Health promotion in the Netherlands

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Health promotion in the Netherlands

• And the case of ..
• Erik Ruland, MD, MPH
• deputy director NIGZ and former program manager
  Hartslag Limburg

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The Netherlands healthy and well cared for.

• Population 16.407.491
• Life expectancy 76 (m), 81 (f)
• Vaccination coverage 99
• Health insurance coverage 99
• General practitioner 95 of population
• Only 5 of consultations is referred to hospital
• Costs of health care sector 8.6 of BNP
• Municipal/regional public health institutes
  100

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The NetherlandsHealth in the newspapers

• New insurance system for basic cure
• Free private insurance for additional cure
• Revision of local political responsibilities for
  chronic care and prevention
• Issue related campaigns on smoking, obesity,
  physical activity, etc
• Every week a different fundraising issue

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Overview

• Introduction
• National structures
• The role of the NIGZ
• Local structures The case of Limburg
• Including analytical observations on policy and
  structures

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DutchHealth Promotion Structure
General public Community Services Workplace
Schools
dent. pharm.etc
Local Politics
58 mental
16 alc.drug
100 home care
Patient-Org.
45 municipal
9400 gp
100 hospitals
PUBLIC
HEALTH
HEALTH
CARE
insurances
local money
NATIONAL INSTITUTIONS
Neth PH Fed.
Du Ass Prev HP
TRAINING
RESEARCH
HS/DCH/94-whoq
DEPARTMENT OF EDUCATION, HEALTH, LABOUR, ETC.
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1. National policy and structures

• Marginal position of Public Health 1
• Lack of unity in language
• National policy strong on epidemiological based
  ambition, weak in capacity and structure
• Diversity in institutions with cooperation
  rethoric, but competition for practice

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The Dutch HP professionals

• About 1500 people, Association covers 55
• Health Educators in Municipal Health Inst. And in
  Home-care
• Prevention-specialists in Mental Health and in
  Alc./Drug Institutions
• Patient Educators in Hospitals (related union)
• Basic Training
• 58 university, 40 poly-technic
• Registration a push to quality

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2. NIGZ Netherlands Institute forHealth
promotion and Disease Prevention
NIGZ motivates, supports and facilitates people
in choosing a healthy lifestyle (Inspired by
the Ottawa Charter)
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Determinants SES, lifestyle, social and
fysical environment, services
Topics disease, lifestyle
Scale mass-, group individual
Setting school, workplace, community, hospital
Organisation national/lokal, public/private
partnership
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- build support 3. IMPLEMENTATION - large
scale - monitor
- methods 2. INNOVATION - pilots with the local
level
process
- quality - policy 4. INSTITUTIONALISATION -
professional development
trends, social map 1. KNOWLEDGE evidence, best
practice
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NIGZ strategy characterisics

• LOCAL- national linkage
• Setting and target group first, topic second
• Long term commitment
• Professional Quality
• Framework, Preffi, OPUS, certification
• Easy access extensive www use
• Emphasis on advocacy in political arena

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NIGZ basics

• /- 120 employees, 90 fte
• Annual budget /- 8 million, 36 subsidized by
  ministry of Health, Welfare and Sports
• Acquisition of about 20 major projects a year
• NIGZ-facilities knowledge centre, publisher,
  congres centre and public aid and information
  services by phone and www

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2. NIGZ and National structures

• Legislation covers only Research Council
• Diversity in status, power and overlap in roles
• Health Foundation private fundraiser
• Netherlands Nutrition centre 2 ministries
• NIGZ issue free, but focus on obesity
• Shared core set of figures in VTV/RIVM
• Tension between
• Visibility (seen to be doing) and real impact
• Instant reply and long term

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3. Local structures

• Local Community (National Union VNG)
• City council
• Alderman as issue manager
• Municipal Health Service (National Union GGDNl)
• Other local or regional partners (misfits in
  scale)

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• ..

(1994 1998 - 2004)
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Problem identification

• Oct. 1994 !! Expert meeting of the
• Netherlands Heart Foundation
• Epidemiological basis
• Lack of unity between municipalities, public
  health institutes, GPs and hospitals
• not my cup o tea problem
• Conclusion the need to develop a regional pilot
  project to create more unity.

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Maastricht Region

• 5 municipalities
• 4 LSES areas
• 186.000 inhabitants,
• of which 20.000 in the selected LSES areas

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Project aim

• To reduce CVD through health promotion
  (non-smoking, nutrition and physical exercise),
• for the entire population, specifically for
• LSES-groups, and
• medical high risk groups
• to realize a sustainable model for the
  integration of public health and medicine
• to evaluate scientifically the processes, effects
  and cost-effectiveness

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The organizational model
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Scientific research 4 PhD studies

• process evaluation
• effect evaluation risk factors, morbidity and
  mortality
• cost-effectiveness
• Maastricht University Dept. of Health Education,
  General Practice, Cardiology, Health Organization
  Policies Economics
• Nat. Inst. Public Health (RIVM)
• results in 2003/2004

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• The Hartslag Limburg Community project
• 1998 2001 gt 300 health promotion activities
  (physical exercise, nutrition, non-smoking)
• Both at regional, municipal and LSES area level
• Annual budget US 50,000 ? 200,000

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The Community approachlinking strongand
weakpersonal contact and
mass media andlobbying for sports
facilities in LSES areas
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A daily television programto promote physical
exercise for the elderly(Febr. 1999 Sept.
2000)
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School programs that promote joining a sports club
School programs that promote membership of a
sports club
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Nutrition education at the community center
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The local weekly win-win for shop owners, the
Hartslag volunteers and the municipal dept. of
social affairs
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Creating supportive environments
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Annual New Years quit smoking
campaignCongratulations!

• 40 coverage
• Free nicotine replacement therapy for high risk
  patients and LSES areas

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Create local visibility PM visits Maastricht
(May 2000)
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Factors for success

• initial involvement of all main partners
• initial planning of long term sustainability
• detailed preparation 3 year term contracts with
  main partners on input, throughput, output
• invest in network management
• work continually for commitment, especially with
  policy makers and management
• argue with figures
• win-win for each partner
• make yourself visible!

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Sustaining support the annual Hartslag Meeting
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Failure factors

• cultural barriers
• ignorance of procedures of partner organizations
  (misty layers of middle management)
• misunderstanding of interests of partner
  organizations
• too much focus on the inside (deadlines and
  bureaucracy), at the expense of focus on the
  outside (image building)
• underestimating the magnitude of effort needed to
  succeed
• too little effect, too little time to show
  results

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Achievements of

• Reductions of risk factors
• Reductions of socioeconomic divide
• Integration of public health and medicine is
  feasible,
• but change management is required in order to
  realize sustainable partnerships.

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3. Local structures

• Legislation on Municipal Health Service
• Public Health political, press and public
• 20 innovation protects 80 continuity
• Normal tensions between policy, science and
  practice

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Final conclusions

• Be aware of the variety in speed
• Activities change quickest
• Policy change takes years
• Structures and funding often decades
• Information is overestimated
• HPromotion requires also advocacy and community
  involvement
• Legislation and structures help, but.

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INVESTMENT IN QUALITY AND SUSTAINABILITYfor
health REQUIRES LEADERSHIP
of courageous politicians, Innovative managers
and dedicated HP professionals