Proceedings of the Subcommittee on Population Health
Issue 1 - Evidence, November 22, 2007
OTTAWA, Thursday, November 22, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:00 a.m. to examine and report upon the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
The Chair: Good morning. I am Senator Keon, chair of the Subcommittee on Population Health. We are very deeply appreciative of you joining us by way of video conference. We have a beautiful winter scene outside. We are getting 15 centimetres of snow as we speak, so I am sure you are green with envy over there in Sweden.
I understand we have, from the Swedish Ministry of Health and Social Affairs, Irene Nilsson-Carlsson; from the Swedish Institute of Public Health, Dr. Gunnar Ågren; from the Karolinska Institute, Department of Public Health Sciences, Ms. Piroska Östlin; and, in addition, we have Mr. Bernt Lundgren.
As I said, my name is Senator Keon. With me is Senator Lucie Pépin, deputy chair of the committee, Senator Joyce Fairbairn and Senator Eggleton, who is actually chair of the Standing Senate Committee on Social Affairs, Science and Technology. Also, we have Senator Joan Cook and Senator Catherine Callbeck.
Irene Nilsson-Carlsson, Deputy Director General, Public Health Division, Swedish Ministry of Health and Social Affairs: Thank you, senators, for inviting Sweden and us to this video conference and for providing us with the opportunity to present the Swedish case. I am head of the division for public health in the Swedish government's ministry of health and social affairs. I would like to share with you some of the lessons learned during the development of the public health policy for Sweden.
To start with, the normal procedure when developing a policy is that it should be delivered within a limited time. However, creating a modern public health policy means involving and engaging other parts of society. It requires reflections, rethinking and numerous discussions to understand the concept and to start establishing a common ground. A general commitment in the society is essential if you want a public health policy with a real impact on public health. That is a clear experience of ours.
The government was aware of this and so appointed a national public health committee. This committee was to present proposals on national objectives for the development of public health. In the instructions given to the committee, it was clearly stated that the committee should adopt a process-oriented working method and to heavily involve the public and voluntary sectors at large.
Moreover, the committee was given three years to accomplish its task. In most cases, government committees are given much less time. My point is that if you want to have a process like this, it takes a lot of time and there can be no shortcuts. The advantage of providing such an amount of time is, of course, that the society has time to prepare and adjust to what is coming.
Keeping the momentum going during such a long process requires fuel. The fuel in our case included a number of expert reports and pamphlets relating controversial opinions around, for example, alcohol and tobacco. It included many of the social determinants as well as numerous meetings, consultations and public debates all around the country. That was important.
Another very crucial aspect in this process was the composition of the committee. It was based on three pillars. We have representatives of all the political parties in the Parliament, from left to right. We have leading public health scientists and a lot of experts representing the most relevant national state agencies, as well as regional and local authorities and a number of NGOs.
When the committee delivered its report, it took the government almost another two years to process the proposal before it was put forward to the Parliament for the final decision in 2003. This was also an important phase during which we had a lot of time for discussions with all the other ministries.
Why determinants? Sweden decided to have a determinant approach instead of one focusing on diseases when developing our public health strategy. You could ask why we did so. Given the limited time for this presentation, I will give you the short version.
Most public health strategies that we knew of at that time were outcome oriented. Objectives and targets were formulated in terms of reduced morbidity and mortality. Of course, that is what we all want to achieve in the end, but the important question is: How do we get there?
In a sense, one can say that we turned things upside down and started to look upstream. The idea was to focus on what is reachable with political measures. This was a political committee and a political process. That is why we would like to focus on what is reachable with political measures.
One role of the politicians is, for example, to create societal conditions that promote good health — conditions that are beyond the immediate control of the individual. While personal health was rather understood as an individual aspect and individual responsibility, public health, on the other hand, was seen as the responsibility of the society at large. By approaching the determinants of health, public health also becomes a clearer political issue, and that was important.
More or less everyone agrees on positive outcomes, but the main issue is how to get there. There are indeed discussions and different political opinions on the means for that.
By making health more political in this sense, it also becomes more interesting and part of the public debate. For the Swedish government and the majority of the parties in the Parliament, it was agreed to put equal opportunities to good health as an overarching aim of the public health policy in Sweden.
I know you have already seen the headings of the 11 public health domains. We actually do not call them ghosts so I will not repeat them here and now, but I would like to point out the apparent contributions from the field of health promotion. You can also easily trace the action areas in the Ottawa Charter, the idea of a healthy public policy spelled out in the Adelaide recommendations, as well as the focus of health supporting environments and the evidence-based approach.
We think it is important to point out that the domain should be seen holistically and interlinked with each other. For example, promotion of good eating habits are linked to socio-economic conditions, as well as to secure and healthy conditions for growing up. This is something we have to focus more on.
The implementation of the objectives involves many different policy areas and ministries. The determinant approach made it much more understandable for the other ministries that they had a crucial stake in the health policy. Some ministries became more interested in health such as Environment, Agriculture and Consumer Affairs, and the ministry of Finance.
In general, we have experienced strong support from other ministries to contribute to the improvement of health. Often, other ministries find that what benefits public health in their policy areas will only strengthen their argument for additional measures in their policy areas.
The first step was to establish an executive structure in order to facilitate the implementation of the Swedish public health strategy. Our solution was to identify already existing objectives in other policy areas and put them in a public health context and give them sectoral responsibilities. When we found that other ministries already had aims and goals that were in line with the public health policy, we thought it was wise to build on them.
The second step was to appoint a special minister of public health and strengthen inter-ministerial mechanisms within the government.
The third was to establish a national steering group for public health issues in which their respective director general represents the most relevant national agencies. The minister of public health chairs the steering group. The fourth was to make the Swedish national institute of public health the coordinating agency.
Having decided to take the determinant approach, it was only natural to look for how this was expressed in existing policies. Surprisingly, or not, we found that much was already in place but not framed in "public health'' terms. Instead of inventing new policies, we started by pointing out and strengthening the health dimension of existing policies.
