Joint Action Health Equity Europe Research Articles

Addressing health inequalities in Europe: key messages from the Joint Action Health Equity Europe (JAHEE)

Health inequalities within and between Member States of the European Union are widely recognized as a public health problem as they determine a significant share of potentially avoidable mortality and morbidity. After years of growing awareness and increasing action taken, a large gap still exists across Europe in terms of policy responses and governance. With the aim to contribute to achieve greater equity in health outcomes, in 2018 a new Joint Action, JAHEE, (Joint Action Health Equity Europe) was funded by the third EU Health Programme, with the main goal of strengthening cooperation between participating countries and of implementing concrete actions to reduce health inequalities. The partnership led by Italy counted 24 countries, conducting actions in five policy domains: monitoring, governance, healthy living environments, health systems and migration, following a three-step implementation approach. Firstly, specific Policy Frameworks for Action (PFA) collecting the available evidence on what practice should be done in each domain were developed. Second, different Country Assessments (CAs) were completed to check the country’s adherence to the recommended practice in each domain. The gap between the expected policy response (PFA) and the present policy response (CA) guided the choice of concrete actions to be implemented in JAHEE, many of which are continuing even after the end of JA. Final recommendations based on the best results achieved during JAHEE were elaborated and agreed jointly with the representatives of the involved Ministries of Health. The JAHEE initiative represented an important opportunity for the participating countries to work jointly, and the results show that almost all have increased their level of action and strengthened their capacities to address health inequalities.

Monitoring Health Inequalities in 12 European Countries: Lessons Learned from the Joint Action Health Equity Europe.

To raise awareness about health inequalities, a well-functioning health inequality monitoring system (HIMS) is crucial. Drawing on work conducted under the Joint Action Health Equity Europe, the aim of this paper is to illustrate the strengths and weaknesses in current health inequality monitoring based on lessons learned from 12 European countries and to discuss what can be done to strengthen their capacities. Fifty-five statements were used to collect information about the status of the capacities at different steps of the monitoring process. The results indicate that the preconditions for monitoring vary greatly between countries. The availability and quality of data are generally regarded as strong, as is the ability to disaggregate data by age and gender. Regarded as poorer is the ability to disaggregate data by socioeconomic factors, such as education and income, or by other measures of social position, such as ethnicity. Few countries have a proper health inequality monitoring strategy in place and, where in place, it is often regarded as poorly up to date with policymakers’ needs. These findings suggest that non-data-related issues might be overlooked aspects of health inequality monitoring. Structures for stakeholder involvement and communication that attracts attention from policymakers are examples of aspects that deserve more effort.

Policy Recommendations for healthy living environments and municipal health promotion in Europe

Abstract   Municipalities can be the motor for health equity. But how should health promotion policies at all levels be formulated in order to mobilize local action for health? The Work package (WP) “Healthy Living Environments” in the Joint Action Health Equity Europe (2018 - 2021) focussed its work on this question. Based on a common Policy Framework for Action (PFA) and 14 Country Assessments (CA), actions were implemented representing a wide spectrum of policy responses to promote health equity through a municipal health promotion approach. At the end of the project, policy recommendations subsume the expertise and experience of the partners contributing to the sustainability of results. The policy recommendations were generated in 3 steps: Relevant project documents were collected and analysed, including the PFA, the CA, the reports and evaluation of actions and the results of a Delphi study conducted in the frame of the project. A synopsis of these documents was analysed in a workshop with the WP partners, resulting in decisions about the concept and necessary messages the policy recommendations should include. Some of the implemented actions and collected practices from the project were selected to elaborate the individual recommendations along these examples. A working group drafted the policy recommendations. After a second workshop to discuss the draft, the final recommendations were consented by the WP partners.   The preliminary results include recommendations for different political levels, as health equity needs multi-level and multi-stakeholder health in all polices approaches along a quality-oriented process. A specific equity lens and a focus on existing frameworks, tools and capacity-building approaches is needed. Also the stronger deficits of municipal health promotion like the lack of scientific evidence or data at local level were identified. Ways of applicability and integration into the agendas of the audience will be discussed.

