A National Public Health Strategy for Sweden - "a Green Paper" [
22] published in 2000 proposed Public Health Goals addressing structural and environmental health determinants. One objective focused on a more health promoting Health and Medical Services and their key functions in health promotion. Another focused on access to accurate health information as a prerequisite for equitable good health. Apoteket AB was pointed out as a public health actor with the responsibility to provide producer independent, accurate and accessible health information to pharmacy customers.
These statements marked a starting point for Apoteket AB's "Health Dialogue" (HD) projects intending to involve pharmacies actively in public health work and to contribute to improved long-term public health. The HD experiences laid foundations for formulation of an Apoteket AB Action plan 2002 and the HS concept. The Action Plan declared HS as a setting for health in which partners (local pharmacies, primary health care and municipalities) could allocate resources and enable long- term health dialogue with the population. Furthermore, the Action plan indicated that a HS should be located near a pharmacy, or as part of ordinary pharmacies, in primary health or municipality centres to profit from the pharmacy customer flow.
The former Swedish Public Health Objective Bill [
1] was the third important national policy document for the HS development. The bill diminished Apoteket AB's responsibility for health information and stated that responsibility for health information should rest on all relevant public sectors allocated with this responsibility. The policy also stated that all sectors of society should bear responsibility for supplying of health information at no cost to the population and should support healthier living. The Pharmacies were however, encouraged to continue taking advantage of the big flow of customers visiting them to provide objective and accessible health information.
According to the Apoteket AB Action plan, 30 HSs were established between 1990-2005 in 18 of the 21 county councils in Sweden. Two HSs started during the late 90's as pharmacies with expanded health information activity using district nurses as a health counselling resource. Most of the responded 26 HSs were established between 2003 and 2005 (table
1). An additional 25 were planned. The ambition was to establish one large HS in each county council nationally.
Table 1
HSs included in this study and the year of establishment
At the time of this study, seventeen HSs were integrated into the ordinary day to day activities of the PHC or the Pharmacy (depending on the location), while one HS was in project form. Respondents at eight HSs were uncertain if their HS was in project form or an integrated ordinary activity. At local level, policy formulation emerged in discussions between local pharmacies and county councils but, this process was mainly guided by the Apoteket AB Action plan. Contracts with Apoteket AB were finalized mostly at local level. It is not clear as to what extent HSs' personnel, interest groups; patient or community associations were involved in the local policy formulation. Thirteen of the responding 26 HSs had written agreements with county councils, 10 had verbal agreements and three had none. Four HSs also had additional agreements with municipalities and one with private companies.
The common overall aims for HS in the investigated local policy plans were to improve population health, facilitate inhabitants' responsibility for self-care, and to be a meeting place for health promotion. Survey respondents considered that local aims and activities corresponded well with those formulated at the national level. Five categories of objectives for HS emerged in the local documents: partnership, personnel, finance, activity and community health promotion. The partnership category focused on improvement of intersectoral collaboration and creation of shared settings for public health actions mainly between the pharmacy, county councils and municipalities. Other actors could be invited to participate in specific HS's activities and in production of health information material. The personnel category focused on HS's agreements including participating personnel professions, stipulated time for duty at HS and education for HSs' personnel. The finance category focused on partners' responsibility for costs such as salaries, offices, computers, health information material, tests and evaluations. The activity category focused on mediating accurate and contemporary health information, supporting self-care and strengthening individual actions for health with an emphasis to healthy eating habits, physical activity, use of tobacco and alcohol and promoting sexual health, in order to correspond to the national health goal objectives. Finally, the community health promotion category focused on commitment to use HS as a setting for community actions that could support healthy lifestyles for individuals, groups and communities.
The concept of "health promotion" was used positively to express a new approach for a more health- promoting health and pharmacy service throughout the documents and survey response. Different expressions such as "promoting health", "risk and disease prevention" and "public health work" were used to express HS's activities. Also, survey respondents used different terms to explain HS objectives, activities and implementation. Survey respondents expressed the need for clear guidelines as far as HS's activities were concerned. According to the respondents, there was a gap between the stated objectives in the policy documents and how they were implemented in the practice i.e. HSs. Common reflections on health promotion resulted in comments like, "unclear objectives could weaken a common approach" and "inability to act according to national aims".
The implementation process could be seen as both a top down as well as bottom up process. Top down in the sense that the national Apoteket AB governed the HS's structure and content. Bottom up, as the HSs' groups were established with representatives from local pharmacies and county councils including HSs' personnel.
