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Policies and strategies to promote social equity in health. Background document to WHO - Strategy paper for Europe

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Abstract

This is the second in a series of discussion papers from the WHO Regional Office for Europe. The first covers concepts and principes of equity in relation to health, and should be read in conjunction with this paper (Whitehead 1990). The present paper sets out to develop the discussion further by outlining a strategic approach to promote greater equity in health between different social and occupational groups. This draws on the work of WHO advisory groups and associated litterature listed at the back, together with practical examples from industrialized countries where strategies have been put into action. The first part (section 1-9) of the paper outlines why equity is seen as a priority and distinguishes different policy levels for interventions. Specific equity aspects related to each policy level are then highlighted as well as some case studies. The second part of the paper (section 10-14) deals with putting policy into practice. Special attention is then paid to the need for comprehensive approaches to combat social and occupational inequities in health as illustrated in terms of a strategy matrix. Furthermore the democratice process within which healthy public policies are to be discussed and determined is discussed as well as organizational aspects as regards the implementation of an equity oriented health policy. Finally checklists are presented focusing upon how to make things happen.
Dahlgren, Göran & Margaret Whitehead
Policies and strategies
to promote social
equity in health
Background document to WHO – Strategy paper
for Europe
This working paper was originally published in print form in September 1991. The figure
“The Main Determinants of Health” has been revised in this version.
Arbetsrapport/Institutet för Framtidsstudier; 2007:14
ISSN: 1652-120X
ISBN: 978-91-85619-18-4
Former Working Papers:
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ISSN: 1652-120X
ISBN: 978-91-85619-18-4
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Numerous studies and models address the determinants of health. However, in existing models, the spatial aspects of the determinants are not or only marginally taken into account and a theoretical discussion of the association between space and the determinants of health is missing. The aim of this paper is to generate a framework that can be used to place the determinants of health in a spatial context. A screening of the current first serves to identify the relevant determinants and describes the current state of knowledge. In addition, spatial scales that are important for the spatial consideration of health were developed and discussed. Based on these two steps, the conceptual framework on the spatial determinants of health was derived and subsequently discussed. The results show a variety of determinants that are associated with health from a spatial point of view. The overarching categories are global driving forces, policy and governance, living and physical environment, socio-demographic and economic conditions, healthcare services and cultural and working conditions. Three spatial scales (macro, meso and micro) are further subdivided into six levels, such as global (e.g., continents), regional (e.g., council areas) or neighbourhood (e.g., communities). The combination of the determinants and spatial scales are presented within a conceptual framework as a result of this work. Operating mechanisms and pathways between the spatial levels were added schematically. This is the first conceptual framework that links the determinants of health with the spatial perspective. It can form the working basis for future analyses in which spatial aspects of health are taken into account.
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Thesis
