Report No. 20 (2006-2007) To The Storting National Strategy To Reduce Social Inequalities in Health

Report No.
20 (2006–2007) to the Storting
National strategy to reduce social

inequalities in health
Report No. 20 (2006–2007) to the Storting

Translation from the Norwegian. For information only.

Table of Contents
1 Introduction . . . . . . . . . . . . . . . . . . . 5 2.4.4 Areas with Sami and Norwegian

1.1 A fair distribution is good public settlements . . . . . . . . . . . . . . . . . . . . 28
health policy . . . . . . . . . . . . . . . . . . . . 5 2.4.5 People living alone . . . . . . . . . . . . . . 28
1.2 Comprehensive policy to reduce
social inequalities . . . . . . . . . . . . . . . . 6 Part I Reduce social inequalities that
1.3 Objective: To reduce social contribute to inequalities in
inequalities in health . . . . . . . . . . . . . 6 health . . . . . . . . . . . . . . . . . . . . . . . 31
1.4 Four priority areas for reducing
social inequalities in health . . . . . . . . 6 3 Income . . . . . . . . . . . . . . . . . . . . . . . 33
1.4.1 Reduce social inequalities that 3.1 Objective: Reduce economic
contribute to inequalities in health. . 7 inequalities . . . . . . . . . . . . . . . . . . . . 34
1.4.2 Reduce social inequalities in health 3.2 Policy instruments . . . . . . . . . . . . . . 34
behaviour and use of the health 3.2.1 Taxation system . . . . . . . . . . . . . . . . 34
services . . . . . . . . . . . . . . . . . . . . . . . . 7 3.2.2 Monitor developments in income
1.4.3 Targeted initiatives to promote inequalities . . . . . . . . . . . . . . . . . . . . 34
social inclusion . . . . . . . . . . . . . . . . . . 7
1.4.4 Develop knowledge and 4 Childhood conditions . . . . . . . . . 36
cross-sectoral tools. . . . . . . . . . . . . . . 7 4.1 Objective: Safe childhood
1.5 Limitations . . . . . . . . . . . . . . . . . . . . . 7 conditions and equal development
1.6 Summary . . . . . . . . . . . . . . . . . . . . . . . 8 opportunities. . . . . . . . . . . . . . . . . . . 36
4.2 Policy instruments . . . . . . . . . . . . . . 36
2 Facts about social inequalities 4.2.1 Kindergarten and school. . . . . . . . . 36
in health in Norway . . . . . . . . . . . 11 4.2.2 Maternal and child health centres
2.1 Systematic inequalities in health . . 12 and the school health service . . . . . 37
2.1.1 Substantial and growing social 4.2.3 Mental health services for children
differences in mortality among and young people . . . . . . . . . . . . . . . 39
adults . . . . . . . . . . . . . . . . . . . . . . . . . 12 4.2.4 Child welfare service . . . . . . . . . . . . 40
2.1.2 Most of the main causes of death 4.2.5 Participation in organisations and
are unevenly distributed in society 13 cultural activities . . . . . . . . . . . . . . . 42
2.1.3 Significant social inequalities in
mental health . . . . . . . . . . . . . . . . . . 14 5 Work and working environment 45
2.1.4 Inequalities in health through the 5.1 Objective: Inclusive working life
life course . . . . . . . . . . . . . . . . . . . . . 14 and healthy working environments 45
2.2 Social structures affect health. . . . . 14 5.2 Policy instruments . . . . . . . . . . . . . . 45
2.2.1 Income. . . . . . . . . . . . . . . . . . . . . . . . 15 5.2.1 Working environment legislation. . 45
2.2.2 Childhood conditions. . . . . . . . . . . . 17 5.2.2 The Norwegian Labour Inspection
2.2.3 Work and working environment . . 19 Authority . . . . . . . . . . . . . . . . . . . . . . 46
2.3 Systematic inequalities in health 5.2.3 Company health services . . . . . . . . 46
behaviour and access to health 5.2.4 Higher employment among
services . . . . . . . . . . . . . . . . . . . . . . . 21 immigrants . . . . . . . . . . . . . . . . . . . . 46
2.3.1 Health behaviour . . . . . . . . . . . . . . . 21 5.2.5 Action Plan against Social Dumping 47
2.3.2 Health services . . . . . . . . . . . . . . . . . 25 5.2.6 National system for monitoring
2.4 Groups with special health work and health . . . . . . . . . . . . . . . . 47
challenges . . . . . . . . . . . . . . . . . . . . . 26 5.2.7 Increase research on sickness
2.4.1 Groups with long-term social absence and exclusion from
problems . . . . . . . . . . . . . . . . . . . . . . 26 working life . . . . . . . . . . . . . . . . . . . . 48
2.4.2 Children and young people at risk . 26 5.2.8 Sickness absence and exclusion
2.4.3 Immigrants . . . . . . . . . . . . . . . . . . . . 27 in high-risk industries . . . . . . . . . . . 48
Part II Reduce social inequalities in 8.2.4 Voluntary organisations . . . . . . . . . . 77
health behaviour and use of the 8.2.5 Deprived geographical areas. . . . . . 78
health services . . . . . . . . . . . . . . . 51
Part IV Develop knowledge and
6 Health behaviour . . . . . . . . . . . . . . 53 cross-sectoral tools . . . . . . . . . . . 81
6.1 Objective: Reduced social
inequalities in health behaviour . . . 54 9 Annual policy reviews . . . . . . . . . 83
6.2 Policy instruments . . . . . . . . . . . . . . 54 9.1 Objective: Systematic overview of
6.2.1 Accessibility in schools and developments . . . . . . . . . . . . . . . . . . 84
kindergartens . . . . . . . . . . . . . . . . . . 55 9.2 Policy instruments . . . . . . . . . . . . . . 84
6.2.2 Measures in the local community. . 55 9.2.1 Review and reporting system . . . . . 84
6.2.3 Work as an arena . . . . . . . . . . . . . . . 57
6.2.4 Lifestyle guidance in the health 10 Cross-sectoral tools. . . . . . . . . . . . 85
service . . . . . . . . . . . . . . . . . . . . . . . . 57 10.1 Objective: All sectors of society
6.2.5 Regulate access to goods and assume responsibility. . . . . . . . . . . . 85
services . . . . . . . . . . . . . . . . . . . . . . . 58 10.2 Policy instruments . . . . . . . . . . . . . . 85
10.2.1 Health impact assessments
7 Health services . . . . . . . . . . . . . . . . 62 nationally and locally . . . . . . . . . . . . 85
7.1 Objective: Equitable health and 10.2.2 Municipal social and land-use
care services . . . . . . . . . . . . . . . . . . . 62 planning . . . . . . . . . . . . . . . . . . . . . . . 86
7.2 Policy instruments . . . . . . . . . . . . . . 62 10.2.3 Partnerships for public health. . . . . 87
7.2.1 User charges . . . . . . . . . . . . . . . . . . . 64
7.2.2 Governance and organisation of 11 Advancing knowledge. . . . . . . . . . 89
the health service . . . . . . . . . . . . . . . 65 11.1 Objective: Increase knowledge
7.2.3 Research and advancing knowledge 67 about causes and effective
measures . . . . . . . . . . . . . . . . . . . . . . 89
Part III Targeted initiatives to promote 11.2 Policy instruments . . . . . . . . . . . . . . 89
social inclusion . . . . . . . . . . . . . . . 69 11.2.1 Monitoring and surveys . . . . . . . . . . 89
11.2.2 Research . . . . . . . . . . . . . . . . . . . . . . 89
8 Targeted initiatives to promote 11.2.3 Evaluation of measures . . . . . . . . . . 91
social inclusion . . . . . . . . . . . . . . . 71
8.1 Objective: Better living conditions 12 Economic and administrative
for the most disadvantaged people . 72 consequences . . . . . . . . . . . . . . . . . 92
8.2 Policy instruments . . . . . . . . . . . . . . 72
8.2.1 Inclusion in the labour market . . . . 72 Appendix
8.2.2 Health and social services . . . . . . . . 74 1 International experiences . . . . . . . . 94
8.2.3 Housing policy . . . . . . . . . . . . . . . . . 77
The Ministry of Health and Care Services

Report No. 20 (2006–2007) to the Storting
Recommendation from the Ministry of Health and Care Services, dated 9 February 2007,
approved in the Council of State on the same date
(The Second Stoltenberg Government)
1 Introduction
1.1 A fair distribution is good public tors. Social inequalities in health are an expression
health policy of systematic injustices, and this is happening in a
society that upholds the principle that everyone
The Norwegian population enjoys good health. should have equal opportunity to achieve good
However, averages conceal major, systematic ine health.
qualities. Health is unevenly distributed among The Government believes that public health
social groups in the population. We have to work needs to be based on society assuming
acknowledge that we live in a stratified society, greater responsibility for the population’s health.
where the most privileged people, in economic Each individual is responsible for their own health,
terms, have the best health. These inequalities in and it is important to respect the right of the individ
health are socially determined, unfair and modifi ual to have authority and influence over their own
able. The government has therefore decided to ini life. However, the individual’s sphere of action is
tiate a broad, long-term strategy to reduce social limited by factors outside the individual’s control.
inequalities in health. Even lifestyle choices such as smoking, physical
Many factors play a part in creating and perpet activity and diet are greatly influenced by socioeco
uating social inequalities in health. The situation is nomic background factors not chosen by the indi
complex, but we can nevertheless state that it is vidual. As long as systematic inequalities in health
generally social circumstances that affect health are due to inequalities in the way society distributes
and not the other way round. Although in many resources, then it is the community’s responsibility
cases serious health problems lead to loss of to take steps to make the distribution fairer.
income and work and difficulties completing edu A fair distribution of resources is good public
cation, social status still has a bigger impact on health policy. The primary goal of future public
health than health does on social status. An over health work is not to further improve the health of
view of current knowledge compiled under com the people that already enjoy good health. The
mission from the EU concludes that social inequal challenge now is to bring the rest of the population
ities in health in all countries in Europe, including up to the same level as the people who have the
Norway, are primarily due to inequalities in mate best health – levelling up. Public health work
rial, psychosocial and behaviour-related risk fac
6 Report No. 20 (2006–2007) to the Storting 2006– 2007
National strategy to reduce social inequalities in health
entails initiatives to ensure a more even social dis Work to reduce social inequalities in health will
tribution of the factors that affect health. require long-term, targeted effort in many areas.
The strategy lays down goals for this work in the
following areas: income, childhood conditions,
1.2 Comprehensive policy to reduce employment and working environment, health
social inequalities behaviour, health services and social inclusion. It
will take time before we can measure the results of
This Report to the Storting along with two other the policy in the form of reduced inequalities in
Reports to the Storting (Report no. 9 to the Stort health in all these areas. For this reason, time lim
ing (2006–2007) Employment, welfare and inclusion its have not been set for achievement of the goals;
and Report no. 16 to the Storting (2006–2007) rather they require continuous input over the next
Early intervention for lifelong learning) form part of ten years.
the Government’s comprehensive policy for reduc The Government will monitor progress
tion of social inequalities, inclusion and combating towards each of the goals in order to ensure that
poverty. The strategy to reduce social inequalities we are on the right track. Assessment indicators
in health comprises the health aspect of this policy. will therefore have to be found for each objective to
This Report to the Storting lays down guide allow annual policy review on efforts to reduce
lines for the Government and Ministries’ efforts to social inequalities in health (see chapter 9).
reduce social inequalities in health over the next
ten years. The strategy traces out the main frame
work and shall govern the Ministries’ work on: 1.4 Four priority areas for reducing
– Annual budgets social inequalities in health
– Management dialogues with subordinate agen
cies, regional health enterprises, etc. Complex problems require comprehensive solu
– Legislation, regulations and other guidelines tions. There are many causes of inequalities in
– Interministerial collaboration, organisational health, ranging from basic determinants such as per
measures and other available policy instru sonal economy and childhood conditions, via risk
ments factors such as working environment and living con
ditions, to more immediate causes such as health
Importance is attached to describing responsibili behaviour and use of the health services. These var
ties in the individual priority areas and the mea ious areas can be regarded as interrelated and par
sures to be used to help reduce inequalities in tially overlapping causal chains. The conditions and
health. Measures to reduce social inequalities in surroundings in which children grow up affect their
health are largely linked to the follow-up of other education and employment opportunities later in life,
Reports to the Storting, plans of action and priority which in turn affect their health as adults. Moreover,
areas, for example Report no. 9 to the Storting access during childhood to resources such as a
(2006–2007) Employment, welfare and inclusion, healthy diet, fresh air and physical activity have a
Report no. 16 to the Storting (2006–2007) Early direct impact on health in later life.
intervention for lifelong learning, The Action Plan to Work to combat social inequalities in health
Combat Poverty, The Diet Action Plan (2007–2011) must be combined with targeted efforts aimed at
and The National Health Plan for Norway. An particularly vulnerable groups through general
important element of the future efforts to reduce
social inequalities in health will be ensuring that
this perspective is also integrated into subsequent
initiatives.
1.3 Objective: To reduce social

Objective
The primary objective of this strategy is to:
• reduce social inequalities in health by levelling
up Figure 1.1 Interlocking causal chains
2006– 2007 Report No. 20 (2006–2007) to the Storting 7
welfare schemes and special initiatives aimed at It is necessary to investigate more closely
specific groups. Inequalities in health are most whether the Norwegian health service is serving
noticeable in groups with low income and little edu to narrow or widen the health divide. Services
cation, so it is important to give these groups prior should be accessible to everyone, regardless of
ity. However, tailored measures targeted at specific their social background and should help reduce
populations are not always the most effective social inequalities in health.
instruments. In many cases, targeting, for example
on the basis of means testing, can have a stigmatis
ing effect and actually undermine the purpose. 1.4.3 Targeted initiatives to promote social
General welfare schemes are less stigmatising and inclusion
serve to prevent people ending up in high-risk sit We have a special responsibility to include people
uations. In addition, social inequalities in health who are at risk of being excluded from education,
affect all social classes, not only the most disadvan employment and other important arenas because
taged. We must therefore continue to build on the of barriers created by society. Exclusion from soci
Nordic tradition of general welfare schemes and at ety and being treated as inferior lead to deterio
the same time implement special measures to help rated health and greater risk of early death. Many
the people with the most problems. disadvantaged people need more targeted ser
In keeping with the identified need for a broad vices. Universal schemes must therefore be sup
approach, this strategy operates with the following plemented with services and schemes tailored to
four priority areas: 1) Reduce social inequalities the individual that take account of these special
that contribute to inequalities in health, 2) Reduce needs. User-oriented and specially adapted public
social inequalities in health-related behaviour and services are essential to ensure that everyone,
use of the health services, 3) Targeted initiatives to regardless of their background and circumstances,
promote social inclusion, and 4) Develop knowl has access to equitable services. We must ensure
edge and cross-sectoral tools: inclusive work life, inclusive schools and adapted
health and social services. The public sector must
collaborate with voluntary organisations in this
1.4.1 Reduce social inequalities that respect.
contribute to inequalities in health
The social circumstances we live in form the foun
dation for our health. The basis for social inequali 1.4.4 Develop knowledge and cross-sectoral
ties in health is laid very early on, and childhood is tools
a sensitive period in life. Early interventions are Social inequalities in health are closely related to
therefore necessary to prevent social inequalities social inequalities in other areas of life. Efforts to
in health developing. Good, safe childhood condi reduce social inequalities in health must therefore
tions for everyone, fair income distribution and be followed up in all sectors. Systematic reporting
equal opportunities in education and work are the is necessary to monitor the progress of work to
most important investments society can make to reduce social inequalities in health. Health impact
reduce social inequalities in health. assessments and social and land-use planning will
be important instruments to this end. The Partner
ships for Public Health scheme will be strength
1.4.2 Reduce social inequalities in health ened and developed further.
behaviour and use of the health We have enough knowledge to implement mea
services sures. However, we need to build up our knowl
Health behaviour varies according to social back edge about the causes behind social inequalities in
ground and has an enormous impact on health. We health and effective policy instruments to ensure
have to respect the individual’s right to make their that the measures we implement increasingly
own choices and judgements, but we must achieve their intended purposes.
acknowledge that a healthy lifestyle is also a ques
tion of resources, motivation and energy. Attention
needs drawing to the underlying, structural causes 1.5 Limitations
of behaviour in order to encourage healthy lifestyle
choices. Policy instruments influencing cost and This Report to the Storting deals with inequalities
availability play a central role in reducing social linked to education, occupation and income.
inequalities in lifestyle diseases. Health problems in certain groups will be dis
cussed to the extent that their health problems 1.6 Summary

coincide with inequalities in health linked to educa
tion, occupation and income. For example, we In this Report to the Storting, we present a broad,
know that chronic disorders occur more fre long-term strategy to reduce social inequalities in
quently in populations with little education and low health by levelling up.
income. We also know that gender, ethnic back Chapter 2 describes social inequalities in
ground and place of residence often play a part in health in Norway. Average health in the population
social inequalities. is good. Mean life expectancy is high, infant mor
The correlation between gender and social ine tality is low and most people consider their health
qualities in health is complex. Taking life expect good. However, these averages conceal major ine
ancy as our starting point, social inequalities are qualities: life expectancy has increased in most
less pronounced for women than for men. Mea educational groups, but it has risen most in groups
sured using other health criteria however, such as with a long education. We find social inequalities in
mental health, social inequalities are much greater health almost regardless of how we measure social
among women. Certain studies indicate that skew position and almost regardless of the indicator we
distribution of access to health services between use to measure health.
the sexes. Social, economic, physical and behavioural fac
Some of the indicators most commonly used to tors all affect the individual’s health – positively
measure social background are traditionally and negatively. On the population level, there is
harder to apply to women than men. Personal clearly a correlation between social and economic
income, for example, does not always reflect circumstances and health. Whether we group the
women’s social position. Many women have little population by income or level of education, we see
or no personal income, but live in a high-income that the groups’ health improves gradually in keep
household. Household income – adjusted for the ing with the increase in level of income or length of
number of members – is therefore often a more apt education. The link between social position and
expression of actual access to resources than per health forms a gradient and affects all levels in
sonal income. Using occupation as an indicator of society. This chapter studies in more detail the sig
social position is problematic without also includ nificance of income, childhood living conditions,
ing gender, because choice of occupation is often occupation, health behaviour and access to health
coloured by gender. services.
Within most ethnic groups, we find many of the Education, occupation and income are used as
same social inequalities in health as in the popula the main indicators of social position. In some
tion in general. Nevertheless, a number of more cases, however, other social and demographic
specific health problems are more widespread in background factors may affect socioeconomic sta
some ethnic groups than others, and in some tus and health. In this chapter we look more closely
cases, they coincide with socioeconomic position. at the particular challenges facing groups with last
However, it is not the case that there are some ing social problems, children and young people in
health problems common to all ethnic minority high-risk situations, immigrants, people in areas
groups. Access to health services may also vary with Sami and Norwegian settlement and people
between and within ethnic groups. living alone.
The correlation between social inequalities in Four main priority areas have been defined to
health and place of residence is often more help us attain the goal of reducing social inequali
straightforward and obvious than it is for gender ties in health by levelling up rather than down. In
and ethnic background. The best example of this is the introduction, we explain our reasons for choos
perhaps Oslo, where differences in average life ing these four priority areas. The first priority area
expectancy between different urban districts can (part I) covers fundamental social factors that con
be up to 12 years or more among men. There are tribute to social inequalities in health. Here we
also relatively large regional inequalities in mortal present strategies to reduce social inequalities in
ity. These kinds of geographical inequalities in income, childhood conditions and work. The sec
health often coincide with inequalities in living con ond priority area (part II) covers factors that have
ditions. a more immediate impact on health. This part lays
out a strategy to reduce social inequalities in health
behaviour and access to health services. The third
priority area (part III) deals with targeted actions
to promote social inclusion. The fourth priority
area (part IV) includes policy instruments to ing and other health-related behaviour. Lifestyle
advance knowledge and raise awareness about varies with social background and has a major
social inequalities in all social sectors. impact on people’s health. This means that we
need to focus attention on the underlying and
structural causes of these behaviours and then
Reduce social inequalities that contribute to introduce measures that will promote healthier
inequalities in health choices. With a view to ensuring reduction of
Chapter 3 describes policy instruments to reduce social inequalities in health behaviour, the Govern
economic inequalities in society. Income directly ment is going to give greater priority to policy
affects individuals’ ability to take advantage of instruments that influence cost and availability in
opportunities to improve their health – better liv its efforts to prevent lifestyle diseases. The Minis
ing conditions, healthier food, health-promoting try of Health and Care Services will also take steps
leisure activities, etc. However, the impact of to stimulate low-threshold activities.
investing in health diminishes gradually as income Chapter 7 is about the role of the health ser
increases: the higher the income, the smaller the vice. Even though the most important determi
benefit of further increases in income. This means nants of health are outside the control of the health
that fair income distribution helps level out ine sector, the health services still play a crucial role.
qualities in health and improve average health. For example, there is a correlation between social
The Government is going to continue its work background and the likelihood of surviving certain
to ensure that the tax system promotes fairer types of cancer, even if we take time of diagnosis
income distribution in society. Trends in income in into account. Since we have limited knowledge
the population are reported in the annual budget about the correlation between social background
propositions and via the special review and report and treatment in the health service, it is necessary
ing system for social inequalities in health, as to investigate whether the Norwegian health ser
described in chapter 9. vice is helping to level out social inequalities in
In chapter 4, priority is given to ensuring that health or if it is actually reinforcing them.
all children have equal opportunities regardless of The Government wants to improve knowledge
their parents’ financial situation, education, ethnic about social inequalities in access to health ser
identity and geographical identity. The foundation vices and further develop specially adapted
for social inequalities in health is laid early on in schemes to ensure that everyone has access to
life, and childhood is a critical period. Early action equitable services.
is therefore necessary to prevent social inequali
ties in health developing. The Government wants
to create safe childhood conditions through kin Targeted initiatives to promote social inclusion
dergartens, schools and high-quality services for The emphasis in chapter 8 is on preventing social
children and young people across social divides. exclusion of groups that drop out of education and
Chapter 5 discusses policy instruments linked employment because of poor health or for other
to working environment legislation, the Norwe reasons. Many disadvantaged people need more
gian Labour Inspection Authority, company health targeted services. Universal schemes must there
services, inclusion of the immigrant population in fore be supplemented with specially adapted ser
the labour market, national monitoring of work and vices and measures tailored to the individual. User-
health, and research on sickness absence in the oriented and specially adapted public services are
health and care sector. With a view to reducing necessary to ensure that everyone, regardless of
social inequalities in health linked to work, the their background and circumstances, has access to
Government will continue its investments to pro equitable services. The Government will take
mote a more inclusive labour market and will take steps to promote inclusion in the workplace, inclu
steps to ensure a healthier working environment in sion at school and adapted health and social ser
occupations with significant occupational stress. vices. In this chapter, importance is attached to pol
icy instruments for social inclusion linked to the
labour market, health and social services, volun
Reduce social inequalities in health behaviour and tary organisations and deprived geographical
use of the health services areas.
Chapter 6 discusses policy instruments to reduce
social inequalities in diet, physical activity, smok
tors and on all administrative levels about the

Develop knowledge and cross-sectoral tools social distributional effects of social processes,
Chapter 9 deals with establishment of a review and strategies and measures. Cross-sectoral tools such
reporting system for monitoring progress in the as health impact assessments and social and land-
work on reducing social inequalities in health. use planning are important policy instruments,
Social inequalities in health are intricately linked to along with stronger partnerships for public health
social inequalities in many different areas. The and building up local competencies about public
Government has therefore decided that efforts to health.
reduce social inequalities in health shall be fol Chapter 11 underlines the fact that we have suf
lowed up in all sectors. The Ministry of Health and ficient knowledge to implement measures where
Care Services will collaborate with the relevant causal connections are obvious and proven, but
ministries to ensure annual policy reviews, which that we still need more knowledge about causes
will also be used as the basis for presentations in and effective policy instruments in this area.
the Ministry of Health and Care Services’ budget The Ministry of Health and Care Services will
propositions. These reports must discuss the main strengthen research on social inequalities in
measures and strategies on the national level. health. A monitoring system is also proposed to
Chapter 10 describes in more detail the need to track developments in social inequalities in health.
raise awareness among decision-makers in all sec
2 Facts about social inequalities in health in Norway
«The Norwegian population enjoys good health.

However, averages conceal major, systematic inequalities.
Health is unevenly distributed between social groups in the population.»
Figure 2.1 Social inequalities in health

2.1 Systematic inequalities in health

Short education
The correlation between social position and health
Medium education
is gradual and continuous through all social strata.
Long education
In general, it is not the case that there is a cut-off
point in terms of income or education where health 1200
Deaths per 100 000 per year

suddenly improves dramatically. This means that
social inequalities in health pose a challenge on all 1000
social levels.
800
It should be mentioned that hereditary factors
do not explain social inequalities in health. Heredi 600
tary factors affect the individual’s health, but have
little effect on systematic variations in health that 400
follow education, occupation and income. Social
inequalities in health are mainly due to differences 200
in material, psychosocial and behaviour-related
0
risk factors.
1970-77 1980-87 1990-97 1999-03
2.1.1 Substantial and growing social

Figure 2.2 Mortality by education, men 45–59
differences in mortality among adults
years.
Figures 2.2 and 2.3 demonstrate trends in mortal
Source: The Norwegian Institute of Public Health
ity according to level of education among adults
(45–59 years) from the 1970s to the present (note
that follow-up time was shorter in the last period. corresponding figures for women were 78.0 years
The individuals monitored in this period will be and 81.4 years respectively.
slightly younger and thus have slightly lower mor Thedifferences in mortality are smaller for
tality). In the period since the 1970s, mortality has women than for men. This is primarily because
dropped for most educational groups, but it has women in this age group have lower mortality than
dropped most in the group with the longest educa men.
tion. The inequalities between the educational We find social inequalities in health pretty
groups have therefore increased. In 2001, life much regardless of how we measure social posi
expectancy for 30-year-old men who had com tion. Here we have used education to indicate
pleted lower secondary school (i.e. a total of nine
years of education) was 71.8 years, compared with
76.7 years for men with a university education. The
1200
Short education
Box 2.1 Definitions 1000 Medium education
Long education
• Social inequalities in health: inequalities 800
in health that vary systematically with
level of education, occupational group or 600
level of income.
• In this chapter, we use education – short 400
(7–9 years), medium (10–12 years) or
200
long (13 years or longer) – as the main
indicator of social position. 0
• Mortality: the number of deaths per 1970-77 1980-87 1990-97 1999-03
100 000 inhabitants per year.
• Life expectancy is calculated on the
basis of the mortality rate in all age Figure 2.3 Mortality by education, women 45–59
groups at a given time. years.
social position, but there are also clear inequalities

in health if we use occupation and income as indi
cators. We will discuss this later in the chapter.
1000
Others
2.1.2 Most of the main causes of death are

Cancers
800
unevenly distributed in society Cardiovascular
Figures 2.2 and 2.3 show differences in mortality
regardless of cause. In the age group 45–59 years, 600
cardiovascular diseases are the dominant cause of
death for both sexes. Figures 2.4 and 2.5 show
400
cause-specific mortality rates for the various edu
cational groups based on mortality figures from
1990–1997. (The category «Other» includes respi 200
ratory tract diseases and accidents/violent
deaths). These figures show that the differences in
mortality between the educational groups appear 0
in all categories of cause of death. This suggests Short Medium Long
common, underlying causes – living conditions education education education
and social factors – that manifest themselves via
different disease mechanisms. This consistent pat Figure 2.5 Cause-specific mortality by education,
tern is the reason why the World Health Organiza women 45–59 (1990–97).
tion recommends paying more attention to social Source: The Norwegian Institute of Public Health
factors than disease-specific solutions.
Statistics Norway’s health interview surveys,
which are repeated every three or four years, not changed significantly from 1995 to 2002 for men
include questions about self-assessed health. The or women. Figure 2.6 shows the percentage of peo
results consistently show a higher percentage of ple in the different educational groups who
people with a long education who regard their
health as good or excellent than among people with
a short education. The size of these differences has
Percentage with good or excellent self-assessed health
95
Men
Women
90
Others
1000 85
Cancers
Cardiovascular
80
800
75
600
70
400
65
200
60
Short Medium Long
0 education education education
Short Medium Long
education education education
Figure 2.6 Percentage of people who assess their
health as «good» or «excellent» by education,
Figure 2.4 Cause-specific mortality by education, men and women 25–64 (2002).
men 45–59 (1990–97).
Source: Statistics Norway and the Norwegian Institute of
Source: The Norwegian Institute of Public Health Public Health.
assessed their health as good or excellent in 2002. been marked improvements in survival in connec
The differences between the sexes are insignificant. tion with birth and the first year of life, there is still
These surveys also show that ever fewer peo a higher risk of stillbirth and death in the first year
ple lose all their teeth. The number of teeth people of life among children of parents with a short edu
have is used as an indicator of the population’s den cation. Infant mortality fell substantially in the
tal status. Self-assessed dental health generally fol period 1967–1998, and inequalities in mortality in
lows the same social patterns as self-assessed gen the first four weeks of life – neonatal mortality – by
eral health. mother’s education have also decreased. However,
the inequalities in infant death after the first four
weeks – post-neonatal mortality – have increased,
2.1.3 Significant social inequalities in mental mainly as a result of greater inequalities in sudden
health infant death syndrome and infections.
Statistics Norway’s health interview surveys also Children and young people in Norway gener
monitor mental health using a standardised bat ally have good health, and there have been few
tery of questions (Hopkins Symptoms Check List). A studies of possible social inequalities in health in
score above a certain level indicates significant these age groups. Some studies have observed a
symptoms of depression or anxiety. There are clear higher frequency of chronic disorders such as
inequalities between educational groups. Figure asthma, allergies and eczema in households where
2.7 shows that the inequalities in this area are sig the parents have a short education. Social inequal
nificantly greater among women than among men. ities have also been found in mental health, espe
There were no material changes between 1998 and cially in certain risk groups. For example, children
2002 in this area. of parents with mental ailments, children of par
ents with alcohol/drug problems and children that
experience violence in the family.
2.1.4 Inequalities in health through the life Social inequalities in health are more pro
course nounced in adults than at other stages of life. Social
Social inequalities in health are manifest through inequalities in health among adults are described
out the whole life course. Although there have above.
Inequalities in health remain marked up to a
very old age. The oldest age groups are dominated
25 by women, and they more often live alone and have
a shorter education than the men in this age group.
Percentage with symptoms of depression and anxiety
Men
In this age group, men tend to be healthier than
Women
women.
20
Many of the most common categories of disease
in the population take a long time to develop and are
due to detrimental influences that accumulate
15 throughout life. A growing number of international
and Norwegian studies demonstrate that living con
ditions during childhood have a major influence on
10 health later in life. Therefore, although social ine
qualities in health are often most pronounced in the
adult population, we need to consider the entire life
5 course in order to reduce inequalities in health.
0 2.2 Social structures affect health

