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


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)


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)


Framework of the Commission on Social Determinants of Health includes multilevel causal paths and multilevel means–aims chains (CSDH 2008, 43, Fig. 4.1)


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).


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


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


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


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


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)


Life expectancy in Finland 1750-2013. In 2014 L.E. for women 83.9, for men 78.2 yrs. (Statistics Finland)


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)


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)


… 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)


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)


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


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)


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.


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


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


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.


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)


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


http://www.stat.fi/til/ksyyt/2014/ksyyt_2014_2015-12-30_tie_001_en.html





hannele palosuo: how do we understand social determinants in finninsh health policy?

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