The chance of Sweden's public health targets making a difference
Introduction
The Swedish public health targets have existed since 2003 (Table 1). The targets are modern in the sense that they focus on health determinants rather than on mortality or morbidity. The overarching purpose of the targets is to create social conditions that ensure good health on equal terms for the entire population [1].
Most of the targets deal with determinants at the societal level. Societal interventions are more effective than interventions on the individual level [2], [3], [4]. Thus, the health care sector is considered only one of many sectors important in improving public health.
A national committee consisting of one representative from each of the seven political parties in the Swedish parliament, researchers and national experts drafted the public health targets. The committee was appointed in 1995, began its work in 1997 and completed it in 2000. Three drafts where published. These documents were circulated for opinions to national authorities, county councils and local municipalities as well as non-governmental organisations. The governmental bill was published in 2002 and adopted by parliament in April 2003.
Internationally, early health targets focused on production in the health care system. In the 1950s and 1960s the targets could be formulated in terms of desired number of beds or number of health professionals per 1000 inhabitants [5]. The view of governmental responsibility for health changed in the 1970s. Lalonde suggested that the greatest potential health improvements lay in changing environments and lifestyles [6]. The WHO's declaration of Alma-Ata in 1977 stressed governmental responsibility for public health, not only health care [7]. Consequently, public health targets were formulated with a broader perspective (e.g. in terms of mortality such as those formulated by the US Surgeon General in 1979 [8]).
The broader perspective was developed further in the 1980s through WHO's strategy of Health for All [9] and the Ottawa Charter [10]. In the European Health for All document that followed there were targets on mortality, morbidity, environment and lifestyle [11].
In the WHO conference in Sundsvall in 1991 focus shifted further towards physical and social environments [12]. Subsequently, the Australian government formulated targets using this environmental perspective [13]. This development probably reflected the increased awareness of socioeconomic inequalities in health as shown, for example, in the Black report [14]. The equity perspective is also evident in WHO's policy document Health 21 [15].
Several countries have formulated national public health targets, more or less influenced by the broad perspectices that have evolved internationally during the past decades [13], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30]. The Swedish public health targets reflect an even further shift of focus in that social environments are on top of the list of targets (Table 1). Kickbusch has described the Swedish policy as the first one representing “a third public health revolution” [31].
van de Water and van Herten put public health target setting into a process of what they call health policy development [32]. They include four stages in their model: understanding the problem, choosing a solution (including target setting), implementing solutions, and monitoring and evaluation. These four stages resemble the stages in rational planning: Forecasting external and organisational events, defining desired outcomes, generating alternative strategies, evaluating strategies and monitoring results [33].
There are four main actors involved in policy processes: politicians, the administration, private actors and the members of society (Fig. 1). The administration refers to all bodies and actors that implement political decisions. The group of private actors includes firms, NGOs, associations, trade unions, etc. Public health targets are a tool in governing, i.e. the way in which politicians control and influence the activities of the administration.
The common form of governing, in which decision makers use targets as a primary tool rather than rules or direct instructions, is denoted in this paper as governing with targets. This form of governing is related to, and in other texts sometimes referred to as, management by objectives (MBO). However, the concept and theories of MBO are dealing primarily with the management of employees within organisations rather than the governing of organisations.
Governing with targets has its origins in the notion that the administration possesses the best knowledge of how to implement measures. Accordingly, the implementation is completely delegated to the administration. This separates governing with targets from governing through direct instructions or governing with rules.
It is important that the administration is involved and has influence in the target formulation process. The idea is that those responsible for taking measures to achieve the targets must also be owners of the targets. van Herten and Gunning-Shepers discuss the optimal balance between the “top” where the political decision makers are and the “bottom” where the professionals responsible for carrying out the decisions are [16]. Lundquist argues that to achieve successful governing the administration must not only understand and be able to carry out the decisions but they must also have the will to do so [34]. The importance of involving sub-ordinates in the target formulation process has also been emphasised in evaluation of management, both in private [35] and public organisations [36].
Another prerequisite for governing with targets is that the targets are explicit. van Herten and Gunning-Shepers highlight the importance of targets being specific, measurable, achievable, realistic and time bound [17]. In governing with targets explicitness becomes especially important because the decision makers do not tell the administration what to do but rather what to achieve. The targets must then be explicit in order for the administration to understand what to achieve. The administration's understanding of the decision is, as Lundquist contends, one of the basic factors in successful governing [34].
A third prerequisite for governing with targets is that there is a follow-up system. The follow-up is one of the fundamental elements of rational approaches to policy in general [33], [37] and in governing with targets the follow-up is especially important. This is for the same reason that explicit targets are important: governing with targets means telling the administration what to achieve but not what to do. If the measures are not followed-up, decision makers cannot be sure the administration is carrying out the decisions.
To conclude, in a model of the policy process governing with targets means governing with focus on preparation, decision making and follow-up but not on implementation (Fig. 2). With this model, it becomes possible to analyse the chance of the Swedish public health targets making a difference.
The purpose of this study was to assess the possibility of the Swedish public health targets functioning as a tool in governing by analysing (1) the influence of the administration in the target setting process, (2) the explicitness of targets and (3) the follow-up system.
Section snippets
Methods
Three document analyses were conducted. The material consisted of the documents from the committee drafting the Swedish public health targets, the written opinions from referral bodies on the committee's three drafts and the governmental bill with the adopted public health targets (Table 2). Some texts are available in English [1], [38], [39].
In the first part of the study the administration's influence in the target setting process was analysed. In Sweden, the primary way of involving the
Prerequisite 1: influence of the administration
The referral bodies judged the first draft as vague. It was a universal opinion that “targets and strategies must not be too vague, unclear and short-sighted”. At the same time, other referral bodies did not want the public health targets to be too governing. Many actors meant that it was important “that the national strategies were not seen as directives for how the work should be conducted”. A third frequent opinion was that the health care sector was not stressed enough. Referral bodies
Discussion and policy implication
A finding of this study is that the Swedish public health targets are not sufficiently explicit to function as a tool in governing with targets (Fig. 3). The explicitness is of great importance in governing with targets because implementation is delegated to the administration.
Although public health targets exist in several countries, there are only a few empirically based evaluations. These studies give a picture that is similar to that of this study, i.e. although public health targets have
Acknowledgements
We wish to thank two anonymous reviewers for their constructive comments on an earlier version of the manuscript. This work was supported by a grant from Sophiahemmet University College, Stockholm, Sweden.
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