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From vision to reality? The Ottawa-charter in Norwegian health policy

Elisabeth Fosse and Asbjoern Roeiseland

Introduction

The Ottawa-charter may be characterised as the “Bible” of Health Promotion. By this we mean that it is the ultimate ideal and vision of how the goal of health should be obtained through actions at various levels: global, national, community and individual. In this, the Ottawa- charter could be characterised as one follow up of the earlier World Health Organisation (WHO) document Health for all by the Year 2000.

Both the Ottawa-charter and the Health for all strategies outline that radical changes at all levels would be required if the goals should be obtained. However, both documents outline visions and goals beyond political reality. If the goals were to be obtained, it would require drastic changes in power relations both at the global and the national level. It is in this sense it might be significant to characterise the Ottawa-charter as a Bible: it is a vision to reach for beyond the politics of everyday life.

Still, both documents have political implications at the national level. The Health for all strategies has been transformed into national public policy documents in many countries. Also the Ottawa-charter has been made into public policy in several counties. In Norwegian health promotion policy, the Ottawa-charter has been made an explicit point of departure. In 1992 a Government White paper on health Promotion policy was released. [1]

The purpose of this article is to scrutinise the Norwegian health promotion policy in order to study how the ideology of the Ottawa charter has actually has been put into public policy. The article takes its point of departure in Norwegian public health policy and how it has been implemented in the last decades. In this purpose, we draw on theories of Political science, more specifically theories where the organisation and implementation of public policy is being scrutinised.

Public Policy: Symbol, Conflict or Learning?

The organisation of the public sector and the policy that is being implemented through the public apparatus is constantly changing. This is especially the case with the public health sector, which has been undergoing several reforms during the last two decades. Bur why do these changes occur? What are the most important factors to explain the changes of health promotion policy that have taken place during the last years?

In the present article we will argue that these changes occur through interplay of several factors. The change of policies is partly due to international impulses that the Norwegian government has received, among them from WHO. On these grounds we find it significant to argue that there is a connection between international agreements and declaration like the “Ottawa-charter” and the practical actions that take place at the local level in Norway. In other words, we will be arguing in favour of our metaphoric title: we believe in a connection between vision and reality. However, we will also argue that the development of Norwegian health policy is not a direct function of international impulses. There will also be a translation and an adaptation to Norwegian conditions, and in this process both power and symbols play a significant part.

Within political science there exist several general theories that tries to explain why policies and the organisation of the public sector change over time. The so-called neo-institutional theories especially focus on the symbolic aspects of institutional reform processes. When reforms are considered to be symbolic it implies that organisations only “adjust the facade ” to show that the organisation is being modernised, but in practice the routines and actions of the organisation remain unchanged. Through this process, organisations will have one formal, symbolic structure, and one informal, but real structure (Røvik 1992, Brunsson and Olsen 1990).

A second hypothesis postulates that the organisation of policies is being changed as a consequence of conflicts between different actors. In this sense, policy will be a reflection of the present distribution of power between the actors who take part in the decision- and implementation processes. This theory implies that the process of developing public policy is regarded as an everlasting game between different actors and institutions, and it also implies that the different actors pursue different interests (Bardach 1977, Bishop 1981).

A third theory emphasises that public policy is being changed because the surroundings of the policy is continuously changing. As a consequence of this there will be a continuing learning process where objectives and means will be adjusted to one another (Majone and Wildavsky 1979). This perspective of organisational learning implies that development and change of public policy will be regarded as a constant, evolutionary process rather than a development where one step is taken at the time.

These three perspectives on reforms might be called a symbol-, a conflict- and a learning perspective on reforms. The three theoretical perspectives constitute the most common explanations for changes of public policy and organisational change within contemporary political science.

In this article we will be using these three theoretical perspectives to highlight possible explanations why public policy within the field of health promotion has been changing over the last years. Our point of departure is the ideological changes as especially the WHO is expressing them in international conferences and declarations. The question being raised is whether these ideological changes have any direct influence on national definitions of problems and if this is so, will it subsequently have implications for the implementation of the policies at the local level? And if there is a deviance between the international ideologies and the Norwegian health policy: How can the deviance be understood, at what levels do they occur and how do they fit in with the three theoretical perspectives?

WHO, Health Promotion and Disease Prevention

The WHO has played a significant part in shaping our ideologies and understanding of health and the concept of health after World War II. The WHO definition of health was formulated in 1946 and in this health is not defined only as «absence of disease», but also consists of subjective elements, such as well being (NOU 1976:24).

Until the mid 1980s the WHOs strategies emphasised disease prevention, such as vaccination programmes and smoking regulations. However, during the last decade, the concept of “Health Promotion” has been developed and increasingly focused. The WHO at the so-called Ottawa-conference outlined the strategies for this work in 1986. In the Ottawa-charter five main strategies for health promotion are being outlined (WHO 1986):

• Build healthy public policy

• This point is about political actions and interventions such as legislation, economic policy, taxation and organisational changes. 

