2 A public health policy for our time
The population of Norway is in good health. Over the last century, we have experienced a significant improvement in the health and life expectancy of the entire population. Work to improve the nation’s health runs like a red thread through the development of the Norwegian welfare state. Developments in legislation and regulations, public hygiene, knowledge and public education have had a significant impact. Step by step, measures and reforms within many sectors of society have contributed to these developments, through the establishment of universal welfare programmes, comprehensive schooling accessible to all children and young people, improved housing, water and sanitation conditions, vaccinations, a high quality public health service, and the development of a labour market which safeguards the rights and health, safety and environment of its workers.
High quality health services are important if good health is to be achieved throughout the population. Historically, however, the development in sectors other than health and improvements in welfare have been of much greater significance. Improvements in the standard of living have been necessary in order to improve the population’s health, while a healthy population that is able to work has simultaneously been a prerequisite for economic growth.
This positive development shows that we have solved many health problems, but we must now prepare ourselves to face new challenges. Norway, along with the rest of the world, is facing a global trend of illnesses which, in many cases, are related to our lifestyles, to what we eat and drink, and to too little physical activity.
Increased life expectancies and ageing populations, combined with improved treatments and lifestyle changes, have resulted in more people living with chronic conditions. Medicinal and technological advances result in increased expectations of the specialist health service, and prioritisation becomes increasingly demanding. At the same time, there is still broad social inequality relating to health. In order to meet these challenges, the government will develop a public health policy for our time. This policy draws upon historical experience, builds on new knowledge, and is rooted in the values of equity and fair distribution.
2.1 Health is related to how we organise society
The population’s health and social inequality in terms of health is influenced by welfare developments and differences in living conditions. Developments in health are closely related to the circumstances in which we grow up and the conditions under which we live. This is a question of facilitating societal development which provides optimal conditions for good health. We have a particular responsibility towards children and young people, and the government believes that this is where the majority of efforts should be directed. If we succeed in developing a healthier society, we will also create a foundation for inclusive workplaces, creativity and innovation, and contribute to social development in a range of other areas. Good health and improved living conditions within the population are therefore objectives of all public policy.
Good health involves having enough energy to meet life’s everyday demands. This energy provides individuals with freedom of choice and the opportunity to live an independent life. Individuals have considerable responsibility for their own health, and authority and influence over their own lives. However, such responsibility cannot be limited to the individual alone. The prerequisites for being able to exercise freedom of choice are limited by societal inequalities in resources. We almost never make choices outside of a specific context or situation that affects our decision, and which we as individuals often have limited control over. Social conditions influence these choices, and from a government perspective, we must be aware of the possibility to facilitate healthy choices. Society has a responsibility to facilitate self-expression and create equal opportunities. This is about developing a society which distributes resources fairly, and which provides individuals with the opportunity to use their own resources and exercise true freedom of choice. The objective of public health work is not to limit freedom of action – but to create opportunities.
The government takes a broad approach to the development of a healthier society. This includes everything from kindergartens and schools, communities and recreational opportunities such as sports and culture, to workplaces and transport, urban planning and commerce and industry. This goes to the very heart of the policy – the importance of fair distribution and the willingness to redistribute. Since Norway also has clear social inequalities in terms of health, we need a policy of fair distribution, with access to kindergartens and leisure activities that do not cost more than families can afford, a taxation policy which distributes the burden fairly, schools and universities free from tuition fees, and health and care services that are accessible to everyone. The public health policy must also attend to the needs of the indigenous population, national minorities and immigrants, for example in terms of cultural understanding and language barriers. Emphasis will be placed on the significance that the knowledge and attitudes of ethnic groups have upon health and the development of public health measures. In combination, this constitutes an effective public health policy.
Norway has achieved good results from tobacco control through advertising bans, smoking bans in workplaces, public places and restaurants, taxation and other measures. We have a vision of a tobacco-free society. We have had the courage to challenge the tobacco industry. International tobacco control measures have been of great significance in the development of the Norwegian policy, and international collaboration on effective public health measures will become no less important going forward. New international trends in consumption patterns that influence the health of the Norwegian population create the need for national initiatives and global strategies.
We must have the courage and willingness to challenge other industry sectors. New challenges can provide an opportunity and incentive for the development of new forms ways of collaboration and the sharing of responsibilities. We can utilise this opportunity to develop a stronger culture of social responsibility and participation.
