HEALTH INDICATORS FOR SWEDISH CHILDREN by Lennart Köhler A CONTRIBUTION TO A MUNICIPAL INDEX Save the Children fights for children’s rights. We influence public opinion and support children at risk in Sweden and in the world. Our vision is a world in which all children's rights are fulfilled • a world which respects and values each child • a world where all children participate and have influence • a world where all children have hope and opportunity Save the Children publishes books and reports in order to spread knowledge about the conditions under which children live, to give guidance and to inspire new thought. and discussion. Our publications can be ordered through direct contact with Save the Children or via Internet at www.rb.se/bokhandel © 2006 Save the Children and the author ISBN 10: 91-7321-214-8 ISBN 13: 978-91-7321-214-4 Code no 3332 Author: Lennart Köhler Translation: Janet Vesterlund Technical language edition: Keith Barnard Production Manager, layout: Ulla Ståhl Cover: Annelie Rehnström Printed in Sweden by: Elanders Infologistics Väst AB Save the Children Sweden SE-107 88 Stockholm Visiting address: Landsvägen 39, Sundbyberg Telephone +46 8 698 90 00 Fax +46 8 698 90 10 [email protected] www.rb.se Contents Foreword 5 Background 6 1. Measuring and evaluating the health of a population 6 2. Special conditions in measuring the health of children and adolescents 11 3. Some features of the development of children’s health and wellbeing in Sweden 14 4. Swedish municipalities and their role in children’s health 23 Indicators of children’s health 27 5. Basis for constructing health indicators for children 27 6. Principles for municipal inficators of children’s health 31 7. A set of indicators for children’s health 33 8. From indicators to a municipal index 47 9. What is not available now but should be and perhaps will be soon 54 Results, conclusions and further work 58 10. Situation in the municipalities 58 11. Conclusions 64 References 67 Municipality table 1 77 Individual indicators and children’s health index for the’ 2000’ period (6 indicators). Municipalities in alphabetical order. Municipality table 2 84 Individual indicators and children’s health index for the ‘1990’ period (5 indicators). Municipalities in alphabetical order. Appendices 91 Appendix 1. Technical description of indicators used 91 Appendix 2. Technical description of indicators not used 99 Appendix 3. Final indicators 119 Foreword While I was given the task of constructing a health index for children on the municipal level by Save the Children, this does not mean that I carried out this work entirely on my own. I discussed the design and progress of the work with a reference group with a broad range of competence (Sven Winberg and Eva Svedling, Save the Children Sweden, Anders Hjern, Swedish National Board of Health and Welfare, Marie Berlin, Statistics Sweden, Johanna Alfredsson, Gävleborg County Council) and was encouraged at all times by the senior management of Save the Children, particularly by Project Manager Kalle Elofsson. In compiling municipal data for the different indicators, I received technical assistance from the Swedish National Board of Health and Welfare (Claes Hedberg, Milla Pakkonen and Anders Åberg), from the Swedish Institute of Infectious Disease Control (Viktoria Romanus) and from Professor Tapio Salonen at Lund University (poverty index). I had long discussions about constructing indices with Professor Bo Eriksson at the Nordic School of Public Health in Göteborg, who also helped me in processing the raw data and producing an index based on the individual indicators. I am very grateful for all the help and support I received during different stages of the work. Göteborg, January 2004 Lennart Köhler Foreword to the English translation The original work was written in Swedish and published in 2004. In the beginning of 2006, Janet Vesterlund made the translation into English and, in addition, Keith Barnard made a technical language edition. Allmänna Barnhuset, Stockholm, financed this work. In the interval of two years between the Swedish and the English version, important books were published, relevant reports written and the author may have become wiser. Nevertheless, the decision was made to stick to the original contents, without updating. New references and ideas will be saved for a follow-up report, which will appear in a few years’ time. Göteborg, May 2006 Lennart Köhler 5 BACKGROUND 1. Measuring and evaluating the health of a population Health as a component of welfare Being able to measure and evaluate states of health is a central problem in all health care: it is important in each and every contact with individual patients and is a necessary part of epidemiological studies of groups, regardless of whether as a basis for allocating care resources or assessing effects of measures taken, treatment or prevention. But a population’s state of health is not merely the result of care efforts on different levels; it is also a part of welfare and, as