Multilevel governance of health promotion – on the role of municipalities 

1. Multilevel governance of
health promotion – on the
role of municipalities
Examples from Norway
Marit K. Helgesen
Norwegian Institute for Urban and
Regional Research (NIBR)

2. Change in governance
• How is health promotion governed?
• Is there a role for municipalities?
• Do they have the necessary capcity?
• How are policies framed?
• Are there similarities and differences?

3. Content of speech
• Nordic welfare state and municipalities
• Health promotion and dterminants for health
• Theoretical perspective:
– Multi-level governance
– The cooperative turn
• Multi-level governance of health promotion
in the four Nordic countries
• The cooperative turn: two models of health
promotion in municipalities?

4. Decentralised character of
welfare states
• Service provision traditionally a municipal
responsibility within limits of national
governmental regulations
• Municipalities have a dual role
– Implement national policy goals
– Local democratic arena – prioritizing of funding
• Important role in the provision of welfare
services

5. Health promotion
• Health in the public sphere affect health
positively:
– Infrastructure for sanitation
– Building of welfare state
• Individual lifestyles in focus
– Patients take part in producing their own health
• Changing theoretical backdrop
health promotion

6. Source: Dahlgren and
Whitehead 1991
Determinants for health

7. Multi-level governance
• Change from:
• Hierarchy: command and control targeting
content of services
• New Public Management: contracts,
performance- and strategic management
measures targeting results
• New Public Governance: designing and
framing networks targeting processes

8. Cooperative turn
• Change from hierachy towards network
modes of governance
• Bringing together diverse actors across
sectors and levels of formal authority
• National state taking the interest of actors at
lower levels into consideration
• Combine central intervention with local self
regulation

9. Capacity as municipal size
• D: 98 municipalities, average of 55 000
inhabitants, 5 regions
• S: 290 municipalities, 21 elected county
authorities
• F: 320 municipalities, wanted average of 20
000 inhabitants not reached, samkommuner
• N: 428 municicpalities, 19 elected county
authotrities, average of 10 000 inabitants –
about 100 municipalities with 3000 inh. or
less

10. Capacity as competence
• D: citizen-oriented prevention in municipalities,
patient-oriented shared with regions
• S: both levels to carry out health promotion,
established political or administrative board,
county autorhorites often take the role as
initiators
• F: municipalities decides on health promotion
• N: included in municipal planning, have public
health coordinator

11. Legal instruments
• D: health promotion included in law on
health and care, agreements between
municipaliteis and regions
• S: health promotion in law on health and care
• F: act on health promotion and health and
care
• N: acts on health promotion and health and
care, agreements between municipaliteis and
regions

12. Economic instruments
• D: municipal co-funding of hospital
admissions, motivate health promotion
initiatives
• S: municipalities fund their health promotion
• F: grants are given to fund trials and reforms
• N: municipal co-funding of hospital
admissions, motivate health promotion
initiatives

13. Pedagogical steering instruments
• D: statistical tool focus healt behavior, individual
diseases and self-assessed health
• S: follow ups on national goals publicized, hp in
cooperation with county councils
• F: «Welfare Compass» information on various
determinants for health, state agencies provide policy
support
• N: «Health profiles» information on various
determinants for health, state agencies provide policy
support, hp in cooperation with county councils

14. PHA regulation: health profiles and
local knowledge on determinants for
health
• Health profiles basis of knowledge on health
determinants
• Provided by Public Health Institute, issued once
a year, statistical indicators accommodated to
the local level
• Municipalities and counties complete by
qualitative indicators for local areas
• Input for planning
• Few national guidelines and exmples

15. Knowledge base
Planning
Decisions on
planning goals
Interventions and
measures
Evaluation
Source: Paulsen and
Moltumyr, Kommunetorget.no
The systematic health promotion

16. HCMA: Healthy living centers
• Defined as health care
• Target population in need of changing health
behavior; groups at risk
• Pedagogical instrument, voluntary for
municipalities
• Municipalities can apply for special grants
• Evidence based, thorough elaborated
guidelines

17. Multi-level governance
• Building on the traditions of decentralised
service provision in all Nordic countries
• A clear role for municipalities in health
promotion
• Similar between countries: to provide the
contingencies of prevention and the services
of which health promotion can be a part

18. The cooperative turn: two models of
health promotion in municipalities?
• Cooperative turn: municipal self regulation
• Two models: S and F apparently more
autonomous in their implementation of health
promotion
• D and N: health promotion the twin practice
of health care
• Economic NPM incentives motivate municipal
self regulation to establish health promotion as
health care service in the municipal health
sector

19. Thank you for your attention