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Public Health Services and Health Promotion

Veronika Reisig, Joseph Kuhn

(last update 27 August 2014)


Definition

The public health service in Germany comprises all public institutions dealing with matters of (public) health and healthcare at the national, federal state and local levels. National level institutions include, for example, the Federal Ministry of Health as well as other federal agencies such as the Federal Centre for Health Education (BZgA), the Robert Koch Institute (infection control, epidemiology, health reporting) or the Paul Ehrlich Institute (vaccines). At the federal state level there are the individual Ministries of Health and Specialist Authorities or Institutes of Health. At the local level we find the  communal health authorities. In addition, there are a number of other agencies that are concerned with health and healthcare matters but are not generally subsumed in the term “public health services,” examples being food control or occupational health and safety authorities.

Public health services have a broad range of activities that serve to maintain and improve the overall health of the population (Health Protection), including those of health promotion. In the following we focus on the role of public health services at the local (communal) level - the local health authorities. The tasks fulfilled by the other public authorities with respect to health promotion may be found in the key terms actors, offers and structures as well as health promotion V and Health Promotion and the Healthy / The Social City / The Perspective of Local Politics.

Germany has a total of over 400 local health authorities of very different sizes, from very small rural offices with less than 20 employees to very large urban ones with more than 100 employees. The staff in health authorities is multiprofessional, including (public health) physicians, social workers, sociomedical assistants and hygiene inspectors. In most of the German federal states the local health authorities are part of the municipal structure, that is, they are completely integrated into the municipal administration. Exceptions to this rule may be found in Bavaria, whose health authorities are attached to the municipal authorities only with regard to their administrative management; and Baden-Wuerttemberg, whose public health physicians are federal state civil servants working in an otherwise communal authority. In recent years a number of the local health authorities have been renamed, resulting in such labels as “Specialist Service for Health,” “Department of Healthcare” (e.g., in a municipal authority) or “Subordinate Health Office.” The assigned tasks of the public health services are regulated in a complex mesh of national and regional regulations, among others, in individual federal state level public health service laws. In all federal states, however, health protection and health promotion as well as the closely aligned area of health reporting are expressed tasks of the public health services. The terms and exact definitions of these tasks, however, differ from one state to another.

Range of Tasks of Local Health Authorities with Respect to Health Protection and Health Promotion

The tasks of the local health authorities with respect to health protection/prevention and health promotion are very diverse. They comprise, among other things, the following:

  • Infection control (e.g., notification system, examination of outbreaks)
  • Hygiene (e.g., drinking water and hospital hygiene)
  • Environmental medicine (e.g., contamination and pollution)
  • School enrollment and other screenings
  • Vaccination programs
  • Counseling and support programs (e.g., in the fields of child health, addiction, disability, mental health, HIV/AIDS, travel vaccinations)
  • Implementation or coordination of projects and actions at the local level (e.g., school projects, health fairs)
  • Networking (e.g., networks concerning addiction prevention or mental health, health conferences).

Traditional official forms of top-down intervention and the idea of health promotion often find themselves at odds. In their prevention work, local health authorities are expected to live up to a “double competence” at various levels:

  • First, regarding a pathogenetic as well as a salutogenetic approach (cf. salutogenetic perspective),
  • Second, regarding the sovereign control and inspection tasks as well as participative approaches based on partnership with the goal to support, encourage (cf. empowerment/qualification) and strengthen the resources of citizens,
  • Third, regarding a mixture of steering methods, ranging from sovereign “government” to participatory “governance,” i.e., moderating methods.

Communal Health Promotion: The Potential of Local Public Health Services

Health is part of our everyday life, and many of the determinants of health are influenced (at least partially) at the local level - for example, in urban development, traffic planning, the availability of childcare, education, sports and other leisure activities, local environmental protection and local economic development. The municipalities are often the central players on the stage of health promotion. Among the communal stakeholders the local health authorities in particular have the mandate to maintain and promote the health of the local citizens.