6.L. Workshop: On the way to health equity – strengthening health promotion governance at local level in Europe

Abstract   Health equity is influenced by the local social and physical environment people are living in. Municipalities all over Europe have a key role in shaping and addressing these living conditions. This is why one of the Work packages in the Joint Action Health Equity Europe focussed on how municipalities can contribute to health promoting and equity-oriented living environments. 17 national, regional and local public health authorities from 13 countries collaborated in this 3-year policy-level project, exchanged knowledge and practices, and implemented actions, tools and policies that promote healthy living environments. The first step in the project was to adopt a common Policy Framework for Action which summarizes the current evidence for healthy living environments and the role of municipalities. It provides a conceptual model for integrated municipal approaches. As a second step in the project, country assessments were conducted. Municipalities have a clear mandate to promote health. However, there is a big heterogeneity in resources, structures and capacities within and between countries. Key challenges are deficits in political commitment, accountability and intersectoral working. Yet, national and regional public health authorities have the potential to contribute a lot to support municipalities, like quality development, providing data, integrating health equity in existing structures, plans and approaches or collaborating with the broad range of existing stakeholders and networks. A synopsis from all the project documents, evaluation and an accompanying research project resulted in the final Policy Recommendations for Healthy Living Environments that this workshop presents, focussing on the following questions: How should health promotion policies be formulated in order to mobilize local action for health? What are the opportunities and barriers for health promotion at local level? How can the experience from JAHEE be integrated into the different structures of municipal health promotion in different countries? The first question will be taken up in the first presentation, presenting the development and contents of the final Policy Recommendations for Healthy Living Environments. The second presentation addresses the opportunities and barriers identified by a Delphi Study that has been conducted in the frame of the project work. The last question around sustainability and transferability of structures will be addressed through a roundtable discussion bringing in the experience from project partners and a local policy-maker. The workshop will give the possibility for stakeholders that were not involved in the Joint Action to inform themselves about the activities in different European countries. The broadening of the audience is also crucial for enhancing awareness of health equity and healthy living environments, increasing the acceptance and dissemination of the policy recommendations at national levels and developing a perspective for future actions. Key messages Municipalities can be the motor to build sustainable and equitable health promotion policies and structures. A common quality process has to be promoted and supported by frameworks, tools and capacity-building across political levels and sectors.

Health inequalities -development of a monitoring system in Finland

Abstract Background Health in Finland has developed positively in recent decades, but there are still large differences between population groups. Wide inequalities persist between socio-economic groups, for example by education, occupational status and income, in different domains of health such as self-reported health, morbidity, and mortality. Our aim in the sub-project of the Joint Action Health Equity Europe was to describe the status of national health inequality monitoring in Finland, and to present ideas for improving the situation, including the key indicators to be monitored. Methods Several nationally representative registers and population surveys are the key sources of health information in Finland. We summarized information on the current state of socioeconomic health inequalities and their development over the past decades to identify research based health topics and indicators, selecting those where clear differences have been identified between education or income groups among the working-aged people. Results We recommend 13 indicators to monitor and evaluate socio-economic health inequalities in the Finnish adult population. They cover five topics: health status, functioning, work ability, lifestyles and social factors. The recommended indicators are in line with the Nordic recommendation of inequality indicators and allow comparison between EU countries. This is the first step in developing a full monitoring system. The second step is needed to reach an agreement on the implementation. Conclusions High-quality population survey and register data make it possible to monitor health inequalities in Finland. Register-based data need to be supplemented with population surveys, both health interview and health examination surveys, to provide necessary information on risk factors, functioning and perceived health. Key messages The key characteristics of successful systematic monitoring of health inequalities are regularity, up-to-date information, validity of selected indicators and coverage of the most important phenomena. Monitoring enables identification of health needs which must be recognized in policy-making, targeting of services, regional benchmarking and support for health impact assessment in policy-making.

