Hannele Palosuo: How do we understand social determinants in Finninsh health policy?
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Transcript of Hannele Palosuo: How do we understand social determinants in Finninsh health policy?
How do we understand social determinants in Finnish health policy?
Helsinki, 13 January 2016
Hannele Palosuo, Visiting Researcher
National Institute for Health and Welfare, Helsinki
Outline
• Social determinants of health, inequalities in health
• Work of the Commission on Social Determinants of Health (CSDH)
• Reducing inequalities in Finnish health policy
• Similarities and differences in the CSDH approach and Finnish policy lines
• Current trends in determinants and outcomes
• Social determinants as policy problems
• What should/could be done?
• Conclusions
13 Jan 2016 Hannele Palosuo
Social determinants of health
• ”shorthand for describing health approaches that move beyond biomedical and behavioral risk factor approaches to health promotion” (Raphael 2006)
• ”societal risk conditions rather than individual risk factors (Wikipedia)
• ”Together, the structural determinants and conditions of daily life constitute the social determinants of health and cause much of the health inequity between and within countries.” (Marmot et al. 2008)
• > not only social causes of health/disease but causes of causes of health and disease
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Social determinants/social causes consequences: inequity/inequalities in health
• Inequalities in health can be reduced only by addressing the root causes = social determinants/social conditions,
• … and their causes = politics, ways of governance, economic organisations and arrangements
• [Epidemiological] research: cause effect
• [Health] policy: means aims/goal (Leppo 2009; Sihto 2010)
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The work of the Commission on Social Derterminants of Health (CSDH) unique in connecting perspectives and evidence arising from
• epidemiology, social epidemiology
• social sciences, incl. economics
• environmental sciences
• health policy, public health
• other policies
• politics
• social justice (moral philosophy)
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Framework of the Commission on Social Determinants of Health includes multilevel causal paths and multilevel means–aims chains (CSDH 2008, 43, Fig. 4.1)
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CSDH Final Report 2008: ”Social injustice is killing people on a grand scale”. Work of the Commission introduced in Finnish in a report (Palosuo et al. 2013).
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Health inequalities a long term concern in the Finnish health policy
1970s – 1980s: “Golden era” in Finnish health policy (Leppo 2010; 2013)
1972 Even distribution in health pronounced as an aim for health policy (Report of the Economic Council)
1972 Public Health Act primary health care reform
1970’s School reform, day care for children, national planning mechanism
1972- North Karelia Project
1986 Health for All by the Year 2000, Finnish national strategy
1993 Revised national HFA: more emphasis on equity
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Commitment to reduce health inequalities continues
2001 Health 2015 Public Health Programme: quantitative target for reducing mortality differences between social groups
2008 National Action Plan to Reduce Health Inequalities
2008- National Programmes for social welfare and health care (Kaste I 2008-2011; Kaste II 2012-2015)
Equity in health emphasized in strategies of the Ministry of Social Affairs and Health 2006 and 2011
Government Policy Programme for health promotion (2007-2011)
Government programmes 2003, 2007, 2011, 2015
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National Action Plan to Reduce Health Inequalities (2008-2011) focussed on social determinants (15 action proposals on four main lines (MSAH 2008:25)
Welfare policies tackling social determinants of health (2 proposals)
Promoting healthy habits through their prerequisites (5 proposals)
Promoting equity and need based use of health and social services (4 prop.)
