry of Health and Women. 439 Fuchs, M. (2009). Not insured persons in Austria: empiric findings and methods of resolution (Nicht krankenversicherte Personen in Österreich: empirische Erkenntnisse und Lösungsansätze). Journal of Austrian Social insurance Soziale Sicherheit. June 2009, pp European Foundation for the Improvement of Living and Working Conditions 2007: Employment and working conditions of migrant workers April

184 It was also shown that individuals from Turkey or countries of the former Yugoslavian Republic engage in a more risky lifestyle than Austrian citizens, resulting in them being obese more often, smoking more and showing less interest in physical activity Asylum seekers, undocumented immigrants Illegal immigrants (without residence permit) cannot fight for or represent themselves. Several organisations support this population group and raise awareness for their problems and needs among decision makers and the general public. Little accurate data is available on this population group; despite some being collected by NGOs and welfare institutions. 442 Generally speaking, no public social or health care support exists for undocumented migrants. They are not allowed to register with social insurace (health, accident or pension insurance) nor do they receive social welfare benefits. 443 Social services as well as some subsidies are linked to legal residence status and length of residence status. Illegal resident immigrants do have access to emergency health care because hospitals are legally obliged to take in and treat individuals in serious danger. Hospitals can reclaim resulting costs after discharge. Sometimes these remain irrecoverable. In general illegal immigrants have to pay privately for any health care services they require. Because they are afraid of being detected and deported they postpone care or only seek treatment in case of emergency. Many do not have the financial means to afford necessary care. Still hospitals will usually treat undocumented migrants, even if the individual in question does not require emergency care. 444 Research findings show that socially disadvantaged persons, especially asylum seekers, show a higher level of stress than managers. 445 Undocumented immigrants live in constant fear of being reported, detected and deported. Health problems can arise due to psychological strain, isolation, difficult living conditions, lack of stability and separation of family members Children and young people Mortality, Morbidity Among children of 1 to 9 years congenital malformations account for 25.6% of all deaths, followed by illnesses of the nervous system and cancer (both 16.3%) and accidents (14%). 446 The most frequent cause of death among individuals between 10 and 19 years is injuries, accounting for about 30.6% of all deaths. Other common causes are cancer (14.1%), suicide (9.4%), drug abuse and illnesses of the nervous system are (both 8.2%) Statistics Austria (2008). Socio-demographic and socio-economic determinants of health. Commissioned by the Federal Ministry of Health, Family and Youth. Vienna IOM International Organization for Migration, EMN National Contact Point Austria within the European Migration Networt (2005). Illegal Immigration in Austria. A survey of recent Austrian migration research. Vienna Accessed at on 2 September IOM International Organization for Migration, EMN National Contact Point Austria within the European Migration Networt (2005). Illegal Immigration in Austria. A survey of recent Austrian migration research. Vienna Accessed at on 2 September PICUM - Platform for international cooperation on undocumented migrants (2007). Access to Health Care for Undocumented Migrants in Europe. Belgium Poverty Network (2003) in Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 446 Statistics Austria (2009). Yearbook of Health Statistics Vienna Accessed at on 23 March ibid April

185 Among those dying due to traffic accidents, young people (between 15 and 24 years) are overrepresented (31.3%), 16.8% were between 25 and 34 years. Health status, health behaviour Children from families with a low income show a lower health status than those of high income families. Since access to health services is comparable for both groups however, differences are to a large extent related to their unhealthier living conditions and habits. 448 Based on a study performed by Staedler 449 among children in pre-school, children from a socially disadvantaged background (parents with a lower level of education and with a migrant background) require three times as much dental treatment than children without a migrant background with a high level of education. Among 12-year olds, children in grammar schools (Allgemein Höhere Bildende Schule, AHS) had about half as many dental lesions as the respective group of children in Hauptschulen (schools providing education up until the level of compulsory education). A large proportion of treatment costs are spent on a relatively small group of individuals who usually have a lower level of education and do not visit the dentist on a regular basis. A study investigating the dental status of 6-year old children showed that children with a migrant background had significantly worse teeth than those without a migrant background (29% without tooth decay vs. 52% without tooth decay). 450 According to results of the HBSC survey 2005/ , the socio-economic situation of a family influences both the health status and the health behaviour of a child. Children and adolescents from families that were economically better off appeared to be healtier than children and adolescents from families that were not so well off economically. Those of the first group showed a greater risk of being a culprit in bullying or drunk though. Another factor proving to have an influence on the health and health behaviour of the target group is family composition. Children and adolescents from single parent families had, when compared to families with both parents a lower probability of being healthy. Adolescents from families with stepfamilies displayed a higher risk of getting drunk or smoking. Also the school environment was important for the health and health behaviour of the students. Children and adolescents who had a good relationship with their fellow-students and teachers had a higher probability of being healthy. Equally they showed a lower risk to be involved in bullying attacks, to smoke or drink Elderly The elderly population does unfortunately not always receive sufficient attention and their problems may not be heard. With regard to health, it is difficult to identify the stakeholders and experts who are responsible for health issues related to the elderly people in Austria. This is because those responsible are in many cases also responsible for a range of other agendas. Gerontology, which deals with social, psychological and biological aspects of aging and geriatrics, and looks at diseases of the elderly, has, because of the increasing discussion on the aging population, 448 BMSK (2008) National Report on Strategies for Social Protection and Social Inclusion. Accessed at D.pdf on 25 October Städler, P. (2007). Die Situation der Mundgesundheit in Österreich. Dental Tribune Austrian Edition 10 (2007). Pp ÖBIG 451 Dür, W., Griebler, R. (2007). The health of Austrian school students in their living conditions. Results of the WHO-HBSC Survey Commissioned by the Federal Ministry of Health, Family and Youth. Vienna Comment of the author: HBSC stands for Health Behaviour in School-aged Children. For further information see The HBSC survey is undertaken among 11-, 13- and 15-year old children in 41 countries of the WHO European Region and North America. April

186 received more attention in the past. Problems of the elderly population involve medical problems, provision related to health care services, social, economic and other problems. Medical problems are for example restricted mobility, instability (risk of falls), lack of control over bodily functions, dependence on others for help, depression, pain, impaired intellect or memory, impaired vision or hearing. Central topics areas in connection with health care provision for the elderly population are the availability of resources for long term care (beds, health professionals, etc.), the management of comorbidities, the management of chronic illnesses, integration of care, co-ordination of providers (inpatient care and ambulatory care but also the collaboration of ambulatory providers among each other) and the use of multiple medications (potentially resulting in interactions) as well as general over-medicalisation. The over-, under and misuse of medical services is also a crucial aspect which should be looked into more closely. Social problems of elderly people are isolation, lack of social integration, contacts and networks. These can lead to loneliness, social withdrawal and also to medical problems such as for instance depression. Economic problems involve problems related to social security, housing, income and financial stability. Other problems, with regard to health of the elderly are insufficient information, lacking knowledge of technology as well as health illiteracy. The older generation is often still used to accepting the instructions of authorities such as doctors without questioning these. Due to the increase in life expectancy and demographic changes, the share of the population composed by older individuals will increase significantly in the future. Even now innovative models, structures, financial resources and skilled labour for long-term care are lacking. In case these issues are not tackled severe shortages and problems are to be expected in the future Gender aspects Life expectancy The life expectancy of men at birth is 77.6 years, female life expectancy at birth amounted to 83.0 years in The gap in life expectancy between men and women has been decreasing over the past decades. 452 Mortality The death rate of men dying from a heart attack is still double the rate of women. 453 The risk of dying from lung cancer has dropped for men since 1998 whereas it has increased for women. Still men have a 2.5 times higher risk. The risk of dying from cancer was 58.9% higher for males than it was for females in Men mostly die due to lung cancer, prostate cancer, colon cancer, cancer of the pancreas, stomach cancer and cancer of the liver. The most common causes of death related to cancer among women are breast cancer, lung cancer, cancer of the colon, cancer of the lymphatic and hematopoietic tissue, cancer of the pancreas, ovarian cancer and stomach cancer. Deaths due to injuries or intoxication accounted for 5.5% of total deaths, about 2/3 affecting men. Morbidity Discharges from hospital attributable to women are more than a fifth higher than those attributable to men. For the age group of the population older than 80 years women account for the double to triple amount of discharges than men. These differences are predominantly based in the age structure of the 452 Statistics Austria (2009). Yearbook of Health Statistics Vienna Accessed at on 23 March Ibid April

187 population. Also in the age group years, women display double as many hospital discharges; this is related to pregnancy and births. 454 The risk of falling ill with cancer in 2005 was, based on the age-standardised rates, 1.4 times higher for men than it was for women. Between 1996 and 2005 incidence of new cancers increased for men by 11.1%, for women it dropped by 1.3% in the same time period. In 2007 the majority of AIDS patients were male (78.1%). More than half of the causalities resulting from traffic accidents and three quarters of the fatalities were men. Especially high proportions were reported for drivers of Lorries and motorbikes which may be related to the fact that more men than women use these types of motor vehicles. More than four fifths of occupational diseases affected men. Among the diseases most relevant for the awarding of a disability pension, those of the sceleton, muscles and connective tissue ranked first among males, whereas mental illnesses were most common among females. Health behaviour The Vienna Health and Social Survey of 2001 yielded that the attitude and approach to health depended on gender (women tending to be more active), that health promotion activities increased with age and level of education. Women demonstrated a more critical perception of their health status than men, the difference being especially prominent between women and men of a lower income class. Smoking is increasing, especially amongst young women with a low level of education Regional issues The concentration of individuals with tertiary education increases with the size of the community/city. Cities with a university show an especially high share of university graduates. The concentration varies considerably across the districs within the cities. 456 Mortality Life expectancy at birth was highest in Tyrol and Vorarlberg for both men and women. Infant mortality was highest in Vienna and Lower Austria in 2007 (5.4 respectively 4.4 per 1,000 livebirths) and lowest in Tyrol (2.2 of 1,000 live-births). When looking at regional differences, the data for deaths due to malignant growths of 1998/2004 shows a considerably incidence in the north-east of Austria, in Vienna and especially Lower Austria, but also in parts of Styria. Mortality rates are lowest in parts of Salzburg, Upper Austria, Carinthia and Lower Austria. 457 The regional distribution of death rates due to cardiovascular diseases shows a clear East-West divide, mortality being much higher in the East, North-East and South-East of Austria, especially in Vienna, Lower Austria and Vienna and also in parts of Styria and Upper Austria than in the West and South-West of Austria, in Vorarlberg, in Tyrol, Salzburg and Carinthia. Morbidity In 2005 Carinthia reported the highest age-standardised incidence of new cancer cases, followed by Burgenland and Tyrol.The lowest rates were reported for Upper Austria and Salzburg. The provinces with the highest age-standardised incidence rate for prostate cancer were Vorarlberg, Burgenland and Carinthia, the provinces with the lowest rates were Vienna and Styria. Age-standardised incidence rates for breast cancer were highest in Carinthia, Vienna and Styria and lowest in Vorarlberg and 454 Statistics Austria (2008). Yearbook of Health Statistics Vienna Accessed at on 5 October Schleicher, Hlava (2003) in Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 456 Statistics Austria (2009). Education in figures 2007/08. Key indicators and analyses. Vienna Statistics Austria. Mortality: Malignant growths 1998/2004 regional districts. Accessed at on 5 September 2009 April

