1. 13.6.2013 Hannele Palosuo 1
National Action Plan to Reduce Health Inequalities –
From Rhetoric to Action?
Presentation at the 8th Global Conference on Health Promotion,
Europe Day, 13 June 2013, Helsinki
Hannele Palosuo
Division of Welfare and Health Policies, THL, Helsinki

2. Outline
• Tackling inequity in Finnish health policy
• Where are we now? Health inequalities and some of
their determinants
• Main lines of the National Action Plan
• The context of health and other public policies in a
”Five I’s” framework (Information, Ideologies,
Interests, Institutions, and Implementation)
• Conclusions
13.6.2013 Hannele Palosuo 2

3. Tackling inequity in Finnish health
policy has a long history
13.6.2013 Hannele Palosuo 3
• 1960s and 1970s: Equity-oriented health care reforms aimed to
reduce inequity in access to care regionally and to reduce income
differences in access to health care
• 1972 Economic Council pronounced equal distribution in health as
an aim for health policy
• 1986 Health for All by the Year 2000, Finnish national strategy
• 1993 Revised HFA: more emphasis on equity
• 2001 Health 2015 Public Health Programme
 2008 National Action Plan to Reduce Health Inequalities 2008-
2011
• Equity emphasized also in strategies of the Ministry of Social Affairs
and Health 2006 and 2011, and National Programmes for social
welfare and health care (KASTE I 2008-2011; KASTE II 2012-2015)
as well as Government Policy Programme for health promotion
(2007-2011)

4. Where are we now? Finland has been successful in raising the level of
the population health, but there’s growing inequity: Life expectancy of
men and women (aged 35 yrs) by income quintiles in Finland in 1988-2007
(Tarkiainen et al. 2012; MSAH 2013)
RED GRAPHS: WOMEN
• HIGHEST
• TO
• LOWEST INCOME
QUINTILE
BLUE GRAPHS: MEN
• HIGHEST
• TO
• LOWEST INCOME
QUINTILE
13.6.2013 Hannele Palosuo 4

5. Finland is a Nordic welfare state with egalitarian ideals and practices,
but development in some important social determinants has not
supported reducing health inequalities
– Finland has still relatively low income differentials (Gini Index
25.8 in 2010), but income and wealth differences have grown
more rapidly than in most OECD countries
– Poverty (share of low income households) increased from
about 7% (1995) to 13 % (2009) (more so in families with small
children, lone-parent families, single households)
– Share of recipients of social assistance now on a much higher
level than 20 years ago
– Level of social assistance has stayed lower than it used to be
– Share of unemployed growing again (8,8 % April 2013)
– Homelessness pertains and even increases
13.6.2013 Hannele Palosuo 5

6. National Action Plan to Reduce Health Inequalities (2008-2011)
aimed to tackle social determinants and had 15 action proposals
on four main lines:
(MSAH 2008:25)
13.6.2013 Hannele Palosuo 6
Welfare policies tackling social determinants of health (2 proposals)
Promoting healthy habits and their prerequisites (5 proposals)
Promoting equity and need based use of health and social services (4 prop.)
Developing knowledge base and tools (e.g. HIA) (4 proposals)
Social gradient
Disadvantaged
groups
Prevention
of margin-
alisation
Target groups;
age groups,
special groups

7. The context of health policy and programmes affects the
chances of implementation and outcomes. Five I’s framework
(Palosuo et al. 2013, based on Weiss 1995; Collins & Hayes 2007)
13.6.2013 Hannele Palosuo 7
Ideologies
Implemen-
tation
Interests
Information
Institutions

8. There are both positive and negative (or contro-
versial) developments within different domains…
INFORMATION
POSITIVE NEGATIVE
Good epidemio-
logical data and
know-how in
research
Lack of research
on policies and
politics;
-Gap/ gradient
problem not
solved (esp.
concerning the
gradient);
- “Information
steering” not
sufficient
IDEOLOGIES
POSITIVE NEGATIVE
Health is a common
value and important
for all;
- Equity an explicit
value in the Finnish
Constitution;
-Political agreement
to reduce health
inequalities;
- Universalism as a
tradition of welfare
state
Neoliberal ideology;
- International /
supranational
economic
pressures;
- Free choice and
individualism;
- Pressure to switch
over to selective/
residual social
policy
13.6.2013 Hannele Palosuo 8