Developing knowledge base and tools (e.g. HIA) (4 proposals)
Social gradient
Disadvantaged
groups
Prevention
of margin-
alisation
Target age
groups and
special groups
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Overarching recommendations of the CSDH and main lines of the Finnish Action Plan to Reduce Health Inequalities
CSDH (2008)
1. IMPROVE DAILY LIVING
CONDITIONS
- Equity from the start (childhood)
- Healthy places
- Fair employment and decent
work
- Social protection across life
course
- Universal health care
2. TACKLE THE INEQUITABLE
DISTRIBUTION OF POWER,
MONEY, AND RESOURCES
3. MEASURE AND UNDERSTAND
THE PROBLEM AND ASSESS THE
IMPACT OF ACTION
FINNISH ACTION PLAN (2008)
- INFLUENCE POVERTY, EDUCATION,
EMPLOYMENT, WORKING
CONDITIONS AND HOUSING
- SUPPORT HEALTHY LIFESTYLES IN
GENERAL AND SPECIFICALLY IN
GROUPS WHERE UNHEALTHY HABITS
ARE COMMON
- IMPROVE EQUITY AND NEED-BASED
AVAILABILITY OF SOCIAL AND
HEALTH SERVICES
?
- DEVELOP MONITORING SYSTEM
- STRENGTHEN INFORMATION BASE
(INCL. IMPACT ASSESSMENT)
- DEVELOP TRAINING & INFORMATION
ON HEALTH INEQUALITIES
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CSDH 2nd rec.: inequitable distribution of power, money, and resources (rarely addressed in health policy) some similar elements in Finnish health policy documents
CSDH
Health equity in all policies,
systems and programmes
Fair financing
Market responsibility
Gender Equity
Political empowerment –
inclusion and voice
Good global governance
Finland
Health 2015 addresses ”different
sectors”; Health in All Policies was
one of the main streams in developing
National Action Plan (MSAH 2008)
Poverty reduction and income
mentioned in Action Plan, but no stand
on income differences or economic and
fiscal policies nationally or
internationally
Appeal made to business responsibility
and labour market parties
Reducing sex difference in mortality a
specific target in Health 2015
Preventing marginalisation; the role of
civil society in ”bottom up” influence
No attention to governance,
administration or international activity 13 Jan 2016 Hannele Palosuo
Finland places well in international comparisons on welfare, happiness, competitiveness, economics etc. together with other Nordic countries (eg. OECD, EU; Wilkinson & Pikett 2009)
• Example: Finland ranked best in a global index comparison within the EU countries (Raunio & Saari 2013, from Table 1, p. 166)
FINLAND SWEDEN ROMANIA
Least failed 1 2 26
Prosperity 3 2 24
Global dynamics 1 2 25
World
competitiveness
2 1 26
Newsweek 1 2 25
Boole-value (Sum
of rank order
scores)
8 (best 9 (second) 126 (lowest)
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Life expectancy in Finland 1750-2013. In 2014 L.E. for women 83.9, for men 78.2 yrs. (Statistics Finland)
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Differences in life expectancy between social groups have increased. Life expectancy of men and women in highest and lowest income quintiles in Finland in 1988-2007 (Tarkiainen et al. 2012; data)
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Development in social determinants of health: Improvements… (depending on time scale)
Level of education has generally increased
Unemployment rate 8.2 % in Nov. 2015 (Labour Force Survey); number of long-term unemployed and job seekers over 50 yrs have increased (Ministry of Employment and the Economy)
Income differentials grew most rapidly of OECD countries in 1995-2005; have slightly decreased since 2008. In 2014 Gini Index in Finland was 27.03 (EU 28 countries average 30.9 in 2014) Poverty (share of low income persons) increased from 7,6% (1995) to 13,7 % (2010), but has slightly decreased in recent years. Persons at risk of poverty 12.5 % in 2014 (lower than EU average). (Statistics Finland, Eurostat)
Higher poverty rates in lone-parent families, single households, unemployed, retired persons
Homelessness had decreased in 2014, incl. long-term homelessness and that of immigrants (ARA 1/2015)
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… but also worries
Share of recipients of social assistance on a much higher level than before 1990’s recession (Kuivalainen et al. 2013)
Share of people completely dependent on basic social security has increased (in 2013 4.3 %) (THL Working paper 1/2015)
Consumption of alcohol has decreased since 2007 - total consumption per 15- yr. population 11.2 litres of 100% alcohol in 2014 (Findikaattori.fi).
