Linz 08

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www.fhi.se
Swedish public health policy Tackling social
determinants of health by an inter-sectoral
approach Seminar in cooperation with Moscow
School of Political Studies, 2008-11-19 (SIPU)
Bosse Pettersson, Independent Public Health
Consultant Senior Adviser, Swedish National
Institute of Public Health
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My input is about

• The Swedish experience
• Europes health challenge - the burden of disease
  and implications
• Process, reporting monitoring
• Open for debate and discussion

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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 children and
  in road traffic
• Falling death rates up to age 65 in heart
  diseases
• Improved survival in many cancer diseases
• etc

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But, there are old and emerging problems!

• Since the 1990s 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 children, adolecscents and women
  
• Falling healthy life expectancy among women 45
  and older

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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!

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Is there anything to do?

• Peoples well-being and health can be improved by
  health promotion and disease prevention
• 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 caused by chance
  they origin from systematic social unjustice

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What does it look like in Sweden?

• More than 70 of the total disease burden (DALY,
  2002) is due to
• Cardio-vascular diseases
• Mental ill-health
• Tumores
• Injuries

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Disease burden 2002, FEMALES(Allebäck, Jakobson
Moradi in PHPR 2005)
Mental illness
Cardiovascular diseases
Tumours
Eyes-ears
Musco-sceletal
Respiratory
Injuries
Others
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Disease burden 2002, MALES(Allebäck, Jakobson
Moradi in PHPR 2005)
Cardiovascular diseases
Mental illness
Tumours
Injuries
Eyes-ears
Respiratory
Musco-sceletal
Others
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... 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 has
  become an issue of global security

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Building bricks in the Swedish public health
strategy

• Historical tradition state responsibility and
  popular movements
• Longstanding commitment across political parties
  although different emphasis and ideologies
• Evolved as a concern on all political levels in
  1980s but, the County councils (regional)
  forerunners
• Infra-structures for modern public health
  gradually in place from the 1980s state seed
  money speeded up the development on local level

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To keep in mind a value driven policy

• Health inequalities the major concern the first
  national public health report in 1987 revealed
  surprising differences for Sweden

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Model for national public health strategy the
principal foundation
National public health objectives
Health determinants
Health outcomes distribution
Inter- ventions
Bosse Pettersson, 2003
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11 Objectives 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
food -Tobacco, alcohol, illicit drugs, doping,
and gambling
Lifestyles and health behaviours
4-8 Working life Environments products
Health promoting health services Protection
from communicable diseases Sexuality and
reproductive health
Settings and environments
1- 3 Participation and influence in society
Economic and social prerequisites Growing up
conditions
Societal structures and living conditions
Bosse Pettersson, 2003
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Why determinants as outcomes?

• Politicians cannot prevent deaths and illness in
  cancer, nor heart diseases etc, but can influence
  what is behind the upstream approach
• Reducing inequalities overall priority

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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
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How to make it work?

• a special Minister of Public Health appointed
  national high-level Director-General Committee
• sectoral responsibilities defined for more than
  30 national state agencies by existing political
  goal areas including sets of existing sub-goals
  determining health
• public health integrated into daily business

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The Swedish National Public Health Institute
SNIPH

• Timely reorganized 2001 with remit fit for
  purpose 3 major missions
• Monitoring and evaluation including
  facilitation and co-ordination of the public
  health strategy at administrative level
• Centre of knowledge for effective public health
  methods
• Overall supervision of selective preventive
  legislation in the fields of alcohol and tobacco

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The 2005 Public Health Policy Report (PHPR 2005)
Describes Determinants for health and
indicators. The implementation of the public
health policy on national, regional and local
level. Propose New and additional actions
required for the fulfillment of the policy Use
Basis for the Governments communication to the
Parliament.

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Priority proposals (42 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 increased 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.

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Summing up Monitoring is a lever for
multi-sectoral implementation, the Swedish case

• Continous steering from the government across
  concerned sectors
• Determinants approach in general well understood
  to place other sectors role in public health
• Use of indicators key
• Support to players outside the health service to
  identify their public health role.
• Transfer ownership and leave to other agencies to
  shape their own agenda
• Public health work offers added value for the
  agencies

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Thanks, end of introductory presentation!

• Some additional slides prepared in case they are
  relevant for the discussion .

