Comparative Social Policy FAMILY POLICY AND INEQUALITIES IN HEALTH IN DIFFERENT WELFARE STATES Elisabeth Fosse, Torill Bull, Bo Burström, and Sara Fritzell

This article focuses on differences in health and welfare outcomes for families with children in three European countries, discussed in relation to national policies for child and family welfare. Data consist of policy documents and cross-national surveys. The document analysis was based on policy documents that described government policies. The statistical analyses utilize data from the European Social Survey. For the analyses in this article, a sub-sample of child families was selected from the countries Slovenia, Sweden, and the United Kingdom. Data showed that England’s policy has mainly addressed socially disadvantaged groups and areas. Sweden and Slovenia are mainly developing universal policies. The United Kingdom has high scores for subjective general health, but a steep income gradient in the population. Parents in England experience the highest level of at-risk-of-poverty. Sweden generally scores well on health outcomes and on level of at-risk-of-poverty, and the gradient in self-rated general health is the mildest. Slovenia has the weakest economy, but low levels of inequality and low child at-risk-for-poverty scores. The Slovenian example suggests that not only the level of economic wealth, but also its distribution in the population, has bearings on health and life satisfaction, not least on the health of children.

This article focuses on differences in health and welfare outcomes for families with children in three European countries, discussed in relation to national policies for child and family welfare. Social inequalities may be defined as a “wicked” problem (1). Searching for scientific bases for the confrontation of problems of social policy is bound to fail, International Journal of Health Services, Volume 44, Number 2, Pages 233–253, 2014 © 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.44.2.c http://baywood.com

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because of the nature of these problems. They are “wicked problems” whereas science has been developed to deal with “tame” problems. Policy problems cannot be definitively described. Moreover, there is no objective definition of equity; policies that respond to social problems cannot be meaningfully correct or false; and there are no objective “optimal solutions” to social problems. Social inequalities in health are a highly political issue. Leftist or social democratic parties will traditionally have a policy to reduce social inequalities in the population and to consider the differences inequitable, while right-wing parties might consider the differences as “natural” and use a different language, for instance, by calling them disparities instead of inequities (2, 3). THEORETICAL BACKGROUND What policy measures are necessary in order to reduce social inequalities in health among families with children? According to the English Marmot Review’s “Fair Society, Healthy Lives” (4), reducing health inequalities will require action on six policy objectives: give every child the best start in life; enable all children, young people, and adults to maximize their capabilities and have control over their lives; create fair employment and good work for all; ensure a healthy standard of living for all; create and develop healthy and sustainable places and communities; and strengthen the role and impact of ill health prevention. While there may be lack of agreement on what policy measures are necessary in order to reduce social inequalities in health among families with children, researchers have suggested the following (5–8): • Increasing quality of life and reducing social inequalities among children will demand resources. Countries need to spend more resources on children and families to reduce inequalities. • It is necessary to do so with comprehensive, intersectoral action. • It is also necessary that comprehensive, intersectoral policies must be combined with targeted measures aimed at disadvantaged and vulnerable children and families. • Macro-level policies, in terms of universal and generous welfare policies, will provide a security net and promote the health of children and families. There is an overall recognition that policies developed in sectors other than the health care sector play an important role for the health of the population. Policies to keep children and families out of poverty and ill health seem to include labor market policies; cash benefits; childcare; access to education; participation in culture, sport, and recreation; access to decent housing and safe neighborhoods; access to health care; and access to social services. One particularly vulnerable group is single parents. While many single-parent families do very well, as a group single-parent families (both parent and child) are

Family Policy and Inequalities in Health / 235 at increased risk of adverse health and welfare outcomes. Most research has focused on single mothers, not fathers. Single mothers are found to have increased levels of financial stress (9, 10); increased levels of psychological distress, depression, and poor self-rated health (9, 11–13); and reduced levels of subjective well-being, such as life satisfaction (14, 15). In this article, we have studied how differences in health and welfare outcomes for families with children can be understood as a result of national policies for child and family welfare in Slovenia, Sweden, and the United Kingdom. The article aims at answering the following questions: Are there inequalities in the living conditions and welfare between single-parent and couple child families in these countries? Is the issue of social inequalities for child families addressed in policy? METHODS To address the research questions, we applied quantitative and qualitative methods, each of which are described below. The quantitative analyses sought to expand knowledge about the existence of differences in health and welfare outcomes between the three countries and between single- and couple-parent families, while the qualitative data explored relevant social policies. In the present study, document analysis is used in combination with statistical analyses of social inequalities in health in the three countries participating in the study. Quantitative Methods Data Source and Sample. The statistical analyses for this article were performed using European Social Survey (ESS) data. ESS is a biannual survey collecting data from approximately 30 European countries with a methodology that maximizes comparability across countries. Samples are representative of countries. Data are collected in home interviews by trained interviewers. The ESS project has, as the first social science project, received the Descartes prize for excellent standards in methodology (16). The ESS data have been collected since 2002; for the analyses in this article, cumulative data from all five rounds, including 2010, were used, except for the analysis on attitudes toward family policies and services (Table 3), for which the relevant variables were available only in ESS4 from 2008. All parents living with their children were selected. Children were defined to include stepchildren, adopted children, foster children, and children of partners. Parents’ age was restricted to 50 or less to exclude elderly parents living with grown children. The exception is the analysis from ESS4, where the upper age limit was set to 55 to increase sample size. To separate between single-parent and couple families, we used the item “lives with husband, wife or partner.” We did not separate by gender, so single-parent families could be headed by males or females. Sample sizes are shown in Table 2 and in Table 3 for ESS4.

