Scandinavian Common Sense: Policies to Tackle Social Inequalities in Health

By Marie-France Raynault and Dominique Côté

When some claim austerity is the only answer to today’s economic woes, a close look at the best practices in Scandinavia and Finland gives pause for thought.

Cited as models for their egalitarian social and health policies, these countries also have thriving economies where the gap dividing rich from poor is smaller than elsewhere. Despite their quasi mythic status, the policies implemented to combat inequalities in health are neither well known nor understood.

Policies discussed in Scandinavian Common Sense include education, housing, conciliation of work and family life, daycare, sustainable development and more. For these policies to be part of political debate, be it in Quebec, Canada, the United States or elsewhere, they must be in the public domain. That is the purpose of this book.

• Language: English
• Publisher: Baraka Books
• Release date: Nov 3, 2015
• ISBN: 9781771860659

Marie-France Raynault

Marie-France Raynault (MD, MSc Epidemiology, FRCP(c), FCAHS) is a medical doctor specialized in public health. She heads the Département de médecine préventive et santé publique at the Centre hospitalier de l’Université de Montréal. She also heads the Lea Roback Research Centre, which she co-founded. Throughout her career, her main interest has been the health of the poor.

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PREFACE TO THE ENGLISH EDITION

It is becoming increasingly clear that despite its impressive history of producing conceptual models and written documents about the importance of addressing social inequalities in health through public policy action, Canada does not do very well in implementing this vision. In contrast, the Nordic nations have achieved worldwide recognition for their success in building upon principles of human rights, social equity, and the importance of democratic participation to put into practice a wide range of public policies that promote the health and well-being of all of their residents. This excellent book provides an accessible but thorough overview of many of these public policy accomplishments.

These actions have taken place in the spheres of equitably distributing income and wealth, securing employment and improving workplace conditions, promoting early child development and family-friendly policies, assuring access to housing, education, and acting to improve gender equity and reduce social exclusion. In short, improving the quality and equitable distribution of the social determinants of health. As a result they have produced societies where economic and social security is provided to all of their members. Not surprisingly, they have also created societies where overall health is excellent and quality of life is high. The Nordic nations accomplish this at the same time as their economic performance in terms of economic growth and employment levels equals or out-performs Canada.

In addition to its thorough overview of equity-promoting public policy related to the important social determinants of health, the book’s emphasis on the Nordic approach towards sustainable development is particularly innovative and useful. Nordic nations’ efforts in this area are remarkable and closely related to their achievements in the other public policy areas detailed in this book. Environmental issues have generally been overlooked in analyses of how public policies can promote the health and well-being of the population in general and the vulnerable in particular.

The most striking conclusion to be drawn from this overview of public policy in the Nordic nations is that their governing authorities – with the full support and democratic participation of their public – believe in implementing public policies that improve rather than threaten the health and quality of life of their residents. They do this on the basis of the best available evidence and with a vision that asserts that even in an era of economic globalization, government, labour, business, and civil society can work together to improve the lives of people.

The vision of creating healthy and responsive societies is especially prominent in the Nordic nations, and this book does an excellent job of showing how to implement such a vision. I would note however that it is also present in the conservative nations of continental Europe where even without the strong historical influence of social democratic parties of the left, governments strive to promote the security and well-being of their members. It is a sad commentary that the public policy situation in Canada – e.g., growing income and wealth inequality, growth in precarious work, mediocre health and well-being of children, lack of national strategies for addressing food insecurity and housing insecurity, and consistently high and deepening levels of poverty – has fallen so far behind these other nations.

This excellent book seeks to rectify the Canadian situation by providing analysis of some of the macro-level factors shaping equity-promoting public policy in the Nordic nations such as intersectoral cooperation and the presence of proportional representation in the electoral process, meso-level descriptions of how Nordic nations develop and implement their public policies, and micro-level findings of the effects these public policies have on the population in general and the vulnerable in particular. It is thoughtful, comprehensive, and sure to enlighten.

While the provision of this information to Canadians will be absolutely essential in seeing its content applied to the Canadian scene, this will in itself not lead to the kinds of public policies necessary to promote Canadians’ health and well-being. As demonstrated by the development and passage in Quebec of Bill 112, Stratégie de lutte contre la pauvreté et l’exclusion sociale – Strategy against poverty and social exclusion – what is required to bring on health supporting public policy is creation of a broad social movement that literally forces Canadian public policymakers to implement the kinds of reforms envisioned in this book.