Joint Action Health Equity Europe - turning knowledge on health inequality monitoring into actions

Abstract Growing social inequalities in health challenge a sustainable development. To reduce health inequalities, it will be necessary to provide relevant data to policymakers on how health inequalities and the social determinants of health are distributed within populations over time, i.e. it will be necessary to form appropriate health inequality monitoring systems (HIMS). One of the aims with Joint Action Health Equity Europe (JAHEE) and the specific objective of work package five (WP5) is to advance partner countries ability to monitor national health inequalities. Country assessments has been conducted to assess the status of the HIMS in the participating countries, and a joint framework has been developed, describing the core components of an “ideal” HIMS. All partners have committed to the overall objective of the WP5 through the identification and implementation of concrete actions, which is now ongoing. The countries in JAHEE WP5 are Cyprus, Finland, Germany, Italy, Lithuania, Netherlands, Poland, Romania, Serbia, Slovenia, Spain and Sweden, where The Public Health Agency Sweden is the lead. The aim of this presentation is to present the experiences from JAHEE WP 5, and what they imply is needed to build coherent health inequality monitoring systems at a national level. More specifically, the JAHEE project in general, the WP5 project in particular will be presented, the structured work process described, and some general results and conclusions discussed

28.K. Workshop: Advancing health inequality monitoring in Europe – challenges, opportunities and actions

Abstract Much of the focus on health inequality monitoring is based on aggregate descriptions at national levels where averages or proportions are compared. However, inequalities evolve from systematic differences in living conditions, circumstances, and opportunities between population groups within geographical entities. To be able to follow such trends in health, to detect less favourable trends at an early stage, and to reveal the trends in the population and in subgroups of the population, it is essential to have a national health inequality monitoring system (HIMS) in place. In fact, in line with the “no data, no problem” notion, one might even claim that the most essential part of combatting social inequalities in health is a well-functioning health inequality monitoring system. The Joint Action Health Equity Europe (JAHEE) is a Joint Action financed by the Third Health Programme 2014-2020 of the European Union. It represents an important opportunity for countries to work jointly to address health inequalities and achieve greater equity in health outcomes across all groups in society in all participating countries and in Europe at large. One of the aims with JAHEE and the specific focus of work package five (WP5) is to advance member states ability to monitor national health inequalities. The overall objective of the work conducted in JAHEE WP5 is to attract attention to and improve countries' capacity to monitor health disparities in a “do something, do more, do better” manner. The advancement of HIMS varies greatly between countries in Europe. Yet, there is scope for improvement in virtually all countries. In addition, challenges that impede the way health inequality monitoring can be conducted are often common across countries. These challenges cannot be eliminated within the course of a three-year EU project. The JAHEE project, however, offers an unique opportunity to move forward by working together in a structured work process that allow partner countries to share, build and transform available knowledge into concrete actions aimed at strengthening national health inequality monitoring systems in Europe. In this workshop, we will present the experiences from JAHEE WP5 and give examples on concrete actions and initiatives taken across Europe to challenge some of the barriers faced and to strengthen the national health inequality monitoring processes in Europe. There will be room for discussion between each presentation and in the end of the workshop. Key messages Raised awareness a politically committed system infrastructure to assure sustainability in health inequality monitoring. Raised awareness of need for agreed data but also agreed methods to compile data to measure inequalities within populations.

Health inequality monitoring - measuring what and how, exactly?

