The ambition of Health in All Policies in Norway: The role of political leadership and bureaucratic change

The Role of Chief Medical officers in making Public Health Overview Documents in Norwegian Municipalities. A qualitative Study

AIMS

To investigate how Chief Medical Officers experience their role in the municipalities´ work with making the public health overview documents, demanded by the Norwegian Public Health Act from 2012.

METHODS

A qualitative study with semi-structured focus group interviews with 21 Chief Medical Officers from 20 different municipalities in Norway. The interviews were conducted in 2017. The data were analyzed thematically.

RESULTS

The Chief Medical Officers were mainly positive to participating in making public health overview documents. They took on roles as leaders of the work, medical advisors, data collectors towards local GPs and listening post to other sectors. Organizational factors like too small positions and a lack of tradition to involve the CMO in public health work were experienced as barriers to their involvement. The collaboration with the public health coordinators was said to be rewarding, and the intersectoral process involved employees from other sectors in a new way in public health. Although there were some positive experiences, several CMOs considered the use and impact of the public health overview document as limited.

CONCLUSION

There was a large variation in the amount and the type of involvement the Chief Medical Officers had in making the public health overview documents in Norwegian municipalities. More research is needed to understand if this has any consequences for the quality of public health work in the municipalities and whether it is a sign of a changing role of the Chief Medical Officers.

How effective is the health promotion policy in Sichuan, China: based on the PMC-Index model and field evaluation

BACKGROUND

Many countries around the world highlight the health in all policies (HiAP). However, most of the related research focused on the influential factors and implementation strategies, with less concern on the evaluation of HiAP. In response to HiAP's call, the Chinese government has proposed health promotion policies (HPPs) in counties or districts, the evaluation of HPPs in sample counties or districts of Sichuan province in China is an essential basis for optimizing policy content, improving policy implementation, and ensuring health promotion's continuous and efficient operation.

METHODS

This paper established an evaluation system for HPPs based on the PMC-Index model and then quantitatively analyzed 37 representative HPPs from the pilot areas in Sichuan province. In addition, a team of experts conducted a field assessment.

RESULTS

The results showed that the average PMC index of 37 HPPs was 7.091, and correlation analysis showed that there was a significant correlation between the PMC index and expert score.

CONCLUSIONS

This study indicates that the overall consistency of HPPs was good and proves a connection between the formulation and implementation of HPPs.

How to Evaluate Health in All Policies at the Local Level: Methodological Insights Within Municipalities From the WHO French Healthy Cities Network

BACKGROUND

This article proposes a method for analysing the degree of maturity of Health in All Policies (HiAP) among World Health Organization-French Healthy Cities Network (WHO-FHCN) as part of the GoveRnance for Equity, EnviroNment and Health in the City (GREENH-City) project. We focused on the creation or enhancement of health-promoting environments, and more specifically, public green spaces.

METHODS

We conducted a cross-sectional quantitative study guided by the evaluative framework of the HiAP maturity level developed by Storm et al mixed with a qualitative interpretation. A self-administered questionnaire was sent to elected officials and health department officers in the 85 member cities of the WHO-FHCN in 2017. Subsequently 58 cities were included in the analysis, which was based on a multiple correspondence analysis (MCA) and a hierarchical ascending classification (HAC).

RESULTS

Thirty-two criteria among a total of 100 were identified and were used to organize the cities into 8 groups which was then reduced to three profiles among the cities: a less advanced HiAP profile, an established HiAP profile and an advanced HiAP profile. This process allows us to identify 4 dimensions that make it possible to evaluate the level of maturity of cities in the HiAP process, namely: (1) the consideration of social inequalities in health and/or health issues in the policies/actions of the sector studied, (2) occasional intersectoral collaboration, ie, one-off initiatives between the health department and others sectors, (3) the existence of joint projects, ie, common projects between two or more sectors, (4) the existence of intersectoral bodies, in this case on the theme of urban green spaces including an intersectoral committee and/or working groups.

CONCLUSION

Four dimensions which allow to the measurement of the degree of progress in implementing health-all-policies are proposed. With a view to integrating knowledge into public action, this study carried out under real conditions offers a realistic method to evaluate HiAP.