• Create supportive environments

•  This point underlines that a health promoting strategy must aim at securing and protecting god environments and preserve natural resources. 

• Strengthen community action.

• In this point focus is on local community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health.

• Develop personal skills

This point underlines that health promotion should support personal and social development by securing information, health education and knowledge.

• Reorient health services

In this point, focus is especially on the role of the health services. The health sector must increasingly move in a health promoting direction. This must lead to a change of attitudes and change of the organisations within the health services that leads to a focus on the total needs of the individual as a whole person.

Implementation of the strategies of the Ottawa-charter would demand radical changes in societies, at the global as well as the national level. However, like so many international documents, the Ottawa-charter is characterised by idealistic goals, but they are vague and unspecified and containing a vast potential for political conflicts. Consequently, a direct connection between vision and reality cannot be taken for granted. On the other hand, even if the ideas are vague and conflicting, if international declarations are going to be taken seriously, such connections should be expected. With this point of departure, we will be looking for the traces of the Ottawa-charter in Norwegians health policy, both at national and local levels. Our focus will be on the change of ideologies that has been taken place during the last 15-20 years.

The development of a local health service in Norway 

It seems natural to divide the development of the local health services in Norway in three time phases. These phases are parallel to the largest reforms of the legislation of the public health sector. Three main reforms have been taken place during this period, first, the Municipal Health Care Act from 1984, and the changes in the Act from 1988. The third phase reflects the changes of the Act in 1992. But before we present these reforms, we will give a brief overview of the situation for local health services before 1984.

Phase 1: Problems of co-ordination and problematic incentives (1960-1984)

The development of the health services in the 1960s and the 1970s was strongly influenced by the extensive building of hospitals. The political attention was on hospitals. Most of the health personnel worked within the hospital sector, and also the largest part of the economic resources were spent on building and running hospitals. The first Government Green Paper on primary health was presented in the early 1970s. (St.meld.nr.85 (1970-71)). Some actions were implemented in this sector during the 1970s, and the education of health personnel was increased and strengthened.

One major problem was that the various services were administered by different administrative levels. [2] The state, the counties and the municipalities had the responsibility for various services, but no one had the responsibility for co-ordinating resources. The financing was earmarked grants from the state to services at the other levels, and naturally, the services that received the largest grants were prioritised.

Phase 2: The growth of the local health services (1984-1992)

From the 1970s on, ideologies of community action, local government and decentralisation became increasingly dominant in the public debate, throughout the Western world. This ideology was also strongly present in the work of the committee who prepared the Municipal Health Care Act (NOU 1979:28). The Municipal Health Care Act was passed in 1984.

As a consequence of the Act, the municipalities were granted the responsibility for primary health care. The financing system was changed accordingly, from a system with earmarked grants to economic grants, which in principle implied that the municipalities could prioritise themselves how the grants were to be spent.

In the Act, health promotion and disease prevention were given a central position. (The Municipal Health Care Act, § 1­-2). The health promoting and disease preventing tasks of the municipality were specified as:

• Environment health care

• Community health clinics

• School health clinics

• Health Education

In the preparing documents to the Act, the expectations of the health promotion and disease prevention activities of the municipalities were relatively vaguely expressed. Government supposed that a general increase in the resource within primary health care would contribute to an increase within these activities as well (NOU 1979:28).

In 1988 two important changes were made in The Municipal Health Care Act. First, the municipalities were given the formal responsibility for Environment Health Care. [3] Environment health Care was a new concept, and in the Act it was defined as:

“The factors in the environment that at any time, directly or indirectly influence health. These include among others biological, chemical, physical and social environment factors”. (The Municipal Health Care Act § 4a-1).

The more specific tasks belonging to Environment Health Care were not specified in the Act itself. The health authorities have, however, specified the tasks in other documents: The effects of environment pollution on health, the social environment and health, nutrition and health and disease prevention (Ot.prp. nr. 40 (1986-87): NOU 1991:10).

The establishing of Environment Health care as a responsibility for the municipalities represented more than a change in the administrative system. Basically, there was a modernisation of the contents and the tasks of the health services. More attention was paid to “modern” health problems, and the psychosocial environment was defined as part of the concept of Environmental health care. (NOU 1984:28).

Environment health care was, however, not the only modernisation of the Act in 1988. Another paragraph was also added, (§1-4). Here it is stated that the local health services should contribute in securing that health consequences of public policies also are considered in the other areas of public sector (Ot.prp.nr.40 (1986-87). This implies an understanding that health problems to a large part are due to problems created in other fields of society, and that the problems only in a minority of cases should be solved by the health services. The new paragraph thus presented an opening up to cross-sector co-operation in matters concerning health.