188 Upper Austria. Lung cancer incidence rates wer highest in Vienna, Burgenland and Carinthia, lowest in Upper Austria and Salzburg. Vienna is the province with the highest incidence of AIDS cases in 2007, followed by Upper Austria which reported the highest number of deaths due to AIDS, followed by Tyrol and Vienna. April

189 2 Equity of access to curative and public health services In Austria social insurance covers risks of sickness, unemployment, work-related accidents and occupational illness as well as old age. Access to health services is guaranteed for most Austrians by means of coverage by social health insurance (98.8% if the population in 2008). About 46% of the insured population are gainfully employed persons and voluntarily insured persons, 26% are dependents, 25% are pensioners and 3% are others. 458 Austria has a statutory social insurance system whereby coverage is linked to employment and sickness fund affiliation depends on professional and regional aspects. Insurance contributions are based on income and are not related to risk of illness. Dependents can be insured free of charge under certain circumstances. Unemployed who are entitled to cash benefits are insured as well as asylum seekers under federal supervision. Recipients of social welfare benefits recipients will be covered by social health insurance as of September Private health expenditure in Austria amounted to about 23.1% of total health expenditure in Because of the high social health insurance coverage, private health insurance only plays a minor role and is usually offered only in the form of supplementary or complementary instead of substitutive health insurance. In % of the population signed up for private health insurance. 460 The Austrian health care system is characteristed by low-threshold access to (ambulatory and inpatient) health services for the majority of the population, independent of their risk of illness, social status, income, gender or beliefs. Insured have more or less free access to care when visiting contract partners of social insurance. Benefits are financed primarily through the income-dependent contributions paid in equal shares by employers and employees. The benefits package is fairly generous and involves visits to GPs, direct access to nearly all specialists (a referral from a GP is needed for some specialists, e.g. radiologists), hospital care, rehabilitation, physiotherapy, etc. Claiming of benefits (type and scope) is virtually independent of the social insurance contributions made by the insured person. Many services involve user charges, but a variety of exemption mechanism are in place to reduce the burden on defined population groups/individuals. The amount of user charges can depend on the health insurance fund affiliation (e.g. civil servants and self employed pay a certain co-payment per physician visit) or be the same for all insured groups (e.g. prescription charge). About 20% of the insured population is exempt from paying prescription charges. Exemptions are e.g. based on the existence of an infectious, severe or chronic disease, are granted for some types of insured event or benefit (maternity, opportunistic health check-up) or based on the income of the insured. 461 In addition to existing exemptions, an annual cap for prescription charges of 2% of the insured person's annual income was introduced in January Barriers to accessing both curative as well as public health services can be based on financial or employment-related grounds (low income or socio-economic status, atypical employment arrangements, unemployment, lack of insurance coverage), include geographical barriers (not being able to reach a provider within a certain time or in some cases having restricted choice due to for 458 Main Association of Austrian Social Security Institutions (2009). Social insurance in figures. Accessed at df on 3 June Statistics Austria, accessed at on 23 March Ladurner, J. (2008). Private health insurance in Austria. Country questionnaire prepared for the following report: Thomson, S., Mossialos E. et al (2009). Private health insurance in the European Union. Final report. Prepared for the European Commission, Directorate General for Employment, Social Affairs and Equal Opportunities. 24 June LSE Health and Social Care. London School of Economics and Political Science 461 Mossialos, E., Merkur, S., Ladurner, J. et al Incentives and payment systems for physicians in selected countries with a special focus on Austria. Report for the Main Association of Austrian Social Security Institutions. Vienna: Main Association of Austrian Social Security Institutions April

190 instance living in a rural area), cultural barriers (for instance applying to individuals with a migrant background), lack of knowledge and health illiteracy (low level of education, lack of information) or other barriers such as health system barriers (waiting times, administrative barriers), language problems, age, gender or disability. The manner in which information or services are provided may not be user-friendly or easily accessible. It is however important to match these with the level of knowledge and understanding of the targeted population. In September 2010 a needs-orientated minimum collateral is planned to be introduced in Austria. It comprises 12 monthly payments of 733 per year 462 and is aimed at reducing poverty and at defining a national minimum standard. In addition to the collateral every province in Austria can increase the payment by granting further subsidies. The introduction of the minimum collateral also means that social welfare benefits recipients, who were previously not covered by social health insurance, receive an e-card, thus providing them with easy access to health services. 463 Some individuals, who suffer from specific conditions, or require specialised care, may furthermore be restricted with regard to their treatment options as appropriate or sufficient facilities are scarce. This for instance involves facilities for ambulatory neuro-rehabilitation, palliative- and hospice care and psychotherapy. 464 Like in many other countries, disadvantaged and vulnerable population groups (especially those who are not covered by the social health insurance system) receive a considerable amount of assistance and care from NGOs and charities. These face significant financial pressure and often operate under difficult conditions (lack of financial and human resources, insufficient backing, restrictive legislation). Also, several health care institutions or providers offer services at reduced fees or free of charge to for instance illegal immigrants or homeless. The following two chapters look into issues related to equity of access to curative and public health services. Equity of access is based on the idea of equal access for equal need. Data on utilisation are frequently, due to missing data on those individuals not accessing health services, used as a proxy to assess and describe equal access. Research performed on the linkage of utilisation patterns and socioeconomic characteristics of individuals is still very limited in Austria. 2.1 Promoting access to care and healthful lifestyles of disadvantaged groups As described before, social health insurance coverage in Austria is very extensive and includes nearly the entire population. In the past social insurance has tried to extend coverage to as many people as possible, by for instance also including individuals in atypical employment arrangements. A central problem in providing health care services to individuals or population groups in need is the difficulty of identifying and reaching the individuals in question. This is especially complicated in connection with individuals who cannot maintain stable living conditions, including homeless or illegal immigrants. It is however necessary to provide easy and low-threshold access and to pick people up from where they are, live and work. Currently representatives of disadvantaged groups are scarcely involved in the definition, development and implementation of services for disadvantaged groups. Because of lack of research it is not known whether the individuals reached are reached in a correct, adequat and effective way. The direct involvement of those in need and the design of services based on the needs of the potential recipients are essential measures in order to provide targeted services. 462 The amount is based on the height of the compensatory allowance for reduced earnings (Ausgleichszulage) 463 Federal Ministry of Labour, Social Affairs and Consumer Protection, Homepage, Frequently asked questions, accessed at on 15 February BMSK (2008) National Report on Strategies for Social Protection and Social Inclusion. Accessed at D.pdf on 25 October 2009 April

191 Disadvantaged individuals rarely experience only one but rather several burdensome circumstances at the same time, which are partially closely related or entwined and aggravate the situation such as poverty, lack of education, migration background or existance of poor health. Another problem in Austria is the missing co-ordination and integration of health and social services which can result in gaps of service provision. Individuals such as for instance illegal immigrants, who experience difficult and often instable living conditions, will find it hard to achieve continuity of care. Many measures are undertaken to ensure and promote equal access to health care services for those in need. To reach certain groups, however, further information is required on how to identify and approach them in a most effective way. Services aiming at securing and promoting access to care, also for disadvantaged groups are: - Social insurance contributions are defined on the basis of income (contribution base) and independent of personal risk, sex, age or any other personal characteristics. - Individuals, who are lacking insurance coverage for whatever reason, have the possibility of taking out voluntary health insurance, of signing up for private health insurance or of forgoing social insurance coverage totally. Dependents can be insured for free, the co-insurance of partners living in the same household may be subject to a defined fee. - Insurance coverage is frequenly lost because of losing entitlement (e.g. to unemployment benefits). Thereafter individuals may under certain circumstances be entitled to receive emergency benefits which generally also include social health insurance coverage which is granted under the same conditions as it is granted for those receiving unemployment benefits. - The benefits package is fairly comprehensive and even though a variety of user charges exist, exemptions are widely applicable to vulnerable individuals or population groups (depending on income and illness related aspects). - Services can generally be reached within a maximum of about 90 minutes in rural areas; in cities the number of service providers is higher and travelling distances shorter. Some specialists may be difficult to approach, either due to their limited number (e.g. child psychiatrists), due to uncoordinated opening hours, or because of long waiting lists (for an appointment). - Access to health service providers respectively free choice of health providers can be limited for disabled people because disabled access to buildings does not exist in all places or information is not provided in an adequate way for people with for instance hearing impairments or impaired vision. Since 2001 group practices signing a contract with social insurance have to ensure barrierfree access to their facilities. - Information on health services or other health related information is not always available in languages other than German. Especially translation services are frequently lacking. Cultural understanding and sensitivity among providers is partially missing. - Access to certain services (e.g. eligibility for a long-term care cash benefit) may be linked to EUcitizenship and thus not be available to migrants. - Individuals who cannot work because they have to care for a sick family member are, under certain circumstances, covered by social health insurance. Many of these are over-burdened and neglect their own health. This applies to carers in general; even if they do not give up work they may still be subject to considerable emotional and physical burden. Very few services are known which are targeted specifically towards this group of people. - Lack of awareness for the need of health services may be a problem rooted in low health literacy, lack of (appropriate) education and information, but also in the existence of mental illness (insight into illness, distorted perception of reality) - Travel expenses arising in connection with accessing health services which could be used otherwise are covered by social health insurance under certain conditions April