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Variables. Life satisfaction was measured by “All things considered, how satisfied are you with your life as a whole nowadays?” with the response format ranging from 0 = extremely dissatisfied to 10 = extremely satisfied. Happiness was measured by “Taking all things together, how happy would you say you are?” with the response format ranging from 0 = extremely unhappy to 10 = extremely happy. Subjective general health was measured by “How is your health in general? Would you say it is ___?” using the response options (1) very bad, (2) bad, (3) fair, (4) good, or (5) very good. Financial stress was measured by “Which of the descriptions on this card comes closest to how you feel about your household’s income nowadays?” using the response format (1) living comfortably on present income, (2) coping on present income, (3) finding it difficult on present income, or (4) finding it very difficult on present income. Attitudes toward family policies and services were measured by “What do you think overall about the provision of affordable child care services for working parents?” (0 = extremely bad to 10 = extremely good); “How much responsibility do you think governments should have to ensure sufficient child care services for working parents?” (0 = should not be governments’ responsibility at all to 10 = should be entirely governments’ responsibility); and finally “How much responsibility do you think governments should have to provide paid leave from work for people who temporarily have to care for sick family members?” with the same response format as the previous question. Main source of income was measured by “Please consider the income of all household members and any income which may be received by the household as a whole. What is the main source of income in your household?” with response options (1) wages or salaries, (2) income from self-employment excluding farming, (3) income from farming, (4) pensions, (5) unemployment/redundancy benefit, (6) any other social benefits or grants, (7) income from investment, savings, insurance, or property, or (8) income from other sources. For Table 4, we collapsed categories 1–3 and 7–8. Analyses. For the analysis design, weights were used as recommended by ESS to adjust for sampling design characteristics in the specific countries. Data were described in frequency and descriptive analyses, using mean as the central tendency. Differences in mean were tested by independent samples T-tests for differences between single and couple families (Table 2) and with one-way Analysis of Variance for differences between countries (Table 3). Post hoc analyses for ANOVA were performed with LSD and Tukey HSD. Qualitative Data: Document Analysis In comparing different countries, it is vital to have an understanding of the institutional contexts of the countries studied and it is necessary to classify

Family Policy and Inequalities in Health / 237 institutional differences across countries. Vining and Weimer (17) outline two types of comparative studies: the study of institutional design itself (first order policy instruments) and the policy instruments used as mechanisms of the institutional design (second order policy instruments). Within political science, the traditions could be divided into studies focusing on policy design, including the content of the policy, and a second tradition, studying the implementation of policies. The present study has its focus on the design of the policies. Document analysis is a research strategy within qualitative methods. Documents may be used in combination with other methods, but analysis can also be used as a method in its own right (18, 19). When using documents as a data source, it is important to study them in their context and to understand the purpose of the documents. It is also important to critically assess the authenticity, credibility, representativeness, and meaning of the documents (20). In this project, authoritative political documents, such as government white papers and government action plans, are the data sources. Political documents usually meet the criteria of authenticity and credibility as they are expressions of formulated government policies. Representativeness in this context is linked to whether the document is typical or atypical. In all the countries, we have access to several documents and, in these countries, the policies presented are typical of documents produced at the same time. The issue of meaning will be essential in the analysis as it concerns the explicit and implicit values of the policies presented. Policy documents serve as valuable data sources as they are produced by governments and have credibility and authority. They also serve as guiding principles and tools for government action and will thus reflect government ideology and intentions regarding the choice of policy instruments to deal with policies regarding health inequalities. The procedure for selecting the documents was as follows: national websites were searched for documents; in the two countries that do not have English as their native language, we searched for documents published in English. An exception to this is Sweden, since the authors understand Swedish. We started the searches at the websites of national ministries, looking for the institutions responsible for policies regarding (a) families and children and (b) health inequalities. All countries had well-updated websites, with all the most important documents translated to English. The chosen documents were sent to the national project partners for them to validate the choice of documents and supply the selection. They were also asked to control if there were important documents that only had been published in the native language. According to the project partners, the most important documents had been retrieved in the selection process. The documents were analyzed based on the following questions: Are there national policy goals regarding the reduction of social inequalities in health? Do these issues hold a high priority on the national agendas? Who is responsible for policies to reduce social inequalities among children and families? What strategies are chosen? Are these comprehensive/intersectoral strategies?

