Marit Helgesen

Reducing social inequities in health in Norway: Concerted action at state and local levels?

Norwegian national policies have been distinguished by their focus on equity, contributing to comprehensive policies to reduce the social inequities in health (SIH). The newly adopted Public health act, which aims at reducing the SIH, endorses these acknowledgements while highlighting the importance of municipalities as the key actors in public health. Municipal obligations include inter-sectoral policies for health, health impact assessments (HIA), and the development of local health overviews. Against the background of a system of local autonomy in Norway, this article illuminates whether, and how, municipal public health policies reflect national priorities. Our data are based on one qualitative study, combining document content analysis and expert interviews conducted in 2011, and one quantitative questionnaire sent to municipal chief administrative officers in 2011. Our findings indicate a divide between national and municipal public health strategies. Many municipalities focus on life-style and health-care related measures. Only few municipalities acknowledge the social determinants of health and have implemented HIA and health overviews. Arguing for the importance of concerted multi-level action to reduce the SIH, we need to better understand the gap between national and municipal approaches. We thus suggest further research to illuminate the challenges and success factors faced at local levels.

Health in All Policies: A cross-sectional study of the public health coordinators’ role in Norwegian municipalities

Aims: The public health coordinator (PHC) is a municipal-government position in Norway whose role is to organise and oversee municipal policies and functions to support national public health goals. This cross-sectional study investigates conditions associated with use of PHCs by Norwegian municipalities in the period immediately before the new Public Health Act came into effect in 2012, decentralising responsibility for citizen health to the municipal level. This study provides descriptive baseline data regarding Norwegian municipalities’ use of PHCs in this time – a marker for municipal engagement with inter-sectorial collaboration – before this policy was nationally mandated, and explores whether municipal characteristics such as structure, socio-economic status and extent of Health in All Policies (HiAP) implementation were associated factors. Methods: All Norway’s municipalities (N=428) were included. We combined Norwegian register data with survey data. Descriptive analyses and bi- and multivariate logistic regression analyses were performed. Results: A total of 76% of Norwegian municipalities employed a PHC in the period just before 2012. Of the PHCs employed, 22% were employed full time and 28% were located within the staff of the chief executive office. Our study indicates that partnership for health promotion with county councils (OR=7.78), development of a health overview (OR=3.53), collaboration with non-government sectors (OR=2.85) and low socio-economic status (OR=0.46) are significantly associated with Norwegian municipalities having a PHC. Conclusions: This study suggests that the municipality’s implementation of HiAP, as well as lower socio-economic indicators, is associated with the use of PHCs in Norway, but not factors related to municipal structure.

Multi‐level governance in Norway: universalism in elderly and mental health care services

Purpose – Based on a case study of Norway, the purpose of this paper is twofold: to present recent trends in the development of the multi‐level governance of the care services for the elderly and people with mental illness towards what we call the cooperative turn; and to discuss the implications of this trend for universalism in service provision.Design/methodology/approach – The paper is a study of documents and the recent research literature.Findings – A shift towards the cooperative turn can be identified as a change from command‐and‐control instruments to soft regulation mechanisms. Regulations and economic means are increasingly complemented by informational means. Soft versions of the steering instruments are used to target the results and processes of local policies. Hard instruments do not disappear, and a mixture of all the abovementioned instruments governs the two policy fields. This has implications for universalism defined as territorial uniformity, accessibility and coverage as user groups ...

Governance of public health: Norway in a Nordic context

Introduction: The two pillars of public health are health promotion and disease prevention. Based on a notion of governance in the state -local relation as changing from hierarchical via New Public Management (NPM) to New Public Governance (NPG), the governance of public health in Norway is contrasted to governance of public health in the other Nordic states: Denmark, Finland and Sweden. Aim: The article aims to present and discuss the governance of public health as it is played out in the state-local relationship. Methods: The method is to study central state documents in the four countries, as well as articles, research reports and papers on public health. Results: The article shows that the governance modes (hierarchy, NPM and NPG) exist in parallel, but that their mechanisms actually vary in use. Legal, economic and informational mechanisms are, to a varying degree, in use. Conclusions: In Finnish and Swedish public health policies, health promotion is at the forefront; while Danish and Norwegian public health policies spur the local governments to carry out interventions to prevent disease and hospital admissions.