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At a glance Some comparisons, Russia Sweden
and the wider Europe
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Sweden?
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What is the correlation between spending and
population health outcomes in relative terms?
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What is the correlation between spending and
population health outcomes in purchase power
terms?
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Determinants of health

• what kind of jargon is that?
• A tragic story from real life

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Healt determinants a tragic illistration
Death Ill Crisis
Shot/bullit
Health Well-being
Bosse Pettersson, 1998
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Health determinants A tragic illustration
Death Ill Crisis
Shot/bullit
Weapon
Bosse Pettersson, 1998
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Health determinants A tragic illustration
Death Ill Crisis
Allowed/Banned
Shot/bullit
Weapon
Bosse Pettersson, 1998
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Health determinants A tragic illustration
Death Ill Crisis
Allowed/Banned
Shot/bullit
Weapon
Right
Bosse Pettersson, 1998
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Health determinants A tragic illustration
Death Ill Crisis
Exposed to/ witnessed violence
Allowed/Banned
Shot/bullit
Weapon
Right
Bosse Pettersson, 1998
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Health determinants A tragic illustration
Death Ill Crisis
Exposed to/ Witnessed violence
Vulnerable/ Poor
Allowed/Banned
Shot/bullit
Weapon
Right
Bosse Pettersson, 1998
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Health determinants A tragic illustration
Social cohesion
Life experiences
In public health terms
Values/ ethics
Death Ill Crisis
Policy
Method
Exposure
Exposed to/ Witnessed violence
Vulnerable/ Poor
Allowed/Banned
Shot/bullit
Weapon
Right
Outcome
Event
Tool
Legislation
Environment/ Life conditions
Bosse Pettersson, 1998
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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.

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11 public health objectives 2003/2008 (1)

• Participation and influence in society.
• 2008 Same
• 2. Economic and social security.
• 2008 Economic and social prerequisites
• Secure and favourable conditions during childhood
  and adolescence.
• 2008 Growing up conditions during childhood and
  adolescence
• Healthier working life.
• 2008 Health in working life
• Healthy and safe environments and products.
• 2008 Environments and products
• A more health promoting health service.
• 2008 Health promoting health services

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11 public health objectives 2003/2008 (2)

• Effective prevention against communicable
  diseases.
• 2008 Protection against communicable diseases
• Safe sexuality and good reproductive health.
• 2008 Sexuality and reproductive health
• Increased physical activity
• 2008 Physical activity
• Good eating habits and safe food.
• 2008 Eating habits and 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.
• 2008 Tobacco, alcohol, illicit drugs, doping and
  gambling

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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
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Implementation - many players are responsible!

• Interventions integrated within 31 policy areas
  of public governance.
• Over 20 national state authorities obliged to
  consider the effects on public health of their
  activities and to follow up their work.
• Local authorities (n 290) and County councils (n
  21, regional) requested to develop cooperation
  and coordination of their public health work.
• A National Steering Group for public health
  issues established under the leadership of the
  Minister of Public Health and Director-Generals
  for 17 sectoral state authorities.

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The role of SNIPH in monitoring the
implementation of the public health policy

• Support others to identify their role within the
  public health field
• Co-ordinate the national monitoring of the
  sector-wide public health work
• Be responsible for the overall evaluation of the
  overarching public health aim
• Present a Public Health Policy Report to the
  Government every 4th year, first in 2005

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Collection of Basic data for PHPR 2005

• Research findings on the correlations between
  selected determinants - health
• 42 determinants, 36 principal indicators and 47
  sub-indicators
• Swedish public statistics and SNIPH
  investigations
• Reports from 22 national state authorities
• Visits to 8 (of 21) County administrative boards
• Visits to 10 and a questionnaire to all Local
  authorities (290)
• Interviews with all County councils (21)

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The challenge to engage agencies - normative
starting points

• Players must
• consider which determinants that are important
  and for which groups
• establish indicators to follow up
• build capacity, make HIA and act on the
  determinants
• monitor the effects of their interventions
• suggest new steering mechanisms and
  interventions
• report to stakeholders

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Monitoring and evaluation of public health
strategy
Public Health Policy report
Health determinants
Impact efficiency
Health outcomes distribution
Correlation
Inter- ventions
Info
Population Health report etc
Monitoring evaluation
system
Indicators
Bosse Pettersson, 2003
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D O N E!

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"...Reducing health inequities is, for the
Commission on Social Determinants of Health, an
ethical imperative. Social injustice is killing
people on a grand scale."
Michael Marmot (chair), Frances Baum, Monique
Bégin, Giovanni Berlinguer, Mirai Chatterjee,
William H. Foege, Yan Guo, Kiyoshi Kurokawa,
Ricardo Lagos Escobar, Alireza Marandi, Pascoal
Mocumbi, Ndioro Ndiaye, Charity Kaluki Ngilu,
Hoda Rashad, Amartya Sen, David Satcher, Anna
Tibaijuka, Denny Vågerö
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CSDHs overarching recommendations

• Improving daily living conditions?
• Tackle the inequitable distribution of power,
  money and resources
• Measure and undertand the problem and asses the
  impact of action

What does it mean for Austria, Sweden and other
European countries?
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From the WHO World Health Report 2008 on Primary
Health Care 30 years after Alma-Ata
Thank you!