Part 3
Targeted initiatives to promote social inclusion

8 Targeted initiatives to promote social inclusion

«Universal schemes must be supplemented with individually tailored services and measures that take account of groups with special needs. User-oriented and specially adapted public services are essential to ensure that everyone, regardless of their background and circumstances, has access to equitable services.»

8.1 Objective: Better living conditions for the most disadvantaged people

Objective

• Better living conditions for the most disadvantaged people

Other goals

• Reduce the number of adults who leave school with poor basic skills

• Enable more people to work

• Improve accessibility of health and social services

• Eliminate homelessness

• Reduce inequalities in living conditions between different geographical areas

8.2 Policy instruments

In its report The Solid Facts, the World Health Organization states that being excluded from society and being treated as inferior lead to poorer health and a greater risk of premature death. Living in a community marked by difficult living conditions, high unemployment and poor housing poses a health risk. Unemployment and unstable contact with the labour market in themselves entail a health risk. Relative poverty can also lead to social exclusion through a lack of accommodation, education and other factors necessary for full participation in society. Discrimination, stigmatisation and unemployment can also lead to social exclusion. These are all factors that obstruct participation in society. People who live or have lived in institutions, such as, for example prisons, child welfare institutions and psychiatric institutions, are particularly vulnerable.

Almost half of the income of people with limitations in functioning and participation comes from transfers. Many people with reduced functional capacity experience discrimination and marginalisation and are therefore at risk of getting caught up in a vicious circle of social problems and health problems. The passivity and dependence on services that marks the situation of many people with reduced functional capacity are to a great extent created by society through various obstructions and barriers preventing their independence and participation.

The overview of current knowledge Social inequalities in health in Norway published by the Directorate for Health and Social Affairs points out that there is limited knowledge about effective measures to reduce social inequalities in health, but that international experiences suggest that measures to combat poverty and unemployment are important. It is also pointed out that universal welfare schemes will probably have a buffer effect, and that broad initiatives aimed at specific groups to counteract social inequalities will probably help reduce inequalities in health and improve public health. Other potentially effective measures include low-threshold measures for certain specialist health services aimed at specific groups, health services without user charges, and cross-sectoral partnerships between the state and other actors in deprived areas.

Public assets such as education, health and social services, and kindergartens are decisive for distribution of resources and living conditions in the population. Many disadvantaged people also need more targeted services. Universal schemes must be supplemented with individually tailored services and measures that take account of groups with special needs. User-oriented and specially adapted public services are essential to ensure that everyone, regardless of their background and circumstances, has access to equitable services.

8.2.1 Inclusion in the labour market

Employment is vital to ensure income, feel valued by society and have a sense of inclusion and involvement. People who fall outside the labour market also tend to fall out of other parts of the welfare society.

The Government wants to eliminate poverty and reduce social and economic inequalities through universal welfare schemes, strong community solutions and by giving everyone the opportunity to participate in working life. The Government’s policy to combat poverty and prevent development of a society with broad divides between people in work and people who are unemployed is laid out in Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusion and Action Plan to Combat Poverty.

Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusion emphasises use of welfare contracts as a continuous and systematic principle to define mutual expectations, requirements and commitments between the administration and the user in concrete terms.

In the Report to the Storting, the Government paves the way for greater use of special work-oriented measures and services to lower the threshold into working life and raise the threshold out of working life, including adapting measures to meet the needs of immigrants and people with reduced functional capacity.

The Report to the Storting gives notice that the use of policy instruments is going to be made more flexible and coordinated, based on the individual’s needs. The Government is also going to introduce a new system with a temporary minimum income in the National Insurance Scheme to replace various rehabilitation benefits and temporary disablement benefit. This reform will also help steer use of resources away from administration of benefits and towards active interventions and follow-up.

The strategies and initiatives mentioned in the Report to the Storting along with the reorganisation of the labour and welfare administration constitute a major policy reform in the field of labour and welfare. The new labour and welfare administration, the Norwegian Labour and Welfare Organisation (NAV) forms a framework for comprehensive and coordinated services for job seekers and people who need special adaptation of the environment at work. The NAV reform’s main objective of getting more people into work and activity and fewer people on benefits makes the local NAV offices important arenas in the work to prevent poverty and ensure social inclusion. The new labour and welfare administration entails coordination of several central-government and local-government services. This provides breadth in the portfolio of tasks ensuring a comprehensive labour and welfare policy and constitutes a better starting point for providing assistance to people on the fringes of the labour market. Users of NAV offices shall have easy access to services and receive quick, comprehensive clarification of needs, individual follow-up adapted to the needs of the individual and coordinated services.

