## A Life Well Lived

## Source details

**Canonical URL:** [A Life Well Lived](https://www.imf.org/en/publications/fandd/issues/2021/12/countries-lessons-life-well-lived-bala-behsudi-jaquiery)

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## Bibliographic details
- Authors: ANALISA R BALA, ADAM BEHSUDI, ANNA JAQUIERY
- Published: December 2, 2021

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### Overview: three country case studies
- Focus: Denmark, Costa Rica, and New Zealand as examples of policies and institutions that promote health and happiness.
- Key message: delivering services at the community level, cultivating social trust, and accounting for well-being at the highest policy level play important roles.

### Denmark — social trust, collective action, and welfare institutions
- Core features:
  - High social trust among citizens and in government institutions.
  - Robust social welfare system: generous unemployment benefits, free health care and higher education, heavily subsidized childcare.
  - Low perceived corruption and a tradition of consensus politics (no single party has held a majority since the early 1900s).
- Pandemic outcomes and behaviors:
  - More than 75 percent of eligible citizens as of late October were fully vaccinated.
  - At the height of the pandemic, more than 60 percent of the adult population was being tested each week.
  - Survey finding: over 90 percent of Danes trust national health authorities.
- Local well-being example:
  - Dragør (2014): municipal survey with the Happiness Research Institute led to investments in an indoor swimming center, sports facilities, senior programming, and improved public space to support work-life balance.
- Challenges:
  - Difficulties integrating immigrants and refugees into the labor market.
  - Debates over perceived strain on the social welfare system have eroded trust in some corners.
- Analytical perspectives:
  - Christian Bjørnskov: happiness in Denmark arises from a combination of trust, tolerance, strong institutions, economic development, and resilient democracy—not solely extensive welfare.
  - Michael Bang Petersen: tight relationship between functioning political institutions and social trust; citizens come to trust fellow citizens when institutions "have your back."

### Costa Rica — primary health care, social pacts, and "pura vida"
- Core features:
  - Cultural framing: "pura vida" denotes health, work, and time with friends and family.
  - Strong welfare provisions: free education, guaranteed state pension, universal access to electricity and drinking water (100 percent), and universal health coverage.
- Health system design and outcomes:
  - Investment profile: in the 1970s, Costa Rica spent more on health as a proportion of GDP than some advanced economies.
  - Child mortality: dropped from about 74 deaths per 1,000 in 1970 to 17 by 1989.
  - Life expectancy: rose from 75 in 1990 to 80 (well above the US).
  - Health spending: the country spent 7.3 percent of GDP on health care versus 10 percent world average in 2017.
- Primary care model (EBAIS):
  - Every person is assigned to an equipo básico de atención integral en salud (EBAIS) — local primary health care teams including physicians, nurses, and community health workers.
  - Annual household visits by health workers; data combined with electronic health records to set targets and focus resources on higher-risk areas.
  - Implementation: EBAIS initially targeted underserved rural areas before expanding to urban centers, building robust data on social determinants of health.
- Governance and continuity:
  - Long-term "social pact": successive governments build incrementally ("the one that follows must put in one more brick") supporting long-term investments in welfare and health.
  - Historical policies: free and compulsory primary education since 1869.
- Additional factors:
  - Environmental policy and green energy shift driven by self-interest in preserving hydropower resources; link between greener environment and jobs.

### New Zealand — institutionalizing well-being in budgetary policy
- Policy innovation:
  - Wellbeing Budget 2019 prioritized five areas: mental health, child well-being, supporting aspirations of the Māori and Pasifika populations, building a productive nation, and transforming the economy.
  - Investment: $NZ 1.9 billion in mental health included in Budget 2019.
- Context and challenges:
  - Population: 5 million people.
  - Child poverty: in 2020 up to 210,500 children lived in poverty (18.4 percent), according to New Zealand’s statistics agency.
  - Significant social problems: among the worst for family and sexual violence in OECD measures.
- Institutional and process shifts:
  - Emphasis on holistic measures of well-being beyond income; recognition that health and the economy are linked.
  - Calls for better measurement and decision-making infrastructure to translate well-being concepts into outcomes.
  - Movement toward devolving resources and co-designing solutions with communities, Māori and other providers.
- Measurement and implementation gaps:
  - Analysts note statistical capacity exists but is underutilized: need measures that follow individuals over lifetimes and link community wisdom to data.
  - Treasury perspectives: continuing to build understanding of well-being; process matters—empowering communities and giving them resources is critical.
- Pandemic effects:
  - COVID-19 "upped the ante" on joined-up responses for children and young people; government consistency on goals across subsequent budgets despite pandemic challenges.
- Mental health strategy:
  - Introduction of early support services at GP practices and community centers; a recently unveiled 10-year mental health strategy acknowledged the need to give people tools to care for their own well-being.

### Cross-cutting findings and policy implications
- Findings:
  - Social trust is a key enabler for public-good provision and collective responses (Denmark).
  - Community-based primary care models can deliver strong health outcomes at relatively low cost (Costa Rica: EBAIS; life expectancy and child mortality improvements).
  - Institutionalizing well-being in budgeting and policy frameworks can reorient priorities toward health, child welfare, and mental health (New Zealand: Wellbeing Budget 2019).
  - Long-term, incremental policy continuity and cross-party commitment support durable welfare outcomes (Costa Rica "social pact").
- Policy recommendations and processes emphasized:
  - Invest in community-level service delivery and data systems that link household-level visits to electronic health records (Costa Rica model).
  - Foster and maintain social trust through transparent, efficient institutions and low corruption to sustain redistributive welfare policies (Denmark lessons).
  - Institutionalize well-being metrics in budgeting and decision-making, while devolving resources and decision rights to communities and indigenous providers to co-design solutions (New Zealand experience).
  - Prioritize measurement infrastructure that can follow individuals over their lifetimes and provide evidence for targeting resources and evaluating outcomes.
  - Recognize multi-dimensionality of well-being: health, education, social connections, environment, and safety must be considered holistically.

*Reported by ANALISA R. BALA, ADAM BEHSUDI, and ANNA JAQUIERY.*

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_Source: https://www.imf.org/en/publications/fandd/issues/2021/12/countries-lessons-life-well-lived-bala-behsudi-jaquiery_