Europe faces an enormous – and growing – investment gap in social services, including social housing, education and health. It is essential for health promotion providers to begin exploring the opportunities offered by complementary and innovative funding mechanisms. Social investment offers an opportunity to both private and institutional investors, who are likely to be more involved in social investment and services in Europe in the coming decades due to public investment constraints, government investments, and policies to encourage private sector participation. The devastating impact of COVID-19 on health inequalities demonstrates a clear need to ensure not only investments in crisis preparedness, but also to involve investors in building wider social infrastructures to improve resilience of communities.
Investing in health promoting services
Health promoting service providers would benefit from being proactive in seeking innovative financing opportunities and knowledgeable of financial language, measures, and instruments.
There are benefits to thinking beyond health sector budgets alone to realise systemic change and make substantive progress. This requires smarter thinking about the ways in which cross-sectoral relationships and services can be leveraged to reduce expenditure and improve the quality of service provision. Working with other sectors, including housing, education, and long-term care, can result in a better continuity of care for the community and bring about co-benefits such as improvement in the underlying social determinants of health, ultimately leading to the prevention of illness and reduction of health inequalities.
One way of increasing funding for actions that benefit health is by working outside the health sector and to form cross-sectoral alliances. Health and other social sectors share common goals, benefits, and economic gains from taking a health equity perspective to their work. For example, cross-sector benefits include school health-programmes that cover school-performance, mental health, and health literacy and are inclusive of families and the community. To provide shared funding, sectors can take a joint budgeting approach, including mutually determined targets and outcomes, as well as the breakdown of roles and responsibilities for the delivery of pre-agreed services.
It is important to also encourage investing in infrastructures, as part of a broader shift across sectors that recognises the need for integrated, community-based health and social care and services.
- 'Hard' social infrastructure may include building health centres, good quality social housing, sustainable transport infrastructure, playgrounds or green spaces.
- 'Soft' social infrastructure investments include staff skill development, community programmes, welfare advice services, prevention and early interventions, and person-centred approaches.
While this increased collaboration is welcome, we must acknowledge that these investments carry certain risks for both investors and recipients of investments. For investors this includes political and regulatory exposure; governments can amend the standards of service expected from privatised facilities, the length of their leases or concessions, or the level of risk-weighted returns on capital outlays. For recipients this includes badly drawn contracts, negative impact on staffing, limitations in provisions, and cherry picking of services, which could exacerbate health inequalities. We do not advocate for the privatisation of any service, programme, or facility. However, policymakers must be aware of the possibilities and potential pitfalls from increased investment opportunities.
Investments in both hard and soft social infrastructure- simultaneously - are important for supporting sustainable and effective health promoting services. What we need to see is investments like the programme below from Germany where investments in 'softer' skills are seen as a crucial aspect to improve health and the rehabilitation of workers.
Investing in soft infrastructure has benefits for promoting health and wider benefits felt throughout society. In Germany, a recent project that sought to help employability through vocational rehabilitation is not only a successful example of a soft infrastructure project, it also relied on collaboration between business and rehabilitation centres to share the costs and services of the rehabilitated beneficiaries.
The impetus was due to a survey carried out by the German Confederation of Trade Unions (DGB 2014) that showed that almost half of the employees could not imagine carrying out their current occupation until retirement. At the individual level, this means considerable personal and financial restrictions due to a premature job leave. At the national level, the economy loses considerable resources of labour, which creates additional burden on social security system.
A measure to prevent workers from no longer being able to carry out their work is job-rotation within and between companies, as it counteract this process before health problems develop. This was exactly what the TErrA-project in Germany facilitated. While this project was only a three-year funded programme, and the coordinators are seeking permanent funding, it is the type of project that speaks to the ideas we suggest around soft infrastructure, inter-sectoral collaboration, and positioning health throughout the economy.
Job-rotation as a tool to maintain employability – The TErrA project in Germany
The preventive job rotation process, developed during the TErrA project (2016-2019), is a consulting model for employees who are willing to change jobs and companies that support job rotation for personnel development. Companies and employees go through a 4-step consultation process of (1) sensitisation and orientation, (2) finding perspectives, (3) realisation and (4) aftercare. Throughout the process, personal health status, personal qualifications, specific requirements of possible new jobs and motivation are considered.
The TErrA project in Germany has shown, among other things, that since internal job changes in SMEs are often limited due to low jobs variance, inter-company job changes in a Regional Company Network could enable a good fit between work requirements and employees’ qualifications. Classic examples are a nurse who qualifies as a medical coding specialist, or a roofer, who switches to sales in the construction sector. It also showed that employees must be made aware of their current employment risks and opportunities at an early stage in their career planning in order to prepare for a future job change. The process requires a corporate culture where employers and employees bear joint responsibility for employability.
The major learning of the project was that currently there are no possibilities for the financial support of preventive job rotation. For companies and employees, a job change is usually associated with further training. The costs of such preventive training are currently not covered by pension, accident, health, or unemployment insurance. An entitlement to financial benefits only exists when the first health-related impairments have already occurred. As a result, both employees and companies lack the possibility of shaping a preventative employment career path.
The hope that the German Prevention Act will provide new impulses to fund preventive job rotation has not yet come true. Intending to close the gap, social insurance institutions are designing initial models attempting to move towards preventive employment paths. Nevertheless, there are other laws that could support further development and implementation of the job rotation project. For instance, 'Flexirentengesetz' adopted in 2016, which makes the transition from working life to retirement more flexible, at the same time increasing the attractiveness of working beyond the regular retirement age, allows for a voluntary work-related health check for insured persons aged 45 and over ('Ü45 check'). Another current development is the 'Qualifizierungschancengesetz' (Qualification Opportunities Act) aimed to considerably increase investment in further employee qualifications to keep them fit for the rapidly changing labour market.
The development and coordination of networks to support inter-company job changes should be promoted by the state as structural features of life course-oriented social and labour market policies. In this spirit, the Federal Association of Vocational Rehabilitation Centres is currently developing a consulting service for companies and employees based on the TErrA concept.
Co-financing was developed by the United Nations Development Programme and colleagues. It is an approach whereby two or more sectors or budget holders, each with different development objectives, co-fund an intervention or broader investment area, which advances their respective objectives simultaneously2UNDP, STRIVE, & Gov. Of Japan (2019) Financing across sectors for sustainable development: guidance note. United Nations Development Programme. Co-financing does not require additional resources or increases in capital investment. Rather, it helps optimise allocation of existing resources across sectors to maximize cross-sector outcomes.
The co-financing methodology necessitates different government departments, sectors, or budget holders to move outside their current silos and work together. This includes through effective cross-sectoral governance, planning and financing mechanisms through their inter-institutional and coordination mechanisms.
The co-financing methodology is reliant upon two key expectations:
- that the objective of budget holders is to maximise their sectoral outcomes;
- that budget holders are solely constrained by their budget when making decisions about the interventions in which to invest.
However, when the methodology is put into practice there are numerous potential barriers. This includes institutional feasibility and the incentives and disincentives of the different departments to actively engage and collaborate. Transitioning away from input-based budgeting towards programme or output- and outcome-based budgeting is helping to address barriers involved with co-financing. In addition, funding schemes can be developed where funding is contractually conditional on having an inter-sectoral partnership between health and one or more sectors.
There are new ways emerging to help health planners become more effective in working with other sectors. This will ensure that inter-sectoral collaboration is easier and more efficient.