The Government’s Action Plan to Combat Poverty aims to improve the living conditions and opportunities of the members of society with the lowest incomes and the worst living conditions. In 2007, initiatives aim to ensure that everyone has the opportunity to work, that all children and young people are able to participate and develop, and to improve the living conditions of the most disadvantaged people.

Many of the most disadvantaged people need to improve their competencies and qualifications and require health and rehabilitation services before they can participate in paid work or measures preparing them for employment. In 2006, the focus on targeted labour market measures for long-term recipients of social benefits, young people and lone providers whose main income is social benefits and immigrants who need assistance to find work was made nationwide. The measures are run by the Norwegian Labour and Welfare Organisation (NAV) in close cooperation with the social services in the municipalities. The goal is that participants’ contact with the labour market is improved through integrated assistance from service providers, good advice and guidance, and labour market measures based on individual needs. The investments in this area will be further strengthened in 2007.

Report no. 9 to the Storting (2006–2007) Employment, welfare and inclusion and Action Plan to Combat Poverty propose establishing a qualification programme entitling participants to a qualification benefit for people with significantly reduced capacity for work and income and with no or very limited subsistence support from the National Insurance Scheme. The qualification programme and qualification benefit are intended to improve the opportunities of people whose main source of income over a long period is financial social benefits. The objective is to help more people in the target group find work. The scheme is meant for people who have been assessed as being able to hold down a job if they receive closer, more committed support and follow-up.

Social benefits will continue to function as a lower safety net linked to unforeseen high expenses, short-term and acute needs for assistance and in special transitional phases. The Government has raised the rates in the state advisory guidelines for apportionment of subsistence support in order to improve the economic situation and living conditions of people who need social assistance in a passing difficult situation.

One of the focus areas in the Escalation Plan for Mental Health (1999–2008) is improving the accessibility of work and labour market measures through targeted measures for people with mental ailments. The Directorate for Health and Social Affairs and the Directorate of Labour and Welfare are collaborating on a strategy for labour and mental health. The goal of the strategy is that people with mental ailments shall have better opportunities to make use of their capacity for work. The escalation plan for efforts to combatsubstance abuse is intended to help more drug addicts and alcoholics become socially and occupationally rehabilitated by strengthening and coordinating treatment and rehabilitation measures in the field of substance abuse.

Experiences from the Competence Reform in Norway reveal that the people with the fewest skills and least education to begin with benefited the least from the reform. Report no. 16 to the Storting (2006–2007) Early intervention for lifelong learning therefore paves the way for amendment to the Act relating to Primary and Secondary Education so that adults aged 25 or older who have not completed upper-secondary education are entitled to this education. The Government has also initiated measures to build capacity in and expand the programme for basic competencies in working life and measures to build capacity in education within the Norwegian Correctional Services. For prisoners, specially adapted training can be decisive for successful rehabilitation. For this reason, the Government has made arrangements to improve education for prisoners.

8.2.2 Health and social services

The health service shall offer good quality health and care services to everyone. The goal is equitable services regardless of place of residence, personal economy, gender, ethnic background and the individual’s life situation. People with serious substance abuse problems, prisoners, women and children who have been exposed to violence in close relations and traumatised refugees and asylum seekers need specially adapted measures.

The NAV reform is intended to ensure that people who are completely or partially unemployed and receive public benefits because of illness, unemployment or social problems are offered coordinated services.

People with substance abuse problems

Drug addicts and alcoholics have a documented underconsumption of health services in the municipal health service and in the specialist health service. In recent years, extensive changes have been made regarding who is responsible for what in the health care services for drug addicts and alcoholics. The Drug Reform in 2004 entailed that the regional health enterprises took over responsibility from the county authorities for specialised services for drug addicts and alcoholics. This included medication-assisted rehabilitation. A number of street-based outreach health services have also been introduced to improve conditions for heavy drug addicts, such as dental health services and trial projects with field nursing stations and needle rooms.