Within this comprehensive public health policy, the need for a special minister for public health became apparent to the Prime Minister. In our case, this means the senior minister with a mandate to take initiatives covering all the determinants that are linked to the 11 objectives and to coordinate the government's public health policy.
The main point is that the minister for public health can focus on health promotion and disease prevention in all policy areas.
For the execution of the policy, a national steering group for public health was established and is led by the minister for public health. It is inter-sectoral by nature and includes directors general from almost 20 state agencies, who are commissioned by the government to implement the parts of the public health policy related to their sectoral responsibilities.
The national institute of public health has an important task in coordinating and forcing the pace of the implementation of the national health policy. Dr. Ågren will tell you about that in his presentation.
The government has systematically given guidelines to all concerned state agencies to take actions and report on objectives under their sectoral responsibility. In general, the response, thus far, has been even more positive than expected.
It has been a main objective to put extra efforts into the monitoring and evaluation of this public health strategy. The simple reason behind this is that what is monitored is more likely to be implemented.
In addition, we have a public health report every four years which presents trends in morbidity, mortality and risk exposure, and a public health policy report. The latter, focuses on indicators for health determinants and on suggested priorities and measures for action.
Dr. Gunnar Ågren, Director General, Swedish National Institute of Public Health: I have been Director General of the National Institute of Public Health since 1999. Before that, I was also one of the members of the national public health committee. Our institute is a governmental agency reporting to the ministry of health and social affairs. We receive our instructions from the government, but as with other governmental agencies, we have a high degree of independence in our analyses and executing our work.
One of our main tasks is to monitor and coordinate the implementation of the national public health policy together with other central governmental agencies. The second task is to be a centre of knowledge for methods and strategies within the field of public health as specialists of the local communities and regions with such knowledge. We also have to act as a supervisory agency in the field of alcohol, tobacco and illicit drugs, where we have a lot of legislation. It is important to recognize that the local committees carry out the main part of health promotion activities in Sweden. These communities are responsible for many aspects of daily welfare, for example, schools, sanitation and care of elderly people. They also oversee the Swedish regions, which are responsible for health care, including disease prevention. There are also a number of very important voluntary organizations involved in the field of public health, such as the temperance movement and the organizations for retired people and disabled persons.
In the health sector, there are other important governmental agencies. For example, the national board of health and welfare, with a centre for epidemiology. This centre delivers many relevant statistics on health outcomes. There is also the Swedish institute for infectious disease control, which delivers statistics on infectious diseases.
Our institute is organized primarily to monitor the various domains of objectives. We have a department for analysis and follow-up activities, which has the main responsibility for coordinating activities regarding the public health policy report. This department is also responsible for the annual survey of health-related behaviours, living conditions and self-reported health. This survey comprises approximately 60,000 Swedes every year and provides most of the data concerning lifestyle-related health determinants.
Mr. Bernt Lundgren will provide information on the work with the first public health policy report. I will make some general comments.
First, the central steering group, which was mentioned before, headed by the minister of public health, has been of crucial importance when making public health a legitimate issue in areas of the government administration other than the health sector. It is very important that the directors general come together to discuss those questions, that is, how to implement public health policy and which indicators we have to use and so on. It is very important that a cabinet minister has been the head of this group.
I also think that the synergy effects between public health and other important objectives such as economic growth have also been very important when we implement the public health objectives. When people representing other sectors of society discover that good health facilitates their own goals, they become more interested in the implementation of the public health policy.
This is also very important when implementing the policy at the regional and local level. It has been quite common to look at public health as something that improves growth and regional development in different parts of Sweden.
Although the public health policy report covers all domains of objectives, it is also important — and this is something we have learned — to concentrate efforts on the most important public health problems. In Sweden, some of the most important problems involve alcohol, increasing obesity and lack of physical activity, mental health among young people, and stagnating health among elderly people.
It is more important in the future to have learned that we should concentrate or report more on the most central public health problems.
Bernt Lundgren, Public Health Policy Expert, Swedish National Institute of Public Health: Thank you for the possibility to give some insight into the processes of the implementation, monitoring and evaluation of the broad determinants-based public health policy during the first phase of its implementation, 2003-2005.
I was principal secretary of the Swedish national public health committee, and I am now a public health policy expert in the Swedish national institute of public health. The source for my presentation is the public health policy report, which was handed over to the minister of public health in October 2005. I was principal secretary for that report.
In the report, the experiences of implementation are described, together with a presentation of time series data for 42 important health determinants. In the report, SNIPH — the Swedish national institute of public health — also put forward 29 priority proposals related to health threats and 13 proposals related to policy and capacity. I will now focus on the capacity side.
SNIPH was commissioned by the government in 2002 to develop a monitoring system with indicators related to the new public health policy, and in 2003 and 2004 to support selected state agencies in the understanding of their roles in regard to public health. To achieve this, SNIPH needed to formalize some normative starting points for the work. We developed the strategy emphasizing that players outside the health sector first have to consider which determinants are important within their own spheres of activity and for which groups. They have to establish indicators to follow up and third, build capacity, make health impact assessments and act on the determinants. Fourth, they must monitor the effects of the interventions; fifth, suggest new steering mechanisms and interventions; and sixth, report to stakeholders.
SNIPH submitted a proposal with indicators to the government in March 2003. This proposal was circulate by the government offices to 45 central state agencies for comments. Through this, a process of communication was started between SNIPH and more than 20 central agencies, from agriculture to education. One result of this communication was 38 principal indicators adopted by SNIPH in November 2004. This was later reduced to 36 principal indicators used in the public health policy report and also 47 sub-indicators. I have sent you an appendix where you can see the determinants, the indicators and the sources for the indicators.
At the same time as the work with the indicators was being followed up, we adopted a dialogue approach to support the state sector agencies regarding their roles in public health. The government commissioned 17 state agencies in 2004 and 13 agencies in 2005 to work actively to fulfill the overall aim and report their efforts.