General practitioners' experiences of being involved in local public health work in Norway. A qualitative study

AIM

The aim was to explore how general practitioners experienced being involved in local public health work and how they worked with prevention and health promotion clinically after the introduction of the Public Health Act in 2012.

DESIGN, SETTING AND SUBJECTS

Qualitative study with focus groups interviews with 18 GPs from different municipalities in Norway.

RESULTS

The GPs said that they either had not at all or only to a limited extent been involved in local public health work in their municipalities. They reported finding it hard to prioritize individual disease prevention and health promotion in their clinical work. GPs thought of health promotion as something that mainly concerned healthy people at a group level.

CONCLUSIONS

Based on the experiences of the GPs in this study, there is a gap between governmental expectations to the role of GPs in public health, and how it works in practice.KEY POINTSWith the Norwegian Public Health Act launched in 2012, GPs were expected to contribute to better population health in their clinical work and as data providers to local public health surveillance.The GPs interviewed in this study said they had not been involved in local public health work, and they found it hard to give disease prevention and health promotion priority in their clinical work.GPs expressed various perceptions of what prevention and health promotion entails.

A qualitative study on multisector activities to prevent childhood obesity in the municipality of Seinäjoki, Finland

Background

Multisector activities are needed to prevent childhood obesity due to its multifactorial background. The first aim was to identify the activities that had been undertaken for obesity prevention and deduce their main targets. Second, we analyzed the public health policy approaches (upstream, midstream, and downstream) which were followed. Finally, we studied the perception of interviewees regarding their sectors’ roles in implementing the local obesity program.

Methods

Deductive content analysis was used to analyze semi-structured interviews with 34 key professionals (from seven administrative sectors) who had participated in multisector health promotion during 2009–2016 and five representatives of other core parties.

Results

Several midstream and upstream activities were targeted at making physical activity (PA) and healthy eating (HE) integral parts of children’s lifestyle. One long-term strategy was to create environments for PA accessible to every inhabitant and build and renovate the interiors and yards of schools and day-care centers. The healthiness of meals was increased progressively. In addition to midstream and upstream activities, as a downstream activity, an intervention targeting children at risk of obesity was implemented. The impact of management on the activities was considerable; childhood obesity prevention was included in the city strategy and systematically coordinated at the highest managerial level. Altogether, various sectors operated efficiently to promote obesity-preventing lifestyles; however, not all (important) sectors recognized their role in the multisector process.

Conclusion

Most of the activities to guide children towards obesity-preventing lifestyles were either at the midstream or upstream level. Among the latter, considerable work is aimed at creating opportunities to practice PA and making it a natural part of the daily life. The aim of familiarizing children with lifestyles that include PA and HE was shared across sectors, including sectors that had not yet acknowledged their role in obesity prevention. Strong support from city management and systematic coordination of the activity are important factors that contribute to the engagement of several administrative sectors in working towards a shared aim, such as the prevention of childhood obesity.

Supporting a Healthy Planet, Healthy People and Health Equity through Urban and Territorial Planning

The form of human settlements impacts on planetary health, population health and health equity. Yet goals for urban and territorial planning are only tangentially linked to public health outcomes. The WHO and UN-Habitat support actions to bring health to the fore in planning and design of human settlements, recently publishing 'Integrating Health in Urban and Territorial Planning: a sourcebook' focusing on 'why' action is needed, 'how' to initiate it; and curating several existing resources on 'what' to do. Recommendations for research, policy and practice include calls for rapid development of closer relationships between public health and spatial planning.

