1129685

article-commentary2022
SJP0010.1177/14034948221129685E. FosseNorwegian policies to reduce social inequalities in health

Scandinavian Journal of Public Health, 2022; 50: 882–886

SCAND J PUBLIC HEALTH 50TH ANNIVERSARY ISSUE

Norwegian policies to reduce social inequalities in health:

ELISABETH FOSSE

Institutt for helse, miljø og likeverd, Universitetet i Bergen, Norway

Abstract
Reducing social inequalities in health has been an important aim in the development of the Nordic welfare states. This
Commentary presents the development of Norwegian policies in this area from 1987 to 2021. Social inequalities entered the
political agenda in Norway in the 1980s, but were mostly defined as a problem for selected marginalised groups. The World
Health Organization project led by Michael Marmot was an inspiration for Norwegian policy-makers and the concept of the
social gradient was introduced. From 2005, levelling the social gradient in health became a central strategy in Norwegian
policy-making and culminated in the Public Health Act 2012. This Act focuses on the structural determinants of health and
the municipalities have a central role in its implementation. However, the municipalities are mostly responsible for services
providing downstream measures and have little control over social determinants such as tax or labour market policies. The
Public Health Act is important because it institutionalises social inequalities as a policy field within public health. Not only
the municipalities, but all administrative levels have to contribute to meet the aim of reducing the social gradient.

Keywords: Norwegian public health policy, social inequalities, social determinants of health, national policy, local policy

The reduction of social inequalities is embedded in Health for All 2000 and the Ottawa Charter for
the Nordic social democratic welfare model [1]. In Health Promotion).
Norway, the labour movement was a vital force in This Commentary addresses Norwegian policies
developing public health policies and improving the within public health, with a focus on the social ine-
health of the population in the 1930s. What we today qualities in health from 1987 to 2021. In particular,
refer to as the social determinants of health was on we focus on whether health inequalities have been on
the agenda and living conditions – including a fair the agenda, how these inequalities have been
income, healthy housing and social welfare benefits described and what policies have been developed and
– were increasingly understood as prerequisites for implemented.
good public health. The development of the The concepts developed by Dahlgren and
Norwegian welfare state started after the Second Whitehead [2] of upstream and downstream policy
World War and reducing social inequalities was an measures are useful in characterising the different
important political aim, formulated and imple- approaches to policies that can reduce social inequal-
mented by the social democratic governments in ities in health. Downstream factors are the behav-
office. However, in the 1960s, the focus shifted to ioural, social and psychological risk factors that are
health care measures and more individual measures, most proximal to the individual, whereas e upstream
aiming to change individual lifestyles. The issue of factors are the broader risks to population health at
increasing global social inequalities was reintro- both international and national levels – for example,
duced in the 1980s by global movements such as the global neoliberal trade policies, national economic
World Health Organization (WHO) (including growth strategies that neglect poverty reduction,

Correspondence: Elisabeth Fosse, Institutt for helse, miljø og likeverd, Universitetet i Bergen, Christiesgt 13, 5007 Bergen, Norway. Email: Elisabeth.
[email protected]

Date received 12 July 2022; reviewed 9 September 2022; accepted 10 September 2022

