Johan Mackenbach & Martin McKee
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1 Johan Mackenbach & Martin McKee
2 Context: recent divergence of life expectancy in Europe Successes and failures of health policy in Europe: performance indicators Determinants of health policy performance: economic, social, political
3 Mackenbach 2013
4 IQR = interquartile range Mackenbach 2013
5 Budapest 1956 Moscow 1992 Yalta 1945
6 Mackenbach 2013
7 Tobacco control Alcohol control Food and nutrition Fertility, pregnancy, childbirth Child health Infectious disease Hypertension Cancer screening Mental health Road traffic injury Air pollution Mackenbach & McKee 2013
8 Literature reviews to identify effective interventions Relate implementation to intermediate and final health outcomes Select performance indicators and create summary score Rank countries, identify determinants of health policy performance Mackenbach & McKee 2013
9 Change in cigarette sales ( ) Tobacco control vs. change in cigarette sales R² = Tobacco Control Scale (2004) Mackenbach & McKee 2013
10 Prevalence of iodine deficiency (ca. 2003, %) Salt iodization vs. iodine deficiency R² = Penetration of iodized salt (ca. 2000, %) Mackenbach & McKee 2013
11 Car occupant mortality (deaths per vehicles per year, 2007) Seat belt wearing vs. car occupant mortality R² = Belt wearing in front seats (2007, %) Mackenbach & McKee 2013
12 Health policy performance Tobacco Alcohol Food Fertility, pregnancy and childbirchild health Infectious diseases Hypertension Cancer screening Road traffic safety Air pollution Nordic TCS 2010 Malesmok MalelungcaBtG 2005 Alc cons 20Male liver ciodine defifat%energfruit&veg kteenage prneonatal mmaternal mmeasles imsafety scorpostneonaaids incidesa%mrsa Infl vacc cosbp men 20Stroke morbreast screcerv ca moseat belt Occup morped mort/vso2/mio Urban Ozo Finland ,73 31,5 12,27 29,39 28,3 36, ,20 2,02 3,92 99,0 38,5 0,63 0,55 0, ,3 39,64 2 1,5 89 0,94 0,17 11, Sweden ,49 35,5 8,85 7,83 30,0 35, ,64 1,61 4,24 98,3 42,5 0,88 0,68 0, ,7 38,83 2 2,3 96 0,72 0,13 3, Norway , ,30 4,79 47,1 35, ,44 2,14 4,47 94,0 1,04 0,38 0,0 134,5 37,08 2 3,0 93 0,75 0,11 3, Iceland ,85 7,93 3,23 19,0 39, ,38 0,99 0,00 98,0 48,5 0,80 0,63 0,0 129,6 34,58 2 0,0 88 1,23 0,14 Denmark , ,86 48,1 35, ,49 2,68 7,75 89,0 0,72 0,73 0, ,7 1 3,1 2, Britain & Ireland United King ,68 24,5 12,52 15,39 68,8 37, ,15 3,18 7,59 92,1 39,5 1,47 1,19 5, ,2 45,44 2 2,6 91 0,63 0,24 6, Ireland ,56 25,5 12,87 9,04 56,2 34, ,99 2,28 3,18 93,0 31,0 0,96 0,63 2,5 134,9 38,74 1 4,7 86 1,19 0,39 7, Continental Netherland , ,73 5,71 30,9 37, ,43 2,86 4,72 96,8 45,5 0,99 1,48 2, ,2 33,57 2 2,4 94 0,50 0,13 2, Belgium , ,00 66,9 39, ,76 2,61 99,0 30,0 1,37 1,08 2,1 128,5 1 3,5 79 1,18 0,20 7, Luxembour ,66 5,5 12,76 16,82 32,7 38, ,79 1,42 99,1 0,71 1,43 18, ,9 39,57 2 6,31 Germany 37 53,72 5,5 12,87 38,8 36, ,27 2,58 5,15 39,0 1,25 0,59 0, ,9 1 2,9 95 0,62 0,15 5, Switzerland ,96 13,5 10,76 9,23 36,0 40, ,91 3,07 5,00 0,86 1, ,6 26,91 1 1,2 86 0,46 0,20 1, Austria ,58 5,5 13,00 21,57 21,4 39, ,34 2,50 3,04 82,5 40,5 1,28 0,78 1, ,4 31,97 1 2,9 89 0,96 0,25 2, Mediterranean France 55 61,92 13,5 12,70 15,80 33,2 41, ,96 2,39 7,19 98,0 40,0 1,13 1,61 0,2 131,0 23,74 2 2,3 98 0,89 0,18 4, Spain ,56 7,5 13,07 13,30 34,8 42, ,91 2,14 3,39 96,9 29,0 1,21 2,96 1,1 130,4 33,80 2 2,6 89 1,20 0,29 9, Portugal , ,43 17,19 46,9 35, ,37 3,44 5,25 96,8 27,5 1,63 5,11 17, ,6 69,90 1 4,8 90 1,15 0,34 7, Italy ,09 9,5 9,59 12,64 50,2 39, ,35 2,47 2,18 30,0 1,03 1,63 13, ,9 42,76 1 2,0 65 0,77 0,21 3, Malta ,43 7 8,01 9,13 28, ,78 5,72 7,94 