Within the framework of the escalation plan for efforts to combat substance abuse, the Government will coordinate and bolster services offered to people with substance abuse problems. Tools include research, interventions to raise levels of competence and quality in order to improve services offered by the municipalities and specialist health service, improving the accessibility of the services, and enhancing coordination, user participation and facilities for next of kin.

Steps are to be taken to develop a more knowledge-based service. In this context, closer ties are needed between research and practice. Four social offices are being established at universities and university colleges in order to improve research on topics and methods in the social services and to ensure closer ties to practical experience. In addition, a new research programme is being set up under the auspices of the Research Council of Norway, and a substance abuse research centre is going to be established at one of the universities. The Directorate for Health and Social Affairs is going to collaborate with the Norwegian Association of Local and Regional Authorities (KS) on carrying out projects to investigate whether the organisation of tasks within the social services affects quality and accessibility.

Steps are going to be taken to improve social and health workers’ competencies in substance abuse issues and their knowledge about the links between substance abuse, psychiatric problems and social problems. More expertise is necessary to render service providers better able to recognise substance abuse problems as early as possible and to be able to provide follow-up that is better adapted to the individual’s needs. The central health authorities will contribute to raising competencies by developing survey tools and handbooks. In addition to strengthening research, a new course of continuing education in substance abuse is going to be developed at university colleges for social and health workers, and the current training in substance abuse medicine for doctors and psychologists is going to be improved. The Norwegian State Housing Bank has a grant scheme for continuing education in housing social work that is going to be continued.

Since drug addicts and alcoholics often have serious health problems and social problems, the «individual plan» is an important tool in ensuring coordination of the services they receive. Services must be designed to allow user participation throughout the entire planning process. In order to increase the use of individual plans, the central health authorities are going to attach greater importance to training and assistance in compiling these kinds of plans. The Directorate for Health and Social Affairs, the County Governors and the regional health enterprises have all been ascribed tasks linked to training and developing materials.

The objective of the low-threshold measures within the municipal social and health services is to improve the life situation of substance abusers, including reducing health problems, reducing overdoses and taking steps to ensure that individuals can lead a decent life. Drug addicts and alcoholics often have major health problems and live in circumstances that make it difficult for them to make use of the ordinary health services. Preliminary reports indicate that low-threshold measures reach their target groups, that they improve health and that they may have contributed to a decrease in the number of overdoses. The low-threshold health services are important in preventing the spread of hepatitis and HIV. It also seems that use of special low-threshold health services leads to increased use of ordinary health services. Drug addicts and alcoholics also have problems using ordinary dental health services, because of a lack of money and other circumstances linked to their situation. For this reason, a special financing scheme has been set up for dental health measures for drug addicts and alcoholics undergoing treatment in the specialist health service or who receive municipal services. Arrangements have been made for these services also to include dental treatment. In 2007, the Government is going to initiate an evaluation, the findings of which will then form the foundation for further development of these measures.

Prisoners

Prisoners have many more problems than the normal population. Many prisoners have serious drug problems, psychiatric problems, little education, little contact with the labour market, are homeless, and had a very difficult childhood. These social problems are probably both a cause and consequence of criminality and substance abuse. There is therefore a great need to improve the general living conditions of prisoners. Half of all prisoners have children, and their families will often need extra help to be included in society.

Prisoners and convicts are entitled to the same services as the rest of the population. People who need long-term and coordinated health and social services are entitled to have an individual plan drawn up, detailing planned treatments and interventions. This right is laid down in the Patients’ Rights Act, the Act relating to the municipal health services and the Act relating to social services.

Primary health services for prisoners are provided by the municipality in which the prison is located (cf. Section 1 – 3 of the Act relating to the municipal health services). Specialist health services are generally provided by the health enterprise where the prisoner is registered as living in the Population Registry. The municipality in which the prisoner was resident before incarceration is responsible for social services and other municipal labour and welfare services. Social services are particularly important when planning release from prison. The reality is that very many prisoners are still released with no home, no work, no training opportunities and no therapeutic contact person to go to, and they often revert to substance abuse and crime. In many cases, the prison a person is incarcerated in is a long way from their home municipality. This makes it difficult in practical terms to establish close contact between the prisoner and the responsible service providers. The individual plan is therefore often an important tool in ensuring a comprehensive, coordinated and individually tailored range of services. The Government is going to institute a process to assess how the services aimed at prisoners can be better coordinated, using the individual plan as one of several tools.

