5. Provision of services
Provision of health services in Austria is characterized by relatively unrestricted access to all levels of care including GPs, specialists and hospitals. There is no formal gatekeeping system in place. For ambulatory care, patients can choose between independently practising physicians, group practices, hospital outpatient departments and outpatient clinics. Patients also have choice between SHI contracted physicians (45%) and those without contract (55%), but they are only reimbursed for 80% of the applicable SHI tariffs for non-contracted care.
In general, health care provision remains strongly focused on hospital care. Austria continues to have the second highest number of hospital discharges per population in the EU (after Bulgaria). The current health reform process aims to shift service provision away from hospital inpatient and outpatient departments towards increased provision in the ambulatory (extramural) sector with a particular focus on the strengthening of primary health care. A promising but small step in this direction is the implementation of 75 multidisciplinary primary health care units as part of the primary health care reform between 2017 and 2021. However, in the past, the fragmentation of responsibility and financing between Länder and SHI funds has often complicated coordination and hampered the shifting of service provision towards the ambulatory sector, as this would increase expenditure of SHI funds.
Social and long-term care provision is separate from the health care system in terms of legislation, responsibilities and financing, adding another layer of complexity and further complicating coordination of care provision. LTC provision relies heavily on a non-means-tested cash-for-care allowance paid to approximately 5% of the population. Services are provided in different settings such as informal care by families (42%), formal home care (32%), day care (2%), residential care (19%) and 24-hour home care by privately paid assistants (5%).
Austria has a relatively high density of pharmaceutical provision with community pharmacies, dispensing doctors, hospital pharmacies or pharmaceutical depots. The generics share of prescribed and dispensed pharmaceuticals is relatively low both in volume and value partially because neither INN prescribing (International Nonproprietary Name) nor generic substitution is allowed in Austria. The planned implementation of e-prescription and e-medication applications of the ELGA may improve appropriate prescribing and reduce the adverse consequences of polypharmacy in the next years.
Preventive health care in Austria is still strongly focused on medical prevention, although efforts are under way to include social and environmental aspects. Despite free vaccination programmes for children, Austria has comparatively low vaccination rates among 1 year olds (83% for diphtheria, tetanus and pertussis and 76% for measles). Tobacco consumption is a major public health issue and an important risk factor in Austria, which is likely related to comparatively weak smoking policies and the absence of a comprehensive smoking ban in bars and restaurants.
5.1 Public health
There is a Public Health Service (Öffentlicher Gesundheitsdienst) in Austria, which assumes tasks in the fields of epidemiology and health reporting, health promotion and prevention, health planning and policy consultation, control of communicable diseases, medical crisis management and environmental medicine and hygiene (BMASGK, 2018d). However, public health policy and practice remain highly fragmented, involving many actors from different sectors (education, social services, environment etc.) (BMGF, 2017u), including several federal ministries, SHI funds, the BGA, the Supreme Health Board (Oberster Sanitätsrat), the AGES as well as various bodies of the Austrian health reforms 2013 and 2017 (see sections 2.3.1 and 2.3.4).
Also, universities, research institutes, NGOs and expert associations are involved in public health functions and public health research. These include the Austrian Public Health Association (Österreichische Gesellschaft für Public Health), the LBI-HTA, the Institute for Health Promotion and Prevention and the GÖG, which hosts the FGÖ.
The 10 Austrian Health Targets adopted in 2012 highlight the importance of public health in Austria. These targets provide the guiding framework for public health policy until 2032, following a Health in All Policies (HiAP) approach and aiming to contribute to increased healthy life expectancy (BMGF, 2017s).
Public expenditure on preventive care (according to the system of health accounts) amounted to €555 million in 2015, which corresponds to 1.6% of current health care expenditure (OECD, 2017c).
5.1.1 Communicable disease control functions
Surveillance and control of communicable diseases is mainly under responsibility of BMASGK, which monitors infectious diseases via the electronic epidemiological reporting system (Epidemiologisches Meldesystem, EMS). According to the Law on Epidemics, all health providers and actors are required to report defined communicable diseases to this system (Epidemiegesetz, 1950). This facilitates the temporal and spatial monitoring of diseases and planning of preventive measures (BMGF, 2017r). Foodborne diseases are jointly monitored by health, food and veterinary authorities. To combat outbreaks of foodborne disease a specialized centre was established within the AGES in 2012 (Hofmarcher & Quentin, 2013).
Antimicrobial resistance has been monitored since 2005 including also nationwide surveillance of antibiotic use by non-hospital providers and usage statistics of hospitals (Hofmarcher & Quentin, 2013). Monitoring results are published annually in the Austrian Report on Antimicrobial Resistance. The National Action Plan on Antimicrobial Resistance (Nationaler Aktionsplan zur Antibiotikaresistenz, NAP-AMR) published in 2017 aims to improve the use of antibiotics (BMGF, 2017y). In particular, it strives to limit the development and spread of antimicrobial resistance to sustain the effectiveness of antibiotics and to promote the quality of antimicrobial therapies. Revision of the NAP-AMR will start in 2018 based on the new EU One Health Action Plan against Antimicrobial Resistance published in July 2017 (European Commission, 2017b).
