Advertisements, in particular for spirits, have been subject to some, if voluntary, regulation. Major sport events are often sponsored by manufacturers of alcoholic beverages e. The objective of this stream is to describe the suitability of proposed solutions for a problem in terms of technical feasibility and acceptability within the population. In light of tight budget constraints, one of the major dimensions of feasibility nowadays is the efficiency i.
The acceptability of an intervention has to be analysed within the context i. Therefore, we first scrutinise the cost-effectiveness of proposed solutions and then describe the contextual factors which might be obstacles to health policy change towards prevention. Some might argue that part of the reason for the apparently low efforts on prevention in Germany and elsewhere might have to do with poor expected 'value for money' to be had from any preventive interventions.
Such a view would, however, largely contradict current evidence, which suggests that in particular in the above-mentioned areas there are several highly cost-effective measures that could be implemented, and have been implemented in many other countries. In this section we first briefly review the cost-effectiveness evidence for interventions concerning the prevention of tobacco and alcohol use and subsequently extend the discussion to other areas, allowing us to also highlight the no doubt existing limitations in the evidence.
There is substantial evidence on cost-effectiveness of policies to prevent and reduce tobacco consumption, even if much of this evidence comes from outside Germany [ 20 ]. In particular tobacco taxation has been identified as the most successful and cost-effective measure in smoking reduction [ 21 , 22 ]. The same studies also demonstrate the very favourable cost-effectiveness of banning smoking at work and in public places.
For example a reduction of hospital admission for myocardial infarctions since introduction of smoke-free legislation was shown [ 23 ]. Greater uncertainty surrounds the cost- effectiveness of so-called "social marketing" approaches, i. Nevertheless, health warnings on cigarette packs seem to have reduced consumption by a detectable, yet small amount [ 21 , 22 ].
The analysis of mass media campaigns has so far produced mixed results. For instance, Abelson [ 25 ] claims that anti-smoking advertising and education has no detectable impact on aggregate consumption. However, anti-smoking campaigns may affect consumption indirectly by making tax increases and smoking ban policies more acceptable.
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These findings echo those from US-focused studies [ 26 ]. Several international systematic reviews have consistently shown alcohol taxation, drunk-driving interventions e. As a further example, brief interventions for drinkers at risk have been shown to be cost-effective [ 14 , 27 ]. The above interventions only address a share, if a substantial one, of the total preventable disease burden in Germany and Europe , raising the question how much we know about cost-effectiveness of prevention in other areas.
In recent years there has been a growing interest in such research, as documented by a series of major systematic reviews of the international literature [ 28 - 30 ]. While these studies do definitely document a significant amount of encouraging economic evidence in favour of primary prevention, they also acknowledge the limitations of that literature.
For instance, on the basis of their systematic review of cost-effectiveness evidence for primary prevention of cardiovascular diseases CVD Schwappach and colleagues [ 30 ] found that. From a German perspective, a further limitation is the scarcity of country-specific studies. In the review of Schwappach et al. Similarly, in a systematic review of all economic evaluations carried out in the German health system context covering the period , only 36 out of studies were found to consider preventive measures excluding screening.
Of those, only a small fraction was targeted at primary prevention or population-based approaches [ 30 , 31 ].
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Hence, a rather strong case can be made for more research on the subject in Germany and elsewhere. While evidence is at best one out of many determinants of policy decisions, a more comprehensive evidence base could facilitate decision-making, which at present often follows more intuitive than scientific reasoning: Due to this lack of outcome research in the German context, several researchers try to translate evidence on preventive measures from other countries to the German healthcare system context.
During such a process of translation it is important to consider structural conditions, which are embedded in cultural dimensions and historical developments. Every culture has its own meaning of community, patterns of decision-making, beliefs about health, help seeking behaviour, notions of individualism versus collectivism, attitudes toward the elderly, and approaches to problem-solving [ 33 ]. These structural conditions define a health system and affect an intervention's effectiveness, efficacy, costs, and efficiency.
How to properly address these challenges in the translation process e. With seemingly few existing prevention efforts coupled with at least significant evidence on what could be done in the specific areas mentioned and partly beyond , the question arises of why one observes this contrast. In this section we explore a set of not mutually exclusive hypotheses about obstacles to more and better primary prevention in Germany.
