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The local perspective on the implementation of a national public health policy in Sweden – a case study from two municipalities

Author names (surname, initials): Elisabeth Jansson^a,b, , Elisabeth Fosse^c, Per Tillgren^a,b

Affiliations:

School of  Health, Care and Welfare, Mälardalen University, Box 883, SE-721 23 Västerås, Sweden

^b Department of Public Health Sciences, Karolinska Institutet, Norrbacka, SE-171 76 Stockholm, Sweden

^c Department of Health Promotion and Development, University of Bergen, Christiegt. 13, 5015 Bergen, Norway

 Background:

 In 2003 the Swedish parliament adopted a wide-ranging national objective for public health, focusing specifically on health determinants. It is envisaged that the overall objective will be achieved through the efforts of different bodies, including agencies, county councils and municipalities. Responsibility for implementation is located at regional and local level, without any specified guidelines or, for example, economic incentives for how the work should be performed.

This study’s intention is, from a bottom-up perspective, to investigate public-health policies in two municipalities, and to see whether municipal policies can be related to the national objective.  The bottom-up perspective focuses on the actors, the people responsible for implementation, and on the process as seen from their own perspective. The implementers play a key role, as mediators of empirical knowledge and bases for decisions to the national decision-makers. Thus, in the implementation of national policy at local level, decision-makers are dependent on the decisions made and priorities set by the municipalities in their own local settings, as these are related to competing or similar laws, policies, stakeholders and needs. Local and committed actors have an important function in the implementation process. Serious commitment and occupying a position of power are important aspects of success, but so too is professional expertise. At the same time, local actors’ opportunities to act and implement national targets within their own organization is restricted by surrounding structures, e.g. the party-political (partisan) composition of the municipality and its administrative organization, and also the presence or not of formal or informal support networks.

Methods:

 Scrutiny of documents and interviews provided a foundation for a qualitative case study.

Results:

The results reveal a loose fit between policy implementation and the national public health policy. The local level does not regard the national objective as implementable; instead, it has, to varying degrees, chosen to redefine its goals according to municipal needs and conditions. A success-promoting factor in the two municipalities was the presence of committed and knowledgeable actors/implementers. Also, the municipality with a more centrally controlled and stable party-political leadership succeeded better in implementing structural and intersectoral community-wide policies for coordinated local public-health promotion.

Discussion /Conclusions:

Problems that accompany major, ambitious and non-specific goals, like those in the Swedish public health policy, are that they risk being integrated into a solely symbolic structure, entailing formal adoption but with only a superficial finish.  Below the surface, the informal, original organization remains in the administrations, which hinders implementation.

Swedish municipal self-governance, with its enhanced scope for local action, offers an opportunity for communities to shape their own politics and policies. But, at the same time, this acts as a barrier to opportunities for decision-makers at national-government level to influence and guide the municipalities towards the national objective of more organized and structured health promotion focusing on the determinants of health enhanced knowledge of the policy, and of its specific focus on health determinants, is needed to increase understanding/motivation to implement the national policy locally.