Collective Competence as an Enabler for Service Integration in Health and Social Care Services.

Purpose: Fragmentation in health and social care services can result in poor access to services, lack of continuity and inadequate provision for needs. A focus on integration of services are thus suggested to prevent negative consequences of fragmentation for service recipients. There are, however, few studies that explore the competence needed for integration of services in municipal health and social care organizations. This study explores which types of competence stakeholders require and how collective competence can promote service integration. Methods: This is a single-case study, and the data consist of focus group interviews and individual interviews with service recipients, family caregivers, professionals and managers. The data were analysed both inductively and deductively. Results: The analysis resulted in four main themes: 1) Knowledge about individual life situations and organization and system, 2) investigation competence, 3) person-centred collaboration competence and 4) facilitating competence. The themes form the basis for a collective competence framework that can promote service integration. Conclusion: As service integration involves a high degree of interlinked activities between professionals and organizational units, a collective approach to the concept of competence is presumably applicable. When service integration competence is approached as a collective attribute of a network within and between organizational units, the organization can facilitate this competence by encouraging an active exchange of knowledge between professionals. We also argue that service integration competence increases connectivity and interdependency between professionals and organizational units, and includes service recipients and family caregivers as legitimate extra-professional parts of the collaborative network.

Do Shared Digital Workspaces Boost Integration? The Case of One Early Intervention Initiative for Vulnerable Children in Norway.

Introduction: The paper discusses the implementation of a digital workspace to facilitate collaboration in health and social services for vulnerable children and adolescents in eight Norwegian municipalities. The purpose of the workspace is to enhance collaboration independent of space and time. Collaborating services are schools, kindergartens, school health services, educational services and child welfare services. Methods: The data analysed are from semi-structured interviews with project leaders in primary care, responses of primary care professionals to open questions in a survey, and results from two questions in three subsequent surveys. Results: Project leaders held great expectations of increased collaboration. Variations were found regarding how far the implementation of a new workspace precluded previous methods of collaboration and whether retaining a familiar workspace necessitated strengthening resources to negotiate using the workspace. Organisational and professional cultures hindered the implementation of the workspace. Discussion: Interrelated barriers to collaboration were found at the professional, organisational and systemic levels. Some professionals could adapt the workspace to their existing tasks while others could not. Primary care providers need to strengthen their organisations while implementing the workspace. Conclusion: Concerted action at national and municipal level is needed to successfully implement digital tools.

Being bound and tied by the ropes of frugality: a case study on public management values and service integration.

PURPOSE: New Public Management (NPM) has increased fragmentation in municipal health and social care organizations. In response, post-NPM reforms aim to enhance integration through service integration. Integration of municipal services is important for people with complex health and social challenges, such as concurrent substance abuse and mental health problems. This article explores the conditions for service integration in municipal health and social services by studying how public management values influence organizational and financial structures and professional practices. DESIGN/METHODOLOGY/APPROACH: This is a case study with three Norwegian municipalities as case organizations. The study draws on observations of interprofessional and interagency meetings and in-depth interviews with professionals and managers. The empirical field is municipal services for people with concurrent substance abuse and mental health challenges. The data were analyzed both inductively and deductively. FINDINGS: The study reveals that opportunities to assess, allocate and deliver integrated services were limited due to organizational and financial structures as the most important aim was to meet the financial goals. The authors also find that economic and frugal values in NPM doctrines impede service integration. Municipalities with integrative values in organizational and financial structures and in professional approaches have greater opportunities to succeed in integrating services. ORIGINALITY/VALUE: Applying a public management value perspective, this study finds that the values on which organizational and financial structures and professional practices are based are decisive in enabling and constraining service integration.

Leveling the Social Gradient in Health at the Local Level: Applying the Gradient Equity Lens to Norwegian Local Public Health Policy.

