Programmes and health concepts
Health policy in North Rhine-Westphalia has taken special approaches focusing on the needs of its population. It has traditionally taken an interest in health policy issues that are related to social medicine, public health and environmental problems, whereas autonomous, self-negotiating organizations and institutions have taken prime responsibility for questions of individual medical care.
The state programme for North Rhine-Westphalia, which was mostly developed and published in the 1980s, gives an impression of the direction and the differentiation of approaches taken in different health policy topics according to political needs, including previous health policy in North Rhine-Westphalia.
For the programmes on AIDS, maternal and child health and drugs developed in the late 1980s, the political need was obvious. AIDS was a new threat for the population and a new infectious disease that caused fear and uncertainty among the population, infant mortality was higher than in most of the other Länder and the abuse of illegal drugs was increasing.
The state health conference of North Rhine-Westphalia was first institutionalized in 1992 (see page 45), but expert commissions supported the federal government in developing the programmes.
The AIDS programme
The AIDS programme was published in 1987 (1) and has focused on:
• preventing AIDS, including a variety of mass-media and individual communication measures for special target groups and the general public;
• optimizing the health care system for people with AIDS, including inpatient and outpatient care and the medical and psychosocial sectors;
• promoting solidarity with HIV-positive people; and
• information exchange and cooperation, including the establishment of an AIDS Commission in North Rhine-Westphalia involving organizations, institutions and experts.
The programme has successfully been implemented in cooperation with many different partners in the health care system, especially involving AIDS self-help groups; more than 60 youth workers and more than 40 AIDS coordinators are working in the district health departments, and this is still a central element of the approach towards AIDS in North Rhine-Westphalia. The programme is being continually developed to respond to changing needs.
The programme on maternal and child health
The programme on maternal and child health (2) was established to reduce perinatal and infant mortality
in North Rhine-Westphalia. It has mainly focused on:
• restructuring the obstetrical and neonatal services, now including a network of 16 perinatal centres and 25 obstetrical and neonatal focal points;
• improving services for pregnant women and the newborn in socially disadvantaged areas with particularly high rates of infant mortality;
• reducing sudden infant death syndrome, including obtaining new knowledge on insufficiently known causes and providing psychosocial help to affected families through a cooperative study led by the University of Münster; and
• information exchange and cooperation, including a commission involving various organizations, institutions and experts that critically evaluates the implementation of the programme.
As a result, infant mortality was reduced from 9.5 per 1000 live births in 1987 to 5.9 in 1994. The study on sudden infant death syndrome led to general recommendations on the care of babies. The incidence then declined from 489 cases in 1990 to 252 cases in 1993.
Based on this study, the University of Münster is coordinating a comprehensive multicentre study in Germany as a whole, financed by the Federal Government.
The drug programme
The threat to the general public from illegal drugs and associated criminal activities has drawn political attention for years. The drug programme (published in 1989) has focused mainly on measures to:
• improve information and prevention
• assist drug addicts
• prosecute the illicit drug trade
• promote information exchange and cooperation.
A comprehensive programme on drug addiction has been developed jointly by the expert commission, all partners of the health care and social welfare system (by involving the representative planning board of the North Rhine-Westphalia Health Conferences) and all responsible sectors of the Government of North Rhine-Westphalia.
Other programmes
Special progammes and concepts have been developed in numerous health areas. For example, “Have a heart for your heart”, a worksite prevention and health promotion programme, was developed by the former State Health Institute (now the State Institute of Public Health) and the state division of one health insurance scheme.
In addition, North Rhine-Westphalia has developed programmes on:
• environmental health, with a variety of measures in education, information, prevention and medical care;
• supporting self-help activities and thereby involving affected people in the health care sector, focusing on strengthening infrastructure;
• improving social measures for people who are dying, including several measures in social welfare and health care;
• improving psychiatric care, mainly focusing on community-based psychiatric care;
• improving drug safety, including measures ranging from clinical assessment to monitoring therapies;
and
• preventing skin cancer, designed in North Rhine-Westphalia in cooperation with German Cancer Aid (a nationwide nongovernmental organization), physicians, health insurance schemes and local health authorities, and implemented locally by the urban and rural districts in cooperation with various partners.
