Part 2
Reduce social inequalities in health behaviour and use of the health services

6 Health behaviour

«Attention needs drawing to the underlying, structural causes of behaviour in order to encourage healthy lifestyle choices.»

6.1 Objective: Reduced social inequalities in health behaviour

Objective

• Reduced social inequalities in health behaviour

Other goals

Reduced social differences in:

• diet

• physical activity

• smoking

• other health behaviour

Health behaviour means lifestyle and habits that have a major impact on health, such as diet, physical activity, smoking and drinking.

6.2 Policy instruments

Individual’s health behaviour choices are largely determined by their social environment. Smoking, physical inactivity, unhealthy eating habits and abuse of drugs and/or alcohol are unevenly distributed among groups in the population. With the possible exception of consumption of alcohol, health behaviour that increases the risk of illness tends to be more common in groups with a short education and low income.

Health behaviour is closely related to social structures. Attention needs drawing to the underlying, structural causes of behaviour in order to encourage healthy lifestyle choices. For example we know that there are clear social inequalities linked to who manages to stop smoking. This is not merely a case of some groups having more knowledge about how harmful tobacco products are – it is also a question of resources, motivation and energy. Good public health work in this area therefore needs to focus on making it easier and more natural for people to change their health behaviour – from unhealthy to healthy habits.

Health information campaigns have played a central role in bringing about changes in the population’s health behaviour, but we also know that health campaigns are often most effective in the parts of the population that already lead the healthiest lifestyle. It is therefore necessary to design new campaigns that are better able to reach the target groups from a social perspective. It is also crucial to ensure that good information is available to ethnic minorities, such as non-Western immigrants and Samis.

Measures targeting children and young people are very important because the foundation for good habits is laid early in life and because factors in childhood have a major impact on health later in life. Boys and girls react differently to the same measures. For example, studies show that boys benefit less from traditional information measures. It is therefore important that all strategies and interventions are assessed in view of the impact they will have on both sexes. This also applies to measures targeting the adult population.

The design of public health measures must take account of our multi-cultural society. A large proportion of the Norwegian population identifies with two cultures. Immigrants from non-Western countries often find that establishing themselves in a new country with a different culture and foreign language leads to detrimental changes in diet and less physical activity. Some immigrant groups have stopped eating their traditional varied diet with a high intake of healthy foodstuffs such as vegetables, fruit, lentils and beans in favour of food products containing high levels of fat and sugar. These changes manifest themselves in the higher incidence of certain health problems linked to nutrition, such as obesity and type 2 diabetes in some immigrant groups.

It is important that all significant considerations are included in assessments when proposing new initiatives, in the health sector and in other areas of society. In many cases, levelling out social inequalities will be an important consideration. The Government wants to underline that measures intended to influence health behaviour must always be assessed in light of the goal of reducing social inequalities in health. Health impact assessments are discussed in more detail in chapter 9.

International experiences from intervention studies suggest that structural measures affecting price and accessibility seem to be more effective at reducing social inequalities than information and health education measures. Information campaigns tend to work best in the parts of the population that already have the best health and thus often serve to widen the social gap.

The Directorate for Health and Social Affairs recommends general, broad-based, low-threshold measures and targeted measures aimed at the most deprived and vulnerable groups, especially children and young people. Low-threshold activities require little equipment and no special skills, they should be free of charge or cheap, and should be easily accessible physically, socially and culturally.

The Government wants to make healthier choices more readily available by increasing the emphasis on structural policy instruments in combination with health information measures.

6.2.1 Accessibility in schools and kindergartens

Examples of interventions intended to change health habits include daily physical activity at school and access to cold drinking water and fruit and vegetables at school. Kindergartens and schools are crucial arenas in the effort to encourage healthy habits because they make it possible to reach all children and young people. For example, increasing physical activity at school also leads to increases in physical activity after school hours and on weekends. This effect seems to last well into adulthood. This measure appears to have the greatest impact on children of parents with a short education and low income and non-Western immigrant children.

Major health gains are achieved, in terms of longer life and better quality of life, by offering fruit and vegetables to all pupils in primary and lower-secondary school. Fruit and vegetables for all pupils in primary and lower-secondary education helps establish a high intake of fresh produce in childhood. The evaluation of a pilot project providing children with free fruit and vegetables in schools in Hedmark county shows that this measure reduces social inequalities in intake of fruit and vegetables.

6.2.2 Measures in the local community

Helping smokers give up smoking is an important tool in the drive to prevent use of tobacco products. For several years now, the Directorate for Health and Social Affairs and the County Governors have been training people to hold courses in stopping smoking, and courses are now available throughout the whole of Norway. Many voluntary organisations make a major contribution: for example, the Norwegian National Health Association in Hedmark and Oppland counties collaborates with the local County Governors. This coordination of activities has led to more public health initiatives, and the model is now being applied in other counties.