Capacity to reduce inequities in health in Norwegian municipalities

Aims: One of the goals of the Norwegian Public Health Act is to reduce health inequities. The act mandates the implementation of policies and measures with municipalities and county municipalities to accomplish this goal. The article explores the prerequisites for municipal capacity to reduce health inequities and how the capacity is built and sustained. Methods: The paper is a literature study of articles and reports using data from two surveys on the implementation of public health policies sent to all Norwegian municipalities: the first, a few months before the implementation of the Public Health Act in 2012; the second in 2014. Results: Six dimensions are included in the capacity concept. Leadership and governance refers to the regulating tool of laws that frame the local implementation of public health policies. Municipalities implement inter-sectoral working groups and public health coordinators to coordinate their public health policies and measures. Financing of public health is fragmented. Possibilities for municipalities to enter into partnerships with county municipalities are not equally distributed. Owing to the organisational structures, municipalities largely define public health as health policy. Workforce and competence refers to the employment of public health coordinators, and knowledge development refers to the mandated production of health overviews in municipalities. Conclusions: The capacity to reduce health inequities varies among municipalities. However, if municipalities build on the prerequisites they control, establishing inter-sectoral working groups and employing public health coordinators in authoritative positions, national governance instruments and regional resources may sustain their capacity.

Addressing the social determinants of health at the local level: Opportunities and challenges

Aims: The gradient in health inequalities reflects a relationship between health and social circumstance, demonstrating that health worsens as you move down the socio-economic scale. For more than a decade, the Norwegian National government has developed policies to reduce social inequalities in health by levelling the social gradient. The adoption of the Public Health Act in 2012 was a further movement towards a comprehensive policy. The main aim of the act is to reduce social health inequalities by adopting a Health in All Policies approach. The municipalities are regarded key in the implementation of the act. The SODEMIFA project aimed to study the development of the new public health policy, with a particular emphasis on its implementation in municipalities. Methods: In the SODEMIFA project, a mixed-methods approach was applied, and the data consisted of surveys as well as qualitative interviews. The informants were policymakers at the national and local level. Results: Our findings indicate that the municipalities had a rather vague understanding of the concept of health inequalities, and even more so, the concept of the social gradient in health. The most common understanding was that policy to reduce social inequalities concerned disadvantaged groups. Accordingly, policies and measures would be directed at these groups, rather than addressing the social gradient. Conclusions: A movement towards an increased understanding and adoption of the new, comprehensive public health policy was observed. However, to continue this process, both local and national levels must stay committed to the principles of the act.

The Municipality as Negotiator in Multilevel Governance of Health Care

Abstract This article focuses on the new role of municipalities–as negotiators in multilevel governance of health services. The 2012 health care coordination reform in Norway involves a partnership between health services at the national and municipal levels. Negotiations in these regional partnerships result in regionally different solutions concerning the provision of health services. What does this new role of municipalities require with regards to political steering and administrative management? From interviews in nine municipalities and two regional health authorities, the authors find that the formal cooperation agreements have affected the interaction between municipalities and regional health authorities, with a shift from professional deliberation to strategic negotiations. The new negotiating role of the municipalities requires political will to clarify the room of maneuver for the negotiating actors and support the negotiating solutions when these are within the defined frames. The negotiations stimulate integration between management and professionals, in order to inform the chief executive officer, who is often the negotiator. The negotiators assume an essential role as bridge-builders between the political and professional world in the municipalities, and the professional world of the hospitals and regional health authorities.