Das Bewegungsverhalten der Bevölkerung in Deutschland zeigt einen deutlichen Bedarf an Maßnahmen zur Bewegungsförderung über die gesamte Lebensspanne. Bereits gewonnene Erkenntnisse zum Zusammenhang zwischen dem Bewegungsverhalten und der Ungleichheit in der Bevölkerung zeigen, dass es einen Bedarf an Projekten zur Prävention und Gesundheitsförderung durch Bewegung gibt, welche die gesundheitliche Ungleichheit adressieren und somit die Gesundheit von vulnerablen Gruppen stärken. Im Rahmen dieser Dissertation wurde untersucht, wie Bewegungsförderung auf ganzheitlicher Ebene, also individuumsbezogen und auch strukturell gelingen kann. Im Rahmen von drei wissenschaftlichen Untersuchungen wurde diesbezüglich die Verwendung des Capability-Ansatzes, ursprünglich aus der Gesundheitsökonomie nach Amartya Sen (1993) stammend, hinsichtlich seiner Tauglichkeit als ganzheitlicher theoretischer Ansatz in der Bewegungsförderung bei verschiedenen Projekten über die Lebensspanne untersucht. In einer systematischen Literaturübersicht stellt Artikel I den aktuellen Forschungsstand zu Messmethoden von Capabilities bezüglich Gesundheits- bzw. Bewegungsverhalten dar. Hierbei wurde untersucht, ob bereits Messinstrumente bestehen, welche im Rahmen von Projekten angewandt werden können, um einen Vergleich über Settings hinweg anstellen zu können. Identifizierte Messinstrumente wurden hinsichtlich ihrer Entwicklung sowie deren Validität und Reliabilität begutachtet. Artikel II untersucht im Rahmen eines partizipativen Ansatzes die Verwendung des Capability-Ansatzes im Rahmen von partizipativen Projekten des Capital4Health Verbunds. Der Verbund zielt auf die Entwicklung von Handlungsmöglichkeiten für einen aktiven Lebensstil in verschiedenen Settings über die gesamte Lebensspanne. Hierfür wurde der sogenannte Capability-Cycle basierend auf einem bereits bestehenden Capability-Modell der Gesundheitsförderung entwickelt. Unter Anwendung des Modells wurden 4 Projekte hinsichtlich der Umsetzung des Capability-Ansatzes untersucht. Durch die Verwendung des Capability-Cycle konnte ein Vergleich der empirischen Projekte hinsichtlich der Projektumsetzung, entstandener Umwandlungsfaktoren als Projekt Outcome sowie projektspezifischer Evaluationsergebnisse durchgeführt werden. Die Erkenntnisse zeigen, dass trotz eines gemeinsamen theoretischen Rahmenkonzeptes die empirischen Projekte den Capability-Ansatz unterschiedlich interpretiert und umgesetzt haben. Dies ist teilweise abhängig von den unterschiedlichen sportwissenschaftlichen Disziplinen sowie den disziplinspezifischen bestehenden theoretischen Rahmenkonzepten, welche in die Projektarbeit einfließen. Die dadurch gewonnenen Erkenntnisse des Vergleichs wurden anschließend genutzt, um Empfehlungen für die Verwendung des Capability-Ansatzes in der Gesundheits- und Bewegungsförderung zu entwickeln, welche zukünftigen Projekten zur Verfügung stehen, die den Capability-Ansatz als theoretisches Rahmenkonzept verwenden möchten. Durch die empirisch entwickelten Richtlinien können neue Projekte von den bisherigen Erkenntnissen profitieren und es kann gleichzeitig eine Vergleichbarkeit von Projekten ermöglicht werden. Um die Verwendung des Capability-Cycle als Evaluationsrahmen auch außerhalb des Capital4Health Verbunds zu überprüfen, wurde in Artikel 3 das Projekt „Bewegung als Investition in Gesundheit (BIG) retrospektiv in einer systematischen Literaturanalyse untersucht. Das Projekt entstand im Jahr 2005 mit dem Ziel, Frauen „in schwierigen Lebenslagen“ (so die von den Teilnehmerinnen selbst gewählte Beschreibung) zu befähigen, sich für ihre eigene Gesundheit einzusetzen, und damit die bewegungsbezogene gesundheitliche Chancengleichheit innerhalb kommunaler Settings Hierfür wurde eine systematische Literaturanalyse aller bisherigen BIG-Publikationen (n=37) durchgeführt und hinsichtlich genannter Ergebnisse analysiert. Alle Ergebnisse wurden nach deren Ebene, sprich Multiplikatoren oder Zielgruppe sowie den einzelnen Elementen des Capability-Cycle eingebettet. Hierbei zeigte sich, dass durch die Verwendung des Capability-Cycle eine ganzheitliche Betrachtung der erzielten Ergebnisse sowohl auf der Verhaltens- als auch auf der Verhältnisebene möglich ist. Durch die vorliegende Dissertationsschrift, konnte die Verwendung des Capability-Ansatzes insbesondere in der Gesundheitsförderung durch Bewegung geprüft und weiterentwickelt werden. Die vorliegenden Ergebnisse zeigen, dass der Capability-Ansatz für die Anwendung in der Gesundheits- und Bewegungsförderung eine Grundbasis bildet, welche verschiedene Sichtweisen (Empowerment und Ungleichheitsforschung, sowie das Verhalten selbst) mit einbezieht. In der Zukunft sollte der Ansatz daher in Interventionen weiter Anwendung finden, um diese spezifisch an die Zielgruppen anzupassen und dabei beeinflussende individuelle und strukturelle Faktoren sowie Multiplikatoren und deren Handlungsmöglichkeiten zu beachten.