The food industry can be encouraged to produce foods which contain less salt, sugar, and unhealthy fats. We can challenge those who produce and sell alcohol to take a greater social responsibility. This is a more complex and demanding agenda, and the opposing forces are strong. There is a need for more knowledge and improved facilitation. Provided that the conditions are appropriate, the public and private sector can collaborate to shift the development in a healthier direction. In other cases, we have a responsibility to use the democratic right to adopt regulations, and this applies to our responsibility to safeguard the health of children and young people in particular. When evidence shows that something is harmful to health, the population is entitled to be protected.
2.2 Increased collective efforts for public health
The government will reinvigorate the public health policies. We can improve public health, but this requires that preventive and health-promoting measures become a part of increased collective efforts. In Norway, we have a unique opportunity to meet the new public health challenges. Our society is characterised by social safety and trust, economic sustainability, and a welfare state that makes us well-equipped to face new health challenges. If, collectively, we are to give public health the boost it needs, all of society must contribute. This is a positive agenda motivated by opportunities.
We need a new approach which more firmly creates and anchors ownership of the public health objectives throughout the majority of the population. We shall carry existing policies forward. But facing lifestyle-related illnesses requires an approach which more strongly motivates and inspires each and every one of us. It is not enough for political authorities to own the objectives – they must be anchored throughout society. This applies to voluntary organisations, trade unions, industry and employers in both public and private sectors. The nation’s health is a shared responsibility. Everyone is responsible for developing a society which promotes good health, and every individual is responsible for his or her own health.
For example, industry can take responsibility by producing healthier products, contributing to projects which adopt a public health approach, and by making it easier for consumers to make healthy choices. In terms of diet, there are several good examples of collaboration between the health authorities and the food industry. This collaboration can be developed further, and be made obligatory. Industry can and should take greater responsibility as an employer, for example in terms of attitudes towards and the consumption of alcohol in social contexts, facilitating physical activity and a healthy diet, and measures to create more inclusive and healthier workplaces.
Workplace organisations – both employee and employer organisations – are both challenged and invited to assume their share of the responsibility. Effective public health work will prevent the exclusion of large groups from education and employment. In the same way, public health work is about creating a safe and secure working environment, which is also profitable for the company, and not least, can help to level out social inequalities in health. The workplace is also well-suited for initiating health-promoting measures and preventive work.
There is a long tradition of collaboration between public authorities and voluntary organisations in public health work. This applies to organisations that have public health as a specified work area, sport and outdoor recreation organisations, humanitarian and non-profit organisations, cultural sector organisations, patient and end-user organisations, and a range of other organisations. This is about the organisations’ intrinsic value as a social meeting place, the activities offered by those organisations, the development of health-promoting arenas such as through the creation of alcohol and smoke free areas, outdoor recreation and exercise facilities, and offering healthier foods at events. This collaboration should be developed further, not least within local communities, where the municipalities shall facilitate collaboration with voluntary organisations. The government will initiate a dialogue regarding how voluntary organisations can become even more important collaborative partners in public health work, about the organisation of public sector initiatives, and about the need for improved coordination across sectors.
Local authorities play an important role. One of the objectives of the Coordination Reform is to contribute to promotion of health and the implementation of more effective preventive measures, and to take responsibility at an early stage, in the context of where we live and work. General Practitioners, who form the backbone of municipal health services, can contribute by becoming more involved in health-promoting measures and preventive work. Through the new Public Health Act, local authorities now have greater responsibility for prevention within the health service, as well as public health work across sectors. Local authorities are responsible for maintaining an overview of local public health challenges and opportunities, but choose their own objectives and measures in order to promote the health of their municipality’s inhabitants. Most municipalities feature cultural and linguistic diversity, and linguistic and cultural competence is therefore important. In accordance with the Planning and Building Act, municipalities must take the Sami community into account in their planning. The involvement of local authorities provides opportunities for public health initiatives comprising all sectors. This requires effective management, political engagement, and well-founded plans and the power to implement them. Many local authorities have already taken up the challenge with great enthusiasm, and public health work is now more highly prioritised on municipal planning agendas.
