1. ORIENTING POLICIES ON HEALTH DETERMINANTS - the process of target setting in Sweden – lessons to learn
Public lecture in Graz, Pallais Attems, 19.30, 8 June 2006
Bosse Pettersson
Deputy Director-General

2. Process in 10 phases
Bringing public health back on the agenda – Health for All – Alma Ata (1978) and WHO European 38 targets
Plans, programmes, plans, programmes, plans, …
Supporting and establishing regional and local capacity
Moving outside the health and medical care system – re-establishing a Swedish National institute of Public Health - SNIPH (1992)
Professional training – master programmes in public health – gradually reaching out in other sectors
The policy process and high level political involvement – the understanding of what deteremines health in contemporary societies, not to forget the historical context
Health objectives and targets set as determinants
Focus on monitoring and evaluation – indicators of determinants
Re-orienting SNIPH to become the accountable central agency (2001)
Linking public helth to equity in health and sustainable economic growth

3. Is there a problem?
Health in general is very good
Among the highest life expectancy in the world both for women and men
Lowest smoking rates in Europe and worldwide
Alcohol consumption just below EU average
Low accident rates, especially among childen and in road traffic
Falling death rates up to age 65 in heart diseases
Improved survival in many cancer diseases
etc

4. But there are old and emerging problems!
Since the 1990´s we have observed
Significant increase in sick leave, publically employed women by far the most suffering group
(Rapid?) increase in overwight and obesity among children and adolescents – decrease in physical activity
Increased alcohol consumption and mixed drinking patterns
Increase in violence related injuries
Increase in fatal fall injuries among the elderly
Self reported increase in mental ill health, especially among childdren, adolecscents and women
Falling health life expectancy among women 45+ and older

5. In general …mixed progress and failure
Health is improving in absolute terms for most people, but
for the least priveliged groups significantly slower
in relative terms health inequalities are increasing
Life expectancy beween municipalities and socio-economic status can differ up to approximately 6 years among Swedish men!

6. Peoples’s well-being can be improved by health promotion
Is there anything to do?
Peoples’s well-being can be improved by health promotion
85-90 per cent of the Swedish disease burden is caused by non communicable and/or chronic disesases, where premature deaths and disabilities can be prevented
Inequalities in health are not cased by chance – the origin from systematic social unjustice

7. ... and, if nothing is done …?
The next generation may be the first in modern times to experience shorter lives than their parents
It will pose a serious threat against the affordability of any well developed social welfare system
It has the potential to create unforseen political tensions in our societies – health is becoming an issue of security

8. The Swedish National Public Health Institute – SNIPH (1)
Re-established 1992 (originally founded/operating ) for implemenation of prioritized health promotion and disease prevention programmes
Re-oriented 2001 to have a central position in facilitating, implementing, co-ordinating monitoring and evalution and further development of the national public health strategy
Directly under the Ministry of Health and Social Affairs
since 2002 a special Public Health Cabinet Minister

9. The Swedish National Public Health Institute – SNIPH (2)
Staffing and financial resources
160 staff
Annual budget 2006 – almost 100% tax funded (1 € = 9,4 SEK)
General 136 million SEK ~ € 14,5 mill
Note: In addition,special funding for prevention of hiv/aids, illicit drugs and harmful alcohol consumption

10. National Board of Health& Welfare
Not alone – state level
Besides SNIPH
National Board of Health& Welfare
Swedish Institute for Infectous Diseases Control (SMI)
Swedish Medical Products Agency
The National Social Insurance Board
Swedish Work Environment Authority
National Institute for Working Life
Research Councils (funding) and institutions

11. Not starting from ZERO - building bricks in the Swedish public health strategy
Modern public health and WHO’s Health for All’ fir for purpose
Longstanding commitment across political parties – although different emphasis and ideologies
Evolved as a concern on all political levels – but, the regional a forerunner
Infra-structures for ‘modern public health’ gradually in place from the 1980´s; state seed money speeded up the development

12. Public health institute est. 1938
1. Historical
Long tradition of public health outside the medical sector since 17th century
Church
Popular movements
Public health institute est. 1938

13. 21 County Councils/Regions (political)
2. Contextual [1] – autonomous regional and local levels – WHERE PEOPLE ARE AT!
21 County Councils/Regions (political)
All with community medicine/public health units, but mainly focusing on health and medical care
290 municipalities (political)
App per cent with local health planners, policies and programmes

