|Implemented in this survey?|
The Austrian government has initiated a national strategy to improve child well-being. Guided by ?health in all policies? the Dialogue for Child Health targets kids' behaviors and integrates current policies to make services safe and more accessible. Recent global attention on child health was a strong impetus for the strategy. Success depends on transparent policy formation and implementation following international recommendations.Also,consistent reporting on child health must become the rule.
Initiated by the Minister of Health, around 150 experts and stakeholders from the field of child and adolescent health met in April 2010, to kick off a national process to improve the health and well-being of children in Austria. The Dialogue for Children´s Health is guided by the following principles: prioritizing children's rights and needs, instead of those of healthcare suppliers; involving all stakeholders in children´s health and addressing social determinants of health. The main aims of the Dialogue for Children´s Health are:
Furthermore the process seeks to integrate several distinct initiatives in child health into the Dialogue which also involves the development of provisions for consistent national reporting about children´s health. Currently there are certain activities under way such as:
From May 2010 to March 2011 six working groups consisting of delegates from all jurisdictions, research institutes, professionals working with children, representatives of patient's and children's rights, parents, NGOs and social insurance agency teams will assess the current situation in children´s health, identify deficits and work out possible solutions. The following working groups (WG) are established:
So far all working groups have met several times with varying frequencies.
A special focus is the policy strategy of "Health in all Policies (HiaP)", (see e.g. Ståhl et al. 2006; WHO 1999). Reflecting recommendations made by WHO and other international organizations this focus aims to draw the attention of other ministries to consider the impact of policies or legislation on children's health. Overall HiaP seeks to focus efforts on those policy measures which show significant improvements in children's health and establish sustainable cooperation with other sectors. In the context of the Dialogue for Children's Health the Ministry of Health will take charge in developing and coordinating activities as required.
The method to start the process of the Dialogue for Children's Health is the public health action cycle (see graphic) which describes a spiral of continuous enhancement. The action cycle consists of the four phases:
The Public Health Action Cycle
The main objective of the Dialogue is to develop a national strategy to improve child well-being through a coordinated approach of all sectors and based on the principle of "health in all policies." The Ministry of Health is leading the Dialogue with the involvement of six working groups who will evaluate current initiatives and suggest areas for improvement in child services.
Children, parents, providers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Even though the Dialogue aims for the first time to develop policies integrating all sectors, as the "health in all policy" concept prescribes, similar initiatives were already launched in mid 2000. These initiatves failed to deliver coherent policy measures. In addition, the strategy does not take into account a "life-cycle" approach which, however, is strongly recommended by international organisations.
Controversy may increase once concrete policy measures are under discussion. However, the biggest challenge in this context is for the working groups and the Ministry of Health to arrive at detailed measures.
While the process of the Dialogue is itself a sign of progress, structural or systemic impact may only be expected when detailed measures are implemented and adhered to by various government players.
While public visibility is still low, initiating a Dialogue seems easily transferable to other countries or health systems.
Programmes specifically designed for children have been on the policy agenda for many years. While in the early 1970's the focus was to bring down premature death of infants after birth and to combat infectious diseases more recent activities focus on addressing quality of and access to services for children.
First, introduced in 1974 the "The Mother-Child Health Passport" has had proven success in Austria. It aims at prevention for women during pregnancy and infants up to the age of five years. Over the years, the medical treatment program has continued to develop according to medical advances and clinical developments in this field. The prevention program consists of diverse treatments and services such as blood tests and scans during pregnancy and control of weight and size, orthopedic and other services for the infant. As an incentive the medical examinations are a precondition for mothers to receive child care benefits from social security. Since the start of the program, infant mortality has declined from 23,8% to 3,6% (Gyn-Aktiv 01/10). There are no precise statistics on how many pregnant women participate but it is predicted that at least a majority of pregnant women participate. Unfortunately, however, the number of pre-natal visits appears to have decreased in recent years (LBI 2009). In 2010 the Mother-Child Health Passport was again expanded to include further treatments and is constantly under discussion to continue to improve pre and post-natal care. One third of the programme costs are borne by sickness funds and two-thirds by the special fund for families ("Familienlastenausgleichsfonds" FLAF). While apparent reductions in pre and perinatal mortality have occurred in the last 40 years, no rigorous evaluation about the direct impact of the programme on this and other birth related measures was ever conducted (see also LBI 2009).