Short Medium Long
education education education The causes of social inequalities in health are to be
found in many sectors of society. Below we will
Figure 2.7 Significant symptoms of depression indicate some of the most important mechanisms
and anxiety by education, men and women 25–64 that affect health and the distribution of health in
(2002). the population. The topics discussed in this chap
Source: Statistics Norway and the Norwegian Institute of ter correspond to the four priority areas defined in
Public Health this Report to the Storting.
financial resources directly affects the individual’s

2.2.1 Income health, partly because more money allows people
There is a clear correlation between income and greater opportunities to invest in health – for exam
health in Norway, and the causes of this correla ple better residential environment, healthier food,
tion are probably numerous. These complex mech health-promoting leisure activities and better
anisms are further complicated by the dimension health insurance. The health advantages of income
of time: observed mortality today may be due to gradually decrease as income increases, because
factors long ago. there are fewer and eventually no more opportuni
Figure 2.8 shows mortality among 45–60 year ties to invest further in health.
olds distributed over 20 equisized income groups. This kind of direct causal connection between
The income group at the far left in the figure is the income and health entails that narrowing the
five percent of the population with the lowest income gap will lead to reduction of inequalities in
income, while the income group at the far right is health and better average health. The health of the
the five percent of the population with the highest people in the highest income group in figure 2.8
income. will not deteriorate much by moving down a level
As is shown in figure 2.8, mortality gradually or two on the income scale, but the people in the
decreases as income increases. At the same time, lowest groups will experience substantial health
the reduction in mortality gets smaller as income gains by moving upwards. So transferring income
increases – the bars level out. The greatest differ or other resources from the most advantaged peo
ences in mortality are thus between the groups ple to the least advantaged will increase average
with the lowest income. This tendency is manifest health in the population. How big an impact
for both sexes, although the mortality rate is lower income equalisation has on inequalities in health
for women in this age group. depends on a number of factors, including how
The concave correlation between income and strong the direct causal connection is between
health is a well-known phenomenon and has been income and health. Many studies demonstrate this
much discussed by researchers. One important kind of causal connection, but there is debate as to
explanation of the correlation is that access to how strong it is.
1600
Men
1400
Women
1200
1000
800
600
400
200
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Income groups (20 equisized groups)
Figure 2.8 Mortality 1999–2003 for men and women 45–59 years, distributed over 20 equisized income
groups.
Another explanation of the correlation between

income and health is that health affects income. Box 2.2 The Gini coefficient
Researchers call this health-related mobility. Good
health means people have more time and energy to The Gini coefficient is a measure of income
invest in their education and career, while poor distribution in the population. Using an ima
health can cause problems for education and work. ginary situation where everyone in the
Researchers do not agree on how important these population has exactly the same income as
mechanisms are for the correlation between its starting point, it measures how far actual
income and health. However, most agree it has the distribution is from this situation. A Gini
strongest impact in the lowest income groups. In coefficient of 0 means perfectly even
these groups, financial problems and health prob income distribution (everyone has the same
lems create a vicious circle whereby a lack of income); while a Gini coefficient of 1 means
money leads to worse health, which in turn leads to maximum inequality (one person has all the
even less spending power. In the middle and income). Real populations have a score of
higher income brackets, it seems that income somewhere between 0 and 1, and the grea
affects health rather than vice versa. ter the inequality, the higher the Gini coeffi
A third explanation of the correlation between cient. In Norway, the Gini coefficient rose
income and health is that there are common fac from just below 0.22 in 1990 to roughly 0.26
tors affecting both. It used to be commonly in 2000. In 2000, Denmark had a Gini coeffi
thought that genetics might help explain social ine cient of approx. 0.23, the OECD average
qualities in health, because our genes determine was just above 0.3, and USA was at 0.35.
both our abilities and our health potential. It was One problem with using the Gini coeffici
believed that the lower down the income hierarchy ent to measure income inequality is that it
you went, the more susceptibility genes you would does not indicate where in the income dis
find. Today we know that genetics does not explain tribution the greatest inequalities are.
socially patterned variations in health in the popu Another problem is that it is relative, i.e. it
lation. Genetics may be decisive in connection with does not say anything about the absolute
some diseases, but genes are fairly evenly spread level of income in a country. In principle, an
across the different income groups and do not extremely poor country can have the same
explain inequalities in health that systematically Gini coefficient as a wealthy country.
follow income. Social and environmental factors
play a much larger part in the social patterning of
health we observe in the population.
There may also be other factors affecting both in 1990 (see figure 2.9). So, the increase in income
income and health. For example, we know that inequality in Norway is primarily due to changes in
there is a correlation between education and income distribution among the wealthiest people.
health. There is also a correlation between educa For some years now, there has been interna
tion and income, although this correlation is not as tional debate as to whether the size of the income
clear in Norway as it is in a number of other coun gap – in society as a whole – has a separate impact
tries. Occupation is another factor that can influ on health, in addition to the direct effects that the
ence both income and health. The occupational individuals’ personal economy have on their
groups that incur the most work-related health health. The income inequality hypothesis suggests
problems often also have a relatively low income. that average health is better in areas with small
Evidence suggests that the income gap is wid income inequalities than in areas with a large
ening in Norway. The Gini coefficient, which is a income gap. On the individual level, each individ
measure of income inequality, has risen steadily in ual will be best served by having the highest possi
Norway over the last ten years (see box 2.2). How ble income, because this yields the best health; but
ever, this image of the widening income gap needs if the income inequality hypothesis is correct,
nuancing. The reason for the increase in income everyone will be better off if the individual inequal
inequality is that the richest people are earning rel ities are not too large. In areas where there are
atively much more. From 1990 to 2004, income ine only relatively small differences between people,
quality in the population remained fairly constant – there may well be a stronger sense of community,
with one notable exception: in 2004, the people in less crime and less sense of impotence.
the upper tenth in terms of income had a much A Norwegian study published in December
larger proportion of the total income than they did 2005 suggests that the income inequality hypothe
25
1990
2004
20
Percentage of the total income
15
10
0
1 2 3 4 5 6 7 8 9 10
Income groups (10 equisized groups)
Figure 2.9 Distribution of household income (after tax, per consumer) for people, 1990 and 2004. Per
centage of the total income per decile (tenth of the population).
Source: Statistics Norway
sis seems to apply, at least partly, in Norway. The affect health later in life. The study demonstrates
study, based on deaths among adults (25–66 year that for men there is a direct correlation between
olds) in Norway over a six-year period, found lower their father’s level of education and premature
mortality rates in regions with smaller inequalities death as a result of cardiovascular diseases in adult
in income. This effect was primarily due to lower life. Sons of men with little education are more
mortality among people with little education. Thus, likely to die early because of cardiovascular dis
the study did not confirm that everyone has better eases.
health in areas with less income inequality. What it Research on social inequalities in health in a
did find was that people with less education and life-course perspective is usually based on one of two
lower income benefit, in terms of health, from liv main models. The first model assumes that there is
ing in an area with a smaller income gap. a critical period in life – usually very early – during
which certain types of influence have major conse
quences for health later in life. An example of use
2.2.2 Childhood conditions of this model is the Norwegian doctor Anders
The World Health Organization’s report The Solid Forsdahl’s pioneering studies into the correlation
Facts, detailing the significance of social circum between early childhood living conditions and mor
stances for health, states that every stage in life is tality from cardiovascular diseases in adult life.
important and that children’s and young people’s Forsdahl’s hypotheses have since been refined and
development and education have life-long conse confirmed in many varieties; for example, many
quences for their health. Today’s social inequali studies have proven the significance of certain
ties in health are partly due to inequalities in child influences during pregnancy on morbidity as an
hood conditions several decades ago. The Norwe adult.
gian Institute of Public Health has recently The other main model within life-course stud
published a study confirming that social and eco ies of social inequalities in health is based on the
nomic circumstances in childhood indirectly idea that beneficial and detrimental influences on
(through the person’s own education) and directly health accumulate throughout life. Detrimental
determinants of health are not randomly distrib Children’s living conditions are closely linked
uted in the population, but occur more frequently to the family’s socioeconomic circumstances. A
in some population groups than others. Each indi report from Norwegian Social Research (NOVA)
vidual risk factor increases the risk of sickness and about the impact of the family’s income for chil
early death by a relatively small amount, but if the dren’s living conditions, shows that children in low-
same people are exposed to many risk factors that income families (under 60 % of the median income)
accumulate, the final effect is significant. have a lower score on a number of indicators than
These two main models – critical period and children from a random control sample (see figure
accumulation – are not necessarily mutually exclu 2.10).
sive. It would appear that the health outcome being Education constitutes a major part of children’s
studied determines which of the models is most upbringing. As we stated earlier in this chapter,
appropriate. Some diseases and conditions occur there are clear statistical correlations in the popu
as a result of influences at certain periods in life, lation between length of education and adult
while it is more difficult to identify particularly sen health. Nevertheless, research on social inequali
sitive periods for other diseases. ties in health does not claim a causal relationship
International summaries of knowledge suggest between length of education and health later in life.
that almost all studies of social position in child Over the course of life, however, a lack of education
hood (measured using the parents’ social position) – by dropping out of the education system – may
and mortality in adult life find a clear connection. indirectly cause health problems. One in four
The exact nature of the correlation varies. For pupils that started upper-secondary vocational
some causes of death, for example lung cancer, the training for the first time in 2000 did not complete
correlation tends to be described more indirectly, their education (i.e. receive a certificate) in the fol
as a result of the individual’s own health behaviour lowing five years. We know something about who
as an adult. For mortality from cardiovascular dis these pupils are: the percentage of young people
eases, factors in childhood and adulthood both who complete upper-secondary education
play a direct role. For some causes of death, for increases with the parents’ level of education.
example stomach cancer and strokes, factors in Almost 80 % of the pupils and apprentices that
childhood play a decisive role. started their education in 2000 whose parents had
a long education completed their upper-secondary
Percentage of children...
0 10 20 30 40 50 60 70 80 90 100
who live with both parents
whose main breadwinner has long education
whose family own their home
whose family own a car
whose family own a PC
who travel on vacation at least once a year
whose parents have less than good

self-assessed health
low-income sample control sample
Figure 2.10 Selected indicators of living conditions for children in low-income families versus a random
sample of families. Percentage.
Source: Norwegian Social Research (NOVA)
training in the normal time. By contrast, only 30 % There are large variations in health between
of the pupils whose parents only have compulsory different occupational groups in Norway. Figures
schooling completed their upper-secondary educa 2.11 and 2.12 show life expectancy for selected
tion in the normal time. We do not have much occupational groups in the population.
knowledge about what will happen to the pupils These two figures reveal fairly major differ
who did not complete upper-secondary schooling. ences in life expectancy between occupational
groups, especially among men. While average life
expectancy for a male chef is approx. 71 years, a
2.2.3 Work and working environment male secondary school teacher can expect to live
Factors at work have an impact on health. These almost ten years longer. Statistically, waitresses
factors may be physical (ergonomic, chemical and live until almost 79 years, while female secondary
biological), psychosocial or organisational. In school teachers live more than five years longer, on
keeping with other socioeconomic indicators (edu average.
cation and income), we find a continuous gradient There are several possible reasons for these
of health according to position at work. We also kinds of correlations. Differences in working envi
find a gradient in exposure to harmful factors at ronment constitute one important explanation. Ine
work, within occupations and between different qualities in health-related behaviour, such as smok
occupational categories. This exposure may be the ing, diet and physical activity, also seem to vary
risk of occupational strain injuries, the risk of acci according to different occupational groups to a cer
dents in the workplace, heavy lifts and gas or dust. tain extent. Finally, different forms of health-
However, there is insufficient documentation related mobility may also play a role. Health prob
about the correlation between specific working- lems during education may, for example, cause an
environment factors and the observed inequalities individual to fail to complete their chosen course of
in health. education, which in turn means that their choice of
occupation is limited to jobs requiring little educa
Life expectany (years)

68 70 72 74 76 78 80 82 84
College teachers
Civil servants
Teachers
Business executives
Accountants
Social workers
Shopkeepers
Laboratory technicians
Post office employees
Shop assistants
Preservation industry workers
Butlers and waiters
Cleaning personell
Chefs
Figure 2.11 Life expectancy for a sample of occupations, men (based on occupation at the 1980 census
and deaths recorded 1996–2000).
Life expectany (years)

68 70 72 74 76 78 80 82 84
College teachers
Teachers
Social workers
Civil servants
Accountants
Shop assistants
Post office employees
Laboratory technicians
Shopkeepers
Business executives
Preservation industry workers
Cleaning personell
Chefs
Butlers and waitresses
Figure 2.12 Life expectancy for a sample of occupations, women (based on occupation at the 1980 cen
sus and deaths recorded 1996–2000).
tion. Inequalities in health between occupational The Norwegian Labour Inspection Authority
groups are linked to education: the upper parts of receives reports of 3000–3500 cases of work-
figures 2.11 and 2.12 represent occupations requir related illness each year. In Norway, all doctors
ing a relatively long education. have a duty to report all cases of assumed work-
On average, around 30 000 work-related inju related illness to the Norwegian Labour Inspection
ries are reported to the Norwegian labour inspec Authority, but it is up to the individual doctor to
tion authorities each year, and in 2005, a total of 48 interpret what exactly this means. In 2003, only 3 %
people died in accidents at the workplace in Nor of GPs and fewer than 25 % of company doctors
way. Almost all of the victims of fatal accidents reported one or more cases of work-related illness
were men, with the most at-risk industries being to the Norwegian Labour Inspection Authority, and
agriculture, forestry and the construction industry. there is substantial underreporting or misrepre
A Finnish study estimates that some 1800 sentative reporting of work-related injuries and ill
deaths a year (i.e. 4 % of all deaths in all age ness. The Petroleum Safety Authority Norway
groups) are due to factors in the working environ receives an average of some 650 reports of work-
ment (sickness and injuries). Because mortality related illness each year, and reporting in this sec
varies according to gender, age, occupation and tor is regarded as more complete than for most
industry and these vary from country to country, onshore industries.
these figures cannot be applied to Norway without Statistics Norway’s Survey of Living Condi
adjustment. However, we can be sure that the num tions from 2003 shows that 44 % of the registered
ber of deaths as a result of work-related illness is instances of sick leave during the last 12 months
much higher than the number of deaths due to consisting of a continuous period of sickness
workplace accidents. In the Finnish study, indus absence of more than 14 days was stated as being
trial accidents and other violent deaths (including work related. These surveys therefore suggest
murder and suicide) constituted only 4.5 % of all that a large part of absence from work due to sick
the work-related deaths. nesses is work related. Women report the most
These diagnosis groups are often linked with

Box 2.3 The healthy worker effect organisational and psychosocial factors in the
working environment and working conditions that
One methodological problem facing rese prevail in the labour market these days: increasing
arch on social inequalities in health based rate of change, technological developments, time
on occupation is the so-called «healthy wor pressure, and high efficiency and competency
ker effect». In occupations with major requirements. Several studies demonstrate a cor
health problems, people who cannot bear relation between mobility at work and the risk of
the strain so well will disappear with time. exclusion. Staff cutbacks in particular increase the
This means that the remaining workers are risk of exclusion and sickness absence – even
healthier and have lower mortality. Thus, among the employees that remain. A study con
morbidity and mortality rates will often be ducted by Statistics Norway revealed that fulltime
underestimated in these kinds of occupa employees who in 1993 worked in companies
tions – which often entail heavy, manual where there were staff cutbacks in the period
labour. Some of the people who disappear 1993–1998, had 28 % higher probability of being
from these kinds of physically demanding put on a disability pension in 1999 than comparable
occupations will start working in less physi people working in companies where there were no
cal clerical occupations. Here the tendency cutbacks.
will be that the health risk attached to these Life expectancy is short for people outside the
kinds of occupations is overestimated. In labour market. According to the calculations of life
other words, the healthy worker effect expectancy summarised in figures 2.11 and 2.12,
entails underestimation of the inequalities life expectancy for occupationally passive men was
in health between occupational groups. only 67 years. This is three years shorter than for
the occupationally active group with the shortest
life expectancy. Occupationally passive women
could expect to live for 80 years, which is slightly
health problems and are absent from work due to longer than the worst occupationally active groups.
sickness more than men. This is because many of the occupationally passive
The business sector «health and social ser women included in the statistics have worked in
vices» had the highest level of absence from work the home as homemakers.
in Norway in 2005. Jobs in health and social ser
vices include considerable work-related strain, and
a high proportion of women work in this sector.
2.3 Systematic inequalities in health
Women also tend to have more care tasks within
behaviour and access to health
the family. The high level of sickness absenteeism
services
in the health sector is explained by work situations
entailing strain and repetitive stress injuries and 2.3.1 Health behaviour
time pressure. Time pressure at work leading to Diseases where health behaviour contributes to
extended working hours and overtime may in turn the development of the disease constitute a major
create problems in people’s private life. Stress and health challenge in Norway. These include type 2
the feeling of always being behind may also have diabetes, cardiovascular diseases, Chronic
negative consequences for people’s health. Recent Obstructive Pulmonary Disease (COPD) and cer
years have seen some major reforms, especially in tain types of cancer.
the public sector, that may have led to more work-
related strain in the health sector.
The largest diagnosis groups for exclusion Diet and physical activity
from employment because of extended sick leave Differences in the population’s diet are linked to
and being put on a disability pension are muscu social background variables such as income and
loskeletal disorders (which make up some 45 % of length of education. There are also substantial dif
all instances of sick pay) and mental ailments ferences between women and men and between
(approx. 17 % of instances of sick pay). Among peo age groups. In general, we find that groups with a
ple over the age of 45 years, musculoskeletal disor long education and high income eat a healthier diet
ders are the most common cause of people being than groups with a short education and low
put on disability pension; among people under 45 income. For example, groups with a long education
years of age, mental ailments are the main reason. have a higher intake of fruit and vegetables than
groups with a short education. It has also been formed about the health risks associated with the
shown that children of parents with a long educa various different types of tobacco products.
tion eat more healthily and have more regular In the period 1976–2005, the proportion of daily
meals than children of parents with a short educa smokers with higher education dropped from
tion. around 30 % to 13 %, while the proportion of daily
The Oslo Health Study (HUBRO) reveals that smokers in the group with only compulsory
one in five women and one in four men are inactive schooling remained relatively stabile at around
in their free time. In general, the level of physical 40 %. Since this group has got smaller, it means that
activity in the population is too low. At the same there are now fewer daily smokers. Among young
time, there are clear social inequalities in level of people, there are more girls than boys who smoke.
activity. The proportion of physically inactive peo The reverse is true among non-Western immi
ple is highest in groups with a short education and grants. Young people whose parents are divorced,
low income. People with a long education exercise young people whose parents smoke and young
more often than people with a short education. people planning on taking vocational training are
Children whose parents have a long education more likely to smoke than other young people.
exercise more often than children whose parents Because smoking is so unevenly distributed in
have a short education. Surveys of the level of society, diseases related to smoking are also
physical activity among young people in Oslo dem unevenly distributed. According to the report
onstrate that young people from well-off families 2006:4 How lethal is smoking? from the Norwegian
tend to be more physically active than young peo Institute of Public Health, 6700 deaths in 2003
ple from poorer families. (16 % of all deaths) were due to smoking. Among
Immigrants from South-Asian countries such women, smoking caused 26 % of all deaths in the
as India, Pakistan and Sri Lanka have a signifi age group 40–70 years, while the corresponding
cantly higher incidence of type 2 diabetes than the figure for men was 40 %.
rest of the population. The incidence of type 2 dia
betes in the age group 30–59 in the Romsås and
Furuset urban districts of Oslo in 2000 was 28 % Intoxicants
among women and 14 % among men from South The correlation between alcohol use and social
Asia. By comparison, it was 3 % among women and background is more complex than it is for physical
6 % among men of Western origins. Among people activity, diet and tobacco use. Among men, there is
with a Western background, the risk of developing a J-shaped curve with men with the shortest educa
type 2 diabetes was greatest among the people with tion and lowest income drinking more than men
the lowest income or shortest education. with a slightly longer education and higher
income, before the curve rises once again, with
men with the longest education and highest
Smoking income drinking most. The pattern is different for
Smoking is the health behaviour whose correlation women: women with a short education drink less
with health is best documented. At the same time, than women with a long education. However,
it is the factor where the social inequalities are groups with a short education often have more
most obvious. Smokers are overrepresented in harmful use of alcohol than groups with a long edu
population groups with low income, short educa cation, i.e. they drink more at a time. This means
tion and manual occupations. More than twice as that more people in the population groups with a
many people smoke daily in the group with only short education and low income incur acute alco
compulsory education as do in the group with hol injuries.
higher education. There are fewest smokers in Some population groups are particularly prone
technical/scientific occupations and most among to developing alcohol and/or drug problems. For
people employed in the industrial and transport example, children whose parents are addicted to
sector and unemployed people. In the group with intoxicants and children of mentally ill parents, as
low income or short education, people smoke well as children and young people who themselves
more and they more frequently use the most addic have mental ailments. Against the background of
tive tobacco products. In addition, the average age other knowledge about social inequalities in
at which people start smoking is lower, tolerance health, there are grounds to believe that these
for passive smoking is greater and there are fewer kinds of risk factors vary according to social back
restrictions on smoking at home in the lower social ground, but this is an area where we still need
strata. People in this group are more often misin more knowledge. Drug addicts and alcoholics are
Daily smoking - men Daily smoking - women

60 60
50 50
40 40
%
%
30 30
20 20
10 10
0 0
7-9 10-12 13-16 17 + 7-9 10-12 13-16 17 +
Length of education Length of education
No hard exercise in leasure time - men No hard exercise in leasure time - women
60 60
50 50
40 40
%
30 30
20 20
10 10
0 0
7-9 10-12 13-16 17 + 7-9 10-12 13-16 17 +
Seldom/never vegetables - men Seldom/never vegetables - women

3 3
2,5 2,5
2 2
%
1,5 1,5
1 1
0,5 0,5
0 0
7-9 10-12 13-16 17 + 7-9 10-12 13-16 17 +
Figure 2.13 Inequalities in health behaviour by length of education, men and women 40–45 years.1
1
The diagrams show the percentage of self-reported smoking, no hard exercise in free time and seldom/never eat vegetables for
men and women in the age group 40–45 by length of education. The figures are taken from health interview surveys in Oslo, Hed
mark, Oppland, Troms and Finnmark counties, 2000–2003. 40–45 year-olds are not representative of the population as a whole,
but the figures do give a good indication of the relationship between length of education and health behaviour in the population.
The diagrams show that health behaviour varies systematically with length of education for smoking, physical activity and diet.
The same tendencies are found among women and men. Inequalities in health behaviour are an important cause of the inequali
ties we see in morbidity and mortality among social groups in the population.
overrepresented in groups with a short education deaths as a result of injuries has been on the
and low income. In many cases, abuse of intoxi decline for the last 30 years, but injuries from acci
cants results in people losing their job and social dents are still a major public health problem. At the
problems, which may in turn serve to reinforce the same time, this is a field where we have good
drug/alcohol problem. knowledge about causes and effective preventive
measures. There is room for improvement by
means of efforts in several sectors. There is a lack
Accidents and injuries of research in Norway about social patterns in acci
Accidents and injuries are the fourth most impor dents and injuries. A Swedish study from 2002 sug
tant cause of death in Norway. The number of gests that there are more traffic accidents in
Box 2.4 Experiences with supervision

Service providers, both public and private, Supervision experiences from 2003 show
have a duty to abide by statutory require that in many cases information about patients’
ments concerning their services and staff. As right to choose which hospital they receive
an added security, the authorities carry out treatment at within the specialist health ser
supervision to make sure this is being done vice was unsatisfactory. A survey carried out
and to make sure that companies providing by SINTEF Health shows that patients with a
services check that their activities are being high use of health services tended to make
performed in compliance with the authorities’ less use of the right to choose hospital than
requirements. State supervision is one of other patients. The survey revealed that the
several policy instruments used to follow up system is used mostly for one-off interven
the intentions in the legislation. Supervision tions or consultations within the somatic part
focuses on organisations that provide social of the specialist health service and to a lesser
and health services. Health-care workers are extent by patients with chronic and/or com
also subject to supervision, and they are plex disorders. Thus, patients with large
bound by a special professional law, the needs and/or patients with little knowledge
Health Personnel Act. about the health service made less use than
The experiences of the Norwegian Board of others of the opportunity to influence waiting
Health confirm that in many cases there are time for health assistance.
variations in the accessibility and quality of In 2005, the Norwegian Board of Health
the services offered and that this affects diffe inspected the municipal services for drug
rent patient and user groups differently. There addicts and alcoholics. The reports from these
may be many causes of these variations. An supervisions demonstrate numerous substan
underlying premise for large parts of the tial deficiencies in the services. This and other
health service is that people requiring help supervisions revealed major challenges for
must contact the health service themselves. the services when patients and users have
Patients must also take the initiative to com several or complex problems, as this requires
plain if they feel they have received poor treat coordination between services and between
ment from the health service. This system different levels of service.
works well for the majority, but it does tend to In 2006, the Norwegian Board of Health car
favour patients and next of kin with good ried out a nationwide supervision of services
resources: they know the health service, within interdisciplinary specialised treatment
know what it can offer, and they know how to for drug addicts and alcoholics in the specia
go about getting help. Basing access to servi list health service. The summary of these
ces on self-selection entails that people who supervisions along with the evaluation of the
do not make their needs known, do not know drug reform will provide a more extensive and
their needs or are incapable of looking after thorough description and assessment of the
their own best interests do not get help unless capacity, quality and organisation of the servi
others take action on their behalf. ces available to this group of patients.
Source: Norwegian Board of Health

groups with a short education and low income than the length of the parents’ education. As far as
in groups with a long education and high income. school health services and health centres for
There are grounds to believe that there are major young people are concerned, it appears that use is
social inequalities in accidents in Norway too. On determined more by needs than social position.
the basis of figures provided by Oslo accident and Among adults too, it seems that use of the spe
emergency unit in 2001, the Public Health Author cialist health services increases with length of edu
ity in Oslo has calculated that the frequency of cation and size of income. The pattern appears to
injury is highest in the eastern urban districts of be reversed for use of primary health services, but
the city (Romsås, Grünerløkka-Sofienberg and not if we take morbidity into account, which is
Gamle Oslo) and lowest in the western urban dis higher in groups with a shorter education and
tricts (Bygdøy-Frogner, Ullern and Vinderen). We lower income.
need research that studies these patterns in more Rehabilitation and habilitation services are
detail and considers policy instruments to reduce often intended for people with low income (people
the social inequalities. receiving benefits and/or people with an unstable
relationship with the labour market). Neverthe
less, we have insufficient knowledge about the
Gambling addiction social component.
Studies reveal that gambling addiction often coin As regards mental health, few studies have
cides with other social and health disorders such focused on correlations between use of services
as suicidal thoughts, stress-related symptoms and and social background. One exception is the Oslo
emotional problems. There also appears to be a Health Study, which found more frequent use of
relationship between gambling addiction and psychologists or psychiatrists in inner city areas
drug/alcohol abuse. Young people from low- and in groups with lower incomes.
income families are particularly vulnerable. Few if any social inequalities have been found
According to a study from 2005 carried out by the in the use of dental health services among children
market research company MMI about Norwe and young people in Norway. Among adults, there
gians’ gambling habits, the lowest income groups is a correlation between social background and
are overrepresented among people with gambling taking contact with the dental health service, but
problems. This applies to slot machines in particu once contact has been made, there do not appear to
lar, but the ban on note acceptors introduced on 1 be any inequalities in use of services.
January 2006 has reduced slot machine turnover Statistics Norway recently carried out a study
drastically. As is the case for consumption of about the role of regular GPs as a gatekeeper for
tobacco and alcohol, accessibility is decisive for the specialist health service. This study suggests
consumption. Groups with access to slot machines that there are few social inequalities in referrals if
are more likely to develop a problem. We have we overlook the fact that there are social inequali
insufficient knowledge about the situation with ties in health in the different social groups. How
regard to social inequalities in addiction to online ever, if the analysis takes account of the fact that
money games. people with little education have the poorest
health, the study then shows that people with a
short education are less frequently referred to a
2.3.2 Health services specialist than people with a long education.
Little research has been done into the correlations Few studies have been undertaken in Norway
between the use of the health services and social to investigate whether different social groups
background in Norway. Of the studies that have receive different quality treatment. However, the
been done, only a handful have attempted to study issue of whether disparities in different social
the use of services in connection with morbidity groups’ survival rates for certain diseases can be
and patients’ needs. The studies referred to below linked to factors in the health services has been
nevertheless suggest that there is skew social dis studied for cancer. One study found that patients
tribution in the use of primary and specialist health with low income, only compulsory schooling or
services – especially if we look at use in connection manual work had a lower rate of survival of a num
with presumed need. ber of types of cancer. Mortality is higher even if
Research on the use of the health services we take account of the spread of the cancer at the
among children and young people suggests that time of diagnosis. This suggests that various fac
use of the specialist health services increases with tors in the health service may affect mortality.
increasing in the low-income group, while it is