such, is one of the targets of sociopolitical interventions. Already the Romans were aware of the significance of health as a political instrument. Cicero spoke of salus populi lex suprema, the health of the people is the supreme law. The first useful international register of the components of a standard of living was issued by the United Nations in 1961 (International Definition and Measurements of Living). Since then this work has been further developed with ever greater sophistication and impact by other international bodies such as the Organisation for Economic Co-operation and Development (OECD), the Council of Europe and the European Union. Together with education, employment, income and social relations, health holds a central position in all the registers of the different components of welfare, and thus also in public policy goals. When judging progress in countries’ development, one or more components are regularly included to reflect the health of the population, typically life expectancy and causes of mortality. Even for the World Bank, an organisation focused primarily on economic development, improvements in the health of the population are important goals for aid and development programmes. As such, they must be measured and evaluated (World Bank, Investment in Health, 1993). Growing internationalisation has increased the need of systems for measuring health that make it possible to compare developments between countries and regions. A project in this vein is the European Commission’s Health Monitoring Programme (HMP), which was started in 1997 to develop the EU’s new public health competence. The programme’s objective is to: a) measure the state of health, its determinants and trends within the European Union b) facilitate planning, monitoring and evaluation of EU programmes and actions c) supply the Member States with appropriate information on health issues so comparisons can be made and national health policies supported A secondary project in this programme has been European Community Health Indicators, which has resulted in the development of a set of health indicators for use 6 in each member state (ECHI 2001). These indicators constitute a matrix that covers the most important areas of population health. The proposal is now under consideration in the EU’s Commission and Parliament and if adopted will in time be promulgated as a Directive binding all Member States. Individual countries have developed their own systems for monitoring the health of their populations as a part of their living conditions, and the results are regularly published in in the form of statistics, investigations and scientific reports. They are a rich source of information for politicians, planners and researchers. Sweden was one of the first countries to begin mapping its population’s living conditions. The first initiative was taken in 1965, the so called Low Income Survey (Johansson 1973), the terms of which were: “to make a measure-related survey of the living conditions of the Swedish people, with the specific purpose of identifying persons with low incomes and studying how they live”. The theoretical projections made then came to have major significance for the development of later studies, in Sweden and other countries. A so called resource perspective was applied, whereby it was taken as given that it was the responsibility of society to ensure that resources are equitably distributed, and largely up to individuals to determine how those resources should be used. State of health was given a prominent role as one of these resources, “with the help of which the indivdiual can control and consciously steer the conditions under which he or she lives”, to paraphrase the Low Income Survey (Johansson 1973) and the most recent Swedish Welfare Balance Sheet (Välfärdsbokslut SOU 2001). Data on the living conditions of Sweden’s adult population have been published regularly since 1976. Welfare and its distribution are reported in the following areas: education, employment and working hours, work environment, health, financial situation, housing, transport and communication, leisure time, individual and shared activities, political resources, and security and safety. In October of 2003 Statistics Sweden presented a new analysis of developments in Swedish welfare, Welfare and Hardship in the 1990s (SCB 2003). This is however still based only on the adult population. In 1996 the Swedish Association of Local Authorities, the Federation of Swedish County Councils and the Swedish National Institute of Public Health initiated a joint project, Local Welfare Balance Sheets (Välfärdsbokslut Folkhälsoinstitutet 1999). Its purpose was to develop and test methods for guiding and monitoring municipal activites in a local and realistic perspective, where the focus is the health and welfare of the population. In the model that was developed and tested in some ten municipalities, welfare was described in terms of 13 components that were in turn expressed as some 60 measurable key numbers.