Health Policy and Health Promotion

By Bob Karch

Health Promotion in Austrian National Policy

By Brigitte Svoboda

Austria is a federal state and consists of nine federal provinces (Länder). Thus, national health promotion has developed in a decentralized way, and the basic principles of federalism are reflected in the infrastructure for health promotion. The governments of the provincial Länder either take up health promotion themselves, mainly within the framework of health administration, or they delegate the task to non-governmental organizations. During the last years, most of the Länder established a special NGO for the implementation of health promotion. Due to the de-centralized organization of health promotion in Austria, national and regional networks play a prominent role. National networks are established on different settings such as cities, schools, hospitals, workplace and women's health promotion centres. Regional networks are established on healthy communities (Gesunde Gemeinden).

Health Promotion Policy s often legislated in the Austrian Parliament

The Federal Level

In addition to provincial health promotion factors, there are several factors at the federal level, namely the Federal Ministry of Social Security and Generations and the Federal Ministry of Education, Science and Culture, the Main Association of the Austrian Social Security Institutions, the General Accident Insurance Institute, university institutes and other research institutes. Within the Federal Ministry of Social Security and Generations, health promotion is organized in a matrix. Vertical issues are nutrition, alcohol, smoking, drug abuse and communicable diseases including HIV/AIDS. A special Health Promotion Unit has been set up to develop the horizontal approach. In implementing this horizontal approach, the Health Promotion Unit developed a strategy focusing on settings and the corresponding networks as well as on national and international cooperation.

The Health Promotion Act

Following the growing political awareness of the importance of prevention and health promotion, the Health Promotion Act was launched in 1998. The Federal Government, the provincial Länder, the local governments and cities agreed on a "Health Promotion Initiative" which permitted the establishment and implementation of long-term programs for priority target groups and settings. The resources are to be employed to supplement the measures already existing. The strategies of the Health Promotion Act are in line with the overall health concept of the WHO, which in addition to the biomedical approach, stresses the psychosocial aspects of health. Australian strategies follow the intention of the WHO’s Ottawa Charter on Health Promotion, which has proven its value throughout Europe as a professional framework strategy for health promotion.

National strategies are designed to act at several levels: they provide support for projects at the local and regional level, as well as the structural advancement and development of integrated programmes. They aim at a balance between individual lifestyle information, and more complex activities in the psychosocial field and organizational development approaches in settings. Implementation strategies shall promote both the responsibility of the individual and the responsibility of society for determinants of health. Moreover, in the future a closer connection shall be established between the results of scientific research, practical implementation and evaluation.

The implementation of the measures and initiatives of the Health Promotion Act has been assigned to the "Healthy Austria Fund", a non–governmental organization that was set up specifically for health promotion. It was reorganized in 1998 to cover the administration of measures regarding the Health Promotion Act, and to facilitate the development and implementation of health promotion at national and regional levels. It acts as a platform for the provision of health promotion information and coordination and supports training, evaluation and quality development in health promotion.

In 2000 the agreement of the new government, again, stressed the high importance of disease prevention and health promotion and indicated as one of the government’s goals, the development of a National Health Promotion Plan. It is the intention of the new government to focus on major programmes (e.g. smoking cessation, drug abuse, diabetes) and to bring together the large number of local and regional initiatives in a more coherent way. At the second Austrian Health Conference in 2001, health promotion was again part of the agenda. Prevention according to age was given special priority.

Dr. Brigitte Svoboda may be contacted at: Bundesministerium für soziale Sicherheit und Generationen, Abteilung Gesundheitsförderung, Radetzkystraße 2, A-1030 Wien. Phone: +43 1 71100/4378, Fax: +43 1 713 86 14, e-mail: brigitte.svoboda@bmsg.gv.at http://www.gesundheit.bmsg.gv.at

Developing a National Dutch Action Program for Health Promotion in Schools

By G.J.Buijs, T.Paulussen, R.Loof, J.C.M. van Wijngaarden

At present, four organizations in the Netherlands collaborate to develop a national action program for health promotion in schools. This program will set out the ways in which attention to health promotion in the Dutch education system can be strengthened in the next decade. The program will be supported by a covenant, signed by the ministries of Health and Education, as well as, the national key organizations from the health and education sector.