Thus, the dialogue process started with lunch meetings between SNIPH and agency directors general and county governors about the normative starting points. This was then followed by multi- and bilateral meetings with agency representatives about following up the determinants and reporting initiatives and achievements. The process resulted in reports to SNIPH from 22 national agencies and eight county administrative boards — that is regional state agencies — during 2004-05, and 13 county administrative board reports during 2006. The later board reports were not included in the 2005 public health policy report. Very important in the dialogue and related to the normative starting points was the question of transfer of ownership, meaning that the responsibility of the agencies also includes monitoring the development of health determinants and establishing relevant indicators in the area and using good data for the indicators.
Support to municipalities and county councils from SNIPH have primarily been given in the form of seminars, participation in strategic groups and knowledge reviews and reports. SNIPH has also compiled basic public health statistics for local authorities to help the municipalities plan and monitor their public health work. To obtain information for the report, SNIPH conducted telephone interviews with all 21 county councils, regions, and distributed an electronic questionnaire to all 290 municipalities.
The result is that the central agencies that SNIPH met in the communication process are related to a vast area of different policy; for example, labour market, work environment, housing, integration, equality, education, social security, environmental protection, road traffic, sports, medical care, food and taxation.
The meetings with the directors general resulted in a consensus on the normative approach to public health. There was a marked interest in synergy effect, for example, environmental interventions that also affect health positively. Many central agencies regarded their activities as having a direct effect on people's health, while others regarded the effects as more indirect in that their activities influenced local factors. A summary of what happened shows that the process challenged the established domains of central agencies but, by taking a dialogue approach, obstacles could be overcome. Most agencies involved in the process became actively engaged and contributed to their development. As to the monitoring of indicators, they also reported initiatives and achievements related to health determinants within their respective domains.
The most important task for the regional state agencies — the county administrative boards — is to promote regional development in accordance with the goals decided by the Parliament and government. According to the county administrative boards, their work has both a direct and indirect effect on all domains and objectives, except domain six, the health service. Several of them also report that their coordination responsibility on the regional level and experiences from the area of environmental policy implementation and social supervision in the areas of social service for disabled persons and alcohol provide good prerequisites for deepening and strengthening their role within the public health area.
All county councils have adopted an overall action plan for public health work. In some counties, the plan has also been adopted in partnership with other actors. Seventeen county councils, or 80 per cent, have a department for public health or social medicine to support public health promotion within the county council and in the county, mostly for epidemiological monitoring, public health reporting and knowledge support.
There are currently several examples of how the scope of this support to municipalities has been reduced, bringing objective domain six more into focus at the expense of other objective domains and how the support varies across the country.
Successful preventative measures have been implemented within parts of the health service for a long time. These well-developed preventative activities include, the maternity and child health care services, youth guidance centres, dental care, school health and company health care, infection control and vaccinations, as well as other forms of screening.
A new survey of primary health care centres by the national board of health and welfare shows there is systematic health-promoting work in terms of routines or programs to reduce smoking, obesity and to increase physical activity, but that this is less usual when it comes to alcohol habits and stress-related problems. Here we can do better.
A majority of primary health care centres' directors said they were cooperating with local public health advisory committees in helping to develop health-promoting programs in the local communities. Only a small minority of them have specific programs to offer citizens medical examinations.
It was calculated during the work with the public health policy report that about 5 per cent of the total health service costs are going to disease-preventing measures. We think we could increase that amount.
When it comes to municipalities, there are overarching action plans in 116 of the municipalities, meaning we have 100 per cent more of that than in 1995, according to a questionnaire at that time.
Public health was also mentioned in other overarching plans. Conditions during childhood and adolescence, physical activity and tobacco and alcohol consumption were in focus in 2004.
As many as 76 per cent of the municipalities, compared to 60 per cent in 1995, had some form of public health committee for organized cooperation with other actors, such as county councils and NGOs. According to findings in the 2004 questionnaire, public health promotion was systematically monitored in one-half of the municipalities.
We found that there is growing interest for public health issues in municipalities while the same time there is striking uncertainty as regards how those ambitions are to be met practically. Only a few municipalities can be said to have come far in the development of systematic public health work, based on the analysis of epidemiological data, and systematic planning and monitoring process integrated into the planning and monitoring activities of the municipalities. According to both county councils and municipality representatives, the national public health policy has most definitely helped to reinforce the mandate for pursuing public health issues, both locally and regionally.
In conclusion, the experiences from the implementation of the policy during the first phase of the implementation are that the determinants approach, focusing on structural factors in society, people's living conditions and health behaviours that affect health is in general, well understand and emphasizes the role of other sectors in public health.
The use of indicators to follow up exposures to determinants is of key importance. The support to actors outside the health service is needed to identify their public health role. We found that continuous steering from the government and other political bodies in county councils and in municipalities is of vital importance.
Public health promotion at the regional level in Sweden needs a higher level of coordination. I have not talked about that because of time constraints, but we need to improve in that area. Municipalities need more skill development.
The Chair: Thank you very much indeed, Mr. Lundgren. You have covered a tremendous amount of ground. I could ask questions for several hours, but time will not going to allow it.
Piroska Östlin, Senior Researcher, Karolinska Institute, Department of Public Health Sciences: Thank you very much. Senators, I am honoured to participate in this videoconference. Thank you for inviting me.
I was secretary of the national public health commission. In fact, this is not the first time I have had the opportunity to share the Swedish experience with Canadian public health experts and policy-makers. In May 2003, I had the pleasure to present the work of the commission and its proposals to a big audience at a one-day conference at the Montreal Public Health Department organized by OMISS, which was exclusively devoted to discussing the Swedish experience.
In this opening statement, I intend to provide a short background of the Swedish national public health commission with more detail of why the government set it up and how its work was organized.
Finally, I will list a number of factors that make up the Swedish public health policy and the way in which it has been uniquely developed in the world.
