Original Article
Swedish public health policy: Impact on regional and local public health practice and priorities Marlene Makenziusa,* and Sarah Wamalab a
Uppsala University, Department of Public Health and Caring Sciences, Sweden. E-mail: [email protected] b
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
*Corresponding author.
Abstract
We evaluated the Swedish National Public Health Policy to determine its impact on public health priorities and practice at regional and local levels between 2004 and 2013. We conducted a survey by questionnaire in February 2013 among Swedish county councils/regions (n = 19/21), and municipalities (n = 219/290). The National Public Health Policy facilitated systematic public health practice, particularly for planning, for high priority concerns, including conditions during childhood and adolescence, physical activity, and tobacco prevention. Respondents expressed need for a comprehensive monitoring system with comparable indicators nationwide and explicit measurable objectives. To ensure effective monitoring and follow-up, the measurable outcomes need direct relevance to decision making and high-priority public health issues addressing Sweden’s “overarching public health goal” – to create societal conditions for good health on equal terms for the entire population. Journal of Public Health Policy (2015) 36, 335–349. doi:10.1057/jphp.2015.3; published online 19 March 2015
Introduction The Swedish Parliament adopted the Swedish National Public Health Policy (SNPHP) in March 2003 with representation from all political parties.1 The “overarching goal” is to create societal conditions for good health on equal terms for the entire population.1,2 The SNPHP brings a health determinant perspective to 11 “objective domains” reflecting a holistic approach to public health. These are: (i) participation and influence in society; (ii) economic and social prerequisites; (iii) conditions during childhood and adolescence; (iv) health in
© 2015 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 36, 3, 335–349 www.palgrave-journals.com/jphp/
Makenzius and Wamala
working life; (vi) environments and products; (6) health-promoting and health care services; (vii) protection against communicable diseases; (viii) sexuality and reproductive health; (ix) physical activity; (x) eating habits and food; and, (xi) alcohol, illicit drugs, doping, tobacco, and gambling.1 Work of the World Health Organization’s (WHO) commission on social determinants of health3 inspired Sweden’s health determinants approach for the SNPHP. Since 2003, Sweden’s national government has twice revised the SNPHP,4,5 each time maintaining the determinants approach. Government assigned the Swedish National Institute of Public Health (SNIPH) to monitor and evaluate the impact of the SNPHP for public health practice and population health, and to recommend directions for future policy.6,7 To reinforce the holistic approach, in 2010 Government grouped the 11 objective domains of SNPHP into three “strategic areas”: (i) Good living conditions, (ii) Health promoting living environments and health habits, and (iii) Alcohol, illicit drugs, doping, tobacco, and gambling.2,7 Government’s response to SNIPHs recommendations within these strategic areas has been positive: adoption of approximately 66 per cent (69/104) of the recommendations within 2 years after the publication of the 2010 Public Health Policy Report.2 Sweden is one of few countries with a national public health policy backed by representatives from all political parties. The country has a long history of publicly investing in sectors other than health care that promote population health and prevention of illness, based on, among others, Diderichsen and Whitehead’s model of determinants of health.8 Several studies have shown that economic, social, psychological, behavioural, and environmental factors are major determinants of population health.9–13 A wide range of social and family policies in Sweden aim to tackle health inequalities, for example, universal policies covering paid sick and family leave, pro-health workplaces, heavily subsidised health care, vaccination for children, subsidised preschools, free school meals, and free education at all levels including college and university.14 In comparison to the United States, where social programs are most often restricted to the very poor, Sweden’s programs are progressive, universal, and meant to reach all citizens. As a result of its policy orientation, the United States has lagged behind Sweden or other European countries on several major social indicators.15 Sweden, despite
336
© 2015 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 36, 3, 335–349
Swedish public health policy
its favourable policies, still grapples with health disparities related to class, gender, age, ethnic background, disabilities, sexual orientation, and geography.7,14 From the start of 2014, the Government has taken further strategic action in creating a new, well-coordinated, and larger Swedish Public Health Agency. The Swedish National Institute for Communicable Disease Control, the Swedish National Institute of Public Health, and parts of the National Board of Health and Welfare merged to form one agency: The Public Health Agency of Sweden (Folkhälsomyndigheten).16 We studied the impact of the SNPHP on public health priorities and practice at regional and local levels during the past 10 years since its adoption by the Swedish parliament in 2003. Our evaluation focuses on planning, priorities, practice, and monitoring within the public health system.