Second, Austria provides a broad vaccination plan for children and young people. Through combined financing from the Austrian Social Security and federal taxes, vaccination for children against diphtheria, tetanus, pertussis, haemophilia, polio, hepatitis B, measles, mumps and rubella is offered free of charge. Also vaccination against rotavirus was included since August 2007. Currently the pneumonia vaccine is offered to children at-risk and there are policy proposals to also offer the vaccine to all children as part of the Austrian vaccination plan. However, despite these efforts, immunization rates in Austria are still notably poor according to the OECD 2009 report, with one in five Austrian infants not receiving basic immunizations by the age of two years.
Third, in 1964 a national programme for physician examinations in schools was introduced. This programme is de facto a preventive check-up, which is carried out once every school year. The main aim is to examine the pupils' vision and hearing ability and confirm their ability to take part in sports lessons. In 2004/05 attempts were made to expand this programme by issuing a health pass for young people up to the age of 18 through work-places. Initiated by the Ministry of Health and the Ministry of Education, Science and Culture the health pass for young aimed at creating a scheme for young people which informs them about their own health data and which makes dealing with the existing health care system easier. Around 170 experts (representatives of specialist medical organizations, school physicians and scientists) were involved in its conception. Young people receive a written invitation from the health insurance funds to come to the preventive check-up, and their employer is obliged to give them leave to attend and to pay them for this day. The number of young people's examinations has continually decreased, and fell by an average of 5% per year between 1990 and 2003 (Hofmarcher/Rack 2006). While an integration of the youth health pass into the school physicians' examination was planned, this never materialized.
Fourth, in 2004 a working group for an Austrian Health Plan for children was installed as one part of the 2005 health care reform (see Hofmarcher, HPM Survey 2004). The aim was to evaluate the needs of children and assess the current situation, conduct an analysis of the problems and finally develop a plan for the future.
The four main issues addressed in 2004 were:
The outcomes of the Austrian Health Plan for children were 12 policy papers from 75 experts. However no concrete action resulted from the 2004 plan.
Fifth, in 2007 a permanent commission for children's medicine was installed in the Ministry of Health. Their task is to present proposals related to the medical care of children and youth and to work with the Ministry of Health to bring these measures into effect. A push for pediatric drug safety is also under way through the current Seventh Framework Programme of the European Union which involves a study programme to develop and test off-patent medicines for children in new formulations.
Finally, previous rehabilitation plans were developed for the Austrian Ministry of Health and the Austrian Social Security, including one in 2008 by the Austrian Society for Children and Adolescent Medicine - ÖGKJ (Österreichische Gesellschaft für Kinder- und Jugendheilkunde). Currently, the Gesundheit Österreich GmbH /ÖBIG (Austrian Health Institute) has worked out a new rehabilitation plan which is yet to be released by the Ministry of Health. However, at the moment, access to rehabilitation specialized for children in Austria still lags behind other areas and has yet to meet expected targets.
Child health on the global policy agenda
In the international context, several policy initiatives have put child health on the agenda and provided an international call to action on which OECD member states are now working to respond. The World Health Organization's 2005 European Health Report gave children's health the main focus emphasizing that health in childhood determines health over the total life span and raised the issue of widening inequalities between poor and affluent children within and across member states. This led to the WHO call for the health of children and mothers to be reinstated as a focus of the policy agenda of health and education ministries.
The European Union has also made a political commitment to combating child poverty and promoting child well-being, establishing in 2007 the EU Task-Force on Child Poverty and Child Well-Being. The recommendations of this report were formally adopted by all Member States and the Commission in January 2008. Several other recent European-wide initiatives have put a special emphasis on children's health including the EU Council's adoption of "Equity and Health in all Policies" as well as the United Nations Millennium development goals, especially MDGs 3-5, which aim to reduce child mortality and improve maternal health by 2015.