It was in the mid-1990s when there were a number of circumstances that necessitated the government's decision to draw up a comprehensive equity-oriented public health strategy for Sweden. For example, the recognition that public health development was not satisfactory during the 1990s became a public concern. Although the Swedish population in general enjoyed excellent health compared to other Western European countries, Sweden did not perform better than others in relative terms. For example, socio-economic differences in mortality and morbidity persisted, or even increased, and there were indications of increasing mental and psychosomatic symptoms among children and younger adults, particularly among poorly educated, working-class women.
Another important driving factor was the establishment of the Swedish national institute of public health in 1992, which started to initiate a number of activities for health promotion and disease prevention at both national and local levels.
Stakeholders in the public health field, such as county councils and municipal public health committees, among others, expressed an urgent need for national and local guidelines for their work and called for a national strategy for public health.
In April 1997, the Swedish government appointed a national public health commission with the aim of defining national objectives of health development and strategies to achieve them. The objectives were expected to guide society in promoting health and preventing diseases, injures and their consequences in terms of disability and mortality. It was said that the targets and strategies should contribute to the reduction of inequalities in health among socio-economic groups, between women and men, ethnic groups, and geographical regions of the country. The government requested the proposals be scientifically well founded and stimulate a broad democratic process on health policy issues.
The commission consisted of, as we have heard, representatives of all seven political parties in Parliament and a number of experts and advisers from national authorities, universities, trade unions and non-governmental organizations. The work of the commission was facilitated by a chair with a full-time appointment and by a secretariat comprising four secretaries, sometimes more, who worked full time, providing the commission with background, discussion materials and draft resolutions.
The national public health commission was the first to be set up to address public health in its own right. Previous commissions and proposals related to health were predominantly health-care oriented and public health issues were only part of this larger context.
The work of the commission was accomplished in three phases. During the first phase, a framework was developed that included a broad description of the health development in the country, as well as the responsibilities for health for different sectors of the society. Tools were presented that facilitated a discussion on priorities and strategies, including alternative dimensions for priority setting. Should we set the priorities on diagnosis, on determinants, target groups or arenas for action?
The framework was submitted for consideration and comments to a range of authorities, organizations and experts. After considering the pros and cons of different dimensions for target-setting, the commission decided during phase 2 to suggest health targets primarily in terms of reduced exposure to determinants of disease and injuries, and not in terms of reduced mortality and morbidity, as we heard before.
This decision was a result of the understanding that exposures can clearly be related to their causal roles for the level and distribution of different diseases and their consequences. Moreover, determinants make more explicit the connection between health targets and responsibilities of different sectors and policy areas, such as the labour market, social welfare, housing and schools.
The determinants of health given highest priority were those that were expected to have the greatest potential for reducing the overall levels and the social inequalities in the burden of disease. All these were based on scientific evidence.
There were 14 expert groups appointed to write background papers containing sound scientific evidence on health determinants, such as employment, working conditions, economic factors, social insurance, tobacco, alcohol and drugs. Based on the expert groups' reports, the commission submitted a preliminary proposal on a national public health strategy in December 1999, including the commission's vision, strategic intent and health policy objectives. The proposal has been referred again for consideration and comments to a broad range of stakeholders.
The third and final phase of the commission's work took place during 2000. The most important starting point for this phase was to analyze and act upon the comments and suggestions provided by stakeholders. A survey was conducted, which mapped out 32 national authorities covering a broad range of sectors regarding the direct and indirect effects of their activities on public health. The survey highlighted the current role and responsibility of each authority, and provided valuable information as to how the roles and responsibilities of the respective authorities should be shared and coordinated in the future.
Three additional expert reports have been commissioned. One report dealt with the responsibilities for working with health promotion groups within the health sector; another concerned the situation and special needs of chronically ill and handicapped people; and the third report scrutinized issues related to public health training and research.
In October 2000, the commission presented its final report to the minister of health and social affairs. In it, the commission proposed 18 health policy objectives, grouped into six categories called "overarching guidelines,'' and expressed the strategic intent of the commission. To each objective, a number of more specific targets were linked, together with various indicators for follow-up.
The commission also defined specific target groups for each objective and identified the actors to be responsible for implementation. The health objectives addressed the determinants of health mainly at the societal level. Eight of the objectives dealt with underlying determinants, six with lifestyle factors and four with public health infrastructure.
Finally, I would like to identify a few factors that, in my opinion, made the proposals and working process of the commission unique in comparison with national health strategies in other countries. First, the politicians and experts developed the strategy together. The experts ensured that the proposals were scientifically well founded and that there were prerequisites in place for the implementation of strategies. The politicians, on the other hand, were able to continuously discuss and negotiate during the working process and thereby agree on priority setting. Therefore, the final report developed by the commission was a political document based on scientific evidence. Second, the strategy focused on determinants of health, which required multi-sectoral implementation. The rationale behind this approach, as I mentioned before, was that determinants make it easier for the different sectors to identify their roles, and that the relationship between action and effect is less blurred by time lag and confounders compared to effects in terms of health outcome.
The determinant approach makes the role of the health sector less obvious. Accordingly, the proposed Swedish strategy required implementation in a number of policy areas and sectors, where the health sector is only one of the actors.
Third, the strategy was based on strong scientific evidence. The government's demand for scientific evidence behind the various proposals has mobilized the research community. Over 100 scientists representing different fields of public health research have published 19 reports to support the working process. Fourth, there was a strong emphasis on the democratic and transparent process behind the development of the strategy. The success of any public health strategy depends greatly on the process by which it has been developed. The process that leads to national goals can be just as important as the goals themselves.
It took more than three years to undertake the work involved in the development of the strategy. The process- oriented work of the commission was ensured by the broad consultation process with political and non-governmental organizations, authorities, academic institutions and other experts.
The publishing of 10 short discussion documents for debate on scientifically and politically controversial issues within the public health field was also important. As we heard, they organized seminars and conferences in various regions of the country, arranged by the commission itself or in collaboration with others. Such a working process is, of course, time consuming but absolutely critical for success.