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Quantitative Results The following section compares a selection of economic, health, and welfare outcomes for child families in the three countries. A comparison is provided in Table 1, with the definition of constructs in the table footnotes. As displayed in Table 1, Sweden ranks in the top 10 globally when it comes to the Human Development Index. The United Kingdom ranks lowest of the three countries, at 28th, with Slovenia ranked 21st. Table 1 also shows the GINI coefficient scores for each country. Slovenia has the lowest inequality in family income distribution, with Sweden following close behind. The United Kingdom has the highest degree of inequality. Slovenia has a markedly lower gross national product per capita in purchasing power parity than the two other countries, and each country has a health expenditure per capita that corresponds to the national economy (Table 1). However, a child born in Slovenia has a better chance of reaching the age of 5 than a child born in the United Kingdom. Also, a girl born in Slovenia may expect to live to age 82,

Table 1 Family economic, health, and welfare outcomes Sweden HDI rankinga GINI coefficientb GNP per capita in PPPc Health expenditure per capita

c

Probability of dying under age 5

c

Slovenia

United Kingdom

10

21

28

0.26 (rank 7)

0.24 (rank 1)

0.34 (rank 28)

39,730

26,530

35,840

3,757 (9.6%)

2,552 (9.4%)

3,480 (9.6%)

3

3

5

79/83

76/82

78/82

Child at risk for poverty (couple/single families)d

9/20

12/26

21/38

Child at risk for poverty (ages 0–17, all families)e

14.5

15.2

29.7

Life expectancy (male/female) c

aUnited Nations Development Programme 2011. bOrganisation for Economic Co-operation and Development Factbook 2013. cWorld Health Organization country statistics retrieved 2013. dEuropean Union Statistics on Income and Living Conditions 2008: “Child Poverty and Well-Being

in the EU,” Table 1a, Appendix 2, p. 146. eEUROSTAT 2010.

Family Policy and Inequalities in Health / 239 as long as a girl born in the United Kingdom. Slovenian boys, on the other hand, face a somewhat shorter life span than boys from the two other countries. One of the best-known risk factors for poor health is poverty, and there are varying degrees of income differences in the three countries (Table 1). A commonly used measure of being at risk of poverty is having an income less than 60 percent of the median income in the country. The highest child at-risk-forpoverty rate can be found in the United Kingdom, for both two-parent and single-parent families (Table 1). The United Kingdom scores poorer than the EU-25 average. Slovenia and Sweden cluster together with the lowest risk for child poverty, both above the EU-25 average, despite the poorer national economy of Slovenia. So far we can see that Sweden has a high degree of human development, low degree of family income inequalities, low child at-risk-for-poverty rates, and low child mortality. The United Kingdom scores poorly on inequality and child poverty measures and on child mortality. For Slovenia, a pattern seems to emerge with a closer similarity to Sweden. Slovenia has the weakest economy, but low levels of inequality, low child at-risk-for-poverty scores, and low child mortality. From the numbers presented in Table 1, we cannot show any firm evidence on this, but the numbers definitely support the idea. Table 2 shows the results for perceptions of well-being and financial stress for couple and single parents in Sweden, Slovenia, and the United Kingdom, including the means difference between the groups within each country. The differences between couple and single parents are at the narrowest in Slovenia, with the two other countries having markedly larger differences between couple and single-parent groups for life satisfaction, happiness, subjective general health, and financial stress. It is also worth noting that single parents in Slovenia score higher than single parents in the United Kingdom for life satisfaction and happiness and report a lower degree of financial stress. When it comes to financial stress, single parents in Slovenia score lower than single parents in Sweden. The scores for subjective general health are lower among Slovenian parents; however, there are no differences between couple and single parents in this score, as there is for the other countries. Table 3 shows the results for attitudes toward family policies and services among child families in the three countries. For satisfaction with provision of affordable childcare services for working parents, there are significant differences between the three countries, with satisfaction at the highest in Sweden and the lowest in the United Kingdom. For views on governments’ responsibility for childcare services for working parents and paid leave to care for sick family members, scores in Sweden and Slovenia strongly support such government responsibility, with no significant difference in scores between these two countries. The United Kingdom has a significantly lower score than the two other countries, therefore to a lower degree agreeing that such services are government responsibility. Table 4 shows main source of income of couple and single child

