6. Targeting health inequalities through government reform in Norway



To tackle wide health inequalities, the Norwegian government introduced a comprehensive Public Health Act to embed a health in all policies approach across all levels of government and ensure responsibility for health inequality across sectors.





The public health white paper Prescriptions for a healthier Norway highlights the balance between individual and societal responsibility and identifies social inequality as a problem for particular groups.


An action plan called Challenge of the gradient shifts the health inequalities agenda from a problem for some population groups to a focus on the social gradient.


A Ministry of Local and Regional Government white paper (Regional advantages, regional future) prompts county councils to advocate for a public health role.


Government publishes a white paper on social inequalities in health.


The Coordination Reform programme is launched.


The Public Health Act is enacted, setting out the legal framework for public health at all levels of government and promoting health in all policies.


A new government white paper is published to guide the implementation of the Public Health Act.


Evaluations of the Coordination Reform programme and Public Health Act evaluations are published.,,,,


Norway has historically been described as a social democratic welfare state, with its emphasis on solidarity, universalism, equality and redistribution of resources through a progressive tax system. The country has become increasingly wealthy over the past 30 years thanks to its growing oil economy, yet is home to significant health inequalities. For example, people with the lowest education levels had significantly shorter life expectancies and higher rates of physical and mental illness than those who had been to university.

Norway has three democratically elected levels of government:

  • the Storting (national parliament)
  • county municipalities
  • local municipalities.

All three have public health responsibilities (see Figure 1).

Figure 1: Norway’s levels of government and their public health responsibilities

The intervention

Although past Norwegian governments have sought to reduce health inequalities, their policies traditionally focused on lifestyle interventions targeting disadvantaged groups rather than addressing the social determinants of health more broadly. In 2005, a centre-left government won power on the promise to fight poverty and work for a more equitable society in terms of income distribution, education and health. In 2007, it set out an ambitious 10-year strategy to reduce the health gradient, taking a cross-ministerial approach covering childhood, adolescence and education, work, income, health services, health behaviours and social inclusion.

Following a cabinet reshuffle in 2008, the new health minister set in train a series of reforms, known as the ‘coordination reforms’, to improve health care and give the health sector a greater role in preventing and reducing health inequalities. However, these ambitions were met with resistance from the public health community, which was concerned that increasing the health sector’s role in prevention would undo progress that counties and local municipalities had already made in making health a multi-sector responsibility. They argued that the government should introduce a comprehensive, cross-sectoral Public Health Act that applied to all levels of government.

In 2012, Norway’s Public Health Act came into force with the aim of improving health and reducing health inequalities. The Act applied to all levels of government and was based on five fundamental principles.

  • Health equity: fairly distributing societal resources is good public health policy.
  • Health in all policies: joined-up governance and intersectoral working are key to reducing health inequalities.
  • Sustainable development: public health work needs to take a long-term perspective to meet people’s needs today while not compromising future generations.
  • Precautionary principle: if an action or policy is suspected of being harmful, the absence of evidence of harm should not justify postponing action to prevent such harm.
  • Participation: involving all relevant stakeholders, including civil society, is key to good public health development.

Locally, the act provided a legal mandate for municipalities to deliver public health across sectors. For example, municipalities were required to include public health measures in their local strategic plans across a specified list of social determinants, including housing, education, employment, income, and physical and social environments.

At a county level, the act required counties to identify their public health challenges and use these as a basis for their regional planning strategies and embedding health across departments. Nationally, all government departments were required to adopt a health in all policies approach, and the Ministry of Health and Care Services became responsible for supporting municipalities with local health intelligence and guidance.


  • At national level, the Public Health Act is seen as a useful tool for securing health in all policies because it places a legal duty on all ministries. However, there is limited evidence that ministries have changed their policymaking approach in practice.
  • County-level authorities struggled to embed health in all policies. This was partly due to difficulty shifting the focus from lifestyle issues to the social determinants of health. This was exacerbated by the Ministry of Health and Care Services continuing to launch lifestyle-focused public health campaigns.
  • At local level, many believe the act has raised the prominence of public health and increased action on the social determinants of health in local government. In 2014, almost half the country’s municipalities addressed living conditions as part of their health promotion activities, compared with 6% of municipalities before the act.
  • More municipalities have comprehensively assessed their population’s health needs since the act. In 2014, 38% of localities had completed a comprehensive local needs assessment, compared with 18% before the act.
  • A third of municipal managers reported that public health investment has increased as a result of the act, although spending has mainly been on organisational structures and processes, such as creating new job roles, rather than delivering more health promotion measures.
  • More municipalities now employ a public health coordinator to facilitate cross-department collaboration. This has worked best in places where the post is full time and the coordinator is embedded in the local government. However, many areas have created part-time coordinator roles within the health sector, which has limited coordinators’ ability to lead change.

Lessons learned

What worked well

  • The Ministry of Health and Care Services framed the Public Health Act and the health in all policies approach as tools to support other sectors to meet their objectives, which helped secure cross-sector buy-in.
  • Giving local areas the freedom to set their own public health priorities, rather than having them mandated by the state, achieved political buy-in across parties.
  • Making municipalities responsible for health in all policies nurtured a culture change among local politicians that has started to filter up to county and national levels as they move up in their careers.

What worked less well

  • Legislation alone was insufficient to drive and maintain a cross-sectoral approach to public health. Continued efforts are needed to influence politicians and practitioners to adopt a health in all policies approach.
  • Local areas lacked dedicated senior capacity to drive health in all policies across the municipality and in partnership with neighbouring areas. This limited the extent to which the approach was implemented.
  • Without additional, dedicated funding from national government, local action was largely limited to deploying a coordinator post and supporting joint ways of working, rather than implementing new initiatives.
  • Beyond health protection and environmental health concerns, the act did not give powers to curb private-sector actions that undermine health, so it could not address the impact of commercial determinants of health on the inequalities gradient.

Implications for the UK

A Public Health Act could articulate clear responsibilities at each level of government and may support a health in all policies approach nationwide. Long-term partnerships with representative bodies such as the Local Government Association would be vital to build capacity and secure buy-in from politicians, practitioners and the public.

Small or rural areas may lack the capacity to tackle health inequalities at a local level. However, the closer integration of health and local government across larger geographical footprints, and the emergence of city regions, may create the scale and pooled resources needed to improve conditions for both rural and urban communities.

The case study highlights the importance of public health leadership at a senior level. In the UK, directors of public health are not always embedded at executive level, and this may limit their influence. Meanwhile, there are some interesting UK examples where the public health function is distributed across the council. It would be valuable to investigate whether this has led to better coordination of public health and a health in all policies approach compared with those councils where public health is a discrete function.

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