5.1.2 Health promotion and education
In 2012, both the Federal Health Commission (Bundesgesundheitskommission) and the Council of Ministers agreed upon 10 Austrian Health Targets (Gesundheitsziele) that provide the framework for steering the health system until 2032. Nine of the 10 Health Targets aim at health promotion and related topics such as health literacy and healthy behaviour (see section 6.1.1).
The Health Promotion Strategy that was agreed during the last health reform period 2013–2016 builds upon the framework for coordinated health promotion actions in Austria until 2022. Its priority areas are early childhood intervention; healthy nurseries, kindergartens and healthy schools; healthy living environments and lifestyles of adolescents and people of working age; health literacy of adolescents, people of working age and elderly people and social participation and psychosocial health of the elderly. The strategy also sets rules and conditions for the allocation of resources (BMGF, 2016d).
Two national action plans have been developed to support healthy lifestyles. The first is the National Action Plan on Nutrition (Nationaler Aktionsplan Ernährung) originally adopted in 2011 and updated in 2012 and 2013, which aims to reduce over-, under- and malnutrition and to reverse the trend of rising overweight and obesity rates by 2020. The second is the National Action Plan on Physical Activity (Nationaler Aktionsplan Bewegung) adopted in 2013, which sets targets for specific population groups and gives recommendations on possible measures to increase physical activity (BMLVS, 2013; BMG, 2013b).
The FGÖ is an important player in Austria for health promotion and prevention. In 2015, it financed in total 92 health promotion projects. The highest amount was spent on implementing innovative health promotion and primary prevention pilot projects in different settings (€4.8 million), followed by occupational health promotion projects (€1.6 million) (FGÖ, 2015a; FGÖ, 2015b). Depending on the grant level, either internal or external (€20 000–€60 000) or external (> €60 000) project evaluation is obligatory.
Health promotion is also anchored in a number of strategies (National Strategy on Child and Youth Health, National Strategy on Dementia, National Strategy on Diabetes) as well as the national platform on health literacy (ÖPGK, 2017b) and the National Centre for Early Childhood Intervention (NZFH, 2017a) (see section 2.6.4).
5.1.3 Preventive services
Preventive activities in Austria still focus on medical prevention, involving vaccination, preventive health check-ups, screening for different population groups (e.g. pregnant women and infants or adolescents), and addiction prevention including non-smoking programmes. However, prevention is increasingly taking into account different social contexts with varying social and environmental risk factors.
In close cooperation with the national vaccination committee (Nationales Impfgremium) the BMASGK issues an annual vaccination plan (BMGF, 2017o). Included vaccinations are free of charge up to the age of 15 years and cover diphtheria, haemophilus influenza type B, hepatitis B, human papillomavirus (HPV), measles, mumps, rubella, meningococci of groups A, C, W135 and Y (MEC-4), pertussis, pneumococci, poliomyelitis, rotavirus and tetanus (BMGF, 2017n). Two thirds of programme costs are covered by the federal government, the remainder by the Länder and SHI funds in equal shares. In contrast to other countries, none of the recommended vaccinations are mandatory.
Austria has relatively low vaccination rates, which might, however, be partially explained by lack of systematic documentation and reporting of vaccinations. In 2014, 83% of children aged 1 year were immunized against diphtheria, tetanus, pertussis, 76% against measles and 83% against hepatitis B. In 2014, Austria abolished the age limit for the free measles vaccination and launched a public awareness campaign with the aim to increase uptake. However, in 2015, Austria reported 300 measles cases, corresponding to 35.3 cases per million inhabitants – the second highest, with only Croatia among EU countries reporting a higher rate (ECDC, 2016).
Austria recommends influenza vaccination for infants, different at-risk populations and for adults aged 50 and over. Vaccination is typically subsidized but is generally not provided free of charge. In 2014, only 20.3% of the population aged 65 years and over were immunized compared to more than 70% in the Netherlands and the United Kingdom – both countries that provide influenza vaccination free of charge for the elderly (OECD/EU, 2016).
Against an overall declining trend of smoking in many European countries, the number of Austrian adults who smoke has remained stable since 2000 and was above the EU28 average (see section 1.4) (Eurostat, 2017i). One potential reason for the high smoking prevalence is the comparatively weak smoking policy in Austria in the last decades. The 2008 amendment of the Tobacco Act (1995) prohibited smoking in restaurants and bars but still allowed smoking in separate rooms or when the surface area of an establishment was under a certain threshold. Smoking policy is a topic of public debate, especially as the new federal government revoked plans for a total smoking ban in restaurants and bars after their election in 2017.