There are reasons for optimism in this quest. Canadians are increasingly concerned about the growing social inequalities in their midst. Canadians also see a role for governmental action in addressing these inequalities. If and when Canadian policymakers come to agree that such actions are necessary, this volume will provide a road-map of how to proceed in this task. The authors and the Léa Roback Research Centre are to be commended for providing Canadians with such an excellent, thought-provoking, and hopefully action-provoking resource.

Dennis Raphael, PhD

Professor of Health Policy and Management, York University, Toronto

PREFACE TO THE FIRST EDITION

Sweden and the other four Nordic countries (Denmark, Finland, Iceland and Norway) have implemented some of the most interesting examples of concrete policies to reduce social inequalities in health and to safeguard the well-being of vulnerable groups in our society. This book provides a comprehensive and insightful overview of many of the policies that have been introduced successfully over the years in one or several of the Nordic countries. By linking facts about the present status of social determinants to specific measures taken, the authors provide an instructive description of the actual effects and benefits of different social policies.

While every nation has its own political and cultural specificities we can learn from each other by sharing best practices. In particular, this applies to Canada and the Nordic countries that have a number of things in common, including mind-set, and whose societies are based on a similar set of basic values. Some of the measures taken by the Nordic countries may not be suitable in a different context and others may need to be adapted to local conditions. One also need remember that policies are not static and need to evolve over time. This includes social policies, where we have seen interesting developments in my own country in the last decade. Reforms have been introduced to safeguard the continued relevance and efficiency of the different social programs in a constantly changing society where public funds are not in abundance. I do believe, nevertheless, that many of the policies described in this book have the potential to serve as sources of inspiration and reference points for other countries like Canada.

Ottawa, 12 October 2012

Teppo Tauriainen

Ambassador of Sweden to Canada

INTRODUCTION

Income, social, and health inequalities often depend on decision-makers’ choices and ideologies. These policy choices are based on knowledge and experience accumulated over the course of years in political, economic, social, and cultural contexts.

The accumulating evidence concerning the impact upon health and well-being of broader determinants of health is available to policy makers in Canada, the U.S., the U.K., and Sweden. What is striking is the degree of variation in commitment to applying these findings across these nations.1

This work is an attempt to review, for the benefit of decision-makers, those public policies that have been most successful at reducing social inequalities and poverty. Numerous organizations have used a host of indices to compare countries in this respect. In the context of the struggle against social and health inequalities the example of the Nordic countries is particularly eloquent, for it shows the degree to which public policies really can positively affect an entire society.

The Nordic countries’ decision-makers seem to have derived all the beneficial consequences from what is known about the impact of social determinants on health. These countries, which share the political principles and practices that comprise what is known as the Nordic model, are at the top when it comes to reducing human poverty. Over the course of decades, this model has acquired almost mythic status. It has allowed spectacular results to be attained in several sectors of social development. It has pushed back the limits of what social solidarity and state intervention can achieve.

The Nordic countries were pioneers, and they remain today a part of the world well worth looking at, a vast and unique laboratory for experiments in governance. The small size of these countries, which favours experiments, surely has something to do with this. As well, they remain a source of inspiration because of the richness of their political history, their populations’ consensus support for state intervention and their solidarity on social and ecological issues, and because their political class continues to prioritize the common good.

Even if the Nordic model, whose social policies are typically generous, has undergone major changes, the governments of the Nordic countries still develop equity policies that differ from those of other Western countries in their breadth and in their aims of equity, while continuing to maintain a high level of economic competitiveness. Buhigas Schubert and Martens explain this convincingly:

Nordic societies started doing their homework before many others in Europe, recognising the need to adapt to global competition while at the same time maintaining the welfare state as the essential element of the system – and not even putting it up for discussion. In other words, the transformation needed for successful integration into a globalised economy has not been achieved by cutting welfare, but rather through collective commitment, a vision of the value of investing in high standards, and a willingness to pay for it.2

Even the ways of orchestrating political responses to global economic changes show, at least in the case of Sweden, the continuing existence of a Nordic political process, from which one can also draw inspiration:

The economic recovery was to be the proof of the greatness — in the largest sense of the term — of the Swedish model: trusting relations at all levels of society, a developed feeling among social partners of responsibility, sociological proximity between the political class and the citizens, the limited nature of social cleavages and the strength of the bonds of solidarity, transparency and effectiveness of the bureaucracy… All these factors gave Swedish society its capacity to react rapidly and in a determined fashion, when others were bogged down in insurmountable conflicts of interest.3

The WHO’s Commission on Social Determinants of Health has clearly described the social and political conditions that favour health. One can easily recognize in these descriptions the public policies of the Nordic countries. We have highlighted the common characteristics of the policies that have helped make Nordic societies environments that are fair, and that favour health for the greatest number of people.