2.4 Groups with special health decreasing for women above the low-income
challenges threshold. Income is measured as annual house
hold income adjusted for the number of people in
2.4.1 Groups with long-term social problems the household. The low-income group consists of
Complex, long-term social problems that are detri people with an annual income below 50 % of the
mental to health are more prevalent in certain pop median income.
ulation groups; e.g., prisoners, long-term recipi
ents of social assistance, heavy drug addicts and
alcoholics and some immigrant groups. These Financial circumstances in groups with reduced
groups are not necessarily poor, but many people functional capacity
live in difficult circumstances and have extensive As a group, people with reduced functional capac
health problems. This pattern also applies to chil ity have less money to live off than the average for
dren whose parents belong to these groups. the population as a whole. Three main factors
People with long-term social problems often determine people’s financial circumstances:
have little or no contact with the labour market. As employment (and thus income from work), trans
a result, they have not earned the right to a guaran fers from the state in the form of National Insur
teed income from the National Insurance Scheme ance benefits and social payments, and any extra
or they receive low social security benefits. Exam costs incurred as a result of the individuals’ disabil
ples include people who have spent time in institu ity.
tions and some recently arrived immigrants. Many Statistics Norway’s Labour Force Surveys
of these people are long-term recipients of financial show that while around 75 % of the population as a
social assistance. Long-term recipients of social whole are employed, only some 45 % of people with
assistance have poorer health than the rest of the reduced functional capacity are employed. Add to
population. Prisoners often have low education and that the fact that more physically disabled people
are much more likely not to have a home, work or tend to work part-time. There have not been any
income than the rest of the population. Many are significant changes in this situation in the period
encumbered with large debts, are addicted to 2000–2005.
drugs and/or alcohol and have physical and men Statistics Norway’s Survey of Living Condi
tal ailments. Problems with drugs and alcohol tions shows that on average people with limitations
drive many people into poverty, and heavy drug in functioning and participation have an income
addicts and alcoholics are among the most disad that constitutes around 75 % of the average income
vantaged people in Norway. Mental illness can lead for the population as a whole. Almost 50 % of the
to poverty because the illness makes it difficult for income of people in these groups comes from dif
the sufferer to complete a course of education and ferent types of transfers.
hold down a job. More than 40 % of the patients People with reduced functional capacity often
undergoing forced psychiatric health care do not have various types of extra expenses, for example
have their own home. These patients often have lit because they cannot make use of simple, cheap
tle education, poor personal economy and weak options available to other people and because they
social ties. necessarily have a higher consumption of some
products and services to compensate for their
reduced functional capacity. We do not have ade
Growing inequalities between people with low quate information about the size of these extra
income and the rest of the population expenses, but they vary widely, for example,
The Norwegian Institute of Public Health has according to place of residence. A recent survey
looked at trends in mortality in the age group 45– performed by ECON (a market research com
59 in the period 1994–2003 and compared the low- pany) charting user fees for social services reveals
income group with the rest of the population (see major differences in how the individual municipal
figures 2.14 and 2.15). ities practise the system of user charges.
Mortality among men in this age group is
decreasing in the low-income group and in the rest
of the population, but the inequalities between the 2.4.2 Children and young people at risk
groups is increasing. This is because the decrease Development of mental ailments and disorders in
in mortality is greater among men not in the low- children is closely linked to family problems and a
income group. Among women, mortality is actually
tance from the child welfare authorities in the

period 1990 to 2002. This constitutes approx. 6 % of
1400
all the children and young people under 18 in Nor
1200
way. Just over 10 000 of them had spent time in a
1000
child welfare institution. The survey showed that
Low income
800 children and young people who are in contact with
Above low income
600 the child welfare authorities, and their biological
400 parents, tend to have more health problems than
200 other families. Recent studies show an overrepre
0 sentation of death due to illness and violent deaths
1994-1998 1999-2003 (accidents, suicide, murder) in this group. Chil
dren receiving assistance from the child welfare
Figure 2.14 Mortality men 45–59 with and wit authorities tend to have parents with a lower
hout low income, 1994–2003. income, shorter education and poorer health. We
Source: The Norwegian Institute of Public Health also know that long-term clients of the child wel
fare authorities are more frequently boys, have
parents with a short education and low income, are
children of unmarried mothers and have more
often been neglected or abused.
1400 Half of all inmates in Norwegian prisons have

1200 children. This means that some 4000 children a
1000 year experience their mother or father being
800 Low income imprisoned. This may have serious consequences
Above low income for the child’s life situation and development, in the
600
form of shame, grief, insecurity, anxiety, missing
400
their parent, the risk of bullying and parental con
200
flicts.
0
1994-1998 1999-2003
2.4.3 Immigrants
Figure 2.15 Mortality women 45–59 with and wit
hout low income, 1994–2003. There are major inequalities in education and
income between different groups of immigrants,
and it seems that inequalities in morbidity and mor
tality vary more between immigrant groups than
lack of social resources. Some children and young they do in the rest of the population. It is common
people grow up in such difficult conditions that knowledge that some immigrant groups are more
they have a higher probability of developing men predisposed to some diseases. The Oslo Health
tal ailments and disorders before they are even Study revealed that immigrants from non-Western
born. Children in families where the parents have countries have more psychiatric problems than
mental ailments, abuse drugs and/or alcohol or other Norwegians. Refugees are particularly prone
are violent have an especially high risk of develop to a high frequency of mental ailments. Torture,
ing mental ailments. At least 15 000 children under incarceration and other traumatic events explain
the age of 18 live with one or two parents who are some of the increased frequency of mental ail
receiving some form of mental health care treat ments we find among refugees. The main social
ment. Add to this figure children living with par explanation seems to be unemployment on arrival
ents with mental ailments who are not receiving in Norway, and to a lesser extent financial prob
treatment. It is difficult to calculate how many chil lems. Important psychosocial explanations
dren are being affected by their parents’ drug or include: lack of integration in Norwegian society,
alcohol abuse, as this is often covert, but we reckon discrimination (for example in the housing mar
that around 10 % of the population have an alcohol/ ket), and a general feeling of impotence. 24 % of
drug problem and we know that many of these peo immigrants from Asia and Africa have mental ail
ple live with children under the age of 18 years. ments. 12 % of immigrants from Western Europe
A survey by the Norwegian Institute for Urban and the United States have mental ailments. The
and Regional Research (NIBR) shows that some corresponding figure for ethnic Norwegians is
99 000 children and young people received assis- 10 %.
There is a higher incidence of certain commu 3) people who state they are of Norwegian origins
nicable diseases such as tuberculosis, HIV, hepati (including Kvens and immigrants). One purpose of
tis A and B, malaria, typhoid fever and shigellosis this study was to ascertain the degree of satisfac
in some immigrant groups. Self-reported morbid tion with the municipal primary health care service
ity is higher in some immigrant groups than in the in areas with Sami and Norwegian populations.
population as a whole. Studies from Oslo suggest Patients who spoke Sami were generally less satis
higher incidence of obesity among female immi fied with the municipal medical services than the
grants from Turkey and Pakistan in particular. Norwegian-speaking patients. They were less sat
Type 2 diabetes is more common in many immi isfied with the doctor’s command of the language
grant groups, especially among people from the and stated that there were more misunderstand
Indian subcontinent. ings between doctor and patient caused by lan
There has been a positive turn in dental health guage problems. One third stated that they did not
in children and young people in the population. wish to use an interpreter. The results indicate that
However, studies show that children with an immi great importance should be attached to applicants’
grant background have three to four times poorer language skills when employing doctors in munic
dental health than other Norwegian children. ipalities within the administrative area for the Sami
Women from Sri Lanka, Pakistan and Vietnam language. This might improve satisfaction with the
smoke far less than women born in Norway. By medical services.
contrast, smoking is much more common in some Education is used as an indicator of social ine
male immigrant groups than in the rest of the pop qualities. There are major inequalities in education
ulation. between the three categories, especially among
Some immigrant groups are not very physically the elderly. At the same time, it is important to
active and seem less inclined to use low-fat food underline that education as an indicator of social
products than the rest of the Norwegian popula background does not necessarily reflect social ine
tion. Vitamin D deficiency is more common among qualities in connection with indigenous peoples in
immigrants from Pakistan, Turkey, Iran and Sri the same way as in a monocultural Norwegian pop
Lanka. Immigrants of Pakistani origins have a ulation. Within the same level of education, there
greater risk of stillbirth, sudden infant death syn are few inequalities in self-reported morbidity
drome and birth defects. Women from Somalia had among the three categories once we have adjusted
more complications in connection with childbirth for age and sex.
than other women. In Oslo, it was also found that There are major inequalities among the catego
immigrants were overrepresented among appli ries in terms of health behaviour, but preliminary
cants for abortion. Further studies need to be analyses suggest that this is not so clearly reflected
undertaken to clarify socioeconomic factors and in self-reported sickness.
health among immigrants in Norway. Preliminary analyses of the material in SAMI
NOR show that among the Sami population in cat
egory 1, one in three have experienced discrimina
2.4.4 Areas with Sami and Norwegian tion because of their Sami identity. This corre
settlements sponds with other studies done to ascertain self-
We currently have little knowledge about the cor experienced discrimination among Samis. For
relation between social factors and health in the example, a report from Norut NIBR Finnmark
Sami population, and few studies have been under shows that one in four Samis have experienced eth
taken comparing Sami and Norwegian circum nic discrimination during the last two years. In gen
stances. This is partly due to the fact that many of eral, we know from other studies that ethnic dis
the health and living conditions surveys that have crimination is associated with lower health status.
been carried out have not taken sufficient account This association is most clearly connected with
of ethnic background and special Sami living con mental health, and there are grounds to believe
ditions. The Centre for Sami Health Research has that this may apply to the Sami population as well.
conducted a survey into health and living condi
tions in areas with Sami and Norwegian settle
ments (SAMINOR). This study splits the sample 2.4.5 People living alone
population into three categories: 1) people who Several studies appear to indicate that married and
speak Sami at home and whose parents and grand cohabiting people consistently have better mental
parents speak/spoke Sami at home, 2) other peo and physical health than unmarried and previously
ple who state they are of Sami origins, and married people. In particular, divorcees and wid
ows/widowers have poorer mental health than oth Since the percentage of people living alone in
ers, often manifest in the form of more depression general, and in particular divorcees, is continuing
and anxiety, but also higher mortality. This may be to rise, health problems in these groups constitute
partly related to the fact that marriage and cohabi a growing public health problem. This will also
tation provide social support and partly due to the affect social inequalities in health. According to
fact that married/cohabiting couples have fewer Statistics Norway, relationship breakdown is one
financial problems than people living alone. of the factors that yield the greatest risk of low
Men and women living alone (age 45–59) with income. Children living in low-income families
a short education and/or low income have a rela often have a single main provider with a short edu
tively high risk of death by Norwegian standards. cation. Lone providers’ social problems can have a
Data from Statistics Norway’s health interview sur huge impact on their own and their children’s men
veys show that single people are particularly prone tal and physical health. Although most children
to financial problems and more frequently experi with single or divorced parents manage well, one
ence relationship breakdown. Single providers are Norwegian study has shown that divorce increases
the group that struggle the most with serious the risk of mental ailments during adolescence and
financial problems. Divorce also seems to triple the adult life.
risk of long-term incapacity for work.
2006 – 2007 Report No. 20 (2006–2007) to the Storting 31
Part I
Reduce social inequalities that contribute to
3 Income
«As long as systematic inequalities in health are due to inequalities in the way
society distributes resources, then it is the community’s responsibility
to take steps to make distribution fairer.»
Figure 3.1 Reduce social inequalities that contribute to inequalities in health

community, contributes to a fair distribution of

3.1 Objective: Reduce economic resources, contributes to a better environment,
inequalities promotes employment throughout the country
and improves the efficiency of the economy.
Objectives The taxation system will be improved so it does
• Reduce economic inequalities in the population more to ensure a fairer income distribution in soci
• Eliminate poverty ety. To this end, the Government is attaching
• Ensure fundamental economic security for importance to maintaining and building up com
everyone mon public assets, as opposed to providing tax
relief. Good public welfare schemes are especially
important for the people with the lowest incomes.
3.2 Policy instruments The Government has mapped out a new path in its
taxation policy creating more space for public wel
The Government is going to take steps to reduce fare services. The Government is going to keep
economic inequalities in the population. There is a aggregate taxes and duties at the same level as in
direct correlation between financial resources and 2008, to ensure that economic policy focuses on
health because people’s personal economy affects strengthening common assets. There will be no
their ability to take advantage of health-promoting net tax relief.
products and services. The social groups with the Within allocation policy, the taxation system
lowest income experience the greatest health ben must be regarded in concert with investments in
efits from an increase in income. Societies with other areas. Low-income problems are often very
large income inequalities can generate inequalities complex, and direct support schemes are better
in health by means of indirect mechanisms. Being suited than tax relief schemes for helping disad
relatively worse off than the people one is sur vantaged groups (low-income groups, disabled
rounded by can lead to exclusion from arenas and people, lone providers, etc.) or households in cer
activities. Social exclusion of this nature often tain phases of life (families with young children,
causes stress, which in turn leads to poorer health. students, pensioners, etc.). See the Action Plan to
This means that income redistribution may help Combat Poverty for targeted measures aimed at
reduce social inequalities in health and improve groups with low-income problems.
average health in the population. The Government has set itself the goal of fur
It is important to prevent what is initially a ther strengthening the general allocation of
health problem from triggering financial problems. resources in the taxation system, and the Govern
For low-income groups in particular, health prob ment’s taxation policy has therefore been designed
lems can easily lead to reduced income. A vicious so that people with high incomes and wealth con
circle of financial problems and health problems tribute more to the community. See the fiscal bud
can develop. get for 2007, where the Government increased sur
The Government will take action to avoid devel tax, the minimum deduction (especially for people
opment of a society with a widening income gap with the lowest incomes) and wealth tax. These
and greater inequalities among people. Increased changes will influence distribution favourably.
social inequalities can undermine society’s general
willingness to support collective welfare schemes,
for example, public health services and public 3.2.2 Monitor developments in income
schools for everyone. People with limited social inequalities
and financial resources will be hardest hit by an As part of the review and reporting system pre
unwillingness to spend public resources on these sented in this Report to the Storting, the Govern
kinds of welfare systems. This would further exac ment will also monitor trends in income inequality
erbate inequalities in health and income. Individu in the population. In addition to summary indica
als have the best opportunity to achieve good tors like the Gini coefficient, this kind of review
health in a society with strong social cohesion and and reporting system should also contain indica
equality. tors showing where in the income distribution
changes are occurring. Developments in this area
will be reported in the Ministry of Health and Care
3.2.1 Taxation system Services’ budget and in the annual reports on the
The Government will take steps to ensure that the drive to reduce social inequalities in health as
taxation system provides stable incomes for the described in chapter 9.
Box 3.1 Policy instruments: Income

The Government will: – implement measures to eliminate poverty,
– continue efforts to ensure that the taxation cf. Report no. 9 to the Storting (2006–2007)
system does more to promote a fairer in Employment, welfare and inclusion and
come distribution in society Action Plan to Combat Poverty
– monitor developments in income inequal
ity in the population
4 Childhood conditions
tions. A well developed range of public welfare

4.1 Objective: Safe childhood measures can ensure equal opportunities regard
conditions and equal development less of economic and other personal resources.
opportunities Nevertheless, there is still a need for special mea
sures aimed at children in high-risk situations.
Objective According to the World Health Organization’s
• All children shall have equal opportunities for report The Solid Facts, risk factors can be reduced
development regardless of their parents’ econ by means of better preventive health services for
omy, education, ethnic identity and geographi mothers and children and by improving the level of
cal affiliation knowledge among parents and children. Health
and education programmes of this nature raise par
ents’ knowledge about children’s needs and give
Other goals them more confidence in their own abilities. The
• Full kindergarten coverage and reduced social World Health Organization also states that strate
inequalities in use of kindergartens gies providing equal opportunities for education
• Reduction in the number of pupils starting are important in efforts to improve health. The
school with inadequate language skills report also underlines that better living conditions
• Reduction in the number of pupils who finish and social networks for parents yield better living
their compulsory schooling without good basic conditions for children.
skills
• Reduction in the number of pupils that do not
complete upper-secondary training 4.2.1 Kindergarten and school
• Early identification and good follow-up of chil Kindergartens and schools can help reduce social
dren in high-risk groups inequalities in health through reduction of social
• Greater accessibility to the school health ser inequalities in learning. Kindergartens can identify
vice children with special needs and help ensure they
get the help they need at an early stage. Children
that go to a good kindergarten do better at school.
4.2 Policy instruments Good opportunities for education and work can
help reduce the negative health impacts of poor
Most children and young people in Norway grow childhood living conditions. At the same time, kin
up in good conditions. Nevertheless, there are chil dergarten and school are important arenas for
dren and young people living in families with such measures promoting good health behaviour, for
limited economic resources that they qualify as example by encouraging healthy eating habits and
poor. They tend to be children whose parents have physical activity.
a short education or who are frequently unem In Report no. 16 to the Storting (2006–2007)
ployed. Also at risk of poverty are children who live Early intervention for lifelong learning, the Govern
with a lone provider and children with an immi ment presents a policy to make better use of educa
grant background. tion as a tool for reduction of social inequalities.
Public welfare schemes can help protect Compared with other countries, there are major
against and counteract the negative consequences inequalities in performance among school chil
of growing up in a financially disadvantaged family. dren in Norway, and Norway is one of the coun
General welfare schemes are most important for tries where family background has the greatest
groups with few resources, and since they are impact on children’s academic performance. The
intended for everyone, there is no stigma attached main goal of this Report to the Storting is therefore
to receiving benefits. General schemes can also to ensure that all pupils acquire basic skills regard
help prevent children ending up in high-risk situa less of their family background. Another goal is
that everyone, regardless of their social back

ground, is rendered capable of making informed Box 4.1 FRI
choices about their career and further studies.
In the Report to the Storting on early interven FRI [FREE] is an anti-smoking educational
tion for lifelong learning, the Government has programme in lower-secondary schools.
decided to gradually lengthen the school day in the Previously called VÆR røykFRI [BE smoke-
lowest grades from 21 hours a week to 28 hours a FREE], FRI was reviewed and revised in
week. A longer school day will serve to improve 2006 in collaboration with the Norwegian
the quality of all pupils’ education, but this reform Directorate for Education and Training.
will have the greatest impact on pupils who receive More than 120 000 young people (over
little help with learning at home. A longer school 60 % of the age group) take part in FRI each
day will allow more physical activity and assistance year. The programme has excellent results.
with home work, will give teachers better opportu It builds directly on the latest national curri
nity to assess pupils and will provide a good frame culum (LK06) and is organised so that it
work for meals. A longer school day will mean a does not entail extra classes, rather it repla
gradual decrease in the need for day-care facilities ces other classes.
for schoolchildren.
Continued investments in kindergartens form
the cornerstone of the Government’s work to
reduce social inequalities. Efforts focus on improv maternal and child health centres and the school
ing the accessibility, price and quality of kindergar health service).
tens. However, kindergarten is not an obligatory Social inequalities manifest themselves in
part of the education system, meaning offering young people’s career and educational choices and
children that do not go to kindergarten pedagogi in recruitment to higher education. The most
cal stimulation is a major challenge. Alongside the important tool for reducing these kinds of inequal
focus on developing high-quality kindergartens, ities is giving greater priority to a reduction of
systems must also be developed aimed at children social inequalities in learning throughout the
and parents that do not wish to take advantage of entire course of education.
kindergarten facilities. To prevent illness in the population, it is impor
Children’s language skills vary enormously tant to encourage a healthy diet and physical activ
when they start school, and these inequalities are ity for children and young people. Children and
often linked to family background. Norwegian and young people are at a phase in life where there is a
international studies show that the linguistic foun huge potential for preventing illness. Kindergar
dation laid during the early childhood years is crit tens and schools are therefore important arenas
ical for children’s social skills and learning at for establishing good health habits at an early age.
school. Some children need extra language stimu A continuous school day provides a good frame
lation in early childhood. This applies in particular work for meals, and we are going to introduce a
to children with delayed language development system of fresh fruit and vegetables for all pupils at
and minority-language children needing extra primary and lower-secondary school. With a view
stimulation to help them learn Norwegian. In addi to promoting good health and motor skills, schools
tion to the investments to develop more high-qual are going to have to make sure there is time and
ity kindergartens, the Government also wants to facilities for daily physical activity. Research shows
study the possibility of introducing a municipal that physical activity at school encourages greater
obligation to ensure children facilities for language activity in leisure time and can even improve learn
stimulation if they need it, regardless of whether ing. Provisions for healthy meals and physical
they go to kindergarten or not. This measure was activity for everyone at school in itself can help
announced in the Report to the Storting on early level out social inequalities and improve the bene
intervention for lifelong learning. fits of learning. School also plays an important role
Children’s language development is currently in efforts to prevent the harmful effects of tobacco.
assessed in the medical check-ups at ages 2 and 4
at maternal and child health centres. The Govern
ment is also going to consider calling for a more 4.2.2 Maternal and child health centres and
systematic survey of language skills at the 2-year the school health service
check-up and the 4-year check-up at all maternal Maternal and child health centres offer general
and child health centres (see the discussion of medical services for pregnant women and pre
school children. The service also encompasses a duty for municipalities to offer language stimula
health centres for young people and the school tion. In this context, the government will assess
health service in primary, lower-secondary and whether to initiate measures to ensure more sys
upper-secondary school. The service’s main tasks tematic monitoring of language skills in the mater
include conducting health interview surveys, nal and child health centres on a national level. It is
immunisation, providing information, advice and crucial that monitoring of language skills is fol
guidance, and implementing measures to help chil lowed up by remedial measures. There is no point
dren and young people develop life skills and help in assessing language skills if there are no con
guardians master parenting. crete measures available for children with a
The service has adopted a comprehensive per detected need for language stimulation.
spective on prevention and does a great deal of In accordance with the Regulations of 3 April
interdisciplinary work. This is key to efforts to pre 2003 regarding the local authorities’ health promo
vent mental ailments and in dealing with complex tion and preventive care in the maternal and child
social problems. The service collaborates with health centres and school health service, the service
pupils, homes and schools to create schools that shall assist schools in connection with providing
promote good health through a good learning and instruction in groups or at parent–teacher meet
working environment. The service’s work covers ings to the extent the school requests it. This
topics such as sexuality, relationships and contra means that it is up to the individual school to decide
ception, protection against communicable diseases the extent to which they want to involve the school
(including preventing HIV and STDs), diet, dental health service in the school’s preventive work. It is
health, anti-smoking, drinking and drug cam therefore likely that there will be large variations
paigns, physical activity, and preventing accidents among schools, which will in turn pose a particular
and injury. In order to meet challenges linked to challenge with regard to the goal of reducing social
obesity among children and young people, guide inequalities in learning and health. The Ministry of
lines are currently being compiled for preventing Education and Research is therefore going to con
and treating obesity. New guidelines are also going sider amendments to the Act relating to Primary
to be developed for measuring weight and height. and Secondary Education and appurtenant regula
One of the service’s tasks is to pay particular tions to ensure that the collaboration between
attention to pregnant women, children and young maternal and child health centres and the school
people with special needs. The service is con health service is more firmly established in legisla
stantly on the look out for early signals of ill-being, tion from the schools’ point of view too.
abnormal developments and anti-social behaviour The school health service plays an important
and contributes to steps being taken. If necessary, supporting role in planning physical activity at
the service refers patients for tests and treatment school and provides advice in connection with
and collaborates with other bodies in connection arranging activities aimed at different groups of
with designing services. Maternal and child health pupils, including pupils with chronic illnesses and
centres collaborate with kindergartens, schools, pupils with reduced functional capacity. Arranging
the Educational-Psychological Service and the activities for pupils with reduced functional capac
child welfare authorities. ity requires an assessment of the school’s physical
Maternal and child health centres assess chil environment. The service collaborates with homes,
dren’s language development in connection with kindergartens and other relevant parties on mea
the check-ups at ages 2 and 4 using national guide sures for preschool children aimed at the physical
lines for testing eyesight, hearing and language. environment, groups of pupils and individuals.
Monitoring language development is crucial in One advantage of the maternal and child health
identifying children who need extra language stim centre system is that it is the only arena that has
ulation. This is part of the background for the contact with just about all children of preschool
project Testing pre-school children’s language skills age. Almost all children, regardless of their par
at maternal and child health centres – a scheme that ents’ social position, take advantage of the services
is being tested out in connection with the 4 year offered by maternal and child health centres dur
check-up at maternal and child health centres in 12 ing the first few years of life. The school health ser
municipalities. The project is intended to further vice and health centres for young people are low-
develop language testing of children who speak threshold services available in children’s and
minority languages. In the Report to the Storting young people’s own environment. Through its
Early intervention for lifelong learning, the Govern presence in schools, the school health service has
ment announced that it is considering introducing the potential to reach children and young people in
all social groups. It is important for young people to

