The Nordic countries are often pictured as similar inasmuch as they are egalitarian welfare states with a universal approach to welfare policies. Here, the policies of four Nordic countries towards social inequalities in health are analysed by focusing on how they suggest the inequalities should be tackled. Two types of approach can be identified1: universal policies, which target the whole population, benefits and services being offered to every resident, and residual policies, which target only a section of the population with specific characteristics. These residual policies rely on professional discretion in the decisions about who should be targeted and, consequently, benefit from the interventions. In disease prevention a similar distinction is made between population-based, or mass strategies, and high-risk strategies.2 In mass strategies the interventions target the whole population. In high-risk interventions people are screened to identify those most at risk of death and disease, and the interventions are then targeted at those identified. Furthermore, interventions can be characterised as addressing behaviour or living conditions. As is shown, the four countries' policies differ when it comes to who is targeted and what is targeted.
- Health policy
- social inequalities
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Public health programmes
During the last decades public health programmes have been introduced by the governments of the Nordic countries. In Norway the social democratic government,3 and in Finland the liberal government,4 have launched specific programmes on health inequalities as well as general public health programmes, whereas the liberal Danish government5 6 and the Swedish governments7 8 have only issued general programmes. In 2006 Sweden had a change of government from a longstanding social democratic rule to that of a liberal rule. This implied a radical change of the public health policy.
Who is targeted: the whole population or a residuum?
Whether the whole population or a residuum is targeted is connected with the understanding of social inequalities in health. If the problem is seen as a social gradient, the whole population is usually addressed. If the problem is understood as the poor health of a smaller share of the population, of the excluded or disadvantaged, then these groups are targeted. In Denmark and Sweden the governments define the problem as the poor health of a residuum. In the Danish programme from 2002, the definition of the ‘vulnerable and distressed adults’ includes both health and social characteristics. This definition makes it difficult to understand how the causal inference is made: is disease the cause of social exclusion or vice versa? The 2009 programme uses the term ‘groups with few resources’ but does not specify who belongs to it. This definition of the problem as one of a residuum was also used by the former Social Democratic government in Denmark.9 The Swedish programme of 2008 does not say it addresses social inequalities in health but uses the concept exclusion, which it views as a cause of disease. People are considered ‘excluded’ if they are out of work and/or if they do not participate in elections; thus they are defined by their social standing. The former Swedish Social Democratic government had a very different approach. Its programme8 defined health inequalities as a gradient and was permeated with references to the existence and causes of social health inequalities and with remedies to reduce them. In Finland social inequalities in health are defined as a gradient. Nevertheless, the liberal government focuses simultaneously on ‘special groups such as immigrants, families suffering from intoxicant or mental health problems, single parents, school drop-outs … old people living alone, the homeless and those just released from jail’ (p. 30).4 The same understanding prevails in the Norwegian programme. It defines social inequalities as related to income, education and occupation, viewing them as a social gradient, but it also mentions the need to attend to the problems of special groups such as immigrants. The Norwegian programme advocates a combined strategy, but also states: ‘In many cases, targeting, for example on the basis of means testing, can have a stigmatising effect and actually undermine the purpose. General welfare schemes are less stigmatising and serve to prevent people ending up in high-risk situations. In addition, social inequalities in health affect all social classes, not only the most disadvantaged. We must therefore continue to build on the Nordic tradition of general welfare schemes and at the same time implement special measures to help the people with the most problems’ (p. 6–7).3 The Norwegian government advocates a universal strategy also on the grounds that it will have a lasting impact on health inequalities. It can be concluded that in the field of public health, the alleged tradition of universal strategies is not embraced by all Nordic countries.
What is targeted: individuals' behaviour or living conditions?
When tackling health problems and health inequalities several causes of morbidity and mortality may be in focus, the most prominent being people's behaviour and their living conditions.
In Denmark the interventions are unequivocally on behaviour, and the government states that society has a responsibility towards ‘groups with few resources who need a helping hand in taking care of their health and making healthy choices’ (p. 27).6 The specific initiatives mentioned are recruitment and motivation of people with few resources to achieve behavioural changes, for instance by attending smoking cessation courses. The living conditions of people with few resources, such as the homeless, are obviously not considered a public health issue. In the 2002 programme the healthcare sector was given a prominent role in reducing health inequalities. Since vulnerable and distressed adults ‘have considerable contact with the social and healthcare services …[i]t is important that this contact be used to ensure early intervention’ (p. 72).5 The Danish strategy is a high-risk strategy; it could potentially become a neverending story as no efforts are directed towards preventing people from ending up in the few-resources category.
The Swedish programme focuses on the excluded sections of the population and suggests a combination of interventions. Its ambitions are to reduce exclusion by improving employment and increasing the possibilities of participation, thereby improving health and thus addressing living conditions. The other type of intervention suggested in the programme aims at changing people's behaviour through information and empowering activities such as motivational interviewing. These are, however, not specifically targeted towards the excluded.
The Finnish programme calls for: ‘Social policy measures, income security and education, unemployment and housing’. It also wants to strengthen ‘prerequisites for healthy lifestyles: measures to promote healthy behaviour of the whole population with special attention to disadvantaged groups’ (p. 18).4 Thus, it contains a combination of interventions to change behaviour and living conditions. It also mentions the importance of improving access to, and use of, healthcare.
In Norway the Social Democratic government aims to reduce social differences that contribute to health differences, such as income, childhood conditions and working conditions; to reduce differences in health behaviour and use of health services; and to develop focused interventions for social inclusion. As there are significant differences in health status between different income groups, a reduction of income differences is expected to reduce health disparities. What the government is doing here is making the category the cause.10 If poor people have poor health, more money is expected to improve it. Therefore, a tax reform is suggested.
Common to the Finnish and Norwegian programmes is the emphasis on the responsibilities of the governments, whereas Swedish and above all the Danish programmes emphasise the responsibility of the individual.
All the analysed Nordic countries have universal welfare policies, such as child allowances and free, public schools, and residual policies such as social benefits. When it comes to social inequalities in health, strategies differ. In Sweden and Denmark the governments adhere to a liberal policy where social inequalities are dealt with by targeting the excluded or disadvantaged ‑ a high-risk strategy or a residual welfare policy. The Danish government concentrates on changing behaviours, whereas the Swedish government wishes to reduce exclusion too. The Norwegian and Finnish governments propose universal measures addressing the whole population as well as targeting the most disadvantaged and wish to deal both with behaviours and living conditions ‑ more in accordance with a social liberal or social democratic policy. Although the policies in three of the countries seem relatively consistent over time and are not heavily influenced by the political ideology of the government launching the programme,11 the Swedish programme has changed radically with the recent change in government. To conclude, there is not one but several different Nordic policies towards health inequalities. The English programmes on tackling health inequalities lie somewhere in between those of the Nordic countries.11 To many, the Nordic welfare states represent a model welfare state. However, whether they can be viewed as models is debatable; clearly, they do not encompass one model.
The author would like to thank Niels Arnfred and Lene Koch for useful comments on an earlier draft.