Ministry of Social Affairs

Report No. 16 (2002–2003) to the Storting Short version Prescriptions for a Healthier Norway A broad policy for public health 2 Report No. 23 to the Storting 2001-2002 Improving urban environment Table of Contents

1 Introduction ...... 5 4.3 Mental health...... 20 1.1 The broad approach ...... 5 4.4 The surrounding environment ...... 21 1.2 Objectives ...... 6 1.3 Personal responsibility 5 Building alliances to and social responsibility ...... 6 promote public health ...... 23 1.4 Scope of the White Paper ...... 6 5.1 Partnership model in local government...... 24 2 The diagnosis ...... 8 5.2 Public health in social planning...... 24 2.1 State of health and trends ...... 9 5.3 Impact assessments and health...... 25 2.1.1 The health of the population ...... 9 5.4 Environmental health ...... 25 2.1.2 Risk factors ...... 10 5.5 Alliances with NGOs ...... 25 2.2 Trends and social features ...... 10 2.2.1 Medicalization and focus on risk ...... 11 6 The health services: Prevention 2.2.2 Youth culture is better than cure ...... 27 – «Cool to be grown up» 11 6.1 From pills to green prescriptions ...... 28 2.2.3 A multi-cultural Norway ...... 11 6.2 Better preventive health services 2.2.4 Health and globalization ...... 12 for children and young people ...... 28 2.3 Challenges...... 13 6.3 A stronger role for healthcare 2.3.1 Lifestyle as a risk factor ...... 13 institutions in prevention...... 28 2.3.2 Mental health...... 13 7 Building up new knowledge...... 30 2.3.3 Focus on prevention...... 14 7.1 Health surveillance and research ...... 31 3 Four prescriptions for 7.2 Education ...... 31 a healthier norway...... 16 8 A strategy for women’s health ...... 33 4 Make it easier for people 8.1 Decision-making processes...... 34 to take responsibility for 8.2 Building up and transferring their own health...... 17 knowledge...... 34 4.1 Healthy lifestyle choices...... 18 8.3 Health practice ...... 34 4.2 Reducing social 8.4 Violence and abuse ...... 35 inequalities in health ...... 20

2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 5 Prescriptions for a Healthier Norway

1 Introduction

1.1 The broad approach by the need to help here and now. Giving priority to prevention can also be difficult because this is Report No. 16 (2002-2003) to the Storting throws not dealing with people’s illnesses here and now; the spotlight on health in Norway. It addresses it is dealing with statistical risks and future ill- factors that play a part in creating health pro- nesses – about what may happen, often far into the blems or which help to combat disease. Looking future. In this sense, public health work is more after the health of the population means relating «invisible». As a society, we should adopt a policy to the factors that affect health. These include the which also takes responsibility for directing curative, rehabilitative and nursing/caring activi- future needs and challenges and which tries to ties of the health services. This is important work, reduce future illnesses. which naturally receives a great deal of attention, The main focus of this White Paper is on fac- but the health sector alone is not the most decis- tors that we know effect health, because: ive factor in the development of health and • Each determinant of health often contributes sickness. Our own choices and the way we jointly to several different health problems. organize and adapt society in a number of diffe- • Focusing on factors that affect health helps to rent areas play a far more important role. It is this bring to light the responsibility of other sectors broad approach which is the subject of this White and policy areas for the health of the popula- Paper. tion. This White Paper draws up strategies for a • When action is aimed at known determinants, healthier Norway. The more disease we can pre- we can measure the results in the form of vent, the less we have to cure. The attention of reduced health risks long before they develop politicians is often caught by acute illnesses and into real disease and death in the population.

Box 1.1 Public health work – more energy to cope with everyday demands • Public health work means reducing factors tal and social well-being, and not merely an that entail a health hazard and strengthening absence of disease or infirmity» and this can factors that contribute to better health. The suggest that good health equals a good life. negative factors have an adverse effect on This White Paper takes the view that we want health, be it the things we eat and drink or good health in order to be able to live a good things that are to be found in our social and life, on a par with safe local communities and physical environment. The positive factors meaningful work. Health is then an invest- include, for example, our relationships with ment factor for a good life. the people closest to us and the networks we • Public health work is about promoting physi- become a part of, and the degree to which we cal health by, among other things, influenc- feel our lives are meaningful, predictable and ing living habits and living conditions. But it manageable. These can be called ‘protective’ also about promoting mental health, by help- or ‘coping’ factors and they give individuals ing people to feel that they can cope, giving and groups sustainability and resistance to them self-esteem, human dignity, security, wear. respect and visibility. • The World Health Organization defines health as «a state of complete physical, men- 6 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

1.2 Objectives community can and should influence these choi- ces by providing information, dispensing know- There are several reasons why the Government ledge and shaping attitudes. Knowledge and atti- now – ten years after the Storting debate on White tude-shaping campaigns must be accompanied by Paper No. 37 (1992-1993) Challenges in health-pro- other measures. These may be measures that moting and preventive work – wishes to submit a make healthy choices easier and more attractive, new report containing strategies for the next ten- but they may also be measures that make health- year period. New trends in society bring new damaging choices more difficult. health challenges. Examples of these are globali- Influencing other people, whether individuals zation, a multi-cultural society, a demanding work- or groups, involves major ethical challenges. This place, and drug and alcohol problems. The World work must be based on respect for different Health Organization has shown that a third of the choices and have the fundamental support of the total burden of disease in industrialized countries community. For that reason, public health work is caused by five risk factors: tobacco, alcohol, must always be rooted in the democratic institu- high blood pressure, cholesterol and overweight. tions in society and build on knowledge and dis- At the same time, the knowledge base needed to cussions which embrace the largest possible sec- develop both policies and practice has improved tors of the population. Ethical assessments car- in a number of areas. ried out by central expert bodies are important, Against this background, the Government but they must be accompanied by an ongoing wishes to revitalize public health work. Its objec- debate in the population. If not, there is a danger tive is a healthier Norway through a policy which that measures will be regarded as uncalled for contributes to: interference. • More years of healthy life for the population as Individuals and local communities have a a whole responsibility for public health, but the health of a • A reduction in health disparities between social population is just as much the result of trends and classes, ethnic groups and the sexes. political choices beyond the control of the individ- ual. The picture of disease reflects a general social This White Paper aims for a more systematic and development and the conditions under which we comprehensive policy than hitherto. The Govern- live. Responsibility must therefore be made trans- ment will attach importance to the connection bet- parent in all sectors when national policy is being ween the community’s and the individual’s respon- formulated. From the point of view of public health, sibility for and possibility of influencing the health we must care about what society does to make situation and to showing what the individual and cycling safe and what it does to encourage healthy the community have to gain from effective preven- eating habits. We must care about how schools tive healthcare. The Government seeks to strengt- deal with bullying and how the workplace can have hen public health work in all social sectors through a beneficial and not an adverse effect on health. active partnerships which places responsibility, The challenge lies in getting everyone to pull bind and inspire action. Work must also be done to in the same direction. In submitting this White further develop and reinforce preventive work as a Paper, the Government emphasizes the need to central instrument within the health services. In reinforce the place of public health in all social addition, the focus will be on ensuring that the sectors. This can be done by, for example, launch- measures implemented are based on experience ing tools which ensure that health is taken into and new knowledge acquired, for example, from consideration when decisions are being made in research and pilot projects. A better understanding different social areas. of complex causal relations will make for more effective measures. 1.4 Scope of the White Paper

1.3 Personal responsibility and social Although it is the intention of this White Paper to responsibility survey public health policy as a whole, certain areas and challenges are deemed to be more Every individual has a responsibility for their own important and will be emphasized. Certain health and, in many areas, will have choices and aspects must be considered when selecting a spe- be responsible for these choices. However, the cial priority area, such as 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 7 Prescriptions for a Healthier Norway

