The Nordic Experience: Welfare States and Public Health
Olle Lundberg, Monica Åberg Yngwe, Maria Kölegård Stjärne, Lisa Björk, Johan Fritzell
Health Equity Studies No 12 - August 2008
Centre for Health Equity Studies (CHESS) Stockholm University/Karolinska Institutet
Available online as PDF file [229p.] at: http://www.chess.su.se/content/1/c6/04/65/23/NEWS_Rapport_080819.pdf
“…..Although diseases and their consequences in terms of suffering, reduced function and premature mortality are biological events taking place in human
organs, their ultimate causes are often social rather than biological in nature.
The social aspects of disease and mortality are particularly central when we discuss ways to improve the health of nations and populations. Biological disease processes are clearly important, but the distribution of health risks, including biological ones such as exposure to certain bacteria, is usually socially determined. Prevention, therefore, is largely an issue of social rather than biological change. This is also true for the treatment of disease as long as the availability of medical care and proper medication are not distributed on the basis of need only.
Hence, the social distribution of determinants of health is central to the improvement of public health, both inside and between countries. For example, the consequences of HIV for the human immune system are certainly the result of biological processes, while the AIDS epidemic is very much a consequence of poverty, poor education and unequal power relations between men and women.
The same could be said for TB and other contagious diseases throughout history; improving people’s social conditions through schooling, poverty reduction and better housing, are important means for combating disease. Needless to say, medical interventions such as immunisation and treatment are also important, but there is a social dimension to these services too. While the examples above refer to infectious diseases, there is a social distribution of determinants also for chronic diseases, and this is true for rich and poor countries alike.
Over the past century, social developments have brought about massive improvements in economic, social and political conditions for most people in many countries. The ‘state’ has been transformed into the ‘welfare state’, and ‘citizenship’ into ‘social citizenship’ (see
These differences tend to be characterised according to the differing relative importance of the market, the state and the family for the provision of protection and services. In other words, the main responsibility for common problems faced by most individuals in all societies, such as care of small children and of the old, health care, schooling, and economic security for the sick, the unemployed and the old, can be given primarily to the individual through the market, or to the family, or to the state.
The Nordic countries are usually seen as a specific type of welfare state in which the state has assumed a greater than usual responsibility for social protection and care services. The Nordic welfare states have also been regarded as consciously promoting class and gender equality, high labour market participation, low poverty rates and a high degree of social participation.
How might the Nordic experience of social development through active policy-making be of relevance for the WHO and its Commission on Social Determinants of Health? There are at least two points we wish to highlight here. Firstly, the growth of the welfare state in the Nordic countries has been accompanied by considerable improvements in public health. Several of the Nordic countries were world leaders in life expectancy and infant mortality throughout the 20th century.
Secondly, the Nordic welfare state model has had the explicit goal of strengthening and expanding the resources available to its citizens through welfare state institutions. Rather than being solely dependent on the resources generated by the market or within the family, Nordic citizens have in addition been able to draw on resources provided by the welfare state. Thus, the economic consequences of reduced working ability due to sickness or old age have been cushioned, the professionalization of care for children and the old has relieved families of care burdens, and public day-care and public schooling of high quality for all children has evened out differences in life chances.
Although many of these social policies were implemented to achieve a better society for the majority of citizens rather than primarily to improve public health, they seem incidentally to have targeted factors that constitute the core social determinants of health. But while an association between social policies and public health seems highly plausible there is a need for more systematic evidence on the issue. In this report we will therefore make a first attempt to provide analyses of the extent to which the Nordic welfare state model has actually contributed to improved public health, and we will do so on basis of new as well as existing research from a variety of disciplines…..”