European-wide initiatives have provided an impetus to the Austrian Ministry of Health, which is the leading ministry to develop a strategy of "health in all policies" with a dialogue for children´s health as a showcase for this approach. As everywhere child health is a cross-sectoral matter ("Querschnittsmaterie") and concerted action is needed to address challenges in this area. The following structure exists in Austria:
Other ministries that also are involved in children's health include the Minister of the Economy, who is currently also the Minister of Youth, the Ministry of Finance and a special Ministry for Women (which deals with issues for female children and young women). Further, there is the Ministry of Transportation, Innovation and Technology, the Ministry of Environment and the Ministry of Defence and Sports which also deal with certain aspects of child health. The challenge of this "Ministry-mix" in children's health is finding a consensus on a national health strategy due to different competencies and different financing.
International reporting on child health brought momentum to discussions in Austria
The international impetus for a National Dialogue on Child Health has come from several recent reports on Children's health, including the 2009 OECD Report "Doing Better for Children," the 2007 UNICEF Child Well-Being Report and the 2005/2006 WHO Report "Health Behavior in School-aged Children." These reports have put the spotlight on children's health and revealed both successes and areas needing improvement in OECD countries. The Austrian Ministry of Health has been quick to respond to this international call to action, leading to the development of the national Dialogue on Child and Adolescent Health. The various reports paint a broad picture of the status of children's health in Austria and are a starting point for what a national strategy should address:
Early Childhood interventions:
Principles of health in all policies
|Implemented in this survey?|
While the EU Task Force and high profile international reporting has established child health and well-being as a top priority in OECD countries, there are also several specific Austrian initiatives on Child Health which have contributed to the formation of a National Dialogue on Child Health.
One issue of the Dialogue on Children´s Health is diet. In January 2010 the Ministry of Health presented a draft for a national action plan on diet (Nationaler Aktionsplan Ernährung, NAP.e). The initiative is based on a "health in all policies" concept and aims to improve the diet of the Austrian population with more than 100 measures. The incidence of nutrition-related diseases should be reduced and the rise in obesity slowed. The diet of many Austrians is often high in sodium, sugar and fat. From January to May 2010 the action plan was sent out to stakeholders for examination. A finalized action plan is expected at the end of the year. The project "Right Eating from the Beginning" (Richtig Essen von Anfang an) is one strategy with the focus on children 0-3 years. The report also contains numerous tips for pregnancy and lactation, as well as recommendations for habitat-oriented measures. The Action Plan Diet should also be expanded with an Action Plan for Physical Activity.
Another issue is ensuring the medicines children receive are safe and appropriate. About 50% of drugs used for children are unlicensed or used off-label in that they are only clinically proven for adults. This is due to more complex and costly organizational practices, ethical considerations and a lack of methodological experience in this area. Prior to 2009, pharmaceuticals did not need a special approval for child safety, however the European Law (Regulation (EC) No 1901/2006 of the European Parliament and of the Council of 12 December 2006 on medicinal products for pediatric use) now requires that pediatric drugs must be approved to ensure child safety and aims to improve care of children with clinically proven drugs. The Austrian Ministry of Health has already worked out a policy for safe drugs in collaboration with AGES PharmMed, a division of the Austrian Agency for Health and Food Safety (AGES) which is responsible for the national accreditation of drugs. Thus, this issue has also been incorporated as an integral part of the national Children's Health Dialogue.
