Volume 16 Supplement 5

Economic and institutional perspectives on health promotion activities for older persons

Open Access

A review of health promotion funding for older adults in Europe: a cross-country comparison

  • Jelena Arsenijevic1, 2Email author,
  • Wim Groot1, 2, 3,
  • Marzena Tambor4,
  • Stanislawa Golinowska4,
  • Christoph Sowada4 and
  • Milena Pavlova1, 2
BMC Health Services ResearchBMC series – open, inclusive and trusted201616(Suppl 5):288

https://doi.org/10.1186/s12913-016-1515-2

Published: 5 September 2016

Abstract

Background

Health promotion interventions for older adults are important as they can decrease the onset and evolution of diseases and thus can reduce the medical costs related to those diseases. However, there is no comparative evidence on how those interventions are funded in European countries. The aim of this study is to explore the funding of health promotion interventions in general and health promotion interventions for older adults in particular in European countries.

Method

We use desk research to identify relevant sources of information such as official national documents, international databases and scientific articles. Fora descriptive overview on how health promotion is funded, we focus on three dimensions: who is funding health promotion, what are the contribution mechanisms and who are the collecting agents. In addition to general information on funding of health promotion, we explore how programs on health promotion for older population groups are funded.

Results

There is a great diversity in funding of health promotion in European countries. Although public sources (tax and social health insurance revenues) are still most often used, other mechanisms of funding such as private donations or European funds are also common. Furthermore, there is no clear pattern in the funding of health promotion for different population groups. This is of particular importance for health promotion for older adults where information is limited across European countries.

Conclusions

This study provides an overview of funding of health promotion interventions in European countries. The main obstacles for funding health promotion interventions are lack of information and the fragmentation in the funding of health promotion interventions for older adults.

Keywords

Health promotion Older adults Funding Europe

Background

Health promotion interventions are seen by some as a tool to improve health and to decrease medical costs [1]. In an aging population, health promotion may not only prevent the onset of diseases and reduce the medical costs related to these diseases but it may also positively affect the evolution of (chronic) diseases and increase active participation of older adults in society [1, 2]. In this way, health promotion may save costs for society in general [3]. For example, some health promotion interventions, such as physical activity programs provided by employers during or outside work hours, promote labor force participation among older adults [4]. Such interventions enable older adults to participate in society and may reduce the burden on the social benefits system [5].

Although health promotion for older population groups may be a valuable investment, there is no clear evidence about how it is funded [6]. In general, health promotion is considered a public good and it is usually funded by revenues from general taxation (including regional and local taxes) [1]. However, recent studies show that resources available from general taxation are not always successfully invested in general health promotion interventions [7]. Specifically, resources that governments aim to spend on health promotion can be re-allocated to other issue-based public health activities [7]. Also, recent studies show that differences in funding of general health promotion are observed between countries, including differences in the mechanisms of resource collection and resource allocation [8]. In some countries, like Austria and France, where the funding of the health care system is based on social insurance contributions, there are attempts to include all health promotion in the insurance packages but those attempts have not been completely successful [9, 10]. In some other countries the lack of resources prevents the inclusion of general health promotion in the insurance package, so health promotion interventions are funded by donations and private sources [8]. Furthermore, health promotion includes a broad scope of activities, some of which are often not considered as a part of the health care system but are rather seen as multi sector activities [7]. Some of those general health promotion interventions are community based or related to the education system [11]. Although they do address public health problems it is considered that they should be funded by the Ministry of Education or by private funding (out-of-pocket payments) [7]. This is also a reason why initiatives to include all health promotion interventions in health insurance packages have been generally unsuccessful [7].

Similar findings are also observed for health promotion interventions for the elderly. The evidence shows that health promotion interventions for older people are frequently multi-sector activities that are funded through general taxation but also through health insurance contributions (resources provided by social or private/voluntary insurance premiums), by resources obtained from NGOs, EU projects and users’ private payments (co-payments additional to insurance premiums or full market-price payments) [8, 10]. As populations are aging, the number of health promotion programs targeting older adults is growing [8]. They are mostly focused on a healthy life-style, mental health or injury prevention among older adults [8]. Frequently within one program it is possible to combine two or more interventions, for example mental health promotion with promotion of labor participation among elderly. Those programs are not only multi-sector activities but they are often multi-country activities [8]. This means that the same program can be conducted in different countries at the same time. The multi-sector and multi-country characteristics imply a great cross-country diversity in funding the health promotion programs for older adults.

Furthermore, the resources allocated to all health promotion interventions are relatively small [12]. For example, OECD countries report that they spend on average 3.1 % of their public health expenditure on health promotion in general [13]. Only a small share of the general health promotion resources are used to fund health promotion for older population groups [7, 8, 12]. Even with an ageing population, priority is frequently given to health promotion for the young. This is motivated by observing that the returns of the investment manifest themselves after a longer period of time and health promotion is therefore more effective when the investment is made at a younger age [1]. This diminishes the resources allocated to the funding of health promotion interventions for older population groups.

Aging populations and scarcity of resources are the main challenges in the funding health promotion interventions for older population groups [2, 12]. Although the challenges are identified, there is no overview of how health promotion interventions for the older adults are actually funded in European countries and how existing methods of funding can contribute to sustainable health promotion interventions for the older adults. Previous reports on funding of health promotion in Europe have not included all countries but only provide general and limited information about funding [8, 14]. A comprehensive overview is necessary to identify good practices and help policy makers to improve the funding of health promotion in their countries by learning from the experience of others [8]. An overview of health promotion funding can also help health professionals to better use the existing models of funding for health promotion interventions [15]. Specifically, health professionals can learn how to better use the existing resources. Furthermore, there are a growing number of health promotion programs for older adults. Although evidence about the effectiveness of those programs is limited, some sources emphasize the importance of those programs for the health of older adults [8]. Furthermore, those programs show how health promotion interventions are funded in practice in different countries. Based on the overview of the funding we will discuss whether it is possible to identify successful examples.

The aim of this study is to explore the funding of health promotion interventions in general and health promotion interventions for older adults in particular in European countries. We also provide information on how selected health promotion programs for older adults are funded in Europe. For the purpose of this study we use desk research to identify relevant information based on official national reports, international databases and scientific articles related to funding of health promotion.

Methods

We focus on health promotion interventions such as the promotion of a healthy life style (smoking prevention, prevention of alcohol consumption, promotion of physical activities and promotion of healthy eating), primary prevention activities related to mental health and general well-being, fall and injury prevention as well as promotion of labor force participation among non-retired older adults. Our focus is on these particular interventions since they are most frequently reported in European countries [8]. We do not include secondary prevention activities related to the detection of diseases such as screening tests, as well as primary prevention activities related to vaccinations. Also, we do not include tertiary prevention activities that target older population groups already diagnosed with certain diseases, for example health promotion interventions for older adults diagnosed with diabetes mellitus type 2.

