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The Norwegian Directorate of Health's Annual Report on Measures to Reduce Social Inequalities in Health

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The Norwegian Directorate of Health's Annual Report on Measures to Reduce Social Inequalities in Health The Norwegian Directorate of Health's annual report on measures to reduce social inequalities in health. NORWEGIAN PUBLIC HEALTH POLICY REPORT 2009 IS-1763/E Publication title: The Norwegian Directorate of Health's annual report on measures to reduce social inequalities in health: Norwegian public health policy report 2009 Published: 12/2009 Ordering number: IS-1763/E ISBN 978-82-8081-201-8 Published by: Norwegian Directorate of Health Contact: Division for Public Health Postal address: Postboks 7000, St. Olavs plass, N-0130 Oslo, Norway Street address: Universitetsgata 2, Oslo, Norway Telephone: +47 81 020 050 Fax: +47 24 16 30 01 www.helsedirektoratet.no/gradienten The report may Directorate of Health publications office (Trykksakekspedisjonen) be ordered from: e-mail: [email protected] Telephone: +47 24 16 33 68 Fax: +47 24 16 33 69 When ordering, please state ordering number: IS-1763/E Graphic design: Tank Design AS Printer: RK Grafisk AS Production: 1,000 copies of the report have been printed in a Nordic Swan eco-label production; the contents on 130 g Soporset and the cover on 250 g Soporset. 2 Foreword by the Director General of Health Background paper, Report no. 20 to the Storting (hereinafter 2007 saw the publication of Report no. 20 to referred to as the 'white paper'), was to establish the Storting (2006–2007) National strategy to a reporting system to provide a systematic overview reduce social inequalities in health. This white of progress on the efforts to reduce inequalities in paper emphasised that the prime objective of health. This was to be achieved by monitoring trends national health policy is to achieve more equi- using a set of indicators for the intervention areas table social distribution of health – and health of income, childhood conditions/education, work determinants. It is the case that health and the and working environment, health behaviour, health distribution of health are attributable not only to services and social inclusion. areas traditionally covered by the health sector. The present report is the first output from this Daily living conditions and the circumstances in reporting system. which people are born, grow, live, work and age are the ultimate determinants of health in each Individual and society individual. In order to tackle social inequalities in The use of structural instruments such as price, health we therefore have to direct our attention availability and regulation have, in the field at the underlying causes – the social determi- of public health as in other policy areas, been nants of health. perceived as restrictions on the individual's The social determinants of health that produce freedom of choice and self-determination. In some and distribute health have also come under instances, such criticism may be justified: when increased global scrutiny. In autumn 2009, the official bodies impose restrictions and policies on Directorate of Health published a Norwegian trans- the individual’s scope of action for the sole reason lation of the Marmot Commission's report, "Closing that they claim to know what is best for the indi- the Gap in a Generation – Health Equity through vidual, there is the risk that we end up as a ‘nanny Action on the Social Determinants of Health" state'. Such restrictions and policies are however (2008). The Marmot Commission, set up by WHO, justified when they serve to safeguard the freedom examined the causes of and measures for redressing of other individuals. In any society, the individual's health inequities. One of the main recommendations freedom of scope may potentially encroach on of the Commission was to establish systems for the freedom of others and this will often – in the monitoring health inequities and social determinants absence of rules, policies and restrictions – affect of health. One of the main measures in the white those most disadvantaged in society. Norway's 3 relatively strict regulation of the price and avail- In the main, social inequalities in health do not ability of alcohol was thus not introduced primarily arise because some people choose to lead healthy in order to persuade individuals to lead healthier lives, while others choose to lead unhealthy lives. lives, but because alcohol misuse almost always They arise because of the social constructs that affects the misuser’s family and friends. Similarly, guide individual freedom of choice. A child born to the anti-smoking act was not introduced primarily a financially and socially resourceful family patently to get smokers to quit smoking, but to ensure that has other and far better opportunities than a child everyone has the right to a smoke-free workplace. from a family struggling to make ends meet. Social Low speed limits and speed humps in the road in inequalities in health arise because freedom of residential neighbourhoods restrict the freedom of choice in itself is inequitably distributed in society. the individual to drive as fast as he or she might This inequity of opportunity is due to social con- like, but provide children and others with a safer structs, and structural instruments are the most neighbourhood. Measures to curb the freedom of effective and most just – and perhaps also the the individual are thus justified when they serve to only – way of changing them. Which means that protect the freedom of others. structural instruments, when justified, result above Genuine individual freedom of choice also all in greater freedom of choice – for more people. requires insight into the alternatives that may exist and their potential consequences. It is often the The cross-sectoral approach case that our material, social, cultural and psy- Since health is produced and distributed across chosocial surroundings are powerful determinants many other arenas than in the health sector, many of what we perceive as alternatives and what we of the most important instruments also lie outside believe their outcome may be. If healthy food is of the Directorate's own sector. The efforts to more expensive than unhealthy food, many people reduce inequalities in health thus call for a cross- will take the unhealthy option. If the distance to sectoral approach. The health authorities must to the nearest recreational area is long and awkward, a greater extent be the driving forces in lodging more people will tend to stay at home. And if the a share of the responsibility for public health facts about the health risks of using oral tobacco with other sectors and in taking the initiative are not widely known, then more Norwegians will for extensive cooperation between national choose to use oral tobacco than might otherwise authorities. We must be instrumental in devel- have been the case. Society has a responsibility for oping cross-sectoral solutions that are conducive to putting measures in place that make the healthy sound conditions in which to grow and live, and an choices the easy choices. inclusive and healthy working life. Only in this way 4 can we promote healthier lifestyles, stability and but in which it does not exercise control over participation. those measures. Examples of this would be the The reporting system and the present report introduction of the school fruit and vegetable are based on a formalised cooperation between scheme or increased physical activity in schools. several centralised directorates, ministries and In such circumstances, the health sector should professional environments. Interministerial assume the role of primus motor and negotiator. meetings are held to appraise the progress of the Thirdly, we have situations in which the health work on the reporting system. This is described in sector has some insight, and is able to point to more detail later in the report. The point is that we adverse health consequences of measures in cannot improve public health and how health is other sectors, but where the health sector itself distributed without involving, and lodging respon- does not exercise control over those measures sibility with, other sectors in society. or know precisely how such measures should be Whether the health sector itself is to play designed. Examples of this would include social a leading role in these cross-sectoral efforts inclusion in schools or in working life. depends on the problem at issue, This must be assessed with respect to at least two factors: Challenges for public health policy 1) knowledge of causes and effective measures This report is divided up according to the following and 2) whether the health sector itself exercises intervention areas: income, childhood conditions, control over the measures to be implemented. It work and working environment, health behaviour, may be helpful to think in terms of three different health services and social inclusion. These are key roles for the health sector: determinants of health and the distribution of First, there are the situations in which the health. In the following, from the perspective of health sector itself should and must lead the way. public health policy, we will be indicating a number This would include situations where the sector itself of trends we regard as being matters of serious has established best practices concerning effective concern. We will also be addressing a number of measures and where the sector also exerts control trends within our own field of expertise – health over those measures. One example of this would be behaviour – and outlining measures which we group-based preventive work run by the municipal regard as appropriate for enabling the Norwegian preventive health services, such as the maternal and public to make sound health choices. child health centres and the school health service. In Norway, we are seeing distinct social inequal- Secondly, we have situations in which the ities in schooling and particularly in attainment health sector is familiar with effective measures, of upper secondary level education and training.
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