Abstract The output from health inequality monitoring systems at the national level should be comparable across countries to enable judgements about how health inequalities evolves in the EU. Such comparability presumes a common approach to what kind of data should be compiled, what indicators to focus and what measures to use. Hence, there are many decisions to be made and to agree upon. Only in terms of possible indicators, there is an overwhelming number of possibilities. This is confusing and could easily lead to diverging conclusions on how health inequalities develop within and across countries over time. As part of the Joint Action Health Equity Europe and the work conducted in work package five on monitoring, a core health inequality indicator set is being developed. The set should include a small number of indicators and contain information on health, on social determinants of health and on some measure of social position, preferably education. The indicator set should be based on data already reported to EU and liaised with other indicator initiatives. The final set will be proposed to be included on available EC platforms and specific websites as indicators of health inequalities. Such an indicator set will facilitate valid judgements on how health inequalities evolves in countries and in the EU. In this presentation, we will learn more about the proposed JAHEE indicator set, and about the work process. We will also get a chance to reflect on and discuss the proposed indicators and measures. The auditorium will be invited to reflect on conclusions.

Towards a national health equity monitoring strategy

Abstract The 2017 Italian Review on health inequalities identified two main needs with regards to Italian health equity monitoring. (1) The need to collect a social covariate at individual level in each health information system at local, regional and national level. Such a social covariate is fundamental for monitoring if any avoidable inequality in access, use, quality of care and health outcome is occurring at local, regional, national level. (2) The need to re-engineer and frame the different health equity monitoring surveys already established into an explicit health inequalities monitoring strategy (HIMS). Both challenges are accounted for by Italy in the Joint Action Health Equity Europe workplan. As for the social covariate, a pilot project is conducted. Data from 2011 census (education and area deprivation) and the national identification code used to link individual data on health and services utilization in four representative regions is linked. This will allow monitoring the social variation in selected performance indicators by region, across regions and through time. As for HIMS, previous research projects have designed and successfully piloted different models of low-cost data linkage for already established longitudinal studies. Now these pilot results will evolve into a national HIMS. As a first step, a special project of consensus building will be implemented among institutional partners responsible for the following national longitudinal studies based on record linkage: a) Work Histories Italian Panel followed up prospectively for health outcomes; b) Italian Longitudinal Study: 2000, 2015, 2013 Health Interview Surveys followed up prospectively for health outcomes; c) differential mortality 2011-2017 in the 2011 censused Italian population; d) the network of the metropolitan and regional census based longitudinal studies followed up prospectively for mortality disease registries and health care utilization. Experiences gained will be shared and discussed.

Strategies for reaching vulnerable groups in municipal health promotion

Abstract Background Contrary to the actual goal of health promotion, which is to reach all population groups equally, groups with an already better state of health are reached by such health services whereas vulnerable or socially disadvantaged groups are often not reached. Specific offers for the latter, however, can lead to stigmatization by reducing them on certain risk factors. This results in a further increase of health inequalities. Methods As part of the Joint Action Health Equity Europe (Work Package 6), 13 participating countries have initiated individual projects since autumn 2019 to promote community health and health equity. These projects are based on previously systematically identified country-specific needs. Through content analysis according to Mayring of interim reports and interviews with the project partners, it will now be investigated which strategies have been used to reach vulnerable groups. Recommendations for other countries will be derived from this comprehensive experience. Results At this stage, the observations indicate that different strategies are chosen to reach different vulnerable groups. It can be assumed that direct connection to existing networks, which enable low-threshold access to these groups in their everyday life and participatory approaches that involve the target group in planning and implementation, seem to be promising. Conclusions The diversity, uniquely portrayed by the various projects from different European countries, provides an overview of the differences and similarities in the strategies used for reaching vulnerable groups from which approaches can be generated that are internationally relevant and transferable. Key messages Gaining access to vulnerable groups requires special consideration in health promotion. The results of the JAHEE project (WP6) show promising and diverse strategies for dealing with vulnerable groups.