The gradient in health inequalities reflects a relationship between health and social circumstance demonstrating that health worsens as you move down the socioeconomic scale. Norway's Public Health Act (PHA) specifically aims to tackle the gradient by addressing the social determinants of health. In this article, we draw on data from 2 studies that investigated how municipalities in Norway deal with these challenges. In doing so, we apply theoretical perspectives, as defined in the Gradient Evaluation Framework (GEF), to analyze the implementation of the PHA at the municipality level. The article aims to describe and analyze how local governments follow the requirements of the act. In doing so, we address the following research questions: Which policies are implemented at the local level to reduce social inequalities in health among families and children? How is intersectoral collaboration carried out, and who is taking part in the collaboration? The article draws on both quantitative survey data from questionnaires sent to all Norwegian municipalities and qualitative interview data in 6 municipalities. The findings show that there is raised awareness of the significance of social determinants among an increased number of municipalities, indicating that the PHA is being implemented according to its objectives.

Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups.

BACKGROUND: Norway is internationally known today for its political and socio-economic prioritization of equity. The 2012 Public Health Act (PHA) aimed to further equity in the domain of health by addressing the social gradient in health. The PHA's main policy measures were (1) delegation to the municipal level of responsibility for identifying and targeting underserved groups and (2) the imposition on municipalities of a "Health in All Policies" (HiAP) approach where local policy-making generally is considered in light of public health impact. In addition, the act recommended municipalities employ a public health coordinator (PHC) and required a development of an overview of their citizens' health to reveal underserved social segments. This study investigates the relationship between changes in municipal use of HiAP tools (PHC and health overviews) with regard to the PHA implementation and municipal prioritization of fair distribution of social and economic resources among social groups. METHODS: Data from two surveys, conducted in 2011 and 2014, were merged with official register data. All Norwegian municipalities were included (N=428). Descriptive statistics as well as bi- and multivariate logistic regression analyses were performed. RESULTS: Thirty-eight percent of the municipalities reported they generally considered fair distribution among social groups in local policy-making, while 70% considered fair distribution in their local health promotion initiatives. Developing health overviews after the PHA's implementation was positively associated with prioritizing fair distribution in political decision-making (odds ratio [OR] = 2.54; CI: 1.12-5.76), compared to municipalities that had not developed such overviews. However, the employment of PHCs after the implementation was negatively associated with prioritizing fair distribution in local health promotion initiatives (OR = 0.22; CI: 0.05-0.90), compared to municipalities without that position. CONCLUSION: Development of health overviews - as requested by the PHA - may contribute to prioritization of fair distribution among social groups with regard to the social determinants of health at the local level.

Capacity to reduce inequities in health in Norwegian municipalities.

AIMS: One of the goals of the Norwegian Public Health Act is to reduce health inequities. The act mandates the implementation of policies and measures with municipalities and county municipalities to accomplish this goal. The article explores the prerequisites for municipal capacity to reduce health inequities and how the capacity is built and sustained. METHODS: The paper is a literature study of articles and reports using data from two surveys on the implementation of public health policies sent to all Norwegian municipalities: the first, a few months before the implementation of the Public Health Act in 2012; the second in 2014. RESULTS: Six dimensions are included in the capacity concept. Leadership and governance refers to the regulating tool of laws that frame the local implementation of public health policies. Municipalities implement inter-sectoral working groups and public health coordinators to coordinate their public health policies and measures. Financing of public health is fragmented. Possibilities for municipalities to enter into partnerships with county municipalities are not equally distributed. Owing to the organisational structures, municipalities largely define public health as health policy. Workforce and competence refers to the employment of public health coordinators, and knowledge development refers to the mandated production of health overviews in municipalities. CONCLUSIONS: The capacity to reduce health inequities varies among municipalities. However, if municipalities build on the prerequisites they control, establishing inter-sectoral working groups and employing public health coordinators in authoritative positions, national governance instruments and regional resources may sustain their capacity.

Promoting health by addressing living conditions in Norwegian municipalities.