Even if some of these programmes had not explicitly been attributed to the European regional targets for health for all, the specific objectives, the target groups and the comprehensive way of handling health problems clearly show that the principles and targets of the policy for health for all guided their development. The health for all principles of equity, participation, prevention and health promotion as a central strategic orientation, intersectoral action and international cooperation are central to the health policy of North Rhine-Westphalia.
The State Health Conference of North Rhine-Westphalia
The involvement of people who are affected at an early stage of discussion and planning in the development of new concepts and programmes contributes to the success of health policy. This is especially the case for the pluralistic North Rhine-Westphalia health system.
To institutionalize and cultivate the discussion and decision processes, the Government founded the Health Conference of North Rhine-Westphalia in 1992. The system of health information and reporting was being developed, and a functioning committee for consensual decision-making involving all relevant partners of the health and social care system was considered necessary. The 42 members include health insurance schemes, associations of physicians, dentists and pharmacists, the association of hospitals, associations of local governments, welfare organizations and trade unions, and representatives of employers. Yearly conferences are carefully prepared and held on important topics. Consensual deci-sions and recommendations are published. A representative planning board meets regularly, prepares the annual conferences and decides basic questions.
The yearly conferences have focused on the following topics:
• psychiatric care
• environmental medicine
• health promotion
• the process of health care reform
• ten priority health objectives in North Rhine-Westphalia
• quality assurance in the health care system.
Each conference adopts a consensus paper and resolution formulating tasks for all partners on the specific topic.
Five years of experience have shown that consensual discussion processes can be difficult and may require much time, but are the only way for developmental processes to succeed, especially for difficult health challenges on which different partners have varying opinions. Very often it was felt that the process may already be the objective.
Public health a challenge for North Rhine-Westphalia
North Rhine-Westphalia had already developed new public health structures based on scientific ap-proaches oriented towards Europe. It is currently working with all relevant partners on further develop-ment to respond to new needs. Even before 1990, the Public Health Academy in Düsseldorf was meeting needs in public health training and education for seven Länder. Public health initiatives have become more important in several specific areas and for various reasons, including limited financial resources, an increasing emphasis on efficiency and quality, more emphasis on health promotion and prevention, new approaches for disadvantaged social groups and further development of the health information system.
For these reasons, more innovation was required for the new public health.
Thus the first faculty of health sciences in Germany was founded at the University of Bielefeld in 1994.
Another scientific public health centre is located in Düsseldorf. In addition, there are numerous well reputed public health scientific institutes and academies. One of the five research associations for public health in Germany is based in North Rhine-Westphalia.
In 1995, the State Institute for Public Health (LÖGD) was founded. The former Institute was an important constituent part. LÖGD is a subordinate institute to the Ministry of Employment, Health and Social Affairs and has major tasks such as building up a public health information system. Since 1992 IDIS – now part of LÖGD – has been recognized as a WHO documentation centre.
In 1994, the European Public Health Centre was founded as a nongovernmental association of scientific, practical and political experts with a coordinating office in LÖGD. This centre aims to guarantee information flow between the research, political and practical levels and offers public health cooperation to all member states and institutions. A common understanding of the meaning and the importance of public health (and the new public health agenda) is required to promote joint European efforts to promote European integration.
A reform of the public health service at the district level is being promoted to meet the challenges and
needs on the local level, including the current administrative reforms.
The North Rhine-Westphalia courses of study in public health in Bielefeld and Düsseldorf are active members of the Association of Schools of Public Health in the European Region (ASPHER).
Membership in the Regions for Health Network and the implementation of the Networks aims and principles
North Rhine-Westphalia is a founding member of the Regions for Health Network, which was established in November 1992 in Düsseldorf. North Rhine-Westphalia has since then actively promoted the implementation of the aims and principles of the Network and the WHO strategy for health for all in its health policy. This has included setting up explicit health targets for North Rhine-Westphalia that involve all relevant partners, promoting intersectoral action for the development of health policy, using health promotion, participation and decentralization as guiding principles, aiming at an optimum of quality and efficiency and working at optimizing cooperation, coordination and integration of the partners and sectors on the state and especially local level. The experience and knowledge of and cooperation with other (European) regions were considered to be helpful in these efforts. The Regions for Health Network and the link to WHO became well known in North Rhine-Westphalia, and many active partners were found to support the developments described in the following paragraphs, including within the planning board of the State Health Conference and LÖGD.
