Part 1
Reduce social inequalities that contribute to inequalities in health

3 Income

«As long as systematic inequalities in health are due to inequalities in the way society distributes resources, then it is the community’s responsibility to take steps to make distribution fairer.»

3.1 Objective: Reduce economic inequalities

Objectives

• Reduce economic inequalities in the population

• Eliminate poverty

• Ensure fundamental economic security for everyone

3.2 Policy instruments

The Government is going to take steps to reduce economic inequalities in the population. There is a direct correlation between financial resources and health because people’s personal economy affects their ability to take advantage of health-promoting products and services. The social groups with the lowest income experience the greatest health benefits from an increase in income. Societies with large income inequalities can generate inequalities in health by means of indirect mechanisms. Being relatively worse off than the people one is surrounded by can lead to exclusion from arenas and activities. Social exclusion of this nature often causes stress, which in turn leads to poorer health. This means that income redistribution may help reduce social inequalities in health and improve average health in the population.

It is important to prevent what is initially a health problem from triggering financial problems. For low-income groups in particular, health problems can easily lead to reduced income. A vicious circle of financial problems and health problems can develop.

The Government will take action to avoid development of a society with a widening income gap and greater inequalities among people. Increased social inequalities can undermine society’s general willingness to support collective welfare schemes, for example, public health services and public schools for everyone. People with limited social and financial resources will be hardest hit by an unwillingness to spend public resources on these kinds of welfare systems. This would further exacerbate inequalities in health and income. Individuals have the best opportunity to achieve good health in a society with strong social cohesion and equality.

3.2.1 Taxation system

The Government will take steps to ensure that the taxation system provides stable incomes for the community, contributes to a fair distribution of resources, contributes to a better environment, promotes employment throughout the country and improves the efficiency of the economy.

The taxation system will be improved so it does more to ensure a fairer income distribution in society. To this end, the Government is attaching importance to maintaining and building up common public assets, as opposed to providing tax relief. Good public welfare schemes are especially important for the people with the lowest incomes. The Government has mapped out a new path in its taxation policy creating more space for public welfare services. The Government is going to keep aggregate taxes and duties at the same level as in 2008, to ensure that economic policy focuses on strengthening common assets. There will be no net tax relief.

Within allocation policy, the taxation system must be regarded in concert with investments in other areas. Low-income problems are often very complex, and direct support schemes are better suited than tax relief schemes for helping disadvantaged groups (low-income groups, disabled people, lone providers, etc.) or households in certain phases of life (families with young children, students, pensioners, etc.). See the Action Plan to Combat Poverty for targeted measures aimed at groups with low-income problems.

The Government has set itself the goal of further strengthening the general allocation of resources in the taxation system, and the Government’s taxation policy has therefore been designed so that people with high incomes and wealth contribute more to the community. See the fiscal budget for 2007, where the Government increased surtax, the minimum deduction (especially for people with the lowest incomes) and wealth tax. These changes will influence distribution favourably.

3.2.2 Monitor developments in income inequalities

As part of the review and reporting system presented in this Report to the Storting, the Government will also monitor trends in income inequality in the population. In addition to summary indicators like the Gini coefficient, this kind of review and reporting system should also contain indicators showing wherein the income distribution changes are occurring. Developments in this area will be reported in the Ministry of Health and Care Services’ budget and in the annual reports on the drive to reduce social inequalities in health as described in chapter 9.

4 Childhood conditions

4.1 Objective: Safe childhood conditions and equal development opportunities

Objective

• All children shall have equal opportunities for development regardless of their parents’ economy, education, ethnic identity and geographical affiliation

Other goals

• Full kindergarten coverage and reduced social inequalities in use of kindergartens

• Reduction in the number of pupils starting school with inadequate language skills

• Reduction in the number of pupils who finish their compulsory schooling without good basic skills

• Reduction in the number of pupils that do not complete upper-secondary training

• Early identification and good follow-up of children in high-risk groups

• Greater accessibility to the school health service

4.2 Policy instruments

Most children and young people in Norway grow up in good conditions. Nevertheless, there are children and young people living in families with such limited economic resources that they qualify as poor. They tend to be children whose parents have a short education or who are frequently unemployed. Also at risk of poverty are children who live with a lone provider and children with an immigrant background.

Public welfare schemes can help protect against and counteract the negative consequences of growing up in a financially disadvantaged family. General welfare schemes are most important for groups with few resources, and since they are intended for everyone, there is no stigma attached to receiving benefits. General schemes can also help prevent children ending up in high-risk situations. A well developed range of public welfare measures can ensure equal opportunities regardless of economic and other personal resources. Nevertheless, there is still a need for special measures aimed at children in high-risk situations.

According to the World Health Organization’s report The Solid Facts, risk factors can be reduced by means of better preventive health services for mothers and children and by improving the level of knowledge among parents and children. Health and education programmes of this nature raise parents’ knowledge about children’s needs and give them more confidence in their own abilities. The World Health Organization also states that strategies providing equal opportunities for education are important in efforts to improve health. The report also underlines that better living conditions and social networks for parents yield better living conditions for children.

4.2.1 Kindergarten and school

Kindergartens and schools can help reduce social inequalities in health through reduction of social inequalities in learning. Kindergartens can identify children with special needs and help ensure they get the help they need at an early stage. Children that go to a good kindergarten do better at school. Good opportunities for education and work can help reduce the negative health impacts of poor childhood living conditions. At the same time, kindergarten and school are important arenas for measures promoting good health behaviour, for example by encouraging healthy eating habits and physical activity.