The field of health data for children also requires special attention. Data on the specific contents of child and adolescent health in Austria is extremely poor. Data is mostly collected sporadically and not in a consistent and systematic manner. This issue is also at the forefront across Europe where explicit attempts are under way to improve data collection on children's health that is nationally and internationally comparable given the "statistical invisibility of children." This is a crucial component of international guidelines which emphasize evidence-based policies, quality evaluations and the health impact assessment to ensure policies in child health are appropriate and address the broader social determinants of health. Up to the present, only regional reports were conducted such as in Vienna (2000, 2002), Carinthia (2006) and Upper Austria (2007). Most of the national data for Austria comes from the HBSC and many of these data originate in cross-country qualitative research. At the end of 2010 Gesundheit Österreich GmbH (Austrian Health Institute) will begin regularly reporting on the status of child and adolescent health.
Finally, ensuring services are appropriately geared towards children and supporting family members is needed. Children often do not receive the appropriate health and social services they require in a child-appropriate setting. Austria performs well in "common" treatments and services, such as the supply chain in the treatment of acute appendicitis, the asthma or the flu. However, performance in chronic disease management and developmental disorders lags behind. Developmental disorders are often recognized too late and the treatment options are not sufficient for children in need. Another barrier likely is high co-payments for children in areas such as physical therapy, speech therapy and pschotherapy, that may prevent chidlren from getting necessary treatments. Children also do not always receive care in a youth-specific institution with professionals specially trained to work with children. An emphasis on supporting parents is also critical as children from low-income and educationally disadvantaged families have poorer health prospects than those from high-income and educated families. Children with a migration background and poor family relations are also more disadvantaged. Due to this, it is critical that not only the situation of children is improved but also the situation of parents.
The approach of the idea is described as:
All stakeholders welcome the Dialogue for Children´s Health and agree that Austria performs well in many aspects of child health. However performance could be greatly improved. The stakeholders fear a "two-tiered" system of medicine and emphasize the disadvantaged yet important role of children in society.
The Ministry of Health is the initiator of the Dialogue for Children´s health. The Minister himself declares that the government should be the lobby for children and adolescents.
The ÖGKJ is a medical society of physicians working in the field of pediatrics and advocates strongly for the Dialogue in Child Health.
The Liga is a non-profit and multi-disciplinary organization primarily composed of health care providers and professionals which represents the voice of children and young people. The Liga supports the Dialogue on Children's Health and plays a key role in developing priorities for the Dialogue.
The Freedom Party of Austria emphasizes that prevention for children is an investment in the future and calls for an expansion of the Mother-Child Health Passport and especially the expansion of the vaccination plan for children.
The Greens point out the shortage for children in the field of psychotherapy and psychiatry and call for equal treatment for all children. About 5 months after the start of the Dialogue for Children´s Health the Greens are disappointed because there are not yet any concrete results. A recent push was to abolish co-payment for children in hospitals (Spitalskostenbeitrag).
|Ministry of Health||very supportive||strongly opposed|
|Ministry of Social Affairs||very supportive||strongly opposed|
|Ministry of Education||very supportive||strongly opposed|
|Ministry of Sports||very supportive||strongly opposed|
|Ministry of Environment||very supportive||strongly opposed|
|Doctors||very supportive||strongly opposed|
|Other Health Professionals||very supportive||strongly opposed|
|Österreichische Liga für Kinder- und Jugendgesundheit||very supportive||strongly opposed|
|All Parties||very supportive||strongly opposed|
The 2005 European Health Report and the 2009 OECD report on children's health provided specific frameworks for national governments to implement a strategy for change in children's health. The WHO European Health report advises that national and European responses should follow the four guiding principles of the European Strategy for child and adolescent health and development:
The OECD recommends the following roadmap to develop a National Child Health Strategy:
So far, the method outlined for the Dialogue in Child Health in Austria has for the most part followed the recommendations and steps as laid out in these documents. The Ministry of Health has called for all working groups to first assess the problem in medical, social and epidemiological contexts, then to discuss policy options and strategies for improvements, then to implement these measures and to regularly evaluate their progress. However, a main recommendation of both reports is to take a life-course approach to policies and this is yet to be specified in the objectives of the Austrian National Dialogue.
|Ministry of Health||very strong||none|
|Ministry of Social Affairs||very strong||none|
|Ministry of Education||very strong||none|
|Ministry of Sports||very strong||none|
|Ministry of Environment||very strong||none|
|Other Health Professionals||very strong||none|
|Österreichische Liga für Kinder- und Jugendgesundheit||very strong||none|
|All Parties||very strong||none|
A crude roadmap for the Dialogue was presented requesting established working groups to submit their assessments of the status of child health by March 2011. There is no detailed instruction about the expected output in this context. The process is governed by the Ministry of Health who will be in charge to collate the information provided and to develop policy responses.
