ORIENTING POLICIES ON HEALTH DETERMINANTS - the process of target setting in Sweden 1985-2006 – lessons to learn Public lecture in Graz, Pallais Attems, 19.30, 8 June 2006 Bosse Pettersson Deputy Director-General

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

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

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

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!

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

... 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

The Swedish National Public Health Institute – SNIPH (1) Re-established 1992 (originally founded/operating 1938-1968) 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

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

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

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

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

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. 75-80 per cent with local health planners, policies and programmes

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

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

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

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

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

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

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.

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.

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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 15-29 age group (regional level) Bernt Lundgren 2004

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

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

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

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

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

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

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

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

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

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

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.

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.

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.

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.

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.

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.

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

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

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

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