Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups

Abstract

Background: Norway is internationally known today for its political and socio-economic prioritization of equity. The 2012 Public Health Act (PHA) aimed to further equity in the domain of health by addressing the social gradient in health. The PHA’s main policy measures were (1) delegation to the municipal level of responsibility for identifying and targeting underserved groups and (2) the imposition on municipalities of a "Health in All Policies" (HiAP) approach where local policy-making generally is considered in light of public health impact. In addition, the act recommended municipalities employ a public health coordinator (PHC) and required a development of an overview of their citizens’ health to reveal underserved social segments. This study investigates the relationship between changes in municipal use of HiAP tools (PHC and health overviews) with regard to the PHA implementation and municipal prioritization of fair distribution of social and economic resources among social groups. Methods: Data from two surveys, conducted in 2011 and 2014, were merged with official register data. All Norwegian municipalities were included (N=428). Descriptive statistics as well as bi- and multivariate logistic regression analyses were performed. Results: Thirty-eight percent of the municipalities reported they generally considered fair distribution among social groups in local policy-making, while 70% considered fair distribution in their local health promotion initiatives. Developing health overviews after the PHA’s implementation was positively associated with prioritizing fair distribution in political decision-making (odds ratio [OR] = 2.54; CI: 1.12-5.76), compared to municipalities that had not developed such overviews. However, the employment of PHCs after the implementation was negatively associated with prioritizing fair distribution in local health promotion initiatives (OR = 0.22; CI: 0.05-0.90), compared to municipalities without that position. Conclusion: Development of health overviews — as requested by the PHA — may contribute to prioritization of fair distribution among social groups with regard to the social determinants of health at the local level.

Rethinking the Theory of Change for Health in All Policies Comment on "Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups"

“…However, if we were to conceptualize this finding as an implementation failure, in the sense that the public health coordinators simply do not have the resources (time and mandate) or the skills to create change, one would expect no significant differences between the municipalities who have employed a public health coordinator and the municipalities that do not meet this recommendation. Yet, it does not seem to sufficiently explain the strong negative association between public health coordinators and fair distribution between social groups identified by Hagen et al 1 Thus, in order to better understand this surprising result, we may need to consider a more critical perspective when discussing the appropriateness of the public health coordinators as a HiAP tool. This entails questioning the theory of change of HiAP itself.…”

“…In the article, Hagen and colleagues 1 suggest that some explanation (to the negative association between public health coordinators and fair distribution between social groups) may be found in the high number of health coordinators who are not employed full time. This entails that the public health coordinators do not have the time required to adequately facilitate collaboration and coordination and engage in advocacy, planning, and policy-making.…”

“…The competencies to undertake the role as boundary spanner (that is the facilitating role of establishing collaboration and coordination across sectoral and departmental boundaries to ensure joined-up working) are rather different from traditional public health competences and requires a different set of skills. In the study by Hagen et al, 1 it is neither clear which educational backgrounds the public health coordinators have, nor for which specific skills they have been selected to hold the position. However, others have highlighted how the public health community does not have a good understanding of the policy process and may lack necessary skills.…”

“…The study by Hagen et al 1 investigates the relationships between changes in municipal use of Health in All Policies (HiAP) tools and the extent to which fair distribution of social and economic resources between social groups is taken into account in local policy-making. The study finds that 70% of the Norwegian municipalities considered fair distribution among social groups in their local health promotion initiatives, while only 38% of the municipalities considered fair distribution in their general policy-making.…”

Health in All Policies – Entwicklungen, Schwerpunkte und Umsetzungsstrategien für Deutschland

“…In Norwegen wurden durch das Public-Health-Gesetz von 2012 flächendeckend regionale Public-Health-Koordinationsstellen zur Entwicklung und Umsetzung kommunaler HiAP-Strategien eingerichtet [11]. Evaluationsergebnisse zeigen dabei Erfolge u. a. in der Verringerung gesundheitlicher Ungleichheit insbesondere in solchen Kommunen, in denen die Ansiedlung bei der Verwaltungsspitze gelungen ist und der Prozess durch kontinuierliche Gesundheitsberichterstattung flankiert wird [12].…”