In Report no. 16 to the Storting (2006–2007) Early intervention for lifelong learning, the Government presents a policy to make better use of education as a tool for reduction of social inequalities. Compared with other countries, there are major inequalities in performance among school children in Norway, and Norway is one of the countries where family background has the greatest impact on children’s academic performance. The main goal of this Report to the Storting is therefore to ensure that all pupils acquire basic skills regardless of their family background. Another goal is that everyone, regardless of their social background, is rendered capable of making informed choices about their career and further studies.

In the Report to the Storting on early intervention for lifelong learning, the Government has decided to gradually lengthen the school day in the lowest grades from 21 hours a week to 28 hours a week. A longer school day will serve to improve the quality of all pupils’ education, but this reform will have the greatest impact on pupils who receive little help with learning at home. A longer school day will allow more physical activity and assistance with home work, will give teachers better opportunity to assess pupils and will provide a good framework for meals. A longer school day will mean a gradual decrease in the need for day-care facilities for schoolchildren.

Continued investments in kindergartens form the cornerstone of the Government’s work to reduce social inequalities. Efforts focus on improving the accessibility, price and quality of kindergartens. However, kindergarten is not an obligatory part of the education system, meaning offering children that do not go to kindergarten pedagogical stimulation is a major challenge. Alongside the focus on developing high-quality kindergartens, systems must also be developed aimed at children and parents that do not wish to take advantage of kindergarten facilities.

Children’s language skills vary enormously when they start school, and these inequalities are often linked to family background. Norwegian and international studies show that the linguistic foundation laid during the early childhood years is critical for children’s social skills and learning at school. Some children need extra language stimulation in early childhood. This applies in particular to children with delayed language development and minority-language children needing extra stimulation to help them learn Norwegian. In addition to the investments to develop more high-quality kindergartens, the Government also wants to study the possibility of introducing a municipal obligation to ensure children facilities for language stimulation if they need it, regardless of whether they go to kindergarten or not. This measure was announced in the Report to the Storting on early intervention for lifelong learning.

Children’s language development is currently assessed in the medical check-ups at ages 2 and 4 at maternal and child health centres. The Government is also going to consider calling for a more systematic survey of language skills at the 2-year check-up and the 4-year check-up at all maternal and child health centres (see the discussion of maternal and child health centres and the school health service).

Social inequalities manifest themselves in young people’s career and educational choices and in recruitment to higher education. The most important tool for reducing these kinds of inequalities is giving greater priority to a reduction of social inequalities in learning throughout the entire course of education.

To prevent illness in the population, it is important to encourage a healthy diet and physical activity for children and young people. Children and young people are at a phase in life where there is a huge potential for preventing illness. Kindergartens and schools are therefore important arenas for establishing good health habits at an early age. A continuous school day provides a good framework for meals, and we are going to introduce a system of fresh fruit and vegetables for all pupils at primary and lower-secondary school. With a view to promoting good health and motor skills, schools are going to have to make sure there is time and facilities for daily physical activity. Research shows that physical activity at school encourages greater activity in leisure time and can even improve learning. Provisions for healthy meals and physical activity for everyone at school in itself can help level out social inequalities and improve the benefits of learning. School also plays an important role in efforts to prevent the harmful effects of tobacco.

4.2.2 Maternal and child health centres and the school health service

Maternal and child health centres offer general medical services for pregnant women and preschool children. The service also encompasses health centres for young people and the school health service in primary, lower-secondary and upper-secondary school. The service’s main tasks include conducting health interview surveys, immunisation, providing information, advice and guidance, and implementing measures to help children and young people develop life skills and help guardians master parenting.

The service has adopted a comprehensive perspective on prevention and does a great deal of interdisciplinary work. This is key to efforts to prevent mental ailments and in dealing with complex social problems. The service collaborates with pupils, homes and schools to create schools that promote good health through a good learning and working environment. The service’s work covers topics such as sexuality, relationships and contraception, protection against communicable diseases (including preventing HIV and STDs), diet, dental health, anti-smoking, drinking and drug campaigns, physical activity, and preventing accidents and injury. In order to meet challenges linked to obesity among children and young people, guidelines are currently being compiled for preventing and treating obesity. New guidelines are also going to be developed for measuring weight and height.

One of the service’s tasks is to pay particular attention to pregnant women, children and young people with special needs. The service is constantly on the look out for early signals of ill-being, abnormal developments and anti-social behaviour and contributes to steps being taken. If necessary, the service refers patients for tests and treatment and collaborates with other bodies in connection with designing services. Maternal and child health centres collaborate with kindergartens, schools, the Educational-Psychological Service and the child welfare authorities.

Maternal and child health centres assess children’s language development in connection with the check-ups at ages 2 and 4 using national guidelines for testing eyesight, hearing and language. Monitoring language development is crucial in identifying children who need extra language stimulation. This is part of the background for the project Testing pre-school children’s language skills at maternal and child health centres– a scheme that is being tested out in connection with the 4 year check-up at maternal and child health centres in 12 municipalities. The project is intended to further develop language testing of children who speak minority languages. In the Report to the Storting Early intervention for lifelong learning, the Government announced that it is considering introducing a duty for municipalities to offer language stimulation. In this context, the government will assess whether to initiate measures to ensure more systematic monitoring of language skills in the maternal and child health centres on a national level. It is crucial that monitoring of language skills is followed up by remedial measures. There is no point in assessing language skills if there are no concrete measures available for children with a detected need for language stimulation.