For a descriptive overview of how general health promotion interventions and health promotion for older adults are funded in European countries, we focus on functions proposed as descriptive tools for analyzing the funding mechanism of health care systems in general [16]. Those functions include the collection of funds, pooling of funds, allocation of resources and purchasing of services. Based on these functions, we focus on the following aspects of funding: what are the mechanisms of collecting funds (general taxation, indirect taxes, earmarked taxes, social insurance contributions, private insurance contributions, out-of-pocket patient payments and other funding like funding from NGOs or EU), who are the collecting agents (government, local municipalities, independent public bodies (specialized funds) or providers), and who is funding health promotion, i.e. allocating funds and purchasing services (federal, regional or local government, insurance companies, EU institutions, NGOs or private institutions). We are aware that within each country, different mechanisms of funding and different funding and collecting agents co-exist and can be combined. In some countries collecting, pooling and funding agents can represent the same institution, while in others a distinction is made. Also, multiple mechanisms of funding can be used within the same country. Based on these three dimensions, we present data for 27 European countries. Although the aim of this study is to provide an overview of funding of health promotion in general and specifically for older adults in EU, information for some countries, to the best of our knowledge, was not available or only limited available in English. Those countries include: Latvia, Luxembourg, Malta and Romania.

Furthermore, for clarification we divide the funding sources in three different categories: public funding (taxes and social insurance contributions), private funding (private insurance contribution, out-of-pocket payments, employers) and others funding (from international organizations, EU funds, NGOs funds or funds from foreign governments). We make a distinction between health promotion funding in general and funding of health promotion interventions for older population groups.

To search for relevant information, we use different sources of information such as scientific papers, reports, policy documents and documents coming from international organizations, and the following key words: health promotion, funding (but also financing, costs, coverage), older adults (elderly, older population groups), Europe (but also the country names). We use different combination of key words in searching for scientific articles in PubMed, Google Scholar and the NHS Economic Evaluation Database. Furthermore, we use the same key words to search through the databases and reports by international institutions (OECD, WHO, EU) as well as the websites of national and international projects. We focus on English language documents, but when possible, we also include documents in national languages. This was done for the following countries Austria, Bulgaria, Croatia, Germany, the Netherlands, Poland, and Switzerland. Based on the relevant documents (16 research papers and 48 policy papers, documents and reports), we provide an overview of how general health promotion interventions and health promotion for older adults are funded in different countries based on the three questions presented above. We also provide information to what extent health promotion interventions are funded through public, private or other sources. The results are presented in a narrative form complemented by descriptive tables.

We have also searched the WHO library, OECD library, PubMed, and different project databases such as the Vintage project database, the Health and Aging Project (HALE) database, the Health Pro Elderly project database, the AGE platform Europe database, the European network for mental health promotion database (the ProMenPol Database), European network for work promotion database, the National Institute for Public Health Netherlands database, the EuroHealthNet database and the EUNAAPA project database, to identify programs that address health promotion interventions for older population groups. As indicated above, we focus on programs that address a healthy life style, primary prevention activities related to mental health and general well-being, fall and injury prevention and promotion of labor participation among non-retired older adults. We include programs that provide information about funding (who is funding and how) and who is the main program provider. Again, the results are presented in a narrative form complemented by descriptive tables.

Results

In Table 1, we present our findings on how general health promotion interventions and health promotion for older adults are funded following the three dimensions outlined in the method section. In the majority of the countries the agent that collects resources is also one of the agents that fund the general health promotion programs for example the government in Bulgaria or social insurance in France. While the agents that collect resources include usually one or two governmental bodies, the numbers of agents that fund general health promotion programs are higher and more heterogeneous. Overall, the main agents that collect resources and fund programs are governmental institutions, but funding is also done by private companies, NGOs and EU projects. In countries like Austria, Denmark, Germany, Hungary, Ireland and Switzerland, special funds are created to collect and allocate resources to providers of general health promotion interventions. Resources are usually collected via general taxes and are then allocated to those funds. In Switzerland the resources collected through taxes are combined with private mechanisms of collecting funds, i.e. each person contributes to the insurance general health promotion fund by regular monthly payments.
Table 1

Funding of health promotion interventions in European countries

Country

Who is funding health promotion interventions in general?

Who is funding health promotion interventions for older adults?

What are the mechanisms of funding?

Who is the collecting agent?

Sources

Austria

Government

Social Insurance fund

NGOsa

EU funding

Health promotion for older population groups are also funded by Fund for Healthy Austria and health insurance funds. For individuals who use health promotion activities, they are covered by health insurance package(Article 154b, ASVG)

General taxes

Insurance contributions

Fund for Healthy Austria

9 regional health insurers

6 professional health insurers

Hofmarcher et al. (2006) [26]

Schang LK, et al. (2012) [12].

Belgium

Regional and local entities

Same as general health promotion

General taxes

Local taxes

Earmarked taxes

Government

Local communities

Gerkens S, et al. (2010) [18]

Bulgaria

Government

Social insurance fund

EU projects

There is a National Plan to Promote Active Aging among Elderly in Bulgaria (2012-2030) adopted through Protocol № 24.2 of the Council of Ministers on 20.06.2012.

The objectives of the plan are to promote active aging among the elderly and to develop long-term care and voluntary work directed at the needs of elderly people. The funding of this plan comes from the state budget.

General taxes

Private insurance contributions

Grants (EU projects)

Ministry of health

National health insurance fund

http://journal.frontiersin.org/article/10.3389/fpubh.2015.00175/full

http://www.insurancebulgaria.com/health-insurance-package-health-improvement-and-disease-prevention

http://www.chrodis.eu/wp-content/uploads/2014/10/JA-CHRODIS_Bulgaria-country-review-in-the-field-of-health-promtion-and-primary-prevention.pdf

http://www.hspm.org/countries/bulgaria22042013/livinghit.aspx?Section=3.3%20Overview%20of%20the%20statutory%20financing%20system&Type=Section

Croatia

Government

Social insurance fund

Same as general health promotion

General taxes

Insurance contributions

Croatian Insurance Fund

Vulic & Healy (1999) [27]

Cyprus

Ministry of Health

Different private stakeholders

Same as general health promotion

General taxes

Private contributions

Government

http://www.chrodis.eu/wp-content/uploads/2014/10/JA-CHRODIS_Cyprus-country-review-in-the-field-of-health-promtion-and-primary-prevention.pdf

Czech Republic

Ministry of health

NGO

EU projects

Same as for general health promotion

General taxes

Private contributions

Grants (EU projects)

Ministry of Health

Bryndová et al (2009) [28]

Denmark

Government

Private stakeholders

Same as for general health promotion

General taxes

Private insurance contributions

Private payments

Government

Christiansen (2002) [29]

Estonia

Estonian Insurance fund

European social funding

EU projects

Same as for general health promotion

Insurance contributions

Grants

Estonian Insurance fund

http://www.chrodis.eu/wp-content/uploads/2014/10/JA-CHRODIS_Estonia-country-review-in-the-field-of-health-promtion-and-primary-prevention.pdf

http://programs.jointlearningnetwork.org/content/estonian-health-insurance-fund

Finland

Municipality entities

Financed by municipalities

General taxation

Local taxes

Local municipalities

World Health Organization. (2002) [30]

