Content of presentation

1. You can write unit / affiliation. leave blank if not applicable. To change content go to: Menu -> Insert (Mac = Display) -> Header and Footer Addressingthesocial determinants of health in the Nordic countries: opportunities and challenges Presentation at the 9th Nordic Health Promotion Research Conference, RUC. Denmark, June 12-15, 2019 Professor Elisabeth Fosse University of Bergen, Norway

2. University of Bergen Content ofpresentation • Socialequity as a mainaimof Health promotion • The social determinants ofhealth • The Nordic context • Presentation ofproject and mainresults • Policy analysis: • Governance • Health equity as a wicked problem • Suggestions for political action

3. Basis for health ”The basicconditions for healtharepeace, housing, education, food, income, a stable eco-system, sustainableenvironment, socialjustice and equity. Better healthneeds to be foundedonthesebasicconditions.” (Ottawa Charter, 1986)

4. University of Bergen The social determinants ofhealth • “Health inequities arise from the societal conditions in which people are born, grow, live, work and age, referred to as social determinants of health. These include early years' experiences, education, economic status, employment and decent work, housing and environment, and effective systems of preventing and treating ill health.” (The Rio-declaration on Social Determinants of Health, 2011)

5. University of Bergen Policies and measures • The determinants’ perspective on health inequalities demands an awareness of the structural conditions creating social inequalities that would lead to social inequalities in health. • Important policies that would influence the social determinants are for example tax policies and housing policies.

6. The Social gradient (WHO 2008) Social inequalities in health form a pattern of a gradient through the whole population It is not only the poorest who stand out as having poor health The wealthiest have better health than the second wealthiest etc. Social inequalities in in health is therefore an issue concerning everybody

7. Different types of policies Policies aimed at the poor: Life conditions improves for these but the gradient does not change. Policies aimed at the whole population to reduce the gradient of health The latter type of policies demands focus on structural conditions – will be a political issue

9. WHO Commission on the Social Determinants of Health Summary messages CSDH: Most measures suggested may be characterised as “welfare state policies” Mostly universal policies which are at the core of the Nordic welfare states The commission points to the Nordic model as an ideal.

10. University of Bergen The Nordic welfarestates • The Nordic countries described as Social democratic welfare states • Characterised by universalism and redistribution among social groups, mainly via a progressive tax system. • It is a system of emancipation, both market and the family. • The system is based on high participation in the work force and women are encouraged to work. (Esping-Andersen 1990).

11. University of Bergen Whythe Nordic countries? • The Nordic countries have a high standard of living and small social and economic differences viewed in an international perspective • Despite a long tradition of reducing social inequalities by introducing welfare policies and structural measures, social inequalities have increased over time. • This has been termed the welfare paradox of the Nordic countries • Also differences between the countries (Popham et al 2013, Mackenbach 2012).

12. University of Bergen Abouttheproject • The Nordic arena for public health has initiated a project "Equal Health - Prerequisites at National Level". • The aim of the project was to create better conditions for working towards increased equality in health at the national level in the Nordic countries. The project ” Nordic National policies to increase equity in health” is part of this overall project. • The project is funded by the Nordic Council of Ministries and administered by the Nordic Welfare Centre.

13. Universitetet i Bergen Background for theproject • The project “Tackling Health inequalities locally – the Scandinavian experience” (ScanHeiap) 2014-2016 • Collaboration between National health authorities and associations of local governments in Denmark, Norway and Sweden • Studied these three countries • Lead by Prof. Finn Diderichsen, Copenhagen University. Diderichsen F.; Scheele, C.E. & Little, I. G.(2015): Tackling health inequalities locally: the scandinavian experience. Københavnsuniversitet, Detsundhedsvidenskabeligefakultet.

14. Universitetet i Bergen Social equity- Preconditons at the National level • Include Finland and Iceland in addition to Denmark, Norway and Sweden • Focus on National policies in the Nordic countries • Partners: Dept of Health Promotion and Development, UoB, (Prof. Elisabeth Fosse); Østfold University College (Prof. Marit Helgesen)

15. UNIVERSITY OF BERGEN Research Questions • How do the Nordic countries apply a comprehensive approach to address social inequalities? • Do the countries apply a Whole-of-society approach? • Is Vertical collaboration and support in place? • What Legislation and other governance instruments support the policies?

16. UNIVERSITY OF BERGEN Methods and data • Qualitative methods, with document analysis and expert interviews. • Documents are National policy documents: White papers, green papers, reports etc. • Interviews with policy makers working with issues related to social inequalities in Denmark, Finland, Norway and Sweden. Employees in ministries, health and social departments, local government associations. • Between 4 and 7 interviewees in each country

17. University of Bergen Whole-of-society approach • In all the countries, the health sector, that is the Ministry if Health or/and Social Affairs has the overall responsibility for public health policy, including social inequalities. • The subordinate institutions are responsible for the implementation of the policy. • In general, the health aspect of the policies is being addressed, more than the whole of society approach.

18. University of Bergen A comprehensiveapproach • All the Nordic countries apply both universal and targeted measures in their public health policies, as this is a part of the Nordic welfare model • Denmark, Finland, Norway and Sweden have formulated National policies to reduce social inequalities in health.

