Karl Evang, Health director 1938 – 1972: Knowledge regime US- Public Health

1. “Can bureaucrats order public health? The case of Norway Patient-Centered Health Care Delivery Systems: A Framework“ Charlotte Kiland, Msc, PhD student, Department of Public Health and Sport, University of Agder, Norway Dag Olaf Torjesen, PhD, Associate Professor, Department of Political Science and Management, University of Agder, Norway Paper presented at The 13th International Conference onIntegrated Care, Berlin, Germany, April 11th/ 12th 2013

2. The rise and fall ofthe Norwegian health technocracy Karl Evang, Health director1938 – 1972: Knowledge regime US- Public Health John Hopkins School of Public Health WHO The medicalprofessions Technocratic regime Health directorate (Evang) The countymedical The districtdoctors Evang, Karl (1960): Health service, society, and medicine : present day health services in their relation to medical science and social structures. London: Oxford University Press

3. Public health = The nations biopower • Conservation of the nations resources and the human body and soul • Hygiene and vaccination program • The sports movement • The NGOs • Legislation regulating leisure

4. The municipalhealthcareact in 1984 • The end ofEvang’smedicracy • The districtdoctorsweremunicipalized and lost their status • Hierarchicalunityofcommand and controlwasended in thepublichealthfield • Lackofincentives • Public health gotlowpriority in a global budget system in themunicipalsector • Curative healthcare services financedthroughitimizedpricingsystem • The financeof preventive healthcare included as part of a general purpose grant scheme to themunicipalities • Lackofstateearmarkedfunding in themunicipalhealthsector

5. New reform initiative and newlegislation – will it make anydifference? • Proposing a newinstitutional/structural reform in 2012 – The Cooperation Reform • A new agenda: • Coordinated and «seamless» services • From treatment to illnessprevention, empowerment, healthpromotionand municipal planning • New legislation • 2009: The new planning act – an overall publichealthperspective in all planning at thelocallevel, createenvironmentsconductive to health, «sustainability» • 2012: The public health act – municipalresponsibility for public health, «health in all policies», reducesocialinequalities in health, determinants of health

6. Theoreticalframework • Shiftingknowledge regimes (Slagstad2004) • Shiftingpolitical regimes accompanied by shiftingknowledgediscources • Knowledge regime = knowledge/ science + definedvalues/ ideology+ politicalpower • Poststructuralism • Governmentality (Foucault 1979, 1983; Gottweis 1998) • Biopowervsdisciplinary power • Techniques for achieving the subjugations of bodies and the control of populations • New institutional theory • Justification and theorganizedhypocricy (Brunsson1986,1993) • Consistency and control is difficult to achievewhenwhatcan be saidcannot be done and vica versa • Solution: Combiningideas and actionsinvolvingeitherjustification or hypocrisy

7. Methodology • Region in the south of Norway; Agder • 30 municipalities • Writtendocuments; legislation, reports, internalmunicipaldocuments, power point presentations, web pages • 12 elite interviews; • in-depthopen-endedinterviews • initial interview guides • Informants • Locallevel; municipalities - coordinatorsof public health and chief municipalitydoctors (7) • Regional level; counties - coordniatorsofpublichealth (3) • National level; The Norwegian Directorateof Health, senior advisors in divisonofpublichealth (2)

8. Concludingdiscussion • Shifitingknowledge regimes – • Politicalpower; newlegislationacts • The coordination reform – a direction reform -a knowledge regime shift? • The Cooperation reform and the Public healthact as «theorganizedhypocracy» - lackofconsistency and control: extensivepolitical and bureacraticrhetoric at thenationallevelabouttheimportanceofillnessprevention and healthpromotion, still: • Lackofgovernmentalfundingand (conflicting incitament structures) • Lackoforganizationalbehavior; limitedinitiatives and organizationalactions at thelocallevel • The newlegislationacts + health in all policies: conflictingpressures – collidingknowledge regimes? • The challangesofhorizontalintegration – a municipalsectordominated by a vertical logic (MBO/NPM)?

9. National and municipal spending on Public Health • Total healthexpenditure Norway in 2012: 273 billion (2,4 percentof total healthexpenditure 2012) • Preventive healthcareexpenditure 6,7 billion (2,4 percentof total healthexpenditures 2012) • Part-time postions as publichealthcarecoordinators and planners in 28 of 30 minicipalitieswe have studied • Part time positions in 63 percentofthe Norwegian municipalities (>40%) • Municipal health promoting lifestyle centers in 9 of 30 municipalities in Agder (145 of 429 municipalities in Norway) - biopower

10. The prevention discource as hypocracy • Dysfunctional effects • The lack of consistency and the conflicting demands complicate organizational actions. The new agenda may not be fulfilled due to lack of economical incentives, strong vertical integration and sectorisation • Functional effect • The organized hypocricy and the political and bureaucratic public health discourceis legitimized by a neo liberal knowledge regime • The organized hypocricy of the cooperation reform? Talk: prevention, personalized empowerment, cooperation vs. Practice: handing over patients from hospitals to primary care and their own destiny