8.15

4.18

1.52

Happiness (range 0–10)

Subjective general health (range 1–5)

Financial stress (range 1–4) 2.09

4.01

7.09

6.98

Single mean N = 319

0.57**

0.17**

1.06**

1.05**

Means diff

1.76

3.75

7.48

6.95

Couple mean N = 1,887

1.76

3.76

6.94

6.63

Single mean N = 233

Slovenia

0.12**

0.01

0.54**

0.32*

Means diff

1.84

4.16

7.57

7.25

Couple mean N = 2,700

2.40

3.94

6.63

6.16

Single mean N = 526

United Kingdom

0.55**

0.22**

0.94**

1.09**

Means diff

*Significant at the 0.05 level. **Significant at the 0.001 level. Note: Sample consists of couple and single parents of both genders, age 50 years or lower. All variables are coded so that increasing scores imply increasing presence of the measured concept. Source: European Social Survey cumulative 1–5 (2002–2010).

8.03

Life satisfaction (range 0–10)

Couple mean N = 2,213

Sweden

Well-being and financial stress perceptions

Table 2

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8.15

8.13

Childcare services for working parents should be government’s responsibility

Paid leave from work to care for sick family members should be government’s responsibility 8.16

8.31

5.11

Slovenia N = 447

7.35

7.15

4.46

United Kingdom N = 755

1–10

1–10

1–10

Range

Sweden-UK* Slovenia-UK*

Sweden-UK* Slovenia-UK*

Slovenia-Sweden* Sweden-UK* Slovenia-UK*

Significant differences between countries

*Significant at the 0.001 level. Note: Sample consists of couple and single parents of both genders, age 55 years or lower. All variables are coded so that increasing scores imply increasing presence of the measured concept. Source: European Social Survey Round 4 (2008).

6.40

Satisfaction with provision of affordable childcare services for working parents

Sweden N = 582

Attitudes to family policies and services

Table 3

Family Policy and Inequalities in Health / 241

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/ Fosse et al. Table 4 Main source of household income (in valid percentage of households) Sweden

Slovenia

United Kingdom

Couple

Single

Couple

Single

Couple

Single

Wages, salaries, or self-employment

63.6

61.5

65.2

68.0

71.7

70.6

Pensions

28.8

32.5

30.0

28.5

20.9

23.0

Unemployment/ redundancy benefit

3.2

2.2

1.6

0.6

3.3

2.9

Other social benefits or grants

2.6

1.6

1.1

1.7

1.7

2.3

Other sources

1.8

2.2

2.1

1.2

2.4

1.2

100.0

100.0

100.0

100.0

100.0

100.0

Total

Note: Sample consists of all parents in child families, age 50 years or lower. All variables are coded so that increasing scores imply increasing presence of the measured concept. Source: ESS cumulative 1–5 (2002–2010).

family households in the three countries. The United Kingdom stands out as having a higher share of parents supported by wages, salaries, or self-employment. A lower share of parents is supported by pensions than in the two other countries. A lower share of Slovenian parents is on unemployment/redundancy benefit. Summing up, the United Kingdom has high scores for subjective general health, but a steep income gradient in the population. Parents in the United Kingdom experience the highest level of at-risk-of-poverty, regardless of partnership status. There are also considerable gender differences in life satisfaction in child families in the United Kingdom. The Human Development Index in the United Kingdom is low, while the GINI coefficient shows large economic inequalities. The United Kingdom has the highest child mortality of the three countries. Sweden generally scores well on health outcomes and on level of children at-risk-of-poverty. The gradient in self-rated general health is the least steep in Sweden. There are no differences between mothers and fathers in child families when it comes to life satisfaction. The Swedish population welcomes the responsibility of the state to provide for childcare services. The analyses presented in this section have shown some interesting patterns for the different countries, but also inconsistencies. To some extent, the analyses