have somewhere to go when they have problems 4.2.3 Mental health services for children and
without having to make an appointment and with young people
out having to involve their guardians. Mental health services for children and young peo
The school health service’s ability to reach all ple in the specialist health service have been
children is especially valuable in the work on expanded substantially since 2003. The Escalation
reducing social inequalities in health. In addition to Plan for Mental Health (1998–2008) defines a tar
helping pupils via the school health service, the get of 5 % of the population under the age of 18
service can also refer children to the specialist being offered treatment by mental health care ser
health service and contact other municipal ser vices by the end of the escalation period in 2008.
vices for extra assistance. This means that the The degree of coverage in the mental health ser
school health service needs to function well for vices for children and young people has increased
other municipal health and care services to be able from 2 % in 1998 to 4 % in 2005, and at the current
to perform their tasks satisfactorily. A number of rate of growth, it looks like this target will be met.
studies have shown that the degree to which chil In the past, children and young people with
dren and young people use other health services mental ailments were generally treated and fol
varies according to social factors. For example, a lowed up within the specialist health service. In the
higher proportion of girls used psychologists/psy future, a system is to be developed where the local
chiatrists in the wealthier urban districts of Oslo authorities are more involved in prevention, treat
inner west than in the more working-class Oslo ment and follow-up of children and young people
outer east. with mental ailments. The specialist health service
The school health service has insufficient will deal with cases requiring more specialised
capacity in very many of Norway’s municipalities. diagnosis and treatment. Low-threshold psycholo
Services are especially limited in upper-secondary gist services are going to be established in the
schools. Capacity needs expanding by employing municipalities to improve accessibility for more
more people to ensure that children and young groups in the population. Methods will be devised
people experience the service as a low-threshold that go further in reaching out to children, young
measure and that the school health service is able people and families in their own arenas. These
to identify children and young people with prob kinds of measures will increase accessibility to ser
lems. Expanding the school health service will vices for groups that tend not to be served by the
help ensure that the people who need the most ordinary services offered by the health services.
help receive help from the municipal health ser Municipal services offered to children and
vice or some other municipal service, or are young people have expanded enormously in the
referred to the specialist health service. In this escalation period. At least 20 % of the ear-marked
way, the service will serve to reduce social inequal funds must be spent on measures aimed at chil
ities in the use of the health services. The Govern dren and young people. So far, a total of 29 % of the
ment is therefore going to further develop and fulltime equivalents set up using earmarked grants
build capacity in the school health service. The are in services aimed at children and young peo
current situation will be assessed to ascertain ple. Nevertheless, the services offered in the
required capacity and content of the service in the municipalities are still insufficient. There are seri
future. ous inadequacies regarding diagnosis, treatment
Other identified needs include closer collabora and follow-up of children and young people with
tion with other services and players, recruitment mental ailments. There is also a need to improve
of staff with psychosocial competencies and updat competencies in violence and abuse and the harm
ing existing employees’ competencies. The goal is ful effects of growing up in a family with these
that the service shall identify children and young kinds of problems. In light of these needs, interdis
people with problems as early as possible, provide ciplinary continuing-education courses in psycho
them with the help they need within the service, social work aimed at children and young people
and refer individuals that need treatment in the are being set up at a number of university colleges
specialist health service. Collaboration must be starting in 2007. This course of study will include
developed with school staff, other municipal ser learning about social inequalities in mental health.
vices and the child and adolescent psychiatric clin Many children with mental ailments need assis
ics. Special attention must be paid to the inequali tance from several services, so the services need
ties between boys and girls and the fact that immi to develop good collaboration. To this end, the
grants may have special needs. health enterprises and the state regional child wel
fare services have formalised their collaboration in tory obligation to collaborate. For the child welfare
agreements. These agreements are intended to authorities to be able to perform their tasks aimed
ensure that children needing assistance are at children and young people living in conditions
offered co-ordinated services. that can harm their health and development, they
In the Soria Moria Declaration, the Govern need to receive information from other public ser
ment announced it was introducing a maximum vices that have contact with the child and family.
waiting time and treatment guarantee for young Other public services are bound by law to provide
people under the age of 23 with psychiatric and/or the child welfare authorities with any necessary
substance-abuse problems. In 2006, a working information, the justification for this duty being the
committee was formed, which has proposed a stat child welfare authorities’ need to receive informa
utory time limit of ten days for assessment of the tion.
right to receive necessary health assistance. The This duty to provide information entails a duty
working group also proposed introducing a statu to notify the child welfare service on their own ini
tory time limit of 90 days before treatment is tiative if there are grounds to believe a child is
started. In the spring of 2007, the Government will being mistreated at home or subjected to other
submit a proposition to the Odelsting suggesting forms of serious parental neglect, or if a child dem
introduction of maximum time limits for assess onstrates lasting, serious behavioural problems.
ment and treatment. The purpose of this is to The duty to provide information applies to every
ensure young people with mental ailments and/or one working in public services and bodies, includ
substance-abuse problems better access to special ing schools, kindergartens and maternal and child
ist health services. health centres. It also applies to a number of pro
fessionals, such as doctors, nurses and psycholo
gists. We know that schools, kindergartens and
4.2.4 Child welfare service maternal and child health centres seldom report
The municipal child welfare service is responsible matters to the child welfare authorities. This is a
for implementing measures to prevent parental sign that collaboration in this area is not working
neglect and behavioural problems. The child wel as intended. We do not know why this is so. A sur
fare authorities provide special assistance for chil vey is therefore going to be undertaken to ascer
dren and young people with these kinds of prob tain why other services tend not to report matters
lems. The goal is to implement measures that help to the child welfare authorities.
people receiving assistance live the best possible The number of children receiving assistance
life within the family (or in a foster home or institu from the child welfare authorities is rising. A
tion, as relevant), at school, among friends and report from the Office of the City Auditor in Oslo
later at work. The main challenges in this respect in 2006 expressed concern about the lack of capac
are intervening at an early enough stage with ity in some urban districts. It was also found that
appropriate, preventive measures and monitoring some employees claimed that sometimes the bud
these children as they grow into adulthood. The get did not stretch to necessary measures being
transition from child welfare to adulthood is a criti implemented pursuant to the Act on Child Welfare
cal phase for many children receiving assistance Services. The situation in Oslo is being monitored
from the child welfare authorities, and for this rea closely by the County Governor of Oslo and Aker
son, the child welfare authorities are now also shus and the Ministry of Children and Equality.
authorised to assist young people aged 18–23 The child welfare authorities in the city of Oslo are
years. currently being evaluated by an external audit
The child welfare service has a special respon body. The results of this evaluation will be available
sibility to detect problems at an early enough stage at the beginning of 2007. This evaluation will help
to be able to implement measures to avoid perma provide a clearer understanding of the situation in
nent problems. As far as possible, assistance for the city of Oslo. Once the evaluation is completed,
disadvantaged children needs to be available in the the development of the child welfare authorities in
usual arenas, with the child welfare authorities as a the city of Oslo must be assessed further. The Gov
support. In order to provide timely assistance, the ernment’s strengthening of municipal economies
child welfare authorities depend on good collabo has resulted in improvements in the staffing situa
ration with other municipal services that have con tion in some municipalities and is expected to yield
tact with the children and their families in daily life, further improvements in 2007.
for example schools, kindergartens and the health Pursuant to the Act on Child Welfare Services,
service. The child welfare authorities have a statu the child welfare authorities have a duty to follow
up reports if there are reasonable grounds to child welfare authorities. This will be achieved
assume that there are circumstances warranting through a joint project involving university col
steps being taken. We know that there are varia leges, the municipalities and the employers’ organ
tions between municipalities regarding the num isation in the municipal sector: the Norwegian
ber of reports dropped. The national average is Association of Local and Regional Authorities
17 % of reports not followed up. While it is impor (KS). The university colleges need to be able to
tant to underline that some of the reports to the offer the local authorities better training and semi
child welfare authorities concern matters not cov nars for municipal employees in the region. Basic
ered by the Act on Child Welfare Services, cases training for child welfare workers is also going to
being dropped because of a lack of resources or for be reviewed with a view to implementing improve
other reasons is a very serious matter. As a means ments.
of gaining better insight into the reasons why Children and young people with an immigrant
reports are not followed up, the municipalities will background constitute an important priority area
have to start reporting the reason for a case not for the Ministry of Children and Equality. We want
being followed up from 2007. At the same time, the to improve general competence about multicultur
Ministry of Children and Equality is planning to alism in the municipal and state child welfare
initiate studies to ascertain whether too many mat authorities and ensure that this competence is
ters reported to the child welfare authorities are applied in every-day work. Raising the level of com
being dropped. petence in multicultural issues in the child welfare
The County Governor is charged with super authorities is intended to ensure that this group of
vising that the municipalities/urban district coun users is offered equitable services compared with
cils carry out the tasks ascribed to them in legisla other Norwegian children and young people. The
tion. The Ministry of Children and Equality is Norwegian Institute for Urban and Regional
working on a joint project with the Norwegian Research (NIBR) has been commissioned to com
Board of Health to develop methods and perform pile an overview of knowledge and assess research
supervisions. about available methods and tools for use in work
In many places, the municipal child welfare with children, young people and families with an
authorities do not have sufficient competence. The immigrant background. NIBR is also to identify
Ministry of Children and Equality wants to factors that need to be present to ensure that inter
improve competencies. To address the need for ventions have their intended effect. The Ministry
more systematic knowledge in areas where there of Children and Equality will then use these find
is a risk of deficiencies, written and electronic advi ings to design a practical programme of compe
sory materials and handbooks were compiled in tence raising in the local and state child welfare
2006 for use in the municipal child welfare services services.
on central topics such as foster homes, processing In 2007, the Government is going to initiate a
of cases and routines in the municipality, action broad evaluation of the state child welfare authori
plans and care plans for children receiving assis ties on the regional level. Against the background
tance, supervisors and internal control. The goal is of this evaluation, the Government will then imple
to ensure equitable and knowledge-based child ment measures to improve interdisciplinary ser
welfare services and to intervene at an early stage vices offered to children needing support from the
with appropriate help. The number of children child welfare authorities.
receiving some form of assistance from the child The Government wants to focus on foster
welfare authorities is steadily growing. The child homes in coming years. Over 80 % of children and
welfare services are having to deal with increasing young people taken into public care are placed in
numbers of complex cases involving drugs and foster homes. It is therefore crucial to ensure the
alcohol, mental health care and children with a highest possible quality in all aspects of foster-
multicultural background. To meet these chal home work. Foster children are often very vulner
lenges, the municipal child welfare authorities able and may have experienced a difficult break
need more knowledge about effective methods down of their biological family. Some of the chil
and tools through training of new child welfare dren have behavioural patterns that are extremely
workers and good continuing and further educa challenging for foster parents. To avoid new, dis
tion for people already working in the child welfare ruptive breakdowns and unplanned relocation of
services. In the first phase, efforts to raise compe foster children, work has been started to improve
tencies in the child welfare authorities will be used follow-up and guidance of foster parents. Foster
to develop a knowledge programme for municipal parents also need someone to turn to when con
flicts arise – at any time of day or night. A helpline for participation and having fun. Participation in
system is therefore going to be set up so that foster voluntary organisations forges contacts and cre
parents can contact the child welfare authorities ates social networks. Social networks and a sense
quickly in acute situations outside normal munici of belonging are crucial for individual health. Par
pal working hours. ticipation in cultural activities is fun and gives a
Today’s labour market has very high require sense of achievement. Cultural experiences pro
ments regarding education and qualifications. mote communication, a sense of community and
Young people who have been under the care of or well-being, and in this respect are an important
have received assistance from the child welfare part of growing up.
authorities often need help and follow-up to set Voluntary organisations do not recruit equally
them selves up independently. Effective from Sep from all groups in the population. Groups with high
tember 1998, the Act on Child Welfare Services income and a long education tend to participate
was amended to allow assistance given before a more actively than groups with low income and a
child has reached 18 (if the child consents) to be short education. We know that children from low-
continued or replaced by other forms of assistance income households participate less in activities in
until the individual in question is 23 years old. their free time and at school than other children
There is now a statutory duty to evaluate the need and young people. Vast differences have been doc
to continue existing or introduce new forms of umented in the population regarding participation
assistance for all young people who were taken into in cultural activities. A survey to determine who
care by the child welfare services. In these cases, uses culture revealed that use of art and cultural
the child welfare service is also obligated to draw facilities varies systematically with personal econ
up a plan detailing planned forms of assistance in omy: people with low income make far less use of
the future if the young person in question wishes to publicly financed art and cultural facilities. Positive
continue to receive assistance. Statistics show that childhood experiences of participation in organisa
many employees in the child welfare authorities tions are decisive for activity in adulthood. Partici
believe child welfare clients need following up pation in organisations and cultural activities may
beyond the age of 18. be too expensive for families in a bad financial situ
The Ministry of Children and Equality is once ation. The outcome is that the children may be
again going to take the initiative of informing the excluded from important social arenas.
municipalities about their duty to provide informa Young people with an immigrant background
tion about the right to appeal in cases where the participate less frequently in recreational activities
child welfare service rejects a young person’s than other Norwegian children and young people,
request to continue receiving assistance from the although these young people themselves report
child welfare authorities after the age of 18 years. that they would like to participate in organisations.
The Ministry is also going to investigate various The Institute of Applied Social Science (Fafo)
aspects of after-care more closely. Using a variety report «Young people’s participation in organised
of documentation, the Ministry is going to con leisure activities in multicultural Oslo» from 2005
sider further measures to help make the transition claims that there is a positive correlation between
to adulthood as smooth as possible. The idea is to the family’s economy and young people’s participa
identify good practices that can be shared with the tion in sports teams. This correlation is most
local authorities. In connection with the current clearly observed among ethnic Norwegians and
focus on poverty, development work has been does not explain why ethnic-minority young people
started linked to after-care and rehabilitation after are less active in organised sports than average.
serving a sentence for young people up to the age
of 23. The goal is to help the young person make
the transition to independent adulthood. Music and arts schools
Municipal music and arts schools play an impor
tant role in nurturing a living, dynamic cultural life.
4.2.5 Participation in organisations and The music and arts schools are a recruitment
cultural activities arena for future performers within the various arts
The Government has set itself the goal of increas – on the amateur and professional levels. These
ing participation in cultural activities and organisa schools also provide towns and villages with access
tions in groups that currently do not participate. to cultural activities by making live concerts, the
Cultural activities and voluntary organisations are atre performances and other artistic expressions
important social meeting places and central arenas available to a broad public in large and small local
communities. In this way, the music and arts Cultural organisations that arrange events
schools also recruit audiences to the field of art throughout the country spread culture and create
and culture. Open, inclusive music and arts opportunities for equalisation in terms of cultural
schools with room for everyone who wants to learn activities. The Norwegian Concert Institute, the
will help dissolve inequalities by providing an State Touring Theatre, and the National Museum
arena for more young people to develop important of Art, Design and Architecture, as well as other
aspects of themselves. museums and libraries are taking steps to ensure
greater openness towards the public and are imple
menting changes to make their facilities accessible
The Cultural Rucksack to everyone.
The Cultural Rucksack provides children and A pilot project whereby young people in the age
young people with access to a wide range of cul group 16–20 can buy a cultural card providing
tural activities at school. School is a gathering cheaper access to cultural events will help counter
place for everyone and is therefore ideal for ensur act social inequalities in use of cultural facilities.
ing that everyone is given a basic introduction to The culture card for young people scheme is being
the arts as a foundation for future participation in continued and expanded in 2007.
and use of cultural activities. The Cultural Rucksack
serves to level out inequalities in the use of culture
among children and young people. The scheme Volunteer centres
helps ensure everyone has the opportunity to The many volunteer centres in Norway are impor
experience art and culture and provides pupils tant arenas for voluntary work, participation and
with the opportunity to express themselves generate a sense of belonging in the local commu
through art and culture regardless of geographical nity. They provide a wide range of social care ser
factors and social divides. This scheme is currently vices as well as offering cultural, recreational and
only available to children and young people in pri local activities. The volunteer centres play a key
mary and lower-secondary school, but in 2007 a role in creating good, lively local communities and
number of pilot projects are being carried out in coordinating local involvement, social responsibil
upper-secondary schools. Young people in this age ity and culture.
group are in the process of changing from children The volunteer centres have made it easier for
into adults, and it is important that activities are more people to be involved in voluntary work. The
designed so that they seem meaningful to the indi centres have also tried innovative methods to get
vidual. people involved in local voluntary projects. An
Traditionally, children encounter art and cul active, welcoming attitude combined with concrete
ture with their parents, and this use of culture has tasks linked to the volunteers’ wishes and interests
tended to reflect social inequalities. Schemes like has yielded impressive results. The centres are
the Cultural Rucksack help ensure that encounters also a meeting place for people with time on their
with culture occur independently of social identity. hands in the day time. There are more homemak
In many ways, the Cultural Rucksack represents ers, people on some kind of pension and unem
new content and new methods at school. This can ployed people associated with the volunteer cen
be a positive experience for pupils who have diffi tres than in traditional voluntary organisations.
culties adapting to ordinary teaching at school. The volunteer centres aim to collaborate with
the positive forces available locally: different teams
and associations, congregations, public authorities
Other cultural measures and individuals. Forging contacts, developing net
One of the priority tasks ascribed to the Norwe works and bringing together people who have
gian Archive, Library and Museum Authority something in common are important and useful
(ABM utvikling) is universal design. A network for tasks to stimulate and develop local voluntary
universal design has been established, and an activities, which can also have positive influence on
inspiration seminar for universal design has been the individuals involved.
held at five locations in Norway. The project The
accessible library was carried out in the period May
2001 to December 2004. The purpose of this Grants for schemes in cities
project was to give library users with reduced func The Ministry of Culture and Church Affairs admin
tional capacities the same access to libraries as isters a grant scheme for activity development and
other users. social integration in local sports clubs in selected
urban districts and areas in the largest cities. The existing cultural and leisure activities. The scheme
target group for this scheme is children and young is intended to contribute to qualification, inclusion
people who because of economic or cultural barri and establishment of alternative arenas and to pre
ers are prevented from participating in organised vent anti-social behaviour such as violence and bul
activities. The grant for activity development and lying, crime, drinking, drugs and racism. Within
social integration in local sports clubs is going to the framework of this scheme, there are ear
be increased in 2007. marked funds for measures to tackle poverty prob
The Ministry of Children and Equality adminis lems. Children and young people with an immi
ters a grant scheme for measures intended for chil grant background are given high priority. The
dren and young people in large urban communi grants can be used for holiday and leisure activities
ties. These grants are for measures aimed at and for better contact with the labour market for
groups of young people that do not make use of the young people with little or no education.
Box 4.2 Policy instruments: Childhood conditions

The Government will: – evaluate measures to ensure more system
– initiate a study of the municipal duty to pro atic language testing in maternal and child
vide language stimulation to all children of health centres at the 2-year check-up and 4
preschool age that need it, regardless of year check-up
whether they go to kindergarten or not, cf. – further develop and build capacity in the
Report no. 16 to the Storting (2006–2007) school health service
Early intervention for lifelong learning. – improve municipal services for children
– gradually lengthen the school day at pri and young people with mental ailments
mary level to 28 hours of teaching a week, – initiate measures to follow up young people
cf. Report no. 16 to the Storting (2006– over the age of 18 who have received assis
2007). tance from the child welfare services
– assess the current basis in legislation of – build capacity in the child welfare authori
the duty to provide adapted training in con ties to ensure that children and their fami
nection with a possible amendment of the lies receive help at an early stage
objects clause of the Act relating to Pri – continue and strengthen schemes
mary and Secondary Education, cf. Report designed to reduce social differences in
no. 16 to the Storting (2006–2007). children and young people’s participation
– implement new measures to reduce drop in organisations and cultural activities
out from upper-secondary education, cf.
Report no. 16 to the Storting (2006–2007)
5 Work and working environment
in part-time jobs, immigrants and young people.

5.1 Objective: Inclusive working life Important policy instruments to improve the situa
and healthy working environments tion for these people include preventive working
environment measures and better adaptation of the
Objectives environment, especially in occupations and work
• A more inclusive working life places with much unskilled work, heavy work, time
• Healthier working environments pressure and little possibility of choosing how the
work is performed.
Efforts to prevent injury, improve working
5.2 Policy instruments environments and adapt the workplace must be
undertaken within enterprises. The authorities’
The Government regards two areas related to role is to influence and support this work through
working life as particularly important for reducing policy instruments.
social inequalities in health: continuing the focus
on creating an inclusive working life and working
for a healthier working environment in industries 5.2.1 Working environment legislation
with major occupational stress. A new Working Environment Act came into force
We know that being in work is in itself good for in Norway on 1 January 2006. The purpose of the
health. People outside the labour market consis Act has not changed, namely: to secure a working
tently have poorer health than the occupationally environment that affords full safety from harmful
active part of the population. This does not only physical and mental influences, ensure sound con
apply to recipients of health-related benefits, but ditions of employment and provide a basis
also to people who have been unemployed for a whereby the employer and the employees of
long time and recipients of social assistance. There undertakings may themselves safeguard and
are therefore grounds to believe that a more inclu develop their working environment. The new Act
sive working life will improve the population’s shall also:
health. – ensure equality of treatment at work.
Policy instruments to achieve a more inclusive – facilitate adaptations of the individual
working life are described in chapter 8 in this employee’s working situation in relation to his
Report to the Storting. In this chapter, we will focus or her capabilities and circumstances of life.
on policy instruments aimed at improving working – provide a basis for a healthy and meaningful
environments. working situation and inclusive working condi
Major inequalities in health are also found tions.
among the working population. This is partly due
to differences in physical and psychosocial occupa The new Act defines in more detail the duties of the
tional stress between occupational groups. People employer and employee regarding health, environ
with a short education and repetitive, manual work ment and safety work. The Act also lays down
tend to be more exposed to major health problems. requirements concerning greater participation in
Although we have nowhere near enough restructuring processes. It is spelt out that the
knowledge about the correlations between work requirements concerning the psychosocial work
ing environment, health problems and exclusion ing environment also include requirements con
from working life, it is fairly safe to assume that cerning protection from violence and threats from
easily replaceable workers are the most likely to be customers, clients, etc. The Act is also clearer con
excluded, i.e. people with the least education, and cerning the right to equal treatment in connection
that people with few career options work in the with appointment, for example, the new Act prohib
most harmful working environments. These are its discrimination of part-time employees and tem
usually employees with a short education, women porary employees regarding pay and working con
ditions. The employer’s duty to adapt the working and training. Speakers of minority languages from
environment for employees with reduced capacity non-Western countries are overrepresented in
for work is laid down in the Act, and better follow- working environments with multiple, different
up of this statutory duty may help reduce occupa stresses and among people who have sustained
tional inequalities in health. injuries. The Norwegian Labour Inspection
Authority is increasingly coming across problems
and issues linked to the working environment and
5.2.2 The Norwegian Labour Inspection working conditions for employees from new EU
Authority countries. This applies to the building and con
The Norwegian Labour Inspection Authority is struction industry in particular.
responsible for overseeing that enterprises comply
with the requirements of the Working Environ
ment Act. The Norwegian Labour Inspection 5.2.3 Company health services
Authority reaches around 8 % of enterprises in Nor Company health services are an important work
way through its inspections and must therefore pri ing-environment tool intended to help enterprises
oritise its efforts after a risk assessment based on in their preventive and health-promoting work. A
knowledge and experience about which occupa project has been undertaken in collaboration with
tional groups, industries and sectors have the most the trade unions’ and employers’ associations and
occupational stress. A large proportion of the the affected authorities to assess the roles, respon
resources available for inspections is spent on sibilities and tasks ascribed to company health ser
major projects aimed at high-risk industries, which vices. This project will also assess which criteria
in itself helps reduce social inequalities in health. should be used as a basis for deciding whether an
According to the Norwegian Labour Inspection enterprise should be obligated to establish a com
Authority’s risk assessments, the employees most pany health service and if there is a need for any
exposed to occupational stress work in the health quality requirements or some form of approval sys
and social services, transportation, and commer tem. This project is due to be completed in autumn
cial services such as cleaning. Many of the tasks 2007.
within these industries involve lifting heavy items,
awkward working positions, monotonous repeti
tive work and tight deadlines. Immigrant groups 5.2.4 Higher employment among
from non-Western countries are overrepresented immigrants
in a number of these occupations. Immigrants represent a resource for working life
It is the Norwegian Labour Inspection Author in Norway. A current challenge is how the labour
ity’s experience that changing attitudes and behav market can make better use of immigrants. The
iour requires a strong, high-profile effort over unemployment rate among immigrants is three
time, and in a move to reach more workers, the times higher than among the rest of the popula
Norwegian Labour Inspection Authority has devel tion. Registered unemployment among immi
oped a new strategy attaching greater importance grants dropped from 9 % in the second quarter of
to prevention in its capacity as an advisor and 2005 to 7.3 % in the second quarter of 2006. In the
agenda-setter. By virtue of its role as a guide, for rest of the population, registered unemployment
example, by providing good examples and tools for went down from 2.9 to 2.1 %. Among immigrants,
adaptation of the environment and risk assess the proportion of people in work rose from 56.6 %
ment, the Norwegian Labour Inspection Authority in the fourth quarter of 2004 to 57.5 % in the fourth
aims to contribute to better compliance in enter quarter of 2005. In the population as a whole, there
prises with the requirements intended to ensure a was a marginal increase from 69.3 to 69.4 % in the
safe working environment. same period.
Cultural differences and language problems There are numerous reasons why immigrants
also affect the working environment situation. have weaker contact with the labour market than
They can pose challenges in terms of organisation, the rest of the population. It may be because some
adaptation of the environment and personnel man groups of immigrants have inadequate qualifica
agement at all levels in companies. The Norwegian tions and do not satisfy the requirements in the
Labour Inspection Authority’s 2005 campaign on Norwegian labour market. It may also be because
working environment conditions for non-Western immigrants are more often subject to discrimina
workers revealed major disparities in working life tion in working life. A lack of networks and atti
in Norway as a result of insufficient information tudes towards women working outside the home
have also been cited as causes. Despite variations, and ensure that immigrants and their descendents
immigrants’ contact with the labour market seems have the same opportunities as other members of
to vary with where they come from and how long society. The action plan contains measures for
they have been in Norway. implementation in a number of areas, including a
It is a goal to reduce unemployment and considerable strengthening of efforts aimed at get
increase employment among immigrants. Immi ting immigrants into work.
grant women are to be given first priority. A num
ber of measures have already been implemented,
for example one measure qualifies and adapts 5.2.5 Action Plan against Social Dumping
newly arrived immigrants’ skills for the Norwegian In May 2006, the Government introduced its
labour market, and another measure aims to Action Plan against Social Dumping to counter
improve the labour market’s ability to include challenges entailed by the influx of migrant work
immigrants. The main goal of the introduction ers after enlargement of the European Economic
scheme for immigrants that have recently arrived Area. This action plan includes important mea
in Norway is to improve the ability of newly arrived sures that the Government believes can help
immigrants to find work or embark on training achieve the goal of proper pay and working condi
quickly. It focuses on the individual’s resources tions for everyone and a well-functioning labour
and offers qualification specially tailored to the market. To this end, the government increased the
individual’s needs. From 1 September 2005, all resources and sanctions available to the Norwe
adult immigrants have the right and duty to attend gian Labour Inspection Authority and the Petro
classes in Norwegian and civics. A second chance is leum Safety Authority Norway, and from 1 Decem
a trial system of paid qualification based on the ber 2006, these authorities are entitled to use
same model as the introduction scheme for immi orders, coercive fines and shutdown of operations
grants who have still not established themselves in in connection with inspections of pay and working
the labour market after several years in Norway conditions pursuant to the Act relating to general
and therefore still depend on social assistance. application of wage agreements etc. and the Immi
These projects focus on qualifying people for work gration Act.
and mediating ordinary work to people who need In December 2006, proposals detailing further
basic qualifications. Immigrants are a priority tar measures to combat social dumping were circu
get group when allocating places in labour market lated for review. These proposals concern mea
measures. sures to ensure proper conditions related to hiring
The purpose of the Anti-discrimination Act is to and renting out labour and measures for stronger
combat discrimination and promote equality in a control and follow-up of pay and working condi
broader and more long-term perspective. The Anti tions in industries with generally applied wage
discrimination Act applies in all sectors of society, agreements.
including working life. From 1 January 2006, a spe
cial enforcement system was set up for equality
and discrimination through establishment of the 5.2.6 National system for monitoring work
Equality and Anti-discrimination Ombud and the and health
Equality and Anti-discrimination Board of Appeals. The knowledge we have about the working envi
These two bodies uphold several laws protecting ronment as a direct cause of health problems tends
against discrimination, including the Anti-discrimi to be linked to certain industries, occupations and
nation Act. The Government is particularly keen to circumstances. In light of the broader patterns we
encourage recruitment to working life and is col observe in social inequalities in health, this knowl
laborating with the trade unions’ and employers’ edge is fragmentary and insufficient.
associations to develop a proactive recruitment On 1 January 2006, a national system for moni
policy. toring working environment and health (NOA)
The Government’s Action plan for the integra was established at the National Institute of Occupa
tion and inclusion of the immigrant population and tional Health to gather and process relevant data
goals for inclusion shall serve to ensure that immi and information about working-environment
grants contribute their resources to society as issues and make them available to other users. Rel
quickly as possible, to avoid the development of a evant users include the public authorities, players
stratified society where people with an immigrant in working life, researchers and the general public.
background have poorer living conditions and The aim is to build up a corpus of knowledge for
lower participation than the rest of the population use by all the actors in the area, for designing poli
cies and strategies, and to provide better opportu

nities for measuring and assessing the results 5.2.8 Sickness absence and exclusion in
achieved. high-risk industries
This monitoring system will enable the As a means of reducing sickness absence in indus
National Institute of Occupational Health to help tries with a high rate of exclusion, the Ministry of
quantify social inequalities in the distribution of Labour and Social Inclusion initiated a project in
positive and negative factors in the working envi December 2006, one of the goals of which is to
ronment (exposures) and possible work-related reduce sickness absence in two selected industries
impacts on health. with especially high levels of sickness absence by
The National Institute of Occupational Health focusing attention on specific challenges related to
will also be able to provide analytical studies to the working environment in the industry itself, and
quantify the impact of factors in the working envi by making the trade unions’ and employers’ associ
ronment on social inequalities in health and help ations accountable. This work is to be coordinated
quantify what health selection associated with «the by the Norwegian Labour Inspection Authority
new workplace» means for social inequalities in and carried out in close collaboration with the
health. agencies’ advisory councils made up of the
affected associations and the Norwegian Labour
and Welfare Organisation (NAV).
5.2.7 Increase research on sickness absence In addition to this project focusing on specific
and exclusion from working life industries, the Government wants to study causes
We have a lot of knowledge about individual causes of sickness absence in the health and care sector.
of sickness absence, but we do not know enough Many of the people exposed to the most working-
about the relative strength of the causes and how environment strains work in the health and care
they interact. In light of this, the Government sector. Many of the tasks they perform include
announced in Report no. 9 to the Storting (2006– heavy lifting, awkward working positions, monoto
2007) Employment, welfare and inclusion a new nous repetition, tight deadlines and rotating shift
focus on this area with the intention of stimulating work. Working conditions that are perhaps typical
research collaboration across existing disciplinary of «modern working life» (increasing rate of
boundaries. The new investment in research will change, time pressure and efficiency and compe
start in 2007 and its objective is: tency requirements) also play a role in exclusion
– to contribute to a more coordinated, stronger through extended sick leave and being put on a dis
knowledge base about the causes of sickness ability pension in this sector. Any reductions in
absence, disablement and exclusion from sickness absence and exclusion in the health and
working life. care sector will have a positive effect from a health-
– to ensure research-based knowledge about distribution perspective.
effective policy instruments in order to prevent The state is the main employer within the
sickness absence and disablement and help affected industries and thus has a special responsi
achieve the Government’s goal of an inclusive bility. The Government will therefore initiate a
labour market. study to ascertain the scope of, causes of and pos
– to help ensure that teaching in relevant sible measures to avoid health-related absence in
courses of education is more firmly anchored and exclusion from the health and care sector.
in research. This study is to be undertaken by a committee
made up of people from a wide range of spheres,
and the trade unions’ and employers’ associations
and the working environment authorities are
invited to take part.
Box 5.1 Policy instruments: work and

working environment
The Government will:
– target inspection activities at high-risk
industries and groups
– make efforts to furnish targeted infor
mation for high-risk industries and
groups
– make arrangements to ensure that
enterprises fulfil their responsibilities
regarding prevention and adaptation of
workplaces to a greater extent
– in collaboration with the trade unions’
and employers’ associations, assess the
roles, responsibilities and tasks ascribed
to company health services, the possibil
ity of requirements regarding the devel
opment of company health services and
the need for quality requirements or an
approval system for company health ser
vices
– prevent social dumping, cf. Action Plan
against Social Dumping
– encourage raising levels of knowledge
and better understanding of the broader
causal connections between work and
health, for example between health inju
ries and work-time arrangements
– follow up the more precise require
ments in the new Working Environment
Act regarding preventive and systematic
health, environment and safety work to
prevent exclusion from work
– investigate the scope of, causes of and
possible remedies for health-related
absence from work and exclusion from
the health and care sector
Part II
Reduce social inequalities in health behaviour
and use of the health services
6 Health behaviour
«Attention needs drawing to the underlying, structural causes of behaviour in order to encourage
healthy lifestyle choices.»
Figure 6.1 Health behaviour

