Part 4
Develop knowledge and cross-sectoral tools

9 Annual policy reviews

«Social inequalities in health are closely related to social inequalities in other areas of life. Efforts to reduce social inequalities in health must therefore be followed up in all sectors»

9.1 Objective: Systematic overview of developments

Objective

• Ensure a systematic overview of developments in the work on reducing social inequalities in health

9.2 Policy instruments

9.2.1 Review and reporting system

The Government will monitor developments in the four priority areas defined in this Report to the Storting by means of a new review and reporting system, providing a systematic, regularly updated overview of developments in the work on reducing social inequalities in health. The review and reporting system will be based on the objectives and other goals described in the individual chapters in this Report to the Storting. One or more performance indicators will be developed for each of the defined objectives and goals enabling monitoring of developments over time.

The Directorate for Health and Social Affairs will be responsible for coordinating the design and development of these indicators. This work will be done in close collaboration with the relevant directorates and professional environments in the various sectors involved. The indicators must be selected against the background of common assessments of factors such as which data are available and what kind of indicators are best suited to reflecting trends in social inequalities in the area. Whenever possible, the indicators ought to build on existing sources of data.

It is important that the indicators of social position used in the different areas are compared and coordinated, with each other and with the reports on trends in health outcomes used by the Norwegian Institute of Public Health (cf. chapter 11). In many cases, it may be pertinent to use different indicators of social position in different areas, but it should be a goal that at least one of the three core indicators (education, occupation or income) is used in most contexts.

The Directorate for Health and Social Affairs will publish an annual report based on the review and reporting system. This report must be compiled in such a way that it can be used as a basis for the annual reporting in the budgets. The annual reports will contain a presentation of the main initiatives and strategies on the national level, in conjunction with the goals for reducing social inequalities in health, as well as comments on the trend of each indicator. The report will be compiled in close collaboration with relevant professional environments.

A joint report will be included in the Ministry of Health and Care Services’ budget proposition. The Ministries must collaborate in connection with development of the performance indicators and compiling the budget presentation.

In addition, the Norwegian Institute of Public Health will publish regular reports on trends in social inequalities in health outcomes (mortality and morbidity). This is discussed in more detail in chapter 11 Advancing knowledge.

10 Cross-sectoral tools

10.1 Objective: All sectors of society assume responsibility

Objective

• All sectors of society must do more to promote good health and reduce social inequalities in health.

10.2 Policy instruments

There is a documented need for awareness raising and sharper focus in all sectors and on all administrative levels regarding the social distributional effects of social processes, strategies and measures. Social inequalities in living conditions and welfare schemes may together have had a significant influence on the social inequalities in health. In the same way as we have often overlooked social inequalities in health, perhaps we may also be overlooking systematic inequalities in other basic welfare areas.

It is therefore necessary to render visible how policies in all areas of society have consequences for social inequalities in health. Cross-sectoral challenges of this nature require cross-sectoral tools. Health impact assessments are one such tool that can be used nationally, regionally and locally. Health impact assessments are a systematic assessment of how a decision can affect health and distribution of health in the population. Impact assessments do not simplify causal connections, but this tool does help generate knowledge more systematically. Impact assessment is a tool that helps us ask the questions necessary to evaluate the effects of a measure. This provides a better basis for making decisions and can help raise awareness in policy and strategy design. This does not mean that other sectors have to assess the health impact of every single measure they implement. In many cases, assessing the distributional effects will be enough, because we know that social inequalities in distribution of determinants of health generate social inequalities in health.

Regionally and locally, the municipalities’ social and land-use planning are useful cross-sectoral tools. The purpose of planning pursuant to the Planning and Building Act is to coordinate physical, economic, social, aesthetic and cultural developments in the municipality. Municipal planning is a central arena for ascribing priorities in the municipalities and embraces developments within the municipality as a whole, and developments within individual sectors and areas of activity. The social part of the Municipal Master Plan defines targets for long-term developments in the municipality and thus forms the frame for the individual sector’s activities. For example, defining a goal of reducing social inequalities in health entails that sectors such as schools, culture, business, social services and health must also develop targets and strategies for reducing social inequalities in health.