Monitoring health inequalities in Barcelona

Abstract In Spain, the Public Health Law approved in 2011 foresees the creation of a Surveillance System on Social Determinants of Health and Equity. However, although information on health inequalities has been reported in technical reports and scientific articles before, it is not until now with the change of the Spanish government the political will to set up the more strategic surveillance system approved and foreseen in 2011 is there. The change of government in some cities can be an opportunity to advance in the surveillance of health inequalities and policies to tackle them. In Barcelona, for instance, there is a wealth of information and research on health inequalities, but in the past health inequalities was not clearly prioritised on the political agenda. Hence, although health inequalities have been presented in many reports, a monitoring and surveillance system has not been available nor a prioritised task. This has now changed and as part of Spain's engagement in the Joint Action Health Equity Europe project (JAHEE) a system for Monitoring Health Inequalities in the city of Barcelona is being established. During the course of the JAHEE project the objectives of the system and target populations will be defined, sources of information and indicators identified, dissemination and evaluation structures set up before finally, in the next step, the system is to be implemented. The ambition is that the new monitoring system on health inequalities set up in Barcelona in its final form, will make out a part of the information systems of the Public Health Observatory of the city of Barcelona. In this presentation, we will learn more about the establishment, the content and the experiences gained while setting up the new monitoring system on health inequalities in Barcelona - from defining the objective of the system to implementing it.

Developing a strategic plan for sustainable health inequality monitoring – the basic step towards tackling health inequalities in long run

Abstract Slovenia has had periodic reporting on health inequalities for almost a decade. The importance of reporting is well recognised and stated in the National strategy on health care 2015-2025. Yet, the assessment of the status of the national health inequality monitoring system (HIMS) conducted within the Joint Action Health Equity Europe project, made the unsystematic nature of current practices obvious. A need for developing a more systematic and sustainable HIMS and to have a long-term monitoring strategic plan in place was acknowledged. The set-up of systematic and sustainable long-term monitoring of health inequalities will provide reliable and comparable longitudinal data on the direction, magnitude and trend of health inequalities in Slovenia. This is in turn necessary to inform any future policies and/or programmes, thus stimulating action. Furthermore, identifying relevant stakeholders will facilitate formation of a network of partners who take part in tackling health inequalities, thus allowing for a more proactive (i.e. bridging) role in addressing health inequalities in Slovenia. The aim of this presentation is to demonstrate the process and the steps taken to prepare a document (strategic plan) detailing a systematic approach to long-term monitoring of health inequalities complete with goals, objectives, methodology, a pragmatic set of indicators and an evaluation plan that will inform and facilitate most reporting/monitoring activities

Needs-based decision-making for municipal health promotion – an analysis across 13 European countries

Abstract Introduction In contradiction to many recommendations, municipal health promotion often does not address identified needs. In order to create healthy living environments, all the 13 countries participating in Work package 6 - healthy living environments (WP6) of the EU Joint Action Health Equity Europe have been implementing feasible actions since autumn 2019 based on a country-specific needs analysis. They were supported on a theoretical level by the contents of the WP6 Implementation Template. The aim is to find out if and how the decision-making process from needs-based planning to the implementation of these measures in municipal health promotion was successful. Methods In order to gain an insight into the process 'from needs to action' and to obtain information about the methodological approach to implementation, guideline-based interviews were conducted with the project partners of WP6. These, as well as accompanying questionnaire-based interim reports, were evaluated comparatively in terms of content analysis according to Mayring and with regard to concrete evaluation criteria, obstacles and success factors during individual steps that can be transferred to the Public Health Action Cycle. Results The interim reports of the participating countries show that the step from an identified problem and related needs to a concrete, tailored action is often difficult. The relevant aspects mentioned above will be analysed more detailed during the interviews. It is to be expected that further insights can be gained from this, especially on successful implementation processes. Conclusions The mix of reports and interviews with participants from different European countries offers a broad view of the decision-making process in local health promotion and makes obstacles and success factors transparent for other actors in this field.