‘Health in All Policies’ and the Urge for Coordination: The Work of Public Health Coordinators and Their Impact and Influence in Local Public Health Policies: A Cross-Sectional Study

Building heavily on the Health in All Policies (HiAP) approach, Norway implemented the Public Health Act in 2012 to reduce social inequalities in health. Local public health coordinators (PHCs) at municipal levels were seen as tools to provide local intersectoral public health work. In this study, we examine factors related to intersectoral agency and if intersectoral work is understood as relevant to securing social justice in local policy outcomes. A national web-based survey in 2019 of all Norwegian PHCs (n = 428) was conducted with a response rate of 60%. Data were analysed through multiple linear regression, hierarchical regression modelling and structural equation modelling. Neither factors relating to community contexts nor individual characteristics were associated with intersectoral agency. Organisational factors, especially position size, being organised at the top level and having a job description, were significantly associated with perceptions of intersectoral agency. PHCs seeing themselves as intersectoral agents also found themselves able to affect annual budgets and policy outcomes. We conclude that municipal PHC positions can be important HiAP tools in local public health policies. However, organisational factors affect how PHCs perceive their influence and role in the municipal organisation and thereby their possibilities to influence local policymaking through intersectoral agency.

Local and regional politicians’ considerations of newly arrived migrants’ health in political decision-making: a public health study in northern Sweden

Background and aim

Early action is important for promoting newly arrived migrants’ health. Politicians are major actors in decision-making that affects health outcomes in the population. Therefore, the aim of this study was to explore local and regional politicians’ considerations of newly arrived migrants’ health in political decision-making: whether politicians reflect on or discuss the effects of decision-making specifically on newly arrived migrants’ health, whether considerations differ between municipality and regional politicians, and how knowledge and attitudes are associated with such considerations.

Subject and methods

A cross-sectional quantitative study was conducted. A total of 667 municipality and regional politicians from northern Sweden responded to a questionnaire developed based on interviews with politicians. Bivariate analyses were performed using χ2 tests, the independent samples t-test, and the Wilcoxon signed-rank test. Multivariate analysis was performed using binary logistic regression.

Results

Politicians considered the effects on newly arrived migrants’ health significantly less frequently than those on the total population’s health. Regional politicians discussed such effects more often than municipality politicians. Knowledge (odds ratio [OR] = 1.343), attitude (OR = 5.962), previous experience working on public health issues (OR = 1.784), and female gender (OR = 1.787) were positively associated with considering effects on newly arrived migrants’ health in decision-making.

Conclusion

Politicians play important roles in health promotion, and most consider health-related effects in their decision-making. However, about a third do not consider such effects. General health-related knowledge and attitude are important factors that could be affected or changed during political assignments.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

Health promotion policies for elderly-Some comparisons across Germany, Italy, the Netherlands and Poland

OBJECTIVE

The aim of this study is to compare health promotion policies (HPP) for older adults in four European countries: Germany, Italy, the Netherlands and Poland. We focus on the design, regulations and implementation of policies in these countries.

METHOD

As policy relevant information is mostly available in national languages we have approached experts in each country. They filled in a specially designed questionnaire on the design, regulation and implementation of health promotion policies. To analyze the data collected via questionnaires, we use framework analyses. For each subject we define several themes.

RESULTS

Regarding regulations, Poland and Italy have a top-down regulation system for health promotion policy. Germany and Netherlands have a mixed system of regulation. Regarding the scope of the policy, in all four countries both health promotion and prevention are included. Activities include promotion of a healthy life style and social inclusion measures. In Poland and Italy the implementation plans for policy measures are not clearly defined. Clear implementation plans and budgeting are available in Germany and the Netherlands CONCLUSIONS: In all four countries there is no document that exclusively addresses health promotion policies for older adults. We also found that HPP for older adults appears to be gradually disappearing from the national agenda in all four countries.

Intersectoral Planning for Public Health: Dilemmas and Challenges

BACKGROUND

Intersectoral action is often presented as essential in the promotion of population health and health equity. In Norway, national public health policies are based on the Health in All Policies (HiAP) approach that promotes whole-of-government responsibility. As part of the promotion of this intersectoral responsibility, planning is presented as a tool that every Norwegian municipality should use to integrate public health policies into their planning and management systems. Although research on implementing the HiAP approach is increasing, few studies apply a planning perspective. To address this gap in the literature, our study investigates how three Norwegian municipalities experience the use of planning as a tool when implementing the HiAP approach.

METHODS

To investigate planning practices in three Norwegian municipalities, we used a qualitative multiple case study design based on face-to-face interviews. When analysing and discussing the results, we used the dichotomy of instrumental and communicative planning approaches, in addition to a collaborative planning approach, as the theoretical framework.

