Health as if everybody counted blog
Policies for health equity: Learning from the Danes
Since the report of the Commission on Social Determinants of Health appeared in 2008, several efforts have been made to apply its insights to specific country and regional challenges. The most familiar of these are the review carried out in the United Kingdom, now competed, and the one under way in WHO's European Region – both led by Sir Michael Marmot himself. A less publicized review, led by distinguished public health researcher Finn Diderichsen, was recently completed in Denmark. The English-language version of its report is forthcoming in the Scandinavian Journal of Public Health, and is presented here in pre-publication form.
In many respects, Denmark is a leader in health and social policy. At least until recently, its economic policy dealt successfully with the issues facing a small, open economy by way of a labour market policy known as flexicurity that combines limited job protection with a high level of income protection and training provision. According to OECD figures, in 2009 a laid-off Danish worker could expect to receive unemployment benefits worth 47.7 percent of previous earnings, as compared with 11.7 percent in Canada – a figure that reflects Canada's restrictive eligibility requirements and low insured earnings ceilings. Danish child poverty rates are among the lowest in the OECD, according to figures from the Luxembourg Income Study, although the report notes a worrying increase between 2001 and 2007, partly attributable to reduced unemployment benefits. The country recently adopted a tax on foods high in saturated fats, in an effort to create economic incentives for healthier eating. At the same time, the new report is motivated by concern about the "Scandinavian Welfare Paradox of Health": Scandinavian countries with relatively low levels of economic inequality do not in fact exhibit the lowest levels of health inequality among the high-income countries, at least when crude measures such as mortality and self-reported health are used.
The report's authors identified a list of 12 determinants of health, using a straightforward model developed by Diderichsen and colleagues more than a decade ago for understanding connections among economic and social policies, macro-level variables like social stratification, and individual health outcomes.
(Their original article does not appear to be available on an open-access basis, but pages 15-17 of the new Danish report provide a first-rate short description of the model.) For each of the 12 determinants in the list, they then provide a brief account of the relevant research evidence and an inventory of measures that are likely to be effective in reducing health inequality. Preventing increases in income inequality is identified as a priority, as are planning measures to counteract the tendency of housing markets to increase residential segregation. The inventories sometimes combine conventional 'downstream' interventions with more contextual ones. For example, with respect to interventions for early child development, the inventory includes maternity visits by health nurses and active recruitment of children with special needs through day care institutions and kindergarten classes but also elimination of childhood poverty. And suggested measures to reduce overweight, obesity and their health consequences include taxation and healthy choice programs in school and workplace cafeterias, but also (unspecified) measures to increase physical activity in disadvantaged residential areas.
Like many such reviews, the report focuses on the importance of cross-sectoral policy coordination while emphasizing both its difficulty and the lack of "positive international experiences vis-à- vis reducing inequalities." In an interesting reflection on Britain's lack of success , the report notes (for example) the long period of time required to demonstrate reductions, because the influences on health inequalities operate across the life course, and the fact that "far too many initiatives constitute single temporary projects in local deprived areas" rather than influences on broader public policies. (This observation will sound uncannily familiar to Canadians!)
It is always difficult to assess the comprehensiveness of such reviews without detailed knowledge of the country context, but a few aspects strike the foreign reader as curious. For example, although limited accessibility of healthy foods in thinly populated areas and poor neighbourhoods (the problem of food deserts) is noted, no specific measures to improve accessibility in such areas are proposed. And from a Canadian vantage point, the recommendation to increase school completion through "practical learning targeted at young people who cannot complete a normal academic school program" sounds like a recipe for stigmatization, increased stratification and a less, rather than more inclusive society.
To the extent that the data allow direct comparisons, we should also be aware that health (and socioeconomic) disparities in Denmark are already smaller than in some other high-income jurisdictions. The report notes that differences in life expectancy between neighbourhoods in Copenhagen "are as large as six to seven years" – lower than the difference of more than 10 years (for men) between some of the richest and poorest neighbourhoods in Montréal or the 17 year difference in London and the 28 year difference in Glasgow noted by Marmot and colleagues. And the poverty rate of 10-20 percent in some Danish parishes identified as a cause for concern in the report should be compared with the more than 40 percent of economic families living below the before-tax Low-Income Cutoff in some of Toronto's inner suburban neighbourhoods. (Because of different poverty measures, this comparison – unlike the international comparison of child poverty rates cited earlier – is only approximate.)
Despite these factors the similarity of the issues faced by Canada and Denmark in a global economic environment that tends to increase economic inequality is striking, and the Danish report will be valuable as a starting point and inspiration for Canadian provinces or local jurisdictions wanting to undertake a systematic and theoretically informed assessment of what works to reduce health disparities.
* We are deeply indebted to Prof. Diderichsen for permission to post this material.