10.2.1 Health impact assessments nationally and locally

Official studies carried out by or for central-government administrative bodies must follow the rules laid down in the Instructions for Official Studies and Reports. These instructions define requirements concerning impact assessment of public reforms, amendments to regulations and other measures. Impact assessment shall include an assessment of all the considerations that are material to the case in hand. In addition to the economic and administrative impacts, other significant consequences must also be assessed. Impact assessment should be considered in areas such as health, equal opportunities and the environment. With regard to gender equality and environmental issues, special handbooks have been compiled describing how these considerations can be better incorporated into official studies. The Directorate for Health and Social Affairs is currently working on devising methods to ensure compliance with the provisions concerning health impact assessments in the Instructions for Official Studies and Reports. The Ministry of Health and Care Services will make sure that guidelines are drawn up and made available to all the ministries.

In general, the Instructions for Official Studies and Reports work best for economic and administrative impacts. Experiences from trying to integrate the equality dimension suggest that work needs to be done to develop a broad set of policy instruments to ensure that equality is promoted in all sectors. For example, all ministries are supposed to assess equality within their own budget areas in connection with the fiscal budget. The requirement that equal opportunities be promoted is laid down in the Equal Status Act.

In strategies within the EU, WHO and many countries with which we can compare ourselves, impact assessments are being launched as a measure for reducing social inequalities in health. However, any tool is only as useful as the user makes it. Efforts to combat social inequalities in health require political willingness to put distribution issues on the agenda. The Government is therefore going to adopt a policy that strengthens the individual’s personal safety through strong common welfare schemes and fair redistribution.

The Regulations of 1 April 2005 on Environmental Impact Assessment lay down that when necessary impact assessments shall include analysing the consequences for public health. This applies to consequences for public health due to significant changes in the composition of the population, the housing market, housing needs or the need for services (cf. Section 4 of the Regulations). These are key social determinants of health and social inequalities in health. The Directorate for Health and Social Affairs is working on developing methods and guidelines and building up competencies with a view to ensuring that these considerations are systematically assessed in impact assessments pursuant to the Planning and Building Act.

10.2.2 Municipal social and land-use planning

Local decisions affect childhood conditions, living conditions and health behaviour. The Planning and Building Act is the main tool available to the local and county authorities in their social and land-use planning. The population’s health must be a prime concern in all social and land-use planning. Public health work entails measures to improve the population’s health and measures to ensure a more even distribution of factors that influence health.

Pursuant to Section 1 – 4 of the Act relating to the municipal health services, the municipalities must have an overview of the state of the population’s health and the factors that affect it. A good overview is a prerequisite for putting public health issues on the agenda in connection with decision making and for being able to implement target-oriented, quantifiable measures. This kind of overview or health profile can be based on national data, which is then broken down to the municipal level, and on surveys within the municipalities.

In collaboration with the Norwegian Institute of Public Health and Statistics Norway, the Directorate for Health and Social Affairs has set up a dedicated Internet portal for local authority health profiles that the municipalities can use as a tool in their planning. The portal contains key figures and indicators for determinants of public health, among others, as well as factual documentation, articles on a range of related subjects, examples of local measures and links to other relevant websites. The portal is under continuous development, and tools are being developed for use in municipal planning. The Ministry of Health and Care Services wants to ensure that social inequalities in health are a main priority in future developments.

The Ministry of Health and Care Services is going to consider policy instruments to make data about the quality of the residential environment more easily available to the local authorities. One relevant measure may be development of a better set of indicators for the quality of the residential environment that can be incorporated into the internet portal for local authority health profiles. Another solution is to compile guidelines and examples showing how the quality of residential areas can be assured.

It is a goal that measures to prevent social inequalities in health be ascribed greater priority in the social part of the Municipal Master Plan, the land-use part of the Municipal Master Plan, Municipal Area Plans on various topics and Local Development Plans. For example, there are indications of clear social inequalities in the distribution of environmental factors, such as noise, air pollution, access to green areas, traffic safety and recreation grounds. The Directorate for Health and Social Affairs has commissioned the Institute of Transport Economics, which collaborates with Statistics Norway, to develop a tool for comparing social and economic indicators with environmental indicators in a way that can be used in planning.

