Lessons from Sweden
Health inequalities – social determinants
Inequalities in health exist worldwide. They can be caused by the social determinants of health i.e., the conditions that people are born into and live in.1 It’s important to focus on these factors, as 50% of health outcomes are determined by them.1 A link has been found between individual socioeconomic status and life expectancy, with individuals with lower status often facing worse outcomes.2 This relationship is particularly apparent in the UK. Females from the most deprived areas face a life expectancy that is 7.7 years shorter than their counterparts in the least deprived areas and males from the most deprived areas 9.5 years shorter.3 This highlights the need for the UK to minimise health inequalities by targeting social determinants.
Sweden and the UK
Sweden is well known for being one of the most equal countries in the world.4 It has low rates of income inequality, with a Gini coefficient of 0.27.5 A Gini coefficient is the measure of income distribution within a population. A Gini coefficient of 0 would mean there is complete income equality within the population, whilst a coefficient of 1 would mean complete inequality.5The income distribution within the UK is more unequal than Sweden, with a Gini coefficient of 0.36.5 Differences can also be seen between Sweden and the UK in health inequality. Sweden has a life expectancy of 82 years, 1 year greater than the UK’s.6 Additionally, Sweden has a lower gap in life expectancy of 2.9 years in women and 4.1 years in men, between the least and most educated individuals, compared to the UK, which has a gap of 4 years and 4.4 years respectively.6
So, what has Sweden done to maintain high life expectancy whilst minimising health inequalities, and what can the UK learn? To answer this question, let us consider three initiatives that have taken place in Sweden - from the early years to the school years and finally the working years:
- Family centres to promote early development
- Education improvements in Malmö
- Good quality employment
Early years development
During the early years we develop emotional, physical, and intellectual capabilities and behaviours that can follow us into adulthood to influence our socioeconomic status and health.7,8
Family Centres in Sweden have been a long-standing state-run initiative since the 1970s with the main aim of supporting early child development through strengthening parenting skills, training the unemployed, providing maternity and child healthcare services, and childcare.9,10 Whilst the Family Centres have not been evaluated directly in terms of long-term health effects, research has compared child mortality between England and Sweden.11 Child mortality in children under 4 years old was almost twice as high in England, which is believed to be largely due to poor socioeconomic circumstances impacting the health of pregnant women, leading to adverse birth effects.11 Although it is not possible to link Family Centres directly to this difference, we can hypothesise that as the centres are universal in Sweden and have been around for many years, they may have improved women’s health and socioeconomic circumstances during pregnancy.
There have been similar support services in the UK, such as Sure Start centres. These played a key role in attempting to reduce intergenerational poverty to minimise health inequalities. On evaluation of the centres, there were 5,000 fewer hospital admissions in children who were enrolled by the time they reached the age of 11 compared to unenrolled children.3 However, since 2010 funding has been cut and more than 500 centres have closed, with those who need it the most in disadvantaged areas, suffering the most.3 With child poverty on the rise and continued reductions in support services,3 early child development appears set to continue to be negatively impacted in socioeconomically disadvantaged populations in the UK.
Inequalities that persist beyond the early years to the school years can strongly influence adult socioeconomic status, including further and higher education status and type of occupation, which can then contribute to poorer health outcomes.3,7 Children from more deprived backgrounds will benefit the most from high-quality education as they may lack support at home if parents lack educational skills or must work long hours.
Despite Sweden’s average level of inequality being relatively impressively low there is still work that needs to be done in certain regions of the country. Malmö is one of them. It has one of the youngest populations, highest proportions of foreign-born residents and significant differences exist in life expectancy between the least and most deprived areas in the city.12 A recent initiative undertaken in Malmö is the ‘Every student’s best school’ programme which aims to improve education quality for those students who need it the most.13,14 This has been achieved by ensuring a higher ratio of teachers to students by recruiting more teaching staff in schools in disadvantaged areas with the incentive of increased salaries or by retaining staff by offering skills development courses.13,14
Although research has suggested there may not always be a direct relationship between teacher-student ratios and educational achievement, a key flaw with education in the UK may be the low ratio of teachers to students, with pupil numbers rising whilst cuts to funding have led to reductions in the workforce.3 The most deprived areas have lost the most funding, and these cuts could lead to a reduced quality of education provided to children who again need the best quality education the most.3,15 The gap in education inequality between the most and least deprived pupils widened during the pandemic, where children were forced to study from home due to lockdowns and school closures.16 Children from the most deprived households were sometimes unable to access online teaching resources or were less able to rely on parents to fulfil a teaching role at home, which is likely to have severely impacted their education.16 There have also been suggestions in recent years that, as in Malmö, consideration should be given to offering higher salaries to teachers working in deprived areas, to try to attract the best teachers to work with the students who most need good teachers.17 However, yet, no part of the UK has agreed to this.