Family Policy and Inequalities in Health / 243 illustrate and reflect expected findings regarding the situation of families with children in Sweden versus the United Kingdom. However, the Slovenian example suggests that not only the level of economic wealth, but also its distribution in the population, has bearings on health and life satisfaction, not least on the health of children. In the next part of the article, we will present political documents from the three countries. Based on the findings from the quantitative study, we will ask if the differences between the countries that were found in the quantitative study may reflect differences in policies among the countries. DOCUMENT ANALYSIS1 England2 In the mid to late 1990s, the United Kingdom suffered higher child poverty than nearly all other industrialized nations. Over a period of 20 years, the proportion of children in relative low-income households had more than doubled. The government therefore set an ambitious long-term goal to halve child poverty by 2010 and eradicate it by 2020 (E1). As a first step, the government sought to reduce the number of children in low-income households by at least a quarter by 2004–2005. The government increased financial support for children through tax credits, child benefits, and other benefits by 72 percent. As a result, combined with the government’s success in helping parents into work, the previous trend toward increasing levels of child poverty was reversed. The Children Act 2004 (E2) provided the legislative foundation for a wholesystem reform to support this long-term and ambitious program. It outlined new statutory duties and clarified accountabilities for children’s services. A number of measures were outlined to improve the situation for deprived groups in many areas: health care, childcare, education, work life, and housing. It was underlined that legislation must be part of a wider process of change. In 2003, an action program was launched to tackle social inequalities in health (E3). The program aimed to reduce health inequalities between different geographical areas, genders, ethnic communities, and social and economic groups and to tackle the underlying causes of health inequalities. The wider determinants of health inequalities were in focus, such as poverty, poor educational outcomes, unemployment, and poor housing. Several documents described the status of policy efforts to reduce health inequalities and outlined future action (E4, E5). “Tackling Health Inequalities: 10 1

The documents are identified by country (England = E, Slovenia = SL, and Sweden = SW). They are numbered by using the country letter and a number. Full references are provided in the reference list. 2 Some policy documents include the whole of the United Kingdom.

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Years On” (E6) reviewed developments in health inequalities from November 1998 to November 2008. The three reports sum up the policies and actions that had been implemented in the United Kingdom since 1998. The reports outlined the general policies, where families and children hold a high priority. The rhetoric in the policy documents is influenced by the equity agenda and states very clearly that the aim is to reduce social inequalities in health both by addressing the gap between high and low income and education groups and by reducing the social gradient. However, the action plans based on the policy documents are mainly targeted at disadvantaged groups and areas. The Marmot Review’s “Fair Society, Healthy Lives” (E7) was commissioned by the Labor government, but it was not issued as a government report. A new government consisting of the conservative and the Liberal Democratic Party (the coalition) came into office in 2010. In November 2010, the government issued a white paper on public health, outlining its new strategy (E8). According to the report, the government is radically shifting power to local communities, in order to improve health throughout people’s lives, reduce inequalities, and focus on the needs of the local population. The role of central government will be to establish a framework so that local action can be most effective and to do nationally only the things that need to be done at that level. This includes working across multiple departments to address the wider determinants of health through the new Cabinet Sub-Committee on Public Health. Summary England. In general, health inequalities have been high on the English political agenda for more than a decade. The Labor governments in office from 1997 to 2010 issued a number of policies to reduce social inequalities in health. Children and families have been at the heart of the efforts. The policies developed by the Labor government to reduce social inequalities in health among families and children are clearly comprehensive and demand intersectoral collaboration. The policies aimed at committing both the national and local level and aimed at broad collaboration between actors, both within government agencies and between government agencies and the voluntary sector. The review of health inequalities in England, led by Sir Michael Marmot, embraced a determinant perspective and had a broad, intersectoral approach. The Marmot Review suggested structural measures to reduce social inequities in health. The review is, however, not a committing policy document, but rather a report advising how to move toward a more equal society. The rhetoric in the policy documents was influenced by the equity agenda; however, the action plans based on the policy documents are mainly targeted at disadvantaged groups and areas. The policies are only vaguely connected to other areas of welfare policies, and they did not address issues such as the school system or childcare, which is mainly private, or improving women’s situation through better opportunities for maternity leave.

Family Policy and Inequalities in Health / 245 This dilemma and lack of consistency may reflect the wickedness of the equality issue in the English context. The overall perspective would imply that structural and universal measures would be in place; however, the measures are mainly aimed at deprived groups and geographical areas. This might reflect that these types of measures are regarded as legitimate by the British political system. A new conservative/liberal government came into office in 2010, and it has announced severe cutbacks in public-sector spending. Based on the white paper issued in 2010, it seems that the coalition still supports the aims of the Labor government in reducing social inequalities. However, this aim is included in other aims and the white paper does not provide many concrete targets. A major change is the shift of responsibility for public health measures from the central to the local level. Slovenia. The main objective of the Slovenian Program for Children and Youth 2006–2016 (SL1) was to develop and implement a strategy for achieving the highest possible level of health for children and youth in Slovenia with an emphasis on reducing inequalities in health. In the area of family policies, there is recognition of the government’s responsibilities toward families, both regarding children and in terms of creating a labor market that would make it possible to combine work with family responsibilities. Education policies are also included and have an explicit focus on reducing health inequalities (e.g., by ensuring equal possibilities for education and to improve accessibility). In the area of social policy, the overall aim is to reduce poverty and the social exclusion of children and families by: • Carrying out the established goals of fighting poverty and social exclusion of children and youth in line with the national program of social inclusion. • Continue with measures aimed at reducing poverty in families with a larger risk factor (single-parent families, large families, families with children with special needs, children and youth with growing-up difficulties, the unemployed young, etc.). The Parental Protection and Family Benefits Act 2007 (SL2) outlines the social rights and social benefits to which families with children are entitled. Among these are the right to maternity and paternity leave with economic compensation. Parents are also entitled to part-time work until the child is 3 years old, compensated by the government. There is a child benefit for low-income families, aimed at improving the quality of life of children and mitigating financial distress in low-income families. In the national report on “Strategies for Social Protection and Social Inclusion 2008–2010” (SL3), a number of measures were introduced to increase social inclusion and reduce social inequalities in health. From September 2008,