2.I. Workshop: Implementing local health equity policies in Europe – Needs, governance and tools

Abstract The effects of health inequalities within and between European countries are widely recognized, and reducing health inequalities is on the agenda of many countries. Despite an increasing concern and awareness on health inequalities, a wide gap exists in Europe in terms of political response. Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Healthy urban development has a great potential to reduce health inequalities. Healthy living environments can only be created if sectors other than the health sector are involved. Health in all policies (HiAP) is an approach promoted by WHO since the Ottawa Charta (1986). It acknowledges the need for an integrated approach to health involving different policy fields. The reduction of health inequalities is one core aim. Including HiAP is a smart - and feasible - policy choice and one concrete measure it to use prospective Health Impact Assessment focusing on equity. Working with other government sectors requires an understanding of different mandates and goals, and may involve crossing administrative and budgetary barriers between sectors. Different policy actors and professional disciplines have their own languages and approaches to the problems and opportunities in societal development. For this reason, HiAP needs to promote an understanding of the language, goals and working methods across government sectors. Municipal governments need to build trusting and collaborative relationships both between internal sector silos, and across stakeholders within society. The municipal context offers comprehensive entry points for action. Municipalities seek to provide education throughout the life course, create appropriate conditions for housing as well as for physical activity and healthy eating. Municipalities can also promote the creation of a stable ecosystem. Moreover, a focus on municipalities addresses the local political context, local political regulations and urban or rural planning and development, which are important contributions to improving living conditions. There is valid information on health, health inequalities and its determinants available, but the information is not automatically transformed to concrete policy actions and measures. Besides knowledge, policy implementation requires many other elements to be effective: political will and commitment, collaboration, resources and governance. This session presents current findings and actions in the frame of the EU Joint Action Health Equity Europe (JAHEE). The first contribution includes an analysis of specific governance aspects for healthy living environments that are being addressed in JAHEE: How is the process from needs to decision-making to actions done by the participating 13 countries? After that, 4 examples from the Netherlands, Italy and Spain will describe their needs, governance and tools while implementing local health equity policies in their own context. Key messages The local level is the place where many determinants of health can be shaped and where Health and Equity in all Policies can be realized in an innovative way. There are many existing examples for tools and governance for local health equity policies that can be transferred to other places.

Municipal Health Promotion as Part of Urban Health: A Policy Framework for Action

The link between health, socio-economic status and the living environment is increasingly moving into the focus of public health research and policy. The aim of the European Union’s Project “Joint Action Health Equity Europe (JAHEE)” is to enable countries to identify and implement needs-based measures to promote health equity. In one of JAHEE’s work packages, focusing on healthy living environments as a strategy to tackle health inequities, a Policy Framework for Action (PFA) has been developed. This article gives an insight into the core contents of the PFA, which are valid beyond the project boundaries for all actors that work at the intersection of community health promotion. The PFA was developed as a consensus document in a participatory process between the members of the work package and an interdisciplinary German team of public health experts. Results from project meetings of the partner countries as well as research findings and recommendations from field experts were incorporated. Reducing health inequalities in public health is a cross-sectional issue that needs to be addressed across all policy areas. The municipality setting is of particular importance in this context, as it offers many starting points and can coordinate between all relevant actors with an overarching strategy.

Workshop: Creating healthy living environments in municipalities – European concepts, needs and actions