Planning expertise in the health sector

Greater advantage can be taken of the interdisciplinary planning arena in public health work, if the health service and the rest of the sector make more of their roles as contributors in the planning processes in counties and municipalities. In addition to good knowledge of the field and expertise in monitoring health and other public-health spheres, competence is needed in how this knowledge can be exploited in ordinary planning and decision-making processes. The Directorate for Health and Social Affairs has noted that many municipalities, and especially the municipalities involved in partnerships for public health, request guidance concerning how they can make better use of municipal planning to promote health interests.

In collaboration with the Ministry of the Environment, the Directorate for Health and Social Affairs has set up a five-year development and trial project in a sample of municipalities to ascertain how the Planning and Building Act and the municipal planning system can be used as a basis for and instrument to improve public health work. This experiment, called the Health in planning project also includes improving the planning and processing skills of staff and experts working in the health sector, for example, through seminars and development of relevant courses of basic training, further education and continuing education.

10.2.3 Partnerships for public health

The state awards grants to counties and municipalities that organise their public health work in partnerships. The conditions for receiving this grant is that the county or municipality also contributes its own funds and that the public health work is firmly anchored in the municipal and county-planning system. The purpose of this grant scheme is to make local public health work more systematic and comprehensive by ensuring a stronger administrative and political grounding and by improving coordination between authorities and the labour market, schools, voluntary organisations and others.

In their capacity as a regional development actor and regional planning authority, the county administrations have been ascribed the role of prime movers in the partnerships. County planning is done across sectoral and hierarchical boundaries and is therefore ideal for raising public health issues that require a broad approach and that depend on the central government, county administrations, local government and voluntary sector all pulling in the same direction. Regional central-government agencies, regional health enterprises, university colleges and universities, and voluntary organisations are all important actors in the regional partnerships.

From 2006 on, 16 of Norway’s 19 counties and a large number of municipalities in these counties are involved in the scheme. In the budget for 2007, the scheme has been expanded so that all the counties have the opportunity to apply for funds to establish these kinds of partnerships. The purpose of the scheme is to stimulate development of an infrastructure for local public health work. In addition, grant funds are channelled to local public health measures through the partnerships. These grants are intended to stimulate development of local initiatives to promote a healthy diet and physical activity, and to prevent the harmful effects of tobacco use.

The Directorate for Health and Social Affairs has a responsibility to further develop the partnerships as a way of working towards systematic public health work firmly rooted in social planning and with broad participation in the population. In light of the goal of reducing social inequalities in health, attention must be focused on underlying factors that influence health and how they are distributed. For example, good inclusive schools and inclusive working life play a large part in reducing inequalities in health. It may also be pertinent to bolster efforts aimed at geographical areas with concentrations of social problems.

The workplace is another important arena for preventing social inequalities in health. In addition to monitoring sickness absence and efforts to promote a more inclusive working life, anti-smoking, drinking and drugs campaigns and a health-promoting working environment can be developed as areas of cooperation.

The Government has decided that reducing social inequalities in health will be afforded greater priority in all public health work performed under the auspices of regional and local partnerships.

11 Advancing knowledge

11.1 Objective: Increase knowledge about causes and effective measures

Objective

• Increase knowledge about the scope of, causes of and effective measures against social inequalities in health.

11.2 Policy instruments

Social inequalities in health constitute a complex problem. Moreover, it is only in recent years that Norwegian research has started showing an interest in the social distribution of health. This means that there is still a large need for knowledge in this area.

11.2.1 Monitoring and surveys

This section deals with monitoring developments in social inequalities in health outcomes(mortality and morbidity) in the population. We know a fair amount about the scope of social inequalities in health in Norway (cf. chapter 2). Social inequalities have been well documented using many different means of measuring health and health outcomes, including total mortality in a number of age groups, cause-specific death, morbidity and self-assessed health. However, there is currently no system for monitoring and reporting trends in social inequalities in health over time. An important objective of this Report to the Storting is therefore establishing a system for monitoring this aspect.

Much of the work on developing specific health indicators for this purpose must be done by experts, not least because of the technical elements it entails, such as data accessibility and register linking. Existing sources of data represent a huge potential, but in some areas we still need to generate new data.

