Health, disadvantage, and the welfare state

Doctoral Thesis

In the Netherlands, people with the lowest incomes live on average 8 years shorter and spend as much as 21 more years in poor health than the richest. Strikingly, such disparities are greatest in countries with strong welfare states. This dissertation explores how the organization of the Dutch welfare state affects the health of people in disadvantaged positions.
At the individual level, interviews reveal that health and socioeconomic problems are deeply intertwined. A sudden illness can lead to job loss and debt, while poverty and stress further damage health.
At the organizational level, interviews with middle managers show a persistent gap between policy and practice. Responsibility for bridging that gap is often placed on individuals—professionals or citizens—while structural reforms remain overlooked.
At the policy level, the analysis of “Health in All Policies” demonstrates that political salience of health inequalities is essential; knowledge alone does not drive...Show moreIn the Netherlands, people with the lowest incomes live on average 8 years shorter and spend as much as 21 more years in poor health than the richest. Strikingly, such disparities are greatest in countries with strong welfare states. This dissertation explores how the organization of the Dutch welfare state affects the health of people in disadvantaged positions.
At the individual level, interviews reveal that health and socioeconomic problems are deeply intertwined. A sudden illness can lead to job loss and debt, while poverty and stress further damage health.
At the organizational level, interviews with middle managers show a persistent gap between policy and practice. Responsibility for bridging that gap is often placed on individuals—professionals or citizens—while structural reforms remain overlooked.
At the policy level, the analysis of “Health in All Policies” demonstrates that political salience of health inequalities is essential; knowledge alone does not drive policy change.
The key message of this research is that health is not only a matter of healthcare, but of all policy domains. Accessible services are vital to reducing inequality, and health can serve as a powerful argument for investing in social policy.
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Health inequality

Fundamental cause theory

Social determinants of health

Health in All Policies

The Netherlands