France

Insurance funds

Same as for general health promotion

Insurance contributions

Earmarked taxes

Taxes on alcohol and tobacco products

Social insurance funds

Fund (2012) [31]

Germany

Statutory health insurance funds

Ministry of Health, Labor, Family and Social affairs

Federal Association for Prevention and Health Promotion

Local communities

State Associations for Health Promotion and Prevention;

Private insurance funds

Financial resources from foundations (e.g. Robert Bosch Foundation, Bertelsmann Foundation)

Same as for general health promotion

General taxes

Social insurance fund

Private households

Workers payments

Donations

Social insurance fund

Prävention und Gesundheitsförderung weiterentwickeln. Positionspapier des GKV-Spitzenverbandesbeschlossen vom Verwaltungsrat am 27. Juni 2013

https://www.gkv-spitzenverband.de/media/dokumente/krankenversicherung_1/praevention__selbsthilfe__beratung/praevention/2013-07-11_Positionspapier_Praevention_und_Gesundheit.pdf

Brussig (2014) [32]

Conflicting Rules and Incentives for Health Promotion and Prevention in the German Statutory Health Insurance (GKV).

Health promotion effectiveness: testing the German statutory health insurance agencies evaluation system in health promotion, and preliminary findings from 212 health training courses

Greece

Government

EU funding

Same as for general health promotion

General taxation

Insurance contributions

Grants

Government

http://www.chrodis.eu/wp-content/uploads/2014/10/JA-CHRODIS_Greece-country-review-in-the-field-of-health-promtion-and-primary-prevention.pdf

http://www.ep.liu.se/ej/hygiea/v9/i1/a18/hygiea10v9i1a18.pdf

http://www.euro.who.int/__data/assets/pdf_file/0004/130729/e94660.pdf

Hungary

Government

Health fund for health promotion

Same as for general health promotion

General taxes

There is a special fund for HEALTH PROMOTION financing

Schang LK, et al. (2012) [12]

Ireland

Healthy Ireland Fund

Local communities

Same as for general health promotion

General taxes

Social insurance contributions

Private insurance

Pit of pocket patient payments

Healthy Ireland Fund

What works in health promotion for older people? NATIONAL COUNCIL ON AGEING AND OLDER PEOPLE

22 CLANWILLLIAM SQUARE

GRAND CANAL QUAY

DUBLIN 2, report

Italy

Government

Same as for general health promotion

Tax based

Government

Fund (2012) [31]

Iceland

Government

EU projects

NGOs

Same as for general health promotion

General taxes

Grants

Government

Fund (2012) [31]

http://www.chrodis.eu/wp-content/uploads/2015/02/Italy-CHRODIS-final-draft_rivistoBD_DG.pdf

Lithuania

Government

Insurance fund

Same as for general health promotion

General taxes

Insurance contributions

Insurance fund

http://www.mepactiveageing.ipleiria.pt/files/2012/01/Klaipeda-State-College1.pdf

The Netherlands

Government

NGOs

Government

Local taxes

Private payments

Government

http://www.nationaalkompas.nl/preventie/gericht-op-doelgroepen/ouderen/

Schippers et al (2009) [33].

http://www.rivm.nl/bibliotheek/rapporten/270102001.pdf

http://www.healthproelderly.com/pdf/National_report1_Netherlands.pdf

Norway

Organized and covered by municipalities via general taxes. Some funds are obtained also via Norwegian Health Economics Administration fund

Same as for general health promotion

Local taxes

Private payments

Government

Thomson et al (2011) [34]

Poland

Government

Regional entities

Local communities

National insurance fund NGOs

Same as for general health promotion

General taxes

Earmarked taxes

Social insurance contribution

Governments

Territorial self-government

National insurance fund

Izabela Nawrolska (2013) [35]

Slovakia

Government

Same as for general health promotion

General tax

Social insurance

Users payments

Government

Colombo and Tapay (2004) [36]

Slovenia

Insurance funds

NGOs

EU funding

Same as for general health promotion

Voluntary health care insurance contributions

Grants

Donations

Insurance fund

Specialized fund for health promotion

Jakubowski (Ed.) (2002) [37]

Spain

Government

Ministry of Health

Same as for general health promotion

General taxes

Insurance fund

World Health Organization. (2000) [38]

Sweden

Included in universal coverage

Spare evidence of users payments for older population groups

General taxes

Insurance fund

Care of the Elderly in Sweden Today

Switzerland

Insurance funds

Users payments exists among older population groups

Insurance contributions

Private payments

Fund for health promotion Gesundheitsförderung Schweiz GFS

Gesundheitsförderung Schweiz, Geschäftbericht

e.g. 2013 under: http://geschaeftsberichte.gesundheitsfoerderung.ch/2013/

United Kingdom

NHS

Users payments exists among older population groups

Same as general health promotion

Covered by NHS

Financed by government or charity organizations or private payments

Courbage and Coulon (2004) [19].

Ashton (2001) [39]

aNGOs in Austria also receive money from general taxation

Our results also show that general taxes are the main mechanisms to collect funds. However, other mechanisms are also observed and very often combined with each other. In countries such as Belgium, France and Iceland, general health promotion interventions and health promotion for older adults are funded by a combination of social insurance premiums, general and earmarked taxes (taxes on alcohol or tobacco products) [17, 18]. However, funding via private insurance in combination with other mechanisms of collecting funds is not common (except in Switzerland and Slovenia). General health promotion interventions and health promotion for older adults are sometimes also funded by international projects and local NGOs. NGO donations and EU funding are most often reported in Croatia, Estonia, Lithuania and Slovakia. In those countries public funding is coming from social insurance premiums or general taxes via the Ministry of Health, while EU funding is mostly related to European Commission projects. In the UK, general health promotion and health promotion for older adults are funded through the National Health Service (NHS), but also through charity organizations and private insurance funds [14, 19].

In the Netherlands, general health promotion interventions and health promotion for older adults are funded by local and general taxation and the government is the main funding agent, in particular the Ministry of Health. The main funding agents allocate resources to different institutions such as local communities, the TRIMBOS institute or RIVM. Also, in the Netherlands there is a public-private mix of health promotion funding. An example is the GALM (Groningen Active Living Model) program where 50 % of the funding is received from the government, while additional resources are provided by private stakeholders and patient co-payments [8]. Another example is the Nationaal Programma Ouderenzorg (National Program Elderly Care, NPO) that includes a large number of health promotion projects for older adults organized through eight regional organizations that cover the whole country that are funded through general taxation, private organizations and private user’s payment [20]. In this case, different funding agents and different mechanisms of collecting funds are used within the same country.

Another interesting case, where different mechanism of collecting funds and different funding agents are used within same country is Germany. The dominant source of general health promotion funding is the statutory social health insurance (Gesetzliche Krankenversicherung). It provided 51 % of all funds available for health promotion in general in 2013. The second most important sources are private household resources and funds from NGOs. It is estimated that 19 % of the total amount available for health promotion is coming from those sources. The third group is resources from employers who provide 15 % of the total amount related to general health promotion and the fourth group comprises resources form government budgets with a contribution of 13.4 %. In this way Germany combines public, NGOs and private methods of funding general health promotion interventions.

