Public Health Coordinator - How to Promote Focus on Social Inequality at a Local Level, and How Should It Be Included in Public Health Policies? Comment on "Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups".

The Norwegian Public Health Act of 2012 (PHA)1 states that the social causes of inequality in health have not been devoted sufficient attention in Norwegian health policy. Different means have been implemented to pay more attention to health inequalities at a local level, one is the use of a designated public health coordinator (PHC). Hagen et al2 reveals in a new study, however, that the presence of PHCs' does not add to the priority of reducing inequality as a health objective. This negative association is, by the authors, explained by a widespread use of coordinators before the Act, and as such, not really a new measure. Another factor emphasized is that the PHC position is not empowered by bureaucratic backing. I agree with these explanations. However, the study by Hagen et al2 lacks a critical discussion of how the role of the PHC is situated in an administrative intersection between national health policy based on universal initiatives and social policy in the municipalities historically driven by a focus on poverty and specific target groups. This commentary reflects upon how social inequalities in health at a local level and the responsibilities imposed on the municipalities contest the principals of universalism. The tension between universalism and selectivity needs to be more prominent in the debate on how health inequalities should be abated at the local level, if universalism shall prevail as the overarching principle in Norwegian health policies. The commentary concludes by asking for a more nuanced discussion on how work with health related social problems can support universalistic initiatives. It is also suggested as a task for the PHC to make sure that public health initiatives are systematically evaluated. Documentation of effects will provide knowledge needed about how initiatives affects the social gradient over time.

Tackling health inequality at the local level: Some critical reflections on the future of Norwegian policies.

AIM: In this paper we discuss recent developments in the policy to reduce health inequalities in Norway in relation to challenges and opportunities associated with tackling health inequality at the local level. METHODS: We discuss government documents and research findings on the implementation of policies to diminish health inequalities at the municipality level. Recent policy developments are briefly reviewed in relation to the 10-year strategy to reduce health inequalities passed by the Parliament in 2007. We then identify opportunities and obstacles to successful action on health inequalities at the local level. RESULTS: The 2012 Public Health Act represented a powerful reinforcement of the strategy to reduce health inequalities at all three levels of government: the national, the regional and the local. However, some aspects of the policies pursued by the current government are likely to make local action to tackle health inequality an uphill struggle. In particular, health equity policies that have hitherto been based on universalism and had a focus on the gradient seem to be running out of fuel. Other challenges are an insufficient capacity for effective action particularly in smaller municipalities, and a rather weak knowledge base, including systems to monitor social inequalities and a general lack of evaluations of trials and new initiatives. CONCLUSIONS: We conclude that the Public Health Act opened up many new opportunities, but that a number of municipalities face obstacles that they need to overcome to tackle health inequalities comprehensively. Furthermore, local efforts need to be coupled with sustained national momentum to be efficient.