Our health system requires rethinking

The authors of The Spirit Level believe Sweden has the best health outcomes in Europe. They are right, but for the wrong reason. By Joseph Mahon.

Sweden has consistently had the best health outcomes in Europe since the European Health Consumer Index was established in 2005. As Dr Arne Bjornberg, lead author of the report, put it in an interview with Clare MacCarthy, "Sweden has been the European champion in treatment quality since this index was launched."

Having the best health outcomes means that people live longer, have lower levels of obesity, and a better chance of beating a life-threatening disease. For instance, life expectancy in Sweden is 80, as against 77 in Ireland. In Sweden 10% of adults are obese, as against 20% in Ireland. In Ireland there are 6 infant deaths per 1,000 live births, but only 3 in Sweden.

Why does Sweden have the best health outcomes in Europe? Specifically, why does it have much better health outcomes than Ireland? The Wilkinson-Pickett conjecture outlined in The Spirit Level is that a country such as Sweden does better because it has a lower level of income inequality.

As they put it themselves, "there is a very strong tendency for ill-health and social problems to occur less frequently in the more equal countries... Health and social problems are indeed more common in countries with bigger income inequalities. The two are extraordinarily closely related - chance alone would almost never produce a scatter in which countries lined up like this."

Is the Wilkinson-Pickett conjecture correct?

Well, it should be noted first of all that Sweden does have a lower level of income inequality than Ireland. On the 20% measure [the degree to which the richest 20% are better off than the poorest 20%], the top 20% in Sweden, Norway and Finland are four times better off than the lowest 20%. In Ireland, the top 20% are six times better off.

The Wilkinson-Pickett conjecture identifies a visible pattern, a pattern that is repeated so often, they contend, that it has predictive force; in other words, it authorises us to say things of the kind: If A lives in a low income inequality country, A will live longer than someone who doesn't live in such a country [all other things being equal]. This is equivalent to saying that the social factor identified [low income inequality] is responsible for better health outcomes.

So, the principle underlying the Wilkinson-Pickett conjecture is: Where you have a visible pattern, you have a cause. If you get outcome A in every country with characteristic X, you get outcome A because of characteristic X.

Is this true?

It appears to be true, at least in a broad way. Of the twelve countries with the lowest income inequality, nine feature among the twelve countries whose citizens have the longest life expectancy. But Denmark has the fifth lowest level of income inequality, yet life expectancy in Denmark is only 76.65, where it is 77 in Ireland and the USA, countries with much higher levels of income inequality. Moreover, life expectancy is better in Sweden than in Finland and Norway, yet both of these countries have slightly lower levels of income inequality than Sweden. So, income inequality may not be the only causal factor at play here.

These counter-examples show up the limitations of the Wilkinson-Pickett conjecture: it can tell us why Sweden does better than the USA, but it cannot tell us why the USA does better than Denmark. Neither can it explain why Sweden does better than Finland and Norway, both of which are marginally more equal societies.

So, why does Sweden do better, better not only than high income inequality countries such as Ireland and the USA, but better also than lower income inequality countries such as Norway and Finland?

In an article for the Irish Times Health supplement Health Plus, Clare MacCarthy identified several reasons for the successes of the Swedish health care system, while a Prime Time programme featuring Tommy Gorman's treatment in Sweden for a rare form of adult leukaemia supplied additional data. The various factors outlined there are as follows:

[i] A widespread and well-functioning mammography programme.

[ii] State-of-the-art hospital treatment.

[iii] A strong focus on Swedish-based research: "with Swedish research, new knowledge gets out to the healthcare system much faster" [MacCarthy].

[iv] "All residents have equal access to healthcare services" [MacCarthy]

[v] Emergency hospital referral in cases of suspected serious illness.

[vi] Encouragement of "as many patients as possible into healthcare centres as a first point of contact with the system" [MacCarthy].

[vii] "An increased focus on preventative healthcare - as opposed to emergency plumbing in a crisis - has also helped to move resources to the primary care system" [MacCarthy].

[viii] The option of going to privately-run clinics "which are so heavily subsidised that fees are merely nominal" [MacCarthy].

[ix] Healthcare staff work as a team [Prime Time].

[x] Near parity of salary between different members of healthcare team, from consultant to theatre nurse.

Are some of these factors more influential than others? Well, equality of treatment is immensely important: it is no use having state-of-the-art hospitals if a large segment of the population doesn't have quick access to them. Equality of treatment does not depend on ability to pay, since the State pays for everything. Residents pay indirectly by way of taxation. It depends on a political determination to exclude no one from the best medical treatment.

At the same time, equality of treatment would be of little consolation if the treatment on offer was sub-standard. It needs, as is the case in Sweden, to be driven by a quest for excellence.

In conclusion, Sweden does best, not so much because it is a low income inequality society [the Wilkinson-Pickett conjecture], but because it is a society in which the egalitarian ideal is pervasive, and is motivated by a quest for excellence: low income inequality among medical personnel who are thereby incentivised to work in teams, equality of status, and equal access to a very high, research-driven standard of health care.