Reflecting international debates about the importance of child health, the Austrian Dialogue for children´s health is also a timely response to national claims for an inclusive approach targeting not only health care services per se but also broader challenges regarding children´s wellbeing. While much policy focus in past decades had been on survival in early childhood and prevention of communicable disease the government has come to acknowledge the significance of combating chronic disease through child specific measures and through targeting health and risk behavior of young people. Challenges to commence policies for improvements in children´s health and well-being nevertheless remain:
First, one of the main concerns about the health status of children in Austria is the rise in obesity and a high level of alcohol and nicotine consumption. These main risk factors are strongly associated with low social economic status, migration background and bad family relations. While Austria performs well in terms of child mortality rates and offers comprehensive pre-natal care through the mother-child passport, the new strategy lacks direction when it comes to re-allocating resources towards at-risk children and also for early-child social programs. Also, unnecessary spending for universal policies such as long maternal stays in hospital for a normal birth should be avoided and better allocated. The 2009 OECD Report highlighted these areas as crucial in particular for high-risk children and there are already several programs in place in other countries (Nationales Zentrum, Frühe Hilfe 2010).
Second, while a coordination of different governmental and public health sectors has been implemented in the Austrian National Dialogue, there is not a clear strategy to bring together efforts across stages of children's development and to ensure that interventions for at-risk children remain consistent and do not disappear when a child moves into adolescence. Further, to decrease the prevalence of at-risk behavior in adolescence it is important to anticipate and prevent risks at earlier stages in child development. In this context it is notable that improved measures in school children's health examinations and those for young people drifted off in spite of recent efforts to phase-in better health promotion at school or work (see above) even though the programme for preventive medical-checkups was renewed and expanded recently (see Hofmarcher 2007). As also pointed out by the 2009 OECD report a key component of this objective is establishing targets for child well-being across the life cycle so that different sectors can work together towards a set of clear, stated goals.
Third, even though a wide national consensus on the importance of universal programmes for children exists, e.g. universal child care allowance, children are treated differently across regions in Austria. This occurs mainly through varying provisions in awarding social benefits to families and children in areas where there is significant autonomy of regional governments in designing policies, e.g. social legislation. Recently in September 2010 legislation to replace current social benefits with nationwide minimum collaterals ("bedarfsorientierte Mindestsicherung") was implemented in 3 of the 9 Länder, which unifies claims for people in need for assistance. However, implementation is still pending in the remaining Länder. At the current stage the strategy for the Dialogue does not take account of this situation which is a key component for an approach transcending jurisdictions as the Dialogue envisages doing.
Finally and in this context, provisions for pre-school placements of children to better enable parents to balance family work with labor market demands still lags behind targets in this area and prohibits many relatively poor children to enjoy equal opportunities in comparison to their wealthier peers. While the development of the Austrian "Children and Adolescent Health Dialogue" puts special emphasis on tackling health in-equalities and the coordination of all sectors the importance of targeting at-risk children and implementing a "life-course" approach is yet to be clearly stated in the Austrian strategy.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
It is too early to comment on the impact of this strategy. Quality of services and equity may well rise if health risks of disadvantaged groups are more clearly and consistently addressed. This only becomes observable once policy measures are developed and implemented.