As part of the follow-up to the Action Plan on Physical Activity 2005–2009, the Directorate for Health and Social Affairs has worked with local governments and other actors in four counties (Nordland, Buskerud, Vest-Agder and Oppland) on a joint project to develop systematic programmes for physical activity, dietary guidance and giving up smoking as tools in the municipal public health work. Municipal centres promotting physical activity for certain groups, called « frisklivssentraler» (FLS), and similar models have been set up to implement measures locally. This is a continuation of the low-threshold FYSAK measure, which is a measure implemented at the local level to encourage physically inactive groups in the population to be more physically active. Based in the municipal health service, the programme aims to develop models for systematic use of physical activity aimed at certain groups in public health work.

FYSAK Nordland was established as a model programme for physical activity in selected municipalities in Nordland County in 1995–96 and ran until 1999. The programme was continued as a permanent county-municipal sphere of work from 2000. The model is based on regional collaboration among a number of actors. The objective is to develop promotion of physical activity as part of the municipal health service’s standard range of services, where activities are set up as a collaboration across government agencies and sectors. The target groups for individual measures are defined on the basis of the needs identified by the individual municipality. Evaluations have found very positive results. The Directorate for Health and Social Affairs is going to take steps to ensure that FYSAK and similar measures to promote more physical activity are incorporated into the Partnerships for Public Health in all the counties in Norway.

The Ministry of Health and Care Services is going to strengthen the grant scheme for physical activity to stimulate the development of more low-threshold activities.

It is a goal that Norway should have good residential environments that promote physical activity. Local communities are going to be adapted to encourage as many people as possible to exercise. For example, it should be easy and safe for people to get around on foot or by bicycle. Physical accessibility for people with reduced functional capacity is still substandard in many places, leading to exclusion and marginalisation. A lack of money is often an obstacle to physical activity. Simple outdoor activities and activities in the local environment are often very low cost and can be carried out in most places.

Local low-threshold measures are important in the work on further developing and evaluating the system of «green prescriptions». The municipal health service, the local community and workplaces are good potential arenas for prevention and intervention. In addition to the health service, voluntary organisations and private actors, the Norwegian Labour and Welfare Organisation (NAV) should also be considered as a potential collaborative partner. The activities offered must be based on the municipal land-use plan and must build on existing structures for the local government’s or other actors’ operations and services.

A system of dietary advice courses for patients is currently being tested. These kinds of low-threshold measures are to build on existing services and experiences, and effort should be made to coordinate new measures with existing measures like Active During the Day, measures coordinated by the county and municipal administration, voluntary organisations, municipal centres promoting physical activity ( frisklivssentraler), etc. The Directorate for Health and Social Affairs is going to collect knowledge and arrange experience sharing so that more people have access to these kinds of measures.

The Government wants to prevent lifestyle diseases and improve dental health in high-risk groups in the immigrant population. As part of the Action plan for the integration and inclusion of the immigrant population and goals for inclusion, the Government is therefore going to stimulate establishment of measures to promote physical activity and good eating habits.

6.2.3 Work as an arena

Work is an arena where we can reach groups it has been difficult to reach through information campaigns and other policy instruments. For example, work can be a good arena for promoting healthy eating habits, physical activity and stopping smoking. Large workplaces that have a canteen can arrange courses and other events to raise levels of knowledge among canteen staff and can ensure fresh fruit and vegetables are available. The Ministry of Health and Care Services is going to consider joint measures with labour organisations and providers of food to promote healthier eating habits.

The project «Health-promoting workplaces» focuses on factors that have a positive influence on health in the working environment. When the project was started, a declaration was signed stating that health-promoting workplaces evolve through processes steered by participants and accept and accommodate the needs, resources and potentials of the individual. The inclusive working life idea bank has collaborated with other actors to collect experiences gained from projects and research on health-promoting workplaces.

In order to reach groups outside normal working life, the Ministry of Health and Care Services is going to collaborate with the Ministry of Labour and Social Inclusion on assessing how the Norwegian Labour and Welfare Organisation (NAV) offices can be used as an arena to make public health work more target-oriented.

6.2.4 Lifestyle guidance in the health service

Giving information directly to individuals within the setting of the health services is often especially effective. Documentation shows that advice and interventions in the health services have been very effective for patients with high-risk use of drugs and alcohol. These kinds of interventions function as a supplement to information campaigns and other measures.

The «Learning and Activity Centres» at the regional health enterprises are an important arena for training patients with chronic disorders. Many of the centres now have facilities for groups of chronic patients. Treatment often includes dietary advice and assistance in stopping smoking.