71,5 2,38 2,18 0, ,8 51,19 0 2,4 96 0,19 0,19 18,00 Greece 32 69, ,55 8,28 0,0 36, ,81 2,02 99,2 27,0 1,13 0,85 3, ,5 83,15 1 2,2 75 1,64 0,53 37, Cyprus ,96 5 9,53 8,73 41,3 39, ,84 1,87 97,0 31,5 1,35 1,51 5,9 131,2 40,70 2 1,7 81 1,10 0,39 21,47 Western Balkans Slovenia ,31 9,5 15,31 39,95 23,5 33, ,32 1,57 9,95 97,0 40,5 0,83 0,54 2,2 136,4 53,17 1 3,5 85 1,85 0,32 5, Croatia 85,15 12,76 39,25 22,3 33, ,68 4,28 11,55 96,1 0,99 0,34 135,5 104,76 0 5,5 2,07 0,83 Bosnia-Hercegovina 22,2 10,47 10,53 19,18 4, ,0 4,55 1,77 Serbia 31 82,78 16,79 9,4 39, ,50 4,91 13,91 95,0 2,09 0,52 136,9 140,27 12,5 55 3,71 1,59 Montenegro 37 79,08 13,02 16,7 25, ,74 4,05 95,0 1,74 0,48 135,4 78,24 0 8,5 5,15 1,40 TFYR Macedonia 6,84 10,2 36, ,48 8,56 95,3 3,24 0,44 134,0 0 13,4 2,59 2,14 Albania 57,1 28, ,98 2,51 17,05 99,0 5,28 0,75 133,8 0 4,2 30 8,48 7,49 Centre & East Poland 43 91,45 15,5 13,60 26,89 55,0 29, ,91 4,01 3,11 99,0 1,56 0,42 3,0 135,0 64,09 1 7,8 74 2,11 1,45 22, Czech Repu , ,61 24,98 13,4 35, ,05 1,64 3,67 42,0 1,24 0,28 1,2 133,7 70,77 2 5,2 90 1,77 0,57 16, Slovakia 41 68,74 8,5 14,59 39,92 15,0 34, ,56 3,07 4,97 99,0 2,58 0, ,7 82,13 0 6,5 2,76 1,88 11, Hungary ,84 13,5 14,15 69,80 57,2 39, ,09 3,39 14,67 99,9 36,5 1,74 0,23 1,1 136,1 75,69 1 7,8 71 2,22 0,93 7, Romania , ,30 61,19 46,9 27, ,79 5,47 21,66 4,33 1, ,4 154, ,2 80 5,54 0,80 21, Bulgaria 40 62, ,45 32,49 11,2 30, ,66 5,01 7,94 95,3 3,59 0,38 4, ,3 162,64 0 9,1 3,32 1,34 86, (f) Soviet Union Estonia ,40 15,5 14,05 38,03 67,0 25, ,42 3,18 95,0 35,0 1,81 4,55 13,5 138,6 62,88 2 7,9 90 2,46 0,71 40, Latvia , ,98 76,8 35, ,03 5,03 28,15 97,3 34,0 2,72 4,55 5,3 136,8 122,78 1 9,9 77 2,51 1,86 1, Lithuania , ,02 56,33 59,7 27, ,59 2,84 4,91 95,8 32,5 2,10 1,61 12,5 137,3 110, ,5 2,57 1,53 10, Belarus 53 69,49 14,0 33, ,43 3,07 5,62 97,2 3,83 3,97 136,6 0 6,6 3,06 2,58 Ukraine 50 60,48 56,2 26, ,68 5,57 20,18 90,5 4,06 2,40 137,2 140,67 0 8,3 Republic of Moldova 51 50,28 105,80 27,0 21, ,88 7,77 26,39 96,0 4,31 2,55 133,8 183, ,4 9,88 5,91 Russian Federation 74,21 58,1 25, ,81 6,36 21,69 97,7 4,67 132,3 209,69 0 8,1 33 8,01 4,64 Georgia 31,80 28,71 4,4 20, ,04 11,82 28,63 92,1 3,09 5,29 0 6,3 4,32 Armenia 55 84,81 6,3 24, ,09 8,07 29,19 89,0 3,72 2, ,3 8,73 5,71 Azerbaijan 38 16,95 13,3 15, ,34 6,01 28,50 95,0 3,82 0,69 0 7,0 10,81 6,90 Mackenbach & McKee 2013
13 Mackenbach & McKee 2013
14 Policy area Indicator Lithuania Europe Tobacco Tobacco Control Scale Daily smokers Lung cancer mortality Alcohol Alcohol Control index Alcohol consumption Liver cirrhosis mortality Nutrition Iodine deficiency Fat consumption Fruit and vegetables Pregnancy Teenage pregnancy Neonatal mortality Maternal mortality Child Measles immunization Child Safety Score Postneonatal mortality
15 Policy area Indicator Lithuania Europe Infections AIDS incidence MRSA infections Influenza vaccination n.a. 53 Hypertension Blood pressure Cerebrovascular mort Cancer screening Breast cancer screening 1 n.a. Cervical ca. mortality Road safety Safety belt use n.a. 81 Car occupant mortality Pedestrian mortality Air pollution SO 2 emissions Urban ozone Summary score % high minus % low -28 5
16 Mackenbach & McKee 2013
17 Enormous gaps in implementation of effective health policies in Europe, particularly in Central and Eastern Europe Even in Western Europe, countries could typically reduce years of life lost by 30-50% by adopting policies in countries with best practices Remaining gaps in all areas: tobacco and alcohol control, iodine deficiency, immunisation, child safety, cancer screening, road safety, air pollution,...