• Whether it concerns one or more major health If we regard public health work and preven- problems tion as an attempt to reduce risks in the healthy • Whether it concerns health problems that are part of the population, then there are also other very costly for the country subjects and measures which could be included in • Whether knowledge is available about the a White Paper on public health, but which are not causal relations considered here. • Whether it can be dealt with by effective and These include medical interventions in accepted preventive means healthy persons who have a known or assumed higher risk of becoming ill. For example, high As shown above, this White Paper is concerned blood pressure medicine and cholesterol-reduc- mainly with health risks and protection – and not ing drugs are used to reduce the probability of ill- with treatment, nursing and care. An exception is ness occurring. However, in this White Paper the made in Chapter 11 on women’s health, which focus is mainly on the relationship between such also deals with the curative services. The reason interventions and alternative or supplementary for this is a wish for a comprehensive follow-up of action, such as physical activity, diet and giving up NOU 1999:13 Women’s Health in Norway. smoking. A broader public health perspective might also This also applies to screening, which aims to include instruments which seek to influence the identify persons suffering from a disease or in the gravity and course of a disease once it has been initial stages of a disease, where an early diagno- established and measures to moderate the impact sis can reduce the risk of deterioration and a fatal of health problems on, for example, activity, par- outcome. Screenings are discussed in a number ticipation and living conditions. These are mea- of international documents dealing with preven- sures which can involve social welfare work, reha- tion and public health. In this White Paper, how- bilitation, medical rehabilitation and measures to ever, this much debated subject is not included improve access to services. However, these mea- because screening must be regarded as part of sures are either in the grey zone between treat- the treatment chain – i.e. part of early diagnosis ment and rehabilitation or aim to ease the situa- activities. Reference is also made to the discus- tion of individuals with health and functional prob- sion of mass surveys in White Paper No. 26 (1999- lems and are not given a central place in this 2000) on the basic values for the Norwegian White Paper. health service. 8 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

2 The diagnosis

«Surveys indicate that the level of physical activity is too low in more than half of the adult population»

Figure 2.1: The diagnosis 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 9 Prescriptions for a Healthier Norway

2.1 State of health and trends same number of women and men). In 1955 7,500 cases of cancer were registered. Most of the 2.1.1 The health of the population increase is due to the fact that we have a larger percentage of elderly people in the population. Positive developments, but greater health inequality The percentage of people who survive cancer The health of the Norwegian population is gene- today is far higher than in 1955. We anticipate an rally good and is improving. At the same time, increase in the number of cancer cases due to the improvements are now slower than in countries it larger percentage of elderly in the population. is natural to compare Norway with. In 1970, Nor- While we have seen a levelling off in the inci- way was placed third in an OECD survey of life dence of lung cancer among men since the 1980s, expectancy for men, and first for women. Several there has been a steep rise in lung cancer among countries passed Norway by in the mid 1980s and women. The incidence of lung cancer in a popula- held their lead throughout the 1990s. In 1999 Nor- tion can be seen as a reflection of the smoking way was in eighth place for men and ninth place habits in the same population twenty years earlier. for women. Life expectancy has risen steadily over the past twenty years and today a woman can expect Chronic respiratory diseases to live to the age of 81.4 and a man to the age of The incidence of chronic obstructive lung disease 76. Generally speaking, groups with a higher is estimated to be 6% of the population and there social status have a higher life expectancy than has been an increase in both incidence and num- groups with a lower social status. Well-educated ber of deaths. The mortality rate today is 38.4 per women with a good income have the highest life 100,000 and that is almost as high as for lung can- expectancy and people who are married or have a cer. The registered incidence of asthma in the partner have better prospects than single per- Norwegian population has shown an increase, but sons. The socio-economic disparities in health at the same time the mortality rate has dropped have grown in the course of the past thirty years. considerably. Diseases of the respiratory organs Most of this increase can be explained by a less are the third most important cause of death in favourable health trend in single persons than in Norway. other population groups.

Accidents and injuries Cardiovascular diseases Accidents and injuries are fourth on the list of cau- Cardiovascular disease is the leading cause of ses of death. The number of persons who have death for both men and women. At the same time, lost their lives as the result of injuries has shown a the mortality rate for this group has fallen most. downward trend over the past thirty years. On the other hand, there has been an increase in the number of persons admitted to hospital with acci- Type II diabetes – increase in incidence dental injuries. We estimate that there are about 140,000 persons with type II diabetes in Norway, and this figure is increasing. Since diabetics run a considerably Mental illness higher risk of developing cardiovascular diseases, We estimate that about fifteen per cent of the adult it is possible that this trend will offset the favoura- population suffer from mental illness (more ble development in cholesterol, high blood pres- women than men) and that about ten per cent of sure and smoking. We may then see a levelling off this group are seriously ill. More than twice as or reversal of the decline in cardiovascular disea- many women suffer from depression and anxiety ses. symptoms, while substance misuse is far more common among men. It is estimated that between ten and twenty per Cancer – mortality rate stabilized in the 1990s cent of all children have such serious mental prob- Cancer is the second most important cause of lems that this affects the way they function on a death and here the mortality rate remained stable day-to-day basis and that between four and seven in the 1990s. More than 21,000 persons in Norway per cent need treatment. We estimate that about are diagnosed with cancer each year (about the ten per cent of young people in Norway have 10 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway mental problems that need professional help. In of the population still show obvious nutritional an average tenth grade (15-16 years old), six weaknesses. They eat too much fat, sugar, salt pupils have one or more daily health problems. and alcohol and too few vegetables, fruit, coarse Typical complaints are anxiety, depression, head- grain products and fish. By way of comparison, aches, stomach pains and insomnia. the consumption of fruit and vegetables in Italy is three times higher than in Norway.

More people are living with health problems Four out of five adult Norwegians say that their Thirty per cent smoke every day health is good or very good. At the same time, In 2001, about 30 per cent of the adult Norwegian there are more people living with chronic health population smoked daily (about the same number problems. One out of three adults say they have of men and women). That makes approximately illnesses or conditions that affect their everyday 1.1 million people. In addition, about 400,000 peo- lives and one out of eight have problems that seri- ple smoke now and again. The percentage of men ously affect their lives. who smoke every day has fallen steeply since the 1970s, while the percentage of women has remai- ned relatively constant. Although the percentage Greater risk of communicable diseases of women smokers has not changed in almost Communicable diseases are less common in Nor- thirty years, the underlying picture is more com- way than in most other countries, but this situa- plicated. For example, there are now fewer young tion may change as a result of the increase in and more older women smokers than there were international trade and travel, changes in the pro- in the 1970s. perties of pathogens and the threat of the spread of dangerous pathogens. Alcohol and drugs 2.1.2 Risk factors Norwegians have a low alcohol consumption by European standards, but we have seen a slight Physical inactivity increase in the last ten years. Norway’s drinking The weight of the Norwegian population has culture is still characterized by many incidents of increased gradually in recent decades. The high alcohol intake and a drinking pattern associ- weight of adult men (40-year-olds) has increased ated with many accidents and violence. The use of by 9.1 kg over the past thirty years. At the same narcotics rose from the 1980s to the end of the time, people’s daily physical activities have been 1990s and the increase was particularly noticeable considerably reduced. The number of people who in the second half of the decade. exercise regularly has increased somewhat, but this cannot compensate for the reduction in every- day activity resulting from the diminishing day-to- Social lifestyle differences day demand for physical activity. Surveys indicate There are considerable social differences when it that the level of activity is too low for more than comes to health-related behaviour such as eating, half of the population. Physical activity is also lin- smoking and exercise. For example, we know that ked with social status. Far more people with a pupils taking vocational subjects smoke more, high education exercise than people with a low exercise less and eat less regularly than pupils education. taking academic subjects.