With a view to establishing good systems of collaboration and common plans regionally and locally, the Ministry of Justice and the Police and the Norwegian Association of Local and Regional Authorities (KS) have entered into an agreement on collaboration between prisons and municipalities regarding settlement. A circular has been drawn up clarifying responsibilities, tasks and coordination among the municipalities, the specialist health service and the Norwegian Correctional Services regarding incarcerated and convicted drug addicts, to enhance collaboration and ensure continuity in the measures (Circular G8/2006).

Through the escalation plan for efforts to combat substance abuse, the Government wants to help ensure that more prisoners with substance abuse problems have access to better rehabilitation and treatment during their time in prison. A goal has been set of increasing the number of days of their sentence that prisoners serve in institutions, i.e. in a rehabilitation or care institution or in other municipal facilities for prisoners with substance abuse problems. At present, the prisons in Oslo, Bergen and Trondheim have units offering prisoners with substance abuse problems the option of alternative means of serving their sentence. These units offer rehabilitation of people with substance abuse problems while they are in prison. These units also provide counselling and cooperate with the social services on individual plans for prisoners that need a number of different, co-ordinated services. Based on experiences from these units, three new drug rehabilitation units are being set up in 2007.

A three-year trial scheme, the Drug Programme under Court Control, is currently underway in Oslo and Bergen offering individually adapted rehabilitation as an alternative to prison for convicted drug addicts. The participants receive services from the municipality and the specialist health service as part of an active rehabilitation programme. This trial scheme is also helping develop models for cross-sectoral collaboration between the Norwegian Correctional Services and the participating health enterprises and municipalities. The trial scheme will be evaluated. The Government wants to increase the use of serving sentences in rehabilitation or care institutions (known as a «Section-12 sentence»: under section 12 of the Execution of Sentences Act, prisoners may, in certain cases, serve their sentence in an institution that is not a correctional service facility). In autumn 2006, the Ministry of Justice and the Police circulated a proposal called Quick response, measures to reduce the prison queue and improve the content of serving sentencesfor review. The proposal of increasing the number of «Section 12 days» is included in this draft proposal.

People with long-term psychiatric problems

Many people with long-term psychiatric problems are recipients of social assistance and are prone to social exclusion. One of the main goals of the Escalation Plan for Mental Health is to develop a range of services designed in a way that promotes the individual’s possibilities for social inclusion through having a home of their own, work and participation in leisure activities.

Targeted work to reduce society’s stigmatisation of the mentally ill is another important part of the plan. This is achieved indirectly by developing the possibilities for mentally ill people to live alone and participate in social arenas and in the voluntary sector, for example through interest organisations for the mentally ill. By the end of 2007, 3400 sheltered homes with staff that have competence in mental health care will be ready for habitation. Day centres and organised activities have been set up in many municipalities in collaboration with voluntary organisations. An information campaign aimed at children and young people is also going to be carried out in order to increase knowledge about mental health and prevent stigmatisation.

Victims of violence in close relations and traumatised refugees and asylum seekers

A number of initiatives have been implemented to strengthen the public services’ competencies in sexually and physically abused children and women, children who have experienced violence in close relations, and traumatised refugees and asylum seekers. In 2004, the Norwegian center for studies on violence and traumatic stress (NKVTS) was founded, and in 2006, five regional resource centres on violence, trauma and suicide were being set up. Both the national and the regional centres are important in the drive to improve competencies in the health and social services, the child welfare authorities and the police, among others. NKVTS has been commissioned by the central authorities to start work on improving knowledge in basic and continuing education for various professionals. Special incentive grants have been allocated for building capacity in the health services for people who have suffered sexual abuse and violence in close relations. The goal is to have at least one or two accident and emergency units in each county with this kind of function.

