“Before 1980, socioeconomic inequalities in health were a non-issue in public health (research) in the Netherlands. This changed in the early 1980’s as a result of the publication of the Black Report in England [1], and a report on inequalities in health between neighborhoods in the city of Amsterdam [2]. Gradually, interest in health inequalities rose, first among researchers and then among policy-makers. Interest among policy-makers was further strengthened by the “Health For All by the year 2000” targets of the World Health Organization that the Dutch government officially endorsed in 1985 [3]. In 1986, the Ministry of Health published its Health 2000 report which was the first government document to include a paragraph on socioeconomic inequalities in health [4]. This was followed in 1987 by a conference organized by the prestigious Scientific Council for Government Policy, the outcome of which was a recommendation to start a research program on health inequalities [5] (see Table 1).

“Since then, the Dutch Ministry of Health has followed a systematic, research-based approach to tackling socioeconomic inequalities in health. An initial five-year research program mapped the nature and determinants of socioeconomic inequalities in health in the Netherlands [6]. A second six-year program launched in 1994 sought to gain systematic experience with interventions and policies designed to reduce socioeconomic inequalities in health.”

Source: Mackenbach, J.P., Stronks, K. The development of a strategy for tackling health inequalities in the Netherlands. Int J Equity Health 3, 11 (2004). https://doi.org/10.1186/1475-9276-3-11.

“For the three health outcomes, we find highly significant, positive relationships between financial security and health, a finding widely supported by literature. We also find that being Spanish relative to being Dutch worsens health outcomes. There is ample evidence of countries with different welfare systems having different health outcomes. For instance, Eikemo et al. [14] found that Southern European countries (including Spain) had among the worst health inequalities in Europe, second to Eastern Europe. Southern European countries also had the highest prevalence of poor/fair self-rated health [14]. In contrast, the ‘Bismarkian’ countries, including the Netherlands, had the lowest health inequalities, although average prevalence rates of poor/fair self-rated health.

“However, contrary to our expectation, being Spanish weakens the relationship between financial security and physical health and, to a lesser extent, social health. We find no moderating effect of nationality for the relationship between financial security and mental health. Again, because of the weaker social security system in Spain relative to the Netherlands, as well as the greater income inequality in Spain relative to the Netherlands, we initially expected that financial security would play a larger role in determining health outcomes in Spain than in the Netherlands. We find several possible explanations for our somewhat surprising findings.

“First, we explore the possibility that we have found a true effect. Unemployment and underemployment are much more democratic in Spain than in the Netherlands. In 2014, the overall unemployment rate in Spain was 24.6%. For young people, the unemployment rate was 57.6%. In addition to these already-high unemployment figures, Spain in 2014 had an extremely precarious labor market, with a high number of temporary job contracts and depressed wages [44]. A lack of financial security is clearly more widespread in Spain than in the Netherlands. Given that many more people are financially precarious in Spain than in the Netherlands, it may be that nationality itself, rather than financial security, explains the differences in health outcomes.

“Second, the ESS7 was undertaken only a few years after the Great Recession’s apex in 2011. Therefore, this survey may have not registered the effects of more pronounced financial insecurity on health. It may be that financial security has or will become a more important predictor of Spanish research persons’ health outcomes in the future, but this had not yet become evident. We see some evidence for this explanation with mental health, which stands out as the only health outcome that does not have a weaker effect in Spain than in the Netherlands. Mental health has been found to be one of the first aspects of health to change in response to unemployment, as opposed to measures of physical health such as mortality [45]. It may be that, as time passes, the relationships between financial security and health outcomes become stronger.

“It is also worth emphasizing that the health outcomes we study likely have important similarities regarding their aetiologies. For instance, social health has been shown to be a protective factor against ill health. In a literature review, Kawachi & Berkman [46] demonstrated that social ties often helped to maintain psychological well-being (although there are some exceptions to this, especially among lower SES women, for whom social networks may be stressors). Social networks have also been identified as important agents in physical health behavior change [47]. This is perhaps why social health is less well-explained (based on the models’ adjusted R2s) by financial security than mental health and physical health. Further, mental health and physical health may also be related. There is some evidence that mental health is on the causal pathway between lifestyle and behavior on the one hand, and physical health on the other [48]. Instead, it may be that these three types of health interact with and impact one another. Indeed, this interrelatedness is in line with Huber et al.’s definition of health as a dynamic process [23].”

Source: Thompson, K., Wagemakers, A. & van Ophem, J. Assessing health outcomes in the aftermath of the great recession: a comparison of Spain and the Netherlands. Int J Equity Health 19, 84 (2020). https://doi.org/10.1186/s12939-020-01203-6.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and several other nations.

Page last updated May 19, 2021 by Doug McVay, Editor.