Health advice in the health services is a new focus area in the drive to prevent the harmful effects of tobacco use. The National Strategy for Tobacco Control 2006–2010 defines improving health workers’ knowledge about stopping smoking and one-to-one communication as main priorities. It is important to strengthen the input in the specialist health services vis-à-vis patients with smoking-related disorders. For large groups of patients – for example patients with COPD – stopping smoking is the most effective single form of treatment in curbing the development of the disease. The regional «Learning and Activity Centres» may be an appropriate arena for this work. Strengthening systematic work to help people stop smoking is an important priority. This means developing guidelines, providing healthcare workers with good training, and introducing economic incentives to encourage the health enterprises to give this work greater priority. The training of health care staff needs to include courses on giving advice regarding lifestyle changes in general and help stopping smoking in particular.

GPs and regular GPs advise patients on diet and physical activity. Diet is important in the treatment of many diseases. Giving advice on diet and nutrition takes time, and an ordinary doctor’s appointment is often not enough. In these kinds of cases, doctors can use an hourly rate or, depending on the diagnosis, the rate for «green prescriptions». Green prescriptions can be used in connection with type 2 diabetes and high blood pressure not being treated with medicines, for example. The evaluation of the «green prescription» scheme reveals a great need for auxiliary measures to change health behaviour outside doctor’s offices: many doctors cite a lack of expertise in the municipality to whom doctors can refer patients for further follow-up, for example physiotherapists and dieticians. Over half of doctors report that they have nowhere to refer patients to for further follow-up.

It is necessary to promote good health by improving dental health. The dental health service provides outreach dental health services for children and young people and for groups that are deemed to have special dental health needs. The dental health service is also charged with organising preventive dental health care. This may take the form of general schemes or targeted measures aimed at specific groups. In the spring of 2007, the Government is going to submit a report to the Storting on the dental health service. This Report to the Storting will discuss the issue of how better use can be made of the dental health service as a collaborative partner in public health work and how the dental health service can help reduce social inequalities in general health and dental health.

The health centre for young people is the most important local provider of contraception and advice for young people. Health centres for young people also have an important teaching function through their collaboration with schools concerning relationships and sexuality. The last few years have seen a major expansion in health centres for young people within the municipalities’ primary health services, but it still seems that availability is inadequate in many places – especially in sparsely populated areas. Finnmark county and the other counties in northern Norway have particular problems in terms of availability of health services for young people.

The maternal and child health centres and school health service have been charged with providing guidance, advice and information. Important topics include guidance about diet, physical activity, tobacco, alcohol and drugs. The maternal and child health centres and school health service are an important driving force in preventive work by virtue of their contact with kindergartens and schools, and they are supposed to support and contribute to good eating and mealtime habits and arrangements for physical activity in these arenas. The close, early contact that maternal and child health centres have with families, especially during children’s first year of life, plays an important part in the work to encourage breastfeeding and establish healthy eating habits from the outset. The service also gives advice on use of formula and general advice about nutrition for babies and young children.

6.2.5 Regulate access to goods and services

As part of the follow-up to The Diet Action Plan, the Ministry of Health and Care Services is undertaking a study to ascertain whether it might be appropriate to regulate advertising of unhealthy food and drinks aimed at children and young people. The Norwegian authorities participate actively in the debate about these issues, through the collaboration between the Nordic countries and within the EU and the World Health Organization.

Children and young people eat too much sugar and fat, and much of this comes from sweets, fizzy drinks, soft drinks and snacks. These food products have little nutritional value, but contain a lot of calories and should not make up a significant part of people’s diet. These products lead to obesity among children and young people. Some parts of the food industry spend considerable sums of money marketing these goods, also to children and young people. Studies show that marketing of these kinds of food products constitute a large part of the television advertising broadcast in connection with television programmes for children and young people. It is a well-documented fact that marketing works. Children exposed to advertising and measures to promote sales of these products have a higher intake of these food products than other children. This is reflected in the amount of sugar and fat in their diet.

1 June 2004 saw introduction of the ban on smoking in cafes, bars and restaurants in Norway. Evaluations show that the air quality for employees in these establishments has improved dramatically, and that this has led to a reduction in the number of respiratory complaints and better health. In addition to less exposure to second-hand smoke, it is expected that the ban on smoking will also reduce smoking among employees. This group of employees has relatively little education and low income. A positive side effect is that an important recruitment arena for young people is now smoke-free. It is also likely that the amendments to the legislation have accelerated the decrease in the number of smokers in the population in general.