Though health is naturally part of education, the introduction of the health-promoting concepts in schools nationwide is stagnating. On the one hand, vast and varied numbers of teaching methods and information materials have been developed and distributed among schools. On the other hand, however, for Dutch schools, health is only one of the many issues that they need to address. Apparently, contributions from health organizations do not often meet the needs of Dutch schools. This article analyses the situation in the Netherlands and gives ideas on how to deal with this issue.

Healthy School Policy

In the 1980s the "Healthy School Policy" was introduced by the health sector to work with the parts of national school policy dealing with the health and well-being of the total school population. The Healthy School Policy encompasses all activities that schools plan and undertake in the area of health protection and promotion. It consists of three interrelating pillars:

• Health education in the classroom.
• Individual counseling and guidance for pupils and staff.
• Care for the school environment.

Prerequisite for the successful implementation of Healthy School Policy are support from teachers, school management, school board, pupils and parents.

The interests of the health and education sectors differ with regard to health promotion in schools. For the health sector, school programs need to be effective in terms of healthy (behaviour). The perceived seriousness of a health topic affects the health sector selection process. This implies that, professionals decide for a school what is an important issue; schools add the transfer of the required knowledge, attitudes and skills.

Schools give priority to activities promoting student performance and well being. One of the central goals in Dutch education policy is for students to learn to choose independently. Schools have an increasingly pedagogic task (by taking over, more and more, the role of parents) with an emphasis on learning independently, social and emotional development and social competence.

At present, what the health sector offers to schools does not seem to be based on their needs. Health education is just one of the subjects – like teaching about the environment, peace, development aid and many other issues- that compete with each other for attention from schools. Then there are many problems in the school system itself (constant reorganizations, burn-out of teachers, drop-out of pupils) that negatively influence a school's involvement in developing a health policy.

What Do Schools Want?

Part of the development of the collaborative national action project is to find out what Dutch schools are doing at the moment with regard to school health policy and what their needs are. An inventory was conducted at the end of 2000 on 200 schools with over 500 respondents (teachers, managers, health coordinators). Results show that most schools find it important to pay attention to each of the aspects of a school health policy, and health is an important issue in the curriculum, as well as in student counselling and guidance of pupils from ethnic minorities. Most schools have taken special measures to promote health and safety for pupils and staff, and have regulations on a number of health issues (rules for smoking and drinking, bullying, etc). More than 50 percent of schools want to spend more time on health promotion. To do this, they need better teaching materials, more time and money. It can be concluded that health promotion is an important issue in schools.

So What's Next?

A national action program for health promotion in Dutch schools will be launched by the end of 2001. Research conducted among all national and regional stakeholders demonstrates there is enough support for this.

Important principles of the future program will be:

• Better agreement between what health organizations offer and the needs from schools.
• More coordinated support between the national (and regional) organizations and new ways of collaboration.
• Introduction of a broader definition of prevention, which would involve, apart from the promotion of health, the development level of pupils, school priorities and which would provide links with social competence.
• Research on the effectiveness of health promotion based on a broader concept of prevention.
• Development of a national focal point for health promoting schools.

The national action program will mean a major step forward for health promotion in schools in the Netherlands.

Local Government, Local Health Promotion: The Quality of Life Program in Curitiba, Brazil

By Suely Harumi Ioshii, Mirella P. Belotti, Mônica Sztajn and João Vicente Ferrari

Curitiba is a progressive city in many areas, including health promotion

Curitiba, the capital of the Brazilian state of Paraná, is located in the South of Brazil and is 307 years old.

Curitiba is nationally and internationally acclaimed for its innovative and people-centered urban solutions. The current administration, led by Mayor Cassio Taniguchi, is supported by 3 basic guidelines: job creation, shared administration, and integration of the metropolitan area. The Mayor believes that the city will be better as the conditions of life are better for everyone.

Curitiba’s Quality of Life Program is administered out of City Hall. It is a broad multi-focused program designed for civil servants and founded in the vision of the city worker as a human being in his or her wholeness.

The Program

The theme of "quality of life" in the public administration of Curitiba was made in 1993, focused on the workers of the industrial neighborhood of the city. The objective was to make it easier for those workers to have access to the several programs developed and offered to the community by taking the activities directly to their workplaces.

In March 1997, a policy of increasing the value of the local civil servant proposed by the officer of the Human Resources Secretariat - organ which was created in June 1991, to take care of managing workers of the city hall – was the starting point of the Program of Quality of Life of the City Hall of Curitiba ( QVT/PMC). Interested and motivated employees linked directly to the Human Resource’s Officer’s office formed the staff that has no formal connection with the structural organization of the institution. This gives the group members mobility and more power of articulation, agility and flexibility to make most of the necessary movements to achieve the goals of the program.