Content
The HS's activities were based on a "basic package" stipulated in the Apoteket AB Action plan and objectives in local agreements. Most HSs offered health information in form of pamphlets, access to a customer "health computer" with quality assured health information and tests, and individual health counselling free of charge. Almost all HSs provided health products for purchase, equipment for visitors to measure weight, BMI, waist and blood pressure, and health profiling with coaching at a cost. Several HSs had specific topic activities usually organised in recurrent announced "theme weeks" with local representatives from governmental and non-governmental organisations (NGO's). Depending on local available resources, service for physical activity prescriptions, lectures or study circles, organised physical activities and Nordic walking were offered. Only a few respondents discussed a more focused activity for target groups and chronically ill in accordance with the objectives in the national Apoteket AB's documents. Most respondents pointed out easy access to objective health information, and to individual health support of community inhabitants to increase personal responsibility for health, as the most prioritized of HS's activities.
Stakeholder and Actors
The analyses of documents and survey response indicate that a number of actors were involved at different levels in the HS's policymaking process, referred to as "stakeholders", "partners", "interest groups" and "active HS's actors". Both the central pharmacy chain and personnel at local pharmacies were involved. County councils and primary health services were represented by managers and personnel at HS. These include nurses, physiotherapists, dental hygienists, occupational therapists. The municipalities' health and social sector were mainly represented by health planners.
At local level, county councils and public primary health services were important key stakeholders as they had the responsibility for implementing HS's activities into practice in order to fulfil national and county council aims and objectives of " a more accessible and health promoting health services" [
1]. Apoteket AB appeared as the most powerful "policy keeper" and "agenda setter" for the establishment of HSs and the activities. The central Apoteket AB manager took part in the establishment of all local HSs and the central Apoteket AB and pharmacy personnel were constantly present actors at local HSs. In this way, Apoteket AB kept power and took immense responsibility.
The Swedish Government, the Swedish National Institute of Public Health, Swedish Municipalities and County Councils' Association were mentioned as stakeholders with interest in the HS's development, in both the Apoteket AB Action Plan and by the survey respondents, but could not be identified as "active actors" in the policy formulation or implementation. Neither were governmental organisations nor NGOs, local municipalities and inhabitants mentioned as partners in the documents. According to the survey respondents "the active HSs' actors" on local level, mainly consisted of pharmacy and county council personnel and mostly district nurses. Their presence varied from daily to one day a week, depending on the collaboration agreement. The local documents indicated that county council personnel were more active in the HSs situated at primary health centres. This was also corroborated by the survey respondents who confirmed that HSs located in PHC centres involved other health professionals such as dental hygienists, occupational therapists and physiotherapists in their activities from time to time. Due to differences in involvement, county council actors' power and responsibility varied in relation to the pharmacy actors from one HS to another. Non-governmental organisations were or could be invited to participate in different theme-weeks and campaigns.
Contextual factors
Several contextual, structural, situational and exogenous factors affected the implementation of the HSs. The "Green paper" [
22] and the Swedish Public Health objectives [
1] had particular influence on the development of HSs as they highlighted lifestyle determinants, the need of improvement of health information, and a more health promoting health services. The "Green paper" as well as the Apoteket AB Action plan also referred to an international discourse for more health promoting health services and pharmacies. These discourses supported to a large extent the HS's policy process and gave it high legitimacy.
Another contextual factor was the shared responsibility for HSs between two principal founders; Apoteket AB and county councils. Apoteket AB had a central steered management while the county council had a local steered management. Apoteket AB also had a dual role: to sell pharmaceutical products as a profit-making concern and at the same time, provide health information to reduce consumption of prescription drugs. These overt differences and Apoteket's seemingly incompatible dual role gave at times conflicting roles and could affect the HSs' activity and decisions, according to the survey respondents. However, this was not considered as problematic. Survey respondents also narrated that HS progress and transition after the project phase was affected by lack of adequate resources and guidelines which resulted in little time for planning, development and evaluations.
The populations' need for HSs' services, availability of qualified personnel and the possibility to host activities affected the resource allocation and establishment of HSs. A political will and clearly stated collaboration plans in the local policy plan, acted as catalysts for establishment of new HSs. Furthermore, presence of municipality health planners seemed to be a supporting factor for municipality participation in HSs' establishment. All four collaborating municipalities who had HS's agreements with Apoteket AB and county councils had a health planner, responsible for the municipality public health work, in their workforce.