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The paper argues that the Swedish ‘neo-liberal’ party (Moderaterna) has adapted its policies because of the popularity of the ‘universal’ Swedish welfare state. The party has come to accept that the modern welfare state is irreplaceable. We furthermore argue that the party’s moderate electoral platform in 2006 is earnest. In the “short run” the party can only hope to achieve incremental changes and it recognises this. Simultaneously however, the party in the “long run” wants to gradually change society. Over time the party in its rhetoric and ideological statements has emphasised the short and the long run differently. These differences between the ‘neo-liberal’ 1980s and 2006 should not conceal that the mechanism of welfare popularity largely remains the same. The party’s actual policy proposals tend to suggest incremental changes only in both periods.
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Among the most central questions at the intersection of demography and economics is the impact of large scale demographic processes on long-run economic performance. The classical version of this inquiry, occupying thinkers from Malthus towards those from the mid-to-late 20th century, had to do with whether rapid population growth threatened economic growth. This classical inquiry has been superseded by more sophisticated questioning in which the focus on growth rate of the aggregate population has been replaced by focus on the growth rates of age-specific population sub-groups. Disaggregating the effects of population growth by age-group is generally accepted to be a fundamental improvement over classical inquiry because people’s economic roles and contributions vary by age: the young are net consumers and beneficiaries of human capital investments, adults are net producers and savers, and the old are (at least in theory or to a greater degree than adults) net consumers. Thus the economic consequences of rapid growth in the population size of the young and the elderly could potentially have a depressing impact on growth, while rapid growth in the population size of adults could stimulate growth. The demographic transition brings with it a three stage process in which a baby boom cohort moves through the population’s age pyramid. The life cycle of this cohort creates a first stage in which there is rapid growth in youth population, then a second stage in which there is rapid growth in the adult population, and finally a third stage in which there is rapid growth in the elderly population. The first and third stages can be thought of as the challenging stages since economies must confront the challenge of providing for large dependent populations. However, the second stage can be thought of as a demographic gift or dividend stage since growth in the productive adult population can potentially boost economic growth. The traditional mechanisms for the demog
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Traditionally, pension systems aim to fulfill a number of functions which include income security and consumption smoothing in old age, as well as income redistribution. The main rationale for pension reform lies in the interaction between current demographic trends (e.g. increasing old age dependency ratios) and the design of existing pension systems (particularly, the so called Pay-As-You-Go public systems). Under certain conditions, population aging can in fact undermine the ability of a pension system to fulfill those very aims for which it was created, putting pensioners at risks of higher poverty and inequality, besides creating large fiscal pressures on governments and threaten economic growth. In the literature, we find two main approaches to this debate. On the one hand, economic theory helps us formalize the mechanisms through which aging affects a pension system, given its possible features (e.g. type of benefit offered, degree of actuarial fairness or type of financing); it also helps us quantify costs or returns associated to different pension designs and, consequently, to different pension reform options. On the other hand, the policy debate is centered on models of reform which take from concrete country experiences; overall, it focuses mostly on whether funding pensions (i.e. privatizing and individualizing retirement savings, away from Pay-As-You-Go systems) is the best option for reducing many of the negative economic impacts associated to population aging. After having illustrated both sides of the debate – the theoretical and the empirical - our paper makes two main claims. Firstly, the debate should be re-framed away from whether funding is the best option for pension reform in the face of population aging, towards a redefinition of the problem which rather focus on the type of benefit offered, its coverage, its eligibility conditions and actuarial design (as this controls important behavioral and efficiency implications). Secondly, an