Eating habits 2.2 Trends and social features In the course of the past twenty-five years, the Norwegian diet has become far leaner and the Some social features represent major public consumption of vegetables and fruit has increa- health challenges. These include rapidly chan- sed. These changes go a long way towards explai- ging trends, cultural diversity and globalization. ning the drop in premature deaths from heart Another challenge is our increasing preoccupa- attacks that has been registered over the past tion with health issues and with our own health. twenty years. But the eating habits of a large part 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 11 Prescriptions for a Healthier Norway

2.2.1 Medicalization and focus on risk Box 2.1 Increase in physical Ever-increasing pressure on the use of health ser- and mental problems vices may reflect the fact that we define and handle disease and disorders differently from the • One in every fifth or sixth young person way we used to. To some extent, the increasing complains of life problems that affect their use of health services is linked with the break- ability to function, and every tenth has down of informal and social networks and a resul- such serious problems that they need pro- tant need for professional networks and services. fessional help and assistance. Nonetheless, health seems to be taking a more • The past ten years have seen an increase in and more important place in people’s awareness the use of drugs and alcohol among young and a more predominant place in the mass media. people and so far we have not succeeded in The way people react to illness seems to be chan- reducing the percentage of young people ging and the threshold for seeking professional who smoke. help is being lowered. Fear of illness seems to be • Available data indicates that the average an increasing problem. Growing old and death are weight of children and young people is recognized to a lesser degree as a natural part of increasing, but we have no reliable infor- life itself. mation about how many of them are over- We must beware of the health service becom- weight. Surveys also show that children ing a reception centre for an increasing number of and young people are less active. We know life’s problems. Nor must unrealistic expectations too little about children and young people’s be created about what the health service can intake of energy, but there is reason to achieve. There is a danger of increasing medical- believe that a higher consumption of fizzy ization, whereby more and more of the trials and beverages contributes to weight increase. tribulations of life are viewed as medical prob- lems. Counteracting this will in itself promote health. An increasing preoccupation with illness, symptoms and avoiding risk will in itself seriously adult world and lifestyle. It is a question of making limit development and reduce the population’s your own choices and defining who you are by enjoyment of life. On the other hand, more focus sending clear signals to the people around you. If on health can make public health an easier task smoking is one of these signals, it will be difficult for the authorities. to reduce it without offering an alternative. It is thus important to find the positive health-related trends in youth cultures and build on them. 2.2.2 Youth culture – «Cool to be grown up» The authorities must base their approach on Children and young people are primarily the an understanding of youth culture and on young responsibility of their parents. It is first and fore- people’s terms. We must be familiar with the most their parents’ job to bring them up and act as trends if we want to play on the same side as the role models. But society also has a responsibility health-promoting trends and fight against the neg- to provide for and give them the possibility of a ative trends. Strategies must also be gender-spe- healthy childhood and healthy choices. cific. Health statistics tell us something about the problems, but very little about the reasons behind them. If we want to influence young people’s life- 2.2.3 A multi-cultural Norway style – either by structural adaptation or by atti- At the beginning of 2002, Norway had an tude shaping – we must do so in collaboration and immigrant population of 310,000 persons. Immi- in dialogue with young people. grants from western countries are a relatively The young people of today live a different life homogenous group and do not differ very much from the young people of only five or ten years from the Norwegian population. However, almost ago. While yesterday’s school diaries were full of two-thirds of the immigrant population stem from messages and photos, today’s diaries are full of Asia, Africa and Latin-America. In 2000, there appointments. Children are quicker to adopt an were about 67,000 children and young people belonging to ethnic minorities in Norway. Seventy 12 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway per cent of them originated in Asia, Africa, Central grants is one of the reasons for this situation. or South America, or Turkey. However, it is important to be aware that there are On an average, non-western immigrants have great disparities in life situation between the dif- a lower education, lower income and poorer stan- ferent immigrant groups. dard of living than the average Norwegian. A One of the intentions of this White Paper is to study carried out in 1996 showed that twenty per give more importance to reducing social inequali- cent of non-western immigrants and no less than ties in health. This is the reason why the Govern- seventy per cent of refugee families lived in pov- ment wishes to sharpen the focus on the growing erty. The equivalent figure for the whole of Nor- immigrant population’s special health problems way’s population was 4.5 per cent. The high per- and the need for instruments adapted to their centage of unemployed among non-western immi- needs. This will apply in particular to groups of non-western immigrants.

Box 2.2 Health in the immigrant population 2.2.4 Health and globalization Increasing globalization is a central trend of the • There are greater disparities in health twenty-first century. There is no common under- between the different immigrant groups standing of what globalization is and views of what than between the individual immigrant the economic and social consequences of these groups and the ethnic Norwegian popula- developments will be vary considerably. It is clear tion. however that globalization is a complex process • Stillbirths and deaths in the first week of made up of economic, social, cultural, political and life are less common in infants born of Viet- technological components and that these impact namese mothers and more frequent among on factors that have great significance for public infants born of mothers from Pakistan than health in every part of the world. among infants born of ethnic Norwegian mothers and infants born of North-African mothers. The dividing line between national and • The percentage of persons who regard international health problems is being obliterated their health as good or very good is far As globalization increases, the dividing line bet- lower among immigrants from non-west- ween international and national health problems ern countries than among ethnic Norwe- becomes less and less relevant. At the same time, gians. the interaction of health with other sectors is • Type II diabetes, cardiac infarct and mus- becoming more important. Intersectoral coordi- culo-skeletal pain are reported more fre- nation in order to protect and promote public quently by 59-60 year-olds from non-west- health is becoming increasingly important at ern countries than from other persons in international as well as national level. the same age group. Viruses, bacteria and radioactive and chemical • Only seven per cent of 59-60 year-old pollution are no respecters of national boundaries. women from non-western countries smoke The increasing volume and accelerating speed of every day, as against twenty-four per cent international travel is also significant for how of ethnic Norwegians. infection spreads. The front-line defence against • Seventy-four per cent of the new cases of communicable diseases such as HIV/AIDS and tuberculosis registered in 2001 were dis- tuberculosis and the development of drug-resis- covered among immigrants. tant bacteria lies outside Norway. National mea- • The majority of the persons who are diag- sures are therefore becoming more and more nosed with HIV are immigrants who were dependent on international cooperation and inter- infected before they came to Norway. national agreements. • Refugees report more mental problems than the rest of the Norwegian population. An important reason for this may be that Health and economic developments many have been the victims of traumatic Good health is conducive to economic develop- experiences such as torture and war action. ment and helps to reduce poverty through impro- vement in children’s learning abilities, positive 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 13 Prescriptions for a Healthier Norway demographic change, higher productivity in the zed countries is caused by five risk factors: workplace, reduction in sickness-related expenses tobacco, alcohol, blood pressure, cholesterol and for households, greater savings and thus greater obesity. Obesity, high blood pressure and choles- investment. The WHO Commission for Macro- terol are closely related to physical inactivity and economics and Health issued a report in Decem- a diet consisting of too much fat, sugar and salt. ber 