Measures targeting children and young people

6.1 Objective: Reduced social are very important because the foundation for
inequalities in health behaviour good habits is laid early in life and because factors
in childhood have a major impact on health later in
Objective life. Boys and girls react differently to the same
• Reduced social inequalities in health behaviour measures. For example, studies show that boys
benefit less from traditional information measures.
It is therefore important that all strategies and
Other goals interventions are assessed in view of the impact
Reduced social differences in: they will have on both sexes. This also applies to
• diet measures targeting the adult population.
• physical activity The design of public health measures must
• smoking take account of our multi-cultural society. A large
• other health behaviour proportion of the Norwegian population identifies
with two cultures. Immigrants from non-Western
Health behaviour means lifestyle and habits that countries often find that establishing themselves in
have a major impact on health, such as diet, physi
cal activity, smoking and drinking.
Box 6.1 Gender perspective in health
information
6.2 Policy instruments Getting health-related information to young
Individual’s health behaviour choices are largely boys.
determined by their social environment. Smoking, Studies show that young boys tend not to
physical inactivity, unhealthy eating habits and use traditional channels of information and
abuse of drugs and/or alcohol are unevenly dis services when seeking help or information.
tributed among groups in the population. With the Boys think that they ought to deal with their
possible exception of consumption of alcohol, problems on their own and that it is unmas
health behaviour that increases the risk of illness culine to talk about them. This is particu
tends to be more common in groups with a short larly so for problems related to sex and
education and low income. relationships. Existing facilities are seen as
Health behaviour is closely related to social aimed primarily at girls and not very rele
structures. Attention needs drawing to the under vant. Boys constitute only 5–10 % of the
lying, structural causes of behaviour in order to users of ordinary assistance facilities and
encourage healthy lifestyle choices. For example information measures for young people,
we know that there are clear social inequalities while the proportion of boys who use
linked to who manages to stop smoking. This is not health-related Internet and telephone servi
merely a case of some groups having more knowl ces for young people is around 50 %. Studies
edge about how harmful tobacco products are – it also show that boys need just as much help
is also a question of resources, motivation and and information as girls.
energy. Good public health work in this area there The challenge then is how to design mea
fore needs to focus on making it easier and more sures to meet boys’ needs and that boys feel
natural for people to change their health behaviour are useful. User surveys reveal three impor
– from unhealthy to healthy habits. tant elements: Help and information must
Health information campaigns have played a be provided by professionals, and it must be
central role in bringing about changes in the popu possible to remain anonymous. Secondly,
lation’s health behaviour, but we also know that help facilities and information services
health campaigns are often most effective in the must have built-in possibilities for user con
parts of the population that already lead the health trol and steering. Thirdly, they must be
iest lifestyle. It is therefore necessary to design based on a design where the user is an
new campaigns that are better able to reach the tar active problem solver, as opposed to a pas
get groups from a social perspective. It is also cru sive recipient of information.
cial to ensure that good information is available to
ethnic minorities, such as non-Western immi Source: The Directorate for Health and Social Affairs
grants and Samis.
a new country with a different culture and foreign and on weekends. This effect seems to last well
language leads to detrimental changes in diet and into adulthood. This measure appears to have the
less physical activity. Some immigrant groups have greatest impact on children of parents with a short
stopped eating their traditional varied diet with a education and low income and non-Western immi
high intake of healthy foodstuffs such as vegeta grant children.
bles, fruit, lentils and beans in favour of food prod Major health gains are achieved, in terms of
ucts containing high levels of fat and sugar. These longer life and better quality of life, by offering fruit
changes manifest themselves in the higher inci and vegetables to all pupils in primary and lower-
dence of certain health problems linked to nutri secondary school. Fruit and vegetables for all
tion, such as obesity and type 2 diabetes in some pupils in primary and lower-secondary education
immigrant groups. helps establish a high intake of fresh produce in
It is important that all significant consider childhood. The evaluation of a pilot project provid
ations are included in assessments when propos ing children with free fruit and vegetables in
ing new initiatives, in the health sector and in other schools in Hedmark county shows that this mea
areas of society. In many cases, levelling out social sure reduces social inequalities in intake of fruit
inequalities will be an important consideration. and vegetables.
The Government wants to underline that measures
intended to influence health behaviour must
always be assessed in light of the goal of reducing 6.2.2 Measures in the local community
social inequalities in health. Health impact assess Helping smokers give up smoking is an important
ments are discussed in more detail in chapter 9. tool in the drive to prevent use of tobacco products.
International experiences from intervention For several years now, the Directorate for Health
studies suggest that structural measures affecting
price and accessibility seem to be more effective at
reducing social inequalities than information and Box 6.2 Free fruit and vegetables at
health education measures. Information cam school – pilot project
paigns tend to work best in the parts of the popula
tion that already have the best health and thus In the project Fruit and vegetables in 6th
often serve to widen the social gap. grade, nine primary schools in Hedmark
The Directorate for Health and Social Affairs county took part in the «free fruit at school»
recommends general, broad-based, low-threshold scheme in the school year 2001–2002. The
measures and targeted measures aimed at the project was evaluated as part of Elling
most deprived and vulnerable groups, especially Bere’s doctoral thesis at the Department of
children and young people. Low-threshold activi Nutrition, University of Oslo, 2004. Every
ties require little equipment and no special skills, one ate more fruit, regardless of their previ
they should be free of charge or cheap, and should ous eating habits, gender and social
be easily accessible physically, socially and cultur background. It was found that one year after
ally. the project, pupils were still eating more
The Government wants to make healthier fruit and vegetables. Preliminary findings
choices more readily available by increasing the after three years appear to show the same
emphasis on structural policy instruments in com tendency. This shows that free fruit can
bination with health information measures. bring about permanent changes in chil
dren’s eating habits. Children of parents
without higher education who received free
6.2.1 Accessibility in schools and fruit also reduced their intake of unhealthy
kindergartens snacks such as fizzy drinks, sweets and
Examples of interventions intended to change crisps after the period of free fruit. Initially,
health habits include daily physical activity at these children ate far more unhealthy
school and access to cold drinking water and fruit snacks than children of parents with higher
and vegetables at school. Kindergartens and education. The evaluation shows that a
schools are crucial arenas in the effort to encour scheme that reaches all children and young
age healthy habits because they make it possible to people because it is free can help even out
reach all children and young people. For example, social inequalities in intake of fruit and
increasing physical activity at school also leads to vegetables.
increases in physical activity after school hours
and Social Affairs and the County Governors have It is a goal that Norway should have good resi
been training people to hold courses in stopping dential environments that promote physical activ
smoking, and courses are now available through ity. Local communities are going to be adapted to
out the whole of Norway. Many voluntary organi encourage as many people as possible to exercise.
sations make a major contribution: for example, For example, it should be easy and safe for people
the Norwegian National Health Association in to get around on foot or by bicycle. Physical acces
Hedmark and Oppland counties collaborates with sibility for people with reduced functional capacity
the local County Governors. This coordination of is still substandard in many places, leading to
activities has led to more public health initiatives, exclusion and marginalisation. A lack of money is
and the model is now being applied in other coun often an obstacle to physical activity. Simple out
ties. door activities and activities in the local environ
As part of the follow-up to the Action Plan on ment are often very low cost and can be carried out
Physical Activity 2005–2009, the Directorate for in most places.
Health and Social Affairs has worked with local Local low-threshold measures are important in
governments and other actors in four counties the work on further developing and evaluating the
(Nordland, Buskerud, Vest-Agder and Oppland) system of «green prescriptions». The municipal
on a joint project to develop systematic pro health service, the local community and work
grammes for physical activity, dietary guidance places are good potential arenas for prevention and
and giving up smoking as tools in the municipal intervention. In addition to the health service, vol
public health work. Municipal centres promotting untary organisations and private actors, the Nor
physical activity for certain groups, called wegian Labour and Welfare Organisation (NAV)
«frisklivssentraler» (FLS), and similar models have should also be considered as a potential collabora
been set up to implement measures locally. This is tive partner. The activities offered must be based
a continuation of the low-threshold FYSAK mea on the municipal land-use plan and must build on
sure, which is a measure implemented at the local existing structures for the local government’s or
level to encourage physically inactive groups in the other actors’ operations and services.
population to be more physically active. Based in
the municipal health service, the programme aims
to develop models for systematic use of physical Box 6.3 Active During the Day
activity aimed at certain groups in public health
work. Active During the Day is a measure gran
FYSAK Nordland was established as a model ting people who are partially or fully unem
programme for physical activity in selected munic ployed access to organised physical
ipalities in Nordland County in 1995–96 and ran activities. Active During the Day focuses on
until 1999. The programme was continued as a per the individual’s abilities and skills. By gra
manent county-municipal sphere of work from dually tapping into their own resources, par
2000. The model is based on regional collaboration ticipants can prevent loss of functional
among a number of actors. The objective is to capacities, improve their health, and once
develop promotion of physical activity as part of again take active part in social life.
the municipal health service’s standard range of Active During the Day offers all-round
services, where activities are set up as a collabora physical activity on a daily basis. The mea
tion across government agencies and sectors. The sure is adapted for people with different
target groups for individual measures are defined physical and mental ailments. Bridging the
on the basis of the needs identified by the individ gap between sport and health, Active
ual municipality. Evaluations have found very posi During the Day is a low-threshold measure.
tive results. The Directorate for Health and Social It is open to people no matter how little
Affairs is going to take steps to ensure that FYSAK exercise experience they have or what
and similar measures to promote more physical diseases or problems they have.
activity are incorporated into the Partnerships for Active During the Day has been introdu
Public Health in all the counties in Norway. ced in Fræna, Førde, Molde, Oslo and
The Ministry of Health and Care Services is Akershus.
going to strengthen the grant scheme for physical http://www.treningskontakt.no
activity to stimulate the development of more low- http://www.apd.oslo.no
threshold activities.
A system of dietary advice courses for patients

is currently being tested. These kinds of low- Box 6.4 Hamarøy municipality: Broad
threshold measures are to build on existing ser collaboration on public health
vices and experiences, and effort should be made
to coordinate new measures with existing mea Initiatives such as prescriptions for physical
sures like Active During the Day, measures coordi activity and exercise, close collaboration
nated by the county and municipal administration, with municipal medical officers and NAV
voluntary organisations, municipal centres pro Welfare, and development of the managerial
moting physical activity (frisklivssentraler), etc. role have yielded good results in the work
The Directorate for Health and Social Affairs is on reducing sickness absence in Hamarøy
going to collect knowledge and arrange experi municipality in Nordland county. Since
ence sharing so that more people have access to 2003, sickness absence has dropped from
these kinds of measures. almost 10 % to 5 %. The success is due to:
The Government wants to prevent lifestyle dis – Routines for following up sickness ab
eases and improve dental health in high-risk sence
groups in the immigrant population. As part of the – Employees’ immediate line manager is
Action plan for the integration and inclusion of the responsible for work regarding sickness
immigrant population and goals for inclusion, the absence
Government is therefore going to stimulate estab – Stronger management role
lishment of measures to promote physical activity – All line managers attend a seminar on
and good eating habits. inclusive working life and preventive
work
– Focus on working environment and pre
6.2.3 Work as an arena ventive work and pay for safety dele
Work is an arena where we can reach groups it has gates
been difficult to reach through information cam – FYSAK centre offering exercise on pre
paigns and other policy instruments. For example, scription
work can be a good arena for promoting healthy – Close contact with the doctor and phys
eating habits, physical activity and stopping smok iotherapist
ing. Large workplaces that have a canteen can – Physical exercise during work hours
arrange courses and other events to raise levels of – Strategic collaboration meetings
knowledge among canteen staff and can ensure between: personnel manager, municipal
fresh fruit and vegetables are available. The Minis medical officer, NAV Welfare and NAV
try of Health and Care Services is going to con Working life centre
sider joint measures with labour organisations and – Stable health service
providers of food to promote healthier eating hab – Municipal medical officers with fixed
its. pay
The project «Health-promoting workplaces»
focuses on factors that have a positive influence on Read more at http://www.idebanken.org
health in the working environment. When the
project was started, a declaration was signed stat
ing that health-promoting workplaces evolve
through processes steered by participants and
accept and accommodate the needs, resources and 6.2.4 Lifestyle guidance in the health service
potentials of the individual. The inclusive working Giving information directly to individuals within
life idea bank has collaborated with other actors to the setting of the health services is often especially
collect experiences gained from projects and effective. Documentation shows that advice and
research on health-promoting workplaces. interventions in the health services have been very
In order to reach groups outside normal work effective for patients with high-risk use of drugs
ing life, the Ministry of Health and Care Services is and alcohol. These kinds of interventions function
going to collaborate with the Ministry of Labour as a supplement to information campaigns and
and Social Inclusion on assessing how the Norwe other measures.
gian Labour and Welfare Organisation (NAV) The «Learning and Activity Centres» at the
offices can be used as an arena to make public regional health enterprises are an important arena
health work more target-oriented. for training patients with chronic disorders. Many
of the centres now have facilities for groups of Storting on the dental health service. This Report
chronic patients. Treatment often includes dietary to the Storting will discuss the issue of how better
advice and assistance in stopping smoking. use can be made of the dental health service as a
Health advice in the health services is a new collaborative partner in public health work and
focus area in the drive to prevent the harmful how the dental health service can help reduce
effects of tobacco use. The National Strategy for social inequalities in general health and dental
Tobacco Control 2006–2010 defines improving health.
health workers’ knowledge about stopping smok The health centre for young people is the most
ing and one-to-one communication as main priori important local provider of contraception and
ties. It is important to strengthen the input in the advice for young people. Health centres for young
specialist health services vis-à-vis patients with people also have an important teaching function
smoking-related disorders. For large groups of through their collaboration with schools concern
patients – for example patients with COPD – stop ing relationships and sexuality. The last few years
ping smoking is the most effective single form of have seen a major expansion in health centres for
treatment in curbing the development of the dis young people within the municipalities’ primary
ease. The regional «Learning and Activity Cen health services, but it still seems that availability is
tres» may be an appropriate arena for this work. inadequate in many places – especially in sparsely
Strengthening systematic work to help people stop populated areas. Finnmark county and the other
smoking is an important priority. This means counties in northern Norway have particular prob
developing guidelines, providing healthcare work lems in terms of availability of health services for
ers with good training, and introducing economic young people.
incentives to encourage the health enterprises to The maternal and child health centres and
give this work greater priority. The training of school health service have been charged with pro
health care staff needs to include courses on giving viding guidance, advice and information. Impor
advice regarding lifestyle changes in general and tant topics include guidance about diet, physical
help stopping smoking in particular. activity, tobacco, alcohol and drugs. The maternal
GPs and regular GPs advise patients on diet and child health centres and school health service
and physical activity. Diet is important in the treat are an important driving force in preventive work
ment of many diseases. Giving advice on diet and by virtue of their contact with kindergartens and
nutrition takes time, and an ordinary doctor’s schools, and they are supposed to support and con
appointment is often not enough. In these kinds of tribute to good eating and mealtime habits and
cases, doctors can use an hourly rate or, depending arrangements for physical activity in these arenas.
on the diagnosis, the rate for «green prescrip The close, early contact that maternal and child
tions». Green prescriptions can be used in connec health centres have with families, especially during
tion with type 2 diabetes and high blood pressure children’s first year of life, plays an important part
not being treated with medicines, for example. The in the work to encourage breastfeeding and estab
evaluation of the «green prescription» scheme lish healthy eating habits from the outset. The ser
reveals a great need for auxiliary measures to vice also gives advice on use of formula and gen
change health behaviour outside doctor’s offices: eral advice about nutrition for babies and young
many doctors cite a lack of expertise in the munic children.
ipality to whom doctors can refer patients for fur
ther follow-up, for example physiotherapists and
dieticians. Over half of doctors report that they 6.2.5 Regulate access to goods and services
have nowhere to refer patients to for further follow- As part of the follow-up to The Diet Action Plan, the
up. Ministry of Health and Care Services is undertak
It is necessary to promote good health by ing a study to ascertain whether it might be appro
improving dental health. The dental health service priate to regulate advertising of unhealthy food
provides outreach dental health services for chil and drinks aimed at children and young people.
dren and young people and for groups that are The Norwegian authorities participate actively in
deemed to have special dental health needs. The the debate about these issues, through the collab
dental health service is also charged with organis oration between the Nordic countries and within
ing preventive dental health care. This may take the EU and the World Health Organization.
the form of general schemes or targeted measures Children and young people eat too much sugar
aimed at specific groups. In the spring of 2007, the and fat, and much of this comes from sweets, fizzy
Government is going to submit a report to the drinks, soft drinks and snacks. These food prod
ucts have little nutritional value, but contain a lot of oly, high taxes and prices, an extensive system for
calories and should not make up a significant part inspecting retail outlets and licensed venues, and
of people’s diet. These products lead to obesity tight restrictions on the marketing of alcoholic bev
among children and young people. Some parts of erages. Ours is one of the most restrictive alcohol
the food industry spend considerable sums of policies in Europe. There are therefore grounds to
money marketing these goods, also to children and assume that the alcohol policy we have adopted
young people. Studies show that marketing of hitherto is an important reason why alcohol con
these kinds of food products constitute a large part sumption in Norway is among the lowest in the
of the television advertising broadcast in connec Western world. The Act on the sale of alcoholic
tion with television programmes for children and beverages assigns a major responsibility to the
young people. It is a well-documented fact that mar local governments, partly through their licensing
keting works. Children exposed to advertising and authority. In recent years, we have seen a gradual
measures to promote sales of these products have increase in availability of alcohol. For example,
a higher intake of these food products than other according to the Norwegian Institute for Alcohol
children. This is reflected in the amount of sugar and Drug Research, SIRUS, the number of licences
and fat in their diet. to serve alcohol in Norway has risen from 2439 in
1 June 2004 saw introduction of the ban on 1980 to 7231 in 2005. In spring 2006, the Director
smoking in cafes, bars and restaurants in Norway. ate for Health and Social Affairs published a new
Evaluations show that the air quality for employees handbook on drawing up municipal plans of action
in these establishments has improved dramati on alcohol and drug policy. Here, the local authori
cally, and that this has led to a reduction in the ties are encouraged to see the entire alcohol and
number of respiratory complaints and better drug policy in context and regard their licensing
health. In addition to less exposure to second-hand policy as an important tool in the general efforts to
smoke, it is expected that the ban on smoking will prevent substance abuse, in order to counteract
also reduce smoking among employees. This further increases in the number of licences to sell
group of employees has relatively little education and serve alcohol.
and low income. A positive side effect is that an On 1 July 2006, a ban was introduced prohibit
important recruitment arena for young people is ing use of note acceptors in gambling machines.
now smoke-free. It is also likely that the amend This measure is part of the Government’s efforts
ments to the legislation have accelerated the to prevent gambling addiction until gambling
decrease in the number of smokers in the popula machines are phased out altogether. The ban on
tion in general. note acceptors has already led to a marked
Despite a minimum age limit of 18 for buying decrease in turnover for gambling machines. The
tobacco products, studies show that around half Government has decided to introduce night-time
the young people aged 13–17 who smoke have no closing hours (midnight to 7 AM) on gambling
problems buying tobacco. A proposal suggesting a machines and obligatory labelling of machines
new system for supervising selling to minors was with information and warnings about the conse
circulated for review in autumn 2005 and is cur quences of exaggerated use of the machines. Gam
rently being considered by the Ministry of Health bling machines are going to be banned completely
and Care Services. The Norwegian Food Safety starting 1 July 2007.
Authority is the proposed supervisory authority.
The Government is considering proposing intro
duction of a supervisory system. The Government Changes in prices and taxes
is also considering a proposal to ban visible dis Tobacco prevention work traditionally uses taxes
plays of tobacco products in retail outlets. This pro as a tool. Research shows that young people are
posal is currently being developed. Steps are also particularly sensitive to changes in the price of
being taken to get all the county municipalities in tobacco. Older smokers have a longer smoking
Norway to introduce a ban on smoking in school history and established psychological smoking rit
hours in upper-secondary schools for pupils and uals as well as physiological nicotine dependence.
staff alike. This measure is important because it is Young people have less money to spend on
at this age that most people start using tobacco. tobacco, and young smokers do not have the same
It is well-documented that the most effective firmly established tobacco habits and are therefore
tools in alcohol policy are those that reduce avail easier to influence.
ability and raise the price. The main elements in A review of research on measures to reduce
Norway’s alcohol policy are a strong retail monop smoking among young people (carried out by
Lund and Rise, 2002, on commission from the eral policy instruments that will help improve the
Directorate for Health and Social Affairs) shows population’s diet. However, the impact of this
that income is decisive for price sensitivity. Sensi instrument will depend on the degree to which the
tivity to changes in price means that groups with taxes affect the price and how sensitive the con
limited financial resources generally reduce their sumers are to price in their choices. The health
demand to such a great extent that the group impact will also be weakened if the price rise leads
spends overall less money on tobacco. Groups with to consumers simply buying these products
greater spending power – that are not so price sen abroad instead.
sitive – consume roughly the same amount of Pursuant to proposals in Proposition no. 1 to
tobacco after a price rise and thus bear a larger the Storting (2006–2007) Decisions on taxes and
part of the expense. Raised taxes can thus contrib customs, the Storting has changed taxes on non
ute to reducing social inequalities in health behav alcoholic beverages so that drinks with added
iour since this policy has the greatest impact in the sugar and sweeteners are taxed, while bottled
poorest groups. water and juice are exempt from taxes. We would
It is assumed that the most important effects of prefer this tax only to apply if the sugar content
an increase in taxes will be fewer young people passes a defined lower limit, motivating the indus
starting to smoke and adults stopping smoking try to lower the sugar content in beverages. How
altogether, as opposed to people who continue to ever, a lower limit would depend on requirements
smoke cutting down their daily consumption. Peo regarding labelling specifying the sugar content.
ple who continue to smoke despite increases in The current EU regulations do not call for this kind
taxes will experience an increase in expenses. The of labelling, but Norway has proposed this solution
economic burden of an increase in tax on tobacco to international bodies.
will be greatest for people with the worst financial Calculations carried out by the Norwegian
situation. The health benefits of an increase in the Agricultural Economics Research Institute demon
tax on tobacco must therefore be considered in strate that a 12 % drop in the price of fruit and veg
light of the burden increased taxes will entail for etables in Norway would cause an increase in the
people with limited financial resources. total demand of between 4 and 15 %. Among young
Taxes are a key tool in Norwegian alcohol pol people living alone and couples with children, total
icy. Like changes in prices of other goods, an demand for fruit and vegetables is expected to rise
increase in the price of alcohol will have the great by 11–12 %. These groups spend less of their food
est impact on consumption in groups with limited budget on fruit and vegetables than other house
financial resources. It is therefore reasonable to holds. However, it must be pointed out that there
assume that a reduction in taxes on alcohol and the will always be a great deal of uncertainty associ
price of alcohol would lead to the greatest increase ated with these kinds of calculations.
in consumption – and therefore also injuries – in It is the Government’s view that the interests of
groups with limited financial resources. It is impor children and young people should be given prior
tant to continue a restrictive alcohol policy with ity. Cheaper fruit and vegetables will serve to
high taxes to avoid an increase in alcohol-related increase consumption among young people and in
illness and injuries in these groups. When consid families with small children in particular. These
ering the level of tax on alcohol and tobacco, we are important target groups for establishing good
must also take into account developments in habits at an early age, which can help reduce the
unregistered consumption. risk of illness later in life. As part of the follow-up to
The population’s diet can be influenced by mak the Diet Action Plan, the Ministry of Health and
ing unhealthy products relatively more expensive. Care Services will take the initiative to ensure that
Special taxes on unhealthy products are one of sev economic policy instruments are considered.
Box 6.5 Policy instruments: Health behaviour

The Government will: – collaborate with the trade unions’ and em
– use pricing and taxation policy instruments ployers’ associations to assess measures
to help reduce social inequalities in diet promoting physical activity and healthy
– help facilitate daily physical activity and a food at work
good system for providing meals in pri – invest in lifestyle guidance in the health
mary, lower-secondary and upper-second service, including improving maternal and
ary schools child health centres and the school health
– introduce a scheme to provide fruit and service
vegetables for all pupils at primary and – ensure that measures proposed to influ
lower-secondary school ence health behaviour are always assessed
– assess measures to limit the availability of in light of the goal of reducing social ine
tobacco qualities in health
– strengthen the grant scheme for physical
activity in order to encourage low-thresh
old activities and assess similar measures
to influence diet
7 Health services
The Norwegian health service is constantly

7.1 Objective: Equitable health and evolving. A report from The European Observatory
care services on Health Systems and Policies summarises the
main trends in Norway’s health reforms over the
Objective last few decades thus: «Taking an aggregate view
• Equitable health and care services of health care reform over several decades, the
general focus of the 1970s was on equity questions
and the build-up of health services; the 1980s on
Other goals cost containment and decentralization; the 1990s
• Better knowledge about social inequalities in on efficiency and leadership; and the beginning of
the use of health services the new millennium on structural changes in the
• Better knowledge about factors that contribute delivery and organization of health care.» All these
to social inequalities in the use of health ser considerations were important. In the future devel
vices and factors that can counteract these opment of the health service, fair distribution is
imbalances once again the focus of attention.
• Better health services for at-risk groups
Health and care services should be equitable in Possible distortion mechanisms

terms of availability, use and results. In this Report We know that there is a correlation between social
to the Storting, the term «the use of health ser background and use of the health service. We do
vices» covers all three central aspects of the ser not have sufficient knowledge to determine the
vice. causal connections between social background
and the use of health services. We need to investi
gate further whether the Norwegian health ser
7.2 Policy instruments vice is serving to level out or exacerbate social ine
qualities in health. Although our knowledge about
Although the population’s health is primarily influ social inequalities in the use of health services is
enced by factors beyond the control of the health somewhat limited, hypotheses have been pro
sector, a well functioning health service is never posed in Norwegian and international research
theless an important prerequisite for good public about possible distortion mechanisms that may
health. In Norway, we have a very high level of affect different social groups’ use of the health ser
ambition for our health services. We want high- vices.
quality services that are available within an accept In the primary health service, for example, one
able waiting time and distance and that the ser might expect to find social inequalities in the use of
vices and facilities offered reach everyone regard the regular GP with regard to treatment, follow-up
less of their social background. Most of these high and referral to the specialist health service. In the
ambitions have been met, and Norway has one of specialist health service, there may be mecha
the best health services in the world. Neverthe nisms that make services less accessible to groups
less, we must acknowledge that there are still defi with a short education and low income. Legal, eco
ciencies and challenges in many areas. There is nomic, organisational and pedagogical factors may
broad consensus in Norway about the main goals play a part. A number of possible mechanisms that
of the health policy. The Government will work sys may obstruct equitable health and care services
tematically to achieve these goals. Errors and defi are discussed below.
ciencies in organisation or services revealed by Legal policy instruments such as patients’
user experiences or supervisory activities will be rights, the right to an individual plan, the right to
followed up. be assessed and the right to receive necessary
medical assistance may have a social bias. Patients’
rights are intended to ensure equal access to in society, the threshold into the health service
health services through the legal right to receive seems especially high. This is the case for heavy
necessary medical assistance, freedom of choice drug addicts, alcoholics and prisoners, for exam
(right to choose hospital, regular GP), the right to ple. Drug addicts and alcoholics are often in a situ
receive information, co-determination and the ation where it is difficult for them to take advantage
right to a second opinion. Since to a certain extent of the available health and care services. Access to
use of these kinds of rights requires resources in health and care services is often particularly weak
the form of knowledge (for example, about the for drug addicts and alcoholics who developed sub
application process and availability of the service), stance abuse problems at an early age. They often
it is conceivable that defining these rights in law in have deficient or incomplete schooling, weak or no
fact perpetuate or even exacerbate social inequali contact with the labour market and do not have
ties. The Norwegian Board of Health’s supervi enough money – background factors that are sys
sions have also found that the goals of the patients’ tematically linked to inequalities in health. For a
rights legislation cannot be met unless sufficient person who spends all their available funds financ
effective steps are taken to make the requirements ing their addiction, user charges for health ser
known and used in the specialist health service. vices often prevent them from using these ser
Only limited research has been done in this area vices.
from the perspective of law and sociology of law. Medical insurance and privately financed
We need more knowledge about the significance of health services can generate inequalities in the use
laws and regulations for the goal of equal access to of health services. Private insurance against user
health services. charges may serve to undermine the purpose of
How the health service is funded affects the the system of charging users for certain services
distribution of services. The financing system and medicines: i.e. to reduce demand for low-prior
influences the range of health services offered, ity health services. This in turn exacerbates social
and user charges for services and medicines affect inequalities. It is therefore important that the wait
demand. ing time for publicly financed health services is not
The system of performance-related financing is significantly longer than for privately financed
intended to encourage more treatment activity, but health services.
can also lead to an unintended distortion away
from patients and statutory tasks not covered by
the system. Since chronic and complex ailments
are unevenly distributed in society, too low prioriti Box 7.1 «The inverse care law»
sation of these kinds of ailments can lead to greater
social inequalities in health. So far, there is no evi In 1971, the British GP Julian Tudor Hart
dence that the system of performance-related published an article in the British Medical
financing has actually led to unintended distortions Journal titled The Inverse Care Law. Hart
in the range of services offered. The change in the claimed that the availability of good medical
block funding from 40 % to 60 % should help reduce care tends to vary inversely with the need
any problems linked to these kinds of distortional for it in the population served. In other
effects. words, the health service is best where the
The correlation between user charges and con need is smallest.
sumption of health services is well documented According to Hart, the inverse care law
internationally. A study surveying use of user will, be strongest where the health service
charges in the health sector in different countries is exposed to market forces. If health servi
(carried out by the Programme for Health Eco ces can be bought with money, the people
nomics in Bergen) refers to a number of studies with the greatest spending power will be
supporting the hypothesis that demand is affected able to buy the best services. However, the
by user charges. User charges reduce demand for correlation between income and health
both necessary and unnecessary services, and entails that the people with the least spen
they tend to affect health and economy in a socially ding power have the greatest need for
biased way. The studies indicate that people with health services. The hypothesis is that a
low income and people belonging to certain social health service governed by market forces
groups are hardest hit. will function best where there is least need
The organisation of the health service affects for it.
patients’ access to the services. For some groups
7.2.1 User charges