Encouragingly, smoking rates among adolescents and young adults have decreased since the year 2000. The recently launched tobacco prevention initiative YOLO (“You only live once”, www.yolo.at/) of the BMASGK, the FGÖ, the HVB and the Austrian Association for Addiction Prevention (Österreichische ARGE Suchtvorbeugung) specifically targets young people aged 10–14 years (FGÖ, 2017a). In 2016, Austria published its first Addiction Prevention Strategy, which covers legal and illegal drugs, including alcohol and tobacco, and provides guidance for addiction policy in the forthcoming years (BMG, 2015b).
In each of the nine Länder there are Institutes for Addiction Prevention that aim to combat and prevent addictions to legal substances (alcohol, tobacco or pharmaceuticals) as well as illegal substances and behavioural addictions. These institutes conduct sensitization and information campaigns as well as prevention projects (Suchtvorbeugung, 2017).
A range of population-wide screening programmes are available. Once a year, preventive screenings are offered to all inhabitants above 18 years regardless of their insurance status. For persons without health insurance coverage, the federal government reimburses SHI funds for incurred costs. Screenings comprise anamnesis and early detection of noncommunicable diseases (coronary heart disease, metabolic diseases and cancer) as well as stool tests for occult blood to screen for colon cancer. The screening also covers prevention of addictive disorders (i.e. alcohol, tobacco, and pharmaceuticals), parodontal disorders and age-related diseases. Patients aged 50 years and above are recommended a colonoscopy every 10 years and patients older than 65 years a regular check of hearing and sight. Gynaecological examination (including screening for cervical cancer) and examinations for specific age risk groups (e.g. biennial breast cancer screening for women aged between 45 and 69 years) also belong to preventive population-wide screenings.
Since 2014, a new nationwide breast cancer screening programme that meets international and European quality standards targets women aged 45–69 years. They receive written invitations for participation every two years. Women aged 40–44 years and 70 years and older can voluntarily sign up for the screening.
In 2015, the SHI funds spent €122 million for preventive examinations (HVB, 2017b). In the period 2005–2015, the number of preventive screenings provided to people aged 19 years and above per 1000 inhabitants increased by 19.7%. However, this increase was particularly pronounced only in a few Länder (Vienna, Burgenland, Carinthia, Tyrol and Lower Austria), while screening rates remained stable or even decreased in the others (see Table5.1).
Apprentices aged 15–18 years are eligible for the adolescent screening programme (Jugendlichenuntersuchung) that aims for early detection of diseases, as well as awareness raising and support for a healthy lifestyle (HVB, 2017b). Additionally, annual school medical examinations are anchored in the School Education Act (Schulunterrichtsgesetz, 1986).
The mother-child-pass is a screening programme for pregnant women and infants up to the age of 5. Pregnant women are entitled to five screening cycles, three ultrasound exams, one HIV test, an oral glucose tolerance test and support by consultant midwives, while infants have to undergo five medical screenings during the first 14 months. The full parental leave allowance is only granted if all of the 10 screenings during pregnancy and the first 14 months have been taken up. Six further screenings for infants are foreseen between the age of 22 months and 62 months. Since its introduction in 1974, nearly all pregnant women participated in the programme and perinatal mortality was reduced substantially (Bancher-Todesca, 2014). Since then, the programme was adapted and extended. Currently, its further development is anchored in the federal government’s working programme 2017–2022, which focuses on its evaluation and improvement and its enhanced use in early childhood support (BMGF, 2017m).
Finally, opportunistic screening for prostate cancer is also available in Austria but it is not part of the annual preventive examination (BMGF, 2016c).
5.1.4 Occupational health services
The Employee Protection Act regulates responsibilities in the field of occupational health and safety at the state and enterprise level. The Act also defines the nomination of dedicated health and safety representatives and the requirements of medical personnel responsible for safety measures within organizations, which may vary by company size. The Accident Insurance Fund also plays an important role in the field of occupational health as it has the statutory mandate for prevention of accidents, occupational diseases (according to the ASVG) and safety (ASchG 1994).
Occupational health promotion and prevention is very fragmented in Austria mainly relying on voluntary small-scale projects. The Austrian Network for Occupational Health Promotion (BGF Netzwerk, 2017) advises companies on adequate occupational health programmes. The FGÖ provides financial project support either as a share of a project’s process costs (for large companies) or as a lump sum of €2000 or €3000 (for SMEs) (Fonds Gesundes Österreich, 2017). After a stepwise introduction, the federal government’s secondary prevention programme “Fit2work” was implemented nationwide in 2013. Fit2work is a low-threshold programme which aims to preserve the employability of employed and unemployed people and particularly targets people with vulnerable employability (Hausegger et al., 2015).