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European Social Charter – report Austria

Article 11 – The right to protection of health

Monitoring of the initiatives of the Austrian government:

Since 2006 the Österreichischer Strukturplan Gesundheit (Austrian structural plan for health; ÖSG 2006) is the first plan to encompass the entire health care system. Its aims are to ensure high quality as well as to improve supply efficiency on the basis of lowest costs while maintaining the quality level. From a mental health view the decentralisation of psychiatric care is of special interest as well as the balancing idea of regional differences.

This so called paradigm shift is based on a national framework with the method of Leistungsangebotsplanung (capacity supply planning). This integrative health planning framework has different goals, e. g. equality in services for all patients, “as much as necessary – so little as possible”, special attention to the youth etc.

Within the framework of the ÖSG, integrative regional care planning and seam-management (Nahtstellenseam-management) are two principles. The aims, planning principles and methods are discussed around two topics – acute hospitals (Akutkrankenanstalten) and link management. The Leistungsangebotsplanung (capacity supply planning) and quality criteria are described by eight types of offers – from care management (normal and intensive), bed- and no-bed running special institutions, special care institutions, reference centres, special fields and medicine-technical health equipment.

Neurology and psychiatry are divided within the ÖSG. Psychiatry is described as “structures for the treatment, rehabilitation and care as well as the covering of social care needs for acute, long-term and chronic mentally ill”. First, basic requirements are shown that can be described as “principles1”. Second, the care structures (Versorgungsstrukturen) are divided into the intramural sector and the extramural sector with complementary institutions and services. Decentralisation is still a leading word. From a professional view, the working principles of the staff should be interdisciplinary working in a multi-professional team. Last but not least, the capacity supply (Leistungsangebote) are divided into general and special services.

Based on a person-oriented principle – “the individual person stays in the centre of all efforts” – reality seems to be a little bit different. The Austrian health system/structure and social care system is still divided into two parts – the social sector and the health sector. Furthermore the competences are still understood in a federal way with the consequence of different competencies, (sometimes) unclear

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Bedürfnis- und Bedarfsgerechtheit, Gemeindenähe und –integration, „ambulant vor stationär“, Integration in die Grundversorgung, Regionalisierung, Vollversorgung und Vernetzung, Partizipation

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and intransparent financing and complex law regulation. The Art 15a B-VG agreements are based on unanimity. This leads to high consens requirements. The financial distribution of taxes between the different corporations (nation/country, [federal] states and communities) by the “Finanzausgleich” (tax revenue sharing) is (usually) always fixed for 6 years. Therefore structure reforms like a “health system/structure reform” are always dependent on financial decisions.

From this financial view(s), health and social services for people with mental health problems are always as good as the offering structure/service offer exists. There is a proverbium (Martin Schenk) that describes the situation very well: “poor services for

poor people”. Mental health problems lead to poverty – poverty leads to mental

health problems. Planning and reality are not always the same – needs and their covering as well.

Ability of the health system to respond appropriately to avoidable health risks:

If the Austrian report deals with the general public policy, legal framework and reforms, many new laws are quoted: general environmental laws, waste, noise protection, air pollution, clean waterways, promotion for sanitary engineering measures, protection against radioactive contamination, Asbestos, Environmental Impact Assessment Act of 2000 and its application – many laws but little

connection with mental health.

It seems that the view is focused on maybe avoidable health risks that are produced by “hard technical factors”. There is no word about the general public policy,

legal framework and reforms that are focused on mental health and well-being.

There are new laws – anti-discrimination themes, equity, employment rights and so on – that should help to avoid health risks. But they are not mentioned here. There the conclusions must be made as follows: It is more a technical than a human

approach to the health themes. And mental health is not even mentioned. It is

hardly to ask what was first – the technique or human mankind ... and health, especially mental health is a very important basis of human being.

Accessibility to the health system to everyone without distinction:

The accessibility to the health system to everyone without distinction can be shown by the percentage of persons living in Austria who are fully covered. The Austrian report describes the principle approach on “equity which is necessary to grand equal access to the social insurance benefits to all participants, regardless of their nationality”. The “participation rate” – the statutory health insurance coverage – is 98,5 %.