Part of the explanation for a limited public policy response on prevention may be that the German population simply does not demand such policies as it runs against what some consider a very strong preference for individual freedom and a dislike of government interference in seemingly private business. Interestingly, while such individual preferences are hard to quantify, public opinion surveys tend not to confirm a particularly individualistic preference among the German population.
The World Value Survey asks respondents in many countries whether "people should take more responsibility to provide for themselves", or "the government should take more responsibility to ensure that everyone is provided for". Overall, Germany ranks among the European countries with the highest preference for government involvement [ 36 ]. There is, however, a clear distinction between Eastern and Western Germany in that the latter displays a significantly more individualistic attitude than the former, possibly due to different historical experiences [ 37 ].
In the debate on government's role in prevention, the overarching principle of individual freedom has frequently been invoked as a counter-argument to an augmented public policy stance on prevention, especially in relation to policies that would seek to change people's health-related behaviour. If the above opinion survey results are an accurate representation of the German population's preferences on government intervention in the health behaviour arena, then such counter-arguments would appear unfounded.
The introduction of non-smoking regulations in Germany referred to in more detail below may further illustrate this debate. Opponents to the regulations warn against what they see as an overly paternalistic approach that is at odds with other "free market" values [ 38 ]. However, several recent opinion polls have shown that legal regulations to ban smoking in public restaurants meets the approval of about three quarters of the population [ 39 ].
Hence, the individualism hypothesis is not really backed up by what the population as a whole feels, as opposed to a group of stakeholders and opinion leaders opposed to more intrusive prevention policies. The question remains, however, how to better align individual preferences and public health goals in general. Research identified the concept of personal risk perception as an important factor for individual behaviour as well as for attitudes towards government intervention [ 40 , 41 ].
A lack of coherence between individual preferences and public health measures might arise, if individuals perceive restrictions in their personal freedom and choice as being disproportionate to the perceived risk of harm to the general public [ 41 - 43 ]. Two major findings are that first, people tend to evaluate risks of unwanted effects as higher for "others" than when applied to themselves, and second, people tend to be "myopic" towards risks that are delayed far into the future [ 41 , 44 , 45 ].
A possible pathway for public health policy might therefore be to strengthen messages of more short-term adverse events and externalities of behaviour, next to suitable solutions, in order to align the individual risk perception with community health goals. An example, referring to the case above, is the change in focus within the "smoking in public places" debate from the harm smoking does to the smoker herself to the harm inflicted upon third persons "external costs" through passive smoking, which may have added momentum to smoking-related public health advocacy [ 46 ].
This idea could be transferred to the area of alcohol by articulating the effects of alcohol consumption on road traffic accidents and anti-social behaviour, as opposed to stressing "private" long-term outcomes such as liver cirrhosis. A further discussion of this mechanism and the role of public health policies in this task is beyond the scope of this article. However, more research in this area is needed. Another potential obstacle to more prevention and health promotion arguably consists in their negative connotation with aspects of public health activities during the Third Reich era , often defined by the term "Volksgesundheit" [ 47 , 48 ].
During this period the principle of "only a healthy nation is a strong nation" was taken as justification for, among others, interventions to enforce physical activity and to combat alcohol and tobacco use. The idea also incorporated the perverted ideas of racial hygiene and eugenics - including the notorious activities concerning "euthanasia" and mass sterilization of people with handicaps or deemed "unfit" [ 49 ]. This extremely negative historical legacy of prevention and public health may explain a degree of over-sensitivity even nowadays.
Justified or not, the concern that public health i. The politics stream describes the political context in which health policy is set. Since policy change is dependent on actors working together and reaching compromises, the attitudes and interests of each institution or individual involved needs to be aligned e. While some authors commonly use this section to describe changes in political actors over time e.
We try to identify whether structural problems in the organisation of legislation, the nature of social health insurance, or the influence of actors from private industry represent obstacles to the formulation and implementation of prevention policies.
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Germany's public policy in many areas, including healthcare, follows a federal meaning shared sovereignty rather than a centralised decision-making process. In particular, each state has the right to implement or reject laws on prevention. Taken together, there is a multitude of players, at national and state level, all contributing partially to prevention in Germany.
