Swedish Public Health
Policy
Focus on social determinants and
multisectoral interventions
Bernt Lundgren, Public Health Policy Expert, Swedish National
Institute of Public Health (SNIPH)
WWW.fhi.se
Lecture about Swedish Public Health Policy, Netherlands Embassy,
Stockholm, 3rd of October 2007
Purpose and content
•
Sweden – society and health.
•
Origins of the new Swedish public health policy.
•
The Swedish Public Health Policy.
•
Implementation – many players are responsible.
•
Clouds on the health sky.
•
Proposals relating to health threats and capacity.
•
Summary and Conclusions.
Bernt Lundgren 2007
Sweden – society and health
9 million people, 12% born abroad.
A mixed economy, a big public sector and a
universal welfare system.
GDP per capita is about 29 500 euro (274 000 SEK,
rate 9.3 )
The level of total social benefits is about 33% of
GDP.
Three levels of government with the power to tax:
the state, 21 county councils and 290 local
authorities (municipalities).
Bernt Lundgren 2007
Average lifespan in Sweden 1751-2000
100
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
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










60


Females







Males





40




80
20
0
0
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
5
0
79 181 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 198 199 199 200
1
51 791 816 841 851 861 871 881 891 901 911 921 931 941 951 961 971 981 986 991 996
7
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Life expectancy at birth
(Source WHO World Health report 2001)
100
80
60
Males
Females
40
20
0
Afganistan
USA
Australia
Russia
South Africa
India
Sierra Leone
Vietnam
Sweden
Franc
Infant mortality in Sweden
Probality of dying during the first life-year (number per 1000 born).
7
6
5
4
3
2
1
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Gunnar Ågren 2004
Percentage of daily smokers, 16-84 years,
1980-2002
Andel dagligrökare
Males
Females
40
Män
30
Kvinnor
20
10
0
1980
1985
1990
1995
2000
June 1st 2005 – smoking was prohibited in restaurants
Källa: Undersökningen av levnadsförhållanden, SCB
Proportion of daily smokers
Blue-collar workers
Lower non-manual employees
Intermediate and higher non-manual
employees
0
5
10
15
20
25
Per cent
Men
Women
Source: Swedish National Institute of Public Health 2004
Origins of the new Swedish
public health policy
In the 1980´s - increasing costs for health care – a
disproportionate amount to highly specialized hospital
care. A need to emphasize prevention.
HIV/AIDS illustrated the need for a comprehensive
preventive strategy.
Increasing concern about inequity in health.
A strategy group on public health in the government
administration was formed in 1987.
Swedish National Institute of Public Health founded 1992.
Bernt Lundgren 2007
Stimulus from international work
about prevention and health
promotion
• Lalonde Report 1974
• Alma-Ata Resolution 1976 – emphasis on primary
care
• Health for all by the year 2000 – 1981
• Ottawa charter 1986
The National Committee for Public
Health 1997-2000
•
Appointed by the government.
•
All main political parties were represented and a
number of experts and NGO:s.
•
Main task 1: to propose national public health goals
and strategies to guide public health work sector-wide,
with special focus on reducing inequities in health.
•
Main task 2: to “politicize” the public health issue.
Bernt Lundgren 2007
Final report: ”Health on Equal Terms–
National Goals for Public Health”
Six overarching strategies.
18 national goals for public health, 50 subgoals.
The goals were expressed in terms of
determinants of health.
A number of indicators for each goal.
Time horizon – 2010.
Bernt Lundgren 2007
The Swedish public health policy
On the 16th of April 2003 The Parliament approved
the government white paper, ”Public health
objectives” (prop. 2002/03:35).
It stress the need for a long-term, goal-oriented and
multisectoral public health work.
Focus a better co-ordination and a rising
knowledge of the collected effects of interventions.
Bernt Lundgren 2007
One overarching national public
health aim:
The aim is: “ to create social conditions that will
ensure good health, on equal terms, for the entire
population”.
Equity in health has a high priority.
The overall aim shall be achieved by implementing
initiatives in 31 policy areas related to 11 domains
of objectives.
Bernt Lundgren 2007
Focus on equity and equality
• Improve the health situation for those with the worst
health – an equity and gender equality perspective.
• Focus on certain vulnerable groups:
o Children and adolescents
o Elderly
o Persons with disabilities
o Immigrants
o HBT (homosexual, bisexual
and transgender) persons.
Bernt Lundgren 2007