In accordance with the Regulations of 3 April 2003 regarding the local authorities’ health promotion and preventive care in the maternal and child health centres and school health service, the service shall assist schools in connection with providing instruction in groups or at parent–teacher meetings to the extent the school requests it. This means that it is up to the individual school to decide the extent to which they want to involve the school health service in the school’s preventive work. It is therefore likely that there will be large variations among schools, which will in turn pose a particular challenge with regard to the goal of reducing social inequalities in learning and health. The Ministry of Education and Research is therefore going to consider amendments to the Act relating to Primary and Secondary Education and appurtenant regulations to ensure that the collaboration between maternal and child health centres and the school health service is more firmly established in legislation from the schools’ point of view too.

The school health service plays an important supporting role in planning physical activity at school and provides advice in connection with arranging activities aimed at different groups of pupils, including pupils with chronic illnesses and pupils with reduced functional capacity. Arranging activities for pupils with reduced functional capacity requires an assessment of the school’s physical environment. The service collaborates with homes, kindergartens and other relevant parties on measures for preschool children aimed at the physical environment, groups of pupils and individuals.

One advantage of the maternal and child health centre system is that it is the only arena that has contact with just about all children of preschool age. Almost all children, regardless of their parents’ social position, take advantage of the services offered by maternal and child health centres during the first few years of life. The school health service and health centres for young people are low-threshold services available in children’s and young people’s own environment. Through its presence in schools, the school health service has the potential to reach children and young people in all social groups. It is important for young people to have somewhere to go when they have problems without having to make an appointment and without having to involve their guardians.

The school health service’s ability to reach all children is especially valuable in the work on reducing social inequalities in health. In addition to helping pupils via the school health service, the service can also refer children to the specialist health service and contact other municipal services for extra assistance. This means that the school health service needs to function well for other municipal health and care services to be able to perform their tasks satisfactorily. A number of studies have shown that the degree to which children and young people use other health services varies according to social factors. For example, a higher proportion of girls used psychologists/psychiatrists in the wealthier urban districts of Oslo inner west than in the more working-class Oslo outer east.

The school health service has insufficient capacity in very many of Norway’s municipalities. Services are especially limited in upper-secondary schools. Capacity needs expanding by employing more people to ensure that children and young people experience the service as a low-threshold measure and that the school health service is able to identify children and young people with problems. Expanding the school health service will help ensure that the people who need the most help receive help from the municipal health service or some other municipal service, or are referred to the specialist health service. In this way, the service will serve to reduce social inequalities in the use of the health services. The Government is therefore going to further develop and build capacity in the school health service. The current situation will be assessed to ascertain required capacity and content of the service in the future.

Other identified needs include closer collaboration with other services and players, recruitment of staff with psychosocial competencies and updating existing employees’ competencies. The goal is that the service shall identify children and young people with problems as early as possible, provide them with the help they need within the service, and refer individuals that need treatment in the specialist health service. Collaboration must be developed with school staff, other municipal services and the child and adolescent psychiatric clinics. Special attention must be paid to the inequalities between boys and girls and the fact that immigrants may have special needs.

4.2.3 Mental health services for children and young people

Mental health services for children and young people in the specialist health service have been expanded substantially since 2003. The Escalation Plan for Mental Health (1998–2008) defines a target of 5 % of the population under the age of 18 being offered treatment by mental health care services by the end of the escalation period in 2008. The degree of coverage in the mental health services for children and young people has increased from 2 % in 1998 to 4 % in 2005, and at the current rate of growth, it looks like this target will be met.

In the past, children and young people with mental ailments were generally treated and followed up within the specialist health service. In the future, a system is to be developed where the local authorities are more involved in prevention, treatment and follow-up of children and young people with mental ailments. The specialist health service will deal with cases requiring more specialised diagnosis and treatment. Low-threshold psychologist services are going to be established in the municipalities to improve accessibility for more groups in the population. Methods will be devised that go further in reaching out to children, young people and families in their own arenas. These kinds of measures will increase accessibility to services for groups that tend not to be served by the ordinary services offered by the health services.

Municipal services offered to children and young people have expanded enormously in the escalation period. At least 20 % of the ear-marked funds must be spent on measures aimed at children and young people. So far, a total of 29 % of the fulltime equivalents set up using earmarked grants are in services aimed at children and young people. Nevertheless, the services offered in the municipalities are still insufficient. There are serious inadequacies regarding diagnosis, treatment and follow-up of children and young people with mental ailments. There is also a need to improve competencies in violence and abuse and the harmful effects of growing up in a family with these kinds of problems. In light of these needs, interdisciplinary continuing-education courses in psychosocial work aimed at children and young people are being set up at a number of university colleges starting in 2007. This course of study will include learning about social inequalities in mental health.

Many children with mental ailments need assistance from several services, so the services need to develop good collaboration. To this end, the health enterprises and the state regional child welfare services have formalised their collaboration in agreements. These agreements are intended to ensure that children needing assistance are offered co-ordinated services.

