Reducing socioeconomic inequalities in health II

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 12

Abstract

TEROKA (Reducing Socioeconomic Health Inequalities in Finland) is a joint pilot project for reducing socioeconomic differences in health. TEROKA has carried out more than ten years of systematic work to strengthen the knowledge and action basis for reducing health inequalities. The most important effort has been TEROKA's involvement in the preparation of a National Action Plan to Reduce Health Inequalities. The action plan was launched in summer 2008 by the Ministry of Social Affairs and Health.

Recent developments

In 2007 TEROKA researchers produced an extensive report on socio-economic health differences in Finland (MSAH 2007; to be published in English in 2008). The report emcompasses information on health inequalities between socioeconomic groups over the last  25 years in Finland. Evidence on health inequalities is provided in terms of mortality, self-rated health, morbidity, functional capacity, mental health, healthy life expectancy, health related behaviour, biological risk factors as well as disparities in the use of health services. One chapter is devoted to discussing the developments of Finnish health and social policy .

The most important recent policy effort has been the National Action Plan to Reduce Health Inequalities (2008-2011) that was launched in summer 2008. The preparation of this action plan was started in 2006. TEROKA partners were invited by MSAH to prepare a background paper for the socio-political ministerial group of the government ( "Socioeconomic health inequalities: an essential societal challenge in Finland. A memorandum for socio-political ministerial group"). This memorandum laid the basis for the preparation of the national action plan and may also have been an important input to convince the policy-makers that there is a need for such an action plan.

The preparation of the action plan was started and has been led by the multi-sectoral public health committee within MSAH. The tasks of the committee were to provide proposals for strategic policy approaches and the most important measures, to identify major stakeholders, and to provide a proposal for the monitoring.

The main principles of the action plan are as follows:

• reinforcing Health in All Policies (HiAP),
• focusing both on 'upstream' and 'downstream' measures,
• reducing health inequalities by levelling up,
• responding to the needs of the most vulnerable
• as well as taking into account the gradient in health across the societal hierarchy.

There are 15 action proposals in the action plan that focus on welfare policy measures, healthy habits, health and social service system and knowledge base and tools.

The reduction of health inequalities has been one of the main goals of the Finnish health policy and an objective of all health policy programmes since the 1980s.This objective has also been articulated in two recent Finnish Government Programmes (2003 and 2007). The action plan aims to implement the most recent national public health programme (2001) that states: "the objective will be to reduce mortality differences between genders, groups with different educational backgrounds, and different vocational groups by a fifth by 2015". The action plan has been closely linked with the Government's multisectoral Health Promotion Programme (2008-2011).

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

The Action Plan has been accepted by different political parties in two consecutive governments and is "consensual" in this sense. However, there are other policy lines that contradict the basic objectives of this action plan, such as the raise of  user fees in municipal health services and reduction of public services and personnel.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Civil Society

• Scientific Community: Researchers from TEROKA group

• Others

Stakeholder positions

The Ministry of Social Affairs and Health has led the preparation of the Action Plan. The basic material and proposals for the action plan were produced by seven expert groups each led by an expert who was invited for this task by MSAH. The action plan was launched by MSAH in summer 2008 (MSAH 2008, in Finnish with an English Abstract, including the proposal drafts produced by the 7 expert groups).

Other ministries than MSAH (except the Ministry of Finance) have been involved through membership in the Multisectoral Public Health Committee which has actively commented on the work. TEROKA partners (STAKES, National Public Health Institute and Institute for Occupational Health have all been involved, as well as University-based researchers) have worked in close collaboration with MSAH and the Multisectoral Public Health Committee in the preparation process of the action plan.

There are also several local actors involved in the process. The provincial administration of Oulu has been active on the regional level in promoting action to reduce health inequalties and has cooperated with the TEROKA project since 2007. The Association of Local and Regional Authorities and several individual municipalities also cooperate with TEROKA. The Healthy Municipalities Network, which is coordinated by STAKES, has health inequality reductions as a priority area.