© Author(s) 2022
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DOI: 10.1177/14034948221129685
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 Norwegian policies to reduce social inequalities in health   883
income inequalities, poverty, work-related health focus on lifestyle factors that may cause disease and the
hazards and a lack of social cohesion. In terms of situation for vulnerable and marginalised groups was
political measures, upstream measures include struc- the focus of attention. The development of increasing
tural measures addressing the social determinants of social inequalities was considered a problem, but was
health, whereas downstream measures are more tar- again formulated as a problem for only some popula-
geted at individuals or groups at some sort of risk. tion groups (author’s translation; p. 8):
Although both upstream and downstream policies
are important in reducing social inequalities in health Risk factors are often particularly concentrated in
[3], an awareness of the structural determinants of vulnerable parts of the population. There is a need to
health is important. shed more light on the special health problems of the
In Norway, reducing inequalities in health was immigrant population. In general, there is a need for
improved adjustment of interventions to the needs of
established as a goal with the adoption of the WHO
groups at risk for developing health problems.
strategy Health for All 2000. In 1987, a Government
White Paper was published as a follow up to these
In line with the emphasis on marginalised and vul-
strategies [3]. Reducing social inequalities in health
nerable social groups, mostly downstream measures
was a central aim in the White Paper (author’s trans-
were suggested – for example, interventions to influ-
lation; p. 22):
ence lifestyles would be assessed in terms of their
consequences for social inequalities in health. At the
With the adoption of the WHO targets for Health for All
in 2000, Norway has made a commitment to reduce time, there was not much research on social inequali-
social inequalities by improving health conditions for ties in health in Norway. Many social themes were
the most vulnerable. analysed using gender or geographical differences as
variables, but social inequalities were not included in
The suggested lines of action related to public health the analysis [8,9].
were to increase the focus on health in policy-making However, in some respects, the policy paper did
in all government sectors. A second action was to point towards more upstream measures. First, social
increase activities within disease prevention and inequalities in health should be introduced as an ele-
health promotion. A third was to stimulate the reor- ment in health impact assessment. Second, compe-
ganisation of health services in a direction that would tence would be built up in the field of health
give special attention to inequalities in terms of social inequalities and, third, a plan of action (the Challenge
background and geographical factors and to promote of the Gradient) would be developed to combat social
equality in the distribution of health services. The inequalities in health [10]. These three areas of action
political strategies were highlighted in this White pointed towards a policy shift. The development of
Paper. However, no specific targets or goals were set. the plan of action was delegated by the Ministry of
In the first White Paper on health promotion from Health and Care Services to the Directorate for
1993 [4], the Ottawa Charter [5] was the explicit Health and Social Affairs. The action plan should
basis for the Norwegian vision of how health promo- provide a foundation for the Directorate for Health
tion policy should be expressed. Even though the and Social Affairs in their work on social inequalities
White Paper had a general focus on the broader in health. The action plan indicated a shift of focus
determinants of health, issues of equity and social compared with former policy documents. In the plan,
inequalities in health were not included. This policy it is argued against a perspective where the focus is
document was followed by a number of action plans only on the poorest groups (author’s translation; p. 9):
in several areas. Even though the rhetoric of the
White Paper was inspired by a broad understanding Working to reduce social inequalities in health means
of health, the policies to follow it up were narrower in making efforts to ensure that all social groups can
achieve the same life expectancy and be equally healthy.
focus and mostly concentrated on downstream meas-
Differences in health not only affect specific occupational
ures in fields such as accidents and injuries [6]. groups or the poorest people or those with least
A new White Paper on public health was published education. On the contrary, research indicates that we
in 2003 [7]. It was entitled ‘Prescriptions for a healthier will not address the relation between socioeconomic
Norway’ and outlined Norway’s public health policy for position and health if we base our activities on strategies
the next decade. It was the first time since 1987 that that focus on ‘the poor’ as an isolated target group.
inequalities were raised as an issue in a White Paper.
However, it was mainly conceptualised as a problem for In 2005, a left-wing, red–green coalition took over
a small minority of the population. There was a strong office in Norway. One of their main aims was to
884    E. Fosse
reduce poverty and social inequalities. The action health work entails initiatives to ensure a more even
plan was perfect for their purpose and the national social distribution of the factors that affect health.
policies were developed further based on the
Challenge of the Gradient [11]. The Norwegian Public Health Act was adopted in
The Directorate for Health and Social Affairs was 2012 and may be considered as a follow up to the
