SOCIOECONOMIC INEQUALITIES IN HEALTH IN EUROPE. Johan Mackenbach Department of Public Health Erasmus MC

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1 SOCIOECONOMIC INEQUALITIES IN HEALTH IN EUROPE Johan Mackenbach Department of Public Health Erasmus MC

2 ECONOMIC PROSPERITY average income per inhabitant, 2002 World Bank 2004

3 LIFE EXPECTANCY at birth, in years, men 2003 WHO 2005

4 GDP AND LIFE EXPECTANCY rich countries only GDP still predicts life expectancy, even among richer countries Glei et al 2009

5 HEALTH EXPECTANCY inequalities by level of education, Netherlands, 1999 RIVM 2002

6 HEALTH INEQUALITIES IN EUROPE by level of education or income, ca Inequalities in self-reported health or mortality documented Mackenbach 2005

7 The paradox of public health: despite prosperity, more equal income distribution, welfare state, equal access to health care, persisting, even widening health inequalities

8 TWO RESEARCH STRATEGIES Zooming in: individuals, and how they differ in socioeconomic position, specific risk factors, and health outcomes Zooming out: societies, and how they differ in social structure, risk factor distribution, and health inequalities

9 OUTLINE Cross-country comparisons of health inequalities within Europe (and with the US) The welfare state and health inequalities: explanations of a paradox National policies to tackle health inequalities in Europe

10 EUROTHINE TACKLING HEALTH INEQUALITIES IN EUROPE Data on inequalities in mortality or self-reported available Supported by a grant from the European Commission

11 RELATIVE INEQUALITIES BY EDUCATION TOTAL MORTALITY, 1990s, MEN Relative inequalities in total mortality by level of education among men in 18 populations 5 Relative index of inequality FIN SWENORDENENG BEL SWZFRA ITA BARMADBSQ SLO HUN CZR POL LIT EST EUR Mackenbach et al 2008

12 3000 ABSOLUTE INEQUALITIES BY EDUCATION TOTAL AND CVD MORTALITY, 1990s, MEN Total CVD FIN SWE NOR DEN ENG BEL SWZ FRA ITA BAR MAD BSQ SLO HUN CZR POL LIT Mackenbach et al 2008 EST

13 ABSOLUTE INEQUALITIES BY EDUCATION TOTAL AND CVD MORTALITY, 1990s, WOMEN FIN SWE NOR DEN ENG BEL SWZ FRA ITA BAR MAD BSQ SLO HUN CZR POL LIT EST Total CVD Mackenbach et al 2008

14 ABSOLUTE INEQUALITIES BY EDUCATION TOTAL AND INJURY MORTALITY, 1990s, MEN FIN SWE NOR DEN ENG BEL SWZ FRA ITA BAR MAD BSQ SLO HUN CZR POL LIT EST Total Injuries Mackenbach et al 2008

15 Smoking by educational level Huisman et al 2005

16 RELATIVE INEQUALITIES BY EDUCATION SMOKING-RELATED MORTALITY, 1990s Relative inequalities in smoking related causes of death 9,00 8,00 7,00 RII 6,00 5,00 4,00 3,00 2,00 1,00 0,00 FIN SWE NOR DEN ENG BEL SWZ ITA BAR MAD BSQ SLO HUN CZR POL LIT EST EUR Men Women

17 RELATIVE INEQUALITIES BY EDUCATION ALCOHOL-RELATED MORTALITY, 1990s Relative inequalities in alcohol related causes of death RII 9,00 8,00 7,00 6,00 5,00 4,00 3,00 2,00 1,00 0,00 FIN SWE NOR DEN ENG BEL SWZ ITA BAR MAD BSQ SLO HUN CZR POL LIT EST EUR Men Women

18 RELATIVE INEQUALITIES BY EDUCATION OBESITY (BMI >30) INEQUALITIES IN OBESITY Men Women Relative Index of Inequality FIN SWE NOR DEN IRE ENG NET BEL GER FRA ITA SPA POR SLV HUN CZR LIT LAT EST EUR

19 CORRELATION BETWEEN INEQUALITIES IN OBESITY AND IN DIABETES The relationship between educational inequalities in diabetes (y-axis) and obesity (x-axis) across Europe for women Inequalities in diabetes and obesity (WOMEN) 7 Portugal 6 5 Czech Republic Spain Italy RII Diabetes Latvia Sweden Netherlands Hungary Norway Estonia Lithuania Germany Denmark Belgium France Finland RII Obesity

20 RELATIVE INEQUALITIES BY EDUCATION MORTALITY AMENABLE TO MEDICAL CARE, 1990s Relative inequalities in amenable mortality RII 10,00 9,00 8,00 7,00 6,00 5,00 4,00 3,00 2,00 1,00 0,00 FIN SWE NOR DEN BEL SWZ FRA ITA BAR MAD BSQ SLO HUN CZR POL LIT EST EU Men Women