In the Soria Moria Declaration, the Government announced it was introducing a maximum waiting time and treatment guarantee for young people under the age of 23 with psychiatric and/or substance-abuse problems. In 2006, a working committee was formed, which has proposed a statutory time limit of ten days for assessment of the right to receive necessary health assistance. The working group also proposed introducing a statutory time limit of 90 days before treatment is started. In the spring of 2007, the Government will submit a proposition to the Odelsting suggesting introduction of maximum time limits for assessment and treatment. The purpose of this is to ensure young people with mental ailments and/or substance-abuse problems better access to specialist health services.

4.2.4 Child welfare service

The municipal child welfare service is responsible for implementing measures to prevent parental neglect and behavioural problems. The child welfare authorities provide special assistance for children and young people with these kinds of problems. The goal is to implement measures that help people receiving assistance live the best possible life within the family (or in a foster home or institution, as relevant), at school, among friends and later at work. The main challenges in this respect are intervening at an early enough stage with appropriate, preventive measures and monitoring these children as they grow into adulthood. The transition from child welfare to adulthood is a critical phase for many children receiving assistance from the child welfare authorities, and for this reason, the child welfare authorities are now also authorised to assist young people aged 18–23 years.

The child welfare service has a special responsibility to detect problems at an early enough stage to be able to implement measures to avoid permanent problems. As far as possible, assistance for disadvantaged children needs to be available in the usual arenas, with the child welfare authorities as a support. In order to provide timely assistance, the child welfare authorities depend on good collaboration with other municipal services that have contact with the children and their families in daily life, for example schools, kindergartens and the health service. The child welfare authorities have a statutory obligation to collaborate. For the child welfare authorities to be able to perform their tasks aimed at children and young people living in conditions that can harm their health and development, they need to receive information from other public services that have contact with the child and family. Other public services are bound by law to provide the child welfare authorities with any necessary information, the justification for this duty being the child welfare authorities’ need to receive information.

This duty to provide information entails a duty to notify the child welfare service on their own initiative if there are grounds to believe a child is being mistreated at home or subjected to other forms of serious parental neglect, or if a child demonstrates lasting, serious behavioural problems. The duty to provide information applies to everyone working in public services and bodies, including schools, kindergartens and maternal and child health centres. It also applies to a number of professionals, such as doctors, nurses and psychologists. We know that schools, kindergartens and maternal and child health centres seldom report matters to the child welfare authorities. This is a sign that collaboration in this area is not working as intended. We do not know why this is so. A survey is therefore going to be undertaken to ascertain why other services tend not to report matters to the child welfare authorities.

The number of children receiving assistance from the child welfare authorities is rising. A report from the Office of the City Auditor in Oslo in 2006 expressed concern about the lack of capacity in some urban districts. It was also found that some employees claimed that sometimes the budget did not stretch to necessary measures being implemented pursuant to the Act on Child Welfare Services. The situation in Oslo is being monitored closely by the County Governor of Oslo and Akershus and the Ministry of Children and Equality. The child welfare authorities in the city of Oslo are currently being evaluated by an external audit body. The results of this evaluation will be available at the beginning of 2007. This evaluation will help provide a clearer understanding of the situation in the city of Oslo. Once the evaluation is completed, the development of the child welfare authorities in the city of Oslo must be assessed further. The Government’s strengthening of municipal economies has resulted in improvements in the staffing situation in some municipalities and is expected to yield further improvements in 2007.

Pursuant to the Act on Child Welfare Services, the child welfare authorities have a duty to follow up reports if there are reasonable grounds to assume that there are circumstances warranting steps being taken. We know that there are variations between municipalities regarding the number of reports dropped. The national average is 17 % of reports not followed up. While it is important to underline that some of the reports to the child welfare authorities concern matters not covered by the Act on Child Welfare Services, cases being dropped because of a lack of resources or for other reasons is a very serious matter. As a means of gaining better insight into the reasons why reports are not followed up, the municipalities will have to start reporting the reason for a case not being followed up from 2007. At the same time, the Ministry of Children and Equality is planning to initiate studies to ascertain whether too many matters reported to the child welfare authorities are being dropped.

The County Governor is charged with supervising that the municipalities/urban district councils carry out the tasks ascribed to them in legislation. The Ministry of Children and Equality is working on a joint project with the Norwegian Board of Health to develop methods and perform supervisions.

In many places, the municipal child welfare authorities do not have sufficient competence. The Ministry of Children and Equality wants to improve competencies. To address the need for more systematic knowledge in areas where there is a risk of deficiencies, written and electronic advisory materials and handbooks were compiled in 2006 for use in the municipal child welfare services on central topics such as foster homes, processing of cases and routines in the municipality, action plans and care plans for children receiving assistance, supervisors and internal control. The goal is to ensure equitable and knowledge-based child welfare services and to intervene at an early stage with appropriate help. The number of children receiving some form of assistance from the child welfare authorities is steadily growing. The child welfare services are having to deal with increasing numbers of complex cases involving drugs and alcohol, mental health care and children with a multicultural background. To meet these challenges, the municipal child welfare authorities need more knowledge about effective methods and tools through training of new child welfare workers and good continuing and further education for people already working in the child welfare services. In the first phase, efforts to raise competencies in the child welfare authorities will be used to develop a knowledge programme for municipal child welfare authorities. This will be achieved through a joint project involving university colleges, the municipalities and the employers’ organisation in the municipal sector: the Norwegian Association of Local and Regional Authorities (KS). The university colleges need to be able to offer the local authorities better training and seminars for municipal employees in the region. Basic training for child welfare workers is also going to be reviewed with a view to implementing improvements.