The much-dispersed responsibilities and interests may well hinder the implementation of prevention policies that would otherwise benefit from coordination and harmonisation across regional borders. The recent debate around smoking ban laws is a case in point. In a national law was enacted banning smoking in public facilities, but the legislation that concerns smoking bans in restaurant and bars was transferred to the state level and resulted in a range of very diverse regulations, some of them complex, based on voluntary efforts with multiple exceptions for small bars, clubs and places holding traditional events [ 51 ].
Some innkeepers filed a lawsuit against the states' smoking prohibition at the Federal Constitutional Board. The court decided that such a law was in accordance with the German constitution because the government has the duty to safeguard the life and health of the general population. However, it has to be guaranteed that the federal legislation ensures both equality and consistency for all parties involved [ 52 ]. In response to the built-in exceptions, such as the freedom to run so-called "smoking clubs" to which only registered members have access, a petition for a referendum was initiated in the state of Bavaria enrolment period November 19 th - December 2 nd.
The aim of the petition is a unified law for the protection of non-smokers without exceptions. An additional, related problem may be that there is no central agency for public health in Germany that could help coordinate prevention policies where suitable. In contrast, often programmes are continued, even though proved to be unsuccessful e. Nevertheless, not all health topics are covered broadly. There are approximately funds of this kind in Germany, mostly organized at the state level. They have gained more legal rights recently to offer preventive measures to their customers.
In , insurance funds spent the highest amount ever for primary prevention: Substance abuse is not an explicit target of this programme, but is considered as one minor point within the scope of workplace health promotion and primary prevention activities within the "setting approach", e. The insurance funds are also allowed to incentivise their members through programmes such as monetary compensation or free fitness centre memberships.
Critically though, they can only finance these incentives from cost savings. This is unlikely to be a sensible economic requirement, as programmes that would still provide good value i. Given that customers are free to switch to another insurance fund, these programmes are rather used as marketing tools than as concerted prevention efforts. The overall lack of coordination and responsibility tends to produce a vacuum of interpretation sovereignty on prevention topics.
This might be one reason why in Germany industrial lobbyists have a strong influence on legislation and fiscal measures, arguably particularly so in the health field.
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The severely watered down legislation of the smoking ban in public places may exemplify the influence of the tobacco lobby [ 54 ], as may the industry's strategies to oppose the advertisement ban at the European level as well as managing to maintain the establishment of different tax levels for different types of tobacco [ 39 , 55 ]. By contrast, some other preventive measures, e. The decision process was accompanied by a large industry-funded media campaign.
The case for greater public support for research on prevention, especially of the non-clinical sort, has already been highlighted above. Research on preventive interventions is subject to a market failure: From a sheer economic efficiency and not even from any moral or public health perspective, such knowledge is thus undersupplied compared to the social optimum.
Hence, government ought to step in and help promote the production of evidence that the population at large would benefit from, but cannot produce if decisions are left to "the market" alone [ 57 ].
File:Bundesarchiv B 145 Bild-F078267-0023, Bonn, Ministerpräsidenten mit EU-Kommissar Delors.jpg
The development of a sound scientific basis and structured financial support can improve the impact of healthcare, as appears to have been the case in the German rehabilitation services sector. The establishment of a long-term research programme has improved the recognition and outcomes of rehabilitation services - a traditionally rather neglected area. Prevention research, especially in the non-clinical arena, poses its own challenges, arguably the chief one being the attribution of changes in health outcomes to the intervention examined [ 58 ].
Population-based interventions tend to be more complex than the prescription and intake of a drug, and the not flawless gold standard of evaluation in the medical field - the randomised controlled trial RCT - cannot easily be implemented. Fortunately, though, there are other statistical methods that may allow the assessment of causality in such cases, but they have been underutilized in public health research to date [ 59 , 60 ].
A low public support for non-clinical research is of course not solely a feature of Germany but may well apply globally. While similar data do not exist for Germany, there is no reason to assume that the share is significantly higher in Germany. Nevertheless, there are also some positive trends: This programme is running from until and includes 60 research projects [ http: The Federal Centre for Health Education BZgA is a partner in this national comprehensive network to strengthen research in primary prevention, with the objective of establishing structures for sustainable primary prevention.
