Setting the scene what are the core challenges?

Transcription

1 Setting the scene what are the core challenges? Professor Olle Lundberg, Commission Chair

2 Setting the scene An ambitious task Our countries can be treated as a public health laboratory We can learn a lot from more comparative work I will focus on one case: Sweden

3 Health inequalities has a long history Abraham Bäck

4 Already in 1765 Bäck claimed that: many pestilences ravage among the worseoff, while few of the wealthier fall ill When I consider the causes behind diseases and excessive mortality among the peasantry, and the worse-off in the towns, the first and foremost are poverty, misery, lack of bread, anxiety and despair. (Bäck 1765)

5 Why is the case of Sweden of interest? Sweden (and other Nordic countries) have been seen as forerunners in terms of welfare policies and equity in general The Black report pointed to Sweden/Norway But inequalities in health and mortality have been persistent also here The Nordic paradox In all Nordic countries health inequalities have actually tended to increase

6 Earlier work for public health and health equity Increasing focus on public health, prevention and cross-sectorial work through 1980s and 1990s (Government bills 1984/85:181 and 1990/91:175) The Swedish public health policy (Government bill 2002/03:35) is a framework that: Starts with the overarching objective to create societal prerequisites for good health on equal terms for the entire population Is based on a social determinants approach, and the 11 objective areas include the main drivers for health and health inequalities Has been in place for more than 10 years

7 International commissions/initiatives

8 National and Nordic initiatives

9 Swedish local/regional initiatives

10 The Swedish Commission for Equity in Health

11 The Commission s assignment On basis of The Government s long-term objective to close the avoidable health gaps in one generation, the Commission has been given two tasks: 1. To submit proposals for actions that can contribute to a reduction in health inequalities 2. To increase awareness and stimulate discussion around health inequalities

12 Central starting points Health is important for all: 86% see health as very important in Sweden! Compare with love: 70%, happiness: 63%, and wealth: 8% [from the national SOM-surveys (Society, Opinion, Media), 2014] Good health is linked to a range of key conditions and prerequisites Many policy areas and programmes are therefore of importance for health and health equity

13 Two types of inequalities in health Health inequalities are defined as: Systematic differences in health between groups in different social positions We differ between two types of health inequalities: The health gradient running through society The health of groups in marginal and/or vulnerable positions and the rest of the population

14 Explanations for health inequalities Inequalities in health arise through inequalities in circumstances, conditions and environments (resources) between people in different social positions We stress the dynamic interrelationship between health and the main social determinants Health is therefore both a precondition for and a result of other key resources (early life, education, work, income etc.)

15 Explanations for health inequalities (2) Inequalities in key resources produce differences in the risk for ill health In addition, inequalities in resources lead to differences in vulnerability between people in different social positions Furthermore, inequalities in health are shaped by differences in people s scopes of action Socially determined patterns of action Lack of resources (scarcity) affect the scope of action and ability to make decisions in itself

16 Inequalities in mortality in Sweden

17 Life expectancy at 30, ,0 60,0 50,0 51,4 48,1 54,5 51,1 56,4 57,3 53,4 54,5 40,0 41,2 39,5 30,0 Women Men 20,0 10,0 0,0 No education Basic Upper secondary Tertiary < 3yrs Tertiary 3+ yrs Source: Statistics Sweden

18 Age at death by education, women Source: Statistics Sweden

19 Age at death by education (30+) Mean and standard deviation (SD), women and men Period Women Men Measure Basic Upper secondary Tertiary Basic Upper secondary Tertiary Mean age at death 81,1 83,2 85,2 76,9 79,0 81,5 SD (30+) 13,0 11,6 10,5 13,1 12,0 10, Mean age at death 81,3 83,9 85,8 77,8 80,1 82,5 SD (30+) 13,5 11,4 10,5 13,3 12,0 10, Mean age at death 81,4 84,4 86,8 78,1 81,1 83,9 SD (30) 13,7 11,5 10,3 14,1 12,0 10,5 Source: Statistics Sweden

20 How to achieve more equal health?

21 Two ways to reach more equal health The Commission identifies two important types of action to achieve more equal health: 1. Action on social determinants More equal conditions and opportunities for people in different social positions 2. Improving governance and follow-up More strategic governance, follow-up and evaluation, both within the public health policy framework and more generally

22 1. Social determinants We point out seven life areas where inequalities in conditions and opportunities (resources) are essential for health equity: 1. Early life development 2. Knowledge, skills and education 3. Work, working conditions and work environment 4. Incomes and economic resources 5. Housing and neighbourhood conditions 6. Health behaviours 7. Control, influence and participation

23 Three types of measures To strengthen people s own abilities to act and generate resources A good start in life, strengthen knowledge and skills, help people make healthy choices Provide more of collective resources that work compensating E.g. Increase enrolment rates in pre-school Do better or differently in order to achieve better quality and availability for citizens and users Work or organise services differently, collaborate in smarter ways, adopt more strategic governance and follow-up

24 So what are (some) core challenges? To reach a better understanding of how health inequalities are generated Tackle both inequalities in resources and in the scope of action between social groups To find ways to break vicious circles Not simply addressing particular problems In the Swedish (Nordic) context how to develop and adapt existing (complex) welfare systems To identify and handle conflicting objectives

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