Children and young people with an immigrant background constitute an important priority area for the Ministry of Children and Equality. We want to improve general competence about multiculturalism in the municipal and state child welfare authorities and ensure that this competence is applied in every-day work. Raising the level of competence in multicultural issues in the child welfare authorities is intended to ensure that this group of users is offered equitable services compared with other Norwegian children and young people. The Norwegian Institute for Urban and Regional Research (NIBR) has been commissioned to compile an overview of knowledge and assess research about available methods and tools for use in work with children, young people and families with an immigrant background. NIBR is also to identify factors that need to be present to ensure that interventions have their intended effect. The Ministry of Children and Equality will then use these findings to design a practical programme of competence raising in the local and state child welfare services.

In 2007, the Government is going to initiate a broad evaluation of the state child welfare authorities on the regional level. Against the background of this evaluation, the Government will then implement measures to improve interdisciplinary services offered to children needing support from the child welfare authorities.

The Government wants to focus on foster homes in coming years. Over 80 % of children and young people taken into public care are placed in foster homes. It is therefore crucial to ensure the highest possible quality in all aspects of foster-home work. Foster children are often very vulnerable and may have experienced a difficult breakdown of their biological family. Some of the children have behavioural patterns that are extremely challenging for foster parents. To avoid new, disruptive breakdowns and unplanned relocation of foster children, work has been started to improve follow-up and guidance of foster parents. Foster parents also need someone to turn to when conflicts arise – at any time of day or night. A helpline system is therefore going to be set up so that foster parents can contact the child welfare authorities quickly in acute situations outside normal municipal working hours.

Today’s labour market has very high requirements regarding education and qualifications. Young people who have been under the care of or have received assistance from the child welfare authorities often need help and follow-up to set them selves up independently. Effective from September 1998, the Act on Child Welfare Services was amended to allow assistance given before a child has reached 18 (if the child consents) to be continued or replaced by other forms of assistance until the individual in question is 23 years old. There is now a statutory duty to evaluate the need to continue existing or introduce new forms of assistance for all young people who were taken into care by the child welfare services. In these cases, the child welfare service is also obligated to draw up a plan detailing planned forms of assistance in the future if the young person in question wishes to continue to receive assistance. Statistics show that many employees in the child welfare authorities believe child welfare clients need following up beyond the age of 18.

The Ministry of Children and Equality is once again going to take the initiative of informing the municipalities about their duty to provide information about the right to appeal in cases where the child welfare service rejects a young person’s request to continue receiving assistance from the child welfare authorities after the age of 18 years. The Ministry is also going to investigate various aspects of after-care more closely. Using a variety of documentation, the Ministry is going to consider further measures to help make the transition to adulthood as smooth as possible. The idea is to identify good practices that can be shared with the local authorities. In connection with the current focus on poverty, development work has been started linked to after-care and rehabilitation after serving a sentence for young people up to the age of 23. The goal is to help the young person make the transition to independent adulthood.

4.2.5 Participation in organisations and cultural activities

The Government has set itself the goal of increasing participation in cultural activities and organisations in groups that currently do not participate. Cultural activities and voluntary organisations are important social meeting places and central arenas for participation and having fun. Participation in voluntary organisations forges contacts and creates social networks. Social networks and a sense of belonging are crucial for individual health. Participation in cultural activities is fun and gives a sense of achievement. Cultural experiences promote communication, a sense of community and well-being, and in this respect are an important part of growing up.

Voluntary organisations do not recruit equally from all groups in the population. Groups with high income and a long education tend to participate more actively than groups with low income and a short education. We know that children from low-income households participate less in activities in their free time and at school than other children and young people. Vast differences have been documented in the population regarding participation in cultural activities. A survey to determine who uses culture revealed that use of art and cultural facilities varies systematically with personal economy: people with low income make far less use of publicly financed art and cultural facilities. Positive childhood experiences of participation in organisations are decisive for activity in adulthood. Participation in organisations and cultural activities may be too expensive for families in a bad financial situation. The outcome is that the children may be excluded from important social arenas.

Young people with an immigrant background participate less frequently in recreational activities than other Norwegian children and young people, although these young people themselves report that they would like to participate in organisations. The Institute of Applied Social Science (Fafo) report «Young people’s participation in organised leisure activities in multicultural Oslo» from 2005 claims that there is a positive correlation between the family’s economy and young people’s participation in sports teams. This correlation is most clearly observed among ethnic Norwegians and does not explain why ethnic-minority young people are less active in organised sports than average.

Music and arts schools

Municipal music and arts schools play an important role in nurturing a living, dynamic cultural life. The music and arts schools are a recruitment arena for future performers within the various arts – on the amateur and professional levels. These schools also provide towns and villages with access to cultural activities by making live concerts, theatre performances and other artistic expressions available to a broad public in large and small local communities. In this way, the music and arts schools also recruit audiences to the field of art and culture. Open, inclusive music and arts schools with room for everyone who wants to learn will help dissolve inequalities by providing an arena for more young people to develop important aspects of themselves.