Phase 3: More local responsibility and more emphasis on community (1993- )

The processes that could be identified in the second phase, has been utterly developed in the third phase. The reason why we take the year of 1993 as a watermark is basically that the municipal legislation was reformed in that year.

Due to these reforms the municipalities were more autonomous than earlier in matters of organisation of municipal tasks. One way this is expressed is that the health services no longer have the formal responsibility for health promotion and disease prevention. The local authorities are responsible, but may delegate authority to a lower level of administration. This autonomy may be interpreted as a shift of implementation models. Earlier, the local health services represented both a state authority and a local authority. [4] The health sector seemed to be a more important frame of reference for local health workers than the local authorities (Aurdal 1992). Due to the reform of 1993 the municipalities became the primary unit at the local level. This shift may be described as a change from a sector-based implementation model to a territorial-based model (Roeiseland 1996).

From 1994 there were also changes in the organisation of the central health administration. The name of The National Directorate of Health was changed to The National Board of Health. This was more than a changes of names, in the reorganisation The Directorate lost the central position it had had in the health administration during the whole post-war period. The reorganisation is thus another illustration of the decline of the era of a strong sector-dominated health administration in Norway.

Parallel to the changes of the administrative system, there have also been changes in the understanding and the contents of health promotion and disease prevention. In 1993 a Government White paper on health promotion and disease prevention was delivered (St.meld.nr.37 (1992-93)). This document expresses an explicit support to the WHO view on disease and health. The document was also a means to implement the ideals of the Ottawa-charter in Norway.

Has Norway implemented the Ottawa-charter?

The growth of a municipal health service and the other changes that have taken place in Norway since the mid-seventies might be regarded as a break-through for the WHO interpretation of disease and health. This applies for example to the principle that considerations of health are to be a premise in planning and implementation in all municipal sectors. This principle is recognising the fact that health problems arise in all sectors of society, while the task of the health services is to repair the damages. The reform process also expresses a changed view on health promotion: It is a cross-sector responsibility to secure that health factors are considered in all municipal activities. In practice it will be necessary with co-operation between the various professions and municipal sectors to achieve this.

However, there are also deviations between the Ottawa-charter and Norwegian health policy. In the Government white paper it is strongly emphasised that that the local community will be the arena for health promotion. This is related to the Ottawa-charter and the argumentation is that better local communities will provide better lives for people and empower them to make «health promoting» choices about their lives and their life styles (St.meld.nr.37(1992-93)) The most significant example is that local communities could contribute to solving mental health problems.

Still, there are several of the points made in the Ottawa-charter that are being left out in the Norwegian policy document. Among them is the point that health promotion also must imply solving structural problems, based on the fact that the organisation of society itself may cause disease. The health consequences of unemployment are hardly discussed; neither is transport policy, taxation policy or welfare policy in general. In other words: The most radical parts of the Ottawa-charter have been boiled down to issues of local community and cross-sector co-operation.

The Government white paper reflects policy areas that have been considered to be problematic for a long period of time. The priorities of Health promotion that is being outlined are diseases that have been given low priority by the health services. Among them are chronic diseases, and complex diseases, like psycho social diseases (Juul Jensen 1983, NOU 1991:10). For more than a decade, the strengthening of local community work has been regarded as a democratisation strategy by the authorities, both in general and within the health services (St.meld.nr.16 (1979-80), Martinsen 1989). Accordingly, the ideology that there should be more inter-disciplinary and cross-sector co-operation are not new. Consequently, we find no self-evident and direct connection between WHO ideology and Norwegian policy-making.

Symbol policy, conflict or learning?

In the introduction we argued that the development and change of public policy and public administrative systems might be viewed from three different theoretical perspectives: a symbol perspective, a conflict perspective and a learning perspective. The question now is to which extent the three perspectives might contribute to an understanding of the implementation of the WHO strategies into Norwegian health promotion policy.

With the symbol perspective in mind, we should ask whether the present health promotion policy is actually a «true» expression of the objectives of the policy, or whether it is just «adjusting the facade» by introducing the policy as if it was new and radical. It seems evident that the transformation from vision to political reality brings out some symbolic elements. As pointed out earlier, it is especially the emphasis on the local communities that are being related to the structural strategies of the Ottawa-charter. However, strengthening of local communities has been public policy for a long period of time. To push our point, we would argue that the emphasis on community action seems to be wishful thinking in the sense that communities should be capable of solving complex problems that the health services are not able to deal with.