Tasks include process definitions, evaluation of combined results and communication to political decision makers, research community and practical institutions. In the intermediation between science and the practical field, the BZgA could play an even greater role. In Germany, substantial health gains could be reaped from the implementation of evidence-based, cost-effective preventive interventions and policies.
However, applying the "three-streams" framework proposed by Kingdon [ 5 ], we showed that there are obstacles in the policy and politics streams that hinder substantial policy change. While in the "problem stream" there is sufficient evidence to scale up prevention efforts in some public health areas in Germany, especially alcohol and tobacco, in general there is a comparative shortage of research on non-clinical preventive interventions.
Some of the existing barriers in Germany are at least in principle amenable to change, provided the political will is sufficient. However, political decisions tend to be driven by short term election period perspectives, and hence the long term horizons of many prevention policies may not always align with political decision-makers' time horizons. More research on prevention by itself is no panacea but could help facilitate more policy action. In particular, there is an economic efficiency-based case for public funding and promotion of research on non-clinical preventive interventions [ 57 ], in Germany and beyond, to confront the peculiar challenges that set this research apart from its clinical counterpart.
It is beyond the scope of the present article to exhaustively discuss all the options for a more concerted effort on prevention in Germany. We highlighted only selected key points where improvement seems necessary and feasible. This does not readily provide us with a complete positive model of how prevention as a whole ought to be institutionalised in Germany or any other country. With wide variation in how prevention is delivered and institutionalised across European countries [ 62 ], a single optimal model has yet to emerge.
While lack of the perfect model is no excuse for inaction on prevention in Germany, completing the picture of the features of such an ideal model of a national prevention policy should be high on the public health and social science research agenda. For this purpose international cross-country comparative research, rather than a single country case study would seem one promising approach.
UW and MS conceived the article and prepared the first draft. Both contributed equally to the paper. MGG helped further revise and finalise the draft. TAB contributed to the production of the first draft and subsequent revisions. All authors contributed to the drafting of the final version. All authors have read and approved the final manuscript. National Center for Biotechnology Information , U.
Published online Aug Author information Article notes Copyright and License information Disclaimer. Received Jan 25; Accepted Aug This article has been cited by other articles in PMC. Abstract Background Recent years have seen a growing research and policy interest in prevention in many developed countries. Discussion We review the evidence on the considerable existing scope for health gains from prevention as well as for greater prevention policy efforts in Germany.
Summary In Germany, there are substantial health gains to be reaped from the implementation of evidence-based, cost-effective preventive interventions and policies. Dilemmas on the right and the road to proportional representation; From macro- to micro-historical analysis in comparative research 2. Kurzbeschreibung "The expansion of suffrage and the introduction of elections after authoritarian interludes are momentous political changes that represent only the first step in the process of democratization.
In the absence of institutions and guarantees that protect the electoral autonomy of voters against a range of actors who seek to influence their votes, these rights can just be hollow promises. This book examines the adoption of electoral reforms that protected the autonomy of voters during elections and sought to minimize undue electoral influences. Empirically, the book focuses on the adoption of reforms protecting electoral secrecy in Imperial Germany during the period between and This book shows that the political impetus for changes in electoral institutions originated with politicians that faced relatively high costs of electoral intimidation and identified the economic and political factors that affect the latter"-- 3.
Kurzbeschreibung "The process of democratization that unfolded in European countries during the nineteenth century involved multiple dilemmas of institutional design.
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The first question concerned the scope of political suffrage. The transition from restrictive to extended suffrage took place either through the adoption of piece-meal changes in the scope of the franchise or through dramatic extensions that enfranchised nearly all citizens.
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Reforms enacted in Britain exemplify the first approach. There, the expansion of suffrage proceeded gradually. The first Franchise Act, enacted in , extended the scope of suffrage from five to seven percent of the population. The second Franchise Act of extended the scope of suffrage to sixteen percent of the population Cook By contrast, both France and Germany adopted electoral reforms that expanded the share of the enfranchised population suddenly and dramatically.
In Germany, the electoral law adopted in introduced universal suffrage for men. Similarly, France adopted universal male suffrage in Im Bereich Kataloginformation werden die bibliographischen Details angezeigt.