White papers and government reports on public health from the various Nordic countries all show that public health has become an important policy issue during the last two decades or more. This
development has undoubtedly been influenced by international trends, in particular trends that have been formulated by the WHO, as witnessed by direct references in some white papers. But in the Danish case the stagnation in life expectancy during the 1980s and early 1990s as analysed by the
33 Government’s Committee on Life Expectancy (Bjerregaard, 1994) has given impetus to improve public health.
As documented by Vallgårda (2007, 2010, 2011) there are some differences among the countries with respect to the interpretation of public health problems, and the approaches seem to have changed somewhat over time within each country. How this has influenced legislation and actual efforts has yet to be explored. Thus, we can only conclude from the documents that public health with some variation in approaches has been high on the political agenda during the last two decades. While institutes of public health were established during the 20th century to monitor the health of the populations (except for Iceland, which established an institute in 2003), an increasing professionalization of the public health workforce has taken place through the establishment of public health education programmes during the last two decades.
Mean health and share of the population with good or very good health is higher in the Nordic
countries and the UK, as compared to Germany which may support a tentative hypothesis that centrally initiated public health activities matter. However, life expectancy in Germany is similar to what is found in the other countries with centrally initiated public health activities. An exception is Denmark which introduced policies to counter smoking and excessive alcohol consumption relatively late.
Recurrent efforts have succeeded in increasing the Danish life expectancy since the mid-1990s in step with the other Nordic countries, but there is still a gap between Denmark and these countries in life expectancy.
Another spectacular development is overweight which has increased in all Nordic countries during the decade studied. There is, however, no indication of Iceland being an outlier in terms of the four non-medical determinants of health that is reported.
Mean self-assessed health in the Nordic countries as weighted by the TTO weights developed for Sweden by Burström et al. (2014) is relatively close together with few statistically significant
differences, and higher than in Germany. We use Swedish weights assuming that respondents in other Nordic countries would assign the same weights to the five response categories of self-assessed health.
The levels and their statistical variations are between 0.93 and 0.95 on a scale from 0 to 1 in 2012.
34 Substantially, this may be considered as a state of affairs with good accomplishments, although some improvements are still possible.
A comparison of percentages reporting good or very good health across the lower and the upper income halves indicates that health inequality increased in Germany and Denmark between 2002 and 2012.
However, while the change in Germany was Pareto optimal in the sense that the percentage in both income groups increased, although with a faster increase for the upper income group, the same was not true for Denmark, as the percentage reporting good or very good health dropped in the lower income group, while it increased in the upper group. For the remaining Nordic countries (Finland, Iceland, Norway and Sweden), the percentage reporting good or very good health rose faster in the lower income group than in the upper one, thus indicating a reduction in inequality. For the UK, the changes in percentage for the upper and lower income groups were similar, thus indicating unchanged
inequality.
We found very low concentration indices in all countries, although they are statistically significantly different from zero. These results are not surprising in the light of what has been found in earlier international studies, for example by van Doorslaer et al. (1997). One may assume that inequality in income may be associated with socio-economic inequalities in health. Our results show that income-related inequalities in health in the Nordic countries are similar or lower than in less egalitarian
countries like Germany and the UK. The differences across countries as well as tendencies over time in the concentration indices are comparable to those shown for percentages reporting good or very good health across lower and upper income groups.
It has been indicated by former studies (Brekke and Kverndokk, 2012) that the concentration index may be a misleading measure of health inequality, as a reduction in income inequality (in the sense that income is transferred from the rich to the poor) may lead to an increase in the concentration index, given that those with better health are lifted from the lower income percentiles. However, a comparison of the 2012 Gini and concentration indices is not much supportive of this, as the countries with the lower Gini tends to be those with the lower concentration indices also (with a rank correlation between the two series of around 0.5). Anyway, we are aware that this cross sectional relationship may not necessarily imply a causal relationship. For the case of Denmark and Germany, health inequality rose over time, which may support the suggestion, but the increases are in concert with the distribution of
35 percentages discussed above reporting good or very good health across income groups, where it was shown that the percentage rose faster for those in the upper income group than for those in the lower.
Also, the unchanged health inequality for the case of the UK is neither supportive of the suggestion.
The Gini coefficient is shown for 2012 only because 2002 data are not comparable. While ESS reports income in 12 percentiles in 2002, income is reported in deciles in 2012. However, most other results, including concentration indices, are based on income ranks, which are less sensitive to the number of percentiles. The Gini coefficients are lower in the Nordic countries than in Germany and the UK.
We used two approaches to analyse socioeconomic differences in health - one comparing health in two different socioeconomic groups (low and high), the other by computing the concentration index. The first approach is a traditional approach (see for example OECD (2016, p. 72-73)), which uses only limited information (average health in two groups). The concentration index approach is based on information about the whole range of socioeconomic groups (or individuals ranked by socioeconomic status), and their self-reported health status is weighted by a scale that expresses preference weights.