The Conflict perspective also points to essential conditions for health promotion policies. There is little doubt that the content of the WHO declarations contains a potential for political conflicts along several dimensions. An implementation of the Ottawa-charter would imply important changes in society, for example in the direction of an increased sustainable development, globally as well as locally. Such reforms claim for major changes within economy and politics, and would subsequently lead to a transformation of political power to local communities. An implementation of the Ottawa-charter would also challenge the powerful system of professions within the health services. The present Norwegian health promotion policy can thus be viewed as a compromise. The issues that have been raised and the prioritisation that have been made are the ones that could be raised and still avoid political conflicts. On the basis of an optimistic interpretation, it could be argued that that the development during the past ten years could be regarded as steps toward more radical changes later on.

This leads us on to our third perspective. In the learning perspective changes are considered to be part of an evolutionary process, and changes in policies reflect changes in the surroundings. Even this perspective contributes to an understanding of the Norwegian health promotion policy. It could help us understand the organisational changes that have been taken place the last years. At the state level there has been a concentration of power and influence over the policy formation process, from the sector administration of the Health Directorate to the Ministry of Health and Social Affairs. At the local level there has also been a shift from focus on the health sector to the more general policy perspective, as the local authorities now have gained more responsibility and influence, both on the organisation of the health services in general, but also on health promotion. All these changes have one thing in common: they close the gap between health promotion policy and other fields of policy and cross-sector decision arenas. In other words, the reforms bring health promotion closer to the political centre of attention, and thus make it more feasible that the policies might be implemented (Fosse 1999).

If we regard the whole reform period, from 1984 until today, we will conclude that all the three theoretical perspectives contribute to highlight the development. They also contribute to an understanding of public policy within the field of health promotion, as it has been expressed in the public policy documents in the 1990s. How the policy is actually being implemented at the local level, is of course a different issue. It is far from certain that the municipalities implements the intentions of the state. Studies that have been made indicate, however, that the policies are being implemented, although not entirely according to the objectives that have been set by central government (Fosse 1999). This is, however beyond the focus of this article.

References

Aurdal, L. (1992): Lokal statleg styring av dei "tunge" kommunale sektorane helse og undervisning. I Jarle Weigård (red): Lokal statlig styring. NIBR-rapport 1992:4

Bardach, E. (1979): The implementation game. What happens after a bill becomes a law, Cambridge: The MIT Press.

Bishop, J. (1981): “Briefing for implementation. The missing link?” I C. Fudge, S. Barett (ed): Policy and Action,

Brunsson, N., J. P. Olsen (ed)(1990): Makten att reformera, Stockholm: Carlssons.

Christie, W. (1988): Politikk og fag på samme lag? En bok om planlegging i kommunehelsetjenesten , Oslo: Tano.

Fosse, Elisabeth (1999): Implementation of Health Promotion Policy in Norwegian Municipalities. In Watson J. and S. Platt (eds.): Resaerching Health Promotion. Routledge, London

Jensen, Uffe Juul (1983) Sygdomsbegreber i praxis. København: Munksgaard.

Majone, G., A. Wildavsky (1984): “Implementation as Evolution” i J. L. Pressman, A. Wildawsky (ed): Implementation, Berkeley: University of California Press.

Martinsen, Kari (1989): Omsorg, sykepleie og medisin.

NOU 1979:28: Helse og sosialtjenesten i lokalsamfunnet.

NOU 1984:28: Helserådstjenesten, Sosialdepartementet.

NOU 1991:10: Flere gode leveår for alle. Forebyggingstrategier, Sosialdepartementet.

Ot.prp. nr. 40 (1986-87): Miljørettet helsevern i kommunene.

Røvik, Kjell-Arne (1992): “Institusjonaliserte standarder og multistandardorganisasjoner” i Norsk Statsvitenskaplig Tidsskrift.

Roeiseland Asbjoern 1996: Statlige målsetninger og lokal praksis. Om kommunenes arbeid med miljøbetingede helseproblem. Nordlandsforskning rapport 11/96

St.meld. nr. 16 (1979-80): Bedre nærmiljøer.

St.meld. nr. 37 (1992-93): Utfordringer i helsefremmende og forebyggende arbeid, Oslo: Sosialdepartementet.

St.meld. nr. 41 (1989-90): Helsepolitikken mot år 2000. Nasjonal helseplan, Oslo: Sosialdepartementet.

St.meld. nr. 85 (1970-71): Om helsetjenesten utenfor sykehus.

WHO (1986):

WHO (1988): Healthy Public Policy - Report on the Adelaide Conference, 2nd International Conferences on Health Promotion, April 5-9 1988 (WHO, Copenhagen, Adelaide, South Australia, 1988).

[1] In 1999 another policy document on Health Promotin has been released. This is a Green paper on Public Health Policy

[2] In Norway, there are three administrative levels, the central, state level, the regional county level and the local, municipal level.

[3] This field had earlier been regulated through the Public Health Act from 1860 (Sunnhetsloven).

[4] According to the legislation, the health services could review [overprøve] the local authorities, and eventually stop certain actions or claim that certain actions were to be implemented.

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