14. 2. Contextual [2] – local level
Municipalities the 3rd autonomous political level.
Initially health protection
Social welfare responsibility – increasingly linked to health
Health promotion concept better understood than disease prevention

15. Professional training – MPH programmes critical to skilled workforce
Piloting started on national level in 1988
Established during the 1990‘s
Still increasing interest
14 universities & university colleges with MPH programmes (Complete or partial)
Well educated workforce in modern public health
Emerging employment opportunities

16. Why determinants as ‘objectives and targets’?
Politicians cannot directly prevent deaths and illness in cancer, nor heart diseases etc, but can influence what is behind – the ‘upstream approach’
Inequalities overall priority

17. Age, sex, heredity Environment Public economic strategies Tobacco
Eating habits
Haglund, Svanström, KI, revision, Beth Hammarström
Age, sex,
heredity
Sleep
habits
Physical
activity
Educa-
tion
Sex &
life together
Housing
Illicit drugs
Contact
children
and adults
Agri-
culture
& food-
stuff
Traffic
Work
environment
Alcohol
Leisure &
Social
network
Health-&
medical care
support
assistance
Social-
insurance
Employ-
ment

18. National public health objective domains
Model for national public health strategy – the principal foundation
National public health objective domains
Health
determinants
Health outcomes
&
distribution
Inter-
ventions
Bosse Pettersson, 2003

19. Model for national public health strategy – the links
National public health objective domains
Health
determinants
Impact &
efficiency
Health outcomes
&
distribution
Correlation
Inter-
ventions
’Upstream approach’
Bosse Pettersson, 2003

20. One overall national public health aim
“ To create social conditions that will ensure good health for the entire population”.
Equity perspective on health.
To be achieved by implementing initiatives in 31 national policy areas related to 11 objectives.

21. 11 public health objectives
Participation and influence in society.
Economic and social security.
Secure and favourable conditions during childhood and adolescence.
Healthier working life.
Healthy and safe environments and products.
A more health promoting health service.
Effective prevention against communicable diseases.
Safe sexuality and good reproductive health.
Increased physical activity.
Good eating habits and safe food.
Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling.

22. 11 Objective domains in brief
One overarching aim: To provide societal conditions for good health on equal terms for the entire population
9-11: Physical activity
-Eating habits and safe food
-Tobacco, alcohol, illicit drugs, doping,
harmful gambling
11 Objective domains in brief
Lifestyles and health behaviours
4-8: Healthier working life – Sound and safe environments & products – A more health promoting health care system – Effective protection against communicable diseases – Safe sexuality and a good reproductive health
Settings and environments
1- 3: Participation and influence on the society – Economic and social security – Safe and favorable growing up conditions
Societal structures and living conditions
Bosse Pettersson, 2003

23. How to make it work?
a special Minister of Public Health appointed + National high-level Steering Committee
sectoral responsibilities defined for more than 30 national agencies by existing political domain objectives
public health integrated into ‘daily business’ – existing sectoral objectives and targets influencing health

24. The Swedish National Public Health Institute – SNIPH (2)
Remit – 3 major missions
Monitoring and evaluation of the public health strategy and facilitate its implementation
Centre of knowledge for effective health promotion and disease prevention methods
Overall supervision of selective preventive legislation in the fields of alcohol and tobacco

25. Tools for implementation
Determinant’s indicators with inequality and gender dimensions
Governmental directives to concerned sectoral state agencies
Health Impact Assessment (HIA) recognized
Datasets and planning tools for reviewing and integration public health at local municipal level are elaborated
Basic municipal public health data on the web
Local Welfare Management Systems (LOWEMANS)

26. Shortcomings and criticism
to vague, determinants are difficult to explain
to small resources allocated for general public health infrastructures
Intervention research is lacking
need training of exiting professionals in concerned sectors
lack of funding to municipalities and county councils where major efforts are expected to take place

27. Good practices work
traffic accidents; speed limits, road construction, safe vehicles, bicycle helmets
high taxes on alcohol reduces health related harm
comprehensive tobacco prevention reduces smoking incidence and related illness and premature deaths

28. Implementation by monitoring & evaluation
INDICATORS
for monitoring and evaluation the policy
to be agreed by involved state agencies, and negotiated with local municipalities and regional County Councils
to form the base for the new Public Health Policy Report, to be delivered by the Government to the Parliament once each 4th year, first in 2005

