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
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
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
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 subindicators
•
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 diseasepreventing 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
Content
•Organisations
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
Policy design
Policies for
politics
Support
Input
’Black
box’
Output
Feed –back
Efter Easton, 1965