How does Swedish public health policy address determinants of health?
Interview with Commissioner Denny Vagero, Sweden
Dr Denny Vågerö is the Professor of medical sociology and Director of CHESS, Centre for Health Equity Studies, a research institute set up by Stockholm University and the Karolinska Institute. He is a member of the Royal Swedish Academy of Sciences, and of its standing committee on health. Dr Vågerö's present research focuses on health inequalities and on how health is determined at different stages of life. The on-going Russian public health crisis, and its historical roots, is another of his research interests. Dr Vågerö has been a key figure in European health inequalities research and is presently Vice-President of the European Society of Health and Medical Sociology. He was involved in the Swedish Government´s Commission on Work, Environment, and Health, where he wrote its report about “jobs exposed to special health risks” and formulated policies to combat them. He has worked in the Swedish Parliament´s Census Commission and is Scientific Advisor to the Swedish National Board of Health and Welfare.
Why is it important to address the socioeconomic determinants of health?
Addressing the socioeconomic determinants of health is important because there are enormous inequities in health across the globe. These are linked to social and economic policies. In the past fifteen years, there has been an increase in health inequities. The result is a global health divide.
How are socioeconomic determinants of health relevant to countries in the WHO European Region?
In WHO’s European region, there is a health divide, both between and within countries. Some countries are not improving their health record. In fact, life expectancy today in the Russian Federation, for instance, is lower than it was 40 years ago. This is because overarching policies have focussed on ensuring economic growth and increasing capital, not on improving population health. In some of these countries, there has been increased economic growth in parallel to decreasing life expectancies. This means that the benefits of growth are only reaching a small pocket of the population, i.e. those people already in high-income socioeconomic groups. The expansion of the European Union has generally been very positive in pushing countries to improve their health records. Countries that are preparing to join have made positive adjustments in their policies. However, health inequities persist in the EU. In Western Europe, we still see a social patterning of health outcomes. People in high-income and high-education groups have better health.
One key determinant of health is employment, in both Western and Eastern Europe. We need to increase opportunities for healthy employment, which is linked to better health and survival. Studies in Sweden show that employment of women results in their improved health status and survival. However, women moving into bad jobs report an increase in back problems and similar ailments. In the next five-to-10 years in the European Region, it will be very important that EU policy creates the conditions for national governance for health. Alcohol, for instance, is an underestimated public health problem. Present EU alcohol policies treat it as a commodity rather than a public health issue. This contradicts past decisions, and the EU’s current alcohol policy has made some Nordic countries take steps backward. National policies that treated alcohol as a public health issue have been softened. This has negatively impacted population health and resulted in increased health inequities. The EU has a responsibility to ensure that national implementation of its policies actually improves health outcomes. The same can be said for the EU common agricultural policy. In light of the European Region’s high rates of cardiovascular diseases and obesity, the EU should ensure that the policy promotes healthy eating and nutritional improvements for the whole population. Fruits and vegetables should be made cheaper, so that all of the population can access them. The policy should not subsidize animal fats, but rather fruits and vegetables.
How does the Swedish public health policy address wider determinants of health and work to eliminate health inequities?
The Swedish public health policy aims to create the social conditions to ensure good health for everyone. The policy is an outcome of an extended two-decade process of awareness-raising within the health system and among policy-makers and civil servants in other sectors. The process resulted in a shared understanding that health is not produced by the health system alone. It is produced, rather, by others sectors and, thus, is the responsibility of all sectors. For instance, the housing sector is to accountable for its role in securing healthy homes, and the transportation sector is accountable for ensuring a low level of deaths on the road as well as pedestrian safety, especially in places where there are young children. The 11 target areas of the Swedish Public Health Policy, which were designed by an inter-sectoral committee, reflect this understanding.
The targets reflect an agreement, at the highest political levels, of the importance of an inter-sectoral approach to health. But this agreement alone does not solve the problem. Implementing the targets is a challenge, and assessing how to improve implementation is an essential next step. A major block is that some ministries do not consistently address health considerations in their policies. Inter-sectoral rhetoric is not the same as inter-sectoral action. Pressure from below has been useful in ensuring that health concerns are incorporated. For instance, target 4, which is “Better health in working life”, has benefited from active pressure and support from employees and trade unions. Pressure from these groups has pushed the government to advance towards this target. I fear also that sometimes issues regarding socioeconomic determinants of health are simplified, and their complexity is not recognized. A better link between research and policy is necessary.
Could you describe the work currently being advanced by the Centre for Health Equity Studies?
The purpose of the Centre for Health Equity Studies, CHESS, is to link social and medical scientists to study health inequities both within and between countries. We take a deep look at the problem. We look at how health inequities are transferred from one generation to the next and the causes behind this. This research partly stems from the question: “Why do we still have health inequities in a welfare state like Sweden?” We focus on foetal and childhood factors, adult behaviours, and economic and social circumstances including social policies. We see that policies need to be very long-term, because the situation cannot be reversed in just a few years, or even in one generation. We are now producing a report on the long-term impact of social and welfare policies on public health. This report is for the Commission on Social Determinants of Health.
CHESS researchers have shown that the social environment in a residential area impacts health, beyond the effect of known individual risk factors. We also examine the relationship between education and income and mortality. Higher education and income levels consistently correlate with longer life expectancy. The relationship is graded. We take a lifecourse approach in our research. This is very important because a person’s health is determined by what happens throughout one’s life, and in fact even before that. Assessing the impact of socioeconomic determinants, therefore, requires a historical view that takes into account the history of a population, including its exposure to conflicts and its social and economic transitions.