If we combine the main funding agent with the most often used mechanisms of funding, we see that in the majority of countries, the main funding agents are government institutions and insurance funds while the main mechanism of collecting funds is general taxation. This includes countries like Bulgaria, Greece, Finland, Iceland, Italy, Norway, Poland, Portugal, Spain and Sweden.

If we combine the main mechanism of collecting funds (via general taxation and different funding) and collecting agents, we observe diversity among European countries. For example, in Norway and Finland general health promotion interventions and health promotion for older adults are funded by local communities that collect resources via general taxes, while in Sweden, resources collected by general taxes are allocated through the universal health insurance agency. In this way, general health promotion interventions in Sweden are part of the universal health care coverage. In Poland resources are collected by general taxes but can be allocated by local and regional authorities. However, evidence shows that in most countries where the government is the main agent of funding and where mechanisms of collecting resources is dominated by general taxation, there are also private and external funding agents, mostly NGOs and private companies via donations.

Only few European countries such as Germany, Finland, Iceland, the Netherlands, Norway and Sweden have specific budget line in their national budget for funding general health promotion.

In Table 2, we show to which extent public, private and others funding (those coming from NGOs and EU projects) are combined in different countries. Although general health promotion interventions are funded mostly by public internal funding, there is a significant number of countries where public funding is combined with external sources (7/27). Public funding is also combined with private sources and this is the case in seven countries (Denmark, Germany, the Netherlands, Norway, Slovenia, Switzerland and the UK).
Table 2

Funding of health promotion activities based on type of sources

Country

Type of sources for funding health promotion

Austria

Public and others sources

Belgium

Public sources

Bulgaria

Public and other sources

Croatia

Public and others sources

Cyprus

Public sources

Czech Republic

Public sources

Denmark

Public and others sources

Estonia

Public and others sources

Finland

Public sources

France

Public sources

Germany

Public private and others sources

Greece

Public sources

Hungary

Public sources

Ireland

Public and private sources

Italy

Public sources

Iceland

Public sources

Lithuania

Public and others sources

The Netherlands

Public, others and private sources

Norway

Public, others and private sources

Poland

Public and others sources

Portugal

Public

Slovakia

Public and others sources

Slovenia

Public, others and private sources

Spain

Public sources

Sweden

Public sources

Switzerland

Public and private sources

United Kingdom

Public and private sources

In Table 3, we present selected programs on health promotion for older population groups and their funding. We identified 98 different programs. The majority of the programs for older adults are funded by public sources. In some countries (Finland, Denmark), the government is directly involved in funding. In other countries, the Ministry of Health is the main agent of funding (21.6 % of all programs in our sample are funded directly by the Ministry of Health). Programs funded by the EU fall within the framework of cooperation between countries, while two programs are jointly funded by governments of two neighboring countries, i.e. a program for social networking among older population groups in Poland funded by the German and Polish government and a program for mental health prevention funded by the government of Slovenia and Hungary.
Table 3

Funding of programs related to health promotion interventions for older population groups

Country

Name of the program

Type of activity

Target group

Who is provider

Funding

Austria

Kleeblatt

Diet, exercise, motivation, social life

General

Public non-profit

organization

Fonds Gesundes Österreich

Fonds Gesundes Vorarlberg

Austria

“Happy together” –

Fitness and nutrition courses for migrants from Turkey

Fitness, nutrition

Educationally disadvantaged older people

Older people from minority ethnic groups

Older women

Socio-economically disadvantaged older people

Public non-profit

organization

Fonds Gesundes Österreich

Fonds Soziales Wien

Wiener Krankenanstaltenverbund

Austria, Germany, Italy, Lithuania, UK

SenEmpower

Self-employment

Older adults

EU funds

Life Long learning programs EU

Austria

Aktiver Lebensabend

Active-retirement

Older adults

Public non-profit

organization

City of Graz

Austria

Moving stories

Story and theater in nursing homes

Older adults

Public non profit

Health fund austria

Austria

Health of the elderly generation

-

Older adults

Public non-profit

Bundesministerium für Gesundheit

Austria

Plan60 – Health promotion for older people in urban areas

Social inclusion, Better quality of life

Older than 60

Public non-profit

Fund for healthy Austria

Austria

Changing Track at Third Age

Social inclusion

Older women

Public non-profit

European Commission

Austrian statutory cooperation

Own funding

Austria

Active Ageing! Investment in the health of older people

Social inclusion

Health education

Minorities

Public non-profit

World Health Organization (WHO)

Fonds Soziales Wien

Austria

The spider and the net

Social inclusion

Older women-caregivers

Public non-profit

City of Graz (finished)

Austria

Staying mobile for life

Physical and mental fitness

Older adults

Public non-profit

The Federal State of Vorarlberg

Material support by the cities and other sponsor(ongoing)

Austria

Ripe Apples

Healthy life style

Older adults

Public non-profit

Federal Ministry for Education, Science and Culture, Fund for a Healthy Austria, City of Graz (finished)

Austria

Promoting Healthy Ageing in Rural and Semi-Urban Communities in Austria

Social networking

Older adults

Public non-profit

Fund for a Healthy Austria

finished

Austria

Productive Ageing in the GiroCredit Bank

Age friendly working environment

Older adults

Private profit

Bank-ongoing

Austria

Women’s Autumn

Healthy aging

Older women

Public non-profit

Fund for healthy Austria

Austria

Counselling at the Street Corner

Information about healthy aging

Older migrants

Public non-profit

Federal State of Vienna-ongoing

Austria

LENA - Learning in post-professional phase

Learning in older age

Older adults

Public non-profit

EU Commission

Austria

LIMA – Life Quality in old age

Mental trainings

Older adults

Public non-profit

Fund for healthy Austria

Austria, Germany, Italy, Portugal, UK

LISA – Learning in Senior Age

Education for elderly

Older adults

Public non-profit

EU Commission-government co-funding

Austria

Schmid Skrew Factory

Factory for elderly

Old workers

Private profit

The project is part of the LIFE-Programme of the voestalpine company-ongoing

Austria

SMZ Liebenau – Seniors platform

Social networks

Older adults

Public non-profit

Sozialmedizinisches Zentrum (SMZ) Liebenau

Netherlands

Pink buddies

Loneliness, depression

Older -homosexual

NGOs

The Schorer Foundation receives financial support for their projects from private funds, local authorities and sponsors.

Netherlands

GALM/Groningen Active Living Model

Physical activities

Older adults

NGOs, public

The government contributes 50 % to a local project on the basis of the so-called ‘Breedte Sport Impuls’, a financial regulation encouraging sports activities. Participants contribute about € 2.50-€ 3.00 per person.