A study from the ministry for health and women2 shows other results. This study is based on quantitative and qualitative methods. In the introduction different official dates are shown like the 1 %-rate of people living in Austria who are not insured

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BMGF: Quantitative und qualitative Erfassung und Analyse der nicht-krankenversicherten Personen in Österreich; Wien 2003 – vgl.

http://www.bmgfj.gv.at/cms/site/attachments/6/6/3/CH0620/CMS1192607321880/quantitative_und_qu alitative_erfassung_und_analyse_der_nicht-krankenversicherten_personen_in_oesterreich.pdf

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(80.000 people) from 2002. That means that the coverage-rate in Austria was 99 % in 2002. After this study, the dates must be corrected:

In June 2003, up to 3,1 % or 205.000 persons over 15 years are not fully covered. 160.000 persons (2,4 %) have absolutely no coverage.3

Men are a little but people from 15 – 29 years are very over-proportional presented. Little education and not being Austrian are further risk factors.

The health constitution is bad: depression, mental problems, little self confidence, little health sense, drug abuse and alcoholism.

Living alone, being male and an average age of 35 have one in common: a blatant “lack of care” regarding health. These people are mostly asylum seekers (52 %), then jobless people/unemployed (24 %).4

This report shows that access to health is much dependent on the insurance

state. And this insurance state is mainly based on employment or officially recognised partnership (marriage preferred) – one third of all insured are also

insured under the policy of the employed family member. No insurance leads to exclusion that can be described as follows: “It is forbidden becoming ill.5” The missing health insurance status leads little or no services. The experts define the following recommendations6:

more and more precise information

more transparency in the rights to access – there is much discretion

employment is still the belt of insurance

a more individual approach

Health and social security should be – must be – human rights. If these human rights are violated mental health problems occur. The Austrian report says that individuals who are not included in the health system receive social assistance – yes and no. It always depends on the social status and the capability to claim for rights. At the end rights must be declared as accessible rights to social protection. A legal right for

inclusion (e. g. Oö. Chancengleichheitsgesetz) is a very good approach. Now it

must be shown if good theory leads to good practice.

No unnecessary delays in the provision of treatment as well as access to treatment based on transparent criteria:

We miss a notice regarding delays in the provision of treatment as well as any comment to the access of treatment based on transparent criterias.

Adequate staffing and facilities:

Recently a doctor gap because of the generation development was argued. There will be missing doctors after a big quantity of doctors will go into retirement.

The adequate staffing is based on a multi-professional level. The ÖSG declares different groups – doctors, care professionals, clinical psychologists,

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The dates must be taken as „maximum-dates“. 4

These dates are based on interviews – and they are not considered representative. 5

BMGF (2003); p. 91 6

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psychotherapists, social workers and other experts for different therapies. There are still “intraprofessional rules” that sometimes avoid the necessary cooperation. The person-oriented approach to mental health problems is sometimes covered by professional and institutional logics. Mental health problems need professionality

(by experts) rather than profession (by titles) – it is more important what is inside

instead of what is on a “business card”. This argument should never undergo the necessary education but should focus on the important question what the person with mental health problems needs – and this adapted to his/her social daily life.

Satisfactory conditions of stay in hospital and compatibility with human dignity:

The Medizinische Universität Wien (Medical University of Vienna) takes part in an EU project called “HELPS”. Its target is to improve the physical health status of mental ill persons who are living in (social) psychiatric institutions. This idea is very welcome because of the well-being approach where physical and psychiatric aspects come together. At the end of the project, a European experts network and information system should be established. The promotion and prevention of the body if the soul has problems is a consequent and necessary “amalgamation” of human being aspects. As a result, satisfactory conditions of stay in hospital and the compatibility with human dignity should become a “state of the art-concept” on a European level.

Measures to prevent activities that are damaging health:

A measure that is taken by the Austrian government is the introduction of the cap for the prescription charge, amounting to 2 % of the insuree’s income and administrated through the e-card (electronic health card). Especially chronically ill persons or persons suffering from multiple disease make a profit from this measure.

This intervention is a good step to prevent health. The targeted groups must spend only a certain amount of their income. But it must be said that the “entrance fee” is still the e-card. If somebody is not insured, this person cannot benefit.

On an official, governmental and administrative level, the FGÖ (Fonds Gesundes Österreich) is the “entering force” to promoting public health. Its aim is to support projects of health promotion and primary preventive health care. The budget of € 7,3 million a year leads to the following conclusion: Promoting public health is “sponsored” by the state € 1,-- per person a year. Promotion, especially prevention is also offered by other bodies like the National Insurance Bodies. But the “prevention rate”, especially for mental health topics, is still low:

2 % for medical rehabilitation

0,5 % for health improvement and prevention of diseases

0,8 % for disease precaution/screening and health promotion7

7

Hauptverband der österreichischen Sozialversicherungsträger: Statistisches Handbuch der österreichischen Sozialversicherung; Wien 2008 (p. 267 f

http://www.sozialversicherung.at/mediaDB/MMDB136296_Statistisches%20Handbuch%20d.%C3%B6 st.SV-2008.pdf

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Development of senses of individual responsability:

Our comment/recommendation: We think it is necessary to develop a sense of individual responsability for criterias supporting mental health and well-being as well as the development of public responsability for a mainstreaming policy for mental health and well-being.