29. Demands on indicators Strong correlation to health.
Strong validity for the determinant.
Meaningful and possible to change by political decisions.
Be relatively inexpensive to admininstrate.
Stratified by sex, age, type of family, different geographical levels (including the municipal level), socio-economic group and ethnicity where possible.
Bernt Lundgren 2004

30. 1. Principal indicators for the domains of objectives
Principal indicators for each of the eleven domains of objectives will be presented.
The lowest geographic level for data collection is given in brackets.
Bernt Lundgren 2004

31. 1.1 Participation and influence in society
1) Election turnout in municipal elections
(municipal level)
2) Index of gender equality (municipal level)
3) Percentage of actively employed in the workforce (municipal level)
Bernt Lundgren 2004

32. 1.2 Economic and social security
4) Income inequality (Gini-coefficient; municipal level)
5) Percentage with a low economic standard among families with children, pensioners, persons on sick leave and long term disability (< 50, 60% of median income, < national poverty level; municipal level)
6) Index of ill-health (sickness benefit, early retirement; municipal level)
7) Percentage of long-term unemployed and long term registered at the employment office (municipal level)
Bernt Lundgren 2004

33. 1.3 Secure and favourable conditions during childhood and adolescence
8) Quality of the relationship between children and their parents (national level)
9) Level of education of pre-school employees (municipal level)
10) Diplomas from primary school and upper secondary school (municipal level)
11) Extent to which pupils can influence school (national level)
12) How pupils are treated by teachers, other grown-ups and fellow pupils (national level)
Bernt Lundgren 2004

34. 1.4 Healthier working life
13) Self-reported work-related health status (regional level)
14) Index of accumulation of risk factors
(regional level)
15) Index of job strain (job demand, job control and social support; regional level)
Bernt Lundgren 2004

35. 1.5 Healthy and safe environments and products
16) Nitrogen dioxide levels in outdoor air (municipal level)
17) Levels of persistent chemical substances in breast milk (national level)
18) Percentage of population exposed to unhealthy noise levels (municipal level)
19) Injury incidence (dead or treated in hospital) per 100,000 in different environments (municipal level)
Bernt Lundgren 2004

36. 1.6 Health and medical care that more actively promotes good health
Indicators under development.
Bernt Lundgren 2004

37. 1.7 Effective protection against communicable diseases
20) Incidence of compulsory notifiable diseases (regional level)
21) Yearly follow-up of the vaccination coverage of children (measles, mumps, rubella; municipal level)
22) Yearly follow-up of anti-microbial resistance (regional level)
Bernt Lundgren 2004

38. 1.8 Safe sexuality and good reproductive health
23) Number of pregnancies and abortions per 1,000 women under 20 years of age (municipal level)
24) Incidence of chlamydia infections in the age group (regional level)
Bernt Lundgren 2004

39. 1.9 Increased physical activity
25) Percentage of population physically active for at least 30 minutes per day (national level)
26) Percentage of ninth graders (15-16 year-olds) and final year upper secondary school students (18-19 year-olds) with at least a pass grade in the subject 'Health and physical activity' (national level)
27) Percentage of population walking or cycling in relation to total personal transport (regional level)
Bernt Lundgren 2004

40. 1.10 Good eating habits and safe food
28) Body Mass Index, BMI (regional level)
29) Percentage of population eating at least 500g of fruit and/or vegetables every day (national level)
30) Percentage of infants breastfed (exclusively) at the ages 4 and 6 months (the municipal level)
31) Incidence of reported campylobacter- and salmonella infections (municipal level)
Bernt Lundgren 2004

41. 1.11 Reduced use of tobacco and alcohol, a society free from illicit drugs and doping, and a reduction in the harmful effects of excessive gambling
32) Self-reported tobacco use (municipal level)
33) Self-reported exposure to environmental tobacco smoke (regional level)
34) Total consumption of alcohol (municipal level)
35) Mortality from alcohol-related diseases and injuries (municipal/national level)
Bernt Lundgren 2004

42. 1.11 Reduced use of tobacco and alcohol, a society free from illicit drugs and doping, and a reduction in the harmful effects of excessive gambling (cont)
36) Self-reported use of narcotics (regional level)
37) Mortality from narcotics related diseases and injuries (municipal/national level)
38) Prevalence of excessive gambling (national level)
Bernt Lundgren 2004

43. Monitoring and evaluation of public health strategy
Policy report
Health
determinants
Impact &
efficiency
Health outcomes
&
distribution
Correlation
Inter-
ventions
Info
Population Health
report etc
Monitoring
& evaluation
system
Indicators
Bosse Pettersson, 2003