An EU working committee made up of people from a broad range of backgrounds prepared a proposal in 2001 suggesting guidelines for monitoring social inequalities in health in the member states. A Norwegian monitoring system ought largely to follow these recommendations. The working committee’s proposal states that if possible a monitoring system ought to:

• include nationally representative data for mortality on the individual level

• include nationally representative survey data for self-assessed health

• use at least two of the three core indicators of social status (education, occupation, income)

• use the same classification of social status over time

• use both absolute and relative expressions of inequalities

• discuss any possible sources of error

The Norwegian Institute of Public Health bears the main national responsibility for monitoring health, including developing indicators of social inequalities in health outcomes.

Chapter 7 on health services proposed special monitoring of social inequalities in the use of health services. Chapter 5 on work and working environment included a discussion of national monitoring of work and health.

11.2.2 Research

A monitoring system will meet many of the needs we have for knowledge about the scope of and trends in social inequalities in health. However, it will provide little information about the causes of inequalities in health and which measures may serve to reduce them. In order to improve our understanding of social inequalities in health and develop effective political measures that can help reduce those inequalities, we need to know more about the underlying mechanisms. In the first instance, then, we need more knowledge about mechanisms and policy instruments. This also includes research on the health service’s contribution to inequalities in health.

Social inequalities in health is a field of research with inherent, fundamental questions concerning what creates good health and what creates ill health. This is a field where researchers apply theories and knowledge from a number of different disciplines, including demographics, sociology, psychology, epidemiology and medicine. This entails that research on the topic of social inequalities in health is not only useful as a foundation for political decisions, but has far-reaching relevance. It yields fundamental knowledge about mechanisms that promote health and mechanisms that induce sickness, and it is scientifically interesting for many different disciplines. It is therefore important that groups of researchers who do not usually define their research as related to inequalities in health (for example, clinical research or physical environment and health) are involved. Research on social inequalities in health ought to be multidisciplinary and interdisciplinary.

In many other countries and in the EU, the increased political attention being paid to social inequalities in health has been accompanied by greater investments in research in the field. For example, the Netherlands have had two nationally financed research programmes, the latter of which focused on testing and evaluating measures. In the United Kingdom, the national research councils have allocated large sums of money to several major programmes and projects dealing with various aspects of social inequalities in health. In Sweden, a special research institute has been set up with public funding: the Centre for Health Equity Studies (CHESS). The EU has financed a series of major projects on social inequalities in health, some with a focus on comparing the situation in different countries and trends within Europe, some with a focus on providing explanations, and some with a focus on the success of various measures and policies to reduce inequalities. The research being performed in other countries may be relevant for Norway, but the transfer value of this research will often be limited and uncertain because of differences between countries.

Some topics are especially important for the future design of measures to reduce social inequalities in health. Examples include social inequalities among children and young people that we generally know too little about. This topic entails particular challenges. For instance, what we called «core indicators» of social status above are not available for this group (children do not usually have education, an occupation or income), nor are the most commonly used indicators of health (mortality and self-assessed health) particularly apt. Since this is an age group that is given high priority in preventive work, research on social inequalities in health and social inequalities in the distribution of health determinants among children and young people ought also to be a priority.

Geographical perspectives on social inequalities in health are being afforded ever greater place in international research, and there is a need for better research in this field in Norway too. Knowledge about the significance of the local environment for health and inequalities in health may also be able to make an important contribution to the design of measures to combat social inequalities in health in the future.

In the past, there has been little health and social research on multi-cultural communities in northern Norway. This is reflected in the lack of knowledge about the challenges the health service faces regarding the Sami population. The drive to build up multi-cultural competencies within the health and social services and within research communities is therefore crucial.

Another research area that may be important for future policies is the significance of different types of prevention arenas for health behaviour – such as, for example, school, the workplace and leisure. This is an ideal area for intervention research.

The Government’s research effort concerning sickness absence is discussed in chapter 11.

The need for better knowledge about social inequalities in access to and use of the health services is discussed in chapter 7. Focused research is needed to ascertain which organisational, legal and economic mechanisms contribute to inequalities in access to and use of the health services in particular.