Despite a minimum age limit of 18 for buying tobacco products, studies show that around half the young people aged 13–17 who smoke have no problems buying tobacco. A proposal suggesting a new system for supervising selling to minors was circulated for review in autumn 2005 and is currently being considered by the Ministry of Health and Care Services. The Norwegian Food Safety Authority is the proposed supervisory authority. The Government is considering proposing introduction of a supervisory system. The Government is also considering a proposal to ban visible displays of tobacco products in retail outlets. This proposal is currently being developed. Steps are also being taken to get all the county municipalities in Norway to introduce a ban on smoking in school hours in upper-secondary schools for pupils and staff alike. This measure is important because it is at this age that most people start using tobacco.

It is well-documented that the most effective tools in alcohol policy are those that reduce availability and raise the price. The main elements in Norway’s alcohol policy are a strong retail monopoly, high taxes and prices, an extensive system for inspecting retail outlets and licensed venues, and tight restrictions on the marketing of alcoholic beverages. Ours is one of the most restrictive alcohol policies in Europe. There are therefore grounds to assume that the alcohol policy we have adopted hitherto is an important reason why alcohol consumption in Norway is among the lowest in the Western world. The Act on the sale of alcoholic beverages assigns a major responsibility to the local governments, partly through their licensing authority. In recent years, we have seen a gradual increase in availability of alcohol. For example, according to the Norwegian Institute for Alcohol and Drug Research, SIRUS, the number of licences to serve alcohol in Norway has risen from 2439 in 1980 to 7231 in 2005. In spring 2006, the Directorate for Health and Social Affairs published a new handbook on drawing up municipal plans of action on alcohol and drug policy. Here, the local authorities are encouraged to see the entire alcohol and drug policy in context and regard their licensing policy as an important tool in the general efforts to prevent substance abuse, in order to counteract further increases in the number of licences to sell and serve alcohol.

On 1 July 2006, a ban was introduced prohibiting use of note acceptors in gambling machines. This measure is part of the Government’s efforts to prevent gambling addiction until gambling machines are phased out altogether. The ban on note acceptors has already led to a marked decrease in turnover for gambling machines. The Government has decided to introduce night-time closing hours (midnight to 7 AM) on gambling machines and obligatory labelling of machines with information and warnings about the consequences of exaggerated use of the machines. Gambling machines are going to be banned completely starting 1 July 2007.

Changes in prices and taxes

Tobacco prevention work traditionally uses taxes as a tool. Research shows that young people are particularly sensitive to changes in the price of tobacco. Older smokers have a longer smoking history and established psychological smoking rituals as well as physiological nicotine dependence. Young people have less money to spend on tobacco, and young smokers do not have the same firmly established tobacco habits and are therefore easier to influence.

A review of research on measures to reduce smoking among young people (carried out by Lund and Rise, 2002, on commission from the Directorate for Health and Social Affairs) shows that income is decisive for price sensitivity. Sensitivity to changes in price means that groups with limited financial resources generally reduce their demand to such a great extent that the group spends overall less money on tobacco. Groups with greater spending power – that are not so price sensitive – consume roughly the same amount of tobacco after a price rise and thus bear a larger part of the expense. Raised taxes can thus contribute to reducing social inequalities in health behaviour since this policy has the greatest impact in the poorest groups.

It is assumed that the most important effects of an increase in taxes will be fewer young people starting to smoke and adults stopping smoking altogether, as opposed to people who continue to smoke cutting down their daily consumption. People who continue to smoke despite increases in taxes will experience an increase in expenses. The economic burden of an increase in tax on tobacco will be greatest for people with the worst financial situation. The health benefits of an increase in the tax on tobacco must therefore be considered in light of the burden increased taxes will entail for people with limited financial resources.

Taxes are a key tool in Norwegian alcohol policy. Like changes in prices of other goods, an increase in the price of alcohol will have the greatest impact on consumption in groups with limited financial resources. It is therefore reasonable to assume that a reduction in taxes on alcohol and the price of alcohol would lead to the greatest increase in consumption – and therefore also injuries – in groups with limited financial resources. It is important to continue a restrictive alcohol policy with high taxes to avoid an increase in alcohol-related illness and injuries in these groups. When considering the level of tax on alcohol and tobacco, we must also take into account developments in unregistered consumption.

The population’s diet can be influenced by making unhealthy products relatively more expensive. Special taxes on unhealthy products are one of several policy instruments that will help improve the population’s diet. However, the impact of this instrument will depend on the degree to which the taxes affect the price and how sensitive the consumers are to price in their choices. The health impact will also be weakened if the price rise leads to consumers simply buying these products abroad instead.

