Establishing social services for health promotion in health insurance states: Germany, Switzerland and Austria compared

Prevention and health promotion are important areas of welfare state activity and can be considered parts of the critical infrastructure. They have been considerably expanded in Western welfare 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 legitimisation patterns for the chosen institutional forms. To this end, health reforms, debates and statements 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 responsible 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 commonly associated with it are increasingly used in the context of prevention and health promotion. In contrast, normative justifications seem to be losing importance.