Hannele Palosuo, National Institute for Health and Welfare, Finland


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Hannele Palosuo, National Institute for Health and Welfare, Finland

  1. 1. 13.6.2013 Hannele Palosuo 1National Action Plan to Reduce Health Inequalities –From Rhetoric to Action?Presentation at the 8th Global Conference on Health Promotion,Europe Day, 13 June 2013, HelsinkiHannele PalosuoDivision of Welfare and Health Policies, THL, Helsinki
  2. 2. Outline• Tackling inequity in Finnish health policy• Where are we now? Health inequalities and some oftheir determinants• Main lines of the National Action Plan• The context of health and other public policies in a”Five I’s” framework (Information, Ideologies,Interests, Institutions, and Implementation)• Conclusions13.6.2013 Hannele Palosuo 2
  3. 3. Tackling inequity in Finnish healthpolicy has a long history13.6.2013 Hannele Palosuo 3• 1960s and 1970s: Equity-oriented health care reforms aimed toreduce inequity in access to care regionally and to reduce incomedifferences in access to health care• 1972 Economic Council pronounced equal distribution in health asan aim for health policy• 1986 Health for All by the Year 2000, Finnish national strategy• 1993 Revised HFA: more emphasis on equity• 2001 Health 2015 Public Health Programme 2008 National Action Plan to Reduce Health Inequalities 2008-2011• Equity emphasized also in strategies of the Ministry of Social Affairsand Health 2006 and 2011, and National Programmes for socialwelfare and health care (KASTE I 2008-2011; KASTE II 2012-2015)as well as Government Policy Programme for health promotion(2007-2011)
  4. 4. Where are we now? Finland has been successful in raising the level ofthe population health, but there’s growing inequity: Life expectancy ofmen and women (aged 35 yrs) by income quintiles in Finland in 1988-2007(Tarkiainen et al. 2012; MSAH 2013)RED GRAPHS: WOMEN• HIGHEST• TO• LOWEST INCOMEQUINTILEBLUE GRAPHS: MEN• HIGHEST• TO• LOWEST INCOMEQUINTILE13.6.2013 Hannele Palosuo 4
  5. 5. Finland is a Nordic welfare state with egalitarian ideals and practices,but development in some important social determinants has notsupported reducing health inequalities– Finland has still relatively low income differentials (Gini Index25.8 in 2010), but income and wealth differences have grownmore rapidly than in most OECD countries– Poverty (share of low income households) increased fromabout 7% (1995) to 13 % (2009) (more so in families with smallchildren, lone-parent families, single households)– Share of recipients of social assistance now on a much higherlevel than 20 years ago– Level of social assistance has stayed lower than it used to be– Share of unemployed growing again (8,8 % April 2013)– Homelessness pertains and even increases13.6.2013 Hannele Palosuo 5
  6. 6. National Action Plan to Reduce Health Inequalities (2008-2011)aimed to tackle social determinants and had 15 action proposalson four main lines:(MSAH 2008:25)13.6.2013 Hannele Palosuo 6Welfare policies tackling social determinants of health (2 proposals)Promoting healthy habits and their prerequisites (5 proposals)Promoting equity and need based use of health and social services (4 prop.)Developing knowledge base and tools (e.g. HIA) (4 proposals)Social gradientDisadvantagedgroupsPreventionof margin-alisationTarget groups;age groups,special groups
  7. 7. The context of health policy and programmes affects thechances of implementation and outcomes. Five I’s framework(Palosuo et al. 2013, based on Weiss 1995; Collins & Hayes 2007)13.6.2013 Hannele Palosuo 7IdeologiesImplemen-tationInterestsInformationInstitutions
  8. 8. There are both positive and negative (or contro-versial) developments within different domains…INFORMATIONPOSITIVE NEGATIVEGood epidemio-logical data andknow-how inresearchLack of researchon policies andpolitics;-Gap/ gradientproblem notsolved (esp.concerning thegradient);- “Informationsteering” notsufficientIDEOLOGIESPOSITIVE NEGATIVEHealth is a commonvalue and importantfor all;- Equity an explicitvalue in the FinnishConstitution;-Political agreementto reduce healthinequalities;- Universalism as atradition of welfarestateNeoliberal ideology;- International /supranationaleconomicpressures;- Free choice andindividualism;- Pressure to switchover to selective/residual socialpolicy13.6.2013 Hannele Palosuo 8
