Insurance funds, active in many countries’ health systems, are key players in funding health services. Several European countries have enabled health insurance funds to finance preventive work of public health services. This has huge potential for combining well-planned health promoting services and sustainable financing. It also offers a range of different sectors the opportunity to become involved in aligning their work towards common targets.
In addition, the potential savings for insurance funds are a positive cycle that can lead to further increases of finance available for preventative and health promoting measures. Other institutional investors and funds, such as pension funds, are another potential source of increased funding that has the potential to work across sectors and create positive feedback through improving health and wellbeing, increasing their return on investment, and boosting the pensions for an active aging population.
In 2015, the German parliament passed the Health Equity and Public Health Act (“the Prevention Act”) which aims to reduce socially determined health inequalities and to improve coordination between actors which can promote and enable good health. This political arrangement allows for German health insurances and care funds to invest approximately €500 million per year in health promotion and prevention. It is an ambitious policy development that holds potential for the development of similar models.
The German Prevention Act
The Prevention Act is an innovative mechanism to improve health equity as it includes actors from both within and outside the health sector. Guided by the national prevention strategy, German social insurance institutions work together with regional authorities and the Federal Employment Agency to agree on ways of cooperation in health promotion in schools, companies, day-care centres and more.
The Prevention Act (Präventionsgesetz – PrävG) was passed by the German parliament and entered into force on 25 July 2015. Essentially, the new legislation strengthened the cooperation and coordination between actors in the area of prevention and health promotion. In addition to statutory health insurance, pension insurance and accident insurance, social nursing insurance and private health insurance companies are now also involved.
The Act clearly specified a mandate of statutory health insurance, established a common understanding of disease prevention and health promotion and facilitates setting common goals. The National Prevention Conference (NPK) was set up to develop and update a National Prevention Strategy. The social insurance institutions, together with the federal government, the federal states, the municipalities, the Federal Employment Agency and other the social partners set common goals and agree on a common approach.
On the basis of a national prevention strategy, the social insurance institutions agree with the Länder and with the participation of the Federal Employment Agency and the local umbrella organisations on the specific way of cooperation in health promotion in different settings like nurseries, schools and companies to name a few. Since 2016, health insurance funds are obliged to support the establishment and strengthening of health-promotion structures with 7 € per insured person, about € 500m in total. The pattern of expenditure can be observed in the graph below.
In June 2019, the Federal Minister of Health received the first prevention report about the experiences applying the law. Every 4 years, the NPK Prevention Report will give an overview of the achieved goals set in the prevention strategy. Part of the evaluation was conducted against four commitments: to grow up healthy, to healthy living and working, to being healthy in old age, and to reducing unequal health opportunities.
In more detail:
- It was concluded that children and adolescents of school age, children in the kindergarten and their parents, as well as expectant and young families were frequently reached. Most often, the activities aimed to improve health literacy, promote healthy eating and exercise, and strengthen mental health and resilience.
- The long-term care insurance reached residents of inpatient care institutions. Additionally, activities of the private health insurance as well as of the federal government, the municipalities and the civil society reached persons in municipalities. The content of nursing care activities most often included promoting physical activity, mental and cognitive functions. The activities of the private health insurance also included health literacy, disease and accidents prevention.
- 40% of the health insurance commitments took place in the so-called “social hot spots” and 10% in enterprises with a high proportion of employees without completed vocational training.
The report has also shown that National Framework Agreements were concluded in all 16 federal states. The vast majority of negotiating partners are satisfied with the status of agreement implementation.
In the Netherlands, the Combined Lifestyle Intervention (CLI) focuses on starting, and maintaining, a healthy lifestyle. The intervention includes advice and guidance for forming healthy eating habits, following a healthy exercise pattern, and coping mechanisms for such issues as stress and a lack of sleep which have an impact on health and wellbeing. The development and implementation of the CLI took more than ten years, from the publication of a report on how prevention could fit into the healthcare system by the Dutch Healthcare Institute in 20061Westert, G. P., &Verkleij, H. (2006). Dutch health care performance report., to the inclusion of such interventions in basic insurance packages in 2018.
Combined Lifestyle Intervention (CLI) in the Netherlands
Combined lifestyle interventions (CLI) are designed to reduce risk factors for lifestyle-related diseases through increasing physical activity and improvement of dietary behaviour. Starting January 2019, the CLI is covered by the basic package of health insurers. A CLI is a combination of treatments focused on healthier foods and eating habits, exercise more and, if necessary, individual psychological treatment to change behaviour. Only CLI’s that are proven effective are covered.
The RIVM (National Institute for Public Health and Environmental Hygiene) evaluates lifestyle interventions on their effectiveness. Not everyone with weight related problems or in need of coaching on healthy living, is eligible for CLI. In order to qualify for treatment, a referral by the family doctor is needed. The family doctor determines this on the basis of Dutch Standard for Overweightness and Obesity. Referral can only take place in case of a moderately increased weight related health risk.
The tasks, roles and responsibilities of the main actors involved in organising the service:
- The Dutch Healthcare Institute: establish what interventions are reimbursed and determine whether programmes meet the requirements.
- The Dutch Healthcare Authority: establish a policy (including the rate at which intervention is reimbursed) and monitor implementation.
- The Dutch Association of Healthcare Insurers: determine whether programmes can be reimbursed under the basic insurance package.
- The National Institute for Public Health and Environment: assessment of the quality, effectiveness and feasibility of the programmes and monitoring the implementation of the CLI.
Their tasks, roles and responsibilities of the main actors involved in implementing the service:
- Health insurers: decide which programmes to purchase and conclude contracts with lifestyle coaches or healthcare professionals who want to offer the CLI.
- Intervention owners: distribute their programmes and provide training to healthcare professionals who will be offering their programme.
- General practitioners and medical specialists refer patients to one of the programmes.
- Lifestyle coaches or other primary-care professionals: carry out the programme.