Box 7.3 Medicinal products
The Government has decided to reduce user
charges on health services and keep them at a low An important objective for Norway’s medi
level. In the fiscal budget for 2006, the second cinal product policy is that the population
upper limit for user charges was reduced from shall have equal and easy access to safe and
3500 to 2500 NOK from 1 January 2006. User effective medicinal products regardless of
charges for physiotherapy for people who were their ability to pay. The reimbursement sys
previously entitled to free physiotherapy on the tem is intended to ensure that the popula
basis of their diagnosis were discontinued from 1 tion has access to important medicinal
July 2006, in accordance with the proposal in Prop products regardless of their ability to pay.
osition no. 66 to the Storting (2005–2006). Correct and effective treatment of disea
There is variation in the current exemption and ses and health problems often requires use
cost-sharing schemes: for some services and prod of medicinal products. The total costs per
ucts, individuals must cover all the expenses in full patient for treatment with medicinal pro
(for example normal dental treatment for adults ducts can vary from a few hundred Norwe
and some medicines). For some services, the state gian kroner (NOK) to several million NOK
covers the costs in full. This is the case for in per year. Ability and willingness to pay for
patient treatment in hospital, community nursing medicines varies from person to person, but
and technical aids. Certain treatments are free on at some point expenses can reach a level
the basis of diagnosis: GP services in connection where the state has to step in and help. Wit
with infectious diseases that pose a threat to public hout public support for medicinal products,
health, pregnancy and childbirth, and physiother effective treatment would largely depend on
apy for patients with certain diagnoses. There is the patient’s income.
also a system of exemption by age. For example Much necessary medicinal treatment is
children under the age of 12 are exempt from pay financed through the blue prescription
ing for health services and children under 18 are regulation, treatment in hospitals and nurs
ing homes, and through the contribution
scheme. State budgets cover the costs of
Box 7.2 Reimbursement from the around 70 % of the total sales of medicines,
National Insurance Administration which in 2005 was 16.1 billion NOK.
Access to safe products is assured via a
The state reimbursement schemes do much well-functioning chain of distribution. Nor
to ensure equal access to necessary treat way’s 550 pharmacies and 1200 medicine
ment. The «blue prescription» system regu outlets ensure satisfactory geographical
lates the right to reimbursement of availability of medicinal products.
expenses for medicines (cf. regulation no. Regular GPs issue the most prescriptions
330 of 18 April 1997 on support to cover for medicinal products. Access to a regular
expenditure on important medicines and GP is therefore decisive for sufficient medi
special medical equipment (the blue pres cinal treatment. Regular GPs also adminis
cription regulation)). ter society’s funds through the right to
Under the provisions of Section 5–22 of prescribe medicinal products on the Natio
the National Insurance Act, contributions nal Insurance Scheme’s account.
can be made to cover expenses for health
services when these expenses are not
otherwise covered pursuant to the National
Insurance Act or other legislation. The main exempt from paying for psychologists and services
expenses covered by the reimbursement within child and adolescent psychiatric clinics.
scheme (measured by the size of the Pensioners on a minimum pension are exempt
expense) are medicines and dental treat from paying for «blue prescription» (reimburse
ment and glasses for children. In connec ment scheme) medicines. Dental health services
tion with reimbursement of expenses for are free for children and young people up to the
treatment, any necessary travelling and age of 18 (school dentist), for the elderly, for peo
overnight expenses can also be covered. ple on long-term sick leave and disabled people in
institutions and receiving community nursing, for
the mentally handicapped and for people receiving insurance basic amount (2G) when the services
municipal treatment for substance abuse. People are to fulfil a need for help that yields requirements
with occupational injuries and war injuries are also for services pursuant to Section 4–3 of the Act
exempt from cost-sharing under certain circum relating to Social Services. If a personal safety
stances. alarm is provided in these kinds of cases as a sub
The two-tiered system of upper limits for user stitute for a daily visit from a supervisor, or meals
charges provides exemption from expenditure are delivered instead of help cooking at home, the
above a certain level for services covered by the rules in the regulation on exemption by income
scheme. Exemption by income is a principle for apply. However, if the service is provided as an
municipal, home-based services and long-term optional municipal service, the municipality is free
stays in retirement homes and nursing homes. A to calculate user charges. Nevertheless, the
flat rate is used for short-term stays. municipality may not charge more than the cost of
Proposition no. 1 to the Storting (2006–2007) the service. Reference is also made to Report no.
the National Budget for the Ministry of Health and 25 to the Storting (2005–2006) Long-term care –
Care Services, contains a review of the systems of Future challenges for a more detailed discussion of
user charges for health services. The Government financing and user payment in the care services.
is going to return to the problems and issues raised
in this review in the budget for 2008. Reducing
social inequalities in health will be an important 7.2.2 Governance and organisation of the
element and will be taken into account when con health service
sidering possible changes in the system of user The health authorities are responsible for ensuring
charges for health services. Pursuant to proposals that everyone has satisfactory access to necessary
from the Government, the Storting (the Norwe health services. Nevertheless, we find that users
gian Parliament) has decided that from 2007 drug such as, for example, old people in poor health,
addicts visited by ambulatory teams from an outpa people with mental ailments, drug addicts, and
tient service for drug abusers will not be charged mentally handicapped people are not always able to
user fees. make their needs and rights known. This can lead
The state currently regulates the local authori to these groups not using the health services to the
ties’ right to take payment for care services same degree as the population as a whole, despite
through two different sets of regulations: one for the high morbidity rate in these groups. The Min
home services and one for services in institutions. istry of Health and Care Services wants to ensure
The Government has considered different alterna equitable services for weak patient groups through
tives to ensure more equal user payment. Overall, optimum governance and organisation of the
the Government does not find that the disadvan health service.
tages of the current system justify an extensive It is important to ascertain whether health-pol
reform. The consideration that users must not suf icy instruments – such as financing schemes,
fer from restructuring means that the system will forms of organisation, regulation and guidance –
be continued as it is for the time being. Neverthe perpetuate or exacerbate social inequalities in
less, the Government will monitor developments in health. In the same way that the goal of reducing
the municipalities and continually assess the need social inequalities in health must be made a prior
for steps. ity in many areas in society, it is also necessary that
The Government wants to ensure that users of the Ministry of Health and Care Services takes
municipal services in a difficult financial situation steps to ensure that reducing social inequalities in
are better protected against user charges and pay health is an important priority and is considered
less than they currently do. Several municipalities when introducing new or changing existing gover
have introduced cost-sharing on a number of ser nance mechanisms in the health sector.
vices in a way that has not been in compliance with Most of the services offered by the specialist
the regulations. This has happened in particular in health service are provided under the direction of
connection with provision of a personal safety the public authorities. Contracted specialists are an
alarm, meals-on-wheels, and when setting user important part of the specialist health service.
charges for these services. The Ministry of Health Work has been instituted to study and develop the
and Care Services has therefore sent out a special situation in order to ensure even better integration
circular underlining that user charges for these of the contracted specialists in the regional health
kinds of services are covered by the exemption enterprises’ responsibilities for providing special
rule for people earning less than twice the national ist health services, partly with a view to ensuring
correct prioritisation in keeping with the Patients’ tion as a whole. However, as a group, homosexuals
Rights Act and the prioritisation regulation, and to and lesbians experience more problems than the
facilitate appropriate distribution of tasks between average for the population. This group is particu
contracted specialists and the health enterprise larly prone to drug abuse, mental ailments and sui
and thus promote better utilisation of resources cide. Although their health problems are not nec
and ensure equal availability of specialist health essarily linked to social inequalities, it is important
services. that the health service is aware of ailments and dis
Social inequalities pose a challenge in the work eases that particular groups or minorities are pre
on ascribing priorities in the health service. It is an disposed to. This can prevent a vicious circle of
explicit goal to counteract social inequalities in health problems and social exclusion.
health by identifying the needs of groups in the Information and communication technology is
population that require special measures, such as, a valuable tool for getting information about health
for example, refugees, asylum seekers, prisoners services and options out to the population. This
and drug and gambling addicts. It seems some technology can help increase accessibility to this
patient groups are more likely to be given low pri kind of information among all groups in the popu
ority than others, and it is conceivable that this is lation, for example through universal design of
due to the fact that there is a correlation between websites.
the status of the academic disciplines and the In the spring of 2007, the Government is going
patients’ socioeconomic status. We therefore need to submit a report to the Storting on the dental
targeted efforts to ensure better distribution of health service. Social inequalities in health are also
resources between diagnosis and subject areas. reflected in dental health. The Report to the Stort
There are currently large disparities in the way the ing on future dental health services will discuss
prioritisation regulation is interpreted and applied. matters such as availability of services, use of user
The Directorate for Health and Social Affairs and charges and establishing rights in legislation. The
the regional health enterprises have therefore initi significance of the dental health service for social
ated the joint project Riktigere prioritering (Getting inequalities in health in general and in dental
priorities right) in an attempt to contribute to more health in particular will be evaluated in the report
uniform practices. to the Storting.
Information and good communication are The need for good, effective habilitation and
essential for a good outcome of treatment. There rehabilitation services is growing. Rehabilitation
are strong, often unspoken expectations that the can be decisive for the individual’s quality of life
users of public services are the same, also in terms and ability to lead an independent life after com
of culture, or that they ought to behave like the pleted medicinal treatment.
majority of the population when using health ser The Government will guarantee rehabilitation
vices. For Samis and non-Western immigrants, for and retraining for everyone who needs it after ill
example, this may result in their benefiting less ness or injury. The Government will also work to
from the services than other members of the pop ensure that children with restricted functional
ulation. This represents a breach of the political capacities or chronic illness are offered good,
objective of equitable services and maximum interdisciplinary habilitation services. The Minis
equality in availability and outcome of services. try of Health and Care Services is going to propose
With regard to minority-language patients, it is par a national strategy for habilitation and rehabilita
ticularly important that health workers ensure that tion in the health and social services. This strategy
language or cultural differences are not causing will lay the foundation for clearer prioritisation of
misunderstandings that affect the treatment. It is habilitation and rehabilitation as priority areas for
also important to take into account the fact that dif local governments and health enterprises and
ferences in social background between patients ensure better collaboration between public service
and health workers can influence communication. providers and private suppliers of rehabilitation
It may be difficult for patients to talk about some services. Importance will be attached to ensuring
disorders and ailments. The problems may then greater geographical equitability in the range of
appear diffuse and difficult to treat. Cases of this institution-based services on offer, better quality
nature include, for example, women and children services through qualification requirements and
who have experienced or are experiencing abuse advancement of knowledge, and an individual
and violence in close relationships. approach to users. Users shall encounter services
Most homosexuals and lesbians have good that are accessible and effective, safe and coordi
health – like other minority groups and the popula nated. The work on reducing sickness absence and
Report no. 9 to the Storting (2006–2007) health services. This will then form the basis for
Employment, welfare and inclusion will be followed further measures to reduce any social inequalities.
up by means of collaboration with the Ministry of Indicators need developing for the accessibility of
Labour and Social Inclusion on a joint focus on the specialist health services in order to monitor
rehabilitation in order to get more people in work. and influence tendencies in social inequalities in
accessibility.
Social inequalities in health will be a central
7.2.3 Research and advancing knowledge consideration in current and new evaluations of
We have inadequate knowledge about social ine health services. The drug reform has recently
qualities in access to health services, the use of been evaluated. One of the main objectives of the
health services and the outcome of treatment. drug reform was to increase access to the health
More research and surveying of this area are services for a group of patients. A basic starting
therefore necessary. Figures from Statistics Nor point was that treatment for drug addicts and alco
way show that in 2005, almost 176 billion NOK was holics should be more easily available than previ
spent on health. This corresponds to an average ously and that specialised health services neces
cost per inhabitant of 38 000 NOK. Among the sary to reduce somatic and mental problems
many areas where we find causes that help create should also be more closely linked to interdiscipli
and perpetuate social inequalities in health, the nary specialised treatment of abuse and addiction.
health services represent one of the areas with the The evaluation demonstrates that more drug
most obvious impact on health. However, it seems addicts have received treatment, the services
that the health service is the area among those cov within the specialist health service are better coor
ered in this Report to the Storting that we know the dinated, and the quality of the services has
least about with regard to social inequalities in improved. Nevertheless, there is still a long wait
health. ing time for treatment, there is still a need for
We lack data on how well the health service increased treatment capacity, and the quality of the
works for groups with a minority background. services still needs to be improved. Collaboration
Work has been initiated to develop indicators to within the specialist health service needs improv
measure performance in relation to the goal of ing – especially in connection with services for
equitable health services for all groups in the pop drug addicts and services within mental health
ulation regardless of ethnic, linguistic or religious care. The collaboration and interaction between
affilitation. We also need more knowledge about the specialist health service and the municipal ser
how able the health service is to identify the spe vices also still needs improving. These factors will
cial health problems facing homosexuals, lesbians all serve to improve the availability of health ser
and bisexuals. Oslo has established a number of vices for drug addicts.
specially adapted health services for this group of For a number of years, many of the municipali
users. Examples include the Olafia clinic’s advi ties have received central-government incentive
sory service for homosexuals, lesbians and bisex funds for establishment and operation of low-
uals and The city of Oslo’s health centre for young threshold health measures for drug addicts and
lesbians, homosexuals and bisexuals. alcoholics. These are measures to meet this group
In recent years, medical technology has devel of patients’ needs for health services and help
oped rapidly, resulting in lower mortality from improve access to the other health services. This
acute coronary arrest and a number of other dis grant scheme, which is administered by the Direc
eases. Improvements in public health are closely torate for Health and Social Affairs, is going to be
linked to factors outside the health service, but evaluated in 2007, hopefully providing valuable
according to the Norwegian Institute of Public knowledge about whether these measures have
Health, it is likely that medical technology will fur actually enhanced access to the health services for
ther reduce mortality, so that the health service drug addicts.
will play an ever more important role in improving Many of the questions we need answers to
public health. It is therefore paramount that the regarding the impact of the health services on
health service does not exacerbate social inequali social inequalities in health will require a more
ties, but rather serves to reduce social inequalities long-term research effort. This applies in particu
in health. lar to questions linked to which mechanisms con
The Government wants to give high priority to tribute to the social inequalities we have observed
the need for knowledge in this area. We therefore in the use of health services.
need a survey of social inequalities in the use of
In order to ensure equitable specialist health

services, it will be important to strengthen the pri
Box 7.4 Policy instruments: The health
ority focus areas and programme plans under the
service
direction of the Research Council of Norway, espe
cially the programme for research on health and The Government will:
care services. A new research programme on sub – consider changes in the cost-sharing
stance abuse is in the process of being established, schemes with reducing social inequali-
which will be relevant for research on social ine ties as an important aspect
qualities in the use of health services. Epidemio – further develop low-threshold health
logical research under the direction of the Norwe services
gian Institute of Public Health and the higher edu – develop indicators of quality and priority
cation sector is also going to be strengthened. To in the specialist health services, includ-
improve research on social inequalities in the spe ing a way of measuring social inequali-
cialist health service, the Ministry of Health and ties in accessibility
Care Services is going to consider instructing the – focus on distributional effects when
regional health enterprises to channel funds for introducing new or changing existing
research into this area. regulatory mechanisms in the health
Measures to build capacity in the school health sector with regard to legal, financial,
service are discussed in more detail in chapter 4 on organisational and pedagogical gover-
childhood conditions, and low-threshold health nance tools
services are discussed in chapter 8. – survey social inequalities in the use of
health services
– strengthen research on factors that con-
tribute to social inequalities in the acces-
sibility and quality of health services
– ensure that reduction of social inequali-
ties is considered when evaluating
potential reforms in the health service
– against the background of new knowl-
edge, assess measures to reduce any
social inequalities in the use of health
services
Part III
Targeted initiatives to promote social inclusion
8 Targeted initiatives to promote social inclusion
«Universal schemes must be supplemented with individually tailored services and measures
that take account of groups with special needs. User-oriented and specially adapted public services
are essential to ensure that everyone, regardless of their background and circumstances,
has access to equitable services.»
Figure 8.1 Targeted initiatives to promote social inclusion

that there is limited knowledge about effective

8.1 Objective: Better living conditions measures to reduce social inequalities in health,
for the most disadvantaged people but that international experiences suggest that
measures to combat poverty and unemployment
Objective are important. It is also pointed out that universal
• Better living conditions for the most disadvan welfare schemes will probably have a buffer effect,
taged people and that broad initiatives aimed at specific groups
to counteract social inequalities will probably help
reduce inequalities in health and improve public
Other goals health. Other potentially effective measures
• Reduce the number of adults who leave school include low-threshold measures for certain special
with poor basic skills ist health services aimed at specific groups, health
• Enable more people to work services without user charges, and cross-sectoral
• Improve accessibility of health and social ser partnerships between the state and other actors in
vices deprived areas.
• Eliminate homelessness Public assets such as education, health and
• Reduce inequalities in living conditions social services, and kindergartens are decisive for
between different geographical areas distribution of resources and living conditions in
the population. Many disadvantaged people also
need more targeted services. Universal schemes
8.2 Policy instruments must be supplemented with individually tailored
services and measures that take account of groups
In its report The Solid Facts, the World Health with special needs. User-oriented and specially
Organization states that being excluded from soci adapted public services are essential to ensure that
ety and being treated as inferior lead to poorer everyone, regardless of their background and cir
health and a greater risk of premature death. Liv cumstances, has access to equitable services.
ing in a community marked by difficult living con
ditions, high unemployment and poor housing
poses a health risk. Unemployment and unstable 8.2.1 Inclusion in the labour market
contact with the labour market in themselves entail Employment is vital to ensure income, feel valued
a health risk. Relative poverty can also lead to by society and have a sense of inclusion and
social exclusion through a lack of accommodation, involvement. People who fall outside the labour
education and other factors necessary for full par market also tend to fall out of other parts of the wel
ticipation in society. Discrimination, stigmatisation fare society.
and unemployment can also lead to social exclu The Government wants to eliminate poverty
sion. These are all factors that obstruct participa and reduce social and economic inequalities
tion in society. People who live or have lived in through universal welfare schemes, strong com
institutions, such as, for example prisons, child munity solutions and by giving everyone the
welfare institutions and psychiatric institutions, are opportunity to participate in working life. The Gov
particularly vulnerable. ernment’s policy to combat poverty and prevent
Almost half of the income of people with limita development of a society with broad divides
tions in functioning and participation comes from between people in work and people who are unem
transfers. Many people with reduced functional ployed is laid out in Report no. 9 to the Storting
capacity experience discrimination and marginali (2006–2007) Employment, welfare and inclusion
sation and are therefore at risk of getting caught up and Action Plan to Combat Poverty.
in a vicious circle of social problems and health Report no. 9 to the Storting (2006–2007)
problems. The passivity and dependence on ser Employment, welfare and inclusion emphasises use
vices that marks the situation of many people with of welfare contracts as a continuous and systematic
reduced functional capacity are to a great extent principle to define mutual expectations, require
created by society through various obstructions ments and commitments between the administra
and barriers preventing their independence and tion and the user in concrete terms.
participation. In the Report to the Storting, the Government
The overview of current knowledge Social ine paves the way for greater use of special work-ori
qualities in health in Norway published by the ented measures and services to lower the thresh
Directorate for Health and Social Affairs points out old into working life and raise the threshold out of
working life, including adapting measures to meet immigrants who need assistance to find work was
the needs of immigrants and people with reduced made nationwide. The measures are run by the
functional capacity. Norwegian Labour and Welfare Organisation
The Report to the Storting gives notice that the (NAV) in close cooperation with the social services
use of policy instruments is going to be made more in the municipalities. The goal is that participants’
flexible and coordinated, based on the individual’s contact with the labour market is improved
needs. The Government is also going to introduce through integrated assistance from service provid
a new system with a temporary minimum income ers, good advice and guidance, and labour market
in the National Insurance Scheme to replace vari measures based on individual needs. The invest
ous rehabilitation benefits and temporary disable ments in this area will be further strengthened in
ment benefit. This reform will also help steer use of 2007.
resources away from administration of benefits Report no. 9 to the Storting (2006–2007)
and towards active interventions and follow-up. Employment, welfare and inclusion and Action Plan
The strategies and initiatives mentioned in the to Combat Poverty propose establishing a qualifica
Report to the Storting along with the reorganisa tion programme entitling participants to a qualifi
tion of the labour and welfare administration con cation benefit for people with significantly reduced
stitute a major policy reform in the field of labour capacity for work and income and with no or very
and welfare. The new labour and welfare adminis limited subsistence support from the National
tration, the Norwegian Labour and Welfare Organ Insurance Scheme. The qualification programme
isation (NAV) forms a framework for comprehen and qualification benefit are intended to improve
sive and coordinated services for job seekers and the opportunities of people whose main source of
people who need special adaptation of the environ income over a long period is financial social bene
ment at work. The NAV reform’s main objective of fits. The objective is to help more people in the tar
getting more people into work and activity and get group find work. The scheme is meant for peo
fewer people on benefits makes the local NAV ple who have been assessed as being able to hold
offices important arenas in the work to prevent down a job if they receive closer, more committed
poverty and ensure social inclusion. The new support and follow-up.
labour and welfare administration entails coordina Social benefits will continue to function as a
tion of several central-government and local-gov lower safety net linked to unforeseen high
ernment services. This provides breadth in the expenses, short-term and acute needs for assis
portfolio of tasks ensuring a comprehensive labour tance and in special transitional phases. The Gov
and welfare policy and constitutes a better starting ernment has raised the rates in the state advisory
point for providing assistance to people on the guidelines for apportionment of subsistence sup
fringes of the labour market. Users of NAV offices port in order to improve the economic situation
shall have easy access to services and receive and living conditions of people who need social
quick, comprehensive clarification of needs, indi assistance in a passing difficult situation.
vidual follow-up adapted to the needs of the individ One of the focus areas in the Escalation Plan for
ual and coordinated services. Mental Health (1999–2008) is improving the acces
The Government’s Action Plan to Combat sibility of work and labour market measures
Poverty aims to improve the living conditions and through targeted measures for people with mental
opportunities of the members of society with the ailments. The Directorate for Health and Social
lowest incomes and the worst living conditions. In Affairs and the Directorate of Labour and Welfare
2007, initiatives aim to ensure that everyone has are collaborating on a strategy for labour and men
the opportunity to work, that all children and tal health. The goal of the strategy is that people
young people are able to participate and develop, with mental ailments shall have better opportuni
and to improve the living conditions of the most ties to make use of their capacity for work. The
disadvantaged people. escalation plan for efforts to combatsubstance
Many of the most disadvantaged people need to abuse is intended to help more drug addicts and
improve their competencies and qualifications and alcoholics become socially and occupationally
require health and rehabilitation services before rehabilitated by strengthening and coordinating
they can participate in paid work or measures pre treatment and rehabilitation measures in the field
paring them for employment. In 2006, the focus on of substance abuse.
targeted labour market measures for long-term Experiences from the Competence Reform in
recipients of social benefits, young people and lone Norway reveal that the people with the fewest
providers whose main income is social benefits and skills and least education to begin with benefited
the least from the reform. Report no. 16 to the competence and quality in order to improve ser
Storting (2006–2007) Early intervention for lifelong vices offered by the municipalities and specialist
learning therefore paves the way for amendment to health service, improving the accessibility of the
the Act relating to Primary and Secondary Educa services, and enhancing coordination, user partic
tion so that adults aged 25 or older who have not ipation and facilities for next of kin.
completed upper-secondary education are entitled Steps are to be taken to develop a more knowl
to this education. The Government has also initi edge-based service. In this context, closer ties are
ated measures to build capacity in and expand the needed between research and practice. Four social
programme for basic competencies in working life offices are being established at universities and
and measures to build capacity in education within university colleges in order to improve research on
the Norwegian Correctional Services. For prison topics and methods in the social services and to
ers, specially adapted training can be decisive for ensure closer ties to practical experience. In addi
successful rehabilitation. For this reason, the Gov tion, a new research programme is being set up
ernment has made arrangements to improve edu under the auspices of the Research Council of Nor
cation for prisoners. way, and a substance abuse research centre is
going to be established at one of the universities.
The Directorate for Health and Social Affairs is
8.2.2 Health and social services going to collaborate with the Norwegian Associa
The health service shall offer good quality health tion of Local and Regional Authorities (KS) on car
and care services to everyone. The goal is equita rying out projects to investigate whether the
ble services regardless of place of residence, per organisation of tasks within the social services
sonal economy, gender, ethnic background and the affects quality and accessibility.
individual’s life situation. People with serious sub Steps are going to be taken to improve social
stance abuse problems, prisoners, women and chil and health workers’ competencies in substance
dren who have been exposed to violence in close abuse issues and their knowledge about the links
relations and traumatised refugees and asylum between substance abuse, psychiatric problems
seekers need specially adapted measures. and social problems. More expertise is necessary
The NAV reform is intended to ensure that peo to render service providers better able to recogn
ple who are completely or partially unemployed ise substance abuse problems as early as possible
and receive public benefits because of illness, and to be able to provide follow-up that is better
unemployment or social problems are offered adapted to the individual’s needs. The central
coordinated services. health authorities will contribute to raising compe
tencies by developing survey tools and handbooks.
In addition to strengthening research, a new
People with substance abuse problems course of continuing education in substance abuse
Drug addicts and alcoholics have a documented is going to be developed at university colleges for
underconsumption of health services in the munic social and health workers, and the current training
ipal health service and in the specialist health ser in substance abuse medicine for doctors and psy
vice. In recent years, extensive changes have been chologists is going to be improved. The Norwe
made regarding who is responsible for what in the gian State Housing Bank has a grant scheme for
health care services for drug addicts and alcoholics. continuing education in housing social work that is
The Drug Reform in 2004 entailed that the regional going to be continued.
health enterprises took over responsibility from the Since drug addicts and alcoholics often have
county authorities for specialised services for drug serious health problems and social problems, the
addicts and alcoholics. This included medication- «individual plan» is an important tool in ensuring
assisted rehabilitation. A number of street-based coordination of the services they receive. Services
outreach health services have also been introduced must be designed to allow user participation
to improve conditions for heavy drug addicts, such throughout the entire planning process. In order to
as dental health services and trial projects with field increase the use of individual plans, the central
nursing stations and needle rooms. health authorities are going to attach greater
Within the framework of the escalation plan for importance to training and assistance in compiling
efforts to combat substance abuse, the Govern these kinds of plans. The Directorate for Health
ment will coordinate and bolster services offered and Social Affairs, the County Governors and the
to people with substance abuse problems. Tools regional health enterprises have all been ascribed
include research, interventions to raise levels of tasks linked to training and developing materials.
little contact with the labour market, are homeless,