2.3 National objectives
The government’s objectives for the public health work are as follows:
Norway shall be among the top three countries with the highest life expectancy in the world
The population shall experience more years of good health and well-being, with reduced social inequalities in health
We shall create a society that promotes good health throughout the entire population
The objectives build on the government’s strategy for reducing social inequalities in health as laid down in White Paper no. 20 (2006 – 2007) Nasjonal strategi for å utjevne sosiale helseforskjeller (National Strategy for the Reduction of Social Inequalities in Health), and in the national healthcare plan presented in White Paper no. 16 (2010 – 2011). The preamble of the Public Health Act states that the Act shall contribute to social development which promotes public health and the reduction of social inequalities in health, while also promoting good social and environmental conditions.
The basis of the public health policy is that health not only involves the absence of disease, but also includes high energy levels, satisfaction, and well-being. Good health is something that we can have more or less of – it is not simply a case of being either healthy or ill.
2.3.1 Among the three countries in the world with the highest life expectancy
One of the government’s objectives is that Norway shall be among the top three countries in the world with the highest life expectancy. This objective will be achieved by reducing premature death and reducing social inequalities in mortality. Norway is committed to the World Health Organization’s objective to reduce premature deaths as a result of lifestyle-related illnesses by 25 per cent by 2025.
The objective that Norway shall be among the three countries in the world with the highest life expectancy is new to public health policy, but simultaneously builds on the existing objectives to improve health and life expectancy. A good position in international rankings is not an objective in itself, but life expectancy is a good measure of the health situation of a population. We are well-equipped to achieve this objective. We have a high standard of living, relatively low social inequality, good welfare schemes and a high quality healthcare service. The Nordic welfare model represents a society characterised by security and a high level of social confidence, along with economic and demographic sustainability. In the 1950s, life expectancy in Norway was the highest in the world, and in the 1960s and 1970s we were among the three countries in the world with the highest life expectancy. Although we have seen a sharp increase in life expectancy, we are currently only among the ten or eleven countries in the world with the highest life expectancy. There is no reason that we should not be among the countries with the highest life expectancy in the years to come. This objective must be seen in the context of the other objectives, and efforts to increase life expectancy must be targeted towards strengthening the prerequisites for a long life with good health.
2.3.2 More years of good health and well-being, with reduced social inequalities in health
One objective is that the public health policy shall contribute to individuals experiencing more years with good health and well-being, and reduced inequalities in health.
There is a clear correlation between socio-economic resources and health. If we group the population by income and level of education, we see that the higher a person’s income or level of education, the better their health status. The relationship between social position and health is gradual and continuous, and therefore affects all levels of society. We find many of the same social inequalities within the indigenous population, national minorities and immigrant groups. At the same time, however, education and income do not necessarily reflect social inequalities in the indigenous population in the same way as within the Norwegian population in general.
The results of the global burden of disease project suggest that when life expectancy increases, a larger number of those years will be with reduced health. High quality data shall be developed both in order to monitor whether the objective is achieved, and to be able to better assess future needs. Disability and assistance needs are related to factors other than purely medical ones. For example, it appears that although the incidence of diseases is increasing, the number of elderly people with assistance needs and impaired mobility in the Norwegian population has reduced in recent years.
2.3.3 Create a society that promotes good health throughout the entire population
The government will create a society which promotes health and reduces social inequalities in health without a decline in the health of any group. The objective is based on the fact that there are a range of social factors that affect health and the distribution of health throughout the population. For example, this applies to factors such as the drop-out rate from high school, environmental impacts, income inequality and social differences in lifestyle. By setting objectives for factors that affect health, it also becomes possible to see results in the form of reduced risk long before they result in illness and death. In addition, this helps to highlight the responsibility of sectors and participants with responsibility for the measures.
Social inequalities in health are primarily caused by differences in material, psycho-social and behavioural risk factors. This means that the work to reduce social inequalities in health is also about promoting social cohesion through the reduction in inequalities in income and education. Ethnic discrimination is another factor which can result in health problems. A society which promotes health and shall reduce social inequalities in health must take social, economic, cultural, and environmental conditions into account.
In order for national objectives to function as an effective tool in the work to follow-up and develop the public health policy, it is necessary to render the objectives concrete through the use of performance targets and indicators.
