The principle of equal opportunity has always been of special importance in North Rhine-Westphalia’s health and social policy. North Rhine-Westphalia has been governed by the Social Democratic Party for many years and since May 1995 by a coalition government of the Social Democratic Party and the Green Party, and considers itself the social conscience of Germany.
Germany’s social insurance system is based on the principle of social solidarity, and the health care system thus provides an excellent basis for realizing the principle of equal opportunity among various
social groups. The quality of health care is high, and care is in principle available to all residents in the same way. Very recent changes in federal legislation on the financing of the health insurance system have led to higher co-payments (despite opposition by the majority of the Länder, including North Rhine-Westphalia). Effort is required to ensure that the generally equal access for all to health care services is maintained in the future, despite narrowing resources.
In future political discussions about further health care reform, North Rhine-Westphalia will make all political efforts to maintain equal access for all to health care services, while ensuring high-quality care and appropriate financing of the health system.
Despite the formally equal access for all, the principle of equal opportunity is not always fulfilled for some population groups, such as:
• the long-term unemployed, single mothers and the homeless;
• elderly people;
• foreigners and migrants; and
• people with chronic mental disorders, long-term drug addicts, and those with AIDS.
Efforts must be made to ensure that health promotion programmes focus particularly on less affluent socioeconomic groups. For example, the new state programme on drug addiction will especially plan preventive measures for vulnerable target groups. Surveys on lifestyle, alcohol consumption, smoking, participation in health monitoring and disease prevention schemes, and morbidity and mortality data indicate that disparities in health status and in socioeconomic status are closely correlated.
Equity and the principle of creating equal opportunities for health also require considering people’s exposure to unhealthy and stressful working conditions. In accordance with the principles of health for all, a further aspect of equal opportunity is the health status in rural versus urban areas and differences between different regions in the country. The state and everyone responsible for public health therefore have to concentrate all their efforts on:
• finding such problems and problem groups by analysis and evaluation within the health reporting; and
• trying to achieve equal opportunity by actively influencing the structures of access, utilization and quality in services for disease prevention and health care.
Equity in health information
Limited resources in the health care system make it even more crucial to set aims and targets and to focus on target groups. Careful monitoring, analysis and assessment of the situation are necessary to identify these groups and to get further information for making political decisions.
North Rhine-Westphalia has therefore developed a public health information system in recent years (see
page 58) that includes information on various aspects of the situation of underprivileged groups.
Research
The Ministry of Employment, Health and Social Affairs has led numerous research studies taking a social viewpoint that comprise a basis for analysis and assessment in the health care sector, including the topics:
• disabled people (1993)
• immigrants (1994)
• the social situation of families with many children (1994)
• lifestyles of single mothers or fathers (1993)
• housing shortage and homelessness (1992).
A recently set up ministerial working group, including the social, employment, family and health sectors, is discussing the general effects of such social aspects and the necessity of a common data bank.
Public health reports
A section of a 1995 report as part of the North Rhine-Westphalia public health report series (5) deals especially with health status and quality of life and, in this context, with social inequity and health.
Further, the 1997 public health report (6) deals with the question of equity in various chapters (such as those on smoking, violence against children, violence against women and children’s work). Also, the adopted set of health indicators considers various aspects of equity. A new report on the health of immigrants is being prepared.
North Rhine-Westphalia is coordinating the new European Union Health Monitoring Programme for 1997–2001 for the German Länder. An application to this programme is planned for a project on social equity, focusing on the health of children and young people.
Infant mortality
In 1993, the Government of North Rhine-Westphalia permitted data from birth certificates to be combined with those from death certificates, enabling statisticians to make conclusions on various social parameters in infant mortality.
More effort is required in monitoring and assessment (see page 59).
Programmes focusing on disadvantaged social groups
The health policy of North Rhine-Westphalia has focused on vulnerable social groups such as mothers and children and drug addicts.
Maternal and child health (see also page 43)
Measures for prevention and early detection of disease are less effective and infant mortality and morbidity are higher among disadvantaged social groups, including those with poor education, very
young mothers, migrant families and high unemployment.
A pilot scheme on improving services for pregnant women and newborns in areas with substantial social challenges has been successful. Specially trained midwives working at the local health authorities are paid to look after pregnant women and newborns in their homes, giving them advice and motivating them to take part in the prevention and early detection programme offered. This state-wide service is intended to be established gradually in the whole of North Rhine-Westphalia, involving the health insurance schemes. The limited public resources at the local level have to cover the expenses, at least in part, and this is a problem (see page 53).
