Causality, social selectivity or artefacts? Why socioeconomic inequalities in health are not smallest in the Nordic countries

Abstract

The Nordic welfare states aim at providing equality of the highest standards for all their citizens. However, numerous studies have demonstrated that socioeconomic inequalities in morbidity and mortality are not among the smallest in these countries as compared with other European regions.1–7 Recently, this has spurred health researchers to evaluate the extent to which the Nordic welfare regime is capable of diminishing socioeconomic health inequalities.8,9 After all, the conclusion that the Nordic welfare regime does not succeed in reducing health inequalities would have serious implications for health policy world wide. In this commentary, we aim at evaluating why the Nordic welfare regime does not completely succeed in reducing socioeconomic inequalities in health, despite its egalitarian nature. Our presentation is divided into three types of explanations: causality, social selectivity and artefacts. Scholars have generally argued that a distinction should be made between relative and absolute socioeconomic health inequalities. Moreover, the absolute health status of the weakest socioeconomic groups (e.g. manual workers) is considered to be most important as a marker of the ability of welfare regimes to reduce socioeconomic disparities in health. Using this distinction, it was concluded that whereas the Nordic countries perform only intermediately whenever relative inequalities are considered, they have lower absolute inequalities and a higher average absolute health status of the lowest socioeconomic groups as compared with other European societies (although this applies mostly to Sweden and Norway, and only to a lesser extent to Denmark and Finland). Since the authors argue that welfare regime performance should mainly be evaluated …