Thus, the information contained in this method is more comprehensive. There is no contradiction between results from these two approaches, as they are related to different questions. However, it is important to be aware of the different impressions that are provided by the two approaches.
The analysis of non-medical determinants of health, which have often been seen as indicators of health behaviour, shows great variation among the countries. Along with traditional determinants, such as tobacco, alcohol and fat, the consumption of sugar is included because it has been shown that excessive intake of sugar leads to a risk of overweight. Similar results were found by Asgeirsdottir (2016), who concluded that in spite of the often perceived homogeneity of the Nordic populations, there are
interesting differences that need to be further explored. Due to the cross-sectional nature of the data, the present study does not allow any causal relations between these determinants and health. But it can be concluded from the observed differences that more can be accomplished in terms of reducing these risk factors. Still, a higher level of most risk factors was found in Germany and the UK.
Resources in health care vary substantially among the countries. Some of this reflects variation in income. Norway with the highest GDP has the greatest share of population employed in health care and the highest expenditures measured in US dollars, but the lowest share of GDP. Although OECD
36 uses common definitions, what is included may differ from country to country. We found no significant association between the use of resources and various measures of health.
37 References
Acheson D (1998). Independent inquiry into inequalities in health. London, The Stationery Office.
http://www.archive.official-documents.co.uk/document/doh/ih/ih.htm
Anell, A., Glenngård, A.H. and Merkur, S. (2012). Sweden: Health system review. Health Systems in Transition,14(5):1–15. European Observatory on Health and Policies, Geneva.
Ásgeirsdóttir, T. L., Ragnarsdóttir, D.O. (2013). Determinants of relative and absolute concentration indices: evidence from 26 European countries. International Journal for Equity in Health (open access).
Ásgeirsdóttir, T. L., Ragnarsdóttir, D.O. (2014). Health-income inequality: the effects of the Icelandic economic collapse. International Journal for Equity in Health (open access).
Ásgeirsdottir, T.L., Gerdtham, U.-G., (2016). Health behaviour in the Nordic countries. Nordic Journal of Health Economics 4(1): 7-27.
Boyle, S. United Kingdom (England); Health Systems review. WHO: Health Systems in Transition 13.
No. 1, 2011. European Observatory on Health Systems and Politics, Geneva.
Beveridge, W., (1942). Social Insurance and Allied Services [“The Beveridge report”]. British Library.
Bjerregaard, P. (1994). Samfundsmæssige og sociale forhold, middellevetid og dødelighed. Delrapport fra Sundhedsministeriets middellevetidsudvalg. Sundhedsministeriet, Copenhagen.
38 Brekke, K.A., Kverndokk, S. (2012). Inadequate Bivariate Measures of Health Inequality: The Impact of Income Distribution. Scandinavian Journal of Economics 114(2), 323–333.
Burström, K., Sun, S., Gerdtham, U.-G., Henriksson, M., Johannesson, M.,, Levin, L.Å. and Zethraeus, N. (2014). Swedish experience-based value sets for EQ-5D health states. Quality of Life Research, 23(2),431-442.
Busse, R., Blümel, M. (2014). Germany: Health System Review. WHO: Health Systems in Transition vol. 16 No. 2 2014, European Observatory on Health and Policies, Geneva
Cylus, J., Richardson, E., Findley, l., Longley, M., O’Neill, C., Steel, D. (2015) United Kingdom:
Health System Review. WHO: Health Systems in Transition, WHO, Geneva.
Dahl, E., Fritzell, J., Lahelma, E. et al. (2006) Welfare State Regimes and Health Inequalities. In:
Siegrist J, Marmot M (eds) Social Inequalities in Health. Oxford University Press, Oxford, pp 193–222
Dahl, E., Bergsli, H., van der Well, K.A. (2014). Sosial ulighet i helse – en norsk kunnskapsoversigt.
Oslo: Oslos Universitet.
https://www.google.dk/search?q=Sosial+ulighed+i+helse+%E2%80%93+en+norsk+kunnskapsoversikt
&spell=1&sa=X&ved=0ahUKEwj026bXmcPXAhXJNhoKHUzsCksQBQgjKAA&biw=1200&bih=58 4
Danish Government (1999). Regeringens Folkesundhedsprogram 1999-2008.Copenhagen.
39 Danish Government (2002). Sund hele livet – de nationale mål og strategier for folkesundheden 2002-10. Copenhagen.
Danish Government (2009). Sundhedspakke 2009. Godt på vej mod sundere Danmark – 8 store skridt der gør et godt sundhedsvæsen endnu bedre. Copenhagen.