Further, North Rhine-Westphalia is working out special approaches to reduce smoking and alcohol consumption in pregnancy and smoking in the living environment of babies (to prevent sudden infant death syndrome). In addition, the reduced hospital stays and increasing outpatient births are prompting a programme for the care and early screening of newborns and young mothers – again, especially in disadvantaged groups. Here a programme is being worked out together with all partners of the North Rhine-Westphalia Commission on Maternal and Child Health.
Drugs (see also page 44)
In addition to a drug prevention programme and the fight against drug dealers, much effort has been made in developing a differentiated help and care system for drug addicts that takes into account the fact that motivation for therapy is often fragile. Care and help services with easy access have been developed that offer support and help to people who are not yet ready and able to take part in a therapy programme aiming at abstinence. The methadone projects in North Rhine-Westphalia are among these services.
These efforts have markedly reduced the number of drug addicts dying from drug-related causes in recent years: from 505 deaths in 1991 to 360 in 1995. Special therapy programmes have been developed for addicted women (counselling as well as inpatient therapy institutions).
Other health programmes (see also page 44)
Other health programmes have specifically considered equity, such as “Have a heart for your heart”, a special workplace prevention and health promotion programme, and a programme to improve the comfort of dying people.
Because accident insurance is required by law, equity is also guaranteed in principle at the workplace.
North Rhine-Westphalia has considered the request for equal conditions in occupational safety and health for all employees in all areas, and for more emphasis on health promotion in the workplace by reorganizing its occupational safety and health administration.
North Rhine-Westphalia is working towards improving the situation of special groups by developing new models of working time to improve the compatibility of family and work, and by developing occupational health examinations for young people.
A status analysis on work and health in North Rhine-Westphalia provides a database to enable policy to
be more oriented towards targets and specific population groups.
Equity will be one of the most important guiding principles in future programmes. For example, North Rhine-Westphalia is working on a comprehensive programme to integrate disabled people socially that has an intersectoral approach from the beginning.
Equity in health for the urban and rural populations
Efforts have been made to ensure an equitable distribution of services in urban and rural areas. In 1991 a pilot scheme was adopted in the regular medical care system. Fifteen oncology centres were founded in North Rhine-Westphalia as associations of universities, hospitals and private doctors.
The aim is to provide equal, high-quality medical care to everyone with cancer, whether they live in an urban area near oncology specialists or in the countryside. The oncology centres have established a documentation and information system for the treatment and aftercare of people with cancer, involving all partners.
In the 1970s, North Rhine-Westphalia started to develop a decentralized mental health care system for psychiatric patients that especially focuses on community-based psychiatric care with as much outpatient care as possible. A differentiated outpatient care system, more than 90 day clinics and more than 50 psychiatric departments at general hospitals have been established in local communities. This system is being developed further.
North Rhine-Westphalia’s programme on environmental protection has contributed to equity in living and health conditions in rural and urban areas. Much has been achieved in the industrialized Ruhr area, where coal mining and other industry caused severe air pollution problems. Projects on environmental medicine in prevention, diagnostics and therapy have been developed in North Rhine-Westphalia after the health conference on this topic in 1993.
Health targets
North Rhine-Westphalia’s new target-setting approach is initially focusing on ten targets in accordance with the principles of health for all. The State Health Conference and its planning board discussed equity as a special topic. The Conference decided that equity should not be formulated as a specific target but that it should be regarded as a common theme in all targets. This was explicitly outlined in the preface to the target document (4). The situation for chronically ill and disabled people was also intended to be a common theme.
Importance of public health in the discussion on equity
Public health research, training, education and practice play important roles in the efforts for equity. The special tasks related to social compensation are an important issue in the ongoing discussion on the reform of the public health service at county level in North Rhine-Westphalia. Recent public health development in North Rhine-Westphalia is described above on page 46.
The limited resources of public budgets at the local and state levels in North Rhine-Westphalia are a severe problem, similar to other regions and countries. The 54 urban and rural districts identify the needs and set priorities in social compensation supplementary to the health insurance system. The situation differs substantially according to the size and rural or urban location of the community. Public health policy is challenged to hold its ground in the conflict of interests between the different political sectors.