Pursuant to proposals in Proposition no. 1 to the Storting (2006–2007) Decisions on taxes and customs, the Storting has changed taxes on non-alcoholic beverages so that drinks with added sugar and sweeteners are taxed, while bottled water and juice are exempt from taxes. We would prefer this tax only to apply if the sugar content passes a defined lower limit, motivating the industry to lower the sugar content in beverages. However, a lower limit would depend on requirements regarding labelling specifying the sugar content. The current EU regulations do not call for this kind of labelling, but Norway has proposed this solution to international bodies.

Calculations carried out by the Norwegian Agricultural Economics Research Institute demonstrate that a 12 % drop in the price of fruit and vegetables in Norway would cause an increase in the total demand of between 4 and 15 %. Among young people living alone and couples with children, total demand for fruit and vegetables is expected to rise by 11–12 %. These groups spend less of their food budget on fruit and vegetables than other households. However, it must be pointed out that there will always be a great deal of uncertainty associated with these kinds of calculations.

It is the Government’s view that the interests of children and young people should be given priority. Cheaper fruit and vegetables will serve to increase consumption among young people and in families with small children in particular. These are important target groups for establishing good habits at an early age, which can help reduce the risk of illness later in life. As part of the follow-up to the Diet Action Plan, the Ministry of Health and Care Services will take the initiative to ensure that economic policy instruments are considered.

7 Health services

7.1 Objective: Equitable health and care services

Objective

• Equitable health and care services

Other goals

• Better knowledge about social inequalities in the use of health services

• Better knowledge about factors that contribute to social inequalities in the use of health services and factors that can counteract these imbalances

• Better health services for at-risk groups

Health and care services should be equitable in terms of availability, use and results. In this Report to the Storting, the term «the use of health services» covers all three central aspects of the service.

7.2 Policy instruments

Although the population’s health is primarily influenced by factors beyond the control of the health sector, a well functioning health service is nevertheless an important prerequisite for good public health. In Norway, we have a very high level of ambition for our health services. We want high-quality services that are available within an acceptable waiting time and distance and that the services and facilities offered reach everyone regardless of their social background. Most of these high ambitions have been met, and Norway has one of the best health services in the world. Nevertheless, we must acknowledge that there are still deficiencies and challenges in many areas. There is broad consensus in Norway about the main goals of the health policy. The Government will work systematically to achieve these goals. Errors and deficiencies in organisation or services revealed by user experiences or supervisory activities will be followed up.

The Norwegian health service is constantly evolving. A report from The European Observatory on Health Systems and Policiessummarises the main trends in Norway’s health reforms over the last few decades thus: «Taking an aggregate view of health care reform over several decades, the general focus of the 1970s was on equity questions and the build-up of health services; the 1980s on cost containment and decentralization; the 1990s on efficiency and leadership; and the beginning of the new millennium on structural changes in the delivery and organization of health care.» All these considerations were important. In the future development of the health service, fair distribution is once again the focus of attention.

Possible distortion mechanisms

We know that there is a correlation between social background and use of the health service. We do not have sufficient knowledge to determine the causal connections between social background and the use of health services. We need to investigate further whether the Norwegian health service is serving to level out or exacerbate social inequalities in health. Although our knowledge about social inequalities in the use of health services is somewhat limited, hypotheses have been proposed in Norwegian and international research about possible distortion mechanisms that may affect different social groups’ use of the health services.

In the primary health service, for example, one might expect to find social inequalities in the use of the regular GP with regard to treatment, follow-up and referral to the specialist health service. In the specialist health service, there may be mechanisms that make services less accessible to groups with a short education and low income. Legal, economic, organisational and pedagogical factors may play a part. A number of possible mechanisms that may obstruct equitable health and care services are discussed below.

Legal policy instruments such as patients’ rights, the right to an individual plan, the right to be assessed and the right to receive necessary medical assistance may have a social bias. Patients’ rights are intended to ensure equal access to health services through the legal right to receive necessary medical assistance, freedom of choice (right to choose hospital, regular GP), the right to receive information, co-determination and the right to a second opinion. Since to a certain extent use of these kinds of rights requires resources in the form of knowledge (for example, about the application process and availability of the service), it is conceivable that defining these rights in law in fact perpetuate or even exacerbate social inequalities. The Norwegian Board of Health’s supervisions have also found that the goals of the patients’ rights legislation cannot be met unless sufficient effective steps are taken to make the requirements known and used in the specialist health service. Only limited research has been done in this area from the perspective of law and sociology of law. We need more knowledge about the significance of laws and regulations for the goal of equal access to health services.

How the health service is funded affects the distribution of services. The financing system influences the range of health services offered, and user charges for services and medicines affect demand.