Danish National Board of Health (2011). Ulighed i sundhed – årsager og indsatser.
https://www.sst.dk/da/udgivelser/2011/ulighed-i-sundhed-aarsager-og-indsatser
Department of Health (2000). The NHS plan: a plan for investment, a plan for reform.
London, Department of Health.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset /dh_118522.pdf
Department of Health (2004). National standards, local action: health and social care standards and planning framework 2005/06–2007/08. London, Department of Health.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_
4086058.pdf
Department of Health (2004a). Choosing health – making healthy choices easier. London, Department of Health
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4094550?IdcService=GET_FILE&dID=2344&Rendition=Web
Department of Health (2009). Departmental report 2009. London, Department of Health.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_100819.pdf
40 Diderichsen, F., Andersen, I., Manual, C. and the Working group of the Danish review on social
determinants of health (2011). Health inequality – determinants and policies. National Board of Health, Copenhagen.
https://www.sst.dk/~/media/83A30419FB1B47C1BC0D725AE50E5A3C.ashx
Diderichsen, F., Sheele, C.E., Little, I.G. (2015). Tackling health inequalities locally: A Scandinavian experience. Danish National Research Database, Copenhagen.
https://www.sst.dk/da/planlaegning/ulighed/nordisk-konference/rapporten-tackling-health-inequalities-locally-the-scandinavian-experience
European Social Survey 2017. http://www.europeansocialsurvey.org/ (Accessed April 2017)
European Portal for Action on Health Inequalities (2017). European Partnership for Improving health, Equity and Wellbeing (EuroHealthNet).
http://www.health-inequalities.eu/about-hi/at-national-level/
Finnish Ministry of Social Affairs and Health (2001a). Government resolution on the Health 2015 Public Health Programme. Helsinki: Publications 2001:6.
Finnish Government (2015). Government Resolution on Health 2015. Helsinki.
https://julkari.fi/bitstream/handle/10024/126480/Julk200106.pdf?sequence=1
Finnish Ministry of Social Affairs and Health and the Ministry of Finance (2017): Phase II legislative package of the regional government reform circulated for comments until 19 June.
http://alueuudistus.fi/frontpage .
41 Foldspang, A. (2016). The Nordic Countries: The Nordic School of Public Health, Gothenburg. In A.
Foldspang, J. Müller-Nordhorn, V. Bjergovic-Mikanovic and R. Otak (Eds.). 50 years of professional public health workforce development. ASPHER’s 50th Anniversary Book, ASPHER 2016.
Folkhälsomyndigheten. Home page.
https://www.folkhalsomyndigheten.se/the-public-health-agency-of-sweden/about-us/
Forebyggelseskommissionen (2009). Vi kan leve længere og sundere. Forebyggelseskommissionens anbefalinger til en styrket indsats. København 2009.
Gesellschaft für Versicherungsvissenschaft und -gestaltung e.V. (2017). Gesundheitsziele.de. Nationale Gesundheitsziele. http://gesundheitsziele.de
Icelandic Ministry of Health and Social Security (2001). The Icelandic National Health Plan to the Year 2010.
https://www.stjornarradid.is/gogn/rit-og-skyrslur/stakt-rit/2001/09/22/Heilbrigdisaaetlun-til-arsins-2010-Langtimamarkmid-i-heilbrigdismalum/
Icelandic Ministry of Health and Social Security. (2007). Health and prevention at the forefront - with the collective effort of the nation.
https://www.stjornarradid.is/gogn/rit-og-skyrslur/stakt-rit/2007/02/07/Heilbrigdi-og-forvarnir-i-sokn-med-samtakamaetti-landsmanna/
42 Icelandic Ministry of Health and Social Security (2008). Health policy - Health for the benefit of the whole.
https://www.stjornarradid.is/gogn/rit-og-skyrslur/stakt-rit/2008/11/18/Heilsustefna-Heilsa-er-allra-hagur/
Icelandic Ministry of Welfare. (2011). Results of The Icelandic National Health Plan to the Year 2010 - Final Report.
https://www.stjornarradid.is/gogn/rit-og-skyrslur/stakt-rit/2011/06/10/Arangur-heilbrigdisaaetlunar-til-arsins-2010/
Kakwani, N., Wagstaff, A. and van Doorslaer, E. (1997). Socioeconomic inequalities in health:
Measurement, computation, and statistical inference. Journal of Econometrics 77, 87-103.
Kifmann, M. (2017). “Competition Policy for Health Care Provision in Germany”. Health Policy, 121, 119 – 125.
Lahelma, E., Lundberg, O., Manderbacha, K., Roose, E. (2001). Changing health inequalities in the Nordic countries? Scandinavian Journal of Public Health Suppl. 55: 1-5.
Lahelma, E., Lundberg, O. (2009). Health inequalities in European welfare states. European Journal of Public Health 19(5):445–446.