Research of use to decision-makers

The research that led to the publication of this work was carried out by the Montreal-based Léa Roback Research Centre on Social Inequalities in Health.

The centre was created in response to a call for proposals from the Canadian Institutes of Health Research, for creating centres for research into the health effects of physical and social milieus. The researchers at the Léa Roback Centre focus on the main determinants of social inequalities in health, and on interventions likely to reduce these inequalities. It includes researchers from Montreal universities and from public health organizations. The centre’s researchers carry out studies in the greater Montreal region and interact with local and regional decision-makers in provincial ministries, in municipal government, and in a number of other organizations. The centre’s mission is to produce research results of use to decision-makers, and gives rise to numerous initiatives to exchange knowledge with them.

The choice of studying the Nordic countries

Very few studies have evaluated public policies. As a general rule, governmental interventions or policies are not implemented using a scientific method (i.e., with an experimental and a control group), thus allowing their consequences and effectiveness to be measured. Our study, therefore, focused on the countries that have clearly succeeded in reducing social inequalities. These successes are documented by data and reports from major international organizations such as the United Nations (UN) and the Organization for Economic Cooperation and Development (OECD), as well as by experts on public health and on social inequalities.

The Nordic countries were chosen as the object of this study because, when countries are ranked by how well they fight social inequalities, they are at the top of the list. The countries we chose are Sweden, Norway, Denmark, and Finland. We excluded Iceland; with only 330,000 inhabitants, it is a small state and cannot be compared with Quebec. The other Nordic countries have geographic, demographic, and cultural realities – such as remote regions and a low population density – close to the Quebec context. For the very same reasons, we have excluded a comparison with Japan, which also does well on indicators of social equity and health.

Aim and target audience

In the light of hard data about the Nordic countries’ success, the prime goal of this work is to make known the best practices, highlighting inspiring examples.

In keeping with the Léa Roback Centre’s mission of exchanging knowledge, decision-makers and students comprise the main target audiences for this work. This is why, for each of the themes studied, we explain not only the main policy thrusts but we also (in the sections headed ’Key ideas’) give examples of concrete interventions, illustrating how policies play out in people’s daily lives.

This research project was planned so as to inform those who design and make decisions about policies for application in urban milieus. Our results will also be of interest to anyone working at improving social equity and the health and well-being of populations. Policies are presented concisely so as not to burden the text with detail. The exhaustive bibliography at the end of the work will allow the reader to find not only the original texts of policies, but also studies and syntheses by outside observers.

Methodology

We met individually with Montreal-based decision-makers who collaborate with the Léa Roback Centre to delimit the domains and themes to examine in this survey. Exchanging knowledge with decision-makers is part of the mission of the Léa Roback Centre. These discussions allowed us to define the several fields of interest that have guided our research.

The literature about the policies of Nordic countries that could help in reducing both social inequalities in health and poverty in urban and near-urban areas was chosen, analysed, and summarized. Four types of data sources were used: scientific articles describing or evaluating policies; websites of the governments of the countries studied, of ministries, agencies, municipalities, and organizations such as the Swedish Institute, Statistics Norway, or the Finnish National Board of Education; publications by the governments of the countries studied, such as annual reports, documents on policies, etc., (and, when necessary, direct communications with government agents); and data and publications from major international organizations such as the European Union, the Council of Europe, the European Parliament, the OECD, the United Nations Development Programme (UNDP), UNICEF, UNESCO, and the Nordic Council. We also made use of information from other international organizations such as Eurocities, the network of the 130 largest cities in Europe.

We have compiled the most recent data available using the following criteria for inclusion: symmetry with selected countries in the selected policy fields; the evaluative and instructive nature of the data; and promising practices or practices that have