also assigned the task of establishing a centre of com- White Paper on equity. The act was based on five
petence on social inequalities in health. As a follow basic principles for public health: reducing social
up to Challenge of the Gradient, a national expert inequalities, health in all policies, sustainable devel-
group was established. The mandate of the expert opment, promoting awareness and participation
group was to contribute to the further development [13]. The Public Health Act may thus be understood
of national strategies to reduce social inequalities in as a revitalisation of the social democratic policy that
health. The group members were all highly qualified was the cornerstone of the Nordic welfare state pro-
researchers from the field, representing different ject through its focus on the social determinants of
backgrounds and approaches to studying social ine- health [16].
qualities. In 2005 the national expert group devel- In Norway, public health activities are mainly car-
oped a set of action principles to tackle social ried out at the local government level. The Public
inequalities in health and six general action princi- Health Act established a new foundation for strength-
ples that should be followed in the efforts to reduce ening systematic public health work in the develop-
social inequalities in health. ment of policies and planning. This was achieved
The action principles were in accordance with the both horizontally in terms of better coordination of
ideology outlined in the action plan. Upstream strat- public health work across sectors and actors and ver-
egies were prioritised and these strategies were devel- tically between authorities at the local, regional and
oped further as the government issued the White national levels [14,15]. Local governments are man-
Paper National Strategy to Reduce Social Inequalities dated to produce health overviews, including moni-
in Health in February 2007 [12]. This had a ten-year toring the health status of their population as well as
perspective for developing policies and strategies to positive and negative factors influencing public
reduce health inequalities. health. The act communicates with the Planning and
The main point of the White Paper was that ‘equity Building Act, which is the most important act for
is good public health policy’. This implies a view on local governments. The act states that the overview is
public health policies that aims for a more equal dis- to be the basis of the Planning and Building Act
tribution of positive factors that influence health. The mandated planning strategy made every four years.
emphasis on upstream factors is strong in the paper The local master plan is a central instrument for
(author’s translation; p. 5): Norwegian municipalities and forms the basis for
action plans, policies and concrete measures. The
The Norwegian population enjoys good health. Directorate for Health has a central role in support-
However, averages conceal major, systematic ing the municipalities in the implementation of the
inequalities. Health is unevenly distributed among Public Health Act.
social groups in the population. We have to acknowledge Municipalities have given increased attention to
that we live in a stratified society, where the most public health and health inequalities since the Public
privileged people, in economic terms, have the best Health Act was adopted [16,17]. For example, high-
health. These inequalities in health are socially quality daycare institutions can reduce the risk of
determined, unfair and modifiable. The government has
school dropout and may consequently contribute to
therefore decided to initiate a broad, long-term strategy
levelling the social gradient [18].
to reduce social inequalities in health.
Norwegian municipalities and also the Norwegian
Association of Local and Regional Authorities are
A perspective underlining universal welfare state poli-
encouraged to apply the UN Millennium
cies was further emphasised (author’s translation; p.
Development Goals, which include goals to reduce
5):
poverty and social inequalities, in their policy-mak-
A fair distribution of resources is good public health ing and planning. This has contributed to an
policy. The primary goal of future public health work is increased awareness of health equity. There has also
not to further improve the health of the people that been a development from individual-oriented poli-
already enjoy good health. The challenge now is to bring cies addressing mainly lifestyle issues to a policy
the rest of the population up to the same level as the addressing the social determinants of health and the
people who have the best health – levelling up. Public social gradient in health. In the terminology of
 Norwegian policies to reduce social inequalities in health   885
Dahlgren and Whitehead [2], there has been a devel- Declaration of conflicting interests
opment from downstream to upstream policies. The The author declared no potential conflicts of interest
Public Health Act is of particular significance because with respect to the research, authorship, and/or pub-
it mandates all administrative levels to address social lication of this article.
inequalities.
Differences between governments may also be
observed. Although right-wing governments have Funding
had their main focus on downstream measures, the The author received no financial support for the
policies of left-wing governments have addressed research, authorship, and/or publication of this article.
upstream factors [19]. However, the municipalities
still have a high degree of freedom in making priori- ORCID iD
ties and there are few sanctions for those who do not
Elisabeth Fosse https://orcid.org/0000-0002-
follow up all the intentions of the Public Health Act.
6038-5059
However, we observe an increasing interest and com-
mitment among municipalities regarding issues of
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