In this sense they are on principle predestined to serve as “communal health advocates”:

  • Local health authorities have a high level of health-related competence, a multiprofessional and interdisciplinary staff, a large public presence and close ties to the citizenry.
  • They have access to, and the necessary skills to properly process, present and use the local population’s health data.
  • They are well embedded in the local structures and serve as a sort of hub for any number of local services. They maintain a working relationship to other communal authorities such as school boards, social services and youth welfare services.
  • They have access to the various, including vulnerable, target groups and local settings (e.g., nursery schools, schools, old-age homes, nursing homes, residential districts, municipal or village quarters).
  • They represent a neutral and socially integrative entity, oriented toward the welfare of the community.

Local health authorities can play a major role in supporting health promotion projects and processes. This includes needs assessments and community diagnoses based on meaningful health reporting, the identification and interpretation of scientific evidence as well as the partner-based planning, implementation and evaluation of projects (cf. public health action cycle). However, due to the nature of the many and complex factors that affect health (cf. determinants of health), those activities of local health authorities that aim to promote health cannot be carried out alone. Rather, many other communal partners such as those active in the areas of youth services, education, urban planning and healthcare must be brought on board. In the sense of integrated communal strategies that serve to concentrate and coordinate the resources and services across all sectors and for all age groups, local health authorities together with their communal partners can cover the whole range of action areas relevant to health. Approaches such as early childhood interventions, health promotion and prevention “chains” or the idea of “communal health landscapes” attempt to conceptualize that systematically.

Localhealth authorities may play a number of roles - from providing impulses and initializing, networking and moderating to the complete coordination and maybe steering  of events at the local level. In doing so they can receive conceptual and scientific support from higher-level authorities such as the Federal Center for Health Education (BZgA) or regional specialist authorities. Local roundtables on health-related matters, such as those held in North Rhine-Westphalia (prescribed by law), in Baden-Wuerttemberg (as part of the overall health strategy of that state) and in Bavaria (presently in the model phase), provide the necessary cooperative structures for promoting health. By providing moderation, coordination and other assistance, the public health services can help in the analysis of the local health situation, in the setting of local goals as well as in the cross-linking, pooling and development of resources and services according to need. Structural “docking sites” for the health-promoting work of the local public health services may also be found in the WHO Healthy Cities Network to which more than 70 cities in Germany now belong. There is also the national-regional cooperation project entitled “The Social City,” which supports integrated approaches to developing disadvantaged city districts (health promotion and the healthy/the social city/the perspective of local politics). The communal partner process entitled “Growing Up Healthy for All,” a platform built up by the Federal Center for Health Education (BZgA) and the central communal associations as well as the cooperation network “Equality in Health,” also provides an important framework for integrating the public health services into the structures and networks for local health promotion and prevention.

Health Promotion at the Local Level: The Reality of Local Public Health Services

Among the published reports on successful programs of local health promotion involving local health authorities, the prevention program entitled “Lenzgesund” in the socially disadvantaged district of “Lenzsiedlung” in Hamburg-Eimsbüttel is a primary example of how a local health authority can work together with other partners in a district. Other examples such as the “Municipal Coordinating Office for Migration and Health” of the Frankfurt Health Authority and the “Network for Drug Addiction Prevention” of the Health Authority in Erlangen-Höchstadt may be found in the project databases and internet portals of national initiatives like that of the cooperation network “Health Equality.” Further remarkable initiatives like the health authority initiated prevention chains in Kassel and Münster are described on the internet portal “Growing Up Healthy for All.”

Despite all of these successful models, and despite the observation that today many of the local health authorities  in larger cities have made health promotion part of their core tasks, the local public health service as a whole still fails to adequately live up to its potential as proponent of health at the local level. The paradigm shift that was foreseen at the end of the 1990s by the Municipal Association for Administration Management away from single-case work and toward a systemic social space approach has yet to be broadly realized (apart from some exceptions). The Association of German Counties recently noted in a paper on the future development of public health services a short fall in that development and has declared health promotion and prevention to be one of the “main tasks of public health services.” The reasons behind such deficits are manifold - they range from a broad loss of function  of the public health services following World War II and the rise of a clinical-medical orientation in the German healthcare system, to the prevailing professional traditions in the public health services as well as general cutbacks in public budgets. All of these factors worked together to severely limit the further development of public health services.