Finally, I would like to add that the Swedish public health commission's working process, vision, focus on health determinants and strong demand for scientific evidence have inspired and influenced the current work of the World Health Organization's independent commission on social determinants of health, which is so generously supported by both Canada and Sweden. Hopefully, the WHO commission's work will inspire and guide governments all over the world to incorporate a social determinant perspective into their national policy processes so that in a few years time, the Swedish approach will not appear unique at all.
The Chair: Thank you for this wonderful presentation. We are very indebted to you. We recognize you are well out in front of us and that we can learn a great deal from you.
As you know, one of the problems confronting us is geography. We have a huge geographic area, and geography itself frequently is a determinant of health, although we do not identify it as such. Canada has extreme health disparities so, in addition to identifying the determinants of health as defined by you, the World Health Organization and the British and others, we have to deal with these geographic pockets of people.
I will bring you back to county councils to ask you about the situation in 1995 when Sweden kicked off this whole area. Were there significant disparities in the counties, in the various geographic areas of Sweden? Have you been able to deal with those disparities? Have you seen any progress?
Dr. Ågren: That is a very interesting question. Our institute has tried to study such geographic disparities, for example in the north of Sweden. Our institute is located 600 kilometres north of Stockholm, bringing us closer to those regional problems. Two areas in Sweden have different health situations in general, but in particular, in the populated areas in Northern Sweden there are lower employment figures than in the rest of Sweden. They are the higher proportion of people on sick leave and so on. They have more obesity and worse lifestyle determinants are seen in that area. People there are at a disadvantage. Some suburbs of the larger cities have a high immigrant population and accompanying social problems.
Some reports have stated that we have had an increase in those problems but when making an international comparison, one cannot say that Sweden has large geographical disparities in health. We have socio-economic disparities in health but there is not a large geographical disparity. For example, we have a very small indigenous population. We have made some studies of the health of those people in Northern Sweden, but the reports to date show that they have approximately the same health as the rest of the Swedish population.
Ms. Östlin: We also need to add that the government was sensitive to the geographic disparities when they appointed the commission. They pointed out that the four disparities were socio-economic, gender, ethnic and geographic. It was taken into consideration in the work of the commission as well.
The Chair: You have been functioning for a while but not very long in terms of population health outcomes. Have you noticed a correction in the geographic regions where health disparities were greatest?
Dr. Ågren: We do not have good data on that subject. However, the Swedish government has been very active for quite a long time in trying to reduce those disparities. For example, we have a system whereby we level out the taxes between different areas of Sweden. The regions and local communities have their own right of taxation and the right to take our taxes. Our current system levels this out. We take money from the rich communities and give money to the poor communities. The idea is to create equity in the level of taxation and regions should receive money according to their needs. We have a comprehensive system for levelling this out.
In my view, we have approximately the same geographical disparities as we had in the 1990s. I cannot say that our situation is better but it has not been worse.
Ms. Nilsson-Carlsson: The current government recently introduced a special policy to try to improve living conditions in the countryside. The main aim is to inspire new enterprises in rural areas to provide better working and living conditions in those areas, where it could contribute to better health.
Dr. Ågren: Previously, we looked at health as a reflection of what you could call "bad social circumstances'' in one region. Today, we also look at health as one determinant of economic development. Perhaps one of the best instruments for improving the conditions in one region and improving the conditions for enterprise and so on is to improve the health of the population. We look at health as a factor inside our regional development policy.
Ms. Östlin: We ask do they reflect real geographical disparities or is this a patterning of social disparities? There is a tendency in remote areas to an accumulation of socially disadvantaged people. If that is controlled, perhaps the regional disparities would decrease.
Senator Pépin: We want to have a similar system to help our Canadian population. The new population health policy is the result of a long process involving many different players, such as political parties, constituencies, regional agencies and NGOs. This might be a great challenge. I would like to know the principal issue that the Swedish national institute of public health faced during its three years of work from 1997 to 2000.
How did the commission succeed in reaching an agreement with all of the various groups with their very different interests? Is there anything that we should learn from your experience on this commission?
Dr. Ågren: At the time, I was a politically appointed member of the commission. Other members would likely agree with me when I say that we solved the problem in the usual Swedish way — we compromised through negotiations. For example, one party was interested in family use while another party was interested in equality. We tried to give everyone something. Of course it was a compromise, but I think the commission succeeded because we got very broad consensus.
It is very interesting that when we changed government in Sweden after the last election, the new government stated that they would keep on with the general outline of the national public health policy. I would say that was a result of that compromise.
Ms. Nilsson-Carlsson: I think that was important for us as civil servants. When we built the system in government, we wanted it to be sustainable so we could fit the same structure with different political ideologies and put in many different measures under the same headline, according to the current political aims. It is very positive that we can keep the structure following several elections.
Mr. Lundgren: I think what was happening both within the committee and also outside was important. Inside the committee, as Ms. Östlin said, experts from different fields of society gave their knowledge to the politicians. Sometimes the professors had very good ideas and said we should do this, and the politicians said it is a good idea but it was not possible because it was not time for that from a political perspective. There was a good dialogue between the politicians and the experts. That was one thing.
The other thing was the dialogue with the members of society. Pamphlets were made, and Ms. Östlin has one with her. Those pamphlets were free, and ordinary people in Sweden could phone us up and ask to obtain a pamphlet about tobacco or elderly people and their health. We sent them out, and then they could discuss it with their friends. That was important.
Another thing was the process to which Ms. Östlin referred. It was a process of politicizing the question. We work in the secretariat, and we were out discussing this with politicians and civil servants in the whole country. Of course they were very interested because of that.
The first sub-report was sent out to more than 500 different organizations and they responded with their opinions on it. The second report was sent out to more than 300 organizations, and they came back with their opinions. It was a very interesting process in that respect.
Ms. Östlin: I would like to add something that helped reach consensus between the politicians. We should not underestimate the role of the evidence presented to the politicians. If you have very strong evidence to support your ideas, it is very hard to oppose it. It is important to keep that in mind as well.
