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Health inequalities in European welfare states

Eero Lahelma , Olle Lundberg
DOI: http://dx.doi.org/10.1093/eurpub/ckp120 445-446 First published online: 21 September 2009

A controversial and puzzling finding from studies on health inequalities is that countries that have managed to reduce inequalities in social and economic conditions, itself powerful determinants of health, are not necessarily characterized by smaller inequalities in health.

Fifteen years after the Black Report, a breakthrough in research comparing the magnitude of health inequalities across western European countries was made, providing the first comprehensive evidence on the unexpected patterning of health inequalities: relative inequalities in ill-health and mortality were not smaller in the Nordic welfare states than elsewhere in western Europe.1

Since then scholars have been puzzled by the issue of why affluent Nordic countries with advanced welfare state arrangements and egalitarian policies share large health inequalities with other western European countries. Subsequent studies looking at changes over time have not altered the picture.2–4 A number of viewpoints can be raised to add our understanding of the puzzle and pave way for further analysis.

First of all, it was noted already in the debate on the first comprehensive comparison1 that the unexpected patterning was based on relative inequalities and absolute inequalities would provide additional evidence.5 Looking at absolute measures indeed changed the order of some countries, with Sweden, for example, faring better in terms of absolute than relative inequalities in mortality. Thus, the potential impacts of welfare state arrangements on health inequalities need to be captured by adequate measures.6 Additionally, the quality of data varies between countries and this complicates precise comparisons. However, the unexpected international patterning of health inequalities is unlikely to be an artefact only.

Second, it is known by now that health inequalities are produced as a result of a variety of macro-, meso- and micro-level factors ranging from past and present social structures to living conditions and lifestyles. While we practically lack comparative studies on the macro-social causes of the variation in the magnitude of health inequalities, some recent evidence demonstrates that a high degree of universalism in social protection systems is likely to restrain health inequalities.6 Still, despite high living standards and egalitarian policies, fundamental social inequalities continue to exist in the Nordic countries also.

Third, new evidence from a broader variety of countries suggests that macro-social arrangements can be linked with the magnitude of health inequalities. The latest comparisons also include eastern European countries and an East–West divide in inequalities in mortality emerges.4 Thus, large variations in living standards and welfare state arrangements between East and West Europe are reflected in inequalities in mortality that are much larger in Central and Eastern than Western European countries.

Fourth, it is possible that the western European countries differ less from each other than previously thought. Some non-Nordic countries may have approached the Nordic countries that in turn may have approached other western European countries.7 Furthermore, the typology of welfare state regimes by Esping-Andersen8 often used for pinpointing differences between types of countries may be less sensitive to public health than poverty.9

Fifth, if the contribution of welfare state arrangements to health equity remains unresolved, the other side of the coin, that is buffering against widening health inequalities should also be considered. A key idea of the welfare state is to safeguard a decent living, in particular, when people face social and economic problems. A comparison among the Nordic countries showed that relative inequalities in ill-health remained similar in all these countries even when Finland and Sweden underwent a deep economic recession.10 A benevolent interpretation would be that the Finnish and Swedish welfare state arrangements were able to buffer against pressures towards widening health inequalities under strong economic constraints.

In the midst of the current global economic crisis, health inequalities remain a burning issue. Basic safety networks are necessary and even broader welfare arrangements would be beneficial for preventing the widening of health inequalities and ultimately turning the trend towards smaller health inequalities. This is needed for improving justice as well as the overall level of population health within and between countries. Steps can be taken and the World Health Assembly11, considering the report of the WHO Commission on the Social Determinants of Health12, urges us to tackle health inequalities within and between countries with the aim of closing the gap within a generation.