  9. 9. And tension and conflicts will notdisappear…INTERESTSPOSITIVE NEGATIVELong terminterests arecommon to alle.g. Health in AllPolicies approachConflicting interestsbetween industries andhealth policy (eg.alcohol industries,business related tohealth and healthcare);- Conflicts of interest inthe sphere of work- Fiscal interests (taxrevenues)- Orientation oncompetition (e.g. inEU)- Economic growth vs.austerity plans of thepublic sectorINSTITUTIONSPOSITIVE NEGATIVECross-governmentalcooperation (e.g.Advisory Boardfor Public Health);- Intersectoralcooperation atmunicipal levelDevolution of thestate and weakersteering by thestate;-Tension betweenstate andautonomousmunicipalities13.6.2013 Hannele Palosuo 9
  10. 10. IMPLEMENTATION of the Action Plan, or how to getthrough the jungle of projects, plans and programmes?POSITIVE NEGATIVENational Action Plan to ReduceInequalities in Health (2008) was anaccomplishment as such (first explicitprogramme) + it had an implemen-tation plan and assignments ofresponsibilities-The Action Plan impacted for its parte.g. on raising alcohol and tobaccotaxes and contributed to healthpromotion among vocational students,developing healthier workenvironments and assessing healthneeds of immigrant population.The Action Plan remained acomplementary plan in relation to agreat number of other programmesand important social determinantscould not be addressed- Fragmentary implementation andweak coordination of policyprogrammes (in general)- Modest resources for implementation- Short time-span in politics13.6.2013 Hannele Palosuo 10
  11. 11. Some conclusions• Health is a commonly shared value, but reducing (health) inequalities may not be acommon goal because of conflicting interests in relation to important socialdeterminants of health (i.e. resources and power; see Commission on SocialDeterminants of Health 2008).• Health in All Policies could be an approach for integrating common interests in areaswhere many short term interests are in conflict.• The Finnish Action Plan (2008-2011) is a link in a longer chain and was instrumentalin raising awareness and keeping health inequity on the agenda in some areas of thenational and local policies.• However, social determinants (root causes) of health were not sufficientlyaddressed.• Societal policies on education, employment, working conditions, distribution ofincome and wealth, and universal health care and social security, continue to be key(Commission on Social Determinants of Health 2008).• It is important to pay sufficient attention to the formulation and systematization both ofthe central goals and targets and appropriate means to those ends (and not to getlost in a jungle of programmes and fragmentary projects).• Zygmunt Bauman (2011) warns that growing social inequality may be the mostdisastrous problem that humanity has to confront in this century.13.6.2013 Hannele Palosuo 11
  12. 12. Literature• Bauman Z. Collateral damage. Social inequalities in a global age. Polity Press, Cambridge 2011.• CSDH: Closing the gap in a generation. Health equity through action on the social determinants of health.Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization2008.• Kuivalainen S. (ed.) Social assistance in the 2010s. A study on social assistance clients and grantingpractices. National Institute for Health and Welfare (THL) Report 9/2013, (In Finnish with EnglishAbstract)• MSAH 2008: National action plan to reduce health inequalities 2008-2011. Ministry of Social Affairs andHealth, Publications 2008:25, Helsinki, Finland.• MSAH 2013: Interim report of the 2015 national public health programme. Sosiaali- ja terveysministeriönraportteja ja muistioita 2012:4, Helsinki 2013 (In Finnish).• Palosuo H, Sihto M, Lahelma E, Lammi-Taskula J, Karvonen S. Social determinants in the health policyformulations of the WHO and Finland. National Institute for Health and Welfare (THL) Report 14/2013(forthcoming; in Finnish with English Abstract)• Rotko T, Aho T, Mustonen N, Linnanmäki E. Bridging the Gap? Review into Actions to Reduce HealthInequalities in Finland 2007-2010. National Institute for Health and Welfare (THL) Report 8/2011 (InFinnish with English Abstract).• Rotko T, Kauppinen T, Mustonen N, Linnanmäki E. National Action Plan to Reduce Health Inequalities2008-2011. National Institute for Health and Welfare (THL) Report 41/2012 (In Finnish with EnglishAbstract).• Tarkiainen L, Martikainen P, Laaksonen M, Valkonen T. Trends in life expectancy by income from 1988to 2007: decomposition by age and cause of death. JECH 2012:66:573-578.• Statistics Finland (on income distribution, unemployment)13.6.2013 Hannele Palosuo 12