The Cultural Rucksack

The Cultural Rucksack provides children and young people with access to a wide range of cultural activities at school. School is a gathering place for everyone and is therefore ideal for ensuring that everyone is given a basic introduction to the arts as a foundation for future participation in and use of cultural activities. The Cultural Rucksack serves to level out inequalities in the use of culture among children and young people. The scheme helps ensure everyone has the opportunity to experience art and culture and provides pupils with the opportunity to express themselves through art and culture regardless of geographical factors and social divides. This scheme is currently only available to children and young people in primary and lower-secondary school, but in 2007 a number of pilot projects are being carried out in upper-secondary schools. Young people in this age group are in the process of changing from children into adults, and it is important that activities are designed so that they seem meaningful to the individual.

Traditionally, children encounter art and culture with their parents, and this use of culture has tended to reflect social inequalities. Schemes like the Cultural Rucksack help ensure that encounters with culture occur independently of social identity. In many ways, the Cultural Rucksack represents new content and new methods at school. This can be a positive experience for pupils who have difficulties adapting to ordinary teaching at school.

Other cultural measures

One of the priority tasks ascribed to the Norwegian Archive, Library and Museum Authority (ABM utvikling) is universal design. A network for universal design has been established, and an inspiration seminar for universal design has been held at five locations in Norway. The project The accessible library was carried out in the period May 2001 to December 2004. The purpose of this project was to give library users with reduced functional capacities the same access to libraries as other users.

Cultural organisations that arrange events throughout the country spread culture and create opportunities for equalisation in terms of cultural activities. The Norwegian Concert Institute, the State Touring Theatre, and the National Museum of Art, Design and Architecture, as well as other museums and libraries are taking steps to ensure greater openness towards the public and are implementing changes to make their facilities accessible to everyone.

A pilot project whereby young people in the age group 16–20 can buy a cultural card providing cheaper access to cultural events will help counteract social inequalities in use of cultural facilities. The culture card for young people scheme is being continued and expanded in 2007.

Volunteer centres

The many volunteer centres in Norway are important arenas for voluntary work, participation and generate a sense of belonging in the local community. They provide a wide range of social care services as well as offering cultural, recreational and local activities. The volunteer centres play a key role in creating good, lively local communities and coordinating local involvement, social responsibility and culture.

The volunteer centres have made it easier for more people to be involved in voluntary work. The centres have also tried innovative methods to get people involved in local voluntary projects. An active, welcoming attitude combined with concrete tasks linked to the volunteers’ wishes and interests has yielded impressive results. The centres are also a meeting place for people with time on their hands in the day time. There are more homemakers, people on some kind of pension and unemployed people associated with the volunteer centres than in traditional voluntary organisations.

The volunteer centres aim to collaborate with the positive forces available locally: different teams and associations, congregations, public authorities and individuals. Forging contacts, developing networks and bringing together people who have something in common are important and useful tasks to stimulate and develop local voluntary activities, which can also have positive influence on the individuals involved.

Grants for schemes in cities

The Ministry of Culture and Church Affairs administers a grant scheme for activity development and social integration in local sports clubs in selected urban districts and areas in the largest cities. The target group for this scheme is children and young people who because of economic or cultural barriers are prevented from participating in organised activities. The grant for activity development and social integration in local sports clubs is going to be increased in 2007.

The Ministry of Children and Equality administers a grant scheme for measures intended for children and young people in large urban communities. These grants are for measures aimed at groups of young people that do not make use of the existing cultural and leisure activities. The scheme is intended to contribute to qualification, inclusion and establishment of alternative arenas and to prevent anti-social behaviour such as violence and bullying, crime, drinking, drugs and racism. Within the framework of this scheme, there are earmarked funds for measures to tackle poverty problems. Children and young people with an immigrant background are given high priority. The grants can be used for holiday and leisure activities and for better contact with the labour market for young people with little or no education.

5 Work and working environment

5.1 Objective: Inclusive working life and healthy working environments

Objectives

• A more inclusive working life

• Healthier working environments

5.2 Policy instruments

The Government regards two areas related to working life as particularly important for reducing social inequalities in health: continuing the focus on creating an inclusive working life and working for a healthier working environment in industries with major occupational stress.

We know that being in work is in itself good for health. People outside the labour market consistently have poorer health than the occupationally active part of the population. This does not only apply to recipients of health-related benefits, but also to people who have been unemployed for a long time and recipients of social assistance. There are therefore grounds to believe that a more inclusive working life will improve the population’s health.

Policy instruments to achieve a more inclusive working life are described in chapter 8 in this Report to the Storting. In this chapter, we will focus on policy instruments aimed at improving working environments.

Major inequalities in health are also found among the working population. This is partly due to differences in physical and psychosocial occupational stress between occupational groups. People with a short education and repetitive, manual work tend to be more exposed to major health problems.

Although we have nowhere near enough knowledge about the correlations between working environment, health problems and exclusion from working life, it is fairly safe to assume that easily replaceable workers are the most likely to be excluded, i.e. people with the least education, and that people with few career options work in the most harmful working environments. These are usually employees with a short education, women in part-time jobs, immigrants and young people. Important policy instruments to improve the situation for these people include preventive working environment measures and better adaptation of the environment, especially in occupations and workplaces with much unskilled work, heavy work, time pressure and little possibility of choosing how the work is performed.

Efforts to prevent injury, improve working environments and adapt the workplace must be undertaken within enterprises. The authorities’ role is to influence and support this work through policy instruments.