Alcohol-related mortality in working-age men and women decreased in 2014. 17 % of deaths of men alcohol-related (3rd main group after circulatory diseases and neoplasms), 9 % of deaths of women (4th main group) (Statistics Finland)
Inequality in access to health care continues
Socioeconomic differences in amenable mortality have increased (Lumme et al. 2012)
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Ideologies
Implemen-
tation
Interests
Information
Institutions
Why health policy through social determinants is complicated? A Five I’s framework. (Palosuo et al. 2013, adapted from Weiss 1995; Collins & Hayes 2007)
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Finland: Plenty of information; ideologies controversial
IDEOLOGIES
Health and equity highly
valued.
Universalism traditionally
supported in a welfare state.
All parties support reducing
inequalities in health
But pressure to switch to
selective/ residual social policy,
Neoliberalism: e.g. cutting public
spending, reliance on self-
correcting market mechanism;
stress on free choice.
INFORMATION
Good epidemiological
information basis, plenty of
epidemiological research
But lack of research on
policies and politics
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Interests may be decisive in politics, while institutions tend to change slowly
INTERESTS
Long term interests common
(survival and welfare)
But conflicting interests between
public health and economy
- industries (eg. alcohol, health);
- in the sphere of work
- fiscal interests (e.g. tax
revenues from alcohol)
- Economic growth vs. social
goals (austerity measures hit the
worst-off and weaken the
foundations of welfare)
INSTITUTIONS
Intersectoral mechanisms at the
state level and municipal level
(HiAP, Advisory Board for Public
Health, intersectoral cooperation
at municipal level
Tension between state and highly
independent (often poor)
municipalities
A major reform underway to
reorganise regional administration
and integrate health care and
social services (SOTE)
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The test of plans and programmes is in their implementation
Lots of plans and programmes, which overlap and lack coordination.
Nevertheless, it was an achievement to formulate Finnish National
Action Plan to Reduce Inequalities in Health (2008), with an
implementation plan and assignments of responsibilities.
-The Action Plan contributed to raising alcohol and tobacco taxes; to
health promotion among vocational students and developing healthier
work environments + assessing health needs of immigrant population.
However, most important social determinants are ideologically and
politically sensitive and difficult to impact on (e.g. income inequality and
working conditions in a globally competitive environment).
Implementing policies is often dependent on many uncontrollable
conditions. The time span in politics is often (too) short.
13 Jan 2016 Hannele Palosuo
Worst problem areas
In Finland
Their determinants Examples of action
areas
Health of the lowest income
quintile
Income differences and
accumulation of wealth;
increases in poverty; level
of social assistance
Decrease income
differences, increase
the level of basic
security
Increasing differences in
mortality between social
groups (problem of the
gradient)
Changes in working
conditions; increasing
work demands
Intensify work protection
and occcupational
health services where
needed
High morbidity and mortality
among the long-term
unemployed
Changes in require-
ments of employment;
Marginalisation
Active workfare policy;
Improve health care of the
long-term unemployed
Alcohol-related problems
e.g. mortality in the
working-age population
High level consumption
of alcohol; concentration
of problems;
marginalisation
Tax policy; retain
alcohol monopoly;
decrease ethanol in
beer; prevent
marginalisation
Inequity in the health care
system (differences in access
to care and need-based care)
Multichannel health care
system (discriminates
against the poorer-off)
Strengthen primary health
care; lower level for out-of-
pocket costs for medicines
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Conclusions (1)
• Health is highly valued but there is less agreement concerning social determinants of health, health inequalities and policies ideological differences and conflicting interests
• Health in All Policies is (was?) the Finnish solution for addressing social determinants of health and integrating common interests in policy areas where short term interests may conflict.