192 - Health insurance funds partially cooperate with associations offering assistance to foreigners and migrants, amongst others with the Austrian Integration Fund or with self help groups - Several pilot projects exist to improve the access to care for migrants and non-german speaking individuals - A range of initiatives exists to inform and educate the insured but also the general population or to increase their awareness for health - A range of health services are also available for individuals without insurance coverage. These include: o o o o o o The right to undertake a yearly preventive health check-up The right to access emergency care in hospitals (hospitals are by law not allowed to send away individuals in need of emergency care; they may however claim costs back after the patient is discharged. Expenses are in several cases irrecoverable) Access to treatment of communicable diseases such as tuberculosis is free of charge for anybody 465 Testing for HIV/AIDS and treatment is free of charge in selected institutions Mother-child-pass examinations are free of charge for all mothers and their children A range of health services are free for children, such as various vaccinations (e.g. measles, rubella and polio) up to the age of 15 years 2.2 Equity of access to curative services The Survey of Healthy Aging and Retirement in Europe showed that the proportion of Austrians quoting to forgo treatment (3.63% of which 2.89% because of costs and 0.74% because of care unavailability) was very low, when compared with other countries (8.46% in France, 6.89% in Germany, 10.51% in Greece, 8.58% in Italy or 6.16% in Sweden). The proportion was only lower in Denmark (3.32%) and the Netherlands (2.54%). 466 In Austria the probability of visiting any doctor, of visiting a specialist or of visiting a hospital shows pro-rich income related inequity whereas the probability of visiting a GP does not show any effects on inequity or is even pro-poor. 467 Based on the Micro-census, socially disadvantaged individuals visit GPs more often whereas they visit specialists, dentists or outpatient departments less often than people with a higher social background. 468 Access to ambulatory care for individuals with a lower socio-economic status may entail longer times for commuting and waiting. 469 Analyses of the Austrian Health Institute (ÖBIG, Österreichisches Bundesinstitut für Gesundheitswesen) confirm these findings, stating that people with lower income, independently of 465 PICUM - Platform for international cooperation on undocumented migrants (2007). Access to Health Care for Undocumented Migrants in Europe. Belgium Survey of Healthy Ageing and Retirement in Europe in Mossialos, E., Merkur, S., Ladurner, J. et al Incentives and payment systems for physicians in selected countries with a special focus on Austria. Report for the Main Association of Austrian Social Security Institutions. Vienna: Main Association of Austrian Social Security Institutions. 467 Mossialos, E., Merkur, S., Ladurner, J. et al Incentives and payment systems for physicians in selected countries with a special focus on Austria. Report for the Main Association of Austrian Social Security Institutions. Vienna: Main Association of Austrian Social Security Institutions. 468 Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 469 Pochobradsky, E., Habl, C., Schleicher, B., Hlava, A. (2002). Social inequality and health care. Study commissioned by the Federal Ministry of Health and Women. Vienna April

193 their age or sex, use more health services than individuals with a higher income. They however access specialists less often than high income earners and often receive less expensive medication. 470 A study of the regional sickness fund of Carinthia confirmed the correlation between poverty and illness, showing that the insured exempt from the prescription charge caused higher expenditures for the sickness fund than other groups of insured. 471 Generally speaking, about 20% of the insured population is exempt from paying prescription charges. The average number of visits of general practitioners drops with a higher level of education. Ambulatory clinics i.e. outpatient departments of hospitals also appear to be used more often by individuals with a lower level of education. The contrary applies to visits to dentists which are more frequented by individuals with a higher level of education. 472 Hofmarcher et al analysed data of the European Community Household Panel (ECHP) in 2003 and reported that women with the lowest level of education consulted GPs most often. Specialists are more frequently visited by individuals with a higher level of education, both men and women. 473 Regulations on user charges are partially heterogeneous and thus unevenly distributed across the different social health insurance funds and their insurees; individuals who are insured based on the General Social Insurance Act (Allgemeines Sozialversicherungsgesetz, ASVG) pay on average more user charges than self-employed or farmers. 474 Studies of Hofmarcher et al. and Wurzer et al. referred to before, both report that elderly use more health services than younger insured and cause higher expenses for the health insurance fund. 475 Unemployed and working women consume far more than the average amount of prescription free drugs. 70% of patients undergoing psychotherapeutic care are women. 476 Women have also been reported to receive two thirds of all antipsychotic drugs and tend to self-medicalise (prescription free medication) more often. 2.3 Equity of access to public health services An ÖBIG report states that socially disadvantaged people tend to make less use of free preventive health services such as the free preventive health check-up and mother-child-pass examinations. 477 This fact is underlined by Micro-census data of 1999, also showing that that participation in the Preventive health check-up health examination increased with the level of education. Also individuals with a migration background use free health examinations (preventive health examinations, cancer examinations) less often than the remaining population. This is confirmed by a report of the regional sickness fund of Upper Austria which shows that migrants use the free health check up (also for individuals without insurance) far less often (< 2%) than citizens with an Austrian nationality (10.9%). 470 BMGF (2003) in Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 471 Wurzer, A., Robinig, R., Rodler, J. (2004). User charges, a review for orientation.. regional sickness fund of Carinthia. Klagenfurt 472 Statistics Austria. Microcensus Hofmarcher, M., Röhrling, G. (2003). What do new user charges in Austria entail? MIMEO, pp Probst, J. User charges Social and health policy contradiction in Wurzer, A., Robinig, R., Rodler, J. (2004). User charges, a review for orientation.. regional sickness fund of Carinthia. Klagenfurt 475 Hofmarcher, M., Röhrling, G. (2003). What do new user charges in Austria entail? MIMEO, pp Wurzer, A., Robinig, R., Rodler, J. (2004). User charges, a review for orientation.. regional sickness fund of Carinthia. Klagenfurt 476 Schleicher Hlava (2003) in Habl, C. (2009). Social inequality and health (Soziale Ungleicheit und Gesundheit) in: Dimmel, N.; Heitzmann, K.; Schenk, M. (Hrsg.): Handbook Poverty (Handbuch Armut). Studienverlag 2009; pp. 172 et. sqq. 477 Pochobradsky, E., Habl, C., Schleicher, B., Hlava, A. (2002). Social inequality and health care. Study commissioned by the Federal Ministry of Health and Women. Vienna April

194 Studies show that women with a migrant background are more likely to use curative services than preventive services. 478 Fewer women originally born in Turkey or one of the countries of former Yugoslavia undergo a cervical smear or breast examination than Austrian women (78% vs. 90%). Findings of the Micro-census of 1999 show that visits to gynaecologists decreased with the age of the woman. The readiness to get vaccinated is generally higher among the working population than among the unemployed. Individuals with a migration background (Turkey, former Yugoslavia) are more often not vaccinated than individuals without a migration background. People with a lower social status access preventive health cechk-up less often than those with a higher social status and undertake fewer efforts to maintain their health status. They may moreover have restricted access to information on health care and provision of health services. 479 In their study on social inequality and health care, Pochobradsky et al. investigated whether individuals exempt from the prescription charge were more or less likely to attend the preventive (health). Women exempt from prescription charges (43% more) went to the examination whereas fewer men who were exempt from the prescription charge went to the health examination than men who were not exempt. 480 Data of the Austrian health survey show that willingness to be vaccinated increases with the level of education and that the actual use of vaccinations (Tick-Borne Encephalitis, Hepatitis A and B) increases with a higher level of income. The Austrian health survey conducted by Statistics Austria also proved that use of preventive health check-ups (periodic health examination, PSA test, PAP smear, PSA testing or mammography) increases with a higher level of education and also with a higher level of income. Professional status appears to be significant as far as participation in PSA testing, health examinations and cancer smears is concerned. Results of this health survey displayed that individuals with a high level of education show a lower tendency towards risky behaviour. They also use preventive measures more often than individuals with a low level of education. The first Austrian Men s report concluded that men welcomed a personal invitation to the preventive health.. It also stated that men tended to wait longer before seeking care than women, often not before they had experienced symptoms for a longer period of time. The share of men in Austria taking advantage of the preventive health examination amounted to about 8.8% ( ) 481, in Vienna to roughly 13% (1999). 2.4 Selected health services for disadvantaged groups Several services exist for individuals who belong to one or more than one of the disadvantaged or special need groups identified in chapter 1 of this section. Activities appear to be focussed on Vienna. It was, within the course of this study, not possible to undertake a comprehensive assessment of these services. Neither was it possible to analyse or define regional differences in need as this would require further quantitative analysis, going beyong the scope of this report. Various NGOs and charities offer health services or facilitate access to health services for vulnerable individuals (e.g. those lacking social insurance coverage) by for instance engaging in co-operations with health care institutions or providers or asking for reduced fees/free access. Several of these initiatives and services are subsequently listed. 478 Women s Health report 2005/2006, Viennese Women s Health Report Habl, C. (2004). Options for reducing social inequalities in health care. WISO 2, pp Pochobradsky, E., Habl, C., Schleicher, B., Hlava, A. (2002). Social inequality and health care. Study commissioned by the Federal Ministry of Health and Women. Vienna 481 ÖBIG (2004). First Men s Health Report. Commissioned by BMGF. Accessed at on 9 June 2009 April