The system of performance-related financing is intended to encourage more treatment activity, but can also lead to an unintended distortion away from patients and statutory tasks not covered by the system. Since chronic and complex ailments are unevenly distributed in society, too low prioritisation of these kinds of ailments can lead to greater social inequalities in health. So far, there is no evidence that the system of performance-related financing has actually led to unintended distortions in the range of services offered. The change in the block funding from 40 % to 60 % should help reduce any problems linked to these kinds of distortional effects.

The correlation between user charges and consumption of health services is well documented internationally. A study surveying use of user charges in the health sector in different countries (carried out by the Programme for Health Economics in Bergen) refers to a number of studies supporting the hypothesis that demand is affected by user charges. User charges reduce demand for both necessary and unnecessary services, and they tend to affect health and economy in a socially biased way. The studies indicate that people with low income and people belonging to certain social groups are hardest hit.

The organisation of the health service affects patients’ access to the services. For some groups in society, the threshold into the health service seems especially high. This is the case for heavy drug addicts, alcoholics and prisoners, for example. Drug addicts and alcoholics are often in a situation where it is difficult for them to take advantage of the available health and care services. Access to health and care services is often particularly weak for drug addicts and alcoholics who developed substance abuse problems at an early age. They often have deficient or incomplete schooling, weak or no contact with the labour market and do not have enough money – background factors that are systematically linked to inequalities in health. For a person who spends all their available funds financing their addiction, user charges for health services often prevent them from using these services.

Medical insurance and privately financed health services can generate inequalities in the use of health services. Private insurance against user charges may serve to undermine the purpose of the system of charging users for certain services and medicines: i.e. to reduce demand for low-priority health services. This in turn exacerbates social inequalities. It is therefore important that the waiting time for publicly financed health services is not significantly longer than for privately financed health services.

7.2.1 User charges

The Government has decided to reduce user charges on health services and keep them at a low level. In the fiscal budget for 2006, the second upper limit for user charges was reduced from 3500 to 2500 NOK from 1 January 2006. User charges for physiotherapy for people who were previously entitled to free physiotherapy on the basis of their diagnosis were discontinued from 1 July 2006, in accordance with the proposal in Proposition no. 66 to the Storting (2005–2006).

There is variation in the current exemption and cost-sharing schemes: for some services and products, individuals must cover all the expenses in full (for example normal dental treatment for adults and some medicines). For some services, the state covers the costs in full. This is the case for in-patient treatment in hospital, community nursing and technical aids. Certain treatments are free on the basis of diagnosis: GP services in connection with infectious diseases that pose a threat to public health, pregnancy and childbirth, and physiotherapy for patients with certain diagnoses. There is also a system of exemption by age. For example children under the age of 12 are exempt from paying for health services and children under 18 are exempt from paying for psychologists and services within child and adolescent psychiatric clinics. Pensioners on a minimum pension are exempt from paying for «blue prescription» (reimbursement scheme) medicines. Dental health services are free for children and young people up to the age of 18 (school dentist), for the elderly, for people on long-term sick leave and disabled people in institutions and receiving community nursing, for the mentally handicapped and for people receiving municipal treatment for substance abuse. People with occupational injuries and war injuries are also exempt from cost-sharing under certain circumstances.

The two-tiered system of upper limits for user charges provides exemption from expenditure above a certain level for services covered by the scheme. Exemption by income is a principle for municipal, home-based services and long-term stays in retirement homes and nursing homes. A flat rate is used for short-term stays.

Proposition no. 1 to the Storting (2006–2007) the National Budget for the Ministry of Health and Care Services, contains a review of the systems of user charges for health services. The Government is going to return to the problems and issues raised in this review in the budget for 2008. Reducing social inequalities in health will be an important element and will be taken into account when considering possible changes in the system of user charges for health services. Pursuant to proposals from the Government, the Storting (the Norwegian Parliament) has decided that from 2007 drug addicts visited by ambulatory teams from an outpatient service for drug abusers will not be charged user fees.

The state currently regulates the local authorities’ right to take payment for care services through two different sets of regulations: one for home services and one for services in institutions. The Government has considered different alternatives to ensure more equal user payment. Overall, the Government does not find that the disadvantages of the current system justify an extensive reform. The consideration that users must not suffer from restructuring means that the system will be continued as it is for the time being. Nevertheless, the Government will monitor developments in the municipalities and continually assess the need for steps.