2001 which shows that the global economic These risk factors are increased by smoking and a returns on investments in health are substantial. large intake of alcohol. Both tobacco and alcohol The gains from health-promotion measures are consumption are increasing problems on a world three times as high as the outlay. Three of the basis. In 2000, it was possible to link tobacco to 4.9 United Nations’ development targets for the mil- million cases of premature death and alcohol to lennium are health targets. Norway has commit- 1.8 million of such cases. ted itself, along with other countries and organiza- We are also facing major challenges as tions, to work towards attaining these targets. regards lifestyle and health in Norway. The level Norway’s objective is to improve the state of of physical activity has been reduced. Norwegians health and strengthen the health services in poor still smoke too much, and there is plenty of room countries. This will also help to strengthen our for improvement in diet. defence against communicable diseases and drug- We estimate that more than half of the adult resistant bacteria in Norway. In this way, the population engages in less physical activity than is effect of political decisions will be intensified in recommended and, combined with too high an both areas. intake of energy, this is the most important reason for overweight and type II diabetes. There are reports of an ‘overweight’ epidemic throughout 2.3 Challenges the western world. In Norway, the percentage of persons who are overweight has increased from 2.3.1 Lifestyle as a risk factor the 1960s up until today. Although data is scarce, According to the World Health Report 2002, at available information indicates that overweight is least one third of all disease burden in industriali- also becoming an increasing problem in children. There is a clear connection between overweight and standard of education, and an unhealthy diet Box 2.3 Every period has its own combined with too little exercise is more common challenges in groups with a low social status than in groups with a high social status. Developments in the • In the twentieth century we saw an 1990s show that the decline in smoking among improvement in the health of the Norwe- young people has bottomed out and that the con- gian population that was unparalleled in sumption of alcohol and other intoxicating sub- history. Average life expectancy rose by stances has increased. more than thirty years. If we are to achieve further improvement in • At the beginning of the twentieth century the health of the population, we will have to bring every tenth child died before it was a year about a change towards a healthier lifestyle. Since old. The most serious ‘diseases’ affecting it is the group with the lowest education and the population were infections, epidemics, income that has a lifestyle with the highest risk of hunger and poverty. Every second death illness, it is essential that we reach this group. was due to an infectious disease or epi- demic. • Prosperity brought with it lifestyle diseases 2.3.2 Mental health like: cancer, cardiovascular diseases, pul- In addition to the challenges linked with lifestyle monary diseases and type II diabetes. and physical health, mental problems and disor- • At the beginning of this millennium, we ders are becoming the great new challenge both have seen an increase in disorders caused in Norway and in other western countries. by overweight, physical passivity and dis- Mental health was the subject of the World content. Depression and chronic pain are Health Report 2001. The WHO estimates that gradually becoming just as serious health mental and neurological disorders are responsi- problems as heart disease in our part of the ble for twelve per cent of all lost years of full func- world. tional capacity and that these disorders will repre- 14 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway sent fifteen per cent of the disease burden by the effects of implemented measures. In addition 2020. In Europe, twenty per cent of the total bur- to cultural differences, we also have the challenge den of disability and premature death is caused by of gender differences, and not least social differ- mental disorders. Suicide is one of the three lead- ences, to take into consideration when formulat- ing causes of death in the 15-34 age group. ing and implementing policies. In Norway, with the implementation of the We are still facing major challenges as regards Escalation Plan for Mental Health (1999-2006), we the public health knowledge base. Although we have taken important steps to promote mental now have a better basis on which to initiate mea- health as a priority area, both in the health sector sures in several areas, there remains a great deal and in other social sectors. In addition to the task of work to be done in developing effective preven- of ensuring good follow up and treatment, we are tive measures. In many areas, however, it is not facing major challenges in the work of preventing the lack of knowledge, but the lack of action that mental problems and disorders. Mental disorders is the problem. are a result of the complex interaction of biologi- We already have most of the legislation and cal, psychological and social factors, and there are regulations we need to ensure that health consid- still several areas where we lack sufficient knowl- erations are also taken into account outside the edge about what causes mental illness and about health service. However, we still have a bit to go what constitutes effective measures. before the relevant social sectors have accepted their share of responsibility. At national level, some important structural steps have been taken, 2.3.3 Focus on prevention through the reorganization of central social and In World Health Report 2002, WHO recommends health administration, to strengthen the public national authorities to focus more on preventing health field. A number of smaller agencies in the the risk of disease, which includes focusing more public health field have now been incorporated on scientific research and health surveillance. into a new Directorate for Health and Social Wel- The World Health Organization also emphasizes fare. The way has thus been paved for better coor- the importance of giving priority to effective poli- dination and stronger implementation of public cies to reduce the use of tobacco, unhealthy diets health policies. Furthermore, with the establish- and obesity. The importance of involving NGOs, ment of a Norwegian Institute of Public Health, local communities, the media and other players in the responsibility for major mass surveys and this work is underlined. The report also stresses most national health registers has been gathered that individuals must be given the chance and together in one place. This is an important prereq- encouraged to make healthy lifestyle choices. uisite for the work of strengthening health sur- Over the past ten years, Norway has done a veillance and causal research. However, there is great deal of successful campaigning to prevent still a tremendous need to strengthen the infra- the risk of disease. This has been directed at eat- structure at local level. The involvement of central ing habits and tobacco, among other things. How- authorities in local public health work has to a ever, we can still do a better job of customizing great extent taken the form of time-limited invest- information for the different target groups. We ments in local projects. In the time ahead, there live in a society where changes are taking place will be a need for measures which ensure that more and more rapidly. Young people are the first public health work is given a more permanent and to become aware of changes. That is a significant systematic character. This was also some of the fact we must remember when formulating poli- background for Official Report No.1998:18 A Use cies. We have to try to understand the trends in of Everyone. Strengthening public health work at youth culture and to encourage trends that can local level, which forms an important basis for this facilitate public health work. There are also spe- White Paper. cial challenges inherent in the fact that we have a In recent years, several major reforms have more multi-cultural population. Some of the immi- been implemented in the curative health service. gration populations are struggling with special The most important of these are the introduction health problems and cultural differences create of the regular general practitioner scheme, trans- the need for special measures. Up till now, public fer of responsibility for the specialist health ser- health policy has been more concerned with aver- vices to the State and the Escalation Plan for Men- age factors than with reflecting on the diversity in tal Health. We also have four new health Acts the population. This may have had significance for relating to the specialist health service etc., to 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 15 Prescriptions for a Healthier Norway healthcare personnel, to the establishment and role of the health service in disease prevention. implementation of mental healthcare and to There is room for more prevention work in the patients’ rights. The aim of this new legislationis health service, and it is therefore important to to promote a more effective use of resources and provide the necessary incentives for greater a stronger focus on the patients. Little emphasis involvement in this field. has been given so far in public health policy to the 16 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