Materials and Methods We conducted a cross-sectional survey to assess the effects of the SNPHP between 2004 and 2013 in all municipalities, county councils, and regions in Sweden. We sent the survey questionnaire to respondents in entities, and in positions responsible for public health planning and monitoring.
Questionnaire We constructed study-specific questionnaires in collaboration with experts in the field, conducted a pilot test to validate the questions and to test the procedure, then revised the questionnaires. Each contained multiple-choice questions with an option to describe examples or to add comments to the answers given. The following are examples of questions in the survey: ●
●
●
Have the 11 objective domains in the SNPHP facilitated systematic public health efforts? Have the overarching goal and 11 objective domains been used in the planning and follow-up of local and regional public health efforts? What objective domains have been given special priority over the past 10 years?
© 2015 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 36, 3, 335–349
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Makenzius and Wamala
●
●
Are indicators used to measure the objectives of the public health efforts? How could the use of indicators for measuring goal attainment in public health efforts be improved?
The response rate was 90 per cent (19/21) for county councils and regions, and 76 per cent (219/290) for municipalities. We could not identify a systematic pattern among non-respondents compared with responders. The non-responders were not confined to a particular geographic area. Data collection and storage complied with the ethical guidelines of The Data Inspection Board.17 Respondents’ consent was requested and obtained at the time the questionnaire was filled out.
Analysis of Data Most questions contained multiple-choice options, using a Likert scale (1 = Fully agree, 2 = Agree to a great extent, 3 = Agree to some extent, 4 = Disagree, and 5 = Do not know). To facilitate reporting and analysis, we combined and defined responses 1 and 2 as 1 = ‘high agreement’, and responses 3 and 4 as 2 = ‘low agreement’. To establish statistical significance, we used Pearson’s χ2 test, setting the level at
Swedish public health policy: Impact on regional and local public health practice and priorities Marlene Makenziusa,* and Sarah Wamalab a
Uppsala University, Department of Public Health and Caring Sciences, Sweden. E-mail: [email protected] b
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
*Corresponding author.
Abstract
We evaluated the Swedish National Public Health Policy to determine its impact on public health priorities and practice at regional and local levels between 2004 and 2013. We conducted a survey by questionnaire in February 2013 among Swedish county councils/regions (n = 19/21), and municipalities (n = 219/290). The National Public Health Policy facilitated systematic public health practice, particularly for planning, for high priority concerns, including conditions during childhood and adolescence, physical activity, and tobacco prevention. Respondents expressed need for a comprehensive monitoring system with comparable indicators nationwide and explicit measurable objectives. To ensure effective monitoring and follow-up, the measurable outcomes need direct relevance to decision making and high-priority public health issues addressing Sweden’s “overarching public health goal” – to create societal conditions for good health on equal terms for the entire population. Journal of Public Health Policy (2015) 36, 335–349. doi:10.1057/jphp.2015.3; published online 19 March 2015
Introduction The Swedish Parliament adopted the Swedish National Public Health Policy (SNPHP) in March 2003 with representation from all political parties.1 The “overarching goal” is to create societal conditions for good health on equal terms for the entire population.1,2 The SNPHP brings a health determinant perspective to 11 “objective domains” reflecting a holistic approach to public health. These are: (i) participation and influence in society; (ii) economic and social prerequisites; (iii) conditions during childhood and adolescence; (iv) health in
© 2015 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 36, 3, 335–349 www.palgrave-journals.com/jphp/
Makenzius and Wamala