Another topic requiring greater attention, but where we lack computerised systems that enable routine monitoring is dental health. We currently know too little about the scope of social inequalities in dental health in the population, and there is no straightforward way for us to gain an overview of this situation. Social inequalities in dental health are therefore a topic that requires more research.

The Government wants to improve the research on social inequalities in health. Research on social inequalities in health is currently spread over a range of different research communities and programmes. There is a need for more research on the distributional perspective in relevant research programmes. There is also a need for better coordination of research in this area. Many disciplines and perspectives have important contributions to make to our understanding of social inequalities in health, and interdisciplinary approaches are therefore vital.

11.2.3 Evaluation of measures

More and more of the public sector is becoming the object of evaluation. In the central government, requirements concerning evaluations are laid down in the Financial Management Regulations, where it is stated that «All agencies shall ensure that evaluations are carried out to generate information about the efficiency, effectiveness and results achieved within the whole or parts of the agencies’ mandate area and activities.» In the sense it is used in the central government Financial Management Regulations, an evaluation is a systematic collection of data, analysis and assessment of a planned, ongoing or completed activity, an agency, a policy instrument or a sector. Evaluations can be carried out before a measure is implemented, while it is in operation, or after it has been completed. The requirements laid down in the Instructions for Official Studies and Reports concerning performance of preliminary assessments are an example of a preliminary evaluation intended to ensure good planning of measures and schemes. Ongoing evaluations are carried out to facilitate a change in direction and adjustments in the measure, while retrospective evaluations are usually undertaken to find out whether the measure fulfilled its intended objectives, and what, if any, other consequences the measure may have had.

Evaluations can be performed using a variety of different methods, by different evaluators and with different evaluation topics. Results and achievement of goals are usually central topics in most evaluations. However, many interventions have impacts other than those related to the explicit goals for the measure. For example, a number of measures have unintended consequences for the social distribution of health – or important determinants of health – in the population. If more evaluations of measures that affect health took social distributional effects into account, we would have more knowledge about how to go about reducing inequalities in health.

The Government is therefore going to take steps to ensure that more measures that may have an impact on the social distribution of health in the population are also evaluated from this perspective. In many cases, it will be possible to implement measures as a pilot project in a limited area and compare the impact with control areas. Control studies of this nature are considered a gold standard within research on interventions and measures. Knowledge of this type is in great demand internationally, and Norway has good opportunities for making a contribution here.

12 Economic and administrative consequences

In this Report to the Storting, the Government has focused attention on factors within a number of social sectors that contribute to the creation and perpetuation of social inequalities in health. We need a broad-based approach to the problem, since factors affecting social inequalities in health are found in most social sectors. Many of the efforts to reduce social inequalities in health can be undertaken within the framework of existing economic constraints and administrative systems. For example, inequalities can be reduced by ensuring that the considerations of distributional effects and social inequalities in health are assessed when changing existing and designing new policies. Nevertheless, in some areas extra resources will be needed in the form of new grants.

The Government has attached importance to rendering the causal connections between income and health more visible and demonstrating that the policies we use to promote reduction of social inequalities are also an important element in the work on reducing social inequalities in health. The Government’s decision to maintain and build up common public assets instead of offering tax relief is in part based on the ambition of reducing social inequalities in health. As part of the proposed review and reporting system, the Government will monitor developments in income inequality closely.

The main means of reducing social inequalities in childhood conditions is provision of high-quality kindergartens, schools and services available to all children and young people regardless of social divides. The key elements in the policy to create good, safe childhood conditions are presented in Report no. 16 to the Storting (2006–2007) Early intervention for lifelong learning.

In addition, the Government wants to further develop and build capacity in the school health service. The economic consequences of this step will be assessed in connection with the annual budgets.

The Government is also going to consider measures that can serve as a basis for improving coordination of services for children who need multidisciplinary assistance from the child welfare authorities. The economic and administrative consequences of measures to improve the situation in the child welfare authorities will be assessed in connection with the annual budgets.