44. Emphasized in the first report
Construct a stable ground for public health policy reporting
All domains of objectives
Explain the correlations between determinants and health
Principal- and sub-indicators
Actions on all levels; local, regional, national
Focus on needs to be developed and propose actions

45. Basic data Research findings on the determinants-health correlations
42 determinants, 36 principal indicators and 47 sub-indicators
Public statistics and own investigations
Reports from 22 national authorities
Visits to 8 county administrative boards
A questionnaire to all local authorities
Visits to 10 municipalities
Intervjues with all county councils

46. Positive development, among others
Tobacco consumption is declining in all groups
Vaccination coverage is hight among children
Percentage of pupils in grade 9 in primary school having tested illicit drugs has declined during the last years
Abortions more often happen early during pregnancy
Injuries related to work and traffic environments have declined in number
The Swedes are becoming more and more active in cultural matters

47. Negative development, among others
Election turnout is declining in all educational groups
Percentage of long-term unemployed has increased
Percentage of lone parents with a low economic standard has increased
The ill-health measure (sick-leave and early retirement) has indreased during two decades
Less pupils leaving primary school have complete diplomas
Mental ill-health is increasing among younger people

48. Negative development, among others
Harmful air pollution (particles and ozon) has increased
Every year more than 1000 elderly people dies from accidents when the are falling
The incidence of hiv and chlamydia infections has indreased during the last years
Overweight and obesity are increasing in all groups
The consumption of alcohol has increased 30% within ten years
There is big socio-ec differences in ill-health

49. Priority proposals 42 priority proposals out of nearly 400
29 proposals – take care of health threats; mental ill-health, working life, air pollution and accidents, communicabel diseases, overweight and physical activity, tobacco, alcohol, violence aganist women, inequalities in health.
13 proposals – policy and increase capacity for public health work: sub-objectives, more active actors, co-ordinated regional public helath work, support for more competence in public helath matters in the municipalities.

50. Take care of health threats
Strengthen labour market policy initiatives for the long-term unemployed.
Strengthen efforts to combat discrimination by disseminating more knowledge about its negative health impact.
Those living in vulnerable urban districts should be given the opportunity for greater participation in and influence over the development of their own district and their own living conditions.

51. Take care of health threats
Parents with children of all ages should be given the opportunity to participate in parental support groups.
More knowledge is needed on how workplaces can be health-promoting and sustainable in a way that takes an individual’s entire life situation into consideration.
Injury-prevention efforts should be strengthened nationally as well as regionally and locally, with priority allocated to housing and recreational environments and older people.

52. Take care of health threats
Healthcare authorities should put more resources into health-promoting and disease-preventing efforts within the health service.
Develop methods so that the epidemiological situation can be more rapidly monitored.
Introduce free flu vaccinations for all people over the age of 65.
Youth clinics should be evaluated and their quality guaranteed.
Develop supportive environments for physical activity and good eating habits.

53. Take care of health threats
Make efforts to ensure a coordinated, stepwise increase of the price of tobacco both in Sweden and within the framework of EU cooperation.
Further develop measures to limit availability to alcohol, in which inspection and enforcement are important elements; restaurateurs, pub landlords, retailers and parents are key target groups in this respect.
Keep constant track of gender-related violence and set up goals to ensure freedom from it.

54. Increase capacity for public health work
More agencies should implement the public health policy.
Public health work needs to be developed on the regional level.
Municipalities and county councils want more skills development.
Make health as an economic growth factor a central place in community planning.
Use health impact assessments (HIA) more and regulate the method in the same way as environmental impact assessments.

55. Summary
The New Swedish Public Health Policy puts health high up on the political agenda.
It focus the social determinants of health and a inter-sectoral public health work both nationally, regionally and locally.
It aims at developing population health and public health work through regular monitoring and reporting to the Government who reports to the Parliament.
Bernt Lundgren 2005

56. Two policytriangles (1)
Context
ACTORS
Individuals
Groups
Organisations
Content
Process
From Buse, Mays & Walt, 2005

57. Two policytriangles (2)
Practise
Policy
Science/
Evidenc
Best Practice/IUHPE-FHI, 2005

58. The ’black box’ in the policy processes
Demands
Resources
Support
Policies for politics
Policy design
Output
’Black box’
Input
Feed –back
Efter Easton, 1965