9. And tension and conflicts will not
disappear…
INTERESTS
POSITIVE NEGATIVE
Long term
interests are
common to all
e.g. Health in All
Policies approach
Conflicting interests
between industries and
health policy (eg.
alcohol industries,
business related to
health and health
care);
- Conflicts of interest in
the sphere of work
- Fiscal interests (tax
revenues)
- Orientation on
competition (e.g. in
EU)
- Economic growth vs.
austerity plans of the
public sector
INSTITUTIONS
POSITIVE NEGATIVE
Cross-
governmental
cooperation (e.g.
Advisory Board
for Public Health);
- Intersectoral
cooperation at
municipal level
Devolution of the
state and weaker
steering by the
state;
-Tension between
state and
autonomous
municipalities
13.6.2013 Hannele Palosuo 9

10. IMPLEMENTATION of the Action Plan, or how to get
through the jungle of projects, plans and programmes?
POSITIVE NEGATIVE
National Action Plan to Reduce
Inequalities in Health (2008) was an
accomplishment as such (first explicit
programme) + it had an implemen-
tation plan and assignments of
responsibilities
-The Action Plan impacted for its part
e.g. on raising alcohol and tobacco
taxes and contributed to health
promotion among vocational students,
developing healthier work
environments and assessing health
needs of immigrant population.
The Action Plan remained a
complementary plan in relation to a
great number of other programmes
and important social determinants
could not be addressed
- Fragmentary implementation and
weak coordination of policy
programmes (in general)
- Modest resources for implementation
- Short time-span in politics
13.6.2013 Hannele Palosuo 10

11. Some conclusions
• Health is a commonly shared value, but reducing (health) inequalities may not be a
common goal because of conflicting interests in relation to important social
determinants of health (i.e. resources and power; see Commission on Social
Determinants of Health 2008).
• Health in All Policies could be an approach for integrating common interests in areas
where many short term interests are in conflict.
• The Finnish Action Plan (2008-2011) is a link in a longer chain and was instrumental
in raising awareness and keeping health inequity on the agenda in some areas of the
national and local policies.
• However, social determinants (root causes) of health were not sufficiently
addressed.
• Societal policies on education, employment, working conditions, distribution of
income and wealth, and universal health care and social security, continue to be key
(Commission on Social Determinants of Health 2008).
• It is important to pay sufficient attention to the formulation and systematization both of
the central goals and targets and appropriate means to those ends (and not to get
lost in a jungle of programmes and fragmentary projects).
• Zygmunt Bauman (2011) warns that growing social inequality may be the most
disastrous problem that humanity has to confront in this century.
13.6.2013 Hannele Palosuo 11

12. Literature
• Bauman Z. Collateral damage. Social inequalities in a global age. Polity Press, Cambridge 2011.
• CSDH: Closing the gap in a generation. Health equity through action on the social determinants of health.
Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization
2008.
• Kuivalainen S. (ed.) Social assistance in the 2010s. A study on social assistance clients and granting
practices. National Institute for Health and Welfare (THL) Report 9/2013, (In Finnish with English
Abstract)
• MSAH 2008: National action plan to reduce health inequalities 2008-2011. Ministry of Social Affairs and
Health, Publications 2008:25, Helsinki, Finland.
• MSAH 2013: Interim report of the 2015 national public health programme. Sosiaali- ja terveysministeriön
raportteja ja muistioita 2012:4, Helsinki 2013 (In Finnish).
• Palosuo H, Sihto M, Lahelma E, Lammi-Taskula J, Karvonen S. Social determinants in the health policy
formulations of the WHO and Finland. National Institute for Health and Welfare (THL) Report 14/2013
(forthcoming; in Finnish with English Abstract)
• Rotko T, Aho T, Mustonen N, Linnanmäki E. Bridging the Gap? Review into Actions to Reduce Health
Inequalities in Finland 2007-2010. National Institute for Health and Welfare (THL) Report 8/2011 (In
Finnish with English Abstract).
• Rotko T, Kauppinen T, Mustonen N, Linnanmäki E. National Action Plan to Reduce Health Inequalities
2008-2011. National Institute for Health and Welfare (THL) Report 41/2012 (In Finnish with English
Abstract).
• Tarkiainen L, Martikainen P, Laaksonen M, Valkonen T. Trends in life expectancy by income from 1988
to 2007: decomposition by age and cause of death. JECH 2012:66:573-578.
• Statistics Finland (on income distribution, unemployment)
13.6.2013 Hannele Palosuo 12