Targets for health for all
After the Regions for Health Network was founded, North Rhine-Westphalia started a process of discussing target-setting based on developing new public health structures and a health information system involving the North Rhine-Westphalia Health Conference and its planning board.
After almost two years of consensus-finding, a draft document on ten priority health targets for North Rhine-Westphalia was passed at the 1995 State Health Conference. Difficult discussions at the 1995 conference and within its planning board on the specific direction and content of future health policy in these ten areas finally led to the consensus paper being published (4). The ten health targets cover the following topics (the relevant European regional targets for health for all are listed after each target).
1. Reducing cardiovascular disease target 9
2. Reducing cancer target 10
3. Settings for health promotion target 14 4. Tobacco, alcohol and psychoactive drugs target 17 5. Environmental health management target 19
6. Primary health care target 28
7. Hospital care target 29
8. Community services to meet special needs target 30 9. Health research and development target 32
10. Health information support target 35 The ten topics:
• meet special problems and areas relevant to North Rhine-Westphalia;
• refer to the five areas identified in the 38 targets; and
• tackle health challenges as well as structural challenges.
The target document was an important first step. A workshop on target-setting with international participation was organized in March 1996 in Brussels. It provided more information and knowledge for the further development of the qualitative and quantitative aspects of health targets. A working group of the planning board of the State Health Conference is actively involved in further development.
Healthy North Rhine-Westphalia
The Ministry of Employment, Health and Social Affairs has advertised a competition for the project network Healthy North Rhine-Westphalia, aimed at improving quality, innovation and efficiency in the health care system. All institutions and organizations carrying out projects that are very innovative and of high quality were asked to apply for membership. Several prerequisites have to be fulfilled, one being an orientation towards fulfilling the health targets of North Rhine-Westphalia.
Health prizes are awarded for the best projects. The planning board of the State Health Conference has participated actively in the decision-making process. The first list of outstanding projects has been published, and three projects have been awarded prizes. These projects are excellent examples for other institutions and organizations and are intended to give impetus for further development.
Intersectoral action for health
An important principle of health for all is intersectoral action, as health must be placed on the agenda in many different fields, including research, education, transport, environment, housing and city planning. An interministerial working group within the North Rhine-Westphalia Government was founded to intensify and disseminate the responsibility for health to all sectors in government and administration. Its tasks are:
• to analyse and demonstrate which projects related to health have been carried out in the various sectors; and
• to discuss further intersectoral developments in state policy.
The ministries responsible for education, science and research, environment, city planning and traffic are involved.
According to the subject of discussion they are also involved in the discussions of the State Health Conference.
Local coordination a new approach to meet the need for more coordination and cooperation for health
The traditional sectoral approach no longer meets the requirements of a modern and future-oriented health and social care system at the local level. Strengthening efforts towards more cooperation and coordination is
required to improve the quality, effectiveness and efficiency of health and social care.
A pilot project for North Rhine-Westphalia supported by the Ministry of Employment, Health and Social Affairs was initiated in 1995. The project involves 27 of the 54 urban and rural districts. Round tables are being created for the overall assessment and coordination of the health and social care system, and working groups are being set up in turn on such specific topics as health promotion, psychiatric care and linking hospital care and outpatient care to achieve the following aims:
• optimizing the care of people who are ill and need nursing, especially fairness in covering needs, accessibility and open-mindedness with regard to the interests of the citizens; and
• working out efficient models of participation, cooperation, information and coordination.
The project also aims to initiate a new and innovative approach to planning and steering health and social care at the local level. As all of the participating urban and rural districts are choosing their priorities according to their own needs and aims, they are being supported in consensual health planning processes in priority health areas, which may also lead to setting up health targets at the local level. Interest has been expressed in this.
All partners of the health and social care system are involved, including the physicians’ association, health insurance schemes, hospitals, nursing institutions and patients’ organizations.
For the pilot scheme, the participating counties are centrally supported by:
• project management established at LÖGD;
• data and information management to support the availability of methods and data for analysis and planning;
• a consortium for scientific evaluation, to show whether and how the aims have been achieved;
• the Ministry of Employment, Health and Social Affairs, which is responsible for the overall political steering process; and
• various panels set up to exchange experience between the participating districts, their representatives and those who support the project centrally.