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kindergarten became free of charge for the second and any subsequent child from the same family who is simultaneously attending kindergarten. The majority of the Slovenian population is guaranteed access to social welfare services in the Republic of Slovenia. Yet in practice, accessibility is still limited by an inadequate network of services and programs (insufficient capacities and uneven regional distribution), difficulties in financing, and frequently the poor provision of information or even stigmatization of potential system users. All people with a permanent residence are entitled to services; others only have access to the most urgent ones (SL3). A report on health inequalities in Slovenia was published in 2011 (SL4). This publication is part of the activities agreed upon within the Biennial Collaborative Agreement 2010–2011 between the World Health Organization and the Republic of Slovenia. The aim of the report was to provide insight into health inequalities in Slovenia, on the basis of currently available data. The primary purpose is to encourage discussion that will allow the creation of a vision, a development strategy, a framework for decreasing inequalities, and one or more action plans to deal with health inequalities in Slovenia. According to the report, Slovenia implements a number of universal policies (e.g., in the fields of social security, education, health, taxation policy, and so on) that represent a key foundation for preventing and reducing health inequalities. Various policies and approaches are available that have already proven effective in reducing social inequalities in health. The report was supported by the Minister of Health and the Minister of Labor, Family, and Social Affairs. However, it is not yet clear how the report will be used in developing policies. Summary Slovenia. Slovenia has developed a comprehensive welfare state where the government accepts responsibility for families and children in a number of areas, including work life and childcare. Generally, the policies have several aims: • Developing a comprehensive welfare society with universal arrangements for all citizens. • In areas of family life, this includes support for kindergarten and the right to parental leave in connection with childbirths and children’s illness. • Support to disadvantaged children and families (i.e., child benefits, subsidized school meals, and economic support). As shown above, policies in a number of areas are provided to improve quality of life and reduce social inequalities in health. The policies cover many areas of society, such as health, social services, schools, and work life. Even though the term social gradient is not used, several structural measures are in place, among them a progressive tax system, where persons with low income pay less income tax.

Family Policy and Inequalities in Health / 247 There seems to be a recognition in Slovenia that health inequalities is a wicked issue and that it may be difficult to reach all national objectives. One example mentioned is social services. Even though the majority of the population is guaranteed access to welfare services, there are limitations. Services are not adequately built out, and there is still limited service provision so that all who are entitled to services do not receive them. In recent policy documents, improved welfare services are suggested, with an explicit aim to reduce social inequalities. Sweden The present and the former conservative/liberal Swedish government has living conditions for families, children, and young people as one of its highest priorities, and the policy takes its point of departure in the United Nations Declaration on the Rights of the Child. The government also points to the fact that Sweden is one of the best countries in the world for children to grow up in. The main government strategy over the last several years is the national strategy to develop parental support. This is a universal strategy aimed at all families, targeted at children between 0 and 17 years (SW1). The objectives of the strategy are threefold: increase collaboration between actors and institutions that have activities aimed at persons; increase the number of health-promoting arenas where parents can meet; and increase the number of educated actors to support parents. The Swedish government has also recently launched a new strategy for youth policy (SW2). The target group for the youth policy is all young people between 13 and 25 years. A national youth policy has existed in Sweden for a long period of time and has developed from a focus on leisure time and cultural activities to a comprehensive perspective on the living conditions for young people. The overall target for the current youth policy is that all young people should have access to welfare and influence in society. It is acknowledged that young people have different living conditions. However, there are no specific policies aimed at reducing socioeconomic differences, and no mention of using the monitoring system to map the situation in order to reduce social inequalities. In 2008 the conservative/liberal government issued a report called “Renewed Public Health Policy” (SW3). This was a revision of the report “Health on Equal Terms” (SW4) and has a stronger emphasis on personal responsibility for health. Lifestyle issues and health education are the preferred strategies. The “Public Health Policy Report 2010” has been prepared by the Swedish National Institute of Public Health on behalf of the Swedish government (SW5). The objective of the report is to show how the conditions for health in Sweden have developed (focusing on the period 2004–2009), present measures undertaken, and recommend future measures. The report addresses the 11 areas that constitute the Swedish public health objectives. For several of the areas, social inequalities are addressed. For the population to achieve good health on equal terms, the report deems the following measures to be particularly important:

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• Give children and young people a good start in life and monitor development carefully. • Create good social and economic conditions for all through access to employment and social security systems. This includes increasing transfers to single parents with children and strengthening efforts for people who are excluded from the labor market in order to provide more employment opportunities. • Strengthen participation and influence, above all for young people and the elderly. • Develop and provide health-promoting health care on equal terms. Summary Sweden. Swedish policies have a long history of emphasizing equity. The present government has a strong focus on children and adolescents, but there is no explicit focus on reducing social inequalities in health in recent policy documents. In Sweden there seems to be a shift in priorities from the social democratic to the liberal-conservative government. The main aim of the policy is to support families, especially parents in their role as caregivers. On one hand, the policy aims to strengthen the parent’s role, but on the other hand, structural measures are introduced, such as counseling for all parents. The policy that supports parents for not having their children in public day care has raised debate, and the conflict dimensions run through the right-left political axis. The political left views this as undermining public childcare arrangements and even the social democratic welfare state, since the money may be spent on private childcare arrangements. The current policy documents reflect comprehensive intersectoral collaboration among relevant institutions in policies aimed at children and families. Also, the public health policy argues for contribution from many sectors of society. However, at the moment Sweden does not have an explicit policy aiming at reducing social inequalities in health. DISCUSSION All three countries have comprehensive, intersectoral policies in place for children and families, and these policies are also high on the political agenda in all the countries. The policies are both general policies regarding education and general welfare policies for families and children. All countries also have public health policies in place, and children are a main target group in all the countries. However, the policies have a different focus in the three countries; subsequently, the similarities and differences will be discussed along the same dimensions as each country was analyzed, but in a slightly different order. England had and Slovenia has an overall objective to reduce social inequalities in health. Their strategies are, however, somewhat different. While England had a policy mainly aimed at supporting vulnerable groups and geographic areas, Slovenia combines targeted measures with universal support to families and

Family Policy and Inequalities in Health / 249 children, such as subsidized day care and preschool for all. Slovenia has thus introduced policies that will contribute to reducing the social gradient. In current Swedish policies, there is no explicit aim to reduce social inequalities in health. However, the policy documents take their point of departure in the Swedish welfare model, where redistribution and social equity are explicit aims. Swedish policy in this area is likely to continue to build on the model of universal policies, combined with measures targeted at disadvantaged groups. Health inequalities are a so-called wicked political issue. There are no clear-cut “correct” solutions to the problem and it is a highly politicized issue. Based on their traditions, left-wing parties will support policies to reduce social inequalities, while conservative governments seldom have this issue high on their political agenda. In England, the wickedness of the problem has been quite visible. After the conservative regime of Margaret Thatcher, social inequalities have increased dramatically in the United Kingdom and, particularly, hit poor families with children hard. The first Labor government saw the improvement of living conditions for these groups as one of its most important tasks when it came into office in 1997. This is the background for the strong efforts to reduce health inequalities in the United Kingdom. There are still no clear indications on how the current conservative/liberal democratic government will sustain this policy; however, the cutbacks of social services will hit disadvantaged families particularly hard. Sweden has a conservative/liberal government, and even if the policies of the government build on the Swedish welfare model, the focus on the social determinants of health applied by the former social democratic government has been adjusted and policies are more clearly aimed at personal responsibility and changing individual lifestyles. The issue of social inequalities is not mentioned in the policy documents. In many Eastern European countries, the security nets have been replaced by market-oriented health care solutions based on individual insurance schemes. At the same time, social services and job security have been reduced. Slovenia, however, seems to have moved in a different direction in building up and developing a comprehensive welfare state. Slovenia comes out as an interesting case among the three countries. In terms of gross domestic product, Slovenia is the poorest country of the three included in this study. Still, there are smaller social differences in health in Slovenia than in England (United Kingdom). Furthermore, the child mortality rate is lower than in England (United Kingdom). There are also smaller social differences concerning life satisfaction and lower at-risk-of-poverty rates. Both Slovenia and Sweden have generous family policies in place. A vital point seems to be the fact that family policies are a fundament of these countries. Generous parental leave and affordable childcare of good quality represents a support to dual-earner families in general, but also provides single parents with a safety net that prevents them from falling into poverty. Another important

