Overview

CSDH will need evidence on policies that worksBoth macro- and micro-level policies should be considered when looking for such evidence Our aim is to describe and analyse the Nordic experiences of welfare policies and public healthResearch project commissioned by CSDH, financed by the Swedish Ministry for Health and Social Affairs and CHESS

The Nordic countries

Why look at the Nordic countries?

The Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) have common features in terms of policies and social organisation (welfare state regime)

Why look at the Nordic countries?

These countries have also been doing well in terms of social and material circumstances and public health

Under five mortality per 1000 live births, 2003. Source: WHO

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Why look at the Nordic countries?

Although many opinions on the pros and cons of the Nordic welfare state model in terms of economic performance or individual outcomes…

…only few attempts have been made to link systematically features of welfare policies with public health outcomes

Research on individual welfare, social policies and welfare state development

Research on public health, social determinants of health and health inequalities

To get forward we must combine different research traditions:

The links have been observed

”The clearest achievement of the Scandinavian welfare state has been poverty reduction and a high level of participation in society” O. Kangas & J. Palme

”Autonomy – how much control you have over your life – and the opportunities you have for full social engagement and participation are crucial for health, well-being and longevity” M. Marmot

which suggest that…

…Social Determinants = Welfare Resources

Social determinants basically deals with different aspects of welfare

Welfare is best defined as “the command over resources in terms of money, possessions, knowledge, psychological and physical energy, social relations, security and so on by means of which the individual can control and consciously direct her conditions of life.” (S. Johansson 1971)

Welfare state institutions

Determinants

-Health, mortality, LE-Health inequalities

Three general questions:

The issue of ”Nordic uniqueness”:What are the Nordic characteristics in terms of welfare policies and public health?

The issue of causality:Is there a connection between specific features of Nordic welfare state institutions and public health, and if so, what are the mechanisms?

The issue of applicability:To what extent can the Nordic experiences be applied to other countries in different stages of economic development throughout the world today?

Organisational structure

International collaborators and reference persons

Nordic Expert Group

CHESS Group

Project group at CHESS

Olle Lundberg, PhD, professorJohan Fritzell, PhD, professorMaria Kölegård Stjärne, MPH, PhDMonica Åberg Yngwe, MPH, PhDLisa Björk, MSci

Nordic expert groupDenmarkFinn Diderichsen, PhD, Professor, Social medicine, University of CopenhagenOlli Kangas, PhD, Professor, Institute for Social Research, Copenhagen

FinlandMikko Kautto, PhD, Division Director, STAKES, HelsinkiEero Lahelma, PhD, Professor, Dept of Public Health, University of Helsinki

Island Holmfridur Gunnarsdóttir, PhD, Researcher, Research Center for Occupational Health &

Working Life, Reykjavik

Norge Espen Dahl, PhD, Professor, Oslo University CollegeJon Ivar Elstad, PhD, Professor, NOVA, Oslo

SverigeJoakim Palme, PhD, Professor, Director, Institute for Futures Studies, Stockholm

Collaborations

Leading Nordic researchers in public health and welfare state researchCSDH networks and groups: Gender (Sen+Östlin), Asian team

amongst others

Working method

Identify central issues to be coveredCommissioned reports (external + internal)Seminar discussions to ensurescientific qualityA final report based on commissionedreports, published literature andavailable statistics

Comparisons both between countriesand over time

Analysing country clusters / regimesAnalysing certain policy traits as variables

Some preliminary results

Early foundationsPublic health trends 1900-General importance of welfare policiesSpecific policies

SanitationAlcohol

Early foundations for welfare and public health policies

High degrees of literacy (Sweden 85% 1800)Monitoring – vital statistics collected by parishes first half 18th centuryPreventive measures – midwives 18th century, vaccination early 19th

Public health trendsEarly advantage for most Nordic countries in life expectancy……but Finland a latecomer and Denmark stagnates recentlyOther countries tend to catch up –Japan overtakesInfant mortality still among the lowest and LE among the longest

Life expectancy in Nordic countries 1900-2003

Development of Life expectancy

81.781.769.069.0Japan

77.978.677.2

70.771.370.2

England/WalesUSA

79.779.879.6

69.769.669.8

ItalySpain

78.778.778.278.778.779.4

70.873.570.370.069.670.7

NetherlandsBelgiumWest GermanyAustriaFrance

78.980.078.977.378.180.3

72.473.473.572.469.173.6

SwedenNorwayDenmarkFinlandIceland

Average2000-2003/04Average1960-64Country

Variability in age of deaths >10 (S10)

13.8013.8014.4114.41Japan

14.3413.5215.15

14.5813.7615.40

England/WalesUSA

13.6913.5413.83

14.2014.2514.16

ItalySpain

13.8312.9014.1013.6313.7514.79

14.1713.6214.0514.1014.2914.80

NetherlandsBelgiumWest GermanyAustriaFrance

13.5412.9013.5313.7314.1213.44

13.9813.5613.6713.6514.2514.76

SwedenNorwayDenmarkFinlandIceland

Average2000-03/04Average1960-69Country

General importance“Generally speaking, for the life expectancy of a population to improve, it is better to have wider coverage or universal access to care, than to have more generous benefits, which are channelled to a limited circle of citizens. The very same story is told by pension take-up rates: it is better to give decently to all than lavishly to few.”