43 Lyttkens, C. H., Christiansen, T., Häkkinen, U., Kaarboe, O., Sutton, M. Welander, A. (2016). The core of the Nordic health care system is not empty. Nordic Journal of Health Economics, 4, 7-27.
Malmökommissionen (2013). Malmös väg mot en hållbar framtid.
http://malmo.se/download/18.29aeafd91411614c896da0b/1491299465413/Malm%C3%B6kommission en+10+september+dokumentation.pdf
Marmot M (2010). Strategic review of health inequalities in England post-2010: fair society healthy lives. The Marmot Review. London.
http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf
Danish National Board of Health (2011). Ulighed i sundhed – årsager og indsatser. Copenhagen.
https://www.sst.dk/da/udgivelser/2011/ulighed-i-sundhed-aarsager-og-indsatser
Norwegian Government (2003). Stortingsmelding nr. 16. Resept for et sunnere Norge.
Folkehelsepolitikken. Oslo.
OECD (2015). OECDStat. Health Status. Perceived health status by age and gender.
http://stats.oecd.org/index.aspx?queryid=30117 (Accessed April 2017).
OECD (2017a). Inequalities in health. Paris: OECD.
http://www.oecd.org/health/inequalities-in-health.htm
44 OECD (2017b). OECD.Stat.
http://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_STAT
OECD (2017c): OECD.Stat.
http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_LVNG
OEDCD (2017d): OECD.Stat.
http://stats.oecd.org/Index.aspx?DataCode=POP_FIVE_HIST
OECD/EU (2016). Health at a Glance: Europe 2016: State of Health in the EU Cycle. OECD Publishing, Paris.
http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-europe-2016_9789264265592-en#.WPiCdk1Ppow.
Olsen, K.R., Anell, A., Häkkinen, U., Iversen, T., Ólafsdóttir, T., Sutton, M. (2016). Nordic Journal of Health Economics 4(1): 56-67.
https://www.journals.uio.no/index.php/NJHE/article/view/2801
Palosuo, H., Koskinen, S., Lahelma, E., Prättälä, R., Martelin, T., Ostamo, A., Keskimäki, I., Sihto, M., Talala, K., Hyvönen, E., Linnanmäki, E. (Eds.) (2007). Health inequalities in Finland. Trends in
45 socioeconomic health differences 1980–2005. Publications by the Ministry of Social Affairs and
Health, Helsinki.
Public Health Agency of Sweden (2010). Framtidens folkhälsa – allas ansvar.
https://www.folkhalsomyndigheten.se/publicerat-material/publikationsarkiv/f/folkhalsopolitisk-rapport-2010-framtidens-folkhalsa-allas-ansvar/
Ringard, Å., Sagan, A., Sperre Saunes, I. and Lindahl, A.K. (2013). Norway: Health system review.
WHO: Health systems in Transition Vol 15, no. 8., European Observatory on Health and Policies, Geneva.
Secretary of State for Health (1992). The health of the nation: a strategy for health in England. London, Her Majesty’s Stationery Office.
Secretary of State for Health (1998). Our healthier nation: a contract for health. London, The Stationery Office
http://www.archive.official-documents.co.uk/document/doh/ohnation/title.htm
Secretary of State for Health (1999). Reducing health inequalities: an action report. London, The Stationery Office.
Statens Folkhälsoinstitut (2010). Folkhälsopolitisk rapport 2010. Framtidens folkhälsa – allas ansvar.
https://www.folkhalsomyndigheten.se/contentassets/5d2edf20c6f846cd91a2f7d20361e200/r2010-16-folkhalsopolitisk-rapport-2010.pdf
46 Swedish Government (2002). Regeringens proposition 2002/03:35. Mål för folkhälsen.
http://www.regeringen.se/rattsdokument/proposition/2002/12/prop.-20020335/
Swedish Government (2008). Regeringens proposition 2007/08: 110. En förnyad hälsopolitik.
http://www.regeringen.se/49bbde/contentassets/e6210d374d4642328badd71f64ca9846/en-fornyad-folkhalsopolitik-prop.-200708110
Vallgårda, S. (2007). Public Health Policies: A Scandinavian model? Scandinavian Journal of Public Health 35, 205-211.
Vallgårda, S. (2010). Tackling social inequalities in health in the Nordic countries: targeting a residuum or the whole population? Journal of Epidemiology and Community Health 64, 495-496.
Vallgårda, S. (2011). Addressing individual behaviours and living conditions: Four Nordic public health policies. Scandinavian Journal of Public Health 39(Supppl. 6), 6-11.
Van Doorslaer, E., Koolman, X. (2004). Explaining the differences in income-related health inequalities across European countries. Health Economics, 13, 609–628.
van Doorslaer, E., Wagstaff, A., Bleichrodt, H. et al. (1997). Income-related inequalities in health:
Some international comparisons. Journal of Health Economics, 16, 93-112.