Smoking, especially the “smoke free school campaign” and individual responsability is a good example how to deal with publicity campaigns aiming on basic needs which must be fulfilled for creating, supporting and regaining mental health (basic needs: social cohesion, solidarity, security, power – feeling important and respected etc.).

Health education in schools including medical checks:

Health education in schools is based on the programme “Gesunde Schule” (Healthy School). This is very welcome and target-group-oriented approach to health, also mental health. Different studies show that school in general is a very good field for the combat against stigma and discrimination.8 The publicity campaigns for a smoke-free-school is a further step to prevent and promote mental healthand wellbeing.

But there must be taken into consideration that “risk groups” for mental health problems (little education, migration status etc.) are also risk groups for leaving school earlier as considered. We should draw special attention to the mental health of “school drop outs”. If we think, talk and argue about mental health, we always must consider the ones who are on the edge of the society – or even outside of the society.

Out of the school area, smoking has become a special target as a health theme. The legal protection of the young is e. g. offered by limited access (over 16) to cigarette vending themes. There is still the question, if the young don’t find other ways to cover their needs and habits. It is a good approach – from a life style view the effects should be evaluated.

The precautionary medical checkup screening service exists since 1974. Since 1st October 2005, the “New Precautionary Medical Checkup” is offered. 11,8 % of the Austrian population took part in this checkup (dates from 2006). The Austrian report says that findings of modern lifestyle medicine are reflected in this checkup – furthermore the focusing on physical activities, eating habits and smoking.

The checkup-criterias are based on blood test, clinical examination and consultation. Risky behaviour is integrated via body mass index and cholesterol. There is a missing point from the point of view regarding mental health: Mental health themes

are still missing in this checkup. It looks like that the slogan “there is no health

without mental health” hasn’t arrived till now the medical checkup sphere.

Free and regulare medical checks and screening for pregnant women and children:

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The “Mutter-Kind-Pass” is a free and regulare medical check and screening for pregnant women and children. The obligation to cover this service by the women (and mothers) to receive the “Kinderbetreuungsgeld” is forcing, but effective.

The inclusion of training in educational skills supporting mental health and wellbeing of children should be reflected as a binding step of preparation for people becoming parents.

Narcotic drug policies:

The narcotic drug policy is mainly based on the substitution treatment/programme. This obligatory framework was set up with the object of binding government health services, physicians and pharmacies to exact observance (because of black market problems).

Two new ordinances were published to coordinate and harmonise the approach of the various professions involved in the treatment and to improve the quality of substitution treatment. Many experts criticize this new form of narcotic drug policy on various levels:

First it is still an ongoing public policy view that substitution programmes are not considered as a very effective form of treatment. Many evidence based results underline the important role of substitution programmes.

Second national narcotic drug policies still work with the headline of “abstinence”. This is furthermore an unrealistic approach to people with mental health problems, resulting from drug abuse.

Third it is reality that comorbidity – mental health problems and drug abuse – is more often reality as it is shown in different policy steps.

As the problematic drug consumption has increased in Austria over the past years, different steps to help people with drug problems should be taken. We should learn more from countries that are since many years pioneers within this field (e. g. Switzerland). A more prohibitive approach has – since now – never been successful. It is much more better to empower this targeted groups by social reintegration and covering their personal needs resulting from mental health problems with adequate forms of treatment and care instead of stigmatising them and to pray for a world of “no drugs” – this is neither reality nor future but all in all an unrealistic view of the world in the 21st century.

Some conclusions:

Some comments over all:

no Austrian legal framework for social work

“empowerment” is still a “work in progress” and little respect and involvement of the users

we notice an increasing lack of psychiatrists especially after retirement of the generation which is active now

it’s a fact that we have still structures that look like in the former monarchy rather than being modern, actual and suiting to the 21st century – multi-disciplinary work is a well and often mentioned but still theoretical status quo

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7 Authors and date of this report:

Gernot Koren (pro mente austria)

Elisabeth Muschik (pro mente austria

References

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