2.4 National tools and measures
This White Paper presents a comprehensive government strategy to develop a public health policy for our time and strengthen the preventive work in the healthcare service. The White Paper represents the national authorities’ follow-up of the guidelines presented in the Public Health Act.
Through the Public Health Act, the government is assigned responsibility for the public health work at a national level. Firstly, this involves a national responsibility to identify public health challenges and possibilities by monitoring developments in the state of the nation’s health and factors which affect this. Secondly, it means that the description of the public health challenges shall form the basis for the planning and design of national measures. Thirdly, national authorities are responsible for assisting the municipal sector and facilitating systematic and knowledge-based public health work.
An overall assessment of the public health challenges forms the basis for the tools and measures that are described in this White Paper. The White Paper is based on recognition of the fact that public health challenges cannot be solved within the health sector alone, but are a shared task to be undertaken by society as a whole. The most important thing we can do to strengthen the public health work is to ensure that the nation’s health is taken into account across the various sectors. The Public Health Act has established the legal framework, and in this White Paper, the government sets out the overall guidelines for its implementation.
Recognition that public health work is a cross-sectoral responsibility, and one which covers all sectors of society, is nothing new. However, in this White Paper, the government will go one step further and establish an improved system in order to ensure more effective implementation of the public health policy. The White Paper will also help to highlight how policies in all areas of society affect the population’s health – the principle of «health in all policies.»
Public health work is not the responsibility of the public sector alone – the whole of society must contribute. The government therefore invites the collaboration of participants outside the public sector and shared responsibility for the nation’s health. This applies to industry, labour market partners, voluntary organisations and other participants that can help to improve the health of the population.
This White Paper is also a follow-up of the guidelines in the Coordination Reform. The Coordination Reform assumes a shift in resources towards preventive work and early intervention in the municipal health care service. Through the introduction of municipal co-financing and payment for patients ready for discharge, the government has given local authorities incentives to take responsibility for more patient care and to focus on prevention and early intervention. Local municipalities have also been allocated funds through block grants in order to establish the necessary competence.
2.5 Values and principles
Public health work shall contribute to good health and improved living conditions throughout the population. This does not apply to the health and care sectors in isolation, but is an objective of all public policies. Good health is a value in itself, and increases opportunities for individual self-expression. Good health is a resource and prerequisite for other objectives, such as a productive working life, efficient learning, and the excess energy to contribute to voluntary work. High levels of ill-health and low levels of functional ability place strains on and result in costs for both the individual and society in general in the form of health care services, sickness absences, and social security.
2.5.1 The responsibilities of society and the individual
The population’s health is affected by political decisions and the choices of private sector participants that lie beyond the reach of individuals. Since health is affected by social development and the conditions under which we live, the public health policy is about enabling individuals and local communities to take control of conditions that affect their health. This includes, for example, factors such as financial security, participation and the ability to cope, a sense of meaning and inclusion in education and employment.
There must be a balance between society’s responsibility for public health and the personal responsibility an individual has for his or her own health. Individuals have considerable responsibility for their own health, and autonomy and influence over their own lives. At the same time, however, the individual’s freedom of action in many areas is limited by circumstances beyond the individual’s control. Even smoking, physical activity and diet are influenced by the economic and social background factors which the individual has not consciously chosen. The use of tobacco affects not only users but also their families, surroundings and others due to passive smoking, passive drinking and behaviour resulting from intoxication. As long as systematic inequalities in health are due to inequalities in the way society distributes resources, then it is society’s responsibility to take steps to make this distribution fairer.
Influencing choices that affect health through the provision of information, contribution of knowledge, and influencing of attitudes is a social responsibility. This may involve making it easier and more attractive for people to make healthy choices, and more difficult to make unhealthy choices. The influencing of others also represents an associated ethical challenge. Such influence must be based on a solid foundation of knowledge, and be well-reasoned and discussed. Policy instruments must therefore be based on respect for differences in values and be fundamentally accepted within society. The public health policy should be subject to public discussion and debate which covers as many parts of the population as possible. This is particularly important since immigration has resulted in Norway’s population becoming more linguistically, culturally, and religiously diverse.
2.5.2 The prioritisation dilemma and the prevention paradox
An objective of the health policy is that it should enable the entire population to experience the best possible standard of health. Both the Public Health Act and the Health Care Act stipulate that services and activities shall be organised in a manner which prevents individuals losing years of good health. This means that available resources shall be used in a way which ensures that they contribute to social equality and the best possible health and quality of life.
