Presentation on theme: "ORIENTING POLICIES ON HEALTH DETERMINANTS - the process of target setting in Sweden 1985-2006 – lessons to learn Public lecture in Graz, Pallais Attems,"— Presentation transcript:
1 ORIENTING POLICIES ON HEALTH DETERMINANTS - the process of target setting in Sweden – lessons to learnPublic lecture in Graz, Pallais Attems, 19.30, 8 June 2006Bosse PetterssonDeputy Director-General
2 Process in 10 phasesBringing public health back on the agenda – Health for All – Alma Ata (1978) and WHO European 38 targetsPlans, programmes, plans, programmes, plans, …Supporting and establishing regional and local capacityMoving 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 sectorsThe policy process and high level political involvement – the understanding of what deteremines health in contemporary societies, not to forget the historical contextHealth objectives and targets set as determinantsFocus on monitoring and evaluation – indicators of determinantsRe-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 goodAmong the highest life expectancy in the world both for women and menLowest smoking rates in Europe and worldwideAlcohol consumption just below EU averageLow accident rates, especially among childen and in road trafficFalling death rates up to age 65 in heart diseasesImproved survival in many cancer diseasesetc
4 But there are old and emerging problems! Since the 1990´s we have observedSignificant 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 activityIncreased alcohol consumption and mixed drinking patternsIncrease in violence related injuriesIncrease in fatal fall injuries among the elderlySelf reported increase in mental ill health, especially among childdren, adolecscents and womenFalling health life expectancy among women 45+ and older
5 In general …mixed progress and failure Health is improving in absolute terms for most people, butfor the least priveliged groups significantly slowerin relative terms health inequalities are increasingLife 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 promotion85-90 per cent of the Swedish disease burden is caused by non communicable and/or chronic disesases, where premature deaths and disabilities can be preventedInequalities 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 parentsIt will pose a serious threat against the affordability of any well developed social welfare systemIt 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 programmesRe-oriented 2001 to have a central position in facilitating, implementing, co-ordinating monitoring and evalution and further development of the national public health strategyDirectly under the Ministry of Health and Social Affairssince 2002 a special Public Health Cabinet Minister
9 The Swedish National Public Health Institute – SNIPH (2) Staffing and financial resources160 staffAnnual budget 2006 – almost 100% tax funded (1 € = 9,4 SEK)General 136 million SEK ~ € 14,5 millNote: In addition,special funding for prevention of hiv/aids, illicit drugs and harmful alcohol consumption
10 National Board of Health& Welfare Not alone – state levelBesides SNIPHNational Board of Health& WelfareSwedish Institute for Infectous Diseases Control (SMI)Swedish Medical Products AgencyThe National Social Insurance BoardSwedish Work Environment AuthorityNational Institute for Working LifeResearch 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 purposeLongstanding commitment across political parties – although different emphasis and ideologiesEvolved as a concern on all political levels – but, the regional a forerunnerInfra-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. HistoricalLong tradition of public health outside the medical sector since 17th centuryChurchPopular movementsPublic health institute est. 1938
13 21 County Councils/Regions (political) 2. Contextual  – 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 care290 municipalities (political)App per cent with local health planners, policies and programmes
14 2. Contextual  – local level Municipalities the 3rd autonomous political level.Initially health protectionSocial welfare responsibility – increasingly linked to healthHealth promotion concept better understood than disease prevention
15 Professional training – MPH programmes critical to skilled workforce Piloting started on national level in 1988Established during the 1990‘sStill increasing interest14 universities & university colleges with MPH programmes (Complete or partial)Well educated workforce in modern public healthEmerging 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
18 National public health objective domains Model for national public health strategy – the principal foundationNational public health objective domainsHealthdeterminantsHealth outcomes&distributionInter-ventionsBosse Pettersson, 2003