Netherlands

Activating home visits for and by elderly immigrants

Social-emotional support

Older adults

Public non profit

ZonMw

Netherlands

Friendship enrichment programme for older women

Social inclusion

Older women

Public non profit

ZonMw

Netherlands

GRIP on life: a Bibliotherapy in Self-Management Ability (SMA)

Self-Management Ability (SMA)

Older adults

Public non profit

ZonMw

Netherlands

The course ‘Looking for meaning in life’

Decrease depression

Older adults

Public non profit

Trimbos Institute (Dutch Institute for Mental Health and Addiction) and ZONMW.

Netherlands

Falling-clinics

Preventing falling

Older adults

Public non profit

General health clinics, medical centres or hospitals

Netherlands

‘Be down and brighten up 55+’

Mental prevention

Old migrants

Public non profit

GGZ-instellingen

9 EU countries

Future Elderly

Living Conditions in Europe

 

Older adults

Public non profit

-

Denmark

Healthy Throughout Life

improving quality of life and reducing social inequality in health.

Older adults

Public non-profit

government

Finland

Quality recommendations for guided health-enhancing physical activity for older people

Physical activity

Older adults

Public non-profit

Government, local municipalities

France

The Elderly

Healthy life style

Older adults

Public non-profit

Government

Hungary

Improving the health of the elderly

Healthy life style

Older adults

Public non-profit

-

Austria, Czech Republic, Germany, Italy, Lithuania, UK

From Isolation to Inclusion

Social inclusion, poverty

Older vulnerable groups

Public non-profit

Second Trans-national Exchange Programme of the European Commission, 2005 – 2007

Sweden, Finland, Poland and UK

Ageless at work

Labor participation

Oder adults

Public non profit

EU Commission; funding instrument ESF

Austria, Bulgaria, Germany, Greece, Hungary, the Netherlands,

Slovenia, Switzerland

MATURE@eu

Improve conditions for older workers

Older adults

 

EU-funding instrument:

Leonardo da Vinci

Czech Republic

Older women and mental health promotion

Quality of life of older women, depression, stres

Older women

Private non profit

National Programme on Health - Health Promotion Projects, Ministry of Health of the CR,

Czech Republic

Improvement in the nutrition of older people as a supporting factor of their general health status

Quality of life

Older adults

Public non profit

National Programme on Health - Health Promotion Projects, Ministry of Health of the Czech Republic

Czech Republic

Healthy Aging

Prevention of fall

Older adults in nursing homes

Private non profit

National Programme on Health- Health Promotion Projects, Ministry of Health of the Czech Republic

(Národní program zdraví - Projekty podpory zdraví)

Czech Republic

Effect of reminiscence therapy on the health status and quality of life of residents of care homes

loneliness

Older adults in nursing homes

Public non profit

Internal Grant Agency of the Czech Ministry of Health

Czech Republic

No fear from healthy ageing

Physical activity

Older adults (finished)

Public non profit

National Programme for Health- Health Promotion Projects, Ministry of Health of the Czech Republic (Národní program zdraví - Projekty podpory zdraví, Ministerstvo zdravotnictví CR)

Czech Republic

Cognitive training and physical fitness programmes for older people

Prevention of mental health

Physical activity

Older adults

Public non profit

National Programme on Health - Health Promotion Projects (Národní program zdraví- Projekty podpory zdraví) - Ministry of Health of the CR

Municipal Authority of the City Sokolov

Germany

Fit for 100

Physical activity

Older than 80

Public non profit

Ministry of Labour, Health and Social Affairs North Rhine-Westphalia (MAGS)

Germany

conversation Cafe for Older Citizens of Görlitz

Mental health prevention

Older adults

Public non profit

Insurance companies

Private companies

Germany

Aging and Health - Patient Education for Women

Quality of life

Older women migrants

Public non profit

AOK

Austria, Bulgaria, Germany, Greece, Hungary, the Netherlands, Slovenia, Switzerland

MATURE@eu

Improve conditions for older workers

Older adults

Public non profit

EU-funding instrument:

Leonardo da Vinci

Italy

Immigration as a social resource, rather than a source of fear

Social inclusion

Older adults

Public

Social Solidarity Ministry

12 EU countries

WeDO2 - For the wellbeing and dignity of older people

Social networks, social inclusion

Older adults

Public

European Commission Lifelong Learning Programme

Sweden, Netherland, Norway, Hungary, Italy, Germany, Ireland

IROHLA - Intervention research on health literacy among the ageing population

Health literacy

Older adults

Public

EU

France, Poland and Ireland

EMIN works on adequacy of minimum old age income schemes

Social inclusion

Older adults

Public

Polish Committee for the Scientific Research

Poland

Older Man, Older Woman

Abuse prevention

Older adults

Public

Funds from local authorities

Poland

Encouraging mutual support amongst older people in Antoniuk in Bialystok

Social support

Older adults

Public

Foundation for Polish-German Cooperation

Committee for Scientific Research

Slovakia

I am 65+ and happy to live the healthy life

Quality of life

Older adults

Public

government

Slovakia

Memory training for older people

Mental health

Older adults

Public

Local hospitals

Slovakia

Programmes for active ageing

Social networks

Older adults

Public

Members fees and donations

Slovakia

Seniors, join in

Intergenerational solidarity

Older adults

public

Ministry of Transportation, Post-Office and Telecommunications of the SR

Slovakia

Successful ageing

Mental health prevention

Older adults

Public

government

Slovenia

Career plan for 50+

Labor activity

Older adults

Private

Center for lifelong learning; center for new knowledge

Slovenia

Dancing in old age

Physical activity; social interaction

Older adults

Public profit

City of maribor

Slovenia

Better quality of life for older people

Quality of life

Older adults

public

share CBC, Joint Small Project Fund Slovenia/Hungary 2002.

Slovenia

Foreign languages - University for the third life period

Mental health

Older adults

Public profit

Local communities

Slovenia

Community Nursing Care

Mental health

Older adults

Public

Ministry of Health, National Health Insurance System and local communities, Institute for Health Protection

Slovenia

Intergenerational camps

Solidarity

Older adults

Public

Ministry of Labour, Family and Social Affairs.