Important strategies to prevent violence in close relations include early intervention by the police and public assistance agencies and expanding the treatment services available to perpetrators. Measures to look after women and children who have been victim to violence are discussed in the Plan of Action to Combat Domestic Violenceand Strategy to Combat Physical and Mental Child Abuse.

More general policy instruments to reduce social inequalities in access to the health services are discussed in chapter 7 on the health service.

8.2.3 Housing policy

One of the main goals of housing policy in Norway is that everyone should live in good, safe conditions. Along with work, health and education, housing is a key element in the welfare society. Good housing provides a foundation for a decent life and is often decisive for people’s health and participation in working life. Housing is especially important for children, the elderly, people with reduced functional capacity or poor health and people with little or no contact with the labour market.

Housing-policy instruments have contributed to the distribution of housing in Norway being better than might be expected on the basis of income distribution alone. The central government’s main task in housing policy is to define housing-policy targets and facilitate implementation on the local level. The central government must ensure good, appropriate economic and legal framework conditions and provide measures to raise competencies. The local authorities have a statutory responsibility to provide housing for people who cannot find housing on their own or who are in an acute crisis situation. The municipalities facilitate construction of homes and take advantage of schemes from the Norwegian State Housing Bank for people that are disadvantaged in the housing market.

In general, Norwegian homes are of a high quality. This is the result of a conscious housing policy over many years based on the philosophy that even people with low income are entitled to live well. Nevertheless, some groups live in poor conditions. This applies in particular to people who can be categorised as homeless.

A study performed in 2005 shows that there are 5500 homeless people in Norway. Very many of these people also have other problems, such as substance abuse problems and psychiatric problems. The World Health Organization emphasises that homelessness entails especially high health risks. People who live on the street have a very high incidence of premature death. 15 % of the homeless people in Norway have somatic illnesses or reduced functional capacity. This proportion has remained unchanged since 2003. Homeless people over age 65 have more physical health problems than other homeless people. Three-quarters of the homeless people have mental illnesses and/or are addicted to drugs or alcohol. The proportion of drug addicts and alcoholics has dropped from 71 % in 2003 to 60 % in 2005. The proportion of homeless people with mental illnesses has risen since 1996 and in 2005 was 38 %. There are grounds to assume that somatic illnesses and perhaps also reduced functional capacity are underreported among homeless people.

The Government wants to bolster its efforts for homeless people through the national strategy to combat and prevent homelessnessThe pathway to a permanent home and has set itself the goal of eliminating homelessness. Priority is going to be given to providing people with permanent homes, instead of using hostels and other temporary accommodation. Services will be adapted more to the needs, abilities and situation of the individual, and steps will be taken to ensure good collaboration among the municipalities and the specialist health service, the child welfare service and the Norwegian Correctional Services.

The Government is basing its work on providing housing for homeless people on the principle that everyone has the ability to reside and that the follow-up services offered must be adapted to the challenges and resources of the individual. There is great variation concerning the degree to which individuals are capable of living in their own home and what kind of follow-up services they need. We must recognise that living in a home of one’s own is not always only good; sometimes it also entails challenges, for example in the form of loneliness. The design of housing solutions and follow-up needs must take this into account. Researchers have also pointed out that assistance must not be stopped or reduced too early. It is often when the individual appears to be managing well and has acquired the skills necessary to live alone that they have the greatest need for assistance and support.

8.2.4 Voluntary organisations

Voluntary organisations are social meeting places where people can nurture common interests across social divides. Participation in voluntary organisations contributes to social inclusion because it provides opportunities for developing friendships and being included in a group with shared interests. Social inclusion means individuals are linked to social life through participation in different arenas. Voluntary organisations are arenas where people come into contact with social networks outside their own private sphere.

Voluntary organisations can help provide an alternative sense of identity and social inclusion for groups who drop out of ordinary social functions such as education and employment. Relevant examples include systems providing networks of contacts and volunteer centres. Peer-to-peer support systems organised by voluntary organisations are often felt to be better at treating people as equals than the public support services.

