Bosse Pettersson Deputy Director-General 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

Process in 10 phases 1.Bringing public health back on the agenda – Health for All – Alma Ata (1978) and WHO European 38 targets 2.Plans, programmes, plans, programmes, plans, … 3.Supporting and establishing regional and local capacity 4.Moving outside the health and medical care system – re-establishing a Swedish National institute of Public Health - SNIPH (1992) 5.Professional training – master programmes in public health – gradually reaching out in other sectors 6.The policy process and high level political involvement – the understanding of what deteremines health in contemporary societies, not to forget the historical context 7.Health objectives and targets set as determinants 8.Focus on monitoring and evaluation – indicators of determinants 9.Re-orienting SNIPH to become the accountable central agency (2001) 10.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!

Is there anything to do? Peoples’s well-being can be improved by health promotion 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 ) 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

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

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

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

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

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 & culture Social network Health-& medical care Social support Social assistance Social- insurance Employ- ment

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

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

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 1.Participation and influence in society. 2.Economic and social security. 3.Secure and favourable conditions during childhood and adolescence. 4.Healthier working life. 5.Healthy and safe environments and products. 6.A more health promoting health service. 7.Effective prevention against communicable diseases. 8.Safe sexuality and good reproductive health. 9.Increased physical activity. 10.Good eating habits and safe food. 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.

11 Objective domains in brief Societal structures and living conditions Settings and environments Lifestyles and health behaviours Bosse Pettersson, : Participation and influence on the society – Economic and social security – Safe and favorable growing up conditions 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 9-11: Physical activity -Eating habits and safe food -Tobacco, alcohol, illicit drugs, doping, harmful gambling One overarching aim: To provide societal conditions for good health on equal terms for the entire population

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

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

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

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

Public health – increasingly a global and international matter EU  Public Health Programme -Health inequalities -Health in other policies; agriculture WHO  Strengthen public health dimension – MDG’s  Non-communicable diseases -Alcohol -Diet & physical exercise -Tobacco -Reproductive and maternal & child health -Mental health -Health Promotion – Bangkok Charter  HIV/aids