Slovenia

Mobility for health

Physical activity

Older adults

Public

Univerza za tretje zivljensko obdobje Bela Krajina

Slovenia

Self-help groups for older people

Social inclusion, mental health

Older adults

Public

Ministry of Labour, Family and Social Affairs; local communities

Spain

Expert Patients

Mental health

Older adults

Private

Consejería de Sanidad de la Región de Murcia

Spain

+ plus life

Cognitive skills

Older adults

Private

FATEC-older people association in catalania

Spain

Community project for falls prevention

Fall prevention

Older adults

Public

ABS Salt-local communities

Spain

Supportive Halls

Solidarity neighbors

Older adults

Private

Obra Social Cajamadrid

Italy

The solidarity project

Social support

Older adults

Public

Advisory to the social politics and health promotion of Rome Municipality

donations by TIM society

donations by Gemm Spa

Italy

Clowns in health care homes (R.S.A): jocularity therapy

Mental health

Older adults in nursing homes

Private

CADIAI Social Cooperation

Italy

Improving the quality of life in the third age through new technology

Mental health

Older adults

Public

Region of Liguria (regional funds, national, communitary)

Italy

Immigration as a social resource, rather than a source of fear

Social inclusion

Older adults

Private

Social Solidarity Ministry

Spain

Let’s go

Physical activity

Older adults

Private

Spanish red cross

Spain

Ageing School

Emotional support, physical activities

Older adults

Public

Local communities

Spain

Active Company

Walking activities

Older adults

Public

Red cross

UK

Providing health promotion to older people - Suffolk Social Care

Social support

Older adults

Public

West Suffolk Primary Care Trust

UK

A specialist health and social care team for the promotion of health and independence in ‘at risk’ older adults

Social security

Older adults

Public

Camden and Islington Primary Care Groups

UK

Positive Action on Falls: A Peer Education Approach

Fall prevention

Older adults

Public

Department of Trade and Industry (DTI)

UK

Chair Based Exercise Project

Physical activity

Older people

Public

North Yorkshire and York Primary Care Trust

UK

RISE

Social inclusion

Older adults

Private

Regenerate-RISE, Charitable organization

UK

Health promotion through sports and recreational activities

Physical activities

General population/older adults

Private

Local health authority in the North East of England

UK

Bromley-by-Bow Centre

Emotional support

Older adults

Private

Charitable donations

UK

The Forth view Drama Project

Mental health prevention

Residential home

Public

Fife Council

UK

Sharing and Caring

Mental health

Older adults

Private

Age concern

UK

Older Adults Support Service in Southwark (London, UK)

Alcohol prevention

Older adults

Public

government

Italy

Data club project

Alcohol prevention

Older adults

Public

Research body

UK

Alcohol and older people

Alcohol prevention

Older adults

Public

Funded by other sources: ICGP and National Council for ageing and Older People

Germany

Independent in seniority – addiction issues can be solved

Alcohol prevention

Older adults

Public

government

Germany

Health Promotion for Older Migrants - The Göppingen Project

Healthy life style

Older migrants

Public non profit

Ministry of Health and Social Security

Citizens Foundation of the City of Göppingen

Neue Württembergische Zeitung and Kreissparkasse Göppingen

Germany

Prevention of Falls in Nursing Homes

Fall prevention

Older adults in nursing homes

Public

Federal Association of BKK

Working group Ulm

Working group Hamburg (finished)

Germany

Campaign Addiction Prophylaxis. Work group older people

Alcohol prevention

Older adults

Private

AOK

Germany

Active Health Promotion in Old Age

Mental health prevention

Older adults

Public

Federal Ministry of Family, Seniors, Women and Youth (BMFSFJ).

Foundation Max und Ingeborg Herz.

Germany

Senior Networks of Cologne

Social networks

Older adults

Public

City of Cologne

Germany

Federal Government’s Pilot Project Really fit from 50 onward

Physical activity

Older adults

Public

Ministry of Family Affairs, Senior Citizens, Women and Youth

Kneipp Factories

Greece

Implementation of a physical exercise program for third age people in the municipality of Thessaloniki. Four years on: progress, comments, conclusions.

Physical activity

Older adults

Public

Municipality of Thesaloniki

Greece

Action programs for older people

Physical activity

Older adults

Public

Municipality of Agios Dimitrios

Italy

Evaluation of neighborhood assistance for frail older people

Social support

Older adults

Public

Municipality of Brescia City

Nearly one in six (15.5 %) of all programs are funded through specialized funds for health promotion activities. However, in those countries, other agents of funding are also involved, for example local municipalities in Austria and Germany. Programs with private funding (participants and/or private companies) are less often identified (10.4 %). Programs that are funded through a public-private mix represent 10.3 % of the programs in Table 3. Private agents of funding include private companies or participants. For several programs in Germany, the Netherlands and Switzerland participants pay a fee. This is for programs that are partially funded from public sources (public-private mix).

Discussion and conclusion

Our results illustrate the great diversity in funding of general health promotion and health promotion for older adults across Europe (Table 1). Diversities are observed in the mechanism of collecting funds and the collecting and funding agents. This diversity is not only related to the fact the general health promotion interventions as well as health promotion for older adults are multi-sector activities, but also to the fact that their funding is related to country-specific characteristics such as health care system funding and government organization. For example, general taxation is the most often used mechanism of collecting funds and the government is most often the main agent of funding, but diversities are also observed in this case. In order to secure the funding for multi-sector activities, some governments (Finland, Sweden) include local municipalities as responsible agents for general health promotion and entitle them to use local and general taxation to fund health promotion. Inclusion of local communities as funding agents enable the funding not only for general health promotion interventions related to health care system but also community based interventions [2]. In some other countries, to secure the funding of multi-sector interventions and also to secure the allocation of resources for general health promotion, governments have created specific institutions responsible for health promotion. An example is the Austrian Health Promotion Foundation (FGOE) that particularly aims to secure the allocation of public sources to evidence-based health promotion interventions [21]. In countries like Belgium, France and Iceland earmarked taxes are used for funding general health promotion as well as health promotion for older adults [18, 22]. In Belgium and France earmarked taxes are combined with social insurance premiums, while in Iceland they are combined with local taxes. Earmarked taxes are seen as a financial incentive with a great potential to raise additional resources for health promotion [23]. Nevertheless, they are still not widely applied in Europe [23].

Diversity in funding is observed not only between countries, but also within countries. This is most visible in countries where local communities or regional cantons are the main source of funding. One example is Belgium, where four different regional governments apply different mechanisms to fund general health promotion [18].

Besides general taxation, social insurance premiums and donations from sources such as NGOs or EU projects also play an important role. External funding such as donations from NGOs or EU funds are quite common in Central and Eastern European countries. One of the reasons for this can be the lack of public resources in those countries. Another reason can be that decision makers in those countries know that external funding is available for health promotion and therefore do not allocate public sources to health promotion. Private sources such as private insurance funds, private companies or users are also important but rare actors in funding general health promotion interventions and health promotion for older adults. The limited evidence shows that users’ payments are mostly used as financial incentives to ensure the financial sustainability of health promotion for older population groups. Sometimes, they are also used as an incentive device for users to continue with their activities.

To describe the funding of general health promotion intervention and health promotion for older adults was more difficult than to assess the funding of some other types of health care services. The reason is the lack of detailed data in the literature sources we identified about the scope of the resources invested in health promotion in different countries. Even in databases of the OECD and WHO, there is no specific information on the percentage of public health expenditure on general health promotion in European countries. In some countries, there are estimated data available from national sources [14]. They usually report a percentage of public health expenditure that is spent on general health promotion and prevention [14]. Data related to resources coming from different types of funding such as private contributions or funding from NGOs and EU projects are even more limited. In order to overcome this lack of information, we have created three groups of countries based on the most frequently used type of funding: public, private or others funding (those coming from NGOs and EU funds) (Table 2). Those groups are descriptive and not exclusive; they are rather an attempt to show to what extent public, private or NGOs and EU projects funding are used in different countries. For example, in countries classified as mostly public funding, there are also health promotion interventions that are funded through external or private funding. Although descriptive, those results show the need for more detailed information such as type of resources used for funding and amounts that are invested in the funding of general health promotion. Providing a budget line in governmental budget for funding the health promotion for each target group, can assure the availability of such information.

