The Swedish Agency for Public Management
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Evaluation of the follow-up system for national public health policy (2013:4)

Statskontoret (The Swedish Agency for Public Management) has been commissioned by the government to evaluate the public health policy follow-up system. The Agency has investigated:

  • The follow-up system's fitness for purpose.
  • The use and value of the results from the follow-up.
  • How the task of contributing to the follow-up has affected public health efforts from the agencies concerned.
  • To what extent the follow-up should track developments at the local and regional level.

The evaluation performed by Statskontoret focuses on the indicators which form the basis of the follow-up system, as well as the products in which the results of the follow-up are reported: Folkhälsopolitisk rapport 2010 (Public Health Policy Report 2010), Folkhälsan i Sverige – Årsrapport 2012 (Public Health in Sweden – Annual Report 2012), as well as the online database Folkhälsodata (Public Health Data).

Public health policy is multi-sectoral and based on the overall national goal: to create societal conditions that will ensure good health, on equal terms, for the entire population. The aim of the follow-up system is to follow-up on how the overall goal develops. The key for the government is to gain more knowledge about how different measures affect health in the population. The follow-up is not based on developments in the health of the population, but on the factors which affect health, known as health determinants.

The state's public health institute (the Swedish National Institute of Public Health) is tasked with tracking the development of health determinants, evaluating measures that have been undertaken in the area of public health and providing suggestions for new measures.

The absence of interim goals hinders follow-up

The goal of national public health policy is, according to Statskontoret, comprehensive and visionary. The eleven goal areas that are used to classify health determinants are too wide to allow unambiguous conclusions to be drawn about the development of the overall national public health goal. At the same time, the state's changes to its performance management have meant that policy area goals are no longer used as interim goals in the follow-up of public health policy. According to Statskontoret, the lack of interim goals makes it more difficult to assess whether the national public health policy goal has been achieved based on the public health policy follow-up. Furthermore, a clearer prioritisation in the follow-up is made more difficult by the fact that the goal is built from three different components (societal conditions, good health, equal terms).

Overall, Statskontoret assesses that the overall national public health goal and the eleven goal areas are not sufficient to bring about a focused and expedient follow-up of public health policy. The Agency states that the assessment of the fulfilment of goals would be made easier by a clearer goal structure that uses a number of interim goals.

The indicator system is vast and needs to be revised

Statskontoret has made a number of observations regarding the indicators that are used in the public health policy follow-up. We have established the following:

  • The system comprises a large number of indicators, about 120, not all of which are still considered relevant by the target groups.
  • There is a lack of indicators and determinants in important areas.
  • In several cases, the follow-up is based on health outcomes and not on the factors which affect health.
  • A small proportion of the indicators reflect underlying factors, i.e. factors which policy can affect to a great extent.
  • The indicators have not been systematically and continually revised. The agencies concerned demand joint action on an overhaul of the indicators.

Statskontoret assesses that the indicator system needs to be revised by the National Institute for Public Health and the other agencies concerned so that it can become more relevant. Furthermore, Statskontoret assesses that 120 indicators is too large a number to constitute a basis for a combined assessment of the fulfilment of the overall goal.

The public health efforts of the agencies concerned have been affected to a small extent

Statskontoret can conclude that the efforts of the agencies concerned on public health issues have only been affected in some cases by the task of reporting on indicators for the public health policy report. Our evaluation shows that the foremost reasons as to why the agencies were not affected to a greater extent were that the task of producing basic data did not differ much from the agencies' other assignments and that the public health perspective already exists, in many cases, in the agencies' activities. Another reason is that it was not evident from the government commission that the aim was that the agencies' public health efforts should be affected.

The follow-up is being used, but the value could be greater

The reports Folkhälsopolitisk rapport 2010 and Årsrapport 2012 are primarily directed at the government, the Government Offices and parliament, but local government is also an important target group. Our evaluation shows that Folkhälsopolitisk rapport 2010 is well-known and is used primarily by local government and by the department responsible for public health in the Ministry of Health and Social Affairs. Årsrapport 2012 is less well-known and less frequently used, which can be partly explained by the fact that it does not meet the target groups' expectations that the reporting of public health and health determinant development should be more coordinated. The reports are used to a small extent by officials in the Government Offices, and there are indications that they are infrequently used in general in the Government Offices. The online database Folkhälsodata is aimed at local government, which also makes extensive use of this database.

The value of the public health policy follow-up is considered quite large by the users. However, the value is limited by several factors, such as the limited dissemination of the data in the Government Offices and the fact that policy effects and effective public health measures are not reported in a sufficiently clear way. Taken together, Statskontoret assesses that there are inadequacies in the follow-up system's fitness for purpose that are linked to its use and value. If the value is to become greater, its use in the Government Offices and the coordination of public health reports need to increase.

There is a need to track local and regional developments

Local government has signalled the need for the the national follow-up to track developments at the local and regional level. It is necessary that the follow-up contains data about the development of health determinants and recommendations for evidence-based measures. Statskontoret assesses that there is a need to continuously track these developments and the measures that are taken at the local and regional level.

Many assignments affect agencies' ability to take the initiative

The government has increasingly provided agencies with special assignments. This has reduced the agencies' space to use their own initiative with regard to the follow-up assignments they have been instructed to carry out. This concerns, for example, the coordination of public health reporting between the Swedish National Institute of Public Health and the National Board of Health and Welfare and the revision of indicators. It is also unclear to the agencies how public health reporting is to be coordinated. Due to the large number of agency assignments, Statskontoret believes that these assignments need to be formulated in a very clear manner in order for them to be conducted as expected.

Despite the government's comprehensive management of assignments, it is, according to Statskontoret, the responsibility of the management of each agency to live up to and prioritise the long-term follow-up assignment set out in the agency's instructions. Statskontoret assesses that the agencies' instructions make both collaboration and the use of individual initiative possible in the public health related follow-up.

Proposals

Statskontoret's combined assessment is that there are deficiencies in the follow-up system's fitness for purpose. In the report, Statskontoret submits a number of proposals for increasing the fitness for purpose. Amongst other things, Statskontoret proposes the following measures:

  • In addition to the overall goal, the government adds new delimited interim goals that may be followed up.
  • The agency responsible revises the indicators and health determinants with regard to relevance and number, in collaboration with the agencies concerned.
  • The agency responsible continues making in-depth analyses of developments towards the general goal in the form of a public health policy report.
  • The purpose of Folkhälsodata is expanded to become a national tool for the continual follow-up of the development of health determinants for all target groups.
  • The responsible agency continually gathers and compiles information on measures taken at the regional and local level.
  • The responsible unit in the Ministry of Health and Social Affairs takes a greater responsibility for disseminating the results of the follow-up throughout the Government Offices.

1 The agencies concerned are the Swedish Work Environment Authority, the Swedish Social Insurance Agency, the Swedish Agency for Disability Policy Coordination (Handisam), the Swedish Board of Agriculture, the Swedish Arts Council, the National Food Agency, the Swedish Civil Contingencies Agency (MSB), the National Agency for Education, the Swedish Institute for Infectious Disease Control, the National Board of Health and Welfare, Statistics Sweden (SCB), the Swedish Radiation Safety Authority and the National Board for Youth Affairs.