The mission of the program is the promotion of a movement forchanging the mentality of the civil servant, making him prouder of his role as the builder of a real citizenship as well as a town prepared for the new millennium.

The QVT/PMC contains projects in the areas of health promotion, nutrition, environment, housing, information, culture and leisure. It has a holistic view of the individual, aiming all of the 24 thousand public employees of the city hall of Curitiba who are spread over the 25 organs of the institution at most of 1,300 facilities.

As the program developed it became necessary to identify civil servants who wanted to assume the role of agents of change, acting as monitors, facilitators or multipliers of the ideas, actions and of the philosophy of the QVT. This became possible with the active participation of the workers in the various projects at their workplaces. These people help the staff of the QVT to adapt the projects to the uniqueness of each organ. They are given specific training according to the area of the program they decide to become part of. This group of multipliers keeps growing as the actions of the program get to more facilities of the different organs of the city hall.

Since the beginning, the major challenge faced by the staff, has been that of directing the program’s activities to all of the facilities of the city hall’s structure that are spread over the area of Curitiba. The solution came with integrated networks formed in the different regions of the town. These networks involve facilities from different organs in the same geographic area in order to receive the actions of the QVT program.

The implementation of the projects was only possible because of the practice of a shared model, agreed by the direction, which develops a chain of actions from all the people involved in the process, partners and monitors. The contribution of our many partners has been determinant for us to achieve the global concept of quality of life. Our partners are the people who work at the various Human Resources offices in different Secretariats, the Occupational Health Department group that is formed of physicians, psychologists, social workers, security engineers and technicians, the other Secretariats which work directly with the community, as well as some non-governmental organizations and private institutions.

During the first years of the program, a voluntary mobilization we called "Quality of Life Movement" was formed around the projects in different workplaces by the people involved in them. This way, the program acquired characteristics of integrality, focusing an integrated and holistic view of the worker as a human being; of intersectoriality, emphasizing the partnerships as a mean to make the projects a reality; and of an itinerary character, in order to attend the great number of organs and civil servants of the city hall.

The QVT program presents multidisciplinary characteristics such as making discussions about themes as citizenship and social responsibility possible in activities like the "Breakfast with the Mayor", that happens every fortnight with groups of servants from different Secretariats; the feeling of belonging to the system and the supportability of future generations in projects that refer to the environment; physical activity in the workplace through 10 minute pauses to stretch and break the routine, get closer to the colleagues as a mean to improve the morale and the productivity.

There are also short cultural activities within the working hours and the possibility of belonging to a choir or theatre group. Also, free tickets for theatre presentations are distributed among the interested.

There are specific projects focused on illnesses prevention and health promotion, dental health, women’s cancer prevention, drug and alcohol abuse, good posture, vaccination to those exposed to risky activities, vocal training to the 7 thousand teachers of the public elementary school system, and periodical general physical examinations.

The nutrition projects comprehend a program that brings fresh vegetables directly from the producers who come from the metropolitan area to the civil servants at their workplaces, and that include educational lectures on good nutrition habits and,, practical courses on total use of the food and soy cooking.

Nowadays, new programs on adult education, for those who have not concluded the basic school years, as well as environment programs focusing on waste control are being developed in order to implement the areas of quality of life which were not fully attended.

I. Evaluation Process:

As the program developed, it was essential to know what kind of impact the proposed actions were causing in the lives of the workers, so a questionnaire was developed in order to try to measure some qualitative indicators that were previously identified such as valorization, citizenship, information, morale and wellness.

II. The Future: 

He is not only a civil servant but also a citizen within the City Hall, and the City Hall is the mirror of the town. This is the idea that originates the concept of the civil servant-citizen in which the program is based.

The QVT deals with the idea of self management, the consciousness of the importance of acquiring healthy habits and lifestyle. Consequently, the tendency for the institution is to have, less absenteeism, less health treatment leaves, less labor accidents and more work productivity. For the worker, more motivation and satisfaction. There are gains for both parts, not only for the institution that becomes a better place to work, but also for the employee who becomes a happier human being in the workplace.

The authors of the article work at the Program of Quality of Life of the Secretariat of Human Resources of the City Hall of Curitiba, and are members of the Brazilian Association of Quality of Life – Paraná Branch.