working life; (vi) environments and products; (6) health-promoting and health care services; (vii) protection against communicable diseases; (viii) sexuality and reproductive health; (ix) physical activity; (x) eating habits and food; and, (xi) alcohol, illicit drugs, doping, tobacco, and gambling.1 Work of the World Health Organization’s (WHO) commission on social determinants of health3 inspired Sweden’s health determinants approach for the SNPHP. Since 2003, Sweden’s national government has twice revised the SNPHP,4,5 each time maintaining the determinants approach. Government assigned the Swedish National Institute of Public Health (SNIPH) to monitor and evaluate the impact of the SNPHP for public health practice and population health, and to recommend directions for future policy.6,7 To reinforce the holistic approach, in 2010 Government grouped the 11 objective domains of SNPHP into three “strategic areas”: (i) Good living conditions, (ii) Health promoting living environments and health habits, and (iii) Alcohol, illicit drugs, doping, tobacco, and gambling.2,7 Government’s response to SNIPHs recommendations within these strategic areas has been positive: adoption of approximately 66 per cent (69/104) of the recommendations within 2 years after the publication of the 2010 Public Health Policy Report.2 Sweden is one of few countries with a national public health policy backed by representatives from all political parties. The country has a long history of publicly investing in sectors other than health care that promote population health and prevention of illness, based on, among others, Diderichsen and Whitehead’s model of determinants of health.8 Several studies have shown that economic, social, psychological, behavioural, and environmental factors are major determinants of population health.9–13 A wide range of social and family policies in Sweden aim to tackle health inequalities, for example, universal policies covering paid sick and family leave, pro-health workplaces, heavily subsidised health care, vaccination for children, subsidised preschools, free school meals, and free education at all levels including college and university.14 In comparison to the United States, where social programs are most often restricted to the very poor, Sweden’s programs are progressive, universal, and meant to reach all citizens. As a result of its policy orientation, the United States has lagged behind Sweden or other European countries on several major social indicators.15 Sweden, despite
336
© 2015 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 36, 3, 335–349
Swedish public health policy
its favourable policies, still grapples with health disparities related to class, gender, age, ethnic background, disabilities, sexual orientation, and geography.7,14 From the start of 2014, the Government has taken further strategic action in creating a new, well-coordinated, and larger Swedish Public Health Agency. The Swedish National Institute for Communicable Disease Control, the Swedish National Institute of Public Health, and parts of the National Board of Health and Welfare merged to form one agency: The Public Health Agency of Sweden (Folkhälsomyndigheten).16 We studied the impact of the SNPHP on public health priorities and practice at regional and local levels during the past 10 years since its adoption by the Swedish parliament in 2003. Our evaluation focuses on planning, priorities, practice, and monitoring within the public health system.
Materials and Methods We conducted a cross-sectional survey to assess the effects of the SNPHP between 2004 and 2013 in all municipalities, county councils, and regions in Sweden. We sent the survey questionnaire to respondents in entities, and in positions responsible for public health planning and monitoring.
Questionnaire We constructed study-specific questionnaires in collaboration with experts in the field, conducted a pilot test to validate the questions and to test the procedure, then revised the questionnaires. Each contained multiple-choice questions with an option to describe examples or to add comments to the answers given. The following are examples of questions in the survey: ●
●
●
Have the 11 objective domains in the SNPHP facilitated systematic public health efforts? Have the overarching goal and 11 objective domains been used in the planning and follow-up of local and regional public health efforts? What objective domains have been given special priority over the past 10 years?
© 2015 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 36, 3, 335–349
337
Makenzius and Wamala
●
●
Are indicators used to measure the objectives of the public health efforts? How could the use of indicators for measuring goal attainment in public health efforts be improved?
The response rate was 90 per cent (19/21) for county councils and regions, and 76 per cent (219/290) for municipalities. We could not identify a systematic pattern among non-respondents compared with responders. The non-responders were not confined to a particular geographic area. Data collection and storage complied with the ethical guidelines of The Data Inspection Board.17 Respondents’ consent was requested and obtained at the time the questionnaire was filled out.
Analysis of Data Most questions contained multiple-choice options, using a Likert scale (1 = Fully agree, 2 = Agree to a great extent, 3 = Agree to some extent, 4 = Disagree, and 5 = Do not know). To facilitate reporting and analysis, we combined and defined responses 1 and 2 as 1 = ‘high agreement’, and responses 3 and 4 as 2 = ‘low agreement’. To establish statistical significance, we used Pearson’s χ2 test, setting the level at