Kangas, O. (2006) One Hundred Years of Money, Welfare and Death:Mortality, Economic Growth and the Development of the Welfare State in 17 OECD countries 1900-2000

Specific policies I – Sanitationreforms in Stockholm 1878-1925

Combination of structural changes (water pipes, sewers) and life-style changesCombination of education and ratherrepressive policies (hygienistic propaganda and hygiene control by ”health police”) Policies often initiated by NGO:s, later incorporated into state or municipal policiesMost improvements and interventions were implemented universally and not in a targeted way – lower social classes benefited to a greater extent in the long run

Figure 5. Diarrhoea mortality rates among children <2 years by social class, Stockholm 1878-1925

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1878-1882 1883-1889 1890-1895 1896-1900 1901-1908 1909-1917 1918-1925

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Figure 6. Overall child mortality rates among children <2 years by social class, Stockholm 1878-1925

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social class 1social class 2social class 3social class 4social class 5

Specific policies II – alcohol controlpolicies with popular support

Drinking a social problem, not least for women and children of drinking menTemperence movements with strong support, intermeshed with other movementsControl measures: minimize private interests, high prices, low physical availability –combined with personal sales control and alcohol-specific social controls (1930s-50s)Recent liberalisations has brought increasedconsumption

Preliminary conclusionsThe importance of data availability for monitoring and policymakingThe importance of an interplay between central state and local actors/authoritiesThe importance of policies directed towards infants, children and youthThe importance of combined approaches; structural change and control The importance of universalism

Final remarks

The Nordic model; Welfare state institutions aim at breaking dependencies, improving opportunities for freedomIt should be possible to learn from Nordic examples even if historical circumstances are differentThe Nordic way is not the only way to good public health, but may provide an alternativeTogether with other types of experiences it may at least help to avoid poor policy options

I. Nordic welfare states and public health

The Nordic ModelThe historical formation of a Nordic social policy model Contemporary Nordic welfare states

Public HealthThe development of public healthThe present state

Health inequalitiesSize, shape and development in Nordic countriesand elsewhere

II. Specific policy areas and public health, examples

Family policy and child mortalityPoverty reduction, income transfers and health Pension system and the health of elderly peopleAlcohol policiesReproductive healthWorking life and labour market regulationHealth care and dental care systems

III. Overarching themes and general issues

Introductory:A general model of welfare state institutions and their public health impactMethodological issues - what counts as evidence?

Thematic:Gender, the welfare state and healthIncome redistribution and health - income inequality or conditions among the poorer? Lessons to be learned from transitional countries – the Nordic experience applied

Concluding:How can the Nordic experience be applied to other countries?

Childhood Youth Family Empty nest Old age

Central welfare-state activities

Income distributionPoverty reduction

Welfare-state as employer

Child care & Schooling

Health care

Labour-market Housing-market

Cash

Other state activities Care

0-14 15-44 45-74

Age specific mortality rates

Poverty rates

Democracy and civic society

Care for elderly & disabled

Public health policies

29,1Irleand11,4France1,70France

28,8Finland9,9Finland1,52 Finland

27,6France8,1Irleand1,45 England & Wales

25,4Denmark7,5England & Wales1,40 Sweden

24,6Italy6,3Denmark1,39Irleand

24,0England & Wales6,1Portugal1,39Spain

22,5Portugal6,1Italy1,37Portugal

21,1Spain5,9Spain1,33Italy

20,9Norway5,6Sweden1,33Norway

19,7Sweden5,2Norway1,33Denmark

RiskCountryDiffCountryRRCountry

Absolute level, workersAbsolute differencesRelative differences

Ranking of countries by degree of inequalityMen, 45-65 år

Source: Kunst et al SS&M 1998;46:1459

HDI, income inequality and life expectancy

70,359,363Brazil77,340,810USA78,336,015UK80,125,06Sweden79,325,81Norway80,6--2Iceland78,426,913Finland77,124,714Denmark

Life expGini indexHDI rankCountry

Infant mortality in EU countries, 2003

2,43,1 3,1 3,4 3,6 3,9 4 4 4 4,2 4,3 4,4

4,9 5,1 5,3

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9,4

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Source: Eurostat

Remaining LE at age 30 by education, women

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1986 1988 1990 1992 1994 1996 1998 2000 2002

Compulsory Upper secondary Post-secondary

Källa: SCB

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+1,8

+0,7

Remaining LE at age 30 by education, men

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56

1986 1988 1990 1992 1994 1996 1998 2000 2002

Compulsory Upper secondary Post-secondary

Källa: SCB

+2,2

+3,3

+3,7