21 INEQUALITIES IN MORTALITY by education (US vs. Europe) Kok et al 2009

22 INEQUALITIES IN MORTALITY by education (US vs. Europe) Men United States Europe US-NLMS Whites (NLMS) Blacks (NLMS) East South Central West South Central West North Central South Atlantic Mountain Middle Atlantic East North Central New-England Pacific Czech Hungary Lithuania Poland Estonia France Slovenia Norway Belgium Denmark Switzerland Madrid (spain) Sweden Barcelona Finland Turin (Ita) Basque Kok et al 2009 US-NHIS

23 CONCLUSIONS (1) Health inequalities are omnipresent throughout Europe, but magnitude varies substantially, which suggests great potential for reduction Smaller health inequalities in Southern Europe are probably partly mediated by smaller inequalities in smoking Larger health inequalities is Eastern Europe are probably partly mediated by larger inequalities in smoking, alcohol, and health care deficiencies

24 WHY HEALTH INEQUALITIES PERSIST DESPITE THE WELFARE STATE: HYPOTHESES Welfare state has not eliminated social inequality (material, immaterial) Welfare state has increased social mobility, and health-related selection Welfare state does not protect against prosperity-related diseases

25 Deaths per py (standardised) ADULT MORTALITY men by occupational class, England Low High Pamuk 1985

26 TREND IN MORTALITY BY OCCUPATIONAL CLASS MEN YEARS mortality rate per Finland manual Finland non-manual England manual England non-manual Sweden manual Sweden non-manual period Mackenbach et al 2003

27 CONTRIBUTION OF CVD TO WIDENING INEQUALITIES IN MORTALITY 2 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Finland Sweden Norway Denmark Engl/W Italy obs RR obs RR exp RR (if no change in CVD) Mackenbach et al 2003

28 ISCHEMIC HEART DISEASE mortality by occupational class, England 2,5 Relative Risk (low vs. high) 2 1,5 1 0,5 Low High Mackenbach 1988

29 OBESITY by level of education, women Relative Risk (low vs. high) 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Poorest countries Middle income countries Low 2 3 High Monteiro et al 2004

30 Social inequality persists despite the welfare state Material factors now replaced by lifestyle and psychosocial factors Does this make health inequalities less unfair?

31 CONCLUSIONS (2) Generous and universal welfare policies may be necessary for eliminating health inequalities, but they are not sufficient To (further) reduce health inequalities, welfare policies should be redirected to achieve larger health gains in lower socioeconomic groups Specific interventions should focus on changing health-related behaviour in lower socioeconomic groups

32 NATIONAL POLICY DEVELOPMENTS IN EUROPE Four common milestones in policy development: High-profile independent reports National research programs Government advisory committees Coordinated government action Mackenbach & Bakker 2003

33 INNOVATIVE APPROACHES Policy steering mechanisms (e.g. target setting) Labour market and working conditions (e.g. restructure demanding jobs) Consumption and health-related behaviour (e.g. tailored stop-smoking) Health care (e.g. strengthening primary care in disadvantaged settings) Territorial approaches (comprehensive packages for deprived neighbourhoods) Mackenbach & Bakker 2003

34 COMPREHENSIVE STRATEGIES Britain: Independent Inquiry (1998) Netherlands: Albeda committee (2001) Sweden: National Public Health Commission (2002) Norway: National strategy (2006)

35 STRATEGY RECOMMENDED BY ALBEDA COMMITTEE 26 recommendations 4 specific strategies 11 quantitative targets for intermediate outcomes

36 EXAMPLES OF POLICY RECOMMENDATIONS Poverty reduction School health programs Physical work load Primary care

37 CURRENT SITUATION IN THE NETHERLANDS Government adopts Albeda report 2002 New elections, new government Monitoring scheme, White paper 2007 New elections, new priorities?

38

39

40

41

42 PRIORITY AREAS IN NORWEGIAN STRATEGY (1) Reduce social inequalities: -- income inequalities, (pre)schooling, labour conditions Reduce social inequalities in health behaviour: -- diet, physical activity, smoking, costsharing in health care Norwegian Ministry Health & Care, 2006

43 PRIORITY AREAS IN NORWEGIAN STRATEGY (2) Promote social inclusion -- education, employment, homelessness, geographical areas Develop knowledge and cross-sectoral tools -- policy reviews, health inequalities impact assessment, monitoring, research Norwegian Ministry Health & Care, 2006

44 CONCLUSIONS (3) Health inequalities field in Europe has moved from description, to explanation, to intervention development Some countries in Europe have started systematic policy implementation will these policies work? Look at historical successes: we can reduce health inequalities if we really want

45 HISTORICAL SUCCESSES reduction of inequalities in tuberculosis mortality 7000 Deaths per py (standardised) Low men High men Low women High women Mackenbach 2003

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