In practice, it is often difficult to prioritise prevention over treatment, even if this will provide greater improvements in health in the long term in return for the resources used. Unfulfilled treatment and care needs will always exist. In addition, strong economic interests, the media, and interests of professional organisations direct attention and resources towards specialist treatment. Since no images or stories exist about the ill individuals of the future, ensuring the prioritisation of prevention will always be a political challenge.
If we assume that the resources allocated to health are of a given size, prevention may theoretically be seen as taking resources from those who are currently ill and transferring these resources to healthy individuals. Such an approach may lead to the conclusion that it is more reasonable to undertake preventive work once all pressing problems have been resolved. However, such an approach will never allow for the implementation of preventive work. Even if we utilise resources effectively, we must always assume that the demand for treatment will be greater than what is available. The paradox of this approach is that, over time, it will result in a greater loss of years in good health for society’s individuals. In addition, it is problematic that the approach does not take into account the interests of individuals who will become ill in the future, because no focus is placed on preventive work today. The problem has a clear parallel to environmental challenges, such as the question of what sort of climate or which natural resources we will pass on to future generations. As a society, we must also take responsibility for planning for future needs. Both the Coordination Reform and the Public Health Act are based upon the principle of sustainability, and greater emphasis must therefore be placed on documenting the relationship between the effect on health and the use of resources for preventive measures in order to enable a more direct comparison with medical treatment.
We face a similar prioritisation challenge in terms of prioritising between targeted preventive measures for high-risk groups and broad preventive measures targeted towards the entire population. The trade-off between targeted measures and population-based measures is often referred to as the prevention paradox. This paradox means that measures targeted towards low-risk groups can be just as effective as measures targeted towards groups that are at risk. This is explained by the fact that the low-risk group is large, and the measures will therefore be effective for many. Central to the paradox is the fact that measures that have a seemingly modest effect, but which are directed towards many, can have a far greater public health impact than measures that have a large and measurable effect at the individual level for few.
General welfare schemes are also effective for vulnerable groups. Welfare schemes that are universal and accessible to everyone improve public health, do not stigmatise minority groups, and help to prevent individuals from ending up in vulnerable situations. The World Health Organization and the World Bank recommend universal schemes as an important approach in the context of the follow-up of the development agenda after 2015. The right to kindergarten places for children is a good example. Today, virtually all Norwegian children attend kindergarten, with most enrolling when they are between one and two years old. Through this daily contact with children and parents, employees have the opportunity to identify and provide help to vulnerable children at an early stage. This applies to all kinds of vulnerabilities, from children who require additional language stimulation or follow-up for minor developmental abnormalities, to children exposed to violence, abuse, and neglect.
2.5.3 Five principles for public health work
The Public Health Act is based on five principles for public health work: equity, health in all policies, sustainable development, precaution and participation.
Good health is unevenly distributed between social groups within the population and there are many factors which contribute to creating and maintaining such inequalities. The relationships are complex, but that it is primarily social conditions that influence health, rather than vice versa. Although in many cases serious health problems may lead to a loss of income and employment, as well as problems in completing education, social position still affects health to a greater extent than health affects social position.
There is a gradual and continuous relationship between education, income and health which runs throughout all social groups. With the exception of some particularly vulnerable groups, there is no education and income threshold above which health is significantly improved. This means that social inequalities in health are a challenge that affects society in its entirety, even if the problem is greatest for those groups that have the lowest levels of education and income. As long as systematic inequalities in health are due to inequalities in the way society distributes resources, then it is the community’s responsibility to take steps to make this distribution fairer.
The purpose of the Public Health Act is to promote public health and reduce social inequalities in health. The principle of equity has implications for the formulation of policy at all levels. This means that efforts should be targeted towards the underlying factors that affect health and social inequalities in health, as well as towards giving everyone the opportunity to make good choices. A combination of universal schemes and initiatives targeted towards particularly vulnerable groups is necessary.
Health in all policies
The realisation of «health in all policies» is at the core of the public health work. The principle shall ensure that public health is addressed across all sectors. This means, for example, that the education sector, the transport and communication sector and the cultural sector have a responsibility to assess potential consequences of policy changes for the population’s health.
