摘要：Objectives. We sought to study the factors that determined the success of a recent initiative to generate political priority for the problem of health disparities in the city of The Hague, the Netherlands. Methods. Our study had a prospective design. The qualitative data collection included interviews, document analyses, and observations. Results. Crucial for the success of this initiative was the presence of powerful and credible actors. These actors effectively presented scientific evidence on health disparities and framed the issue in the light of shared values, priorities, and policy principles. Finally, their actions were supported by the national context, including the availability of national scientific research on health disparities. Conclusions. The project in The Hague shows that political priority for tackling health disparities can be generated at a local level. Key factors included framing the issue in the light of shared values and framing the problem and the solution as in line with existing policy principles. The problems associated with tackling health disparities are major challenges for public health policymakers. 1 , 2 Health disparities are rooted in an unequal distribution of power, income, goods, education, housing, and working conditions. 3 Because the distribution of these social determinants is influenced by the allocation of public resources, policies for tackling health disparities depend on political action. 4 Consequently, generating political priority for this issue is essential to adequately tackling the problem. 3 , 5 – 7 In particular, the provision of investments in sustainable policies, actions, and infrastructure 2 is urgently needed. In general, generating political priority for policies to tackle disparities in health is difficult. Challenges include the fact that the causes of health disparities are complex and encompass health-related behaviors, working and living conditions, and accessibility of health care. 8 In addition, policymakers are ready to point out that most of these determinants fall outside the influence of the health care sector—which implies that intersectoral collaboration with many partners would be required. 9 Moreover, the impact that the actions of policymakers has on health may only be visible after many years. 1 , 10 In some cases—for example, intersectoral action on physical environment and nutrition policies to tackle obesity among children in poor areas—the health benefits may only be visible after decades. Given these complexities, how could political priority for policies to tackle disparities in health successfully be generated? In general, theories on agenda setting distinguish various types of factors: the way an issue is presented, opportune moments within political contexts, and characteristics of the issue. 11 , 12 Particular attention has been paid to the role of political and bureaucratic entrepreneurs. Empirical studies that look at the way in which these different types of factors contribute to the agenda setting for health disparities—including the role of the scientific community—are vital but remain scarce. 13 Our aim was to explore the factors that determine the generation of political priority for tackling health disparities at a local level. Political priority is defined as the degree to which (1) political leaders actively pay attention to an issue, (2) the political systems lead to programs that address the problem, and (3) these programs are supported by financial, technical, and human resources. 11 In the city of The Hague, the Netherlands, health disparities have been prioritized for 2 consecutive council periods. This city of about 475 000 residents is known as the most segregated city in the Netherlands. 14 The average standardized household income varies from 70% of the Dutch mean in deprived areas to 220% in nondeprived areas. In general, 15% of households in The Hague live at or below the legal minimum, but in the city's deprived neighborhoods this percentage is as high as 43%. The neighborhoods with a high deprivation score (as measured by income, unemployment, and so on) have a higher mortality rate. 15 Cardiovascular disease, lung cancer, psychosocial problems, and behavioral disorders are more common in these areas. In 2002, health disparities were explicitly addressed by the governing coalition of the mayor and eldermen, hereafter the Municipal Executive, for the first time. This attention was prompted by data from the municipal health monitor, which contains epidemiological information on the health of the population of the city. This monitor showed socioeconomic differences in various health (and health-related) outcomes between neighborhoods. These differences were perceived as a part of, and reflection of, more generalized differences in health according to citizens' individual socioeconomic position. In this article, the term “disparities in health” refers to health differences between deprived and nondeprived neighborhoods. More specifically, our prime concern was with the increased occurrence of health problems in disadvantaged neighborhoods. This issue then became part of the negotiations on a policy agreement to form a new Municipal Executive, resulting in a 4-year action program (2002–2006) and based on a bottom-up, participatory approach. This program fell under the responsibility of the councilor for health affairs. During its implementation, the program changed from a public health sector initiative to an intersectoral program. From 2006 onward, both the financial resources for the program and the number of policymakers and organizations involved increased ( Table 1 ). TABLE 1 A Summary of The Hague's Program to Tackle Health Disparities Political Priority 2002 2007 Draw politicians' attention to the issue Tackling health disparities is 1 of 61 priorities in public health policy Tackling health disparities is the main goal of public health policy Enact policies to address the issue A 4-year program in 6 deprived neighborhoods (150 000 inhabitants) based on a bottom-up, participatory approach and intersectoral policies Continuation of the program Additional policy agreements on intersectoral programs to tackle health disparities on a city level, for instance: • program on health and environment (including city planning) • program on exercise and sport for youths • program on health insurance for inhabitants on social security • health interventions as integrated part of work rehabilitation courses Provide financial means A budget of € 475 000 per year A budget of € 915 000 per year for the neighborhood program A budget of approximately € 2 500 000 per year for the intersectoral approach Provide human resources Program leader (0.6 fte) Implementation coordinator at Municipal Program leader (0.4 fte) Health Centre (0.8 fte) Contract with neighborhood organization (€ 240 000) Policy advisor at city level (1.0 fte) Active involvement and support from the councilor for health Policy advisor “health broker” at neighborhood level (0.8 fte) Implementation coordinator at Municipal Health Centre (1.0 fte) Contract with neighborhood organization (€ 540 000) Active involvement of the councilor for health and support from the city council Open in a separate window Note. fte = full-time equivalent. Since 2002, we have followed the political developments taking place in The Hague. This prospective study, together with the successful outcome of the initiative, provides a unique opportunity to explore the factors that facilitated political priority for tackling health disparities. We will systematically assess the role of the various factors involved. We formulated the following research questions: (1) Which actors played a vital role in generating political priority for tackling health disparities?; (2) How did the actors frame the problem and possible solutions to gain political priority?; and (3) Which aspects of the context favored the generation of political priority?
