"Alt overalt, men overalt forskelligt?": En deskriptiv analyse af tilgangen til etablering af kommunale sundhedspolitikker

Abstract

(Indledning) I de senere år har danskernes sundhedstilstand været nedadgående samtidig med at debatten om folkesundheden har været stigende. Denne debat bygger i høj grad på statistik, der viser, at danskerne har den korteste gennemsnitslevetid i Vesteuropa - og ikke nok med det; i den relativt korte tid vi lever, har vi tilmed også et dårligere helbred. For at rette op på danskerne livsstil, som er en bekostelig affære for samfundet, og forbedre sundhedstilstanden, er der igennem de seneste årtier initieret folkesundhedsprogrammer med større eller mindre virkning. Som en konsekvens af dette samt kommunalreformens opgaveflytning har kommunerne siden 2007 overtaget ansvaret for de forbyggende og sundhedsfremmende tiltag over for borgerne. Sundhedsloven foreskriver kommunernes retningslinier på sundhedsområdet, hvilket er formuleret meget løst, idet ordlyden blot er ”kommunernes opgave i forhold til borgerne er at skabe rammer for en sund levevis”. Langt de fleste kommuner udfører denne lovfæstede opgave ved at formulere og politisk vedtage en konkret sundhedspolitik, der angiver retningslinier, fokusgrupper, mål m.v. over en given årrække. Da sundhedsområdet er et nyt politikområde, er der kun bedrevet meget lidt forskning på området, hvorfor dette speciale skal ses som værende et bidrag til en forhåbentlig voksende debat og interesse for området. Den indtil videre begrænsede forskning viser, at kommunerne i høj grad anvender såkaldte kommunale sundhedsprofiler som et redskab til at strukturere og prioritere sundhedsaktiviteterne ud fra. Statistikken viser desuden, at der kun er marginale forskelle på kommunernes udarbejdede sundhedsprofiler, hvilket betyder, at de samme forhold inden for sundhedsområdet gør sig gældende i kommunerne. Med andre ord er der omtrent samme andel rygere, overvægtige, kronisk syge borgere m.v. i alle kommuner, hvilket gør grundlaget for udarbejdelsen af konkrete sundhedspolitikker meget ensartet. Grundidéen med at overføre de forebyggende aktiviteter til kommunerne er, at kommuner er den myndighed, der er tættest på borgerne og dermed bedst kan varetage de borgernære opgaver og dermed sikre en tilpasning til borgernes ønsker og behov. Til trods for at kommunalbestyrelserne har meget brede beføjelser og en løs lovgivning på området, viser min forskning, der tager udgangspunkt i de nordjyske kommuner, at der er meget store ligheder mellem kommunernes sundhedspolitikker. Idet formålet med sundhedspolitikkerne er, at kommunerne kan udarbejde sundhedspolitiske tiltag, der er møntet direkte på deres egne borgere, er det et paradoks, at der er så stor homogenitet i sundhedspolitikkerne. Denne påfaldende ensartethed vil være udgangspunktet for dette speciales problemstilling, idet der vil blive set nærmere på kommunale beslutningsprocesser, aktørforhold og bevæggrunde bag formuleringen af sundhedspolitikker. Med andre ord vil dette speciale udforske, hvordan kommunerne tilrettelægger en sundhedspolitik, hvori der tages hensyn til de lokale behov, hvilket vil blive analyseret med brug af beslutningsteori og indhentet kvalitativ empiri fra udvalgte casekommuner.

Due to the fact that citizen level health policy has been a municipal task since the municipal reform in 2007, this master thesis falls between the categories of health policy and municipal policy. The thesis sets out with an introduction to the consequences of the initiation of the municipal reform within the health area, including the guidelines of the new law on health. In light of the current health debate, there is an overview of the public health of the Danish population, focusing on the generally unhealthy way of life and the consequently low average age and poor health. The mediocre health condition has given rise to substantial health debates both politically and among the population, and concurrently it has increased the political focus that surrounds the parts of health policy called prevention and health promotion. As a consequence of the municipal reform, prevention and health promotion have become municipal tasks inasmuch as the municipalities are seen to be the natural authorities when citizen issues are concerned. The public sector in Denmark is based on the idea of task solution at a decentralized level with special areas of responsibilities at each level. This gives the municipalities open opportunities to formulate their own policies independent of state and without deference to other municipalities. As such, the municipal autonomy gives the municipalities every opportunity to formulate local policies adjusted to citizen needs and requests, and thus to shape unique policy formulation within, for instance, the health field. As part of the implementation of this first generation municipal health policies, many municipalities have chosen to set up a health profile, holding a detailed description of the general citizen health condition. The profile studies turned out to be quite similar and the regional differences fairly small. Furthermore, most of the municipalities have formulated health policies based on the same four factors (diet, smoking, alcohol and exercise – in Danish shortened to KRAM) which inevitably leads to policies with many similarities. Because of this homogeneity in the policy formulation, this master thesis will be a study of municipalities’ approach to the health tasks as well as the factors and political figures that play important roles within the field of politics and in the decision-making process. The homogeneity among the municipal health policies has captured my interest because I find it interesting to look at the existing facts and study why the municipalities apparently imitate each other and why this phenomenon has had such a big impact on the health policy field. Because of the decentralized task solution, is it natural that the municipalities develop their own unique policies within the health field based on citizen needs and requests, which will presumably generate great diversity in the policy formulation. As such, I will study and analyze the health policy field on the basis of this research question: How are the municipalities able to shape a health policy which is adjusted to the citizens’ specific needs and requests? The approach to the master thesis is to make use of qualitative methods using three municipalities in North Jutland as case studies. To obtain the best possible understanding of the issue, I have chosen to use three theories: new institutionalism, coalition models and negotiation models, and furthermore analyze whether or not there is a use of rationality. Using these theories will provide a general overview of the issues discussed in this thesis as well as of the relevant political figures in the decision-making process, all of which has not yet been researched. This master thesis analyzes and discusses how theory can contribute to explain and characterize decision-making processes in the municipal world. The result of the analysis is that decision-making processes in the chosen case municipalities are characterized by the absence of political disagreements and incremental initiatives, and that they are centered around the fact that the municipalities have acted upon what they experienced to be surrounding expectations and norms of the field, rather than what seemed to be rational. The municipalities consider the health profiles and the KRAM factors as institutionalized recipes with full legitimacy at both administration and policy-maker level. The analysis furthermore shows that the municipalities adjust the potential of the KRAM factors to their local conditions, and in this way both the administration and the politicians play an important role in the formulation of each municipality’s health policy. On the basis of the above, it is feasible to draw the conclusion that the answer to the research question is that the municipalities are able to adjust the health policies to the citizens needs and requests by adopting institutionalized and legitimized recipes like the KRAM factors and health profiles, and then simply adjusting the content to the local conditions of each particular municipality.

A master thesis from Aalborg University

"Alt overalt, men overalt forskelligt?": En deskriptiv analyse af tilgangen til etablering af kommunale sundhedspolitikker

["Everything everywhere, but everywhere diverse?": A descriptive analysis of the approach to establishment of municipalities’ health policies]