Addressing the social determinants of health. Multilevel governance of policies aimed at families with children

The role of municipalities in reducing social inequalities in health The gradient in health inequalities reflects a relationship between health and social circumstance with evidence demonstrating that health worsens as you move down the socio-economic scale. Few European countries have developed specific policies that attempt to level up this social gradient in health. A notable exception is Norway?s Public Health Act (2012), which specifically aims to tackle the gradient by addressing the social determinants of health. The main aim of Norwegian National Public Health Act (NPHA) is to reduce social health inequalities (HI) by adopting a Health in all Policies (HIAP) approach. Most policies are to be implemented at the local level and municipalities are responsible. Municipalities are mandated to develop overviews of the health situation for different population groups, integrate these in municipal plans and develop intersectoral policies to address the challenges. The aim of this project was to answer two main questions: How do municipalities implement the policies and how can they reduce social inequalities? The project has a mixed methods approach. Data consist of two surveys to all municipalities in 2011 and 2014. The study participants were administrative leaders in all municipal sectors. The main focus was on how the municipalities organised their policies regarding HI and HIAP. Furthermore, six municipalities take part in a qualitative study. Policy-makers and administrative leaders was interviewed about the development of the public health work in their municipality. In 2011 13% had developed an overview of health challenges in their municipality and in 2014 the number was 25%. In 2014 we asked if the overview was used to make priorities between policies. 12% had used it to prioritize in their Action Program and 4% in their Master Plan. In the Master Plan local governments outline their long term economic priorities. In 2011 95% had established intersectoral working groups. In 2014 the number was reduced to 62%. In 2014 41% addressed issues of HI in the plan, while 71% addressed HI in measures for health promotion and prevention. The surveys showed that the municipalities to a small extent had adopted the principles of HIAP and HI. Many municipalities focused mainly on life-style and health-care related measures. The findings identified a divide between the national policies and the strategies adopted at the municipal level to implement the NPHA. Municipalities which has started the implementation of the act were included in the qualitative interview studies. Even these studies showed differences between the municipalities. Some municipalities still prioritised individual life style measures, while others were in the process of integrating the policies across sectors. The findings indicate that there is raised awareness of the significance of social determinants among an increased number of municipalities and that they are in the process of developing policies specifically to level the social gradient in health.

This project addresses the implementation of the Norwegian policy to level the social gradient in health. This will demand multisectoral action and a focus on the social determinants of health. Based on a life course perspective, the target group is fam ilies and children. Local governments have the main responsibility for services aimed at families and children, and in a system of multilevel governance, actors at different levels will be able to influence the implementation process. The project aims a t studying local implementation processes, focussing on institutions at different levels. Within health promotion, national government mostly has so-called soft governing tools available to stimulate implementation of national policy targets. Local democr acy provides local decision makers the opportunity to prioritise between targets and local leaders of services will have to follow decisions made by local governments. Traditionally, municipalities are organised in sectors, which does not promote multisec toral collaboration. Regions have a facilitating role in stimulating local health promotion, including action to level the social gradient. The overall research question is: How can social inequalities and levelleling the gradient for socioeconomic dis advantaged groups be addressed at the local level? This has been operationalized in the following questions: How do local policy makers take part in formulating policies towards families and children? Are the issues of levelling the social gradient addre ssed? Do local policy makers support the principle of Health in All Policies? Are local services adhering to reducing inequalities in health and levelling the gradient? The project will collect data in regions and municipalities, combining surveys to all municipalities and county councils with case studies in two regions and four municipalities in each region. The project will build on experiences from Norwegian and European projects