The Government wants to ensure that users of municipal services in a difficult financial situation are better protected against user charges and pay less than they currently do. Several municipalities have introduced cost-sharing on a number of services in a way that has not been in compliance with the regulations. This has happened in particular in connection with provision of a personal safety alarm, meals-on-wheels, and when setting user charges for these services. The Ministry of Health and Care Services has therefore sent out a special circular underlining that user charges for these kinds of services are covered by the exemption rule for people earning less than twice the national insurance basic amount (2G) when the services are to fulfil a need for help that yields requirements for services pursuant to Section 4 – 3 of the Act relating to Social Services. If a personal safety alarm is provided in these kinds of cases as a substitute for a daily visit from a supervisor, or meals are delivered instead of help cooking at home, the rules in the regulation on exemption by income apply. However, if the service is provided as an optional municipal service, the municipality is free to calculate user charges. Nevertheless, the municipality may not charge more than the cost of the service. Reference is also made to Report no. 25 to the Storting (2005–2006) Long-term care – Future challengesfor a more detailed discussion of financing and user payment in the care services.

7.2.2 Governance and organisation of the health service

The health authorities are responsible for ensuring that everyone has satisfactory access to necessary health services. Nevertheless, we find that users such as, for example, old people in poor health, people with mental ailments, drug addicts, and mentally handicapped people are not always able to make their needs and rights known. This can lead to these groups not using the health services to the same degree as the population as a whole, despite the high morbidity rate in these groups. The Ministry of Health and Care Services wants to ensure equitable services for weak patient groups through optimum governance and organisation of the health service.

It is important to ascertain whether health-policy instruments – such as financing schemes, forms of organisation, regulation and guidance – perpetuate or exacerbate social inequalities in health. In the same way that the goal of reducing social inequalities in health must be made a priority in many areas in society, it is also necessary that the Ministry of Health and Care Services takes steps to ensure that reducing social inequalities in health is an important priority and is considered when introducing new or changing existing governance mechanisms in the health sector.

Most of the services offered by the specialist health service are provided under the direction of the public authorities. Contracted specialists are an important part of the specialist health service. Work has been instituted to study and develop the situation in order to ensure even better integration of the contracted specialists in the regional health enterprises’ responsibilities for providing specialist health services, partly with a view to ensuring correct prioritisation in keeping with the Patients’ Rights Act and the prioritisation regulation, and to facilitate appropriate distribution of tasks between contracted specialists and the health enterprise and thus promote better utilisation of resources and ensure equal availability of specialist health services.

Social inequalities pose a challenge in the work on ascribing priorities in the health service. It is an explicit goal to counteract social inequalities in health by identifying the needs of groups in the population that require special measures, such as, for example, refugees, asylum seekers, prisoners and drug and gambling addicts. It seems some patient groups are more likely to be given low priority than others, and it is conceivable that this is due to the fact that there is a correlation between the status of the academic disciplines and the patients’ socioeconomic status. We therefore need targeted efforts to ensure better distribution of resources between diagnosis and subject areas. There are currently large disparities in the way the prioritisation regulation is interpreted and applied. The Directorate for Health and Social Affairs and the regional health enterprises have therefore initiated the joint project Riktigere prioritering ( Getting priorities right)in an attempt to contribute to more uniform practices.

Information and good communication are essential for a good outcome of treatment. There are strong, often unspoken expectations that the users of public services are the same, also in terms of culture, or that they ought to behave like the majority of the population when using health services. For Samis and non-Western immigrants, for example, this may result in their benefiting less from the services than other members of the population. This represents a breach of the political objective of equitable services and maximum equality in availability and outcome of services. With regard to minority-language patients, it is particularly important that health workers ensure that language or cultural differences are not causing misunderstandings that affect the treatment. It is also important to take into account the fact that differences in social background between patients and health workers can influence communication. It may be difficult for patients to talk about some disorders and ailments. The problems may then appear diffuse and difficult to treat. Cases of this nature include, for example, women and children who have experienced or are experiencing abuse and violence in close relationships.

Most homosexuals and lesbians have good health – like other minority groups and the population as a whole. However, as a group, homosexuals and lesbians experience more problems than the average for the population. This group is particularly prone to drug abuse, mental ailments and suicide. Although their health problems are not necessarily linked to social inequalities, it is important that the health service is aware of ailments and diseases that particular groups or minorities are predisposed to. This can prevent a vicious circle of health problems and social exclusion.

Information and communication technology is a valuable tool for getting information about health services and options out to the population. This technology can help increase accessibility to this kind of information among all groups in the population, for example through universal design of websites.

In the spring of 2007, the Government is going to submit a report to the Storting on the dental health service. Social inequalities in health are also reflected in dental health. The Report to the Storting on future dental health services will discuss matters such as availability of services, use of user charges and establishing rights in legislation. The significance of the dental health service for social inequalities in health in general and in dental health in particular will be evaluated in the report to the Storting.

The need for good, effective habilitation and rehabilitation services is growing. Rehabilitation can be decisive for the individual’s quality of life and ability to lead an independent life after completed medicinal treatment.