Socioeconomic inequalities in adulthood can lead to poorer employment opportunities, such as low-quality and low-paid work. This type of employment has been associated with long term stress due to job insecurity and unpredictability which, in turn, can lead to poor health.18,19
Sweden has an in-work poverty rate that is much lower than other EU countries. This suggests there are initiatives that protect their working population, with only 6.9% of the employed population living below the poverty line.20,21 This figure is much greater in Britain, where 18% of the employed population live below the poverty line.22 In both countries, households are regarded as living in poverty if they are living on less than 60% of the nation’s median disposable income.20,23 There is no statutory minimum wage in Sweden,19,20 but there appears to be a large proportion of well-paid jobs, as can be seen by the high-earnings quality value which refers to the extent that an individual’s earnings contribute to their well-being.24 Sweden had a higher earnings quality value at 20.82 USD compared to the UK which was 18.35 USD in 2013.24 The working population are also often protected by unions in Sweden, with 70% of workers unionised.25 These unions help protect workers from low pay and poor working conditions.25 Sweden has clearly been successful in providing well paid and high-quality work, and it has also been successful in providing green employment. The Swedish Government recently developed the green jobs initiative to alleviate unemployment due to the pandemic by employing unemployed individuals and training them to gain skills in green industries such as forest and geological agencies in Sweden.26
Prior to the pandemic the UK was experiencing growth in employment, however this was accompanied by an increase in in-work poverty, which was likely to have been caused by several factors.3 The first being the lack of secure, relatively well-paid jobs for working class people, following the long-term decline in UK industry, such as mining, steel plants and ship building. This form of employment had been replaced by less well paid and sometimes less secure work such as call centres and retail.27,28 There has also been a rise in zero-hour contracts in the UK with just under a million people contracted under them in 2020.3,29 In addition, there has been growth in the gig economy in the UK, including situations where individuals are technically classed as self-employed, preventing them from accessing employee rights such as holiday pay, minimum wage, and pension schemes, whilst still being heavily controlled by their employers.30,31 There have been several Employment Tribunal cases over this matter in the UK, perhaps most significantly the recent Uber case which finally deemed Uber drivers as workers rather than self-employed, enabling access to basic employee rights.31
These factors have contributed to an increase in poor-quality employment in the UK, all of which contribute to worse health outcomes such as self-reported work stress and anxiety, which have also risen in the UK.18,19,32 Trade unions in the UK could provide some protection here. However, only 23% of UK employees were covered by unions in 2018, leaving much of the working population more exposed to low pay, poor working conditions and the poor health outcomes that follow.33,34
As the UK recovers from the pandemic it will be important to support the population who have faced unemployment or poor-quality employment during the pandemic. A potential way to do this, as in Sweden, could be to follow the goals of a Green New Deal to produce well-paid, secure employment opportunities, with investment in green energy jobs.35 This is an example of what could be a win-win for the economy, the environment and greater income and health equality.
Based on the successful initiatives from Sweden, key lessons the UK can take on board to minimise health inequalities across the life course include:
- Investing more in the early years, through initiatives along the lines of Sure Start, to support families in deprived areas.
- Increasing spending in schools to ensure that vulnerable children have the education and support they need from a well-trained workforce, which is especially important to mitigate the consequences of the COVID-19 pandemic on education inequality.
- Ensuring high-quality employment by limiting zero hours contracts; providing clarity regarding ‘self-employment’ in the gig economy; facilitation of trade union membership and/or worker representation; maintaining and strengthening employee rights; and investment in well-paid green jobs as part of the Green New Deal.
Sigrun Clark, July 2021