BMG (2010). Anfragebeantwortung. BMG-11001/0194-I/5/2010. vom 13.08.2010
BMG (2010). Kindergesundheitsdialog. Eine Initiative von Gesundheitsminister Alois Stöger zur nachhaltigen Verbesserung der Gesundheit aller Kinder in Österreich. Wien
BMG (2010). Nationaler Aktionsplan Ernährung. NAP.e / Konsultationsentwurf. Jänner 2010. Wien
Convention on the Rights of the Child. Adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989
European Commission (2010). Child Poverty and Child Well-being in the European Union. Tarki Social Research Institute. Budapest and Applica. Brussels.
Gyn-Aktive (2010). Mutter-Kind-Pass - Der lange Weg zu den Neuerungen. 01/2010. Available at: http://www.medmedia.at/medien/gyn-aktiv/artikel/2010/04/9311_01-10_Mutter_Kind_Pass.php
Hofmarcher, Maria M. (2004): Austrian Health Reform 2005: Agreement reached. Health Policy Monitor. November 2004. Available at www.hpm.org/survey/at/b4/1
Hofmarcher, Maria M. (2005): New rules for preventive health check-ups. Health Policy Monitor. 5. October 2005. Available at www.hpm.org/survey/at/b6/2
Hofmarcher, Maria M.; Rack Hertha M. (2006): Health system review- Austria. Health Systems in Transition. 2006. 8(3).1-247
LBI - Ludwig Boltzmann Institut (2009): Mutter-Kind-Pass. Ein internationaler Vergleich zu den Untersuchungen an schwangeren Frauen. Mai 2009. Wien
Nationales Zentrum. Frühe Hilfen. Bundeszentrale für gesundheitliche Aufklärung (2008): Frühe Hilfen. Modellprojekte in den Ländern. Köln.
Nationales Zentrum. Frühe Hilfen. Bundeszentrale für gesundheitliche Aufklärung (2010): Frühe Hilfen. Modellprojekte in den Ländern. Zusammenfassende Ergebnisdarstellung. Köln.
OECD (2009): Österreich. Doing Better for Children. Organisation for Economic Co-operation and Development. France
Österreichische Liga für Kinder- und Jugendgesundheit (2010), Bericht zur Lage der Kinder- und Jugendgesundheit in Österreich 2010, Wien
OTS Press Releases regarding Kindergesundheitsdialog
Parlamentskorrespondenz Nr. 350 vom 11.05.2010
Ståhl, Timo; Wismar, Matthias; Ollila, Eeva; Lahtinen, Eero; Leppo, Kimmo (Ed.) (2006): Health in All Policies. Prospects and potentials. Ministry of Social Affairs and Health. Finland
UNICEF (2007). Child Poverty in Perspective: An Overview of Child Well-Being in Rich Countries, Report Card 7. UNICEF Innocenti Research Centre. Florence.
WHO (1999): Health 21 - Health for All in the 21th Century. European Health
for All series No. 6. WHO Regional Office for Europe. Copenhagen
WHO Europe (2005/2006). Inequalities in Young People's Health. Health Behaviour in School-Aged Children. Health Policy for Children and Adolescents. No. 5.
WHO Europe (2005). The European Health Report 2005: Public Health Action for Healthier Children and Populations. The World Health Organization Regional Office for Europe. Denmark.
Reinhold Kerbl (2010). Kindergesundheitsdialog. Frischer Wind im Kindergesundheitssystem. Pädiatrie & Pädologie 3/2010. Springer Link. Wien
Reinhold Kerbl in Österreichische Krankenhauszeitung (2010). Kinder - Los. 15.10.2010
Reinhold Kerbl (2010). Kindergesundheitsdialog. Springer Professional Media 28.06.2010
Maria M. Hofmarcher, Bernadette Hawel, Leslie B. Tarver
The authors are grateful for many helpful comments provided by:
Andrea Fried, Gesundheit Österreich GmbH
Reinhold Kerbl, Head of the Department of Child and Youth, Leoben Regional Hospital and Secretary of the Austrian Society for Child and Adolescent Medicine (ÖGKJ)
Klaus Vavrik, President of the Österreichische Liga für Kinder- und Jugendgesundheit (Austrian League for Children and Youth Health)