In addition to the intrinsic value of participating in voluntary organisations, the voluntary sector also provides welfare services. Voluntary organisations supplement government efforts in the following ways:

• Helping identify and put on the agenda new needs that ought to be followed up through public initiatives

• Influencing the work on developing the welfare state by criticising the public authorities

• Tapping into resources and providing services that complement the public services and facilities

The Government wants to nurture and further develop its close collaboration with voluntary and non-profit organisations. Material security is important, but it is not enough to render life good and meaningful. The Government aims to make sure everyone receives care and security, through good public welfare services and by supporting and facilitating involvement in voluntary organisations and development of a vital civil society.

8.2.5 Deprived geographical areas

Geographical inequalities in health usually coincide with geographical inequalities in living conditions. In the work on reducing social inequalities in health, a geographical approach to designing measures is important, not least because it allows measures to be targeted without stigmatising certain groups. When measures are specifically targeted at defined areas that have major health and social problems, it is also easier for us to evaluate the effectiveness of the measures. This kind of approach can also help ensure that the implemented measures reach their intended target group. Oslo is a prime example of the correlation between social inequalities in health and geography. The inequalities in average life expectancy among urban districts vary by almost 12 years for men.

It is not only living conditions and health that are unevenly distributed geographically. Negative environmental factors also tend to be concentrated together in certain areas. If we rank areas in the municipalities according to the quality of the residential environment, clear inequalities will be found in most municipalities. In certain municipalities, especially urban municipalities, there are considerable social inequalities. Inequalities in health and the quality of the residential environment generally coincide and are socially determined: groups that score worse on some indicators tend to score worse on others too. Deprived urban areas are usually areas with a high proportion of recipients of social assistance, social security benefits, etc. Property prices reflect the quality of the residential environment and reinforce the pattern of people with high income moving to areas with a high-quality residential environment and low-income groups moving to areas with a poor-quality residential environment. These kinds of mechanisms result in a geographical concentration of vulnerable groups, which may in turn exacerbate social inequalities in health.

The municipalities have policy instruments at their disposal to prevent deprived areas becoming burdened with even more negative environmental factors, e.g. the Planning and Building Act. By choosing carefully where housing and business premises are located, it is possible to avoid traffic congestion and keep polluting, noisy industrial plants away from residential areas. Measures can also be implemented to improve environmental conditions, for example by ensuring that green spaces, parks and open outdoor areas do not disappear and by planting new green areas. In collaboration with the roads authorities, the municipalities can control traffic and protect particularly sensitive areas.

Local authorities can also improve the range of services offered and implement social measures in deprived areas. A prerequisite for this is that the local authorities have good tools for assessing the quality of the residential environment in the municipality at an appropriate geographical level. The approach used as a basis for the system of incentive funds for regional and local partnerships for public health is also a good starting point for implementing measures aimed at particularly deprived areas. In large towns and cities, the partnerships can set up separate Health Action zones, similar to the spearhead groups used in the United Kingdom (see appendix I). Tools to assess the quality of the residential environment and the Partnerships for Public Health system are discussed in more detail in chapter 10.

In the upcoming Report to the Storting on Oslo «the Capital Report», the Government will discuss central-government policy instruments for combating the increases in social inequality in the Oslo region. The Government wants to fight poverty, homelessness, unemployment, drop-out from upper-secondary education and social exclusion. The efforts in Groruddalen are one example of central and local government collaboration aimed at a defined geographical area with specific health and social problems. The municipality bears the main responsibility, but the Government wants to help prevent the trend toward a divided city with poor living conditions, environmental problems and ghettos of immigrant groups in certain areas. The policy for the capital will build on the Government’s policy for inclusion and integration, the recent major investments in kindergartens and the Knowledge Promotion Reform. Another example of an initiative aimed at a delimited geographical area is the Action Programme for Oslo Inner East, which was terminated in 2006. Experiences from this action programme and suggestions for further follow-up will be discussed in the Report to the Storting on Oslo «the Capital Report». The Ministry of Health and Care Services wants to attach more importance to policy instruments for reducing social inequalities in health in these kinds of efforts. Efforts targeting specific geographical areas may also be an important channel for measures aimed at social groups with a high risk of health problems.

In order to improve knowledge about the effectiveness of measures to reduce social inequalities in health, it is important to evaluate the impact of preventive measures on these kinds of inequalities in health. In many cases, it will be possible to implement measures as trial projects in limited areas and compare the results with control areas. An example of this is the MoRo project that was carried out in the Romsås urban district of Oslo.