195 Free treatment or low threshold access to free health services appears to be mostly concentrated in Vienna, the capital of Austria. AMBER MED (Medical and Social Advisory Services in Vienna) is operated by the Deacony/Protestant Relief Organisation (Diakonie/Evangelisches Hilfswerk) in cooperation with the Austrian Red Cross and offers anonymous and discrete ambulatory medical care, easy access to medical treatment and social counselling and medication for individuals without social health insurance and in need of special care. 482 Aidshilfe Wien provides counselling, testing and treatment to individuals with HIV/AIDS. Care is anonymous, illegal immigrants can receive retroviral treatment as well as social and psychological support. 483 Other initiatives are organised by Caritas, Asyl in Not (Asylum in Need: support committee for individuals who are subject to prosecution for political reasons), Verein Ute Bock (Ute Bock Association: refugee project providing counselling, educational programmes and practical help) and Deserteurs- und Flüchtlingsberatung (Counseling for Deserts and Refugees: offers counselling to refugees and migrants and refers them to other facilities and organisations which may assist them). All of these are situated in Vienna. 484 Karwan house is a house run by Caritas which offers temporary accomodation services to asylum seekers. It provides accommodation for about 180 persons (individuals and families) and grants stays from a couple of days to up to about 1 ½ years. The Hippokrates Project in the Karawan house aims to offer asylum seekers basic medical care. Ganslwirt in Vienna 485 is a project run by the Association Vienna Social Projects in the form of an ambulatory clinic. Individuals without insurance coverage are offered medical consultations and treatment, wound treatment, HIV testing, vaccinations against hepatitis and influenza, treatment of medical conditions related to detoxification, pregnancy tests, advice on safe sex and information on the use and adverse effects of drugs as well as any other questions related to drug abuse. 486 Association Hemayat is specialised in providing medical, psychological and psychotherapeutic treatment and counseling to survivors of toture and war. 487 The ZEBRA 488 association (Centre for medical, juridical and cultural assistance for foreigners (migrants and refugees) in Austria) in Graz offers health related services such as counselling and the procurement of medical treatment. Several health care institutions (e.g. hospitals of religious orders such as the Hospital of the Brothers of Saint John/Krankenhaus der Barmherzigen Brüder in Vienna or Graz or the Hospital Göttlicher Heiland in Vienna) provide a wide range of services related to inpatient and outpatient care to undocumented migrants free of charge. A range of medical specialists co-operates with the above listed institutions. Organisations in other Austrian provinces, for example in Styria, are OMEGA in Graz, which cooperates with Caritas Graz to execute the project Marienambulanz 489 which offers primary care services to uninsured and homeless people in the city of Graz. 482 AMBER-MED, accessed at on 8 October PICUM - Platform for international cooperation on undocumented migrants (2007). Access to Health Care for Undocumented Migrants in Europe. Belgium Aidshilfe Vienna, see PICUM - Platform for international cooperation on undocumented migrants (2007). Access to Health Care for Undocumented Migrants in Europe. Belgium Association Ute Bock, see Asyl in Not, see Named after the restaurant which previously used the premises 486 Ganslwirt. Ambulatory clinic. Accessed at Centre for sociomedical, legal and cultural support of foreigners/migrants, accessed at April

196 The Red Cross Pharmaceutical Depot gives prescribed medication to uninsured people for free. The Louise-Bus Caritas Mobile Unit, which was initiated in 1991 and is run by the Caritas and the Fund for a Social Vienna (Fonds Soziales Wien), offers medical assistance to homeless and uninsured people at seven different places in Vienna. In 2008 more than 1700 individuals were attended to including about 7000 treatments. The majority of these were related to dermatological problems, diseases of the respiratory system and diseases of the muscosceletal system. 490 Several state-run advice centres offer information for illegal immigrants. 489 Marienabulanz Steiermark Teufl, I. (2009). The rolling physician practice (Die rollende Arztpraxis). Daily newspaper Kurier, pp. 19 April

197 3 Potential role of social insurance It is the responsibility and obligation of social insurance to put the needs of its insured population at the centre of interest and to represent its insurees in the best possible way. Having a health system built on principles of solidarity in Austria, social insurance however intends to not limit its activities to its members only but take a broader view and also identify the needs of the population lacking insurance coverage, ultimately aiming to include these in the system of coverage. Social insurance can act as a spokesperson, opinion leader and representative of both its insured population and also the general population. Before implementing measures for a certain population group or selected individuals, it is essential to identify these target groups and explore their needs and problems. Research and data on aspects related to their health status, health behaviour, utilisation of health services and health outcomes of disadvantaged groups is still quite limited. Social insurance could promote the introduction of new indicators (e.g. ethnicity) to its insurance data and encourage the building of adequate and practicable databases as well as funding external or undertaking own research. External research could also be based on research co-operations. Social insurance disposes over a large net of contract providers who provide services to a very diverse population. Through these provider structures the individuals in special need could be identified and addressed by means of a low-threshold approach. In this context reimbursement and incentive mechanisms could play a crucial role. Providers moreover need to be trained adequately to be sensitive to the specific needs of certain patient groups respectively individuals. As a key rule, representatives or members of the concerned population should be involved in the definition, development and implementation of any new measures aimed at improving and promoting the health of the population in question. With regard to the elderly population, specific problems which urgently require addressing are the prevention of falls (promotion of stability and independence), tackling the problem of over-, underand misuse of resources, focusing on polymedication and individuals suffering from multimorbidities and the approapriate provision of services for these. To improve continuity of care approaches such as disease management and case management should be promoted. Information, access to information, understanding of the language and knowledge can determine whether individuals decide to utilise or forgo health services as well as having an influence on the effectiveness of their service utilisation (e.g. expressed by the compliance of service users). Social insurance could support individuals by making sure that administrative structures are easily accessible and that relevant information is provided in a low-threshold, user-friendly and understandable way, thereby making use of various communication channels and multi-language services. Social insurance should aim to create awareness, build knowledge and educate the population. Readability of the information provided respectively the provision of information which is matched to the individual s status of health competence and knowledge, is key and must be ensured in order to be effective. For individuals with a migration background special services and strategies are necessary. Especially with this population it is vital to involve representatives in the development of new concepts. The provision of multi-language information (using a variety of media) and the offering of widespread translation services are important requirements to address this target group. Individuals at risk of or threatened by poverty need to be approached in their own settings. Some of them are simply fighting to survive and have given up taking care of their health status. Social insurance already has ways and could create additional channels to reach these people. Projects and initiatives targeted at such individuals (see Chapter 2.4) could be supported financially or by other means, e.g. co-operations. The promotion of the health of children and young people should be a core interest of social insurance. Special concepts for this population group could be drawn up. April

198 4 Conclusions Promoting the health of disadvantaged and special need groups is a societal responsibility which should involve the efforts of all stakeholders in a concerted and structured way. In Austria these population groups, and consequently their health status, are not high on the political agenda. This is due to many reasons, one of them being that many of these groups do not have any representatives or lobby behind them, another one being that the concept of disadvantage or special need is not clearly defined. Austria shows a very high level of coverage through the statutory social insurance system, with only 1-2% of the population remaining without insurance coverage. These individuals require special attention. Even though the majority of the population is covered, this does not mean that everybody has equal access to or shows equal utilisation of health services, according to their needs; barriers to access remain and have financial, geographical, information, knowledge, system-related (administrative) and cultural reasons. Groups identified as being at a disadvantage or having special needs in this section of the report are: those being at risk of or threatened by poverty, those with a low level of income, a low level of education, those seeking work i.e. being unemployed or those in atypical working arrangements; moreover those without insurance coverage or those with a migration background, and thereof especially undocumented/illegal immigrants and/or asylum seekers. Also those in need of special assistance or protection such as certain groups of particularly vulnerable children or elderly can be disadvantaged. For these groups first the scope of the population affected and then the potential impact of the experienced disadvantage on their health were outlined. Research regarding the health of disadvantaged and special need groups has developed in Austria over the past years but is still limited. Findings give good indications of core problems and suggestions for acions but further research, especially quantitative research, is needed. In order to address and reach vulnerable individuals and population groups it is necessary that these are better identified and segmented. This is complicated because of the difficulty of linking existing databases, because of gaps in data collection and reporting but also because of the complex nature of the issue itself, namely the multiple and interacting determinants of poor subjective and/or objective health (e.g. poverty, lack of education, migration background). The subject of disadvantaged and special need groups is a topic concerning all sectors. It affects a great number of different professionals. At present institutions involved in health related matters and in social services do, according to experts, not co-operate as effectively as they could. The publication of the National Report on Strategies for Social Protection and Social Inclusion by the then Ministry of Social Affairs and Consumer Protection (now Federal Ministry of Labour, Social Affairs and Consumer Protection) in 2008 is a promising example of how different stakeholders can be involved i.e. co-operate successfully. However closer co-operation as well as structured and standardised communication are needed. Analysed literature shows that certain population groups tend to utilise fewer preventive services (including those free of charge) than the average population. Influencing factors seem to be the level of education and the level of income. Also aspects such as cultural behaviour (migration background) and gender aspects appear to influence utilisation patterns. The lack of accessesing preventive services can result in individuals seeking help when health problems are more severe or have even developed into chronic conditions. This should be avoided by emphasising the importance of early intervention. GPs and other professionals acting as points of first contact to the health care system are of considerable value when identifying and approaching individuals in need. Data of the SHARE survey 491 or the ECHP 492 have shown that individuals with a lower income are more likely to visit GPs 491 Survey on Healthy Ageing and Retirement in Europe 492 European Community Household Panel April

199 than specialists. GPs tend to follow patients over a longer period of time than specialists, thus being more likely to detect unfavourable developments or events at an early stage. Several services exist for individuals who belong to the disadvantaged or special need groups identified in chapter 1 of this section. Activities are more present in Vienna than in other Austrian cities. Services listed however present only a selection of those available. A comprehensive assessment of any existing services (with regard to their scope and cost-effectiveness) as well as a projection of future demand based on needs is necessary to draw further conclusions. Social insurance has a range of potential roles when it comes to promoting the health of disadvantaged and special need groups. Improving the quality and availability of data could facilitate their identification. Social insurance could furthermore act as a spokesperson and opinionleader in this field and promote further research or engage in research co-operations. Also with regard to service provision social insurance could take various steps. It could define targets and priority measures for selected groups (e.g. elderly, children, non-nationals, unemployed, highusers), thereby attributing more weight to the topic in general. It could moreover improve access to services by reducing barriers such as knowledge, information or language barriers, e.g. by providing quality assured user-friendly information through various channels. Activities for disadvantaged or special need groups should involve those directly affected to ensure that their needs are addressed in the most adequate and effective way. April