Building Health Promotion Agenda into Nigeria’s National Health Policy

By Godwin Nwadibia Aja

One of the goals of the Nigeria national health policy is to establish a system of health care delivery that is promotive, protective, preventive, restorative and rehabilitative: a system that would ensure that everyone achieve socially and economically productive lives, in the spirit of self-reliance and self-determination. The implementation process includes health education activities through health personnel and the mass media, and in educational institutions, with the aim of enlightening the whole population on good health maintenance, the prevailing health problems and on the most appropriate methods of preventing and controlling them. In practice, however, there is still disproportionately high investment on curative services at the expense of preventive, promotive programs. The policy designers, mostly clinically trained personnel, favor institution-based, curative care rather than community-oriented preventive/promotive programs.

Committed to ensuring equity in the healthcare industry, the Federal Government of Nigeria, in 1977, launched the national health insurance scheme with the aim of facilitating easy access to healthcare for all citizens. Though tremendous groundwork has been done with a view to putting in place an enduring workable system, including establishing guidelines for registration of health maintenance organizations, this laudable program has yet to take off. It is hoped that it will overturn current inequities and increase control over the health of the people. However, there is no clear health promotion component in the proposed scheme: health promotion is not in the catalogue of activity that could be financed by health insurance companies.

Meanwhile, there are several government agencies involved in health-related programs, for example, National Agency for Food and Drug Administration and Control (NAFDAC) and National Drug Law Enforcement Agency (NDLEA).

The primary objective of NAFDAC is to promote and protect public health through the active control and regulation of importation, exportation, distribution, advertisement, sale and consumption of processed foods, drugs, bottled water, chemical and cosmetics. Yet, substandard foods, adulterated or fake drugs, untreated bottled water etc., are displayed and sold indiscriminately in the open. Similarly, the NDLEA is stringent on narcotic control, but there is no clear regulation on the sale of tobacco, alcohol products and smoking in public areas.

Conclusion: Obviously, a clearly defined health promotion component, as part of the existing national health policy, is inevitable. Political, economic, social, cultural, environmental and biological factors known to impact lifestyle, environment, and organized health services need to be properly addressed in the policy. Major risk factors associated with lifestyle and environment, such as smoking, diabetes, high blood pressure, high blood cholesterol and excess alcohol consumption, are on the increase. All the stakeholders, including government officials, committed lawmakers, concerned teachers and students, skilled parents, and understanding employers can provide a supportive social environment. And, integrating health promotion component into all health-related programs in Nigeria, will help bridge the existing gap between curative care and preventive/promotive programs.

Country Profile: Singapore

By Vivian Blaxell

Singapore's new Parliament House

National Health Profile

The state of health in Singapore is good by international standards. The infant mortality rate in 1999 stood at 3.2 per 1000 live births while the average life expectancy rate was 77.6 years. Rising standards of living, high standards of education, good housing, safe water supply and sanitation, a high level of medical services and the active promotion of preventive medicine, have all helped to significantly boost the health of Singaporeans. The leading causes of morbidity and mortality are currently the major non-communicable diseases such as cancer, coronary heart diseases, strokes, diabetes, hypertension and injuries. Cancer and cardiovascular diseases together accounted for approximately 62 percent of the total causes of death.

Health Services

Health services for the country are provided through 3 different Ministries, as well as by the private sector:

Ministry of Health (MOH)

MOH is responsible for providing preventive, curative and rehabilitative health services in Singapore. MOH formulates national health policies, co-ordinates the development and planning of the private and public health sectors, as well as regulates health standards.

Ministry of the Environment (ENV)

MOE is responsible for environmental health services such as sewerage, drainage and waste disposal systems, control of air and water pollution and of toxic chemicals and poisons, the control of outbreak of infectious diseases, vector or insect control and the safety of the food prepared and sold in Singapore.

Ministry of Manpower (MOM)

MOM is responsible for the industrial and occupational health of the workers.

Healthcare Delivery System

In Singapore, there is a dual system of healthcare delivery. The public system is managed by the Government, while the private system is provided by the private hospitals and general practitioners. The healthcare delivery system comprises primary health care provision at private medical practitioners' clinics and outpatient polyclinics, and secondary and tertiary specialist care in the private and public hospitals.