The principle of «health in all policies» has also been established as a principle in international processes, and is based on an increasing understanding of how conditions in most areas of society affect public health.
In the Public Health Act, the principle of «health in all policies» is expressed through the fact that responsibility for public health is not ascribed to the health service, but to the municipality itself. The Act is also based upon the premise that local authorities, county administrations and state authorities shall promote public health and assess the impact of their activities on the health of the population. Preventive measures shall be implemented in the sector using the policy instruments that are most effective.
Sustainable development involves satisfying current needs without this being at the expense of the needs of future generations. The Brundtland Commission of 1987 defined sustainable development as «... development that meets the needs of the current generation without compromising the ability of future generations to meet their needs.» Sustainable development is about facilitating societal development that ensures basic needs are met over time.
A health sector that consumes too many of society’s overall resources, including labour capacity, is not sustainable and may threaten the welfare state’s existence. The objective of the Coordination Reform is to develop a sustainable health service by strengthening the preventive work.
A population in good health is an objective in itself, and is one of society’s most important resources. A focus on public health work is a foundational investment for better lives and a sustainable society. Preventive work is sustainable because it helps to place greater emphasis on the needs of future generations – which results in greater equality between generations. Good health is of great significance both in terms of an individual’s quality of life and in terms of ensuring that society has a healthy and productive population which can contribute to economic growth and prosperity.
The precautionary principle
The precautionary principle shall be applied when establishing norms and standards for effective public health work. This applies to both risk-reducing and health-promoting measures. In many cases there will be uncertainty regarding the relationship between exposure and health benefits, or about the relationship between initiatives and health benefits. When determining norms, it is sufficient that it is probable that an exposure or may pose a health risk. Scientific certainty is not necessary.
The precautionary principle places the burden of proof on the entity responsible for the initiative or exposure, and must be seen in the context of the «health in all policies» principle. Consideration for the population’s health is not only a responsibility for the health service, but for all sectors and organisations engaged in activities that may have an impact on health.
The precautionary principle does not assume that the risk should be non-existent, but that it should be acceptable. The principle provides guidelines regarding how to handle uncertainty. An assessment of what constitutes an acceptable level of risk may also include proportionality assessments. From a sustainability perspective, the precautionary principle not only involves assessing what is needed to prevent health problems and emergency situations, but also what is required in order to promote and maintain the nation’s health. The precautionary principle is also legally established through the chapter of the Public Health Act regarding environmental health, which provides the authority to intervene before any damage to health is caused.
Through the right to freedom of expression, the right to participation is laid down in Article 19 of the Declaration of Human Rights and Section 100 of the Constitution. A child’s right to be heard is laid down in Article 12 of the Convention on the Rights of the Child. In addition, participation in planning is regulated by Section 5 – 1 of the Planning and Building Act. The Sami Parliament has the right to object in municipal planning processes that are of significance for Sami culture and commercial activities in accordance with Section 5.4 of the Planning and Building Act. The Planning and Building Act shall help to ensure a natural basis for Sami culture, commercial activities and social life, see Section 3 – 1 point c. In accordance with Section 3 of the Regulations regarding public health overviews, local authorities shall consider public health challenges specific to the Sami population where there is reason to believe these exist. In this context, it may be appropriate to obtain experience and knowledge of the Sami population both as a basis for clarification and in order to assess the challenges.
The term «empowerment» is often used in health-promoting work in reference to individuals’ and local communities’ power to influence decisions. Synonyms for the term include authorisation, providing legal capacity, and the strengthening or mobilisation of own resources. The core of this concept is the opposite of powerlessness or oppression – it is about how individuals and local communities can take control by mobilising and strengthening their own forces. The possibility to mobilise resources relates to the conditions under which people live. This means that participation can be stimulated by strengthening social resources and improving material living conditions.
The Public Health Act links the public health work of local authorities to the provisions regarding participating in the Planning and Building Act, thereby contributing to the legalisation of the right to participate. The involvement of voluntary organisations is central to ensuring participation in the public health work, and local authorities are obliged to facilitate collaboration with the voluntary sector through the Public Health Act.
See also White Paper no. 10 (2012 – 2013) Good quality – secure services in which the government emphasises the development of a more patient and user-oriented health care service.