5.2.1 Working environment legislation

A new Working Environment Act came into force in Norway on 1 January 2006. The purpose of the Act has not changed, namely: to secure a working environment that affords full safety from harmful physical and mental influences, ensure sound conditions of employment and provide a basis whereby the employer and the employees of undertakings may themselves safeguard and develop their working environment. The new Act shall also:

• ensure equality of treatment at work.

• facilitate adaptations of the individual employee’s working situation in relation to his or her capabilities and circumstances of life.

• provide a basis for a healthy and meaningful working situation and inclusive working conditions.

The new Act defines in more detail the duties of the employer and employee regarding health, environment and safety work. The Act also lays down requirements concerning greater participation in restructuring processes. It is spelt out that the requirements concerning the psychosocial working environment also include requirements concerning protection from violence and threats from customers, clients, etc. The Act is also clearer concerning the right to equal treatment in connection with appointment, for example, the new Act prohibits discrimination of part-time employees and temporary employees regarding pay and working conditions. The employer’s duty to adapt the working environment for employees with reduced capacity for work is laid down in the Act, and better follow-up of this statutory duty may help reduce occupational inequalities in health.

5.2.2 The Norwegian Labour Inspection Authority

The Norwegian Labour Inspection Authority is responsible for overseeing that enterprises comply with the requirements of the Working Environment Act. The Norwegian Labour Inspection Authority reaches around 8 % of enterprises in Norway through its inspections and must therefore prioritise its efforts after a risk assessment based on knowledge and experience about which occupational groups, industries and sectors have the most occupational stress. A large proportion of the resources available for inspections is spent on major projects aimed at high-risk industries, which in itself helps reduce social inequalities in health.

According to the Norwegian Labour Inspection Authority’s risk assessments, the employees most exposed to occupational stress work in the health and social services, transportation, and commercial services such as cleaning. Many of the tasks within these industries involve lifting heavy items, awkward working positions, monotonous repetitive work and tight deadlines. Immigrant groups from non-Western countries are overrepresented in a number of these occupations.

It is the Norwegian Labour Inspection Authority’s experience that changing attitudes and behaviour requires a strong, high-profile effort over time, and in a move to reach more workers, the Norwegian Labour Inspection Authority has developed a new strategy attaching greater importance to prevention in its capacity as an advisor and agenda-setter. By virtue of its role as a guide, for example, by providing good examples and tools for adaptation of the environment and risk assessment, the Norwegian Labour Inspection Authority aims to contribute to better compliance in enterprises with the requirements intended to ensure a safe working environment.

Cultural differences and language problems also affect the working environment situation. They can pose challenges in terms of organisation, adaptation of the environment and personnel management at all levels in companies. The Norwegian Labour Inspection Authority’s 2005 campaign on working environment conditions for non-Western workers revealed major disparities in working life in Norway as a result of insufficient information and training. Speakers of minority languages from non-Western countries are overrepresented in working environments with multiple, different stresses and among people who have sustained injuries. The Norwegian Labour Inspection Authority is increasingly coming across problems and issues linked to the working environment and working conditions for employees from new EU countries. This applies to the building and construction industry in particular.

5.2.3 Company health services

Company health services are an important working-environment tool intended to help enterprises in their preventive and health-promoting work. A project has been undertaken in collaboration with the trade unions’ and employers’ associations and the affected authorities to assess the roles, responsibilities and tasks ascribed to company health services. This project will also assess which criteria should be used as a basis for deciding whether an enterprise should be obligated to establish a company health service and if there is a need for any quality requirements or some form of approval system. This project is due to be completed in autumn 2007.

5.2.4 Higher employment among immigrants

Immigrants represent a resource for working life in Norway. A current challenge is how the labour market can make better use of immigrants. The unemployment rate among immigrants is three times higher than among the rest of the population. Registered unemployment among immigrants dropped from 9 % in the second quarter of 2005 to 7.3 % in the second quarter of 2006. In the rest of the population, registered unemployment went down from 2.9 to 2.1 %. Among immigrants, the proportion of people in work rose from 56.6 % in the fourth quarter of 2004 to 57.5 % in the fourth quarter of 2005. In the population as a whole, there was a marginal increase from 69.3 to 69.4 % in the same period.

There are numerous reasons why immigrants have weaker contact with the labour market than the rest of the population. It may be because some groups of immigrants have inadequate qualifications and do not satisfy the requirements in the Norwegian labour market. It may also be because immigrants are more often subject to discrimination in working life. A lack of networks and attitudes towards women working outside the home have also been cited as causes. Despite variations, immigrants’ contact with the labour market seems to vary with where they come from and how long they have been in Norway.

It is a goal to reduce unemployment and increase employment among immigrants. Immigrant women are to be given first priority. A number of measures have already been implemented, for example one measure qualifies and adapts newly arrived immigrants’ skills for the Norwegian labour market, and another measure aims to improve the labour market’s ability to include immigrants. The main goal of the introduction scheme for immigrants that have recently arrived in Norway is to improve the ability of newly arrived immigrants to find work or embark on training quickly. It focuses on the individual’s resources and offers qualification specially tailored to the individual’s needs. From 1 September 2005, all adult immigrants have the right and duty to attend classes in Norwegian and civics. A second chanceis a trial system of paid qualification based on the same model as the introduction scheme for immigrants who have still not established themselves in the labour market after several years in Norway and therefore still depend on social assistance. These projects focus on qualifying people for work and mediating ordinary work to people who need basic qualifications. Immigrants are a priority target group when allocating places in labour market measures.