Abstract Health equity is influenced by the local social and physical environment we are living in. Municipalities all over Europe have a key role in shaping and addressing these living conditions. This is why one of the Work packages in the current EU Joint Action Health Equity Europe (JAHEE) deals with the living environment, and what municipalities can contribute to shape them in a health promoting and equity-oriented way. Current action in this field is fragmented, varies highly between and within European countries and strongly depends on political leadership. The Work package aims at providing a systematic and structured support for participating countries in taking action to create healthy living environments. In Work package 6 - Healthy living environments, 17 national and regional public health authorities from 13 countries collaborate to exchange knowledge, practices and implement actions that promote healthy living environments. This workshop aims at bringing together current knowledge and experience of why and how to create healthy living environments on the municipal level. Furthermore, it is supposed to inform what countries currently do and need to do in this field of action from the perspective of national public health institutes and ministries of health. And thirdly, an innovative local example of how to put the theory into practice will be presented. The “Should be”: The first presentation will describe the common conceptual basis for the project partners - the Policy Framework for Action. As was agreed upon among the project partners, the specific focus is a broad community approach towards health promotion that is steered from the municipal level. The “To be”: The second presentation will focus on common European challenges and potentials based on the country assessments that were conducted in the frame of the project, and how municipalities can be supported from the European, national and regional levels. Third and fourth presentations will present more in-depth country reports from Greece and Serbia describing the current capacities and potential for municipal health promotion. The “Good Practice”: The fifth presentation from the Netherlands will present an innovative approach from the City of Utrecht that is implemented in the frame of the Joint Action Health Equity Europe. The findings will be discussed using an interactive online-tool, and finally next steps, future actions and recommendations will be outlined. The workshop will give the possibility for stakeholders that are not currently involved in the Joint Action to inform themselves of the activities on the European level. The broadening of the audience is also crucial for enhancing awareness of health equity and healthy living environments as well as increasing the acceptance of the conceptual framework at national levels. Through exchange of knowledge and experience, potential new partners could be reached and involved in the project. Key messages The workshop brings together current knowledge of why and how European municipalities can create healthy living environments. The workshop presents what European countries currently do and need to do in this field of action.

Current capacities and challenges for equity-oriented municipal health promotion in Europe

Abstract As a basis for implementing actions in the frame of Work package 6 - healthy living environments in the Joint Action Health Equity Europe, each of the 13 participating countries conducted a country assessment. Methods The country assessments were self-assessments conducted in the first quarter of 2019. Partners received templates that had been agreed upon beforehand. Most of them conducted the country assessments by themselves or with the help of colleagues from their institutions as a desk-based review, and validated results with external experts and stakeholders. The first part of the country assessment referred to how municipal health promotion capacities are currently developed in the countries. Through the second part of the country assessment, each of the 13 countries selected up to 4 promising practices. Results In most of the 13 countries, municipalities have a clear mandate to promote health. However, there is a big heterogeneity in resources, structures and capacities of municipal health promotion within and between countries. One key challenge is the self-government of municipalities and health promotion as a voluntary task. One of the main problems is a deficit in intersectoral working. It appears that poor municipalities are even more disadvantaged in terms of capacities for municipal health promotion. 33 promising practices were identified, covering programmes, strategies, tools and interventions mostly from the local level, with a big variety of topics and approaches for health equity. Conclusions There is a big fragmentation and heterogeneity in municipal health promotion between and within European countries. National and regional public health authorities are in the position to contribute a lot to support municipalities. This can include promoting quality development, providing data, integrating health equity in existing structures, plans and approaches or collaborating with the broad range of existing stakeholders and networks.

Public health monitoring in Sweden focusing on inequality – a developmental work

Abstract Issue/problem The overarching goal of the Swedish public health policy is to create the right societal conditions for good and equitable health throughout the population, and to reduce avoidable health inequalities within a generation. Relevant health topics and dimensions of inequalities in health should be monitored to enable effective interventions on the local, regional and national level. To achieve this a strong national health monitoring system (HMS) is central. Description of the problem The objective was to develop a high quality HMS to monitor a broad perspective of public health and its determinants, complemented by a more focused monitoring system of inequalities in health, with relevance on the local, regional and national level. A theoretical framework was developed and empirical mapping of relevant indicators conducted. An expert group was consulted and a country assessment of how to monitor health inequalities was carried out within the Joint action Health Equity Europe project. The developmental work started in 2018 and is not yet completed. Results A web-based monitoring system has been implemented to cover the broad perspective of public health and its determinants. All indicators are reported at the national level and, when possible, degradable at the local and regional level. In addition, a report with a focus on inequalities in health on a national level is published annually, and a longitudinal indicator-based comparative study, with results from Sweden’s 21 regions and 290 municipalities was published in 2019. Lessons General public health and inequalities in health may need to be monitored in different ways. To enable effective interventions, consideration must be given to at what level - local, regional or national - policy decisions are made. Key messages High quality health monitoring enables effective interventions. To reduce inequalities in health focused monitoring is required.