Senator Pépin: Where there is a will, there is a way. I think you answered my second question, which was to Ms. Nilsson-Carlsson. You say that to coordinate a government public health policy, a national steering group for public health has been established and led by the minister of health. Could you tell us more about the role of the steering group and its work? Do you have any specific cases upon which this group has made a positive impact?
Ms. Nilsson-Carlsson: So far, we have gone through the eleven domains of objectives and discussed them one by one. During the meetings, for example, the minister of public health has invited the responsible minister for the domain of the objectives that we are discussing at that meeting. For example, when we discuss health care, the minister responsible for health care participates in the meeting. When we are discussing agriculture and food policy, we have invited the minister of agriculture and so on. Therefore, several ministers have taken part in the meetings with the national steering committee. That has been a way to involve all the ministers in the government in the public health policy and to meet with the directors general from most of the different policy areas and come together to discuss public health. This has been an important way to broaden the perspective of public health and make it the responsibility for all policy areas.
Senator Callbeck: Thank you very much for your presentations this morning. I congratulate you on what you have been able to accomplish.
I am interested that you set up a representation from all your political parties, and I think you said there were seven. Is it common in Sweden that all political parties get together to fight a cause, or is this the exception?
Ms. Nilsson-Carlsson: I would not say it is an exception, but it is not very common, either. We have these kinds of committees for very politically sensitive issues. When we need broad involvement, then we use this technique. I think it was a good choice when talking about public health. We have a number of these kinds of politically based committees going on at the moment.
Ms. Östlin: Behind the decision to set up the parliamentary commission was also previous experience with the public health group we set up at the end of the 1980s, which was a group of just experts, not politicians. They defined a public health strategy for the country, but it was not implemented because the expert group was unable to set political priorities and they could not handle the resource allocation, et cetera. Therefore, it was quite obvious that a strategy such as this needed a political platform as well. That is why politicians and experts sat together in that case.
Senator Callbeck: Did it take much lobbying to get all the political parties to tie in?
Ms. Nilsson-Carlsson: No, I do not think so.
Senator Callbeck: Ms. Nilsson-Carlsson, you stated that a general commitment in society is essential if you want a public health policy with a real impact on public health. I agree with that 100 per cent, but that is not easy to do. Obviously, you have been able to do it, and the procedure has been outlined here in papers. I am wondering, from your experience, is there any advice that you would give us? In other words, if you were just starting to do this, are there things you would do differently?
Ms. Nilsson-Carlsson: No, I do not think so when it comes to the procedure. What we had to do in the government was integrate what was suggested from the committee to the steering mechanisms that are already established in the government. We already had a mechanism for steering the agencies, and for the budget process, et cetera. In the government, we adjusted the public health objectives to the already established steering procedures.
If we had thought about that when the guidelines for the committee were written, then we might have been able to avoid a bit of work in the government. I think it was a good idea to try to integrate the public health aim and steering measures with the measures for steering agencies managing the budget. We had to do that in the government. That was something we could have done a bit differently.
I think we accomplished what we set out to do.
Mr. Lundgren: If you want to do in Canada what we did in Sweden, all the politicians in the committee were social policy politicians. Now we know about all kinds of broader and very near determinants of health. If you had such a committee, you could also have politicians from other fields on the committee. We had experts from the fields of labour and other fields that do not just deal with social policy. You could broaden the fields in the committee, perhaps.
Senator Fairbairn: You have made a very interesting presentation to us. It is interesting because it sounds very much like the kinds of problems that we are facing as we are going through our study.
Dr. Ågren, at the end of your presentation you talk about the efforts that had been made in various parts of your society. I know when it comes to literacy and learning, Sweden practically leads the world. It is an issue of great interest and importance to me. I take my hat off to you with regard to the notion that you have gone into society in order to make this effort work.
You mention, for instance, that your policy report covers all sorts of domains. It is very similar to what we are hearing now, certainly through this committee in Ottawa. You mention obesity and lack of physical activity as two of the important issues. You talk about health among young and elderly people. That almost says it all. We are in the same position. We are a much larger country in terms of miles but not in terms of issues.
Obesity in this country, particularly among children, has become a headline issue. This includes the unfortunate prospects that obesity has for the later parts of their lives and health. With respect to physical activity, in Canada we used to have a lot going on for young children in terms of sports and such things in schools. Much of that has drifted off. I wonder whether you can speak to us about those kinds of issues. Much of the strength lies in the families, but it does not always work that way.
As parliamentarians of whatever type, we all want to know that we can make our system work in Canada to make life better. Do you have any anecdotes on those very fundamental issues, particularly regarding young people, that you can give us to reflect what you have suggested in your report?
Dr. Ågren: Those same questions are very central to the discussion in Sweden. For example, when it comes to physical activity and obesity, we followed up on the public health policy. We had a special task from the government to deliver an action program against obesity in order to improve physical activity. I am very glad that the present government will soon deliver a bill to Parliament on this matter. There will be a number of our measures and proposals that will come back.
I think there are different parts to our work with physical activity and obesity. First, we have been working a great deal with trying to increase the awareness about the problem in the population. For example, some years ago we had a campaign called "Sweden on the move'' in order to get people to know that they should participate in some sort of physical activity for at least 30 minutes a day. We monitor these things so we can say, for example, two-thirds of Sweden does participate in at least 30 minutes of physical activity a day. It has improved a bit, but not as much as we hoped.
Nowadays, we try to get physical activity into the planning of a community. For example, when planning routes, new areas for people to live or new facilities for walking or running, we work on integrating physical activity into social planning. We also try to work with school authorities to integrate physical activity into schools.
When it comes to obesity, we have had much discussion about whether we should put special measures on unhealthy foods. The labelling of foods has been part of the debate, but that is a question of general politics, and policy will influence that question.
We have also found that, when it comes to obesity, there are some indications with respect to young people. Perhaps we are not increasing it anymore; our latest results say it has been levelling off. It is too early to say if we have reversed the trend.