In order to illustrate how health promotion for older adults is funded in practice, we have analyzed the funding of health promotion programs. The results show that most often programs are funded by both public and private resources (see Table 3). This is in accordance with the results from the desk research presented in Table 1. However, private funding is more often reported when we use the data from the programs (see Table 3), than in the data from the desk research (see Table 1). The reason for this can be the fact that we used only evidence based programs that are available on web-platforms in English. This may exclude national publicly funded programs from our search. The real extent of the programs that address health promotion for older population groups may be broader than this. Another reason can be the fact that privately funded programs may be overlooked in policy documents that focus on publicly funded interventions. Also our results show that the number of programs funded exclusively through EU funding is growing but their sustainability is questionable. Most of those programs are not sustained after the EU projects are finished [8].

This study shows that health promotion interventions, in general and those focusing on older adults in particular are multi-sector activities that can be funded through different agents and mechanisms of funding. Despite the diversity in funding, public funding is the most often used. In the majority of the countries, both funding from NGOs and EU projects and private funding, are seen as additional tools, but not as the main sources of funding. Although the diversity in funding can be seen as a way to generate more resources for health promotion, it can also impose problems in resource allocation [7]. For example, even if EU resources are available, some countries do not use them but rather rely on internal resources [23].

Overall, the great diversity in the funding of health promotion illustrate that there is no “golden standard” within European countries, but that the model for funding the health promotion reflect country specific characteristics. The existence of a specific fund for health promotion interventions in combination with an evidence-based approach may lead to a more effective use of resources. An example is the Austrian Health Promotion Foundation (FGOE) that allocates resources only to evidence based health promotion interventions.

However, the main problem in funding health promotion is related to the lack of information regarding the type of resources (public, private or others) and the amounts that are invested in health promotion. Providing a budget line for funding general health promotion with governmental annual budgets can be used to overcome this situation. Furthermore, it is necessary to provide the information not only for funding the health promotion based on type of intervention (mental health promotion, tobacco cessation), but also based on target groups (older adults, vulnerable groups etc.). Such a strategy can increase the transparency in the use of resources and improve sustainability of health promotion interventions.

Our results are in accordance with recently published reports [8, 14]. However, this study goes one step further as we combine different types of sources (documentations, data bases and web-platforms). We have also included most European countries, while previous reports are based on overviews of only 14 countries. Nevertheless, this study has some limitations as well. The main limitation is that the results are mainly based on documents that report information about health promotion intervention in general. Most of the documents are policy papers, project reports or “grey literature”, while the number of scientific articles that on the funding of health promotion is limited. The inclusion of all types of documents in the analyses can increase the validity of the conclusions. Another limitation is that the search strategy for some countries relied on English language documents only. This can also influence the extent to which information is detailed. For some countries, where we were able to rely on national language literature, the number of sources and quality of information were higher. On the other hand, in some other countries using the national language documents did not increase the quality of information.

Another obstacle is a lack of information about funding of health promotion interventions for older population groups. The main reason for this is that data regarding the funding of general health promotion are usually reported by the type of activities and not by the target population group. The only exception is younger adults. The lack of clear information on the funding of health promotion for older population is a topic for attention in the future. Even in countries where special institutions to finance health promotion exist, information about the funding of general health promotion is limited. An ageing population accompanied with scarce resources, increases the need for evidence-based and cost effective health promotion interventions.

Despite the limitations mentioned above, this study provides insight in the funding of health promotion in general and for older adults in particular. Our results show that the funding of health promotion interventions is fragmented and includes different funding strategies. Based on the available information, we cannot say what is the “best” way of funding health promotion. If we had more information on the funding of health promotion interventions, we would be able to explore how different mechanisms of funding affect outcomes and whether they can lead to cost savings. Also, this study focuses only on primary health promotion interventions. Some researchers have argued that successful primary health promotion interventions do not contribute to cost savings [24]. They emphasize that the majority of the costs related to older population groups are related to chronic diseases [25]. There is insufficient empirical evidence to support these claims and it is up to future research to examine the relation between the mechanisms of health promotion funding and costs saving for secondary and tertiary health promotion interventions.

This research also gives a broad overview of the extent to which different sources of funding are present in different countries. In some countries general health promotion interventions are dominantly funded by public sources, while in other countries private sources of funding are also used. Whether public sources are spent more effectively than private sources is an issue for future study.

Declarations

Acknowledgements

This publication arises from the project Pro-Health 65+ which has received funding from the European Union, in the framework of the Health Programme (2008-2013). The content of this publication represents the views of the authors and it is their sole responsibility; it can in no way be taken to reflect the views of the European Commission and/or the Executive Agency for Health and Consumers or any other body of the European Union. The European Commission and/or the Executive Agency do(es) not accept responsibility for any use that may be made of the information it contains.

Publication co-financed from funds for science in the years 2015-2017 allocated for implementation of an international co-financed project.

Declarations

This article has been published as part of BMC Health Services Research Volume 16 Supplement 5, 2016: Economic and institutional perspectives on health promotion activities for older persons. The full contents of the supplement are available online at http://www.bmchealthservres.biomedcentral.com/articles/supplements/volume-16-supplement-5.

Availability of data and materials

All data that can be shared is contained within the manuscript.

Authors’ contributions

JA developed the study design, carried out the literature search and analysis, drafted and improved the manuscript, approved the final version and agreed to be accountable for her contribution. WG contributed to the development of the study design, reviewed the literature search and analysis, reviewed and commented on the preliminary drafts and final version of the paper, approved the final version and agreed to be accountable for his contribution. MT commented on the study design, and also reviewed and commented on the final paper draft, approved the final version and agreed to be accountable for her contribution. CS commented on the study design, and also reviewed and commented on the final paper draft, approved the final version and agreed to be accountable for her contribution. MP assessed the study design, reviewed and commented on the literature search and analysis, reviewed and commented on the preliminary paper drafts and the final version of the paper, approved the final version and agreed to be accountable for his contribution.