• The Finnish Action Plan (2008-2011) was instrumental in keeping social determinants and health inequity on the agenda
13 Jan 2016 Hannele Palosuo
Conclusions (2)
• Social determinants (root causes) of health have not been sufficiently addressed
• Policies on education, employment, working conditions, income and wealth, taxes, universal health care and social security, continue to be central
• The central issue is to reduce social inequality as pointed by the CSDH and many contemporary social critics, e.g. Zygmunt Bauman who warned that growing social inequality may be the most disastrous problem that humanity has to confront in this century.
13 Jan 2016 Hannele Palosuo
Literature (1)
• Bauman Z. Collateral damage. Social inequalities in a global age. Polity Press, Cambridge 2011.
• CSDH: Closing the gap in a generation. Health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization 2008.
• Kuivalainen S. (ed.) Social assistance in the 2010s. A study on social assistance clients and granting practices. National Institute for Health and Welfare (THL) Report 9/2013, (In Finnish with English Abstract)
• Leppo K. Kansan terveys on tahdon asia. Terveyspolitiikka ja –palvelut 2010-luvulle. Kalevi Sorsa Säätiön julkaisuja 3/2010.
• Leppo K. Tutkimustiedosta ja terveyspolitiikasta. Sosiaalilääketieteellinen Aikakauslehti 2009:46:124-130.
• Leppo K. Terveyspolitiikan lähtökohtia ja perusteita Suomessa ja kansainvälisesti. In Sihto M, Palosuo H, Topo P, Vuorenkoski L & Leppo K. (Eds.) Terveyspolitiikan perusta ja käytännöt. THL Teema 17, 2013.
• Marmot M. et al. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008 372, Nov. 8, 1661-1669.
• MSAH 2008: National action plan to reduce health inequalities 2008-2011. Ministry of Social Affairs and Health, Publications 2008:25, Helsinki, Finland.
• MSAH 2013: Interim report of the 2015 national public health programme. Sosiaali- ja terveysministeriön raportteja ja muistioita 2012:4, Helsinki 2013 (In Finnish).
• Palosuo H, Sihto M, Lahelma E, Lammi-Taskula J, Karvonen S. Social determinants in the health policy formulations of the WHO and Finland. National Institute for Health and Welfare (THL) Report 14/2013 (in Finnish with English Abstract)
13 Jan 2016 Hannele Palosuo
Literature (2) • Raphael D. Social determinants of health: present status, unanswered questions, and future
directions. International Journal of Health Services 2006:36:4:651-667.
• Raunio T. & Saari J. Euroopan paras maa? In Raunio T. Saari J. (Eds.) Euroopan paras maa? Suomen muuttuva asema Euroopan unionissa. Gaudeamus 2013.
• Rotko T, Aho T, Mustonen N, Linnanmäki E. Bridging the Gap? Review into Actions to Reduce Health Inequalities in Finland 2007-2010. National Institute for Health and Welfare (THL) Report 8/2011 (In Finnish with English Abstract).
• Rotko T, Kauppinen T, Mustonen N, Linnanmäki E. National Action Plan to Reduce Health Inequalities 2008-2011. National Institute for Health and Welfare (THL) Report 41/2012 (In Finnish with English Abstract).
• Sihto M. Tarvitaan enemmän ja parempaa terveyspolitiikan tutkimusta – mutta millaista? Sosiaalilääketieteellinen Aikakauslehti 2010:47:2:81-83.
• Statistics Finland – Causes of death in 2014. http:// www.stat.fi/til/ksyyt/2014/ksyyt_2014_2015-12-30_tie_001_en.html.
• Tarkiainen L, Martikainen P, Laaksonen M, Valkonen T. Trends in life expectancy by income from 1988 to 2007: decomposition by age and cause of death. JECH 2012:66:573-578. Also in Suomen Lääkärilehti 2011:66:48:3651-3657a.
• Venkatapuram S. A Bird’s Eye View. Two Topics at the Intersection of Social Determinants of Health and Social Justice Philosophy. Public Health Ethics 2009:2 (3), 224-234.
• On income, unemployment, alcohol: Statistics Finland; findikaattori.fi, Eurostat, Ministry of Employment and the Economy, EuroStat
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