200 Section V: Health professionals and public health 1 Public health professionals in Austria The field of public health in Austria is strongly dominated by medical professionals who either work for one of the public health authorities on different levels of the health system (as medical officers), for a health system stakeholder such as for instance social insurance, at university or another research institution. Naturally also physicians operating in the clincal environment, such as for instance in hospitals, private practices or rehabilitation centres, or doctors working in the occupational/work setting undertake services which are central to public health, involving services related to prevention, disease control or health promotion. Their focus of activity predominantly lies on curative services though. This is motivated by professional training as well as general financing and reimbursement structures applied in the Austrian health system, which do not encourage providers to undertake preventive- or health promotion services. The responsibilities involved in the provision of many of these services are not clearly regulated and they are usually not or only poorly reimbursed when compared with curative services. Physicians potentially tend to overestimate their current contribution to and role with regard to public health services. Other health professionals such as nurses, pharmacologists, midwives or therapists are slowly moving into the field of public health by acquiring formal training, e.g. in the form of an Master of Public Health degree. For most of these, but especially for nurses it is still not easy to enter such programmes and to use the acquired training in an effective way. Acknowledgement of such a training, for instance in the form of a competitive reimbursement and (extended) responsibilities is in many cases not guaranteed or not given. Individuals with a no background in health such as for instance graduates of social sciences are also increasingly represented in public health positions and in training programmes. In general, acceptance for multidisciplinarity is increasing. Career paths in public health are often non existent or not well defined in Austria. Medical careers (e.g. medical specialisations) are defined best whereas career paths for non-medical professionals are still intransparent. Research positions and other public health positions are often poorly paid and offer limited career opportunities and perspectives. It appears that, for physicians, two factors feature strong motivators for moving into a public health related positon, one being genuine interest in the topic and the other being more or less clearly defined working hours without the need to do on-call work. Such jobs are therefore especially attractive for women doctors with children who are partially still confronted with considerable obstacles when trying to work part time in a hospital. Further details on career paths and opportunities for public health professionals can be found in chapter of this section. A considerable number of physicians in Austria still believe that the field of public health lies within their sole area of responsibility and scrutinize the involvement of other professionals respectively the multidisciplinary nature of public health. However medical doctors who do not pursue the specialty of social medicine, occupational medicine or who do not work as medical officers for the health authorities, as company physicians or at university (in public health related positions) will normally have acquired only a very small amount of training in public health during their medical studies or afterwards. The curriculum for medical students was modified in A selected number of students piloted the new curriculum in Since then several changes have been made which are detailed in chapter of this report. Through the postgraduate training programmes in public health and the undergraduate programmes in related subjects (health promotion, health care management), which have been established in Austria over the past years, gradually more individuals with a professional background other than medicine are moving into the field, thereby contributing to the emergence of a multiprofessional public health community. These individuals have a background rooted in social sciences (economics, business administration, sociology, psychology, etc.), statistics, nursing, midwifery, social work, pharmacy or April

201 law and are spread across all sorts of institutions and levels of the health system. Several also operate outside the health sector, for instance in other ministries or public authorities. The first chapter of section V describes the role of various health professionals with respect to public health in Austria. It starts out by looking at the role of physicians in general and at that of medical officers specifically, continues by describing the contribution of other health professionals to public health such as nurses or midwives and concludes by discussing the role of non-health professionals operating in the field. The second chapter of secion V deals with capacity building for public health. 1.1 Physicians and public health Physicians in general During their medical education at university, physicians in Austria have in the past only received a very limited amount of training on issues related to public health. No postgraduate medical specialisation for public health exists for doctors. Since the revision of the medical curriculum took place in 2001/ , the amount of public health related study content has been increased and is now presented in the curriculum in the form on a teaching block titled Man in environment, family and society 494, which comprises 48 hours of lectures and 12 hours of tutoring in small groups. When compared to other countries, this amount of public health training is still fairly modest. General Practitioners must be trained in prevention and health promotion in order to be accredited in most countries, an understanding accepted by the world federation, WONCA (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians or short World Organisation of Family Doctors). First students of the new curriculum have only recently graduated. It remains to be seen whether the change in the curriculum has an impact on the work, career and career planning of medical doctors. The Austrian health system shows a very strong emphasis on curative medicine; especially physicians working in the clinical setting, as opposed to those working in research, still follow a disease-orientated approach rather than taking a broader view of health when dealing with their patients. During their medical studies and their postgraduate training physicians are trained to work solutionorientated, moving quickly from one patient (case) to another. A patient is rarely followed for a longer time period, which hampers continuity of care and reduces the probability that a physician will apply preventive instead of curative measures. This however not only has its origin in the training of physicians but is furthermore promoted by the structure of the system, reflecting on the one hand the management of the inpatient insitutions physicians work in, which may be understaffed, and on the other hand the reimbursement mechanisms and incentives applied in ambulatory care, which do not encourage the physician to spend much time on a thorough anamnesis, e.g. also assessing the social, living and working conditions of his or her patient. Therefore time spent with each patient generally tends to be short and focussed on the treatment of the symptoms presented, without further investigation into underlying causes. Physicians moreover in many cases lack adequate knowledge in research skills or epidemiology, thus limiting their ability to interpret and apply research findings and associated outcomes thereof appropriately. The new medical curriculum appears to place more focus on research; outcomes thereof remain to be seen. Not only do physicians have little time resources when it comes to patient consultations, but they are in many cases also not well informed about support services available to their patients if these, as a 493 A first pilot class was started in 2001; the first official course for all (new) medical students, following the new curriculum was initiated in The study block is composed of three chapters: chapter 1 (21 hours): man in environment and workplace, chapter 2 (20 hours): man in the social and evolutionary context and chapter 3 (19 hours) being: mental health, life cycle and family. For more details on study block content (in German) see: April

202 consequence of a medical condition, for instance confront them with questions related to housing, work- or family issues. 495 Medical specialties such as social medicine or occupational and work medicine (see chapters and of this section) or research related fields such as epidemiology appear to not be very popular among students and medical graduates. Few people show an interest to move into one of these areas. Also there is only a very small number of training posts available for these specialties. This could be due to various reasons, involving financial and structural aspects, the content of the curricula, the potential fields of work or the lack of clearly defined and promising career opportunities in general Medical officers No universally accepted English translation of the German term Amtsarzt exists in Austria. For reasons of consistency, the term medical officer will be used throughout this report, as it has already been applied in the Health Systems in Transition country report on Austria produced for the European Observatory on Health Systems and Policies by Hofmarcher and Rack. 496 Responsibilities Medical officers play a central role in the provision of public health services in Austria. They work on all levels of the health system, for provincial, district or local authorities but also for the federal authorities. About 300 medical officers exist in Austria, representing roughly 1% of all practising physicians. 497 Duties of medical officers are regulated in the Imperial Sanitary Act and the Physician Act. The interpretation and actual practical implementation of the responsibilities laid out in these acts is subject to considerable regional variation. In 41 the Physician Act stipulates that medical officers are employed by the public health authorities and are responsible for the execution of official duties. They operate in the interest of the population s health. Medical officers also operate as work safety inspectors, police physicians, medical officers in a Federal Police Directorate, Safety Directorate, the Federal Ministry of Internal Affairs or as army doctors. The Physician Act provides a list of the institutions which are defined as public health authorities, including administrative district authorities respectively magistrates for cities with an own statute, provincial governors (indirect federal administration), provincial governments and the Federal Ministry of Health. The Imperial Sanitary Act of 1870 is described in more detail in chapter 2 of this section of the report. It lists the responsibilities of the different actors involved in the public health service and is, regardless of its date of issue, still valid in many aspects today. Duties of medical officers include amongst others the supervision of hospitals, the monitoring of epidemics and of water quality, the compilation of expert opinions, the documentation of statistics and the publication of reports, the documentation of the health status of the general population and the administration of vaccinations. Medical officers in Austria have a great variety of duties which vary depending on the level of the health system they are working on (national vs. regional/provincial vs. local) and also on the geographical area in which they are operating. In very general terms they are responsible for promoting and ensuring the population s health. Based on the Physician Act, medical officers act as authorised experts and compile expert opinions for the provincial governor or the Federal Government. These are on medical questions, related to e.g. trade authorization, the authorization to drive motor vehicles, affect environmental or hygiene issues or exposure to noise, pollutants, etc. Medical officers also appraise health promotion concepts and decide about whether these will be supported by receiving financial resources. 495 In hospitals advice related to topics involving social services, long term care or housing may sometimes be provided by professionals other than medical doctors, e.g. by social workers. 496 Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies 497 Ibid April

203 Medical officers are furthermore in charge of providing services to prevent illnesses (e.g. administration of vaccinations) or offer services in connection with occupational safety (e.g. performing safety audits/assessments in various settings, granting preliminary maternity leave because of the existence of risks to the child s/mother s state of health). The duty which is probably perceived most by the general public is the role of a controlling body which entails assessments/examinations following driving offences, the issuing of certificates (for using a disabled parking spots) or the monitoring of the issuing of prescriptions for narcotics. For the majority of the population and even for many people working in the health sector, the scope of responsibilities of medical officers is not transparent. This is also in part because of the considerable regional variation in this matter. Training Only physicians who are authorised to practice medicine can become medical officers in Austria. The authorization to practice (ius practicandi) is not granted to a medical doctor when graduating from university, but only after he or she has undergone a certain period of practical training, usually in a hospital and in some cases also partially in a physician practice (currently a minimum of three years to qualify as a general practitioner and depending on the specialty five to six years to qualify as a medical specialist) and has taken a final (written) examination. Hospitals or physicians (mostly working in solo practices) training young doctors have to be recognised as teaching institutions by the Austrian Medical Chamber. At present only few doctors choose to undertake part of their training outside of the hospital (in physician practices, group practices or outpatient clinics) which is mostly because reimbursement is higher in hospital and work is perceived to be more diversified. Due to lack of funding and a new collective contract for doctors in training (valid from 1 January 2010), the numbers of private training practices will most likely continue to decline. Physicians who wish to work as medical officers have to enrol in further postgraduate training which at the moment is provided in the form of a course (Physikatskurs). This training can only be undertaken in cities with a medical university, namely Vienna, Graz or Innsbruck. The organisation and structure of the course may vary; one city (Graz) even offers a university degree (master programme for public health) which covers far more material than the standard course for medical officers; other cities provide weekend or blocked training sessions (e.g. 3 months in Innsbruck). The content of the different regional programmes is however comparable (dealing with subjects such as hygiene, sanitation, epidemiology, toxicology and veterinary inspection) but each of them displays specific features. Graduates of these programmes can practice as medical officers throughout Austria, independently of where they have obtained their training. Continuing education and further training for medical officers is largely based on the initiative of the individual professional. Few courses, which are specifically targeted at this group of physicians, are offered in Austria. In the past years the workforce situation for medical officers has changed considerably. It has always been difficult to motivate especially highly qualified physicians to move into this profession for various reasons, one being that medical graduates and fully trained physicians do not dispose of sufficient knowledge of the potential field of work and the duties involved and may believe it to be boring, when comparing it to clincal work, the other being low salaries (in comparison to other jobs for medical doctors) or limited career perspectives. Demographic- and labour force changes have in the recent past lead to more women moving into the medical field and an increasing demand in part time employment. These aspects (clearly defined working hours, possibility of working part-time) incentivise some physicians to apply for posts as medical officers. But restrictive training schedules, which for example involve spending several months in a row in a certain city (e.g. Innsbruck) for training, may pose a problem for some applicants (e.g. those with children), thus resulting in them choosing another career option. It appears that different types of physicians are especially interested in becoming medical officers 498 : 498 Expert interview 27 August 2009 (Regional health authority) April