Authors’ information

JA is post-doc researcher at the Department of Health Services Research, Maastricht University, the Netherlands. WG is Professor of Health Economics at the Department of Health Services Research and also Professor of Evidence Based Education at Maastricht University, the Netherlands. MT is Assistant Professor of Health Economics at Jagiellonian University Medical College in Krakow, Poland. CS is Associate Professor of Health Economics at Jagiellonian University Medical College in Krakow, Poland. SG is Professor of Health Economics at Jagiellonian University Medical College in Krakow, Poland. MP is Associate Professor of Health Economics at the Department of Health Services Research, Maastricht University, the Netherlands.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Health Services Research; CAPHRI, Maastricht University Medical Center
(2)
Faculty of Health, Medicine and Life Sciences, Maastricht University
(3)
Top Institute Evidence-Based Education Research (TIER), Maastricht University
(4)
Faculty of Health Sciences, Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Collegium Medicum

References

  1. Bayarsaikhan D, Muiser J. Financing health promotion. Financ Health Promot. 2007;Discussion Paper No. 4. Geneva: World Health Organization.Google Scholar
  2. Agren G, Berensson K. Healthy ageing: a challenge for Europe. Swed Natl Inst Public Health. 2006;2006:29.Google Scholar
  3. Baker LA, Cahalin LP, Gerst K, Burr JA. Productive activities and subjective well-being among older adults: The influence of number of activities and time commitment. Soc Indicators Res. 2005;73(3):431–58.View ArticleGoogle Scholar
  4. Sowada C, Waldmann T. Investment in work health promotion in small and medium-sized enterprises in Germany. Zdrowie Publiczne i Zarządzanie. 2012;10(2):95–105.Google Scholar
  5. Wakefield SE, Poland B. Family, friend or foe? Critical reflections on the relevance and role of social capital in health promotion and community development. Soc Sci Med. 2005;60(12):2819–32.PubMedView ArticleGoogle Scholar
  6. Chapman L. Meta-evaluation of worksite health promotion economic return studies. J Health Promot. 2003;248:682–0707.Google Scholar
  7. Ziglio E, Simpson S, Tsouros A. Health promotion and health systems: some unfinished business. Health Promot Int. 2011;26 suppl 2:ii216–25.PubMedView ArticleGoogle Scholar
  8. Strumpel C, Billings JR. Overview on health promotion for older people. Eur Rep. 2008;European Report. Vienna: Austrian Red Cross.Google Scholar
  9. Coe G, de Beyer J. The imperative for health promotion in universal health coverage. Glob Health Sci Pract. 2014;2(1):10–22.PubMedPubMed CentralView ArticleGoogle Scholar
  10. Johansson PM, Eriksson LS, Sadigh S, Rehnberg C, Tillgren PE. Participation, resource mobilization and financial incentives in community-based health promotion: an economic evaluation perspective from Sweden. Health Promot Int. 2009;24(2):177–84.PubMedView ArticleGoogle Scholar
  11. Benning TM, Alayli-Goebbels AF, Aarts M-J, Stolk E, de Wit GA, Prenger R, Braakman-Jansen LM, Evers SM. Exploring outcomes to consider in economic evaluations of health promotion programs: What broader non-health outcomes matter most? BMC Health Serv Res. 2015;15(1):266.PubMedPubMed CentralView ArticleGoogle Scholar
  12. Schang LK, Czabanowska KM, Lin V. Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland. Health Promot Int. 2012;27(2):295–305.PubMedView ArticleGoogle Scholar
  13. Merkur S, Sassi F, McDaid D. Promoting health, preventing disease: is there an economic case? 2013.Google Scholar
  14. CHRODIS. HealtH Promotion and Primary Prevention in 14 euroPean countries: a comparative overview of key policies, approaches, gaps and needs. Brussels; Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (CHRODIS); 2015.Google Scholar
  15. Knapp M, McDaid D, Parsonage M. Mental health promotion and mental illness prevention: The economic case. 2011.Google Scholar
  16. Kutzin J. A descriptive framework for country-level analysis of health care financing arrangements. Health Policy. 2001;56(3):171–204.PubMedView ArticleGoogle Scholar
  17. OECD Stat. OECD, Paris. 2012. https://data.oecd.org/. Accessed 15/11/2015.
  18. Gerkens S, Merkur S. Belgium: Health system review. Health Syst Transit. 2010;12(5):1–266.PubMedGoogle Scholar
  19. Courbage C, Coulon A. Prevention and private health insurance in the UK. Geneva Pap Risk Insur Issues Pract. 2004;29(4):719–27.View ArticleGoogle Scholar
  20. Nationaal Programma Ouderenzorg. NPO. http://www.beteroud.nl/ouderen/nationaal-programma-ouderenzorg-npo.html. Accessed on 19/11/2015.
  21. Hofmarcher MM, Rack H, Schwaerzler J. Health care systems in transition: Austria. 2001.Google Scholar
  22. Thomson S, Osborn R, Squires D, Reed SJ. International profiles of health care systems 2011: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. 2011.Google Scholar
  23. Sassi F, Belloni A. Fiscal incentives, behavior change and health promotion: what place in the health-in-all-policies toolkit? Health Promot Int. 2014;29 suppl 1:i103–12.PubMedView ArticleGoogle Scholar
  24. Rechel B, Grundy E, Robine JM, Cylus J, Mackenbach JP, Knai C, McKee M. Ageing in the European union. Lancet. 2013;381(9874):1312–22.PubMedView ArticleGoogle Scholar
  25. de Meijer C, Wouterse B, Polder J, Koopmanschap M. The effect of population aging on health expenditure growth: a critical review. Eur J Ageing. 2013;10(4):353–61.View ArticleGoogle Scholar
  26. Hofmarcher MM, Rack H, Riesberg A. Health care systems in transition: Austria 2006. 2006.Google Scholar
  27. Vulic S, Healy J. Health care systems in transition: Croatia. Copenhagen: European Observatory on Health Care Systems; 1999.Google Scholar
  28. Bryndová L, Pavlokova K, Roubal T, Rokosova M, Gaskins M. Czech Republic. Health system review. Health Syst Transit. 2009;11:1–122.Google Scholar
  29. Christiansen T. Organization and financing of the Danish health care system. Health Policy. 2002;59(2):107–18.PubMedView ArticleGoogle Scholar
  30. World Health Organization. Review of national Finnish health promotion policies and recommendations for the future. 2002.Google Scholar
  31. Fund C. International profiles of health care systems, 2012. Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. 2012. Retrieved July, 25, 2013.Google Scholar
  32. Brussig M, Dragano N, Mümken S. Health promotion for unemployed jobseekers: New developments in Germany. Health Policy. 2014;114(2):192–9.PubMedView ArticleGoogle Scholar
  33. Schippers A, Albers B, Kuijper M, Marx R, van Overbeek M, Visser G. Zorg voor morgen. Schets van preventieve zorg voor ouderen. Utrecht: Vilans; 2009.Google Scholar
  34. Thomson S, Osborn R, Squires D, Reed SJ. International profiles of health care systems, 2011. New York: The Commonwealth Fund; 2011.Google Scholar
  35. Nawrolska I. Finansowanie profilaktycznych programów zdrowtnych. 2013.Google Scholar
  36. Colombo F, Tapay N. The Slovak Health Insurance System and the Potential Role for Private Health Insurance. 2004.View ArticleGoogle Scholar
  37. Jakubowski E. (Ed.). Health Care Systems in Transition, Slovenia. Denmark, Copenhagen: European Observatory on Health Care Systems; 2002.Google Scholar
  38. World Health Organization. Health care systems in transition: Spain 2000. 2000.Google Scholar
  39. Ashton L. Promoting the health and social care of older people: gaining a perspective from outside the UK. J R Soc Promot Health. 2001, 121n; 152-158.Google Scholar

Copyright

© The Author(s). 2016

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