3 Four prescriptions for a healthier Norway

This White Paper advocates a broad health policy. Given the challenges we are facing, the Gov- It is concerned with the many factors that play a ernment will give particular emphasis to the fol- part in creating health problems and which help lowing general strategies for public health: to protect us from disease. It wishes to draw atten- 1. Make it easier for people to take responsibility tion to the connections between the individual’s for their own health and the community’s responsibility for and possi- 2. Build alliances to promote public health bility of influencing the health situation and it wis- 3. Encourage more prevention and less cure in hes to make responsibility visible in a number of the health service sectors and policy areas. 4. Build up new knowledge 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 17 Prescriptions for a Healthier Norway

4 Make it easier for people to take responsibility for their own health

«Success will depend on cooperation between the individual and the authorities – where both parties take responsibility and make an active contribution»

Figure 4.1: Healthy lifestyle choices 18 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

This strategy focuses on the relationship between amount of exercise today. The recommended lifestyle and health and on what can be done to level for children is at least an hour of physical reduce the social inequalities in health. Its aim is activity each day. to make it easier for individuals to take responsibi- The Government wishes to curb the negative lity for their own health. Facilitation and measures trend in physical activity in the population and thus must be directed at social conditions and factors prevent a further drop from today’s overall level of in the environment around us which affect our activity. We must pave the way for more physical way of living and health. The success of this stra- activity in the least active population groups. It is tegy will depend on cooperation between the indi- particularly important to create attractive facilities vidual and the authorities – where both parties and activities for children and young people, which take responsibility and make an active contribu- can compete with computer games and other sed- tion. This White Paper also points to ways in entary indoor pastimes. We need arenas where which society can help to prevent mental pro- they can organize their own activities and social blems by building up individuals’ confidence in games. The surroundings should invite movement, their own ability to cope with life’s problems. games and activity. The necessary steps must be taken to make it safe for them to walk and cycle, for example to and from school. 4.1 Healthy lifestyle choices The Government will pave the way for more physical activity through a collective strategy that The way people live is crucial to their health. A covers a wider range of more policy and social correct diet and regular physical activity can areas. A collective strategy for physical activity reduce the incidence of cardiovascular disease must, in the first place, include initiatives that will considerably; it can reduce the incidence of can- change individual attitudes and behaviour. These cer by a third, and it can prevent an increase in may be general information, guidance from the overweight and type II diabetes. Smoking is the health services, low threshold activities and the greatest single cause of illness and death in our possibility of organized physical activity or of time. There are strong indications that physical organizing one’s own activity. Secondly, this strat- inactivity is on its way to becoming the great egy must include measures to create surround- health problem of the future. ings which inspire physical activity on an every- At the same time, we register social differ- day basis. ences when it comes to lifestyle and health-related behaviour. We also see that these risk factors are distributed unevenly in different groups of the Healthy food – good nutrition population – and that they reinforce each other’s Food and eating habits are an important part of adverse effect on health. our culture and what we eat is important from a nutritional point of view and for our social, mental and physical well-being. In Norway, it is primarily People in motion the nutritional content of diets that the public Physical activity is a source of health and well- health authorities are concerned with. Food being, and it is an important instrument in public safety is generally good, but some cases of health policy. There is less and less demand for disease due to infection in food and water do physical activity at home, at work and at leisure. occur. And yet we also know that increasing physical The general objectives of the Government’s activity can only partly – and especially among the food and nutrition policy remain firm. The nutri- most privileged – compensate for a less active tional content of the Norwegian diet must be such daily life. that it: For people who are physically inactive, even a • Reduces diet-related illness in the population modest increase in daily activity will give a consid- • Is safe from a health point of view erable health gain in the form of less risk of • Satisfies consumers’ demands becoming ill, a better quality of life and improved • Is produced in a sustainable and environmen- functional capacity in old age. The recommended tally acceptable way. level of physical activity for adults corresponds to a thirty minutes’ brisk walk each day. Less than The Government’s nutrition policy must help to half of the adult Norwegian population takes that ensure that the population’s diet has a composi- 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 19 Prescriptions for a Healthier Norway tion that is in keeping with the recommendations in restaurants and cafés. The purpose of the of the Directorate for Health and Social Welfare. amendment is to protect employees in the restau- The most important challenges in this policy area rant business from passive smoking. With a view in the years ahead are to reduce the intake of satu- to reducing the recruitment of new smokers, the rated fatty acids and to increase the consumption Government will consider whether a licensing of vegetables and fruit in all groups of the popula- scheme for tobacco could be an appropriate step. tion. It is also important to encourage people to It will also step up its school-based programme, eat more coarse grain products and fish and to «BE smoke-FREE» and initiate a five-year cam- reduce their intake of sugar and salt. These chan- paign against smoking in the mass media. The ges in diet will, among other things, reduce the number of smokers will be reduced by giving risk of developing heart disease, some types of them help to stop smoking and through local com- cancer, obesity, type II diabetes and osteoporosis. munity-based measures. Since overweight and heart problems are most The Government also wants to make a contri- prevalent among groups with a low social status, bution in the international arena. Women and chil- action to promote healthier eating in these groups dren in developing countries are exposed to mas- will help to reduce social health differences. sive advertising by the tobacco industry, enticing Hitherto, information has been the most them to emulate western ideals. We in our part of important nutrition policy instrument. The Gov- the world must make every effort to ensure that ernment will now give more emphasis to struc- the experience of western countries is not tural instruments, such as legislation and avail- repeated in countries where the people are far ability of healthy food. Policy instruments such as less favourably placed as regards economy, organization, coordination, legal basis, surveil- knowledge about the health hazards and help lance, research, development programmes and from the health services. expertise must be seen in relation to one another. A number of ministries administer regulations and agreements that relate to nutrition policy. The Fighting substance misuse work of the different sectors in this field must be Substance misuse represents substantial cost to coordinated and it is important to continue the the country and to individuals. In October 2002, cooperation between the authorities, the food the Government submitted an Action Plan on industry and the consumer organizations. Alcohol and Drug-Related Problems. This action plan lays the foundation for work on alcohol and drug-related issues for the period 2002-2005 and Smoke-free zones offers a collective strategy for prevention, treat- Tobacco is a major cause of illness and premature ment, rehabilitation and harm reduction. death in the population and probably takes a grea- To reduce alcohol and drug-related problems, ter toll on health in Norway than any other single the action plan proposes a greater focus on pre- preventable factor. A reduction in tobacco con- ventive measures. Efforts will be concentrated on sumption would therefore give a considerable measures that we know are effective, and young boost to public health. people will be an important target group. The Government’s target is to halve smoking Research shows that general measures targeting among young people over a five-year period and the whole population can be very effective, while its long-range vision is a non-smoking younger it is probably possible to identify persons at most generation risk at an early stage. It is therefore of crucial Action to prevent the harmful effects of importance to help the most vulnerable groups as tobacco will be directed at preventing passive early as possible. smoking, reducing the recruitment of new smok- We distinguish between two main groups of ers and reducing the number of daily smokers. To measures in the work of preventing alcohol and attain these targets, more resources will have to drug-related problems: those targeting demand be invested in preventing smoking and a broad and those targeting supply. Prohibition, regulation range of high-intensity, long-duration measures and control will be the most important instru- will have to be introduced. ments to reduce demand. In the case of drugs, The Norwegian Storting has recently passed measures will seek to prevent the supply of drugs an amendment to the Act relating to prevention of that are not for medical and scientific use, while in the harmful effects of tobacco to prohibit smoking the case of alcohol, the aim will be to give sales a 20 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway legal form that has as few harmful effects as possi- 4.3 Mental health ble. It will also be important to have effective pre- ventive measures targeting children and young One of the objectives of the Escalation Plan for people who run a greater risk of or show signs of Mental Health (1999-2006) is to prevent mental abnormal behaviour and targeting groups of problems. Special emphasis is given to preventive young people who have a liberal attitude to alco- measures in the case of children. hol and drugs. The same applies to adult cultures, There is a great need for knowledge and open- for example in the workplace and in leisure time, ness about mental health and an information cam- and help for individuals who are in the process of paign has therefore been initiated in cooperation developing an alcohol or drug-related problem. with a number of consumer organizations. The information strategy has three priority areas: chil- dren and young people, the workplace, and users 4.2 Reducing social and the public services. The main focus so far has inequalities in health been on children and young people, while work targeting the workplace has only recently begun. Public health policy in Norway has been more A separate sub-strategy has been drawn up for the concerned with average factors than with diver- workplace and mental health in collaboration with sity in the state of health of the population. This the Confederation of Norwegian Business and may have helped to conceal significant features in Industry (NHO), the Norwegian Federation of descriptions of status and development and it may Trade Unions (LO), the Norwegian Association of have had significance for the effectiveness of the Local and Regional Authorities (KS) and Mental measures implemented. To reach groups of the Health Norway. population who do not meet the average criteria, it It is extremely important to achieve a collec- is important to be aware of what characterizes tive effort to improve the mental health of chil- their situation and what constitutes ‘their’ pro- dren and young people. This applies in particular blems. The Government therefore wishes to place to preventive work. A Strategy for Children’s and a sharper focus on the differences in health pro- Young People’s Mental Health will be drawn up in blems. 2003. This will help to ensure that surroundings, A strategy to improve public health should pay next-of-kin, schools, the leisure and recreation particular attention to improving the health of sector and the support services attach importance groups whose health is below average for the pop- to children’s and young people’s own resources ulation as a whole. This will mean gearing our pol- and ability to cope. This is an important prerequi- icy more specifically to the parts of the population site for preventing children and young people where both the challenges and the possibilities from developing mental problems and disorders. (prevention potential) are greatest. At the same The target is to ensure that children and young time, we must consider the effects the policies of people who develop mental problems are given several sectors can have on the living conditions local and personal treatment as soon as possible. and possibilities of the most disadvantaged. As a follow up to the Escalation Plan, the preven- Although it is important to emphasize the tive health services (child health clinics and choices and actual responsibility of the individual school medical services) will be given an addi- – particularly when it comes to living habits – tional 800 full-time equivalent posts in the period social inequalities in health will largely be a politi- up to 2006. Moreover, new staff (260 full-time cal and social matter. When the differences follow equivalent posts) will be recruited for other psy- clear social patterns, it is not the individuals’ con- chosocial work at local level. scious choice of lifestyle that is the crux of the A National Plan for Self-Help will be drawn up matter. The problem is that people with a low in 2003 in order to increase the focus on self-help. social status, few assets and few resources also This plan will promote self-help as a tool in the suffer from most pain, illness, disability and prevention of mental problems. The national self- reduced life expectancy. Social inequalities in help plan will be used to ensure that previous health are also a serious matter because health is experience from self-help work is utilized and an important prerequisite for social activity and developed and that more prominence is given to participation in society in a broad sense. self-help in existing networks and organizations. 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 21 Prescriptions for a Healthier Norway

4.4 The surrounding environment action can also be extremely resource-intensive. Decisions must therefore be taken on a sound, Good health depends on a healthy environment. professional basis. Factors that affect the environment also affect health and can aggravate existing illnesses such as cancer, hereditary disease, respiratory illnes- Communicable diseases ses and allergies. They can also weaken immune Over the past decades, we have been able to keep systems, reduce fertility and cause damage to a the communicable diseases that occur in Norway number of different organs. If we are to prevent under control. This is due to prolonged, targeted this, we must be able to assess the health risk of efforts at many levels and in many sectors of soci- the individual factors. This means 1) identifying ety. If we cut back these efforts, communicable the inherent harmful properties of an environ- diseases will soon return. International travel and mental factor, 2) clarifying how the harmful trade help to spread these diseases quickly from effects are affected by quantity and concentration, one part of the world to another and to combat 3) assessing the degree of exposure and 4) calcu- them we need cross-border efforts and internatio- lating how great the risk is of illness or damage to nal coordination. A striking example is EU’s health. These assessments will show whether it is efforts to combat BSE (mad cow disease). For necessary to initiate special measures to limit this reason, Norway takes an active part in inter- exposure to any of the various environmental fac- national control of communicable diseases for tors. While the health benefits can be substantial, some time.