204 - Those who have obtained postgraduate training in public health - Women who rejoin the workforce after having been on maternity leave and/or seek part-time employment, which is not always easily available or granted in hospitals - Physicians who have been working in hospital for a long time and feel that they would like to switch to a job which permits them a better work-life balance and does not entail the duty of oncall work or very long hours Unfortunately few young physicians are motivated to take on a post as a medical officer, possibly for the reasons stated above. It would be very important to make the profession more attractive, especially for highly qualified doctors. These would need to be motivated by factors such as career perspectives and opportunities, demanding work and financial incentives. Public health authorities in Austria have experienced considerable problems in the past with finding sufficient physicians who are qualified and willing to work as medical officers. This has lead to shortages and disruptions of training schedules. Several physicians have been performing the duties of medical officers without having undergone the formal training required for the position. 499 The training for medical officers is at present undergoing reform (see subsequent paragraph). Outcomes thereof and the impact of the reform activities on the future training of medical officers are not yet clear. Various options are being discussed with the involved stakeholders; results are still pending. The Austrian public health service Current reforms Experts interviewed for the present study stated that the public health service in Austria (Öffentlicher Gesundheitsdienst, ÖGD) is overburdened and lacking appropriately trained staff. As already elaborated before, it is difficult to find qualified individuals to fill vacant positions. The perceived necessity for reform of the public health service as well as the shortage of personnel were core motivators for starting the project ÖGD Neu (New public health service) which is part of the reform respectively further development of the Austrian public health service, initiated in the course of the health care reform The reform process was started in the beginning in 2005 by the Federal Ministry of Health together with the provinces and was aimed at revising the catalogue of duties of the ÖGD, in a first step focussing on the definition of core responsibilities and promoting the harmonisation of training for medical officers. Initially the Austrian Health Institute (Österreichisches Bundesinstitut für Gesundheitswesen, ÖBIG), a subdivision of Health Austria Ltd. (Gesundheit Österreich GmbH), was contracted by the Federal Ministry of Health to oversee and document the process of reviewing and redefining the catalogue of duties of medical officers working on the district level. The assignment was soon extended to medical officers working on all levels of the health system. Representatives of ÖBIG are assisted by a working group composed of representatives of the health authorities of all provinces as well as a few other experts. It was argued that a revision of the duties of medical officers would require a prior assessment of their current responsibilities. This resulted in the decision to compile a Handbook for the new Austrian public health service. Work on the handbook was initiated in 2006; it was published in its first version (as a basis for discussion) in November 2007 and outlines future potential fields of responsibility of medical officers as well as providing suggestions on how these can be distributed across the different levels of the health system. Following the publication of the handbook, discussions have been initiated with representatives of the provinces. Next planned steps are the development of a training concept (intended to act as a framework for the definition of a training curriculum) for medical officers, based on the handbook, and the preparation of the implementation of the reform of the public health service in the provinces. Another aim is to develop a legal basis for the public health service, an ÖGD Act, as well as adapting existing legislation. 499 Expert interview 27 August 2009 (Regional health authority) April

205 The project in general and the handbook specifically currently only refer to physicians (medical officers) working in public health authorities. In the future potentially also the duties of non-medical professionals working for the public health service could be defined as well as the training they require for working in such a position. Another issue of discussion will be the transformation of the revised duties into a basic curriculum and the choice of a setting in which the training could be provided. Various strategies are being looked into: - Creating a medical specialty for public health (for medical professionals only) Maintaining the current character of a training course and offering it to medical doctors only - Maintaining the current course character but opening it also to non-medical professionals - Creating a master programme which could be entered by both physicians as well as professionals without a medical background Over the next years, a new training curriculum for medical officers should be finalised. The curriculum should be outcome-orientated and it should be attached to an institution, e.g. a university or an academy. The cross-validation of units from other programmes, e.g. Master of public health programmes still has to be discussed. The legislation basis of the training still remains unclear, possibilities being for instance the integration into the Physician Act, the integration into a separate Act or into other legislation. The model applied in Switzerland, where the training of medical officers was united with the public health training, could potentially serve as an example for Austria Specialists of social medicine Physicians who wish to specialise in social medicine need to complete a defined period of postgraduate training and pass a written examination. Medical specialists usually work in research. Institutes for Social Medicine existing at three medical universities (in Vienna, Graz and Innsbruck) are very small and partially hold fairly conservative views on public health, limiting it to medical aspects and thereby to a certain extent dismissing the multidisciplinarity of the subject of public health. Departments are, according to expert opinion 501, understaffed, lacking funding, partially lacking support from the Medical Universities they are attached to, and struggling to find motivated and highly qualified doctors who wish to specialise in the subject. Research areas covered by these three institutes appear to be subject to considerable variation and could be looked into more closely. Below the number of physicians with a specialisation in social medicine in Austria are displayed. Currently only one full-time training post for social medicine is listed at the Austrian Medical Chamber. 502 Table 10: Specialists in social medicine in Austria Physicians with a specialisation in social medicine Total BG CA LA UA S ST T VO VI Abbreviations: BG=Burgenland, CA=Carinthia, LA=Lower Austria, UA=Upper Austria, S=Salzburg, ST=Styria, T=Tyrol, VO=Vorarlberg and VI=Vienna. Source: Austrian Medical Chamber, received via on 29 July Medical officers are at the moment not obliged to join the Austrian Medical Chamber. If the training were organised as a new medical specialty the decision would have to be taken on whether medical officers need to join or not. Equally potential overlaps with existing medical specialties such as e.g. social medicine would need to be discussed. 501 Research institute 502 Austrian Medical Chamber, accessed at usbildstatt%2fsozmed.htm on 23 March 2010 April

206 1.1.4 Physicians working in occupational medicine Physicians interested in working in the field of occupational medicine can pursue two careers in Austria. One option is to become a specialist in occupational and work medicine, a medical specialty for which training can be entered after graduating from medical university. Very few training posts exist for this specialty in Austria (12 full-time posts and 4 part time posts 503 ) which can mostly be found at centres of occupational medicine. Only 1 training post is located in a university hospital. The specialty is a fairly new specialty (it has been in existence for less than two decades). Physicians trained in occupational and work medicine tend to work either as company physicians, in the clinical setting (currently mainly as doctors for internal medicine) or in one of the aforementioned centres. Some operate in own private practices, thereby although not primarily providing services related to this specialty but instead for instance services related to internal medicine. The other option for physicians is to acquire a diploma for occupational medicine from one of the two academies for occupational medicine in Austria. In order to attend these diploma courses, physicians need to dispose of a defined amount of prior practical training (acquired in hospital or the in a physician pracatice), which is referred to as ius practicandi (the right to practice). The diploma entitles physicians to work as company physicians. Many physicians, usually general practitioners, decide to acquire the diploma as an additional qualification and a potential supplementary source of income. The number of physicians with a medical specialisation in occupational and work medicine and the physicians who have obtained a diploma in occupational medicine are displayed in the table below. Table 11: Physicians with a training in occupational medicine in Austria Physicians with a specialisation in occupational medicine Total BG CA LA UA S ST T VO VI Occupational medicine diplomas awarded Abbreviations: BG=Burgenland, CA=Carinthia, LA=Lower Austria, UA=Upper Austria, S=Salzburg, ST=Styria, T=Tyrol, VO=Vorarlberg and VI=Vienna. Source: Austrian Medical Chamber, received via on 29 July 2009 Before the official training directive (Ausbildungsordnung) for the specialty in occupational and work medicine was defined, a transitory arrangement existed whereby certain physicians who could prove that they had worked in the field of occupational and work medicine for a defined number of years (gaining practical experience), could be awarded the title of a specialist (without taking an examination). This could explain why many specialists in occupational and work medicine also have another medical specialty such as e.g internal medicine. Nowadays a training directive for occupational and work medicine exists and physicians have to, just like with any other specialty, pass a written examination at the end of the training period. As part of their training, future specialists in occupational and work medicine need to undertake the 12-week diploma course at one of the academies referred to earlier on. Both medical specialists and physicians with a diploma can work as company physicians, either on an employed or part-time visiting basis. Responsibilities of a company physician are regulated in the Workers Protection Act. 504 They involve advising the employer, the employees and other staff and bodies on health protection and health promotion measures related to the workplace setting as well as the design of individual workplaces. Company physicians also support employers to meet their legal 503 Austrian Medical Chamber, accessed at usbildstatt%2farb.htm on 3 October BGBl. Nr. 450/1994, latest amendment BGBl. Nr. 159/2001, see April