Beyond that, the development of new concepts and strategic perspectives for Germany’s public health service is hampered by a lack of research on the public health service within the (public) health sciences. Instead of a scientifically based development embedded into the public health community, public health services are increasingly fixed  on their traditional approaches and concentrate on fulfilling sovereign or statutory mandates. These tasks are often precisely laid down by law and are supported by dedicated personnel, whereas for the tasks of planning and organizing health promotion no such structure is present.

In conclusion, it may be said that the local public health service is in many respects ideally placed to assume the role of a central player in communal health promotion. In light of its history, legal and staffing restrictions as well as its organizational culture, this potential is in many places being broadly neglected at the moment. Nevertheless, the concept of health promotion and, more broadly speaking, modern approaches of (new) public health represent a conceptually guiding vision and profile-building task constellation for Germany’s public health services. Important milestones on the path to this goal lie in creating the necessary legal conditions, not least in the form of a prevention law, in redistributing the existing resources in the healthcare system (making public health services the third pillar of the healthcare system alongside outpatient and inpatient care), in strengthening the public health skills in public health services, in bringing together public health services and public health in both science and practice, and in developing a respective mission statement for Germany’s public health services.

References:
Deutscher Landkreistag, Weiterentwicklung des Öffentlichen Gesundheitsdienstes. Beschluss des Präsidiums des Deutschen Landkreistages vom 9./10.04.2013 (http://www.landkreistag.de/ images/stories/themen/MedVersorgung/ Papier_Weiterentwicklung_des_GD.pdf; retrieved on 24 June 2014).
Jilian H, Block P, Gerullis M, Lehmann F, Der ÖGD als koordinierender Akteur? Prävention 36 (4) 2013, 116-119.
Kommunale Gemeinschaftsstelle für Verwaltungsmanagement (KGSt), Ziele, Leistungen und Steuerung des kommunalen Gesundheitsdienstes. KGSt-Bericht 11/1998. Cologne: pp. 7-8.
Kommunale Spitzenverbände, GKV. Empfehlung der kommunalen Spitzenverbände und der gesetzlichen Krankenversicherung zur Zusammenarbeit im Bereich Primärprävention und Gesundheitsförderung in der Kommune. Berlin, 2013 (
http://www.staedtetag.de/imperia/md/ content/dst/internet/fachinformationen/2013/ rahmenempfehlung_praevention_2013.pdf; retrieved on 24 June 2014).
Luthe W (Ed.), Kommunale Gesundheitslandschaften. Berlin, Heidelberg, New York, 2013.
Kuhn J, Wildner M, Zapf A, Der Öffentliche Gesundheitsdienst: Standortbestimmung mit hoffnungsvollem Ausblick. Deutsches Ärzteblatt 109(9) 2012, A 413-416.
Schmacke N, Gesundheitsförderung in der Kommune als Aufgabe des ÖGD. Prävention 36 (4) 2013, 124-126.

Internet addresses:
www.gesunde-staedte-netzwerk.de
www.gesundheitliche-chancengleichheit.de (Kooperationsverbund Gesundheitliche Chancengleichheit)
www.inforo-online.de (Internetportal kommunaler Partnerprozess “Gesund Aufwachsen für alle!“)

Links: Health Promotion and the Healthy / The Social City / The Perspective of Local Politics, Health Protection


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Federal Centre for Health Education (BZgA) / Maarweg 149-161 / 50825 Köln / Tel +49 221 8992-0 / Fax +49 221 8992-300 /
E-Mail:
poststelle(at)bzga.de / E-Mail for Orders: order(at)bzga.de

The Federal Centre for Health Education (BZgA) is a specialist authority within the portfolio of the Federal Ministry of Health.