The Government will guarantee rehabilitation and retraining for everyone who needs it after illness or injury. The Government will also work to ensure that children with restricted functional capacities or chronic illness are offered good, interdisciplinary habilitation services. The Ministry of Health and Care Services is going to propose a national strategy for habilitation and rehabilitation in the health and social services. This strategy will lay the foundation for clearer prioritisation of habilitation and rehabilitation as priority areas for local governments and health enterprises and ensure better collaboration between public service providers and private suppliers of rehabilitation services. Importance will be attached to ensuring greater geographical equitability in the range of institution-based services on offer, better quality services through qualification requirements and advancement of knowledge, and an individual approach to users. Users shall encounter services that are accessible and effective, safe and coordinated. The work on reducing sickness absence and Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusion will be followed up by means of collaboration with the Ministry of Labour and Social Inclusion on a joint focus on rehabilitation in order to get more people in work.

7.2.3 Research and advancing knowledge

We have inadequate knowledge about social inequalities in access to health services, the use of health services and the outcome of treatment. More research and surveying of this area are therefore necessary. Figures from Statistics Norway show that in 2005, almost 176 billion NOK was spent on health. This corresponds to an average cost per inhabitant of 38 000 NOK. Among the many areas where we find causes that help create and perpetuate social inequalities in health, the health services represent one of the areas with the most obvious impact on health. However, it seems that the health service is the area among those covered in this Report to the Storting that we know the least about with regard to social inequalities in health.

We lack data on how well the health service works for groups with a minority background. Work has been initiated to develop indicators to measure performance in relation to the goal of equitable health services for all groups in the population regardless of ethnic, linguistic or religious affilitation. We also need more knowledge about how able the health service is to identify the special health problems facing homosexuals, lesbians and bisexuals. Oslo has established a number of specially adapted health services for this group of users. Examples include the Olafia clinic’s advisory service for homosexuals, lesbians and bisexuals and The city of Oslo’s health centre for young lesbians, homosexuals and bisexuals.

In recent years, medical technology has developed rapidly, resulting in lower mortality from acute coronary arrest and a number of other diseases. Improvements in public health are closely linked to factors outside the health service, but according to the Norwegian Institute of Public Health, it is likely that medical technology will further reduce mortality, so that the health service will play an ever more important role in improving public health. It is therefore paramount that the health service does not exacerbate social inequalities, but rather serves to reduce social inequalities in health.

The Government wants to give high priority to the need for knowledge in this area. We therefore need a survey of social inequalities in the use of health services. This will then form the basis for further measures to reduce any social inequalities. Indicators need developing for the accessibility of the specialist health services in order to monitor and influence tendencies in social inequalities in accessibility.

Social inequalities in health will be a central consideration in current and new evaluations of health services. The drug reform has recently been evaluated. One of the main objectives of the drug reform was to increase access to the health services for a group of patients. A basic starting point was that treatment for drug addicts and alcoholics should be more easily available than previously and that specialised health services necessary to reduce somatic and mental problems should also be more closely linked to interdisciplinary specialised treatment of abuse and addiction. The evaluation demonstrates that more drug addicts have received treatment, the services within the specialist health service are better coordinated, and the quality of the services has improved. Nevertheless, there is still a long waiting time for treatment, there is still a need for increased treatment capacity, and the quality of the services still needs to be improved. Collaboration within the specialist health service needs improving – especially in connection with services for drug addicts and services within mental health care. The collaboration and interaction between the specialist health service and the municipal services also still needs improving. These factors will all serve to improve the availability of health services for drug addicts.

For a number of years, many of the municipalities have received central-government incentive funds for establishment and operation of low-threshold health measures for drug addicts and alcoholics. These are measures to meet this group of patients’ needs for health services and help improve access to the other health services. This grant scheme, which is administered by the Directorate for Health and Social Affairs, is going to be evaluated in 2007, hopefully providing valuable knowledge about whether these measures have actually enhanced access to the health services for drug addicts.

Many of the questions we need answers to regarding the impact of the health services on social inequalities in health will require a more long-term research effort. This applies in particular to questions linked to which mechanisms contribute to the social inequalities we have observed in the use of health services.

In order to ensure equitable specialist health services, it will be important to strengthen the priority focus areas and programme plans under the direction of the Research Council of Norway, especially the programme for research on health and care services. A new research programme on substance abuse is in the process of being established, which will be relevant for research on social inequalities in the use of health services. Epidemiological research under the direction of the Norwegian Institute of Public Health and the higher education sector is also going to be strengthened. To improve research on social inequalities in the specialist health service, the Ministry of Health and Care Services is going to consider instructing the regional health enterprises to channel funds for research into this area.

Measures to build capacity in the school health service are discussed in more detail in chapter 4 on childhood conditions, and low-threshold health services are discussed in chapter 8.