Establishing social services for health promotion in health insurance states: Germany, Switzerland and Austria compared
| Published date | 01 June 2023 |
| DOI | http://doi.org/10.1177/13882627231188671 |
| Author | Caspar Lückenbach,Verena Biehl,Thomas Gerlinger |
| Date | 01 June 2023 |
| Subject Matter | Special Issue: Social services as critical infrastructureGuest Editors: Renate Reiter and Tanja Klenk |
Establishing social services for
health promotion in health
insurance states: Germany,
Switzerland and Austria
compared
Caspar Lückenbach
Bielefeld University, Germany
Verena Biehl
ZHAW Zürcher Hochschule für angewandte Wissenschaften, Switzerland
Thomas Gerlinger
Bielefeld University, Germany
Abstract
Prevention and health promotion are important areas of welfare state activity and can be consid-
ered parts of the critical infrastructure. They have been considerably expanded in Westernwelfare
states in recent years. In the health insurance states of Germany, Switzerland and Austria, new
forms of organisation have emerged. The article describes the evolution and status quo of the
organisation of prevention and health promotion in the three countries and explores the legitim-
isation patterns for the chosen institutional forms. To this end, health reforms, debates and state-
ments of key stakeholders are analysed. A distinction is made between ‘normative’legitimisation
patterns and ‘functional’ones that indicate a ‘social investment’strategy. In Germany, the 2015
Prevention Act created an institutional structure in which the actors involved cooperate closely.
It also gives the health insurance funds a prominent role. In Switzerland, the cantons are respon-
sible for prevention and health promotion; at federal level the main bodies are the Federal Office
of Public Health (BAG) and the Swiss Foundation for Health Promotion (Gesundheitsförderung
Schweiz). In Austria, the Länder are largely responsible, but the federal level gained importance
by establishing Gesundes Österreich GmbH and strengthening coordination. While the term
‘social investment’is not encountered in the debates and documents analysed, many arguments
Corresponding author:
Caspar Lückenbach, Faculty for Public Health, Bielefeld University, Universitätsstraße 25, 33615 Bielefeld, Germany.
Email: clueckenbach@uni-bielefeld.de
Special Issue: Social services as critical infrastructure
European Journal of Social Security
2023, Vol. 25(2) 217–237
© The Author(s) 2023
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DOI: 10.1177/13882627231188671
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commonly associated with it are increasingly used in the context of prevention and health promo-
tion. In contrast, normative justifications seem to be losing importance.
Keywords
Welfare state, health systems, health promotion, prevention, social investment, social services,
institutionalisation
Introduction
Health promotion and disease prevention are important pillars of the critical infrastructure of
welfare states, for a variety of reasons. First, they are intended to help improve the health status
of the population and, in doing so, to strengthen social cohesion by reducing social disparities in
illness and death. Second, population health is an important prerequisite for a state’s economic per-
formance and thus for its ability to allocate adequate resources to welfare state benefits. Third,
disease prevention is an important element in reducing the financial burden of health care and –
as the COVID-19 pandemic has shown –ensuring good health care. Fourthly, there is also an
expectation among the population that the state and policymakers will create the conditions for a
healthy and long life.
In this article, health promotion is understood as the totality of non-medical, disease-unspecific
measures that improve people’s living conditions and thus reduce the resulting burdens (‘settings-
based approach’) and strengthen their capacities for health-promoting lifestyles (Gerlinger and
Rosenbrock, 2023). The term became widespread mainly through the Ottawa Charter of the
World Health Organization (WHO), adopted in 1986 (WHO, 1986). We explicitly take up the
Ottawa Charter’s approach in the article by addressing health promotion and prevention measures
in the context of the social determinants of health, with a focus on population-based interventions,
rather than on the individual (medical) setting, for example, health education. In contrast to this,
primary prevention is understood as specific measures that are intended to prevent certain diseases
or to contribute to reducing the probability of disease occurrence.
The aim of this article is twofold. Firstly, we wish to describe the evolution and status quo of the
organisation of health promotion and prevention in the three countries and to highlight the dif-
ferent approaches regarding the actors involved, the distribution of competences and the chosen
priorities in health promotion (proportional vs. behavioural, main target groups, beneficiaries
and recipients). Secondly, we explore the legitimisation patterns for the chosen institutional
forms. How do political decision-makers justify the interventions and expenditures associated
with health promotion and primary prevention and the benefits that can be expected from them?
Are they legitimised by normative goals or is it seen as a social investment strategy; have the
arguments shifted over time?
For this purpose, we will first distinguish between normative legitimisation patterns and argu-
ments that can be attributed to a social investment strategy. We then briefly present document ana-
lysis as a research method and our data corpus, before describing the development of health
promotion and prevention and the status quo, as well as the legitimisation patterns found in the indi-
vidual countries. We discuss and compare the legitimisation patterns against the background of
country-specific developments and close with a brief conclusion.
218 European Journal of Social Security 25(2)
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