Box 8.1 The field nursing station and had a very difficult childhood. These social
problems are probably both a cause and conse
The field nursing station was established in quence of criminality and substance abuse. There
January 2005 by the Salvation Army on is therefore a great need to improve the general liv
commission from the Ministry of Health ing conditions of prisoners. Half of all prisoners
and Care Services. This is a three-year trial have children, and their families will often need
project fully funded by the state. extra help to be included in society.
The field nursing station has ten beds and Prisoners and convicts are entitled to the same
a few emergency places. It is intended for services as the rest of the population. People who
drug addicts and alcoholics who are not ill need long-term and coordinated health and social
enough to require admission to hospital, services are entitled to have an individual plan
but who need nursing and round-the-clock drawn up, detailing planned treatments and inter
medical care in connection with prolonged ventions. This right is laid down in the Patients’
illness. The field nursing station collabora Rights Act, the Act relating to the municipal health
tes with the social and health services and services and the Act relating to social services.
the hospitals in Oslo. Primary health services for prisoners are pro
vided by the municipality in which the prison is
located (cf. Section 1–3 of the Act relating to the
municipal health services). Specialist health ser
The objective of the low-threshold measures vices are generally provided by the health enter
within the municipal social and health services is to prise where the prisoner is registered as living in
improve the life situation of substance abusers, the Population Registry. The municipality in which
including reducing health problems, reducing the prisoner was resident before incarceration is
overdoses and taking steps to ensure that individu responsible for social services and other municipal
als can lead a decent life. Drug addicts and alcohol labour and welfare services. Social services are
ics often have major health problems and live in cir particularly important when planning release from
cumstances that make it difficult for them to make prison. The reality is that very many prisoners are
use of the ordinary health services. Preliminary still released with no home, no work, no training
reports indicate that low-threshold measures reach opportunities and no therapeutic contact person to
their target groups, that they improve health and go to, and they often revert to substance abuse and
that they may have contributed to a decrease in the crime. In many cases, the prison a person is incar
number of overdoses. The low-threshold health cerated in is a long way from their home municipal
services are important in preventing the spread of ity. This makes it difficult in practical terms to
hepatitis and HIV. It also seems that use of special establish close contact between the prisoner and
low-threshold health services leads to increased the responsible service providers. The individual
use of ordinary health services. Drug addicts and plan is therefore often an important tool in ensur
alcoholics also have problems using ordinary den ing a comprehensive, coordinated and individually
tal health services, because of a lack of money and tailored range of services. The Government is
other circumstances linked to their situation. For going to institute a process to assess how the ser
this reason, a special financing scheme has been vices aimed at prisoners can be better coordinated,
set up for dental health measures for drug addicts using the individual plan as one of several tools.
and alcoholics undergoing treatment in the special With a view to establishing good systems of col
ist health service or who receive municipal ser laboration and common plans regionally and
vices. Arrangements have been made for these ser locally, the Ministry of Justice and the Police and
vices also to include dental treatment. In 2007, the the Norwegian Association of Local and Regional
Government is going to initiate an evaluation, the Authorities (KS) have entered into an agreement
findings of which will then form the foundation for on collaboration between prisons and municipali
further development of these measures. ties regarding settlement. A circular has been
drawn up clarifying responsibilities, tasks and
coordination among the municipalities, the special
Prisoners ist health service and the Norwegian Correctional
Prisoners have many more problems than the nor Services regarding incarcerated and convicted
mal population. Many prisoners have serious drug drug addicts, to enhance collaboration and ensure
problems, psychiatric problems, little education, continuity in the measures (Circular G8/2006).
Through the escalation plan for efforts to com through having a home of their own, work and par
bat substance abuse, the Government wants to ticipation in leisure activities.
help ensure that more prisoners with substance Targeted work to reduce society’s stigmatisa
abuse problems have access to better rehabilita tion of the mentally ill is another important part of
tion and treatment during their time in prison. A the plan. This is achieved indirectly by developing
goal has been set of increasing the number of days the possibilities for mentally ill people to live alone
of their sentence that prisoners serve in institu and participate in social arenas and in the volun
tions, i.e. in a rehabilitation or care institution or in tary sector, for example through interest organisa
other municipal facilities for prisoners with sub tions for the mentally ill. By the end of 2007, 3400
stance abuse problems. At present, the prisons in sheltered homes with staff that have competence
Oslo, Bergen and Trondheim have units offering in mental health care will be ready for habitation.
prisoners with substance abuse problems the Day centres and organised activities have been set
option of alternative means of serving their sen up in many municipalities in collaboration with vol
tence. These units offer rehabilitation of people untary organisations. An information campaign
with substance abuse problems while they are in aimed at children and young people is also going to
prison. These units also provide counselling and be carried out in order to increase knowledge
cooperate with the social services on individual about mental health and prevent stigmatisation.
plans for prisoners that need a number of different,
co-ordinated services. Based on experiences from
these units, three new drug rehabilitation units are Victims of violence in close relations and
being set up in 2007. traumatised refugees and asylum seekers
A three-year trial scheme, the Drug Pro A number of initiatives have been implemented to
gramme under Court Control, is currently under strengthen the public services’ competencies in
way in Oslo and Bergen offering individually sexually and physically abused children and
adapted rehabilitation as an alternative to prison women, children who have experienced violence in
for convicted drug addicts. The participants close relations, and traumatised refugees and asy
receive services from the municipality and the spe lum seekers. In 2004, the Norwegian center for
cialist health service as part of an active rehabilita studies on violence and traumatic stress (NKVTS)
tion programme. This trial scheme is also helping was founded, and in 2006, five regional resource
develop models for cross-sectoral collaboration centres on violence, trauma and suicide were being
between the Norwegian Correctional Services and set up. Both the national and the regional centres
the participating health enterprises and municipal are important in the drive to improve competen
ities. The trial scheme will be evaluated. The Gov cies in the health and social services, the child wel
ernment wants to increase the use of serving sen fare authorities and the police, among others.
tences in rehabilitation or care institutions (known NKVTS has been commissioned by the central
as a «Section-12 sentence»: under section 12 of the authorities to start work on improving knowledge
Execution of Sentences Act, prisoners may, in cer in basic and continuing education for various pro
tain cases, serve their sentence in an institution fessionals. Special incentive grants have been allo
that is not a correctional service facility). In cated for building capacity in the health services
autumn 2006, the Ministry of Justice and the Police for people who have suffered sexual abuse and vio
circulated a proposal called Quick response, measu lence in close relations. The goal is to have at least
res to reduce the prison queue and improve the con one or two accident and emergency units in each
tent of serving sentences for review. The proposal of county with this kind of function.
increasing the number of «Section 12 days» is Important strategies to prevent violence in
included in this draft proposal. close relations include early intervention by the
police and public assistance agencies and expand
ing the treatment services available to perpetra
People with long-term psychiatric problems tors. Measures to look after women and children
Many people with long-term psychiatric problems who have been victim to violence are discussed in
are recipients of social assistance and are prone to the Plan of Action to Combat Domestic Violence and
social exclusion. One of the main goals of the Esca Strategy to Combat Physical and Mental Child
lation Plan for Mental Health is to develop a range Abuse.
of services designed in a way that promotes the More general policy instruments to reduce
individual’s possibilities for social inclusion social inequalities in access to the health services
are discussed in chapter 7 on the health service.
functional capacity are underreported among

8.2.3 Housing policy homeless people.
One of the main goals of housing policy in Norway The Government wants to bolster its efforts for
is that everyone should live in good, safe condi homeless people through the national strategy to
tions. Along with work, health and education, hous combat and prevent homelessness The pathway to a
ing is a key element in the welfare society. Good permanent home and has set itself the goal of elim
housing provides a foundation for a decent life and inating homelessness. Priority is going to be given
is often decisive for people’s health and participa to providing people with permanent homes,
tion in working life. Housing is especially impor instead of using hostels and other temporary
tant for children, the elderly, people with reduced accommodation. Services will be adapted more to
functional capacity or poor health and people with the needs, abilities and situation of the individual,
little or no contact with the labour market. and steps will be taken to ensure good collabora
Housing-policy instruments have contributed tion among the municipalities and the specialist
to the distribution of housing in Norway being bet health service, the child welfare service and the
ter than might be expected on the basis of income Norwegian Correctional Services.
distribution alone. The central government’s main The Government is basing its work on provid
task in housing policy is to define housing-policy ing housing for homeless people on the principle
targets and facilitate implementation on the local that everyone has the ability to reside and that the
level. The central government must ensure good, follow-up services offered must be adapted to the
appropriate economic and legal framework condi challenges and resources of the individual. There
tions and provide measures to raise competencies. is great variation concerning the degree to which
The local authorities have a statutory responsibil individuals are capable of living in their own home
ity to provide housing for people who cannot find and what kind of follow-up services they need. We
housing on their own or who are in an acute crisis must recognise that living in a home of one’s own
situation. The municipalities facilitate construction is not always only good; sometimes it also entails
of homes and take advantage of schemes from the challenges, for example in the form of loneliness.
Norwegian State Housing Bank for people that are The design of housing solutions and follow-up
disadvantaged in the housing market. needs must take this into account. Researchers
In general, Norwegian homes are of a high have also pointed out that assistance must not be
quality. This is the result of a conscious housing stopped or reduced too early. It is often when the
policy over many years based on the philosophy individual appears to be managing well and has
that even people with low income are entitled to acquired the skills necessary to live alone that they
live well. Nevertheless, some groups live in poor have the greatest need for assistance and support.
conditions. This applies in particular to people who
can be categorised as homeless.
A study performed in 2005 shows that there are 8.2.4 Voluntary organisations
5500 homeless people in Norway. Very many of Voluntary organisations are social meeting places
these people also have other problems, such as where people can nurture common interests
substance abuse problems and psychiatric prob across social divides. Participation in voluntary
lems. The World Health Organization emphasises organisations contributes to social inclusion
that homelessness entails especially high health because it provides opportunities for developing
risks. People who live on the street have a very friendships and being included in a group with
high incidence of premature death. 15 % of the shared interests. Social inclusion means individu
homeless people in Norway have somatic illnesses als are linked to social life through participation in
or reduced functional capacity. This proportion has different arenas. Voluntary organisations are are
remained unchanged since 2003. Homeless people nas where people come into contact with social net
over age 65 have more physical health problems works outside their own private sphere.
than other homeless people. Three-quarters of the Voluntary organisations can help provide an
homeless people have mental illnesses and/or are alternative sense of identity and social inclusion for
addicted to drugs or alcohol. The proportion of groups who drop out of ordinary social functions
drug addicts and alcoholics has dropped from 71 % such as education and employment. Relevant
in 2003 to 60 % in 2005. The proportion of homeless examples include systems providing networks of
people with mental illnesses has risen since 1996 contacts and volunteer centres. Peer-to-peer sup
and in 2005 was 38 %. There are grounds to assume port systems organised by voluntary organisations
that somatic illnesses and perhaps also reduced
are often felt to be better at treating people as

Box 8.2 Example of peer counselling: equals than the public support services.
WayBack – Life after prison In addition to the intrinsic value of participating
in voluntary organisations, the voluntary sector
WayBack is a foundation consisting of for- also provides welfare services. Voluntary organisa
merly convicted people who help themselves tions supplement government efforts in the follow
and others achieve a life without crime and ing ways:
drugs. The majority of the board of directors – Helping identify and put on the agenda new
must always be formerly convicted people. In needs that ought to be followed up through
this way, the board of directors will always public initiatives
have first-hand knowledge about what is – Influencing the work on developing the wel
required of people who have chosen to start fare state by criticising the public authorities
afresh. WayBack consists of people who are – Tapping into resources and providing services
there for each other 24 hours a day. that complement the public services and facili
WayBack describes the reality thus: people ties
who have just been released from prison with
new hopes and good intentions experience The Government wants to nurture and further
loneliness, emptiness and frustration. Get- develop its close collaboration with voluntary and
ting assistance from the public services non-profit organisations. Material security is
requires energy, motivation and knowledge important, but it is not enough to render life good
of the rules, legislation and where to go. and meaningful. The Government aims to make
Wherever you go, you are labelled – ex-con- sure everyone receives care and security, through
vict and/or drug addict – a status that means good public welfare services and by supporting
you are unreliable and dubious. This makes and facilitating involvement in voluntary organisa
it difficult, if not impossible, to get a job. tions and development of a vital civil society.
«Accommodation» often means a room in a
hostel where you are surrounded by crimi-
nals and drug abusers. More than a third of 8.2.5 Deprived geographical areas
formerly convicted people are homeless. Geographical inequalities in health usually coincide
Many of them have good intentions of star- with geographical inequalities in living conditions.
ting over again, but few are met with any In the work on reducing social inequalities in
trust. Not many people understand how over- health, a geographical approach to designing mea
whelming this transition is. Public support sures is important, not least because it allows mea
people have limited resources, time and
sures to be targeted without stigmatising certain
insight. People who feel insignificant and
groups. When measures are specifically targeted at
worthless in society may also fall prey to
defined areas that have major health and social
loneliness and the need to score after 4 PM.
problems, it is also easier for us to evaluate the
WayBack works to ensure that formerly
effectiveness of the measures. This kind of
convicted people can lead a life without drugs
approach can also help ensure that the imple
and crime, are more easily reintegrated into
mented measures reach their intended target
society and working life through active buddy
group. Oslo is a prime example of the correlation
support, and can become responsible citi-
between social inequalities in health and geography.
zens. It also helps people released from pri-
The inequalities in average life expectancy among
son find work and somewhere to live and
urban districts vary by almost 12 years for men.
offers meaningful leisure and social activities
It is not only living conditions and health that
in a drug and alcohol free setting.
are unevenly distributed geographically. Negative
WayBack visits prisons and talks to priso-
environmental factors also tend to be concentrated
ners about housing, education and work. A
together in certain areas. If we rank areas in the
contact group is set up for each individual pri-
municipalities according to the quality of the resi
soner. The input required of prisoners who
dential environment, clear inequalities will be found
join WayBack is that they truly wish to lead a
in most municipalities. In certain municipalities,
life without crime and substance abuse and
that they make a positive contribution to the
especially urban municipalities, there are consider
peer-to-peer support work in WayBack. able social inequalities. Inequalities in health and
the quality of the residential environment generally
coincide and are socially determined: groups that
burdened with even more negative environmental

Box 8.3 The Stavanger statistics factors, e.g. the Planning and Building Act. By
choosing carefully where housing and business pre
The Stavanger statistics is a tool for survey mises are located, it is possible to avoid traffic con
ing living conditions at a low geographical gestion and keep polluting, noisy industrial plants
level in order to detect concentrations of away from residential areas. Measures can also be
social problems. Units smaller than urban implemented to improve environmental conditions,
districts will often be required to identify for example by ensuring that green spaces, parks
these kinds of concentrations. «Living con and open outdoor areas do not disappear and by
ditions zones» (levekårssoner) allow us to planting new green areas. In collaboration with the
study trends in living conditions in small roads authorities, the municipalities can control
geographical areas over time. traffic and protect particularly sensitive areas.
Stavanger has defined «living conditions Local authorities can also improve the range of
zones» of approx 1500 inhabitants. It is services offered and implement social measures in
important that as far as possible the zones deprived areas. A prerequisite for this is that the local
have homogeneous types of buildings and authorities have good tools for assessing the quality
residential environment. In Stavanger, the of the residential environment in the municipality at
«living conditions zones» have been defined an appropriate geographical level. The approach
in collaboration with experts in the educa used as a basis for the system of incentive funds for
tion, leisure, health and social sectors in the regional and local partnerships for public health is
urban districts. The statistics consist of 16
also a good starting point for implementing mea
indicators providing information about key
sures aimed at particularly deprived areas. In large
aspects of the population’s living conditions.
towns and cities, the partnerships can set up sepa-
A survey of living conditions is underta
ken each year. These surveys provide a
detailed picture of the inequalities in living
conditions in the municipality and constitute Box 8.4 The MoRo project
an important basis for discussion and reflec The MoRo project is a joint project underta
tion in planning processes. The survey of ken by the Romsås urban district of Oslo,
living conditions is used when allocating ope the Norwegian College of Physical Educa
rating funds to the sectors. Extra resources tion and Sport, the Norwegian Institute of
for enterprises that serve areas with social Public Health and Aker Hospital. It was initi
problems or for infrastructure in these kinds ated against the background of the special
of areas make the areas more attractive to all health challenges in the urban district,
groups in the population. Using land-use including a high incidence of type 2 diabe
planning and housing policy as tools, the tes and cardiovascular diseases. The main
municipality can help reduce social inequali goal was to promote physical activity in the
ties between geographical areas by influen urban district, in the population of the
cing widespread relocation patterns. urband district in general and in groups
with especially high risk of illness.
Interventions were followed up by syste
score worse on some indicators tend to score worse matic evaluations of their impact. Romsås
on others too. Deprived urban areas are usually was compared with another urban district
areas with a high proportion of recipients of social with a similar population. Two health inter
assistance, social security benefits, etc. Property view surveys were carried out in the urban
prices reflect the quality of the residential environ districts, one before and one after the mea
ment and reinforce the pattern of people with high sures were implemented. The evaluation
income moving to areas with a high-quality residen showed that the proportion of physically
tial environment and low-income groups moving to inactive people was reduced by around
areas with a poor-quality residential environment. 25 %, people put on less weight than in the
These kinds of mechanisms result in a geographi neighbouring urban district, and more peo
cal concentration of vulnerable groups, which may ple stopped smoking. The measures were
in turn exacerbate social inequalities in health. effective regardless of education, income
The municipalities have policy instruments at and nationality.
their disposal to prevent deprived areas becoming
rate Health Action zones, similar to the spearhead Knowledge Promotion Reform. Another example
groups used in the United Kingdom (see appendix of an initiative aimed at a delimited geographical
I). Tools to assess the quality of the residential envi area is the Action Programme for Oslo Inner East,
ronment and the Partnerships for Public Health sys which was terminated in 2006. Experiences from
tem are discussed in more detail in chapter 10. this action programme and suggestions for further
In the upcoming Report to the Storting on Oslo follow-up will be discussed in the Report to the
«the Capital Report», the Government will discuss Storting on Oslo «the Capital Report». The Minis
central-government policy instruments for combat try of Health and Care Services wants to attach
ing the increases in social inequality in the Oslo more importance to policy instruments for reduc
region. The Government wants to fight poverty, ing social inequalities in health in these kinds of
homelessness, unemployment, drop-out from efforts. Efforts targeting specific geographical
upper-secondary education and social exclusion. areas may also be an important channel for mea
The efforts in Groruddalen are one example of sures aimed at social groups with a high risk of
central and local government collaboration aimed health problems.
at a defined geographical area with specific health In order to improve knowledge about the effec
and social problems. The municipality bears the tiveness of measures to reduce social inequalities
main responsibility, but the Government wants to in health, it is important to evaluate the impact of
help prevent the trend toward a divided city with preventive measures on these kinds of inequalities
poor living conditions, environmental problems in health. In many cases, it will be possible to
and ghettos of immigrant groups in certain areas. implement measures as trial projects in limited
The policy for the capital will build on the Govern areas and compare the results with control areas.
ment’s policy for inclusion and integration, the An example of this is the MoRo project that was
recent major investments in kindergartens and the carried out in the Romsås urban district of Oslo.
Box 8.5 Policy instruments: Targeted initiatives to promote social inclusion

The Government will: – evaluate and further develop the health ser
– move away from passive minimum income vices available for people with substance
to active measures and services based on abuse problems and other groups who
individual needs for everyone who receives need specially adapted services
a temporary minimum income from the – implement measures to improve coordina
state, cf. Report no. 9 to the Storting (2006– tion between interdisciplinary specialised
2007) Employment, welfare and inclusion treatment for drug addicts and mental
and Action Plan to Combat Poverty health care to ensure that patients receive
– follow up in a systematic and structured coordinated treatment
way people who lack or have insufficient – strengthen the efforts to combat home
work experience from before by means of lessness, cf. Action Plan to Combat Poverty
measures, services and minimum income, and the strategy The pathway to a perma
cf. Report no. 9 to the Storting (2006– nent home
2007) Employment, welfare and inclusion – stimulate greater participation among
and Action Plan to Combat Poverty groups that are underrepresented in vol
– establish a qualification programme with a untary organisations
standardised qualification grant and imple – in the upcoming Report to the Storting on
ment other measures to ensure that every Oslo «the Capital Report» provide a broad
one is given the opportunity to find work, review of measures to reduce social ine
cf. Report no. 9 to the Storting (2006– qualities in the Oslo region
2007) Employment, welfare and inclusion – encourage implementation of measures to
and Action Plan to Combat Poverty reduce social inequalities in health in espe
– improve opportunities for adults to acquire cially deprived areas
basic skills and participate in basic school
ing, cf. Report no. 16 to the Storting
(2006–2007) Early intervention for lifelong
learning
Part IV
Develop knowledge and cross-sectoral tools
9 Annual policy reviews
«Social inequalities in health are closely related to social inequalities

in other areas of life. Efforts to reduce social inequalities in health must therefore be followed up
in all sectors»
Figure 9.1 Develop knowledge and cross-sectoral tools

many cases, it may be pertinent to use different

9.1 Objective: Systematic overview of indicators of social position in different areas, but it
developments should be a goal that at least one of the three core
indicators (education, occupation or income) is
Objective used in most contexts.
• Ensure a systematic overview of developments The Directorate for Health and Social Affairs
in the work on reducing social inequalities in will publish an annual report based on the review
health and reporting system. This report must be com
piled in such a way that it can be used as a basis for
the annual reporting in the budgets. The annual
9.2 Policy instruments reports will contain a presentation of the main initi
atives and strategies on the national level, in con
9.2.1 Review and reporting system junction with the goals for reducing social inequal
The Government will monitor developments in the ities in health, as well as comments on the trend of
four priority areas defined in this Report to the each indicator. The report will be compiled in close
Storting by means of a new review and reporting collaboration with relevant professional environ
system, providing a systematic, regularly updated ments.
overview of developments in the work on reducing A joint report will be included in the Ministry of
social inequalities in health. The review and report Health and Care Services’ budget proposition. The
ing system will be based on the objectives and Ministries must collaborate in connection with
other goals described in the individual chapters in development of the performance indicators and
this Report to the Storting. One or more perfor compiling the budget presentation.
mance indicators will be developed for each of the In addition, the Norwegian Institute of Public
defined objectives and goals enabling monitoring Health will publish regular reports on trends in
of developments over time. social inequalities in health outcomes (mortality
The Directorate for Health and Social Affairs and morbidity). This is discussed in more detail in
will be responsible for coordinating the design and chapter 11 Advancing knowledge.
development of these indicators. This work will be
done in close collaboration with the relevant direc
torates and professional environments in the vari
ous sectors involved. The indicators must be Box 9.1 Policy instruments: The review
selected against the background of common and reporting system
assessments of factors such as which data are avail
able and what kind of indicators are best suited to The Government will:
reflecting trends in social inequalities in the area. – establish a review and reporting system
Whenever possible, the indicators ought to build to monitor developments in the work on
on existing sources of data. reducing social inequalities in health
It is important that the indicators of social posi – report on developments in the work on
tion used in the different areas are compared and reducing social inequalities in health in
coordinated, with each other and with the reports the Ministry of Health and Care Ser
on trends in health outcomes used by the Norwe vices’ annual budget propositions
gian Institute of Public Health (cf. chapter 11). In
10 Cross-sectoral tools
tools. The purpose of planning pursuant to the

10.1 Objective: All sectors of society Planning and Building Act is to coordinate physi
assume responsibility cal, economic, social, aesthetic and cultural devel
opments in the municipality. Municipal planning is
Objective a central arena for ascribing priorities in the munic
• All sectors of society must do more to promote ipalities and embraces developments within the
good health and reduce social inequalities in municipality as a whole, and developments within
health. individual sectors and areas of activity. The social
part of the Municipal Master Plan defines targets
for long-term developments in the municipality and
10.2 Policy instruments thus forms the frame for the individual sector’s
activities. For example, defining a goal of reducing
There is a documented need for awareness raising social inequalities in health entails that sectors
and sharper focus in all sectors and on all adminis such as schools, culture, business, social services
trative levels regarding the social distributional and health must also develop targets and strategies
effects of social processes, strategies and mea for reducing social inequalities in health.
sures. Social inequalities in living conditions and
welfare schemes may together have had a signifi
cant influence on the social inequalities in health. 10.2.1 Health impact assessments nationally
In the same way as we have often overlooked social and locally
inequalities in health, perhaps we may also be over Official studies carried out by or for central-gov
looking systematic inequalities in other basic wel ernment administrative bodies must follow the
fare areas. rules laid down in the Instructions for Official Stud
It is therefore necessary to render visible how ies and Reports. These instructions define require
policies in all areas of society have consequences ments concerning impact assessment of public
for social inequalities in health. Cross-sectoral reforms, amendments to regulations and other
challenges of this nature require cross-sectoral measures. Impact assessment shall include an
tools. Health impact assessments are one such tool assessment of all the considerations that are mate
that can be used nationally, regionally and locally. rial to the case in hand. In addition to the economic
Health impact assessments are a systematic and administrative impacts, other significant con
assessment of how a decision can affect health and sequences must also be assessed. Impact assess
distribution of health in the population. Impact ment should be considered in areas such as health,
assessments do not simplify causal connections, equal opportunities and the environment. With
but this tool does help generate knowledge more regard to gender equality and environmental
systematically. Impact assessment is a tool that issues, special handbooks have been compiled
helps us ask the questions necessary to evaluate describing how these considerations can be better
the effects of a measure. This provides a better incorporated into official studies. The Directorate
basis for making decisions and can help raise for Health and Social Affairs is currently working
awareness in policy and strategy design. This does on devising methods to ensure compliance with
not mean that other sectors have to assess the the provisions concerning health impact assess
health impact of every single measure they imple ments in the Instructions for Official Studies and
ment. In many cases, assessing the distributional Reports. The Ministry of Health and Care Services
effects will be enough, because we know that social will make sure that guidelines are drawn up and
inequalities in distribution of determinants of made available to all the ministries.
health generate social inequalities in health. In general, the Instructions for Official Studies
Regionally and locally, the municipalities’ social and Reports work best for economic and adminis
and land-use planning are useful cross-sectoral trative impacts. Experiences from trying to inte
grate the equality dimension suggest that work view or health profile can be based on national
needs to be done to develop a broad set of policy data, which is then broken down to the municipal
instruments to ensure that equality is promoted in level, and on surveys within the municipalities.
all sectors. For example, all ministries are sup In collaboration with the Norwegian Institute of
posed to assess equality within their own budget Public Health and Statistics Norway, the Director
areas in connection with the fiscal budget. The ate for Health and Social Affairs has set up a dedi
requirement that equal opportunities be promoted cated Internet portal for local authority health pro
is laid down in the Equal Status Act. files that the municipalities can use as a tool in their
In strategies within the EU, WHO and many planning. The portal contains key figures and indi
countries with which we can compare ourselves, cators for determinants of public health, among
impact assessments are being launched as a mea others, as well as factual documentation, articles
sure for reducing social inequalities in health. on a range of related subjects, examples of local
However, any tool is only as useful as the user measures and links to other relevant websites. The
makes it. Efforts to combat social inequalities in portal is under continuous development, and tools
health require political willingness to put distribu are being developed for use in municipal planning.
tion issues on the agenda. The Government is The Ministry of Health and Care Services wants to
therefore going to adopt a policy that strengthens ensure that social inequalities in health are a main
the individual’s personal safety through strong priority in future developments.
common welfare schemes and fair redistribution. The Ministry of Health and Care Services is
The Regulations of 1 April 2005 on Environ going to consider policy instruments to make data
mental Impact Assessment lay down that when about the quality of the residential environment
necessary impact assessments shall include anal more easily available to the local authorities. One
ysing the consequences for public health. This relevant measure may be development of a better
applies to consequences for public health due to set of indicators for the quality of the residential
significant changes in the composition of the popu environment that can be incorporated into the
lation, the housing market, housing needs or the internet portal for local authority health profiles.
need for services (cf. Section 4 of the Regulations). Another solution is to compile guidelines and
These are key social determinants of health and examples showing how the quality of residential
social inequalities in health. The Directorate for areas can be assured.
Health and Social Affairs is working on developing It is a goal that measures to prevent social ine
methods and guidelines and building up competen qualities in health be ascribed greater priority in
cies with a view to ensuring that these consider the social part of the Municipal Master Plan, the
ations are systematically assessed in impact land-use part of the Municipal Master Plan, Munic
assessments pursuant to the Planning and Build ipal Area Plans on various topics and Local Devel
ing Act. opment Plans. For example, there are indications
of clear social inequalities in the distribution of
environmental factors, such as noise, air pollution,
10.2.2 Municipal social and land-use planning access to green areas, traffic safety and recreation
Local decisions affect childhood conditions, living grounds. The Directorate for Health and Social
conditions and health behaviour. The Planning and Affairs has commissioned the Institute of Trans
Building Act is the main tool available to the local port Economics, which collaborates with Statistics
and county authorities in their social and land-use Norway, to develop a tool for comparing social and
planning. The population’s health must be a prime economic indicators with environmental indicators
concern in all social and land-use planning. Public in a way that can be used in planning.
health work entails measures to improve the popu
lation’s health and measures to ensure a more even
distribution of factors that influence health. Planning expertise in the health sector
Pursuant to Section 1–4 of the Act relating to Greater advantage can be taken of the interdiscipli
the municipal health services, the municipalities nary planning arena in public health work, if the
must have an overview of the state of the popula health service and the rest of the sector make
tion’s health and the factors that affect it. A good more of their roles as contributors in the planning
overview is a prerequisite for putting public health processes in counties and municipalities. In addi
issues on the agenda in connection with decision tion to good knowledge of the field and expertise in
making and for being able to implement target-ori monitoring health and other public-health spheres,
ented, quantifiable measures. This kind of over competence is needed in how this knowledge can
be exploited in ordinary planning and decision- administrations, local government and voluntary
making processes. The Directorate for Health and sector all pulling in the same direction. Regional
Social Affairs has noted that many municipalities, central-government agencies, regional health
and especially the municipalities involved in part enterprises, university colleges and universities,
nerships for public health, request guidance con and voluntary organisations are all important
cerning how they can make better use of municipal actors in the regional partnerships.
planning to promote health interests. From 2006 on, 16 of Norway’s 19 counties and
In collaboration with the Ministry of the Envi a large number of municipalities in these counties
ronment, the Directorate for Health and Social are involved in the scheme. In the budget for 2007,
Affairs has set up a five-year development and trial the scheme has been expanded so that all the coun
project in a sample of municipalities to ascertain ties have the opportunity to apply for funds to
how the Planning and Building Act and the munic establish these kinds of partnerships. The purpose
ipal planning system can be used as a basis for and of the scheme is to stimulate development of an
instrument to improve public health work. This infrastructure for local public health work. In addi
experiment, called the Health in planning project tion, grant funds are channelled to local public
also includes improving the planning and process health measures through the partnerships. These
ing skills of staff and experts working in the health grants are intended to stimulate development of
sector, for example, through seminars and devel local initiatives to promote a healthy diet and phys
opment of relevant courses of basic training, fur ical activity, and to prevent the harmful effects of
ther education and continuing education. tobacco use.
The Directorate for Health and Social Affairs
has a responsibility to further develop the partner
10.2.3 Partnerships for public health ships as a way of working towards systematic pub
The state awards grants to counties and municipal lic health work firmly rooted in social planning and
ities that organise their public health work in part with broad participation in the population. In light
nerships. The conditions for receiving this grant is of the goal of reducing social inequalities in health,
that the county or municipality also contributes its attention must be focused on underlying factors
own funds and that the public health work is firmly that influence health and how they are distributed.
anchored in the municipal and county-planning For example, good inclusive schools and inclusive
system. The purpose of this grant scheme is to working life play a large part in reducing inequali
make local public health work more systematic ties in health. It may also be pertinent to bolster
and comprehensive by ensuring a stronger admin efforts aimed at geographical areas with concen
istrative and political grounding and by improving trations of social problems.
coordination between authorities and the labour The workplace is another important arena for
market, schools, voluntary organisations and oth preventing social inequalities in health. In addition
ers. to monitoring sickness absence and efforts to pro
In their capacity as a regional development mote a more inclusive working life, anti-smoking,
actor and regional planning authority, the county drinking and drugs campaigns and a health-pro
administrations have been ascribed the role of moting working environment can be developed as
prime movers in the partnerships. County plan areas of cooperation.
ning is done across sectoral and hierarchical The Government has decided that reducing
boundaries and is therefore ideal for raising public social inequalities in health will be afforded greater
health issues that require a broad approach and priority in all public health work performed under
that depend on the central government, county the auspices of regional and local partnerships.
Box 10.1 Policy instruments: Cross-sectoral tools

The Government will: – develop sets of indicators for social deter
– anchor the use of impact assessments and minants and the quality of the residential
other tools to assess distributional effects environment that can be incorporated into
in the management on the central-govern the internet portal for local authority health
ment, county and municipal levels through profiles that the Directorate for Health and
steering documents and the review and re Social Affairs has developed in collabora
porting systems tion with the Norwegian Institute of Public
– ensure that the issue of distribution is inte Health and Statistics Norway
grated into tools from the Norwegian – refine and bolster the system of incentive
Government Agency for Financial Man funds for regional and local partnerships
agement for public health, and define requirements
– further develop expertise in health impact that social inequalities in health must be
assessments in the Directorate for Health put on the agenda in local public health
and Social Affairs and ensure that the work
issue of distributional effects is given a – contribute to knowledge about social ine
central position in the work qualities in health being incorporated into
– in collaboration with the Norwegian Asso courses and studies on public health and
ciation of Local and Regional Authorities land-use and social planning
(KS), develop tools that the municipalities – through the «health in planning» project
can use in their efforts to take distribu develop methods and tools to take social
tional effects into account in planning and inequalities in health into account in the
policy design municipal planning processes
– establish collaboration between the Minis
try of Health and Care Services, the Minis
try of the Environment and the Ministry of
Local Government and Regional Develop
ment to ensure that social inequalities in
health are given a more central position in
planning regulations and planning tools
11 Advancing knowledge
social inequalities in health in the member states.

