Transcript PowerPoint-presentation

ORIENTING POLICIES ON HEALTH
DETERMINANTS - the process of target
setting in Sweden 1985-2006 – lessons to learn
Bosse Pettersson
Deputy Director-General
Public lecture in Graz, Pallais Attems, 19.30, 8 June 2006
www.fhi.se
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
• 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
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. 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
Environment
Public economic
strategies
Traffic
Agriculture
& foodEduca-stuff
tion
Sex &
life together
Leisure &
culture
Eating habits
Illicit drugs
Housing
Employment
Alcohol
?
Tobacco Social
Work
support
environment
Social
network
Age, sex,
heredity
Socialinsurance
§
Physical
activity
Sleep
Contact habits
children
and adults
Social
assistance
Health-&
medical care
Model for national public health strategy – the
principal foundation
National public
health objective
domains
Interventions
Health
determinants
Health outcomes
&
distribution
Bosse Pettersson, 2003
Model for national public health strategy – the links
National public
health objective
domains
InterImpact &
ventions efficiency
Health
determinants
Health outcomes
Correlation
&
distribution
’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
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.
One overarching aim: To provide societal conditions for good
health on equal terms for the entire population
11 Objective domains in brief
9-11: Physical activity
-Eating habits and safe food
-Tobacco, alcohol, illicit drugs, doping,
harmful gambling
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
Implementation by monitoring & evaluation
INDICATORS
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•
•
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
Public Health
Policy report
InterImpact &
ventions efficiency
Health
determinants
Health outcomes
Correlation
&
distribution
I
n
f
Monitoring
system
o
& evaluation Indicators
Population Health
report etc
Bosse Pettersson, 2003
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
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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
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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
•
•
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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