Box 4.1 Important measures – Making it easier for people to take responsibility for their own health • Continue developing interconnected net- • Initiate the measures in the Action Plan on works of foot and cycle paths. Alcohol and Drug-Related Problems. • Assess measures to increase and improve the • Implement the Government’s plan to reduce quality of physical activity in schools. poverty. • Initiate systematic pilot projects for coopera- • Draw up an action plan to reduce social ine- tion on physical activity in schools, modelled quality in health. on the Swedish Bunkeflo project. • Establish and build up a resource centre in • Assess whether current measures in the field the administration for inequality and health. of sports take the public health perspective • Continue the information strategy under the into consideration to a sufficient degree. Escalation Plan for Mental Health. • Follow up the World Health Organization’s • Draw up a strategic plan for children’s and global strategy on infant and young child young people’s mental health in 2003. nutrition. • Draw up a plan in the course of 2003 to • Encourage schools to ensure that pupils eat strengthen the self-help strategies in the field good quality food at school. of mental health. • Arrange funding of a subscription scheme for • Revise the National Environmental and fruit and vegetables in primary and lower sec- Health Action Plan. ondary schools. • Strengthen surveillance of communicable • Continue to pave the way for good eating hab- diseases, control of communicable diseases its at the workplace, in canteens and other in hospitals and evaluate the need to reorga- large-scale catering establishments. nize emergency preparedness for communi- • Initiate a five-year anti-smoking campaign in cable diseases. the mass media. • Draw up a combined plan for future work on • Initiate an amendment in legislation prohibit- food and control of communicable diseases. ing smoking in catering establishments. • Strengthen food control and evaluate stron- • Intensify anti-smoking campaigns in schools. ger reactions to contraventions of the food • Establish smoke-free hospitals and offer help regulations. to staff and patients to stop smoking. 22 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

The main strategies that have been used in the to contaminated food is not found in the popula- past are still applicable: measures to prevent peo- tion at large. We also have less illness caused by ple coming into contact with infection, measures contaminated food than many other countries. to strengthen individual resistance to infection, However, we continually find ourselves facing and anti-viral measures when disease occurs. It is new challenges and it is costing Norway more particularly important to maintain a high immuni- and more to maintain this favourable situation. sation level in the population, ensure good diag- The production and supply of food and drink nostic systems to reveal and identify communica- must take place in such a way as to ensure that ble diseases and their causes, monitor the inci- the products are safe to consume. Emergency dence of communicable diseases, and initiate preparedness is important as regards food and preventive measures which we know are effec- drinking water, as action is often required at short tive. notice. Participation in international reporting systems for the outbreak of disease or bans on the sale of foodstuffs is essential in this connection. Safe food Food safety is generally good in Norway. Long- established regulation and good supervision of foodstuffs have helped to ensure that illness due 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 23 Prescriptions for a Healthier Norway

5 Building alliances to promote public health

«A broad approach to public health work means mobilizing (and coordinating) a large number of players in society.»

Figure 5.1: Building alliances to promote public health 24 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

If we are going to build up public health work, we regional networks or chains will entail the follow- will need to mobilize and coordinate a large num- ing obligations on the part of the Government: ber of players in society. We will need to strengt- • Firstly, incentive funds will be made available hen the infrastructure and place more responsibi- to match the use of local resources lity for public health work at local level, for exam- • Secondly, national funds earmarked (for exam- ple by encouraging the development of local and ple through the National Cancer Plan) for local regional partnerships for public health. This projects will be channelled through the White Paper opens the door for a clearer assign- regional partnership ment of responsibility and for extensive partners- • Thirdly, regional public health work will benefit hip building both between different public bodies from professional support and advice from and between these bodies and NGOs. Health con- central government. The Directorate for cerns will also be given a larger part in all social Health and Social Welfare and the Norwegian planning, by making this clearer in legislation and Public Health Institute possess a great deal of by developing suitable methods and tools. expertise, which will be used more to the ben- The Government wishes to promote a munici- efit of local and regional public health work in pal approach rather than a sector approach to pub- the future. lic health work. It is necessary to clarify the local authorities’ total and comprehensive political Local partnerships will be expected to: responsibility for public health work. • Undertake local coordinator functions which have their roots in the central administration and are closely linked with the political level 5.1 Partnership model in local • Have an organization that looks after the inter- government sectoral perspective • Be politically committed and ensure that their The Government calls for a national public health activities have a basis in the local and regional chain which will also provide a basis for a far more authorities’ plans systematic cooperation with voluntary organiza- • Cooperate with other major players. tions, educational institutions and other bodies. The regional authorities can play a central part It is essential that regional partnerships include in public health work by virtue of their position in all the expertise that can help to promote public regional planning and regional developments. health. This applies in particular to the NGOs The regional authorities are responsible for social whose help must be enlisted in various forms of planning and social development and this gives cooperation and partnership. them a natural gateway to public health work. Public health work is about developing good, inclusive local communities, about making 5.2 Public health in social planning arrangements for physical activity in daily life, about the connection between culture and health, If public health is to be the political and adminis- and about schools as arenas for health promotion. trative responsibility of the local and regional Regional authorities also have an obligation to authorities, then public health must be assist and guide local authorities in their planning included in central planning and decision-making work. processes. The Planning and Building Act is the Partnerships are based on equality, unambigu- most important legislation for coordinated, inter- ous agreements and clear, reciprocal expectations sectoral social and land use planning in local dis- and obligations. One of the government’s strate- tricts. It is therefore important to establish that gies for public health work in the future will be to public health is an important consideration to be encourage regional partnerships and network taken into account in all land use and social plan- building where the regional authorities undertake ning. This must be clearly stated in the Planning tasks of an inter-municipal nature. and Building Act and the Government advocates The Government will give a helping hand to including public health in the object clause of the regions wishing to enter into systematic, long- Act. term public health partnerships. It will also offer The Municipal Health Services Act requires its assistance where local political levels are will- the local authorities to keep track of the state of ing to commit themselves. Partnerships with health in their district along with factors that 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 25 Prescriptions for a Healthier Norway impact on it. A number of regional and local the Municipal Health Services Act. This responsi- authorities have drawn up local health profiles. bility includes most of the factors in the environ- However, there is a need for a general tool and ment which can affect health either directly or methodology to ensure that these health profiles indirectly, whether biological, chemical, physical can be a useful tool for the local authorities in or social factors. The local authorities provide community planning. public health protection through control and supervision and through collaboration. The latter tasks include responsibility for collecting health 5.3 Impact assessments and health data and helping to ensure that health issues are taken into consideration by other sectors and in Since very many of the factors that impact on municipal planning and decision-making proces- health are beyond the control of the health sector ses. as such, consideration for health must be rende- It is now nineteen years since a review was red transparent and also incorporated in other made of environmental health in Norway and the sectors. For this we need intersectoral tools. legislation relating to it, and we have seen a great Impact assessments are one such tool. They can deal of change as regards determinants of health, give a systematic picture of the consequences of panorama of disease, knowledge base and admin- different decisions for part or all of the population. istrative apparatus. There seems to be a lack of An impact assessment does not give the answers, correspondence between the breadth and balance but it helps to provide a better basis on which to of the tasks stated in the legislation and the actual make a decision. Impact assessments mean asses- situation when it comes to resources, expertise sing factors that affect health, such as: and prioritisation. There is reason to consider, • Lifestyle (nutrition, tobacco, alcohol, physical among other things, the relationship between activity, etc.) supervisory and collaborative tasks and the way • Socio-economic factors (inequality, access to they are geared to physical and social environ- health services, labour market, poverty, social mental factors respectively. This area still bears inclusion, etc.) traces of a sector philosophy, which may be out of • Environmental factors (pollution, noise, acci- step with modern administrative principles. Fur- dents, social meeting places and other physi- thermore, there may be reason to look more cal, chemical, biological or social factors). closely at how we tackle social or psychosocial determinants of health. In order to achieve more We can also look at the effects of decisions on any local attention and expertise in this field, it will be specific groups of the population that might be necessary to consider how both the regional and affected (vulnerable groups, certain age groups, the central authorities can assist the local authori- gender). An impact assessment can therefore ties. Changes have also taken place in related help us to predict whether or not a decision will administrative areas, which greatly affect environ- result in greater health inequality. mental health work at local level. Examples are a To build up the required knowledge and national control authority for food and drinking expertise and to ensure continuity, health impact water and a possible national control authority for assessments must be included in syllabuses for, schools. In view of these changes, there is a need for example, social medicine, social psychology, for a broad and detailed review of environmental studies in public health science, engineering/ health work. planning studies, environmental health studies, etc. If health impact assessments are to be an effective tool centrally and locally, it will be essen- 5.5 Alliances with NGOs tial to have the necessary competence at national level to follow up this work in collaboration with Non-governmental organizations will have two the educational institutions important roles in public health work. The first will be that of initiator and facilitator of action to promote health and quality of life. Member orga- 5.4 Environmental health nizations in the field of culture, recreation and lifestyle, consumer organizations and the broad The responsibility for environmental health lies public health organizations are important part- with the local authorities under the provisions of ners in public health work. They can help to pro- 26 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