Actors and positions

Government
Ministry of Social Affairs and Health	very supportive		strongly opposed
Government	very supportive		strongly opposed
Multisectoral Public Health Committee	very supportive		strongly opposed
Regional level: Oulu State Provincial Office	very supportive		strongly opposed
Civil Society
Finnish Centre for Health Promotion	very supportive		strongly opposed
Some strong large organisations such as Finnish Heart Association	very supportive		strongly opposed
Scientific Community
Researchers	very supportive		strongly opposed
Municipalities
Healthy Municipalities Network	very supportive		strongly opposed
the Association of Finnish Local and Regional Authorities	very supportive		strongly opposed
Individual co-operating active municipalities (e.g. Kainuu region and the city of Turku)	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

The reform does not include any legislative changes.

Legislative outcome

n/a

Actors and influence

Government
Ministry of Social Affairs and Health	very strong		none
Government	very strong		none
Multisectoral Public Health Committee	very strong		none
Regional level: Oulu State Provincial Office	very strong		none
Civil Society
Finnish Centre for Health Promotion	very strong		none
Some strong large organisations such as Finnish Heart Association	very strong		none
Scientific Community
Researchers	very strong		none
Municipalities
Healthy Municipalities Network	very strong		none
the Association of Finnish Local and Regional Authorities	very strong		none
Individual co-operating active municipalities (e.g. Kainuu region and the city of Turku)	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The new action plan on health inequalities has been adopted in June 2008. It includes a short general  plan for implementation, and the MSAH and the Multisectoral Public Health Committee are working on a more detailed suggestion for implementation during autumn 2008. TEROKA partners will be involved in this process by being responsible for developing suitable follow-up indicators and coordinating the follow-up, as well as being partly responsible for the implementation of some parts of the action plan, especially on the municipal level.

The translation of the action plan into actual implementation will take place through the participants of the Multisectoral Public Health Committee who represent all major sectors of the government (except the Ministry of Finance), regions, government research institutes (under MSAH), professional organisations and health organisations. At the local level the municipalities should implement the action plan basically on their own accord.

Monitoring and evaluation

A situation analysis of the implementation of the Action Plan will be made in 2010, before the end of the term of the present government. The situation analysis will be published in a follow-up report of Health Inequalities in Finland (the first report was published in 2007). The Multisectoral Public Health Committee will follow the process of implementation every year.

Expected outcome

This is the first action plan for reducing health inequalities in Finland. It has been prepared with a relatively light organisation and the level of commitment of those who ought to implement it is unclear for the time being. Government research institutes and the TEROKA project are expected to provide expertise and assistance in terms of knowledge and developmental work.

The action plan has to operate in a context where a multitude of other health care programmes, with a higher profile, are ongoing. There are many tendencies in society, operating on the level of social determinants of health, that work against the goals of the national Public Health Programme and the present action plan. Examples of these would be the growth of relative poverty and increasing income differences, as well as a liberal alcohol (and alcohol tax) policy that is no longer guided by public health concerns.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

TEROKA has been a catalyst and activator in drawing attention to health inequalities. It has worked in a close connection with the MSAH and this has contributed to the preparation of the action plan that has been launched. The process of implementing the action plan is underway.

References

Sources of Information

www.teroka.fi

Palosuo, Hannele et al. (eds.) Health Inequalities in Finland. Trends in socioeconomic health differences 1980-2005. Helsinki: The Ministry of Social Affairs and Health, 2007. (in Finnish with English abstract; to be published in English in 2008) www.stm.fi/Resource.phx/publishing/documents/13799/index.htx

MSAH. National Action Plan to Reduce Health Inequalities 2008-2011. Helsinki: The Ministry of Social Affairs and Health, 2008. Available online as PDF file [78p.] at: www.stm.fi/Resource.phx/publishing/store/2008/11/pr1227003636140/passthru.pdf 

Reform formerly reported in

Reducing socioeconomic inequalities in health Process Stages: Policy Paper, Pilot

Author/s and/or contributors to this survey

Sihto, Marita and Hannele Palosuo

The authors are senior researchers at STAKES

Suggested citation for this online article

Sihto, Marita and Hannele Palosuo. "Reducing socioeconomic inequalities in health II". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/fi/a12/1