Worldwide, inequalities in health are increasing, even in well-developed welfare states such as Norway, which in 2012, saw a new public health act take effect that enshrined equity in health as national policy and devolved to municipalities' responsibility to act on the social determinants of health. The act deems governance structures and "Health in All Policies" approaches as important steering mechanisms for local health promotion. The aim of this study is to investigate whether Norway's municipalities address living conditions - economic circumstances, housing, employment and educational factors - in local health promotion, and what factors are associated with doing so. All Norway's municipalities (n= 428) were included in this cross-sectional study, and both register and survey data were used and were subjected to descriptive and bi- and multivariate regression analyses. Eighty-two percent of the municipalities reported that they were capable of reducing inequalities in health. Forty percent of the municipalities defined living conditions as a main challenge in their local public health promotion, while 48% cited it as a main health promotion priority. Our study shows that defining living conditions as a main challenge is positively associated with size of municipality, and also its assessment of its own capability in reducing inequalities in health. The latter factor was also associated with actually prioritizing living conditions in health promotion, as was having established cross-sectorial working groups or inter-municipal collaboration related to local health promotion. This study underlines the importance of inter-sectoral collaboration to promote health and well-being.

Health in All Policies: A cross-sectional study of the public health coordinators' role in Norwegian municipalities.

AIMS: The public health coordinator (PHC) is a municipal-government position in Norway whose role is to organise and oversee municipal policies and functions to support national public health goals. This cross-sectional study investigates conditions associated with use of PHCs by Norwegian municipalities in the period immediately before the new Public Health Act came into effect in 2012, decentralising responsibility for citizen health to the municipal level. This study provides descriptive baseline data regarding Norwegian municipalities' use of PHCs in this time - a marker for municipal engagement with inter-sectorial collaboration - before this policy was nationally mandated, and explores whether municipal characteristics such as structure, socio-economic status and extent of Health in All Policies (HiAP) implementation were associated factors. METHODS: All Norway's municipalities (N=428) were included. We combined Norwegian register data with survey data. Descriptive analyses and bi- and multivariate logistic regression analyses were performed. RESULTS: A total of 76% of Norwegian municipalities employed a PHC in the period just before 2012. Of the PHCs employed, 22% were employed full time and 28% were located within the staff of the chief executive office. Our study indicates that partnership for health promotion with county councils (OR=7.78), development of a health overview (OR=3.53), collaboration with non-government sectors (OR=2.85) and low socio-economic status (OR=0.46) are significantly associated with Norwegian municipalities having a PHC. CONCLUSIONS: This study suggests that the municipality's implementation of HiAP, as well as lower socio-economic indicators, is associated with the use of PHCs in Norway, but not factors related to municipal structure.

Governance of public health: Norway in a Nordic context.

INTRODUCTION: The two pillars of public health are health promotion and disease prevention. Based on a notion of governance in the state -local relation as changing from hierarchical via New Public Management (NPM) to New Public Governance (NPG), the governance of public health in Norway is contrasted to governance of public health in the other Nordic states: Denmark, Finland and Sweden. AIM: The article aims to present and discuss the governance of public health as it is played out in the state-local relationship. METHODS: The method is to study central state documents in the four countries, as well as articles, research reports and papers on public health. RESULTS: The article shows that the governance modes (hierarchy, NPM and NPG) exist in parallel, but that their mechanisms actually vary in use. Legal, economic and informational mechanisms are, to a varying degree, in use. CONCLUSIONS: In Finnish and Swedish public health policies, health promotion is at the forefront; while Danish and Norwegian public health policies spur the local governments to carry out interventions to prevent disease and hospital admissions.

Reducing social inequities in health in Norway: concerted action at state and local levels?

Norwegian national policies have been distinguished by their focus on equity, contributing to comprehensive policies to reduce the social inequities in health (SIH). The newly adopted Public health act, which aims at reducing the SIH, endorses these acknowledgements while highlighting the importance of municipalities as the key actors in public health. Municipal obligations include inter-sectoral policies for health, health impact assessments (HIA), and the development of local health overviews. Against the background of a system of local autonomy in Norway, this article illuminates whether, and how, municipal public health policies reflect national priorities. Our data are based on one qualitative study, combining document content analysis and expert interviews conducted in 2011, and one quantitative questionnaire sent to municipal chief administrative officers in 2011. Our findings indicate a divide between national and municipal public health strategies. Many municipalities focus on life-style and health-care related measures. Only few municipalities acknowledge the social determinants of health and have implemented HIA and health overviews. Arguing for the importance of concerted multi-level action to reduce the SIH, we need to better understand the gap between national and municipal approaches. We thus suggest further research to illuminate the challenges and success factors faced at local levels.