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feature that has not been addressed in the current study is the way in which other labor market and social policies promote dual-earner households and facilitate the reconciliation of work and family, which in turn may have implications for both gender and social equality (13, 21). This is likely one contributing factor to the comparatively low levels of poverty and greater gender equality characterizing the Nordic welfare states (22, 23). CONCLUSIONS The steepness of the income gradient in health and life satisfaction varies between the three countries, and there are differences between the countries regarding living conditions and quality of life in families with children. Slovenia and Sweden show the least steep gradient, while England (United Kingdom) shows the steepest. Slovenia has relatively small differences in health and well-being between social groups and as such seems to be included in a social democratic welfare state type. This pattern suggests that social differences in a country are reflected in the health and well-being of its citizens. Having universal policies in place seems to matter more than the general wealth of the country, as demonstrated in the case of Slovenia. The study confirms findings that universal policies are successful in reducing the social gradient. Family policies that support households with children to combine work and family and that provide income security where needed are important for reducing the risk of poverty and improving the standard of living of families and, ultimately, the health and social well-being of their children. Acknowledgments ¾ The research leading to these results was done within the framework of the GRADIENT project (www.health-gradient.eu) coordinated by EuroHealthNet and has received funding from the European Community (FP7 2007-2013) under grant agreement No. 223252. The present article is based on research undertaken by Work Package Five (WP5) of the GRADIENT project. The authors want to acknowledge the contribution of the partners of WP5: John Kenneth Davies, Tatjana Krajnc-Nikolic, Nigel Sherriff, and Janine Vervoordeldonk. We also want to thank the coordinators at EuroHealthNet for their valuable support and contributions: Giorgio Barbareschi, Caroline Costongs, Aagje Ieven, and Ingrid Stegeman. APPENDIX English Policy Documents • E1 Child Poverty Review 2004 (HM Treasury) • E2 Every Child Matters: Change for Children (HM Government, 2004) • E3 Tackling Health Inequalities: A Programme for Action (Department of Health, 2003)

Family Policy and Inequalities in Health / 251 • E4 Tackling Health Inequalities: 2007 Status Report on the Programme for Action (Department of Health) • E5 Health Inequalities: Progress and Next Steps (Department of Health, June 2008) • E6 Tackling Health Inequalities: 10 Years On – A Review of Developments in Tackling Health Inequalities in England over the Last 10 Years (Department of Health, May 2009) • E7 Fair Society, Healthy Lives. The Marmot Review, 2009. Strategic Review of Health Inequalities in England Post-2010. • E8 Healthy Lives, Healthy People: Our Strategy for Public Health in England (presented to Parliament by the Secretary of State for Health, November 30, 2010) Slovenian Documents • SL1 Programme for Children and Youth 2006–2016 (Ministry of Labor, Family, and Social Affairs, 2006) • SL2 Parental Protection and Family Benefits Act 2007 (official consolidated text) (ZSDP-UPB2) • SL3 National Report on Strategies for Social Protection and Social Inclusion 2008–2010 • SL4 Health Inequalities in Slovenia (January 2011) (authors in alphabetical order by surname: Tatjana Buzeti, Janet Klara Djomba, Mojca Gabrijel…i… Blenkuš, Marijan Ivanuša, Helena Jeri…ek Klanš…ek, Nevenka Kelšin, Tatjana Kofol Bric, Helena Koprivnikar, Aleš Korošec, Katja Kovše, Joica Mau…ec Zakotnik, Barbara Mihevc Ponikvar, Petra Nadrag, Sonja Paulin, Janja Pe…ar, Silva Pe…ar „ad, Mateja Rok Simon, Sonja Tomši…, Polonca Truden Dobrin, Vesna Zadnik, Eva Zver) Swedish Documents • SW1 National Strategy for a Developed Parental Support (Government, 2009) (Nationell strategi för et utvecklad föreldra stöd, Regeringskanselliet, 2009) • SW2 Government Paper 2009/10:53 – A strategy for youth policy (Regeringens skrivelse 2009/10:53 – En strategi för ungdomspolitiken) • SW3 Government Report 2007/08:110 – A renewed public health policy (Regeringens proposition 2007/08:110 – En förnyad folkhälsopolitik) • SW4 Health on Equal Terms. Government White Paper 2002/03:35 (Mål för folkhälsan, Stockholm, Regeringens Proposition 2002/03:35) • SW5 Swedish Public Institute: Health Policy Report 2010: Public Health of the Future – Everyone’s Responsibility (R2010:16)

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Direct reprint requests to: Elisabeth Fosse Department of Health Promotion and Development University of Bergen Christiesgt. 13 5015 Bergen Norway [email protected]