I think very keen monitoring of the problem, both at central and local levels, is very important. We work with looking at an issue and providing our results with the hope that those results get into the political discussion and new measures will be discussed. There is always some sort of interaction.
In terms of the health of young people, the present government is very eager to be involved in parental education. There is a huge demand for good parental education. We are trying to implement what we call evidence-based methods in parental education. That is what governmental agencies can do. It is very much how to stimulate local authorities, those most responsible for these sectors.
Senator Fairbairn: As an anecdote, I come from a small city in the western part of Canada. As is the case with most schools around the world, schools in my community have cafeterias and vending machines, where students can purchase all sorts of things with lots of salt and sugar. Much to the surprise of many in my community, the young people from one school marched on their principal and said that, unless the unhealthy foods in their cafeteria were removed, they would like to have the cafeteria closed down — they were trying to be athletic — the notion of which then reverberated around the community. We forget sometimes how smart young people can be. It sounds as though you are trying to do that.
Dr. Ågren: That is interesting. In Sweden, the local community municipalities are responsible for schools. Intense discussions have taken place in many municipalities; many of them have prohibited the sale of sweets and sodas in school cafeterias.
It is an ongoing discussion. Our role as a governmental agency is to provide facts to that discussion.
Senator Fairbairn: You role is also to give encouragement, which you have done.
Senator Eggleton: Thank you for being with us and sharing the information of your experiences.
In our hearings, we have leaned about a number of social determinants of population health — for example, poverty and lack of adequate housing. It is plain to us that a whole-of-government approach is required, to deal with the various social determinants.
However, there are many different ministries of the government involved in this, and trying to get a whole-of- government, or a horizontal approach, is not easy in a system that traditionally has been very vertical and silo- oriented. The ministers are all responsible for their specific programs and departments.
It is one thing to get people talking about this whole-of-government approach, but it is quite another to keep them committed to it. There needs to be political will, and it must be there all the time because ministers can go off into their silos again and do things that are relevant to their specific mandate.
How do you overcome that? How do you get a whole-of-government approach? How do you keep the commitment, people's feet to the fire, to ensure you can implement policies on population health?
Ms. Nilsson-Carlsson: On a daily basis in Sweden, the government takes all decisions unanimously, and that means we must negotiate with the other ministries all the time. The other ministries, when planning a proposal in their policy area, must share it with us beforehand so we can provide our opinion on their planned suggestions and drafts. Therefore, we always scrutinize what they do, the drafts from other ministries, with a perspective of whether it will gain public health or not. That way, we can keep the discussions ongoing all the time. I think that is one important means that we have.
Then we have the national public health steering committee, which meets over the borders of the ministries and talks about public health. It is then possible to provide guidelines to all the agencies, so we discuss with the other ministries that they must provide guidelines to their agencies to look upon public health in their areas of responsibility.
In terms of implementing public health policy, we use the usual mechanisms for steering and policy-building in Sweden. We have a lot of work going on among the agencies. I think Dr. Ågren could add to that.
Dr. Ågren: I could add that the crucial question is that we must always try to get health into other areas of society. That, of course, is a process, but not an easy one. I remember when the minister of finance for Sweden said he wanted to keep alcohol taxes high because he thinks it is better that people who are drinking are working. That was a good example, that the health arguments even influenced the minister of finance — which, of course, is the most difficult department of government to influence.
Mr. Lundgren: In the public health policy report, we also try to provide ammunition in relation to this. We are saying that it is not enough to guide an outside agency in the small sphere of public health once. You have to guide it several times, and perhaps every year.
It is interesting and important to add public health into instructions for agencies that are not under the ministry of health and social affairs but under other ministries. That way, we are building an alliance for good implementation. Different kinds of agencies will see health as very important for themselves in their tasks.
Senator Eggleton: What happens, though, when you have conflict or a different set of priorities among the ministers, resulting in deadlock as opposed to an agreement on proceeding?
For example, in the U.K., when Prime Minister Blair decided on goals and timetables for reduction of poverty, he put the Minister of the Exchequer, a very senior cabinet minister, in charge, to coordinate the project and to ensure that the funds would be there, to ensure there were not deadlocks, that there was some resolution to the matter, so that the goals and timetables could be met.
Do you have anything similar that would result in keeping the agenda moving forward if there happens to be disagreements over, say, funding issues and priorities, where the finance department can frequently get in the way of these policies?
Ms. Nilsson-Carlsson: We have negotiations with the minister of finance. We start with civil servants, but then we usually have to raise the issues to the state secretaries and then to our ministers to discuss. They must negotiate. Because of the unanimous principle of the government, at the end of the negotiation there must be a common solution on how to distribute the results from the budget negotiation. That depends on the priorities in the ministry and what a minister wants to put highest on the agenda.
We have no special solution for public health issues; it is the same as for all budget negotiations. It depends on the political prioritizations.
Dr. Ågren: The present Swedish government is a coalition government, consisting of four different governments. It is quite obvious they have to negotiate and compromise. That is part of the nature, I would say.
Senator Cook: Thank you, Mr. Chair, and good morning. I do want to commend you. You have made me think outside the box this morning.
I will direct my remarks to Ms. Östlin. You say that your final report was a political document based on scientific evidence. That, to me in itself, is a miracle. You then go on to say that the success of any public health strategy depends greatly on the process by which it has been developed and that the process leads to national goals that can be as important as the goals themselves.
How is your working process managed? Do you have any evidence-based information that you are on track? If I understand the progression here, you must have a strong continuum with every stakeholder in order to reach and deliver this to the consumer.
Am I accurate in my analysis of what you have achieved here?
Ms. Östlin: Yes. The process definitely was important for coming to the final report. We invested a lot in the process. We were able to maintain the dialogue with all these stakeholders because we had a full-time chair and full- time secretaries. The process involved more than 100 scientific experts that provided the evidence that made the reviews for us and provided the basis for the decisions. The request was also made from the government that all propositions and all the proposals should be built on scientific evidence.