The purpose of the Anti-discrimination Act is to combat discrimination and promote equality in a broader and more long-term perspective. The Anti-discrimination Act applies in all sectors of society, including working life. From 1 January 2006, a special enforcement system was set up for equality and discrimination through establishment of the Equality and Anti-discrimination Ombud and the Equality and Anti-discrimination Board of Appeals. These two bodies uphold several laws protecting against discrimination, including the Anti-discrimination Act. The Government is particularly keen to encourage recruitment to working life and is collaborating with the trade unions’ and employers’ associations to develop a proactive recruitment policy.

The Government’s Action plan for the integration and inclusion of the immigrant population and goals for inclusionshall serve to ensure that immigrants contribute their resources to society as quickly as possible, to avoid the development of a stratified society where people with an immigrant background have poorer living conditions and lower participation than the rest of the population and ensure that immigrants and their descendents have the same opportunities as other members of society. The action plan contains measures for implementation in a number of areas, including a considerable strengthening of efforts aimed at getting immigrants into work.

5.2.5 Action Plan against Social Dumping

In May 2006, the Government introduced its Action Plan against Social Dumping to counter challenges entailed by the influx of migrant workers after enlargement of the European Economic Area. This action plan includes important measures that the Government believes can help achieve the goal of proper pay and working conditions for everyone and a well-functioning labour market. To this end, the government increased the resources and sanctions available to the Norwegian Labour Inspection Authority and the Petroleum Safety Authority Norway, and from 1 December 2006, these authorities are entitled to use orders, coercive fines and shutdown of operations in connection with inspections of pay and working conditions pursuant to the Act relating to general application of wage agreements etc. and the Immigration Act.

In December 2006, proposals detailing further measures to combat social dumping were circulated for review. These proposals concern measures to ensure proper conditions related to hiring and renting out labour and measures for stronger control and follow-up of pay and working conditions in industries with generally applied wage agreements.

5.2.6 National system for monitoring work and health

The knowledge we have about the working environment as a direct cause of health problems tends to be linked to certain industries, occupations and circumstances. In light of the broader patterns we observe in social inequalities in health, this knowledge is fragmentary and insufficient.

On 1 January 2006, a national system for monitoring working environment and health (NOA) was established at the National Institute of Occupational Health to gather and process relevant data and information about working-environment issues and make them available to other users. Relevant users include the public authorities, players in working life, researchers and the general public. The aim is to build up a corpus of knowledge for use by all the actors in the area, for designing policies and strategies, and to provide better opportunities for measuring and assessing the results achieved.

This monitoring system will enable the National Institute of Occupational Health to help quantify social inequalities in the distribution of positive and negative factors in the working environment (exposures) and possible work-related impacts on health.

The National Institute of Occupational Health will also be able to provide analytical studies to quantify the impact of factors in the working environment on social inequalities in health and help quantify what health selection associated with «the new workplace» means for social inequalities in health.

5.2.7 Increase research on sickness absence and exclusion from working life

We have a lot of knowledge about individual causes of sickness absence, but we do not know enough about the relative strength of the causes and how they interact. In light of this, the Government announced in Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusiona new focus on this area with the intention of stimulating research collaboration across existing disciplinary boundaries. The new investment in research will start in 2007 and its objective is:

• to contribute to a more coordinated, stronger knowledge base about the causes of sickness absence, disablement and exclusion from working life.

• to ensure research-based knowledge about effective policy instruments in order to prevent sickness absence and disablement and help achieve the Government’s goal of an inclusive labour market.

• to help ensure that teaching in relevant courses of education is more firmly anchored in research.

5.2.8 Sickness absence and exclusion in high-risk industries

As a means of reducing sickness absence in industries with a high rate of exclusion, the Ministry of Labour and Social Inclusion initiated a project in December 2006, one of the goals of which is to reduce sickness absence in two selected industries with especially high levels of sickness absence by focusing attention on specific challenges related to the working environment in the industry itself, and by making the trade unions’ and employers’ associations accountable. This work is to be coordinated by the Norwegian Labour Inspection Authority and carried out in close collaboration with the agencies’ advisory councils made up of the affected associations and the Norwegian Labour and Welfare Organisation (NAV).

In addition to this project focusing on specific industries, the Government wants to study causes of sickness absence in the health and care sector. Many of the people exposed to the most working-environment strains work in the health and care sector. Many of the tasks they perform include heavy lifting, awkward working positions, monotonous repetition, tight deadlines and rotating shift work. Working conditions that are perhaps typical of «modern working life» (increasing rate of change, time pressure and efficiency and competency requirements) also play a role in exclusion through extended sick leave and being put on a disability pension in this sector. Any reductions in sickness absence and exclusion in the health and care sector will have a positive effect from a health-distribution perspective.

The state is the main employer within the affected industries and thus has a special responsibility. The Government will therefore initiate a study to ascertain the scope of, causes of and possible measures to avoid health-related absence in and exclusion from the health and care sector.

This study is to be undertaken by a committee made up of people from a wide range of spheres, and the trade unions’ and employers’ associations and the working environment authorities are invited to take part.