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Olle Lundberg Monica Åberg Yngwe Maria Kölegård Stjärne Lisa Björk Johan Fritzell Olle Lundberg Monica Åberg Yngwe Maria Kölegård Stjärne Lisa Björk Johan Fritzell Health EquityHealth Studies No 12 The Nordic Experience: Welfare States and Public Health (NEWS) Olle Lundberg Monica Åberg Yngwe Maria Kölegård Stjärne Lisa Björk Johan Fritzell Health Equity Studies No 12 Centre for Health Equity Studies (CHESS) Stockholm University/Karolinska Institutet August 2008 ©Olle Lundberg, Monica Åberg Yngwe, Maria Kölegård Stjärne, Lisa Björk och Johan Fritzell, Stockholm 2008 Graphic design of the cover by Ylva Almquist NEWS logotype designed by Fernando Medina-González ISSN 1651-5390 ISBN 978-91-975759-0-4 Printed in Sweden by US-AB, Stockholm 2008 Distributor: Centre for Health Equity Studies Executive summary The idea The Nordic welfare states are distinguished by their emphasis on universal social policies rather than through a reliance on targeted, selective and means-tested policies. The Nordic countries have been successful in reducing poverty and fostering equality of opportunity as well as equality of outcomes, both with regard to class, income and gender. By providing many citizens with welfare resources through welfare state institutions, universal social policies are also likely to affect public health. The analytical approach has been both historical and comparative, which will add to the applicability of the findings. The importance of specific social policies and interventions for health and survival has been studied by analysing qualitative differences between policy schemes, not only by comparing clusters of countries with different types of welfare state. The Nordic countries, past and present The Nordic countries share many historical experiences. Over long periods of history they were united in various constellations, something which is also likely to have resulted in many cultural and societal similarities. The Nordic welfare states were gradually developed from the mid 20th century and onwards. They have many similar characteristics at the institutional level and with regard to policy ambition and equality. Typical features include universalistic social programs, a broad scope of public services, provision of services mainly by the public sector at local level, financing through taxes, and relatively small inequalities both between social classes and between women and men. The Nordic countries are often seen as one distinct cluster of welfare states. The general approach in this study is to go beyond cluster I comparisons and focus on more specific characteristics of welfare arrangements and analyse their impact on population health. The Nordic welfare states can be characterised by three common features: they are comprehensive, institutionalised and universalistic. Population health development Over the 20th century we find a spectacular decrease in infant mortality. In Finland, for example, there was a fifty-fold decline during the 20th century. The Nordic countries are in the lead in infant survival. The gains in life expectancy at age 65 over the last four decades have been lower in Nordic countries than in many others, partly because of a fairly slow increase in Denmark. In terms of individual variability in age at death, Nordic countries are performing better than others, with the United States in particular performing less well. In relative terms, inequalities between social groups are not smaller in the Nordic countries than in other European nations, but in terms of absolute levels of mortality among manual workers Norway and Sweden are faring better than most other countries. General impact of social policy, poverty and inequality Nordic countries have internationally low poverty rates, an outcome that seems to be strongly influenced by the welfare state redistributive system. The Nordic countries are distinctive for their low poverty rates among socially vulnerable groups, such as families with many children, single parents and the elderly. Low poverty rates and a compressed income distribution are beneficial to public health, if we assume that there is a curvilinear association between income and health. This association is likely to be the product of a multitude of factors. In general, command over the resources by which we can control and consciously direct our conditions of life is of vital importance to health. These resources include both the material and the intangible. Various indicators of welfare state characteristics and ambitions, such as social spending and the coverage of social insurances, have a significant impact on overall life expectancy when studied across 17 OECD-countries between 1900 and 2000. II Specific impact of social policy across the life course Nordic countries managed to dramatically reduce infant and child mortality as far back as the 19th century while they were still relatively poor. Important factors behind this include early monitoring of births and deaths, successful implementation of new ideas and techniques, and a combination of central government and local-level actors, including NGOs. This combination is likely to have increased compliance. An analysis of reductions in child diarrhoea mortality in Stockholm around 1900 highlights that economic progress must be translated into specific health-improving interventions. When these interventions were general, affecting the whole population, they also benefited lower social classes more. Family policy legislation, in particular dual-earner family support, seems to have become of importance for cross-national differences in infant mortality in present day OECD-countries, while GDP seems to have become less important. These family policies are particularly developed in the Nordic countries. With the exception of Denmark there is a Nordic model of alcohol control that is linked to lower levels of consumption, lower levels of liver cirrhosis mortality and other alcohol-related mortality, and social problems due to alcohol. Comparing countries, excess mortality among the elderly in the post- war period is related to changes in public pension rights, when the economic development of the country is controlled for. The more generous the basic security pensions the lower the excess mortality among the old. In countries with more generous pensions there is less ill-health among the elderly. Lessons to be learned Universal social policies, in particular income transfer programmes, have positive health consequences. This conclusion is of relevance also from a global perspective. Systems and structures for data collection and processing are important preconditions for social and public health policies. Vital statistics and monitoring of mortality, health and social conditions should provide a knowledge basis for policy formation. While the effect on public health of each specific policy might be small, the combined effect of all policies and institutions is likely to be substantial. This is especially true from a life-course perspective, where a life with access to resources provided by the welfare state, III in addition to the resources of the market and the family, is likely to be longer. Alcohol consumption is rising in many countries, and alcohol is estimated to be the most important contributor to the burden of death also in middle-income countries. Hence, alcohol control policies are one example of a policy area in which the Nordic experience is of obvious interest. Few of the policies reviewed were specific Nordic inventions but rather ideas imported from other countries. The successful implementation of policies appears to be the key factor. The short distance between local actors and the population in the Nordic countries seems to have increased public acceptance and compliance. The Nordic countries are not alone in doing well in terms of public health, which suggest that there are a number of recipes for success. On the other hand our results suggest that residual social policies are a less efficient road to good public health. IV Content Foreword .........................................................................................................1 I. INTRODUCTION..........................................................................................5 1.1 Why is the Nordic Experience interesting? ...............................................................6 1.2 The analytical framework ........................................................................................14 1.2.1 Welfare state institutions and public health outcomes – a general model .....15 1.2.2 Comparisons across time and space – country clusters and institutional variability ..................................................................................................................18 1.3 The report – what it is and what it is not..................................................................21 1.3.1 Delimitations and choices ...............................................................................21 1.3.2 Structure of the report.....................................................................................23 II. NORDIC COUNTRIES: SOCIETIES AND WELFARE .............................25 2.1 The Nordic countries, past and present ..................................................................25 2.2 Characteristics of the Nordic model ........................................................................29 2.2.1 The Nordic model and welfare state typologies..............................................31 2.3 Welfare regimes or institutional characteristics?.....................................................33
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