mote and facilitate a healthy and active lifestyle. Box 5.1 Important measures – Alliances to Their second role will be that of a major contribu- promote public health tor to policy-making on behalf of their members and in that way they can serve as a corrective to • Encourage the establishment of local and administrative and political planning in the field of regional partnerships in order to public health. strengthen the infrastructure for public NGOs will be valuable partners for local and health work and give it a local, democratic regional authorities in the public health chain. basis. There is also a need for arenas where they can • Build up the public health database meet with central authorities. The Government (Norgeshelsa) under the direction of the will take the initiative in establishing forums for Norwegian Institute of Public Health to discussions between the central authorities and provide a coordinated tool from which local the non-governmental sector in the area of public authorities can obtain their own health pro- health, through the Directorate for Health and files. Social Welfare. The purpose of these forums will • Make sure that health impact assessments be the reciprocal exchange of information, discus- become an important tool in social plan- sions and transfer of effective measures. Consid- ning, among other things by building up eration will also be given to establishing a new the necessary competence at national level and different form of arena for dialogue – an and working for the inclusion of public annual meeting or ‘exchange’ where NGOs and health considerations in the Planning and other players can present suggestions for public Building Act. health initiatives. • Set up a committee to undertake a broad review of environmental health. • Develop alliances with NGOs by establish- ing special forums for discussion and annual meetings – an exchange – where NGOs and other players can present good suggestions for action. 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 27 Prescriptions for a Healthier Norway

6 The health services: Prevention is better than cure

«The health service has not fully exploited the potential gains in preventive measures. There are many areas where it is possible to prevent more and cure less.»

Figure 6.1: The health services: Prevention is better than cure 28 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

There is room for more prevention and less cure cal services over the past ten years. In spite of this in several areas of the health sector. The Govern- increase, supervision and evaluations show that ment wishes to see more emphasis on lifestyle the help available to young people is still not ade- action in the work of the health services and a quate. Moreover, these services cannot offer sat- strengthening of preventive health services for isfactory help to the most vulnerable groups, and children and young people. the level of competence of the staff will have to be raised and adapted to meet current needs. The Government therefore wishes to build up 6.1 From pills to green prescriptions these services, so that they can: • Provide help that is more suitable for young We know that physical activity, a change of diet people and more appropriate to the new chal- and giving up smoking can be an alternative or lenges in the field of mental health and living supplement to medical treatment in patients who habits. This will require closer cooperation have been diagnosed with high blood pressure, with other services and players, recruitment of high cholesterol or type II diabetes. Nonetheless, staff with more psychosocial knowledge and the increase in sales of drugs for high blood pres- updating of competence of existing staff. sure and cholesterol indicate that physicians • Provide satisfactory help for all young people more frequently prescribe medicines for their between the ages of 13 and 20. This will mean patients than a change of lifestyle. The challenge a considerable strengthening of the services therefore lies in directing the focus away from for this age group. medication as a «first choice» to lifestyle action • Integrate measures targeting the whole 0-20 and effort on the part of the patient. year target group and measures targeting par- The physician’s choice of treatment in any par- ticularly vulnerable groups and helping vulner- ticular case will be based on his/her professional able parents, children and young people and judgement. However, the increased tendency to give them the possibility of taking care of their prescribe medicines may be due to poor accessi- own health. bility of up-to-date knowledge about lifestyle action as an alternative or supplement to medical The preventive health services available to expec- intervention. It may also be due to an aggressive tant mothers and young children up to lower pharmaceutical industry and the fact that patients secondary school age (about 13)will primarily be expect to receive medicines. Physicians have strengthened by raising levels of competence, weak financial incentives to give lifestyle guid- increasing interdisciplinary recruitment and ance. Moreover, writing out a prescription is less through closer cooperation with other relevant time-consuming for the physician and the patient. services. We need to look more closely at the potential for reducing the use of medicines. 6.3 A stronger role for healthcare institutions in prevention 6.2 Better preventive health services for children and young people The hospitals possess a great deal of knowledge about the risk factors for disease, the factors that The child health clinics and school medical servi- reduce the development of disease, and the ces have an important role to play in preventing development of the panorama of disease in the mental and physical problems and disorders in population (epidemiology). The hospitals are expectant mothers, children and young people important sources of knowledge for primary pre- and in detecting early signs of neglect, unhappi- vention, but their most important contribution will ness and abnormal development. It is the job of be in secondary prevention. The hospital staff’s these services, when necessary, to refer clients widespread contact with people who already have for evaluation and treatment, initiate special mea- a health problem enables the hospitals to provide sures, cooperate in arranging respite facilities and information about factors that affect health and provide information about measures from other development of disease. In light of their own acti- bodies. vities, the regional healthcare institutions also There has been a steep increase in recruit- have a part to play in the work of monitoring ment to the child health clinics and school medi- developments in the disease panorama in the 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 29 Prescriptions for a Healthier Norway region. Surveillance of epidemiological factors provides an important basis for preventive measu- Box 6.1 Important measures res. The regional healthcare institutions should – Health services also be able to provide statistics and knowledge about sickliness, mortality, risk factors, which are • Introduce incentives for physicians to pre- of great significance for planning in the region. scribe physical activity and change of diet The specialist health service is an important as part of the treatment of lifestyles dis- source of data at national level through reports to eases, on a par with those for prescribing the Norwegian Patient Register. Furthermore, no smoking. hospital reports from local quality registers will • Evaluate organizational and financial be an important source of data for existing natio- aspects of the role of the general practitio- nal registers and any new registers for certain ner in the socio-medical services as part of groups of diseases. the evaluation of the regular GP scheme If the local authorities are to be able to fulfil • Strengthen the child health clinics and their public health responsibilities, the specialist school medical service, especially as health service must contribute its expertise regards the help they can offer young peo- through information and guidance. On the guid- ple. ance side, it will be necessary to identify areas • Strengthen preventive work under the where the local authorities can have legitimate direction of the specialist health service. expectations of the specialist health service. In addition to epidemiological knowledge, these areas may be control of communicable diseases, cardiovascular disease, psychosocial problems in useful partners in the implementation of primary children and young people, substance misuse, prevention programmes. It is therefore important and the prevention of asthma and allergies. With to include the specialist health services in local their knowledge of the correlations between risk, and regional partnerships in public health work. prevention and disease, the hospitals should be 30 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

7 Building up new knowledge

«A more systematic build-up of knowledge is needed if we are to do the right things – in the right way.»

Figure 7.1: Building up new knowledge 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 31 Prescriptions for a Healthier Norway

Both policy-making and practice in public health between the Directorate for Health and Social work should ideally be based on reliable informa- Welfare and the Research Council of Norway/ tion. Measures that are planned and implemented research communities with a view to planning must as far as possible be based on knowledge research on actions and intervention in public about causes and effects. health. The requirement of knowledge is easiest to In the field of public health, there is a need for meet when the causal relationship is clear. In the research input from many subject areas and disci- case of some of the most important public health plines – from health subjects, from social subjects problems, such as musculo-skeletal disorders, and the humanities, and from science and technol- mental problems and asthma/allergies, the causal ogy. Research cooperation across traditional disci- relationships are complex and to some extent plines and subject areas must be strengthened to unknown. In order to raise the level of knowledge, ensure the inter-disciplinary knowledge that is we must proceed on several fronts: needed here. The Government wishes to give pri- • Health surveillance ority to eating habits, physical activity, women’s • Causal research health, mental health and social inequality and • Research on actions and intervention health. • Systematic evaluation • Cost-benefit analyses 7.2 Education