19 Model for national public health strategy – the links National public health objective domainsHealthdeterminantsImpact &efficiencyHealth outcomes&distributionCorrelationInter-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 population9-11: Physical activity-Eating habits and safe food-Tobacco, alcohol, illicit drugs, doping,harmful gambling11 Objective domains in briefLifestyles and health behaviours4-8: 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 healthSettings and environments1- 3: Participation and influence on the society – Economic and social security – Safe and favorable growing up conditionsSocietal structures and living conditionsBosse Pettersson, 2003
23 How to make it work?a special Minister of Public Health appointed + National high-level Steering Committeesectoral responsibilities defined for more than 30 national agencies by existing political domain objectivespublic health integrated into ‘daily business’ – existing sectoral objectives and targets influencing health
24 The Swedish National Public Health Institute – SNIPH (2) Remit – 3 major missionsMonitoring and evaluation of the public health strategy and facilitate its implementationCentre of knowledge for effective health promotion and disease prevention methodsOverall supervision of selective preventive legislation in the fields of alcohol and tobacco
25 Tools for implementation Determinant’s indicators with inequality and gender dimensionsGovernmental directives to concerned sectoral state agenciesHealth Impact Assessment (HIA) recognizedDatasets and planning tools for reviewing and integration public health at local municipal level are elaboratedBasic municipal public health data on the webLocal Welfare Management Systems (LOWEMANS)
26 Shortcomings and criticism to vague, determinants are difficult to explainto small resources allocated for general public health infrastructuresIntervention research is lackingneed training of exiting professionals in concerned sectorslack of funding to municipalities and county councils where major efforts are expected to take place
27 Good practices worktraffic accidents; speed limits, road construction, safe vehicles, bicycle helmetshigh taxes on alcohol reduces health related harmcomprehensive tobacco prevention reduces smoking incidence and related illness and premature deaths
28 Implementation by monitoring & evaluation INDICATORSfor monitoring and evaluation the policyto be agreed by involved state agencies, and negotiated with local municipalities and regional County Councilsto 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 gambling32) 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 reportHealthdeterminantsImpact &efficiencyHealth outcomes&distributionCorrelationInter-ventionsInfoPopulation Healthreport etcMonitoring& evaluationsystemIndicatorsBosse Pettersson, 2003
44 Emphasized in the first report Construct a stable ground for public health policy reportingAll domains of objectivesExplain the correlations between determinants and healthPrincipal- and sub-indicatorsActions on all levels; local, regional, nationalFocus 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-indicatorsPublic statistics and own investigationsReports from 22 national authoritiesVisits to 8 county administrative boardsA questionnaire to all local authoritiesVisits to 10 municipalitiesIntervjues with all county councils
46 Positive development, among others Tobacco consumption is declining in all groupsVaccination coverage is hight among childrenPercentage of pupils in grade 9 in primary school having tested illicit drugs has declined during the last yearsAbortions more often happen early during pregnancyInjuries related to work and traffic environments have declined in numberThe Swedes are becoming more and more active in cultural matters
47 Negative development, among others Election turnout is declining in all educational groupsPercentage of long-term unemployed has increasedPercentage of lone parents with a low economic standard has increasedThe ill-health measure (sick-leave and early retirement) has indreased during two decadesLess pupils leaving primary school have complete diplomasMental ill-health is increasing among younger people
48 Negative development, among others Harmful air pollution (particles and ozon) has increasedEvery year more than 1000 elderly people dies from accidents when the are fallingThe incidence of hiv and chlamydia infections has indreased during the last yearsOverweight and obesity are increasing in all groupsThe consumption of alcohol has increased 30% within ten yearsThere 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 SummaryThe 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) ContextACTORSIndividualsGroupsOrganisationsContentProcessFrom Buse, Mays & Walt, 2005
57 Two policytriangles (2) PractisePolicyScience/EvidencBest Practice/IUHPE-FHI, 2005
58 The ’black box’ in the policy processes DemandsResourcesSupportPolicies for politicsPolicy designOutput’Black box’InputFeed –backEfter Easton, 1965