Eleven domains of 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.
Bernt Lundgren 2007
Environment
Public economic
strategies
Traffic
Agriculture
& foodEduca-stuff
tion
Illicit drugs
Housing
Employment
Alcohol
?
Tobacco Social
Work
support
environment
Sex &
life together
Leisure &
culture
Eating habits
Social
network
Age, sex,
heredity
Socialinsurance
§
Physical
activity
Sleep
Contact habits
children
and adults
Social
assistance
Health-&
medical care
Implementation - many players
are responsible!
Interventions within 31 policy areas.
National authorities shall consider the effects on
public health of their activities and follow up their
work.
Local authorities and county councils shall develop
cooperation and coordination of their public health
work.
A national steering group for public health issues
has been established under the leadership of the
Minister of Public Health.
Bernt Lundgren 2007
Swedish National Institute of Public
Health (SNIPH) - three principal
functions
Centre of excellence about public health issues for
the Government and its agencies and for regions,
county councils and municipalities.
Monitor the implementation of the national public
health policy.
Supervision in areas of alcohol, tobacco and drugs.
Bernt Lundgren 2007
Keys to a good implementation
Clear signals from the government and from other
political bodies (through legislation or other steering
mechanisms).
Support to players outside the health service to
identify their public health role.
A more health-promoting health service.
Bernt Lundgren 2007
Identify the public health role
Players must:
• make clear which determinants that
are important and for which groups
• establish indicators
• act on the determinants
• monitor the effect of the interventions
• suggest new steering mechanisms
and interventions
• report to stakeholders
Bernt Lundgren 2007
A more health-promoting health
service
In Sweden: A tradition of good preventative efforts
within maternity and antenatal welfare, receptions
for youth, and school and occupational health
service.
HS in general must be more health-oriented; i.a.
advise on lifestyle factors and also use other
methods than pharmaceuticals.
HS must have a good knowledge of social
determinants of health and methods of prevention.
Bernt Lundgren 2007
Implementation – the national level
• A number of central and regional government authorities
have been asked to describe their roles as regards public
health.
• Many of them point out that their activities affect the health
situation of many people. However, the effects are often
indirect which makes them complicated to follow-up.
Bernt Lundgren 2007
Implementation - regional and local
level
• Municipalities are responsible for activities which affect a
number of health determinants, e.g. social services,
childcare, planning and building issues, etc.
• Municipalities are reasonably well organised for public
health work. Clear improvements during the last decade.
• All county councils – running the health service - have
adopted a public health action plan, often in cooperation
with municipalities or county administrative boards.
Bernt Lundgren 2007
Implementation and monitoring of
the National Public Health Policy
Public Health
Policy Report
Interventions
Effects
HealthCorrelation
Determinants
outcomes
I
n
f
o system
Monitoring
Indicators
Public Health
Report
Bosse Pettersson, 2002
Public Health Policy Report 2005
Show: Determinants for health and
indicators.
The implementation of the public health
policy on national, regional and local
level.
Propose: New actions.
Aim: Basis for the Governments
communication to the Parliament.
Bernt Lundgren 2007
Collection of basic data for PHPR
2005
•
Update of research findings on the correlations
between determinants and health
•
42 determinants, 36 principal indicators and 47 subindicators
•
Public statistics and SNIPH investigations
•
Reports from 22 national state agencies
•
Visits to 8 (of 21) county administrative boards
•
A questionnaire to all municipalities (290)
•
Interviews with all county councils (21)
Four clouds on the health sky
Overweight
Poor mental
health
Alcohol
High
absenteeism
due to illness
BMI, males and females 16-74 years,
1980-2002
Medel-BMI
26
25,5
25
24,5
Män
24
23,5
Kvinnor
23
1980
1989
Källa: Undersökningen av levnadsförhållanden, SCB
1998
2001
The Swedish alcohol consumption
Litres 100% alcohol/inhabitant
10
Sweden entered EU
9
8
7
6
5
1990
1993
1995
1996
1998
2000
2001
2002
PROPORTION OF MEN AND WOMEN WHO
EXPERIENCE ANXIETY OR WORRY
PRESCRIPTION OF DRUGS AGAINST DEPRESSIONS
Million doses per day
6 per cent of the Swedish
people use antidepressants.
In the highest age groups
the proportion is 15—20 per