11.1 Objective: Increase knowledge A Norwegian monitoring system ought largely to
about causes and effective follow these recommendations. The working com
measures mittee’s proposal states that if possible a monitor
ing system ought to:
Objective – include nationally representative data for mor
• Increase knowledge about the scope of, causes tality on the individual level
of and effective measures against social ine – include nationally representative survey data
qualities in health. for self-assessed health
– use at least two of the three core indicators of
social status (education, occupation, income)
11.2 Policy instruments – use the same classification of social status over
time
Social inequalities in health constitute a complex – use both absolute and relative expressions of
problem. Moreover, it is only in recent years that inequalities
Norwegian research has started showing an inter – discuss any possible sources of error
est in the social distribution of health. This means
that there is still a large need for knowledge in this The Norwegian Institute of Public Health bears the
area. main national responsibility for monitoring health,
including developing indicators of social inequali
ties in health outcomes.
11.2.1 Monitoring and surveys Chapter 7 on health services proposed special
This section deals with monitoring developments monitoring of social inequalities in the use of
in social inequalities in health outcomes (mortality health services. Chapter 5 on work and working
and morbidity) in the population. We know a fair environment included a discussion of national
amount about the scope of social inequalities in monitoring of work and health.
health in Norway (cf. chapter 2). Social inequalities
have been well documented using many different
means of measuring health and health outcomes, 11.2.2 Research
including total mortality in a number of age A monitoring system will meet many of the needs
groups, cause-specific death, morbidity and self- we have for knowledge about the scope of and
assessed health. However, there is currently no trends in social inequalities in health. However, it
system for monitoring and reporting trends in will provide little information about the causes of
social inequalities in health over time. An impor inequalities in health and which measures may
tant objective of this Report to the Storting is there serve to reduce them. In order to improve our
fore establishing a system for monitoring this understanding of social inequalities in health and
aspect. develop effective political measures that can help
Much of the work on developing specific health reduce those inequalities, we need to know more
indicators for this purpose must be done by about the underlying mechanisms. In the first
experts, not least because of the technical ele instance, then, we need more knowledge about
ments it entails, such as data accessibility and reg mechanisms and policy instruments. This also
ister linking. Existing sources of data represent a includes research on the health service’s contribu
huge potential, but in some areas we still need to tion to inequalities in health.
generate new data. Social inequalities in health is a field of
An EU working committee made up of people research with inherent, fundamental questions
from a broad range of backgrounds prepared a pro concerning what creates good health and what cre
posal in 2001 suggesting guidelines for monitoring ates ill health. This is a field where researchers
apply theories and knowledge from a number of determinants among children and young people
different disciplines, including demographics, ought also to be a priority.
sociology, psychology, epidemiology and medi Geographical perspectives on social inequali
cine. This entails that research on the topic of ties in health are being afforded ever greater place
social inequalities in health is not only useful as a in international research, and there is a need for
foundation for political decisions, but has far-reach better research in this field in Norway too. Knowl
ing relevance. It yields fundamental knowledge edge about the significance of the local environ
about mechanisms that promote health and mech ment for health and inequalities in health may also
anisms that induce sickness, and it is scientifically be able to make an important contribution to the
interesting for many different disciplines. It is design of measures to combat social inequalities in
therefore important that groups of researchers health in the future.
who do not usually define their research as related In the past, there has been little health and
to inequalities in health (for example, clinical social research on multi-cultural communities in
research or physical environment and health) are northern Norway. This is reflected in the lack of
involved. Research on social inequalities in health knowledge about the challenges the health service
ought to be multidisciplinary and interdisciplinary. faces regarding the Sami population. The drive to
In many other countries and in the EU, the build up multi-cultural competencies within the
increased political attention being paid to social health and social services and within research
inequalities in health has been accompanied by communities is therefore crucial.
greater investments in research in the field. For Another research area that may be important
example, the Netherlands have had two nationally for future policies is the significance of different
financed research programmes, the latter of which types of prevention arenas for health behaviour –
focused on testing and evaluating measures. In the such as, for example, school, the workplace and lei
United Kingdom, the national research councils sure. This is an ideal area for intervention
have allocated large sums of money to several research.
major programmes and projects dealing with vari The Government’s research effort concerning
ous aspects of social inequalities in health. In Swe sickness absence is discussed in chapter 11.
den, a special research institute has been set up The need for better knowledge about social ine
with public funding: the Centre for Health Equity qualities in access to and use of the health services
Studies (CHESS). The EU has financed a series of is discussed in chapter 7. Focused research is
major projects on social inequalities in health, needed to ascertain which organisational, legal
some with a focus on comparing the situation in dif and economic mechanisms contribute to inequali
ferent countries and trends within Europe, some ties in access to and use of the health services in
with a focus on providing explanations, and some particular.
with a focus on the success of various measures Another topic requiring greater attention, but
and policies to reduce inequalities. The research where we lack computerised systems that enable
being performed in other countries may be rele routine monitoring is dental health. We currently
vant for Norway, but the transfer value of this know too little about the scope of social inequalities
research will often be limited and uncertain in dental health in the population, and there is no
because of differences between countries. straightforward way for us to gain an overview of
Some topics are especially important for the this situation. Social inequalities in dental health
future design of measures to reduce social inequal are therefore a topic that requires more research.
ities in health. Examples include social inequalities The Government wants to improve the
among children and young people that we gener research on social inequalities in health. Research
ally know too little about. This topic entails partic on social inequalities in health is currently spread
ular challenges. For instance, what we called «core over a range of different research communities
indicators» of social status above are not available and programmes. There is a need for more
for this group (children do not usually have educa research on the distributional perspective in rele
tion, an occupation or income), nor are the most vant research programmes. There is also a need
commonly used indicators of health (mortality and for better coordination of research in this area.
self-assessed health) particularly apt. Since this is Many disciplines and perspectives have important
an age group that is given high priority in preven contributions to make to our understanding of
tive work, research on social inequalities in health social inequalities in health, and interdisciplinary
and social inequalities in the distribution of health approaches are therefore vital.
impacts other than those related to the explicit

11.2.3 Evaluation of measures goals for the measure. For example, a number of
More and more of the public sector is becoming measures have unintended consequences for the
the object of evaluation. In the central government, social distribution of health – or important determi
requirements concerning evaluations are laid nants of health – in the population. If more evalua
down in the Financial Management Regulations, tions of measures that affect health took social dis
where it is stated that «All agencies shall ensure tributional effects into account, we would have
that evaluations are carried out to generate infor more knowledge about how to go about reducing
mation about the efficiency, effectiveness and inequalities in health.
results achieved within the whole or parts of the The Government is therefore going to take
agencies’ mandate area and activities.» In the steps to ensure that more measures that may have
sense it is used in the central government Finan an impact on the social distribution of health in the
cial Management Regulations, an evaluation is a population are also evaluated from this perspec
systematic collection of data, analysis and assess tive. In many cases, it will be possible to implement
ment of a planned, ongoing or completed activity, measures as a pilot project in a limited area and
an agency, a policy instrument or a sector. Evalua compare the impact with control areas. Control
tions can be carried out before a measure is imple studies of this nature are considered a gold stan
mented, while it is in operation, or after it has been dard within research on interventions and mea
completed. The requirements laid down in the sures. Knowledge of this type is in great demand
Instructions for Official Studies and Reports con internationally, and Norway has good opportuni
cerning performance of preliminary assessments ties for making a contribution here.
are an example of a preliminary evaluation
intended to ensure good planning of measures and
schemes. Ongoing evaluations are carried out to Box 11.1 Policy instruments: Advancing
facilitate a change in direction and adjustments in knowledge
the measure, while retrospective evaluations are
usually undertaken to find out whether the mea The Government will:
sure fulfilled its intended objectives, and what, if – establish a system of monitoring trends
any, other consequences the measure may have in social inequalities in health in the po
had. pulation
Evaluations can be performed using a variety of – strengthen research on the spread and
different methods, by different evaluators and with causes of social inequalities in health
different evaluation topics. Results and achieve – evaluate measures implemented to
ment of goals are usually central topics in most reduce social inequalities in health
evaluations. However, many interventions have
12 Economic and administrative consequences
In this Report to the Storting, the Government has the child welfare authorities will be assessed in
focused attention on factors within a number of connection with the annual budgets.
social sectors that contribute to the creation and The Government has initiated a number of pro
perpetuation of social inequalities in health. We cesses to help reduce social inequalities in access
need a broad-based approach to the problem, since to the labour market and social inequalities in the
factors affecting social inequalities in health are working environment through Report no. 9 to the
found in most social sectors. Many of the efforts to Storting (2006–2007) Employment, welfare and
reduce social inequalities in health can be under inclusion, the Action Plan to Combat Poverty, the
taken within the framework of existing economic NAV reform (the reorganisation of the Norwegian
constraints and administrative systems. For exam labour and welfare organisations) and in the follow-
ple, inequalities can be reduced by ensuring that up to the report submitted by the commission
the considerations of distributional effects and appointed to find ways to reduce sickness absence.
social inequalities in health are assessed when In this Report to the Storting, the Government is
changing existing and designing new policies. Nev proposing commissioning an official study to
ertheless, in some areas extra resources will be assess measures to reduce sickness absence in the
needed in the form of new grants. health and care sector in collaboration with the
The Government has attached importance to trade unions’ and employers’ associations. A fol
rendering the causal connections between income low-up to this study will be considered in connec
and health more visible and demonstrating that the tion with the ordinary budget process.
policies we use to promote reduction of social ine With the goal of reducing the social inequalities
qualities are also an important element in the work in health behaviour, the Government is going to
on reducing social inequalities in health. The Gov attach greater importance in the future to pricing
ernment’s decision to maintain and build up com and accessibility policy instruments in the drive to
mon public assets instead of offering tax relief is in prevent lifestyle diseases. Pricing and taxation pol
part based on the ambition of reducing social ine icy instruments will be given special consideration
qualities in health. As part of the proposed review in the work on reducing social inequalities in diet
and reporting system, the Government will moni (cf. The Diet Action Plan). The Government has set
tor developments in income inequality closely. itself the goal of introducing a system of fruit and
The main means of reducing social inequalities vegetables for all pupils in primary and lower-sec
in childhood conditions is provision of high-quality ondary education. The Government also wants to
kindergartens, schools and services available to all encourage daily physical activity and a good frame
children and young people regardless of social work for meals in primary and lower-secondary
divides. The key elements in the policy to create schools. Reference is made to the more detailed
good, safe childhood conditions are presented in presentation in Report no. 16 to the Storting (2006–
Report no. 16 to the Storting (2006–2007) Early 2007) Early intervention for lifelong learning.
intervention for lifelong learning. Increasing the grants for local low-threshold mea
In addition, the Government wants to further sures to encourage more physical activity will also
develop and build capacity in the school health ser be considered in connection with the annual bud
vice. The economic consequences of this step will gets.
be assessed in connection with the annual budgets. We currently have limited knowledge about
The Government is also going to consider mea social inequalities in the use of health services, and
sures that can serve as a basis for improving coor the Government is therefore announcing new mea
dination of services for children who need multi sures to build up knowledge in this field. A survey
disciplinary assistance from the child welfare of social inequalities in the use of health services
authorities. The economic and administrative con will be undertaken. Against the background of the
sequences of measures to improve the situation in findings of this survey, indicators of quality and pri
orities in the specialist health service will be devel
oped, including indicators to measure social ine sioned to compile regular reports on trends in
qualities in accessibility. More research is to be social inequalities in health outcomes (mortality
done into factors that cause social inequalities in and morbidity). Indicators of health outcome can
access to the health services. In addition, the distri be regarded as indicators of the overall objective of
butional effects must be assessed when proposing this Report to the Storting of reducing social ine
changes in user charges, organisation and the qualities in health. The Government will discuss
funding system. The Government will return to the changes in internal priorities and any other eco
problems raised in the review of user charges for nomic consequences of establishing a review and
health services in Proposition no. 1 (2006–2007) to reporting system in the ordinary budget process.
the Storting (the National Budget) for the Ministry In this Report to the Storting, the Government
of Health and Care Services in connection with the is announcing that it is stepping up its commitment
budget for 2008. to assessing the distributional effects of public pol
The policy instruments intended to promote icies centrally, regionally and locally. Importance is
inclusion of the most vulnerable groups will largely to be attached to developing simple tools to assess
be rooted in Report no. 9 to the Storting (2006– distributional effects. Measures will be imple
2007) Employment, welfare and inclusion, Action mented to render impact assessments more effi
Plan to Combat Poverty and Report no. 16 to the cient as a tool and to improve competencies in the
Storting (2006–2007) Early intervention for lifelong central government, county administrations and
learning. In the current Report to the Storting, the municipalities in this area. To a great extent, these
Government is also proposing steps to build capac will be measures that can be implemented within
ity in and further develop the health services the existing economic and administrative frame
offered to these groups. The Government is also work.
proposing stimulating the implementation of mea It is necessary to improve the monitoring of
sures in areas that have special health and social trends in social inequalities in health, research on
problems. The economic consequences will be the causes of inequalities and research on effective
assessed in connection with the annual budgets. policy instruments to reduce these inequalities. In
The Government is proposing objectives and order to advance knowledge about social inequali
goals in a number of areas and a new review and ties in health, the Government has decided to
reporting system to monitor developments. Some establish a monitoring system to track develop
of the objectives and goals are new, and some are ments in social inequalities in health, to improve
taken from existing policy documents. For each research on the field, and to evaluate measures in
objective and goal, one or more indicators will be terms of their impact on social inequalities in
developed enabling monitoring of developments in health. Knowledge in this area needs improving by
the area over time. The review and reporting sys means of a combination of changes in priorities
tem will be developed in close collaboration with and concrete allocations. The Government will
relevant partners. A joint report on developments return to the economic consequences of these
will be included in the Ministry of Health and Care steps in connection with the annual budget deliber
Services’ budget proposition. The Directorate for ations.
Health and Social Affairs is ascribed responsibility
for coordinating the process of developing the indi
cators in collaboration with relevant directorates The Ministry of Health and Care Services
and experts. The Directorate for Health and Social
Affairs will also publish an annual report based on recommends:
the findings reported through the review and
reporting system. This report must be able to The recommendations of the Ministry of
serve as the basis for the annual reporting on Health and Care Services dated 9 February 2007
developments in the field in the Ministry of Health concerning the national strategy to reduce social
and Care Services’ budget proposition. The Nor inequalities in health be submitted to the Storting.
wegian Institute of Public Health will be commis
Appendix 1
International experiences
The World Health Organization EU

The World Health Organization (WHO) was one of EU work related to social determinants of health
the first actors to put social inequalities in health on and inequalities in health spans many policy areas,
the agenda. A key starting point was the Alma Ata including economic, labour and social policy;
declaration from 1978, which underlined that «The regional policy; research and public health. One of
existing gross inequality in the health status of the the main goals of the EU programme of Commu
people particularly between developed and devel nity action in the field of public health for 2003–
oping countries as well as within countries is polit 2008 is reducing inequalities in health. This is to be
ically, socially and economically unacceptable…» achieved by developing strategies and measures
Since then, the goal of reducing social inequalities aimed at socioeconomic determinants of health.
in health has been included in a number of WHO An expert group on social determinants and ine
documents. For example, WHO Europe aimed for qualities in health has been set up under the Coun
a 25 % reduction in social inequalities in health by cil of Europe’s Public Health Committee, in which
the year 2000 as one of its «Health for all by the Norway is represented.
year 2000» goals in 1985. In 1998, the WHO
Regional Office for Europe published a new health
policy: Health 21 – Health for all in the 21st century, Sweden
the second target of which deals with social ine Sweden has adopted an explicit equality and fair
qualities in health: «By the year 2020, the health ness perspective in all its public health policies. In
gap between socioeconomic groups within coun 1995 a government committee was formed – the
tries should be reduced by at least one fourth in National Public Health Committee – to compile
member states, by substantially improving the national objectives for developments in public
level of health of disadvantaged groups.» health. According to the Committee’s brief, the
Although these WHO initiatives served to put objectives and the strategies were also supposed to
social inequalities in health on the agenda in a num contribute to a reduction in inequalities in health
ber of Western countries, the WHO recognises between socioeconomic groups and other groups.
there is still much work to be done, not least with The Committee’s assessments and recommenda
regard to developing countries. In March 2005, the tions were presented in the Official Government
Director-General of WHO Lee Jong-Wook set up a Report «Health on Equal Terms – national public
Global Commission on Social Determinants of health objectives», which set up 18 national objec
Health. In its explanation of the background to the tives for public health work. These objectives
formation of this commission, the WHO pointed out spanned from broad, socio-political areas such as
that there is a large need in some countries for doc «Strong solidarity and social community «, via life
umentation that can be used in the development of style (for example «Greater physical activity»), to
measures to reduce social inequalities in health. more specialised health-policy fields such as «Fac
The Commission has a three-year mandate period tual health information».
(2005–2008) in which to produce this kind of docu In December 2002, this report formed the
mentation. The Commission is also intended to background for a bill called «the Public Health
function as a spearhead in the work to bring about Objective Bill», with the overall national public
political processes of change in the area. The Com health objective «to create the social conditions to
mission consists of 20 commissioners from different ensure good health on equal terms for the entire
countries, social sectors and academic disciplines. population». The inequality perspective was cen
tral and in addition to social inequalities also efforts to promote health and prevent disease,
included gender, ethnicity and sexual inclination. which increases the coherence in relation to major
The bill emphasised how social structures on dif preventable diseases and disorders between pri
ferent levels can create ill-health and put less mary prevention; individual self-care and health
emphasis on the individual’s choice of lifestyle as a initiatives; and counselling, support, rehabilitation
determinant. This can be illustrated by the eleven and other measures in relation to patients.»
domains of objectives for public health work Healthy throughout Life also stresses the objec
defined in the bill: tive of increasing life expectancy free of disability
– Participation and influence in society or illness for everyone at all ages:
– Economic and social security – Life expectancy should be increased substan
– Secure and favourable conditions during child tially
hood and adolescence – The number of years with high quality of life
– Healthier working life should be increased
– Healthy and safe environments and products – Social inequality in health should be mini
– Health and medical care that more actively mized
promotes good health
– Effective protection against communicable dis The Programme also operates with a number of
eases targets linked to four main elements: risk factors
– Safe sexuality and good reproductive health (such as smoking, working environment, physical
– Increased physical activity activity), environments (such as school and the
– Good eating habits and safe food workplace), target groups (such as pregnant
– Reduced use of tobacco and alcohol, a society women and chronically ill people) and major pre
free from illicit drugs and doping, and reduced ventable diseases and disorders (such as cancer
harmful effects of excessive gambling and mental disorders).
With «Healthy throughout Life», Denmark has
The Swedish Parliament adopted the Govern chosen a slightly different public health strategy to
ment’s public health objectives in April 2003, and Sweden, focusing on factors that affect the popula
the Swedish National Institute of Public Health was tion’s choice of lifestyle. The Danish Government
commissioned to coordinate the national follow-up Programme on Public Health and Health Promotion
within the eleven domains of objectives. The also placed a great deal of emphasis on local
National Institute of Public Health has developed actions and clearly defined its goal of using local
concrete, quantifiable determinants and indicators arenas like primary and lower-secondary schools,
for the various health policy objectives. The results the workplace, local communities and the health
will be reported in public health policy reports service. The idea was that individual follow-up in
every four years. The first report was published in these arenas would afford greater possibilities for
2005. reaching more social strata in the population.
Healthy throughout Life continues this philosophy
for the most part, also stressing the importance of
Denmark involving voluntary organisations and establishing
In 1999, the Danish Government presented The partnerships, but whereas The Programme on
Danish Government Programme on Public Health Public Health and Health Promotion attached
and Health Promotion 1999–2008, An action orien importance to social inequalities in health and con
ted programme for healthier settings in everyday life. crete strategies to reduce them, this aspect is less
The formulated targets are partially based on obvious in Healthy throughout Life. One exception
WHO’s Health 21. The Programme formulated tar is a special indicator programme, developed for the
gets for risk factors, target groups (age groups and purpose of monitoring and documentation. The
health-promoting environments) and organisa indicator programme operates with 14 key indica
tion/structure. tors, two of which are explicit measures of distribu
In September 2002, the Programme on Public tion of health («Social differences in mortality» and
Health and Health Promotion was replaced by the «Social differences in the quality of life»).
new Government’s programme, called Healthy
throughout Life – the targets and strategies for public
health policy of the Government of Denmark, 2002– The United Kingdom
2010. This programme paves the way for «a The first official study on social inequalities in
broader and more comprehensive approach to health in Britain, the Black Report (after the chair
man of the committee, Sir Douglas Black) was pub tors that create the health gap. The UK efforts to
lished in 1980. The report, which was commis combat social inequalities in health have a promi
sioned by a Labour government, was not well nent geographical dimension, in that many of the
received by the new Thatcher Government, which resources and measures are aimed at defined geo
rejected the committee’s proposals as unrealisti graphical areas (Health Action Zones) with poor
cally expensive. living conditions.
Since the Blair Government came to power in 1 July 1999 saw the official opening of the Scot
1997, social inequalities in health have once again tish parliament, and Scotland was granted authority
been high up on the British agenda. An important over a number of policy areas, including health. The
prelude was a new independent inquiry of social new Scottish public health policy also has a clear
inequalities in health and proposals for measures objective of reducing social inequalities in health.
to reduce these inequalities, chaired by former The United Kingdom has been an active pio
Chief Medical Officer, Sir Donald Acheson. The neer in getting inequalities in health higher up on
objective of this study was also to survey the situa the international agenda. In autumn 2005, during
tion and identify the most pressing challenges. The its presidency of the EU, the UK arranged a major
Acheson report showed that inequalities in health conference on social inequalities in health,
had increased steadily and that inequalities in Tackling Health Inequalities.
material conditions were one of the main causes. It
contained recommendations for reducing social
inequalities in many areas, including, for example The Netherlands
taxation policy, education, work, housing policy, In the Netherlands, the focus on social inequalities
the environment and transport in addition to health in health increased gradually during the 1980s,
policy in a narrower sense. partly as a result of a study into inequalities in
In July 1999, the Minister for Public Health and health between different boroughs of Amsterdam
11 other ministers presented Saving lives: Our in 1980, plus the process linked to the WHO Health
Healthier Nation. This white paper defined the fol for all targets. The Health 2000 report published
lowing two main goals for health policy in the by the Ministry of Welfare, Health and Cultural
United Kingdom: Affairs in 1986 included a paragraph on social ine
– improve the health of everyone qualities in health. A subsequent conference
– and the health of the worst off in particular. resulted in the establishment of a national research
programme (1989–93) under the aegis of a com
The report focuses primarily on four causes of mittee that reported directly to the Minister. The
death: cancer, coronary heart disease and stroke, programme was to investigate the scope and
accidents, and mental illness (suicide). nature of socioeconomic inequalities in health and
In 2001, the British Department of Health their determinants.
defined objectives for its work on social inequali When the programme ended in 1994, the com
ties in health. Two objectives were given specific mittee recommended establishment of a new
targets in terms of reductions to be achieved and research programme, but now with a focus on
time limits: developing and evaluating measures designed to
– starting with children under one year, by 2010 reduce socioeconomic inequalities in health. At the
to reduce by at least 10 per cent the gap in mor same time, developments were to be monitored,
tality between the routine and manual group and earlier studies were to be followed up. This
and the population as a whole, and second programme ran from 1995–2000. Reducing
– starting with local authorities, by 2010 to reduce social inequalities in health continued to be defined
by at least 10 per cent the gap in life expectancy as a political objective in various government docu
between the fifth of areas with the worst health ments. In March 2001, the programme committee
and deprivation indicators (the Spearhead of the second national research programme pub
Group) and the population as a whole. lished its report. This document proposes policies
and concrete measures, as well as summarising
In 2003, the UK Department of Health and 11 other experiences and lessons learned from the pro
ministries presented Tackling Inequalities in gramme. Four types of intervention are afforded
health: A Programme for Action. This three-year special attention:
programme has two objectives: to meet the targets – Improving conditions in terms of occupation,
defined above and to function as a broad strategy education or income among the people at the
for reducing social inequalities in health and fac bottom of the social hierarchy
– Minimising the effects of health problems on and diabetes. Examples of policy instruments to be
(downward) social mobility. used include information campaigns in lifestyle
– Limiting risk exposure in the lowest social areas, collaboration with local authorities, collabo
strata ration with trade and industry, incentives for health
– Extra health services for these groups insurance companies and developing healthy
schools. The equality perspective is less explicit in
A Dutch public health report from 2003 attaches the Dutch public health policy.
importance to prevention in general and highlights
three specific preventive areas: smoking, obesity
Published by:
Norwegian Ministry og Health and Care Services
All illustrations: Elisabeth Moseng

Translation from Norwegian by Amesto Translations AS
Internet adress:
www.government.no
Printed by:
PDC Tangen – 05/2007 – Impression 1500
ØMERKE
ILJ T
M
241 379
Trykksak
This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of the
contractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarily
represent the view of the Commission or the Directorate General for Health and Consumer Protection. The European
Commission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use made
thereof.

Report No. 20 (2006-2007) To The Storting National Strategy To Reduce Social Inequalities in Health

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Report No. 20 (2006-2007) To The Storting National Strategy To Reduce Social Inequalities in Health

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Report No.

20 (2006–2007) to the Storting

National strategy to reduce social

National strategy to reduce social

Translation from the Norwegian. For information only.

1 Introduction . . . . . . . . . . . . . . . . . . . 5 2.4.4 Areas with Sami and Norwegian

National strategy to reduce social

1.3 Objective: To reduce social

cussed to the extent that their health problems 1.6 Summary

tors and on all administrative levels about the

2 Facts about social inequalities in health in Norway

«The Norwegian population enjoys good health.

Figure 2.1 Social inequalities in health

2.1 Systematic inequalities in health

Deaths per 100 000 per year

2.1.1 Substantial and growing social

social position, but there are also clear inequalities

Deaths per 100 000 per year

0 2.2 Social structures affect health

financial resources directly affects the individual’s

Another explanation of the correlation between

who live with both parents

whose main breadwinner has long education

whose family own their home

whose family own a car

whose family own a PC

who travel on vacation at least once a year

whose parents have less than good

Life expectany (years)

Life expectany (years)

These diagnosis groups are often linked with

Daily smoking - men Daily smoking - women

Seldom/never vegetables - men Seldom/never vegetables - women

Box 2.4 Experiences with supervision

Source: Norwegian Board of Health

increasing in the low-income group, while it is

tance from the child welfare authorities in the

1400 Half of all inmates in Norwegian prisons have

Figure 3.1 Reduce social inequalities that contribute to inequalities in health

community, contributes to a fair distribution of

Box 3.1 Policy instruments: Income

tions. A well developed range of public welfare

that everyone, regardless of their social back­

all social groups. It is important for young people to

Box 4.2 Policy instruments: Childhood conditions

5 Work and working environment

in part-time jobs, immigrants and young people.

cies and strategies, and to provide better opportu­

Box 5.1 Policy instruments: work and

Figure 6.1 Health behaviour

Measures targeting children and young people

A system of dietary advice courses for patients

Box 6.5 Policy instruments: Health behaviour

The Norwegian health service is constantly

Health and care services should be equitable in Possible distortion mechanisms

7.2.1 User charges

In order to ensure equitable specialist health

8 Targeted initiatives to promote social inclusion

Figure 8.1 Targeted initiatives to promote social inclusion

that there is limited knowledge about effective

little contact with the labour market, are homeless,

functional capacity are underreported among

are often felt to be better at treating people as

that everyone, regardless of their social back

cies and strategies, and to provide better opportu