19. University of Bergen A comprehensiveapproach (2) • DK: Clearlydefinedresponsibility for thehealthsector. Individual preventive measuresaimed at disadvantagedgroups • FIN: Hiapapproach, responsibility for all sectors. In practiceindividual, life style measures. • ICE: Health sectorcentral, individual, life style measures • NOR: Public Health Act, focusonsocialdeterminants,local planning • SWE: National policy, focusonsocial determinants

20. Marit K. Helgesen | Facultyof Health and Welfare Verticalcollaboration and support • Municipalities important in the Nordic countries • The most decentralised in the Western world • Dual role: • Democratic arena – local self governance gives autonomy in deciding how to prioritise revenues • Implementing national policies – front line of the welfare state

21. 26.06.2019 Universitetet i Bergen Side 21

22. Universityof Bergen Explainingfinding applying policy analysis • Governancestructures: multilevelgovernance • Content ofpolicies: healthinequities as a wicked problem

23. University of Bergen Multilevelgovernance • The term “multi-level” pertains to the changed role of municipalities in the central-local relationship. Includes a more egalitarian relation between sectors and levels of formal authority. • The traditional forms of hierarchical government have been decoupled. Centralized leadership is no longer carried out through a detailed hierarchical system • This has been denoted as multi-level governance, understood as a system of continuous negotiation between the national and local level. (Sørensen & Torfing, 2005, 2007).

24. Universityof Bergen Twomodels for National governance(Vabo 2010, 2012, Fossestøl 2010)

25. University of Bergen Denmark Hiearchy: • Health Care act Soft governingtools: • Time limitedfunding and support • Forebyggelsespakker • «Satspuljer» (basedon National priorities)

26. University of Bergen Finland Hiearchy: • Public Health act, included in Health Care act Soft governingtools: • Stimulating and supportinglocalgovernment, including time limitedfunding

27. University of Bergen Norway Hiearchy: • Public Health act (PHA), oneofthemainfocus is to reducesocialinequalities in health by addressingthesocial determinants. • Coordinatedwiththe Plan and Buildingact (PBL). • Localgovernmentsmandated to apply PBL in local planning • National auditsof PBL Soft governingtools: • No permanent funding for PHA via National budgets • Time limitedprojectfunding • Support and follow up from theDirectorateofhealth

28. University of Bergen Sweden Hiearchy: • Health Care act • National Policy «Health onequal terms» from 2000 • National policy onequity in health • National commissiononsocialequity Soft governingtools: • Support to localinitiatives - «Socialsustainability»

29. Conclusions governance perspective • BothHierarchical and soft governingtoolsareavailable in all countries • Norway applieshierarhicalgoverningtools in theimplementationofthe PHA, in addition to soft governingtools. • PHA + a combination ofhierarichical and soft governingtools support theimplemenationofthe PHA.

30. University of Bergen Content of policy Socialinequities/inequalities is a wicked problem: “A wicked problem is a social or cultural problem that is difficult or impossible to solve for as many as four reasons: incomplete or contradictory knowledge, the number of people and opinions involved, the large economic burden, and the interconnected nature of these problems with other problems.” (Rittel and Webber, 1973)

31. University of Bergen Wicked problems • Socialinequalities has thecharacteristicsof a wicked problem. • It is also a verypolitical problem: • Traditionallyleftwinggovernmentsaddressthe problem as a structural problem, while right winggovernmentsdefine it as a poverty problem, withindividualisticsolutions.

32. University of Bergen Redefining wickedissues • Wicked problems may be redefinedinto «tame» problems. • Tame problems are more clearlydefined and have simplersolutions. • Even though all the Nordic countries have policy aims to reducesocialinequalities, the problem sometimes have beenredefined to tame problems.

33. University of Bergen Tame solutions to wicked problems • Whenthehealthsector has themainresponsibility for thesolutions • Whensocialinequalitiesaredefined as life style issues for marginalizedgroups • Whensolutionsareindividual and not structural • Whensolutionsareleft to thelocallevel

34. University of Bergen Conclusions policy content • All countriesaim to reducesocialinequalities • However, in all countriesthewickednessofthe problem is undercommunicated • Measuresaremostly at thelocallevel, and has thecharacterof redefining the problems intotame problems • This meansthatthewider determinants ofhealthare not acknowledged in policy and measures.

35. University of Bergen Policy suggestions 1 • Untilthe 1980’s socialinequalitiesdecreased: thepeakofthe Nordic welfarestatemodel • Socialinequalitiesincreased from the 1980’s: Deregulation, privatization, globalisation • Revitalizationofthe Nordic model: structural, universal policies and measureswiththeexplicitaim to increaseequity in health

36. University of Bergen Policy suggestions 2 • Acknowledgingthewickednessofthe problem- not pretending it is a tame problem • Individualmeasures and a narrowhealthsectorfocus not sufficient • Hierarchicalgovernance and fundingnecessary, togetherwith soft governingtools.

38. UNIVERSITY OF BERGEN