The Government has initiated a number of processes to help reduce social inequalities in access to the labour market and social inequalities in the working environment through Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusion, the Action Plan to Combat Poverty, the NAV reform(the reorganisation of theNorwegian labour and welfare organisations) and in the follow-up to the report submitted by the commission appointed to find ways to reduce sickness absence. In this Report to the Storting, the Government is proposing commissioning an official study to assess measures to reduce sickness absence in the health and care sector in collaboration with the trade unions’ and employers’ associations. A follow-up to this study will be considered in connection with the ordinary budget process.

With the goal of reducing the social inequalities in health behaviour, the Government is going to attach greater importance in the future to pricing and accessibility policy instruments in the drive to prevent lifestyle diseases. Pricing and taxation policy instruments will be given special consideration in the work on reducing social inequalities in diet (cf. The Diet Action Plan). The Government has set itself the goal of introducing a system of fruit and vegetables for all pupils in primary and lower-secondary education. The Government also wants to encourage daily physical activity and a good framework for meals in primary and lower-secondary schools. Reference is made to the more detailed presentation in Report no. 16 to the Storting (2006–2007) Early intervention for lifelong learning. Increasing the grants for local low-threshold measures to encourage more physical activity will also be considered in connection with the annual budgets.

We currently have limited knowledge about social inequalities in the use of health services, and the Government is therefore announcing new measures to build up knowledge in this field. A survey of social inequalities in the use of health services will be undertaken. Against the background of the findings of this survey, indicators of quality and priorities in the specialist health service will be developed, including indicators to measure social inequalities in accessibility. More research is to be done into factors that cause social inequalities in access to the health services. In addition, the distributional effects must be assessed when proposing changes in user charges, organisation and the funding system. The Government will return to the problems raised in the review of user charges for health services in Proposition no. 1 (2006–2007) to the Storting (the National Budget) for the Ministry of Health and Care Services in connection with the budget for 2008.

The policy instruments intended to promote inclusion of the most vulnerable groups will largely be rooted in Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusion, Action Plan to Combat Poverty and Report no. 16 to the Storting (2006–2007) Early intervention for lifelong learning. In the current Report to the Storting, the Government is also proposing steps to build capacity in and further develop the health services offered to these groups. The Government is also proposing stimulating the implementation of measures in areas that have special health and social problems. The economic consequences will be assessed in connection with the annual budgets.

The Government is proposing objectives and goals in a number of areas and a new review and reporting system to monitor developments. Some of the objectives and goals are new, and some are taken from existing policy documents. For each objective and goal, one or more indicators will be developed enabling monitoring of developments in the area over time. The review and reporting system will be developed in close collaboration with relevant partners. A joint report on developments will be included in the Ministry of Health and Care Services’ budget proposition. The Directorate for Health and Social Affairs is ascribed responsibility for coordinating the process of developing the indicators in collaboration with relevant directorates and experts. The Directorate for Health and Social Affairs will also publish an annual report based on the findings reported through the review and reporting system. This report must be able to serve as the basis for the annual reporting on developments in the field in the Ministry of Health and Care Services’ budget proposition. The Norwegian Institute of Public Health will be commissioned to compile regular reports on trends in social inequalities in health outcomes (mortality and morbidity). Indicators of health outcome can be regarded as indicators of the overall objective of this Report to the Storting of reducing social inequalities in health. The Government will discuss changes in internal priorities and any other economic consequences of establishing a review and reporting system in the ordinary budget process.

In this Report to the Storting, the Government is announcing that it is stepping up its commitment to assessing the distributional effects of public policies centrally, regionally and locally. Importance is to be attached to developing simple tools to assess distributional effects. Measures will be implemented to render impact assessments more efficient as a tool and to improve competencies in the central government, county administrations and municipalities in this area. To a great extent, these will be measures that can be implemented within the existing economic and administrative framework.

It is necessary to improve the monitoring of trends in social inequalities in health, research on the causes of inequalities and research on effective policy instruments to reduce these inequalities. In order to advance knowledge about social inequalities in health, the Government has decided to establish a monitoring system to track developments in social inequalities in health, to improve research on the field, and to evaluate measures in terms of their impact on social inequalities in health. Knowledge in this area needs improving by means of a combination of changes in priorities and concrete allocations. The Government will return to the economic consequences of these steps in connection with the annual budget deliberations.