18 Mackenbach, Karanikolos & McKee 2013
19 Condition Excess deaths Condition Excess deaths Lung cancer 151,000 Injuries (1-19) 7,000 Liver cirrhosis 119,000 Infectious dis. 51,000 Other alcohol 14,000 Stroke 584,000 Ischemic heart 937,000 Cervical ca. 11,000 Infant mort. 26,000 Breast ca. 24,000 Maternal mort. <1,000 Road transport 57,000 Mackenbach, Karanikolos & McKee 2013
20 Background: Economic conditions Political conditions Social conditions Will: Political commitment Business support Professional engagement Population support Means: Knowledge and information Institutional arrangements Organizational effectiveness Financial resources Delivery: Initiation or redesign Population coverage Programmatic design Monitoring and evaluation Mackenbach & McKee 2013
21 Health policy performance summary score National income vs. health policy performance Sweden UK Netherlands Denmark Albania Slovenia Czech Rep Hungary Belgium Russian Federation y = 0,0036x - 57,274 R² = 0, GDP per capita ($US) Mackenbach, Karanikolos & McKee 2013
22 Health policy performance summary score (2008, %) Value orientation vs. health policy performance R² = Self-expression values (2000/6) Mackenbach & McKee 2013
23 Traditional values emphasize: God is very important Obedience and religious faith more important than independence Abortion never justified Strong sense of national pride Respect for authority Survival values emphasize: Economic & physical security more important than self-expression and quality of life Would not sign a petition Have to be careful about trusting people
24 Policy area National income Survival values Democracy Left parties Govt. effectiveness Ethnic fractional. Tobacco control score Male smoking Male lung cancer Alcohol policy score Alcohol consumption Male liver cirrhosis Iodine deficiency Fat as % of energy Fruit & veg. cons. Teenage pregnancy Neonatal mortality Maternal mortality Measles immunisation Child safety score Postneonatal mortality AIDS incidence MRSA rate Influenza vaccination Male blood pressure Female stroke mort. Cervical cancer mort. Seat belt wearing Occupant mortality Pedestrian mortality SO2 emissions Ozone concentrations Summary score Mackenbach & McKee 2013
25 The diverging health trends in Europe are a testimony to both the successes and failures of health policy in Europe in the past decades Economic, social and political conditions have been the main drivers of this divergence, but they were partly mediated by specific health policies Europe s diversity offers great opportunities for mutual learning, in which public health and health policy research have an important role to play
26 Mackenbach JP. Convergence and divergence of life expectancy in Europe: a centennial view. Eur J Epidemiol 2013; 28: Mackenbach JP. Political conditions and life expectancy in Europe, Soc Sci Med 2013; 82: Mackenbach JP, Hu Y, Looman CWN. Democratization and life expectancy in Europe, Soc Sci Med 2013;93: Mackenbach JP, Looman CWN. Life expectancy and national income in Europe, : an update of Preston s analysis. Int J Epidemiol 2013;42: Mackenbach JP, McKee M. A comparative analysis of health policy performance in 43 European countries. Eur J Publ Health 2013;23: Mackenbach JP, Karanikolos M, McKee M. Health policy in Europe: factors critical for success. BMJ 2013;346:f533. Mackenbach JP, Karanikolos M, McKee M. The unequal health of Europeans: successes and failures of policies. Lancet 2013;381: Mackenbach JP, McKee M. Social-democratic government and health policy in Europe: a quantitative analysis. Int J Health Serv 2013; 43:
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