Why our welfare state doesn’t always reach vulnerable people
Health image: Pexels
In general, there are significant health disparities between people with low and high incomes, particularly in countries with an extensive welfare state like the Netherlands. PhD candidate Janna Goijaerts researched how the organisation of the welfare state affects the health of vulnerable people.
Dutch people with the lowest incomes live, on average, 8 years less and 21 years longer in poor health than the richest. The Netherlands is no exception here: such health disparities are greatest in countries with strong welfare states. What causes this ‘paradox of health inequity’? To answer this, Goijaerts interviewed managers of public organisations and people with both health and socioeconomic problems.
‘In theory, a lot of help is available in the Netherlands,’ says Goijaerts. ‘But this doesn’t always reach the groups with the most complex co-occurring problems.’ She found several causes for this. ‘Sometimes it’s about people’s mistrust of institutions. But often entitlements are not organised in such a way that they end up with the right target group.’
Luck of the draw
People with multiple complex problems can benefit from a support worker who acts as a linchpin between different support agencies. ‘They can stand up for them, which is good, but it would be better to organise entitlements in such a way that they reach the right people. Because what if you don’t meet that support worker?’
Whether you get the right help depends too much on luck of the draw, says Goijaerts. ‘You see big differences in how people are helped, even within the same organisation. People might not click, or a support worker may happen to have a lot on their mind that day. Support should be designed in such a way that it doesn’t depend on that.’
Head above water
In the interviews, Goijaerts saw that health and socioeconomic problems are often interlinked. ‘Sometimes someone is in debt, which causes stress, and after a while, this causes health problems. But the opposite is also true: someone breaks their knee, loses their job and ends up in debt.’
Problems often escalate, she says. ‘Things haven’t been going well for some time, but people just about manage to keep their heads above water. That’s literally how they describe it. They have long-standing health problems, and if they divorce or lose someone who’s important to them, the whole house of cards topples.’ People experience multiple co-occurring problems and are unable to find their way through the labyrinthine welfare state.
Gap between policy and practice
For her research, Goijaerts also spoke with middle managers at different organisations. They see a gap between policy ambitions and their everyday service provision. ‘Policy is based on the idea that help should be preventive and organised in an integrated way, but that isn’t always achieved in practice.’ Her research shows that the systems are so complex that support workers are often unable to achieve these goals.
For support to have a preventive effect, people should come to the attention of organisations much sooner. Support workers can often solve problems easily in an early stage. ‘Managers said that in practice, help only becomes an option once people have severe and multiple problems. Then it’s really too late.’
How can things be improved?
Access to support should be better organised, says Goijaerts. ‘Now there are rules that exclude people from help. People have to work on their debt before they receive certain support, for example. Or they don’t receive debt relief because they first have to be treated for an addiction. Removing these rules would mean problems are tackled sooner.’
Research also shows that it helps to make policy universal and not to impose requirements on people’s income. ‘The more universal access to assistance is, the fewer taboos and stigmas there are surrounding it. Then people are more likely to make use of it.’
Concrete steps
Politicians should also focus on concrete steps with measurable health effects instead of on abstract policy strategies. This would prevent policy from being bogged down or remaining at an abstract level without being put into practice. ‘For example, you could set a goal of making all social housing mould free within five years. That would have a clear health benefit. You can’t solve everything at once, but at least you’ve done something concrete.