Healthcare Philosophy

The Singapore healthcare philosophy emphasizes the building of a healthy population through preventive healthcare programs and the promotion of healthy living. The population is encouraged through the public health education program to adopt a healthy lifestyle and be responsible for her or his own health. The public is made aware of the adverse consequences of harmful habits like smoking, alcohol consumption, bad dietary intakes and sedentary lifestyles. The child immunization program is targeted against infectious diseases like tuberculosis, poliomyelitis, diphtheria, whooping cough, tetanus, measles, mumps and rubella and Hepatitis B, is offered at the government polyclinics. Health screening programs have been introduced for the early detection of common ailments like cancers, heart diseases, hypertension and diabetes mellitus.

Health Promotion

On April 1, 2001, the Parliament of Singapore effected establishment of the Health Promotion Board (HPB). HPB is charged with advising the Singapore government on all matters related to the good health and healthy lifestyles of the people of Singapore, including policy formation. HPB is also charged with the development and implementation of programs and other activities for promotion of health in the island republic. HPB has an important role in ensuring the continued good health of Singapore school children, and it will spearhead the national health education and disease-prevention effort by promoting healthy lifestyles among Singaporeans, especially working adults and the elderly. It will also focus on preventive health and target programs at specific high-risk groups and diseases.

For further information about health and health promotion in Singapore, visit http://www.gov.sg/moh/ and http://www.hpb.gov.sg/

New Anti-Smoking Measures in Europe

On May 15, 2001, the European Parliament today approved one of the world's toughest anti-smoking laws, ordering blunt health warnings to be printed on cigarette packs and authorizing governments to demand they show pictures of scarred lungs, rotting teeth and other smoking-induced afflictions. The legislation, which will take effect in the 15 European Union member nations in October 2002, also bans cigarette manufacturers from using terms such as "mild" and "low-tar" on the grounds that they falsely suggest lower toxicity. Tobacco companies will also be required to disclose all ingredients and drastically cut the levels of tar and nicotine in their cigarettes.

With healthcare costs soaring as Europe’s population ages, governments have concluded that they must take urgent steps to educate young people better about the dangers of smoking in order to contain what EU officials describe as an epidemic of smoking-related diseases. These health problems are likely to worsen as the Union embraces new members from Eastern Europe, where cigarettes are even more popular then in the Western European states.

Tanzanian AIDS Prevention in a Health Promotion Context

In the June 2001 issue of Health Promotion International, Paulette Schatz of the Canadian Society for International Health, and Kuzvinetsa P. Dzvimbo1, of the Zimbabwe Open University, in Harare, report on a study aiming to bring teenage sexual attitudes and health promotion contexts into HIV/AIDS prevention programming in Tanzania. The study surveyed the attitudes of adolescents (average age 16 years) on sex-related topics such as culture, marriage, sexual behavior and sex education, identified similarities and differences in attitudes according to gender and socio-economic environments, and examined sources of students' knowledge of selected sex-related topics. Findings showed significant differences in attitude related to gender and socio-economic settings, and also in sources of information.

"Less is Better" Responsible Serving of Alcohol Initiative In Ireland

WHO/Harvard Workplace and Health Initiative

Physical and mental disorders often have substantial negative effects on work performance. In some cases, the negative effects on work performance of untreated or poorly treated illness are so large that their financial costs to the employer approach or exceed the direct costs of treatment. In some situations, even self-insured employers can realize financial benefit by investing in outreach and treatment quality assurance programs for workers with untreated target conditions.

The WHO/Harvard Workplace Health Initiative is designed to provide evidence about investment opportunities through a survey than can be quickly completed by a random sample of employees of any work group to provide the employer with information on untreated or under-treated health problems that have the largest effects on work performance. The interview schedule is now being used in a series of demonstration projects aimed at targeting health care investment opportunities for employers.

International Institute for Health Promotion Newsflashes

by Vivian Blaxell

Wolf may be contacted via e-mail at wolf_kirsten@hotmail.com.

Second Annual Global Symposium: Business and Mental Energy at Work 

World Strategic Partners’ second Global Symposium will convene in Geneva, Switzerland, October 25-25, 2001. The Symposium will meet at the facilities of the International Labor Organization, and is assisted by the Global Workforce Partnership, Business and Health Magazine, and the World Federation for Mental Health.

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe.  It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations.  More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation.  Email the IIHP at iihpaa@american.edu.  The IIHP website is http://www.healthy.american.edu/iihp.html.