207 obligations with regard to workplace safety. Their responsibilities are detailed in 81 of the aforementioned Act. They can also work for public authorities or other bodies, ensuring that workplaces comply with certain safety regulations or compiling expert opinions on related aspects. Even small enterprises are obliged to appoint a company physican. The Austrian Social Insurance for Occupational Risks (Allgemeine Unfallversicherungsanstalt, AUVA) supports small enterprises though the installation of centres which dispose of qualified staff and equipment. Depending on the number of employees a company has it may have to provide an own physician for occupational medicine/company physician and to install a working protection committee. Employees tend to not consult their company physician because of personal health problems. They may ask him or her to administer a vaccination or aks them for assistance when experiencing spontaneous health problems during working hours, but will usually prefer to consult a general practitioner or specialist of their personal choice outside of the workplace for further measures. This is partially based on the fact that employees, fearing a violation of data protection, do not want their health situation and their work to be related. The company physician at present holds an ambigous position with regard to his or her responsibilites towards the employer and the employees of the company. This can potentially result in him or her being used beyond their capabilities i.e. in an ineffective way. In some cases employers and representatives of employees reach an agreement whereby company physicians undertake a variety of additional health checks or preventive measures and provide employers with access to anonymised examination data but only doing so with the consent of the worker s representative/s. Findings of a survey commissioned by the Austrian Social Insurance for Occupational Risks and the Austrian Society of Occupational Medicine in the year 2000, in the course of which 300 interviews with representatives of Austrian companies were undertaken, show that companies frequently perceive occupational medicine as a cumbersome compliance with legal requirements instead of viewing it as a tool to promote the health and productivity of their employees. 505 Occupational diseases and the circumstances under which they are declared as such are clearly defined in Austria. Diseases are regulated in 177 of the General Social Insurace Act and listed in Annex 1 of the respective law. For these specific diseases the exclusive causal relationship between the type of work executed in a specific setting and its adverse effect on health has been proven. Individual cases which do not meet these criteria can still be approved by the Federal Ministry of Health under certain circumstances. If this happens several times, a corresponding modification of the disease list is discussed. The Austrian list is not identical to the one used on the European level, a list of occupational diseases which was published by the International Labour Organization (ILO) in 2002 (in the form of an annex to a recommendation) and has been subject to discussion and revision in 2005 and again in Press statement, accessed at on 6 September International Labour Organiszation, Meeting of Experts on the Revision of the List of Occupational Diseases in December 2005: October 2009: April

208 1.1.5 School physicians 507 The role and responsibilities of school physicians are topics of recurring interest and discussion in Austria. Serveral studies on this subject have been composed in the past and options for change discussed, but little has happened so far. Role and responsibilites Competencies regarding the provision of health services at schools by school physicians are shared by the Federal Ministry of Education, Arts and Culture and the Federal Ministry of Health. At the same time a division of responsibilites takes place across different system levels, namely the Federal Government, the provinces, the communities and also the carrier organisations of schools. 508 Physicians can apply for the position of a school physician by sending an application to the school carrier organisation. In the area of compulsory education the position of a school physician is frequently part of the activites undertaken by a community physician and is not reimbursed separately. School physicians need to provide proof that they have acquired the ius practicandi, the right to practise, which, following graduation from medical university, currently involves either, for a general practitioner, about three years of practical training in a hospital and/or physician practice (the ambulatory setting) or, for a specialist, about five to six years of practical traning. Before becoming a general practitioner or specialist, physicians have to pass a final written examination. When applying for the position of a school physician, any diplomas of further eduation or training (e.g. school physician diploma, diploma of psycho-social medicine, nutritional medicine, occupational medicine or sports medicine) are considered beneficial; women and specialists in paediatrics are generally preferred. Basic responsibilities of school physicians are regulated in 66 (1) of the Austrian School Education Act (Schulunterrichtsgesetz) and involve the following: - School physicians have to advise teachers in questions related to the health of their students as well as undertaking any therefore required examinations - Students have to take part in a yearly health examination and in additional examinations, as far as they agree to these. Students are informed about any adverse outcomes of the examinations by the school physician. Further competencies of school physicians or more detailed instructions respectively guidelines on the actual execution or implementation of the above mentioned measures can be regulated in the form of employment contracts between the physician and the respective school, but are not specified by law. In gereral the present legislation basis is limited. Regulations of the Physician Act also apply to school physicians. 507 Based on communication with a representative of the Federal Ministry of Education, Arts and Culture in August and September 2009 and on the following reports: Gerhartl, M., dellegrazie, J., Spitzbart, S., Wilkens, E., Redl, S. (2009). Healthy School Project. Final Report. Main Association of Austrian Social Security Institutions in cooperation with the Federal Ministry of Education, Art and Culture and the Federal Ministry of Health. Frank, W., Konta, B. (2006). Foundations for a Re-organisation of care provided by school physicians in Austria. Final Report. Commissioned by the Federal Ministry of Health and Women (2006) in co-operation with the Federal Ministry of Education, Science and Culture Kaminski, A., Gartlehner, G. (no year available). Screening of school-aged children. Donau University Krems. Department for Evidence-Based Medicine and Clinical Epidemiology. Prepared for the Healthy School Project, commissioned by the Social Insurance Fund of the Railway and Mining Industry. 508 Frank, W., Konta, B. (2006). Foundations for a Re-organisation of care provided by school physicians in Austria. Final Report. Commissioned by the Federal Ministry of Health and Women (2006) in co-operation with the Federal Ministry of Education, Science and Culture April

209 In their report, which was published in 2006, Frank and Konta locate a considerable heterogeneity of the intensity of care provided to students at school. 509 School carriers are only obliged to appoint a school physician, the availabilty of the physician is not regulated by law though. This means that some (usually employed) physicians will spend more time in school than others who attend schools on a visiting basis because they for instance spend the remaining time working as community-, district- or parish physicians or at other schools. Information on the content of school examinations is provided in chapter 4.5 of section I of the present report. The analysis of data collected through school examinations cannot be used for scientific studies or analysis since there is no legislation basis. The forwarding of related data forms is considered problematic because of the risk of a violation of data protection regulations. 510 In several provinces data of the schools is not forwarded to the provinces (e.g. for regional health reporting) or used in any other way. Several provinces are developing computer systems with which data can be assessed anonymously; the health department of the city of Vienna is planning to develop a directive together with the Medical Association. The Head of the School Phyiscian Authority in Salzburg commented that the health forms of school examinations were possibly not the adequate basis for scientific studies because the quality of data provided may show a high variation. 511 So far no evalution has been undertaken to assess the effectiveness of school examinations respectively the impact of these on the health outcomes of the students i.e. the benefit generated for the individual student. Before revising the data situation, it will be beneficial to initially undertake an international review on the role of health professionals in schools, their responsibilities and potential impact, as well as the effectiveness of existing school examinations and school examinations in general. School physicians in Austria Between 2,100 and 2,500 school physicians exist in Austria. They work at about 6,500 institutions of compulsory education and in various other types of schools offering further education (both public and private). About 1,500 physicians work in institutions of compulsory education (partially doing this as part of their work as community physicians, district- or parish physicians), in which contractual agreements are very heterogenous. In larger cities (e.g. Vienna, Graz, Salzburg, Linz, Steyr and Wels) school physicians in institutions of compulsory education are often employed. The remaining about 530 school physicians work in federal schools and are employed by the Federal Government, working one hour per week per 60 students. Table 12: School physicians in Austria Total BG CA LA UA S ST T VO VI Registered school physicians School physician diplomas awarded Abbreviations: BG=Burgenland, CA=Carinthia, LA=Lower Austria, UA=Upper Austria, S=Salzburg, ST=Styria, T=Tyrol, VO=Vorarlberg and VI=Vienna. Source: Austrian Medical Association, received via on 29 July 2009 Discrepancies between the data reported in the text and the data presented in the table are due to various reasons: It is assumed that only school physicians who are actually being separately 509 Frank, W., Konta, B. (2006). Foundations for a Re-organisation of care provided by school physicians in Austria. Final Report. Commissioned by the Federal Ministry of Health and Women (2006) in co-operation with the Federal Ministry of Education, Science and Culture 510 The forwarding of individual data requires consent of the student respectively his/her parents 511 Anonymous (2009). School Physicians: Forwarding of data strictly regulated. Der Standard (daily newspaper in Austria). 13 May April

210 reimbursed for working as a school physician are registered with the Medical Association. Physicians who undertake this type of work as part of their work as a community-, district or parish-physician do not receive any extra remuneration for doing so and may therefore not register. Employed physicians and those working on a full time basis will be more likely to be registered. Many physicians work for several schools at the same time. Discussion points Since the 1960s, various initiatives have been started with the intention of reforming the professional profile of school physicians as well as promoting and facilitating the execution of health-related activites at schools in general. Most of these were unfortunately met by resistence or provoked conflicts of competence and power between the multiple actors involved. These are repeatedly confronted with the challenging task of reaching an agreement on certain core issues. Previous studies and activities appear not to have resulted in any major change of the situation. 512 In their report of 2006 Frank and Konta presented a list of structural problems exsting in connection with the provision of health care services by school physicians to schools students. - Problems of competence - Problemlems resulting from unclear legislation - Problems concerning lacking transparency - Problems related to the actual provision of care - Problems due to heterogeneity - Problems of lacking objectivity - Problems regarding the documentation of services Based on the assessment of the situation in Austria, the authors include an extensive list of reform requirements in their report. It seems though that, similar to previous studies, the study of Frank and Konta did not lead to any fundamental changes in the system. The Healthy Schools Project is an example for a co-operation of the major stakeholders involved in the field, namely the two concerned ministries and social insurance. The final project report has recently been published. The aim of the project was to develop quality standards for promoting systematic and sustainable as well as up to date health promotion activities and health care services in schools, based on existing national and international standards. Standards and recommendations developed in the course of the project should form the foundation for quality improvement interventions and measures related to the health status of school students. 513 Whether the outcomes of the project and the suggestions made by the authors will result in a change of health-orientated activities at schools remains to be seen. 1.2 Nurses 514 The Austrian health system is largely physician dominated; responsibilities and roles of health professionals such as pharmacists or nurses are generally clearly differentiated from those of medical doctors. The majority of nurses in Austria perform work which is focused on the individual, not the population, working either in hospitals, rehabilitation centres or the area of long-term care (institutional care or ambulatory home care). This is rooted in their training and in tradition and also in several factors which are subsequently detailed. The vast share of nurses in Austria still works in the 512 See for example: Gamper, M. (2002). The development of the system of school physicians in Austria. Commissioned by the Federal Ministry of Education, Science and Culture. Vienna Accessed at on 2 September Dür, W., Gehartl, M., dellegrazie, J., Hofmann, W., Redl, S., Spitzbart, S., Wilkens, E. (2009). Healthy Schools Project. Final Report Based on the initiative of the Main Association of Austrian Social Security Institutions, the Federal Ministry of Education, Art and Culture and the Federal Ministry of Health. Vienna Based on two expert interviews conducted in October 2009 April