A couple of objectives were dropped in the final report because the scientific evidence was too weak behind those objectives. It has been really scrutinized also from the evidence point of view.
Senator Cook: May I ask you what goals were dropped along the continuum?
Ms. Östlin: I believe it was one on income inequalities. In the first report or target that we issued, an indicator was not to exceed a certain level. It was dropped because it was believed that the scientific evidence was not strong enough to support that. We had quite low income and equality in Sweden. If we decreased income and equalities even more, there was no evidence that the population would be better. There is certainly no evidence that inequalities in health would decrease.
That was one of the objectives that were dropped because the evidence was not strong enough.
The Chair: May I bring you back to your influence on industrial developments?
I am not quite sure how it works, but I have been aware for some time that things must be walked by the health minister. I do not know if that is the special minister or the determinants on public health or whether it is the other minister of health or the super minister; I am not quite sure how your system works.
Let me give you an example. In one of your counties, some corporate entity wants to build a large plant for processing of forestry products. Someone in the county, I suspect, starts asking questions about what effect this will have on the health of the community. How does the process work? Does that come back up through the county council? Does it come down from the top, from the minister? How does the process kick in?
Dr. Ågren: In general, it is a question for the local community to decide, for example, if you should start some sort of process inside the community.
There is also a regulation requiring the local community to look at the environmental consequences of new investments. We are now working with a pilot project on complementing the environmental consequence descriptions with health consequence descriptions. We are developing tool kits for the local communities. In the future, we think that would facilitate that you should, in more general terms, look at the health consequences of new investments.
For example, we are trying to implement that when we are building roads. The new road may lower the number of traffic accidents, but it may increase the air pollution and it may decrease access to green areas, and so on. We try to look at all those consequences and weigh them together. The decision making process in those cases is at the local level. In some cases, it is done also at a regional level, but we have a complicated regional organization in Sweden where we have state regional agencies for planning purposes and the county councils, which mainly work with health care and those questions and not so much with regional agencies today.
The Chair: In Canada now, "environment'' is the buzz word. We are very environmentally conscious, and the Ministry of Environment seems to get a look at everything that is developing.
To the chagrin of those of us in the health sector, health does not get looked at. You have been incredibly generous to forward us in advance a number of documents that are tremendously helpful to us. They will appear in paraphrased form, and also in recognized form in our final report, I am sure.
I was wondering how far along your tool kit documents are for the synergism between environment and health, and if you could share those with us also.
Dr. Ågren: We have a common European project on health consequence descriptions as a tool kit in the planning process. We have also English documents where we provide examples of how we try to implement those health consequence descriptions, in most cases together with environmental consequence descriptions, because that is the best method today.
We have the same situation, in some respects, as in Canada where the environment is discussed more than health at the planning level. That is also the situation in Sweden. We often want to go further in this area, but there is some development at least.
The Chair: How did you get to the position of having industrial projects and other things reviewed from a health point of view? We are nowhere near that here.
Dr. Ågren: That is a decision made by the local community. We are working on this, as it is a question within this discussion. The government requested that we develop those environmental health consequence descriptions. We are trying to use them, for example, when it comes to state agencies and other governmental agencies. We are also using them inside the regional state administration, which the government directs.
As well, we are trying to implement them in the local communities. However, they are independent, so it is dependent on the political will in the local community to look at health consequences. Still, it is an ongoing discussion.
The Chair: You have no central legislation that mandates this?
Dr. Ågren: Not when it comes to health consequence descriptions. We do have regulations about environmental descriptions.
Ms. Nilsson-Carlsson: You can say that, in performing the environmental impact assessment, you cannot do that kind of assessment without considering health. Therefore, health is already part of the environmental impact assessments.
What Dr. Ågren is talking about is trying to improve this even further, and to have legislation on the environmental impact assessments.
Mr. Lundgren: I should say also that, from the institute's side, we have contact with 13 national state agencies and 21 regional state agencies regarding health impact assessments. That means we discuss the determinants that they can influence and discuss the method of health impact assessments together with them. We meet and discuss those questions. We start by meeting with them together and then meet them one by one. That is an ongoing process.
The Chair: I hope we get there some day. We are not there at this point in time in Canada.
I want to thank you again — and I very much want to thank you for the documents you sent us. I hope you will send us the tool kit, if you can.
Dr. Ågren: Yes.
The Chair: We may well be back to you. We have a little more than a year's work ahead of us yet before our final report comes out. You clearly are leading the field in this. We are enormously grateful to you for sharing your knowledge with us.
Ms. Nilsson-Carlsson: Thank you. We are happy that we could contribute to your work. It is an honour for us.
The Chair: Honourable senators, we must approve our subcommittee budget, which you have before you. It is clearly outlined. It breaks down to professional services of $122,400, transportation $56,858, all other expenditures $8,250 for a grand total of $187,508.
I have looked over this document, which has been well prepared by Ms. Reynolds, Clerk of the Committee, and I think it can be supported. Senator Eggleton will have to present this on our behalf to the Internal Economy Committee.
Senator Eggleton: What are these two conferences about, in Halifax and Vancouver, $9,574?
The Chair: They concern the subject of health care.
Senator Eggleton: Are they specific conferences? This was also in the Subcommittee on Cities budget, and I had it removed because there are no specific conferences in Halifax or Vancouver. This budget takes us to the end of March — and we would know about any conference.
The Chair: Internal Economy probably will remove this item, in that case.
Senator Eggleton: I would suggest we remove them. I do not like to have to justify something I do not have enough information about. They are just general. I had them removed in the Subcommittee on Cities budget.
The Chair: Senator Eggleton is saying that the Internal Economy Committee will take them out anyway, so we may as well take them out.
So with that adjustment, do we have approval of this budget?
Hon. Senators: Agreed.
The Chair: Thank you very much, and thank you all for attending at this teleconference. Today's hearing and the report will be of tremendous importance to us in writing our report.
The committee adjourned.