cent.
Increase in workrelated
sick-leave especially
among women
Absent from work for more than 30
days
De stora sociala
Thousands
200
180 skillnaderna i hälsa
160
140
120
100
80
Den 60
kraftigt ökande
40
arbetsrelaterade
ohälsan
20
0
Males
Females
Brist på fysisk aktivitet
i kombination med dålig kost
74 977 980 983 986 989 992 995 998 001
9
1
1
1
1
1 Ökning
1
1av alkohol
1
1
2
och andra droger
800.000 persons outside the labour market because of sick-leave or
early retirement = 14% of people in working ages. Gunnar Ågren 2003
Inequality in health
Henrik Moberg, maj 2006
Odds ratios (OR) with 95% confidence interval of adverse social and economic consequences among
persons with limiting longstanding illness compared with persons without limiting longstanding illness
stratified for socioeconomic position, adjusted for age, sex, marital state, being foreign born and living
region.
Source: Lindholm et al. Class difference in the social consequences of health. J Epidemiol Community Health
2002;56:188–192
Determinants of social inequities in health
1. Different levels of power and resources
2. Different levels of exposure to health
hazards
3. The same level of exposures leading to
differential impacts
4. Life course effects
5. Different social and economic effects of
sickness
Proposals relating to health
threats
• Reduce social inequality through a strong
universal welfare policy.
• Strengthen labour market policy initiatives
for the long-term unemployed.
• Combat discrimination by disseminating
more knowledge about its negative health
impact.
Bernt Lundgren 2007
Proposals relating to health threats II
• Create scope for greater influence for
those living in vulnerable districts over the
development of their own districts and their
living conditions.
• Develop supportive environments for
health, i.e. accessible and safe cycle
paths, footpaths, green areas and housing
areas.
Bernt Lundgren 2007
Proposals relating to health threats III
• Make freedom from gender-related
violence a new sub-goal of the public health
policy.
• Develop measures to limit availability of
alcohol beverages; restaurant owners, pub
landlords, retailers and parents are key
target groups.
• Adapt tobacco cessation to suit different
target groups and make it available to all
those in need of support.
Bernt Lundgren 2007
Proposals relating to capacity
• Take new steps in the development of public health policy,
infrastructure and practice on the regional level.
• Focus on skills development for municipalities and county
councils.
• Give 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.
Bernt Lundgren 2007
Public health policy for equality in
health and sustainable development
(communication 2005/06:205)
•
The first follow-up of the “Public health objectives
bill” (2002/03:35) in the form of a government
communication to the Riksdag.
•
Basic data: Public health report, Public health
policy report, considerations by relevant actors,
letters and proposals after the Public health policy
report, current policies.
The Swedish public health policy
remains in place (com. 2005/06:205)
•
One overarching national aim
•
Domains of objectives
•
”The evaluation cycle”
•
Determinants
•
Indicators
•
A spread responsibility
•
Interventions that combat the most common health
problems and inequality in health
Key points
(communication 2005/06:205)
•
More work on indicators needed.
•
HIA and health economic analysis important.
•
Continued implementation: ”Role assignment” to
22 national and 21 regional state agencies during
2004-2006, ”HIA task” to 13 national and 21
regional agencies in 2005-2007.
•
No consensus on coordinated regional public
health promotion among county councils and
county administrative boards. More discussion
needed.
Signals from the new Swedish
government elected in September 2006
•Previous government communication
to the Riksdag retracted, but no
change in public health policy.
• More focus on the domains of
objectives related to children, the health
service and health behaviours
(domains 3, 6, 8-11).
• More focus on actors in civil society.
Summing up: Experiences from the
Swedish public health policy
Determinants approach in general well understood and
emphasizes the role of other sectors in public health.
Use of indicators is of key importance.
Support to actors outside the health service needed to
identify their public health role. Transfer of ownership!
Continuous steering from the government and other political
bodies is of vital importance.
Public health promotion on the regional level needs higher
level of coordination.
Municipalities need more skills development.
The new Swedish government does not intend to change the
public health policy.