211 hospital sector. About 400,000 individuals receive long-term care benefits 515 and about 100,000 individuals take advantage of mobile nursing services 516. The demand for ambulatory nursing services (mobile nurses for long-term care) is increasing rapidly. At present this demand is partially met by illegal nurses (estimates of about 40,000 people for 20,000 patients 517 ), who work in private households where they look after individuals requiring long term care. This represents about 5 to 20 times the amount of legal nursing staff operating in this field. No definite figures exist on this issue. So far very few job positions exist which require a nurse to take on a population perspective. Due to educational standards, system structrures, funding and the image of nursing in society, and also among health system stakeholders, the responsibilities of nurses with regard to public health are still very limited in Austria. Further education and training (e.g. in public health or palliative care) are not reflected in reimbursement arrangements, meaning that there are few incentives for nurses to engage in such activities. Reimbursement is not performance-related. Some employers try to motivate their nursing staff to undertake further education by either paying for their training or by offering them educational leave from work. Nurses who have for instance acquired an MPH degree can at the moment only expect a change in salary if they move into another field of work such as teaching (university) or research. The professional contribution nurses can make to public health appears not be be sufficiently valued or acknowledged in Austria. Professions such as family health nurses, community health nurses or public health nurses do not exist in Austria. About a decade ago, the WHO defined a concept for family health nurses, which was was supposed to be implemented in various countries. In Austria the implementation process was headed by the Austrian Red Cross and supported by a multiprofessional group of experts. A final report was presented in 2007 but the concept was not put into practice. 518 It is indeed very difficult to compare the roles and responsibilities of different health care professionals across countries as these are subject to considerable heterogeneity. Tasks performed by nurses in some countries may be performed by other professionals such as physicians, social workers or therapists in others. Comparisons are further hampered by the use of different denominations of the professional groups and varying training and professional structures. As already indicated above, the involvement of nurses in public health is very limited in Austria. Main fields of work for nurses, who are employed by the health authorities of the provinces, have been identified several years ago 519 by the working group Nurses in the public health service 520. As a result thereof, health authorities of the provinces increased the number of nurses working for them. Regardless of this development, the scope of the nurses responsibilities has not undergone a major change. Nurses are still predominantly occupied with operative duties instead of being actively involved in strategic decisions or in structural changes. The tasks performed by them vary across the ,000 of these from the Federal Government, the remaining amount from the regions. Source of 315,000: Main Association of Austrian Social Security Institutions (2009). Austrian Social Insurance in Figures. 23rd edition. August Vienna. Data on long term care benefits recipients as of December Rudda, J., Marschitz (2007). 'Reform der Pflegevorsorge in Österreich II.' Soziale Sicherheit November Shortened version accessed at Artikel.pdf on 23 March Ibid 518 Wild, M., Rottenhofer, I., Fleck, K., Grundböck, A., Holenia, R., Klampfl-Kenny, M., Nagl-Cupal, M., Rappold, E., Reinisch, J., Stelzl, E., Tiefengraber, M. (2007). Implementation of the concept of the familyhealth-nurse of the WHO in Austria. May The Austrian Red Cross in Co-operation with the (then) Federal Ministry of Health, Damily and Youth, the region of Styria (health department) and the Austrian Association for Health and Nursing. 519 These involved: Quality assurance of education, further education and continuing education according to the Nursing Act, health promotion and prevention, health reporting and planning, quality assurance of nursing care both in ambulatory and inpatient care, general duties/involvement in decision-making processes relvant to nursing, financial benefits for long-term care and public relations work as well as counseling/provision of information 520 Klampfl, M. (no year provided). What capabilities does a Public Health expert have? Taking the example Public Health in the Public Health Service home care. April

212 provinces but mostly involve training and quality assurance respectively the undertaking of monitoring functions (e.g. performing audits in hospitals or in nursing homes). Experts who were interviewed for the present study, reported that nurses have generally become more active in the areas of prevention and health promotion and that their contribution to these fields has increased. Further involvement and the extension of their responsibilities are however restricted due to limited funding and also to the lack of adequately qualified nursing staff. As mentioned before, nurses tend to be occupied with operative rather than strategic tasks. Nurses who wish to advance in their career (e.g. become the head of nursing of a hospital department) have to undergo training which is compulsory by law. Part of this training also involves topics such as health promotion or public health. Several pilot projects currently assess the role nurses could take with regard to prevention and health promotion, e.g. in home care. They show promising results (Health network Tennengau Salzburg, Living independently when aging in Vorarlberg). Other potential future responsibilities for nurses stated by experts involve for instance the further involvement in long term care (e.g. assessment of care need, based on which the financial long term care benefit is defined), the collection and assessment of epidemiologically relevant data or the organisation and management of community activities. In addition to the nurses who work for the Austrian public health service, few nurses with postgraduate training in public health hold research positions (e.g. at university or independent research institutions) or work for one of the big system stakeholders in Austria, such as social insurance, the ministries or the provinces. The size of this group may change because more nurses appear to be interested in undertaking further training and also as a result of changes in the training structures. Previously nurses in Austria were trained in schools (which were part of hospitals) and required a basic training of three years. Recently the provinces were granted the possibility of organising the training of nurses in the form of a university degree (at universities of applied sciences). 521 This has so far only been taken up to a very limited degree as it involves the consideration of several administrative issues such as for instance the shifting of funding from the hospitals to the universities of applied sciences or the admission criteria to education having to be changed because the number of students being affected is very large. Nursing schools accept students who have completed ten years of schooling; no school leaving-examination is required whereas universities of applied sciences require students to present with a certificate of their school-leaving examination or a certificate of general educational development. In Vienna the course for nursing is offered for the second time at the University of Applied Sciences FH Campus Wien and in Salzburg the first course has started in autumn Graduates of these courses are awarded a bachelor s degree. In order to ensure the practical training of the nurses, universities have engaged in co-operation arrangements with local hospitals/hospital associations. Most provinces have not modified the training structures of nurses yet due to the above stated reasons. Whether the change in training will have an impact on the salary and responsibilities of nurses remains uncertain. At the moment nurses who have completed a course at a university of applied sciences and those who have undergone training at one of the schools are treated the same way when it comes to work arrangements (responsibilities, salary). 1.3 Midwives Similar to nurses, midwives in Austria mostly operate in the clinical (inpatient or outpatient) setting. They are not involved in the national screening programme for pregnant women and mothers, the mother-child-pass programme. Examinations within the programme are undertaken by physicians (mostly gynaecologists) only. Midwives head birth preparation courses or offer advice on birth and any other issues related to motherhood (e.g. breastfeeding) in hospitals, mother-child centres or parent 521 Amendment of the Nursing Act (June 2008), accessed at on 2 September 2009 April

213 centres. They largely work in hospitals, where they assist births and/or work on a self-employed basis, counseling pregnant women, accompanying them to hospital for the delivery (possible in some hospitals) and undertaking house births. Several midwives have already or ar currently undertaking postgraduate training in public health. Until recently midwifery was not taught at universities but at schools. Training now takes place at universities of applied sciences. 1.4 Other public health professionals Other health professionals involved in the provision of public health services in Austria are therapists, e.g. physiotherapists or speech therapists as well as for instance nutritionists or psychologists. Social scientists dealing with public health issues are for example statisticians, sociologists or economists. These usually work in research institutions, which have researchers from a multidisciplinary background, or in health promotion institutions. Health authorities and other health system stakeholders (social insurance, ministries) also employ individiuals from a variety of professional backgrounds. Both for public health practice and research it is vital to draw on the knowledge and skills of professionals from a wide range of disciplines, involving for instance experts in medicine, economics, statistics, business/management, psychology, epidemiology, sociology, law, anthropology or history. A very specific group of professionals operating in the field are epidemiologists. Austria does not offer any training in epidemiology and only has very few epidemiologists who have been trained abroad. These usually work in small university departments which are either part of or attached to the department of social medicine. Within these departments not all employees may have undergone a specific training in epidemiology but are statisticians or nurses who learn on the job, e.g. by instruction of their supervisor or colleagues. No data on the number of epidemiologists in Austria exists. Before assessing these numbers it has to be clear whether these are based on formal training or practical work/work experience. Non-medical employees of the health authorities on various health system levels do generally not receive professional training. Even at the Federal Ministry of Health, the training of individuals does, with rare exceptions, not correspond with professional minimal standards. April

214 2. Capacity building in public health 2.1 The concept of capacity building Based on Hawe et al. (1999) Capacity building is an approach to the development of sustainable skills, organisational structures, resources and commitment to health improvement in health and other sectors, to prolong and multiply health gains many times over. In Austria capacity building, when mentioned in connection with public health, is frequently limited to workforce development, which is for example undertaken in the form of public health education or training of professionals. In this report it is suggested to take a broader approach towards capacity building, also involving other aspects apart from workforce development. Based on the Capacity Building Framework presented by the New South Wales Health Department in 2001, capacity building involves several dimensions (developing infrastructure, enhancing programme sustainability and fostering problem solving capabilities) and key action areas (organisational development, workforce development, ressource allocation, partnerships and leadership) which are presented in the graph below. Figure 16: New South Wales Health Department Capacity Building Framework Source: New South Wales Health Department (2001) Many of the action areas of the aforementioned model have been already discussed or referred to in other sections of this report (e.g. organisation of public health in Austria, structures, funding, priority setting or health targets) and are therefore only briefly covered in this section. The strong focus on workforce development measures in the following chapters also reflects the understanding and the April