National Action Plan to Reduce Health Inequalities From Rhetoric to Action?

Transcription

1 National Action Plan to Reduce Health Inequalities From Rhetoric to Action? Presentation at the 8th Global Conference on Health Promotion, Europe Day, 13 June 2013, Helsinki Hannele Palosuo Division of Welfare and Health Policies, THL, Helsinki Hannele Palosuo 1

2 Outline Tackling inequity in Finnish health policy Where are we now? Health inequalities and some of their 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) Conclusions Hannele Palosuo 2

3 Tackling inequity in Finnish health policy has a long history 1960s and 1970s: Equity-oriented health care reforms aimed to reduce inequity in access to care regionally and to reduce income differences in access to health care 1972 Economic Council pronounced equal distribution in health as an 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 Equity emphasized also in strategies of the Ministry of Social Affairs and Health 2006 and 2011, and National Programmes for social welfare and health care (KASTE I ; KASTE II ) as well as Government Policy Programme for health promotion ( ) Hannele Palosuo 3

4 Where are we now? Finland has been successful in raising the level of the population health, but there s growing inequity: Life expectancy of men and women (aged 35 yrs) by income quintiles in Finland in (Tarkiainen et al. 2012; MSAH 2013) RED GRAPHS: WOMEN HIGHEST TO LOWEST INCOME QUINTILE BLUE GRAPHS: MEN HIGHEST TO LOWEST INCOME QUINTILE Hannele Palosuo 4

5 Finland is a Nordic welfare state with egalitarian ideals and practices, but development in some important social determinants has not supported reducing health inequalities Finland has still relatively low income differentials (Gini Index 25.8 in 2010), but income and wealth differences have grown more rapidly than in most OECD countries Poverty (share of low income households) increased from about 7% (1995) to 13 % (2009) (more so in families with small children, lone-parent families, single households) Share of recipients of social assistance now on a much higher level 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 increases Hannele Palosuo 5

6 National Action Plan to Reduce Health Inequalities ( ) aimed to tackle social determinants and had 15 action proposals on four main lines: (MSAH 2008:25) Social gradient Disadvantaged groups Prevention of marginalisation Target groups; age groups, special groups Welfare 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) Hannele Palosuo 6

7 The context of health policy and programmes affects the chances of implementation and outcomes. Five I s framework (Palosuo et al. 2013, based on Weiss 1995; Collins & Hayes 2007) Information Ideologies Institutions Interests Implementation Hannele Palosuo 7

8 There are both positive and negative (or controversial) developments within different domains INFORMATION POSITIVE Good epidemiological data and know-how in research NEGATIVE Lack of research on policies and politics; -Gap/ gradient problem not solved (esp. concerning the gradient); - Information steering not sufficient IDEOLOGIES POSITIVE Health is a common value and important for all; - Equity an explicit value in the Finnish Constitution; -Political agreement to reduce health inequalities; - Universalism as a tradition of welfare state NEGATIVE Neoliberal ideology; - International / supranational economic pressures; - Free choice and individualism; - Pressure to switch over to selective/ residual social policy Hannele Palosuo 8

9 And tension and conflicts will not disappear INTERESTS POSITIVE Long term interests are common to all e.g. Health in All Policies approach NEGATIVE Conflicting interests between industries and health policy (eg. alcohol industries, business related to health and health care); - Conflicts of interest in the sphere of work - Fiscal interests (tax revenues) - Orientation on competition (e.g. in EU) - Economic growth vs. austerity plans of the public sector INSTITUTIONS POSITIVE Crossgovernmental cooperation (e.g. Advisory Board for Public Health); - Intersectoral cooperation at municipal level NEGATIVE Devolution of the state and weaker steering by the state; -Tension between state and autonomous municipalities Hannele Palosuo 9

10 IMPLEMENTATION of the Action Plan, or how to get through the jungle of projects, plans and programmes? POSITIVE National Action Plan to Reduce Inequalities in Health (2008) was an accomplishment as such (first explicit programme) + it had an implementation plan and assignments of responsibilities -The Action Plan impacted for its part e.g. on raising alcohol and tobacco taxes and contributed to health promotion among vocational students, developing healthier work environments and assessing health needs of immigrant population. NEGATIVE The Action Plan remained a complementary plan in relation to a great number of other programmes and important social determinants could not be addressed - Fragmentary implementation and weak coordination of policy programmes (in general) - Modest resources for implementation - Short time-span in politics Hannele Palosuo 10

11 Some conclusions Health is a commonly shared value, but reducing (health) inequalities may not be a common goal because of conflicting interests in relation to important social determinants of health (i.e. resources and power; see Commission on Social Determinants of Health 2008). Health in All Policies could be an approach for integrating common interests in areas where many short term interests are in conflict. The Finnish Action Plan ( ) is a link in a longer chain and was instrumental in raising awareness and keeping health inequity on the agenda in some areas of the national and local policies. However, social determinants (root causes) of health were not sufficiently addressed. Societal policies on education, employment, working conditions, distribution of income 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 of the central goals and targets and appropriate means to those ends (and not to get lost in a jungle of programmes and fragmentary projects). Zygmunt Bauman (2011) warns that growing social inequality may be the most disastrous problem that humanity has to confront in this century Hannele Palosuo 11

12 Literature Bauman Z. Collateral damage. Social inequalities in a global age. Polity Press, Cambridge 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 Organization Kuivalainen S. (ed.) Social assistance in the 2010s. A study on social assistance clients and granting practices. National Institute for Health and Welfare (THL) Report 9/2013, (In Finnish with English Abstract) MSAH 2008: National action plan to reduce health inequalities Ministry of Social Affairs and Health, Publications 2008:25, Helsinki, Finland. MSAH 2013: Interim report of the 2015 national public health programme. Sosiaali- ja terveysministeriön raportteja ja muistioita 2012:4, Helsinki 2013 (In Finnish). Palosuo H, Sihto M, Lahelma E, Lammi-Taskula J, Karvonen S. Social determinants in the health policy formulations 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 Health Inequalities in Finland National Institute for Health and Welfare (THL) Report 8/2011 (In Finnish with English Abstract). Rotko T, Kauppinen T, Mustonen N, Linnanmäki E. National Action Plan to Reduce Health Inequalities National Institute for Health and Welfare (THL) Report 41/2012 (In Finnish with English Abstract). Tarkiainen L, Martikainen P, Laaksonen M, Valkonen T. Trends in life expectancy by income from 1988 to 2007: decomposition by age and cause of death. JECH 2012:66: Statistics Finland (on income distribution, unemployment) Hannele Palosuo 12