RESULTS

The municipalities encounter several dilemmas when using planning as a tool for implementing the HiAP approach. Balancing the use of qualitative and quantitative knowledge and balancing the use of structural and processual procedures are two such dilemmas. Other dilemmas include balancing the use of power and balancing action and understanding in different municipal contexts. They are also faced with the dilemma of whether to place public health issues at the forefront or to present these issues in more general terms.

CONCLUSION

We argue that the dilemmas experienced by the municipalities might be explained by the difficult task of combining instrumental and communicative planning approaches because the balance between them is seldom fixed.

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

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.

Public health terminology: Hindrance to a Health in All Policies approach?

AIM

National public health policies in Norway are based on a Health in All Policies (HiAP) approach. At the local level, this means that public health, as a cross-sectional responsibility, should be implemented in all municipal sectors by integrating public health policies in municipal planning and management systems. The paper investigates these local processes, focusing on the use of public health terminology and how this terminology is translated from national to local contexts. We ask whether the terms 'public health' and 'public health work' are suitable when implementing an HiAP approach.

METHODS

A qualitative case study based on analyses of interviews and planning documents was performed in three Norwegian municipalities.

RESULTS

The results present dilemmas associated with using public health terminology when implementing an HiAP approach. On the one hand, the terms are experienced as wide, complex, advanced and unnecessary. On the other hand, the terms are experienced as important for a systematic approach towards understanding public health ideology and cross-sectional responsibility. One municipality used alternative terminology.

CONCLUSIONS

This paper promotes debate about the appropriateness of using the terms 'public health' and 'public health work' at the local level. It suggests that adaptation is suitable and necessary, unless it compromises knowledge, responsibility and a systematic approach. This study concludes that the use of terminology is a central factor when implementing the Norwegian Public Health Act at the local level.

Health and equity in all policies in local government: processes and outcomes in two Norwegian municipalities

AIMS

To identify key factors in implementing Health and Equity in All Policies (HEiAP) at the local level in two Norwegian municipalities in order to accelerate the progress of promoting health, well-being and equity in other local governments.

APPROACH

This case study is presented as a narrative from policy-making processes in two Norwegian municipalities. The story is told from an insider perspective, with a focus on HEiAP policy makers in these two municipalities.

RESULTS

The narrative identified key learning from implementing HEiAP at the local level, i.e. the importance of strengthening system and human capacities. System capacity is strengthened by governing HEiAP according to national legislation and a holistic governance system at the local level. Municipal plans are based on theory, evidence and local data. A 'main story' is developed to support the vision, defining joint societal goals and co-creation strategies. Policies are anchored by measuring and monitoring outcomes, sharing accountability and continuous dialogue to ensure political commitment. Human capacity is strengthened through participatory leadership, soft skills and health promotion competences across sectors. Health promotion competence at a strategic level in the organization, participation in professional networks, crowd sourcing toward common goals, and commitment through winning hearts and minds of politicians and other stakeholders are vital aspects.

CONCLUSIONS

Our experience pinpoints the importance of strengthening system and human capacity in local governments. Further, we found it important to focus on the two strategic objectives in the European strategy 'Health 2020': (1) Improving health for all and reducing health inequalities; (2) improving leadership and participatory governance for health.

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

Health is created largely outside the health sector. Engagement in health governance, policy, and intervention development and implementation by sectors other than health is therefore important. Recent calls for building and implementing Health in All Policies, and continued arguments for intersectoral action, may strengthen the potential that other sectors have for health. This review clarifies the conceptual foundations for integral health governance, policy, and action, delineates the different sectors and their possible engagement, and provides an overview of a continuum of methods of engagement with other sectors to secure integration. This continuum ranges from institutional (re)design to value-based narratives. Depending on the lens applied, different elements can be identified within the continuum. This review is built on insights from political science, leadership studies, public health, empirical Health in All Policy research, knowledge and evidence nexus approaches, and community perspectives. Successful integration of health governance, policy, and action depends on integration of the elements on the continuum.