1.1 Why is the Nordic Experience interesting?
1.2 The analytical framework
1.2.1 Welfare state institutions and public health outcomes – a general model
1.2.2 Comparisons across time and space – country clusters and institutional variability
1.3 The report – what it is and what it is not
1.3.1 Delimitations and choices
1.3.2 Structure of the report
II. NORDIC COUNTRIES: SOCIETIES AND WELFARE
2.1 The Nordic countries, past and present
2.2 Characteristics of the Nordic model
2.2.1 The Nordic model and welfare state typologies
2.3 Welfare regimes or institutional characteristics?
2.4 Education, equality and stratification
III. HEALTH AND HEALTH INEQUALITIES: THE NORDIC COUNTRIES IN A COMPARATIVE PERSPECTIVE
3.1 Levels and trends in life expectancy and mortality
3.1.1 Development of life expectancy and mortality in the Nordic countries during the 20th century
3.1.2 Mortality and life expectancy: the Nordic countries compared to other high income countries
3.2 The size of and trends in mortality variations across countries
3.2.1 Variability in the age of death – the individual level
3.2.2 Social inequalities in mortality
3.3 Mortality in Nordic countries – Concluding discussion
IV. GENERAL POLICY FEATURES AND PUBLIC HEALTH
4.1 Poverty, income redistribution and health
4.1.1 Poverty risks and poverty alleviation
4.1.2 Income redistribution and health
4.1.3 Income and health – evidence and explanations for the individual level relationship
4.1.4 Income inequality and health
4.1.5 Poverty, income redistribution and health – summing up the discussion
4.2 Welfare state development and life expectancy
4.2.1 GDP and life expectancy
4.2.2 Age of the social insurance system and life expectancy
4.2.3 Social spending and life expectancy
4.2.4 Social rights and life expectancy
4.2.5 Pooled cross-sectional time-series analysis
V. POLICY AREAS
5.1 Family and Children
5.1.1 From population policy to family policy institutions – the historical background
5.1.3 Modern family policy in a comparative perspective
5.1.4 The impact of family policy institutions on infant mortality – comparative analyses of 18 OECD countries
5.1.5 Family policy institutions, labour force participation and health among women – cross sectional comparisons of 18 OECD countries
5.2 Nordic alcohol policies and the welfare state
5.2.1 Two centuries of waves of alcohol consumption: serious problems and strong responses
5.2.2 Social class and the old Nordic alcohol control systems
5.2.3 Nordic alcohol controls in recent decades: The total consumption model
5.2.4 Nordic alcohol policies today, in a broad perspective
5.3 Health care and dental care systems
5.3.1 The Nordic experience of dental care and dental health
5.4 Pension systems and health of elderly people
5.4.1 Pension rights and their potential importance for health
5.4.2 Public pensions and old-age mortality
5.4.3 Public pensions and ill-health among retired persons
VI. LESSONS LEARNED
6.1. Welfare policy and health development – summarizing findings with the help of a conceptual framework
6.1.1 Social determinants and consequences of ill-health - a chronic issue in welfare policies
6.1.2 Policy entry points illustrated by examples of Nordic social and health policy.
6.2.1 Applicability, development and type of relevance
6.2.2 Applicability and relevance of specific analyses and results
6.3 Conclusion and general observations
6.3.1 Policy foundations – the importance of data and monitoring
6.3.2 Policy content – important general features
6.3.3 Policy implementation – how to make it happen
6.3.4 Policy evaluation – what is good and what is not
6.3.5 General observations and final remarks
Core team of researchers at CHESS: Professor Olle Lundberg, Professor Johan Fritzell, PhD Monica Åberg Yngwe, PhD Maria Kölegård Stjärne and MSc Lisa Björk.
A Nordic group of experts: Professor Espen Dahl, Oslo University College, Professor Finn Diderichsen, Social Medicine, University of Copenhagen, Professor Jon Ivar Elstad, NOVA, Oslo, PhD Hólmfriður Kolbrún Gunnarsdóttir, Research Center for Occupational Health & Working Life, Reykjavik, PhD Mikko Kautto, The National Research and Development Centre for Welfare and Health (STAKES), Helsinki/ Centre for Pensions, Helsinki, Professor Olli Kangas, Institute for Social Research, Copenhagen and KELA, Helsinki, Professor Eero Lahelma, Dept of Public Health, University
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