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There is nowadays a widespread sense that things have gone badly wrong for young workers in advanced economies, and that the difficulty is caused by a fall in their appeal to employers. It is tempting to attribute the problem to a trend in labour demand that favours older, more experienced workers over younger, less experienced ones. The same line of interpretation has been widely favoured for the other major dimension of employee skill: educational attainment. The contemporary fall in the pay of less educated workers, as compared to more educated ones, in the US and the UK in particular, has been widely attributed to the spread of information technology and globalisation, both of which are taken to raise the productivity of more educated workers relative to less educated ones. An influential account of developments in the US claims that ‘relative demand shifts favouring more skilled workers are … essential to understanding longer-run changes in the US wage structure’ (Katz and Autor 1999: 1513). The same factors might had similar effects in the experience dimension of skill, thereby impairing labour market prospects for young workers. The validity of these propositions has however been contested. Doubts have been raised concerning the existence of skill-bias in technical change (Card and DiNardo 2002). Some commentaries deny the existence of an underlying trend unfavourable to youth (OECD 2002: 20-29). This paper investigates the evidence concerning trends in youth relative pay and employment in developed economies since the mid-1970s, focusing on structural change on the demand-side of the labour market. It improves on previous research by including more countries, and by controlling for macroeconomic fluctuations, which affect youth employment particularly keenly. It then considers the growth of educational participation, as a further, supply-side, influence that complicates the interpretation of changes in youth outcomes.
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One subject that has received ample attention in recent years is the potential negative effects of spatial concentrations of disadvantage on participation in society, particularly in terms of labour market participation and educational careers. This study contributes to the literature on the effects of neighbourhood and school on individual educational outcomes by examining whether and to what extent adolescent educational achievement is determined by neighbourhood and school population characteristics. By using an unusually rich administrative data set of leaving certificates for around 26,000 upper secondary school students who were registered as residing in any of the three metropolitan areas of Sweden in the school year 2004, cross-classified multilevel analyses show that characteristics attributable to upper secondary schools matter much more for the variability in achievement than do neighbourhoods. There are also indications of contextual effects at each level (particularly among boys with an immigrant background) that operate above and beyond the impact of observed individual-level background attributes. Since the estimated effects of concentrations of (dis)advantage and immigrant density at neighbourhood and school level point in different directions, this study demonstrates the benefits of analysing the effects of neighbourhood and school on individual educational outcomes at the same time.
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This study examines labour supply responses to spousal sickness absence (SSA) using a Swedish longitudinal panel data, from 1996-2002. The overall results present an evidence of a decrease in labour supply in response to spousal sickness absence. The effect on labour supply increases with spousal earnings level. Women react stronger than men, and more often respond to current shorter term SSA, whereas men mostly react to longer term SSA.
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This paper contributes to the important policy related literature on income and health by providing a detailed investigation of the family income/child health relationship using matched parent–child survey data from the Swedish Survey of Living Conditions (ULF). This study differs from previous work in the field in a number of respects. First, we focus on both physical as well as on the psychosocial health of the child. Second, we focus on the parent’s socioeconomic background as well as on the liquidity constraint problems the household faces. We find little evidence of an income gradient or effect on children’s physical and psychosocial health. However, our study suggests that the occurrence of liquidity constraints in the household increases the likelihood of the child having a lower psychosocial health status.
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The questions addressed in this paper are: (i) does wage inequality increase with local population size, and if so, (ii) what are possible factors behind this increase? In a cross-section analysis of Swedish local labour markets using unique full population data, the article shows that urban scale, i.e. size of local population, has significant positive effects on wage inequality. Testing for potential explanations, labour market diversification, human capital, migration, age structure and employment are shown to be significantly associated with inequality. Given these effects, the article raises the question of how to understand and incorporate scale effects into models of long-term change in wage inequality.