7.1 Health surveillance and research In most basic educations in the field of health, the main emphasis is on examination, diagnosis, treat- Surveillance is an important part of public health ment of illness and injury, rehabilitation and nurs- policy and it provides a basis for formulating ing of individual patients. In education geared to objectives, planning, implementation and evalua- public health work, the main emphasis is on pre- tion. The aim of surveillance is to support plan- ventive work in groups of the population or in the ners and decision-makers. The Government aims population as a whole. Teaching is interdiscipli- for the most complete health surveillance system nary and based on knowledge from many subject possible, which will make it possible to monitor areas. Most studies in the field of public health developments in the health situation and factors are post-graduate courses and are based on previ- that affect health, and make comparisons between ous basic education and work experience. Public geographical areas and between countries. health work touches on many social fields and Data collection and the administration of should therefore also be included to a greater health and disease registers are dependent on degree in the framework plans for other subjects. continuous research to assure the quality of the White Paper No. 27 (2000-2001) on a quality data. Moreover, data about public health must be reform of higher education in Norway proposes used more efficiently in order to build up the pub- introducing a new degree system which will apply lic health knowledge base. This data must be to most higher level educations. The new struc- regarded as a common property and it is there- ture will have a lower degree (bachelor) which fore important to make the data sources we have will normally take three years and a higher at our disposal available for research in central degree (master) which will take a total of five administration, at hospitals, universities and years. In connection with the reorganization of research institutes. To ensure a more efficient uti- the degree structure, the university colleges have lization, cooperation between central administra- been requested to review the vocational content tion and universities must be strengthened. and direction of their study programmes. It has Research on actions and intervention is a diffi- therefore been suggested that the framework cult field which requires special attention. In Nor- plans for all university college educations should way, the Research Centre for Health Promotion also be reviewed in order to strengthen the public (HEMIL) and the nutritional research group at health perspective in the basic educations. the University of Bergen have chosen children There are many post-graduate courses in and young people as the focus of research. It will health studies today. These last from six months be important to develop these research communi- to two years and qualify students for specialized ties and ensure a long-term build-up of specialist professional posts. Following the reorganization groups. Closer cooperation will be established of the degree structure for higher education, the 32 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

vocational post-graduate courses should be given Box 7.1 Important measures – Building up a place in the new degree structure. One of the new knowledge tasks of a new accreditation body for higher edu- cation to be established on 1 January 2003 will be • Strengthen the Norwegian Institute for to evaluate applications from university colleges Public Health as a national health surveil- to offer studies at master level. This body will lance body, and stimulate more research decide whether and to what degree the present- on material from the national health regis- day post-graduate courses can be included in a ters and from major mass surveys. master’s programme. • Strengthen research on effective preven- Master programmes in International Health tive measures by making the field more and Health Promotion have been established at attractive to research scientists and paving the Universities of Bergen and Oslo, while the the way for a long-term build up of expert University of Tromsø offers a post-graduate communities. diploma in Public Health. The first two are inter- • Develop strategies for more use of national in character. The main challenge here is research-based knowledge about public to establish a master’s programme in public health under the direction of the Director- health work based on the practical challenges in ate for Health and Social Welfare. the field. The subject areas span a wide range of • In particular strengthen action-oriented lifestyle-related subjects from food, physical activ- research on eating habits, physical activity, ity, tobacco, alcohol and drugs to traditional sub- women’s health, mental health and social jects such as control of communicable diseases, inequality in health. radiation control, environmental health, food • Strengthen the public health perspective in hygiene, preventive health services, health sur- basic, continuing and post-graduate educa- veillance, epidemiology and other methodological tion and ensure that post-graduate courses knowledge, and social planning. A master’s pro- in public health are incorporated in the new gramme like this must be adapted to the needs degree structure in the university and uni- and demands of several social sectors, be multi- versity college system. disciplinary, be of a higher degree standard and qualify students for further doctoral studies in public health science. 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 33 Prescriptions for a Healthier Norway

8 A strategy for women’s health

«Since women and men are different, the various measures will have different effects. In some cases it will be necessary to implement different measures for women and men.»

Figure 8.1: A strategy for women’s health 34 Report No. 16 (2002–2003) to the Storting. Short version 2002–2003 Prescriptions for a Healthier Norway

The strategy for women’s health is a follow up of the elderly and to women from minority back- the proposals in Official Report No. 1999:13 grounds. Knowledge will be built up about the Women’s Health in Norway. This report revealed a side-effects suffered by women in particular. The considerable lack of knowledge and poor integra- Research Council of Norway will contrive to make tion of the gender perspective in health policy and gender and gender differences in health and ill- practice. The Report proposes many measures ness a theme in all relevant projects. The National aiming to create structures, routines and tools to Committee for Medical Research Ethics has ensure that the gender perspective is integrated drawn up guidelines for the inclusion of gender as in research and other forms of knowledge build- a variable in all medical research in Norway that ing, policy-making, preventive work, and health relates to humans. The Ministry of Health will services and welfare schemes. Emphasis is given consider an evaluation of these guidelines for in the Report to the user perspective and to inter- medicine. It will also consider whether correspon- disciplinary cooperation, and it makes a point of ding guidelines should be drawn up and applied to stressing that gender – as biology, identity, sym- health research in general. bol and structure – must be included as a neces- sary perspective in research, prevention and the health services. 8.3 Health practice The strategy for women’s health aims to boost research and ensure that the gender perspective One of the prime objectives of the strategy for is given a central place throughout the health ser- women’s health is to ensure that the health servi- vice. The Government wishes to follow up the ces treat women in a more equitable way than has general message in Official Report No. 1999:13, been the case up till now. which underlines the importance of employing a Two points emerge very clearly from descrip- comparative gender perspective in research, pol- tions of how women use the health services. icy-making, health services and welfare schemes. Women have more contact with the health service An important part of the strategy for women’s than men and more often describe their meeting health is to strengthen and continue this work by, with the health service as problematic, full of con- for example, highlighting women in the context of flict and not very constructive. Previous surveys mental health, eating disorders, osteoporosis, of women’s and men’s relationship to general cancer, diabetes, etc. practitioners show that women go to the doctor more often, wait longer for an appointment and are more often displeased with the consultation 8.1 Decision-making processes than men.

Better routines will be established for annual sta- tus reports on the work of integrating the gender Box 8.1 Important measures perspective and gender equality in the Ministry of – A strategy for women’s health Health’s sector areas, for example in routines for • Strengthen research on gender differences administrative procedures, reports and evalua- in risk of disease, development of disease, tion. Attention will also be given to quality assess- diagnosis, optimum treatment and preven- ment and integration of the gender perspective in tion. statistics and in indicator and reporting systems. • Stimulate studies that look at gender differ- The gender perspective will be an important con- ences in relation to the side-effects of med- sideration in health impact assessments. icines. • Focus more on research-based knowledge and measures targeting health and living 8.2 Building up and transferring conditions and the use of the health and knowledge social welfare services by immigrant girls and women. In the field of research, measures will be directed • Follow up efforts to prevent violence and in particular at research into gender differences sexual abuse of women and efforts to in health, causes of diseases to which women in ensure that positive help is available to particular are prone, and research into women’s women who have been abused. mental health. Special attention will be given to 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 35 Prescriptions for a Healthier Norway

8.4 Violence and abuse the incidence of different types of violence against women, the way they are treated by the support The Government’s action plan Violence against services and by the police and courts, and coordi- Women, which expires in 2003, will be carried on. nation of services. The committee will also add- This plan includes a number of measures and pro- ress prevention, and the needs of especially vulne- jects targeting women who have been abused and rable groups such as immigrants, the elderly and aiming to increase relevant competence in the ser- the disabled. vices. A committee set up by the Ministry of Jus- Work is underway to establish a national vio- tice to look at violence against women will submit lence and trauma centre to strengthen research, its recommendation on 1 September 2003. The development of human resources and dissemina- committee’s terms of reference include a number tion of knowledge. of components relating to research and surveys of 2002–2003 Report No. 16 (2002–2003) to the Storting. Short version 35 Prescriptions for a Healthier Norway

8.4 Violence and abuse the incidence of different types of violence against women, the way they are treated by the support The Government’s action plan Violence against services and by the police and courts, and coordi- Women, which expires in 2003, will be carried on. nation of services. The committee will also add- This plan includes a number of measures and pro- ress prevention, and the needs of especially vulne- jects targeting women who have been abused and rable groups such as immigrants, the elderly and aiming to increase relevant competence in the ser- the disabled. vices. A committee set up by the Ministry of Jus- Work is underway to establish a national vio- tice to look at violence against women will submit lence and trauma centre to strengthen research, its recommendation on 1 September 2003. The development of human resources and dissemina- committee’s terms of reference include a number tion of knowledge. of components relating to research and surveys of