Bosse Pettersson

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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
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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

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

4
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 childdren, adolecscents and
  women
• Falling health 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?

• Peopless 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

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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 is
  becoming an issue of security

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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

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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

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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

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Not starting from ZERO - building bricks in the
Swedish public health strategy

• Modern public health and WHOs 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 1980s state seed
  money speeded up the development

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1. Historical

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

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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

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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

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Professional training MPH programmes critical
to skilled workforce

• Piloting started on national level in 1988
• Established during the 1990s
• Still increasing interest
• 14 universities university colleges with MPH
  programmes (Complete or partial)
• Well educated workforce in modern public health
• Emerging employment opportunities

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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

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

• 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.

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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
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
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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

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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

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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
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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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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

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Tools for implementation

• Determinants 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)

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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

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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

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Public health increasingly a global and
international matter

• EU
• Public Health Programme
• Health inequalities
• Health in other policies agriculture
• WHO
• Strengthen public health
• dimension MDGs
• Non-communicable diseases
• Alcohol
• Diet physical exercise
• Tobacco
• Reproductive and maternal
• child health
• Mental health
• Health Promotion Bangkok Charter
• HIV/aids