Reducing Health Inequalities in Europe;

What can be done?

Dr. Martijntje Bakker

Public Health Fund

the Netherlands

Content

• Background

• Inequalities in health in Europe

• How do countries deal with SEIH

• An example: healthcare

History of the Network

• King’s Fund report (1995)

• BMJ editorial (1995)

• Malmö 1996, London, 1997, Rotterdam 1998

• EU funding, 1999

• Helsinki 1999, Barcelona 2000

Purposes of the network

• To exchange the various national experiences with interventions and policies to reduce SEIH

• To explore opportunities for developing comparative or collaborative research to evaluate such interventions and policies

Network members

• 40 members

• 13 European countries (Belgium, Denmark, Finland, France, Germany, Greece, Italy, Lithuania, the Netherlands, Norway, Spain, Sweden and UK)

• WHO representatives

• New-Zealand and USA

Reducing inequalities in healthA European perspective

Edited by Johan Mackenbachand Martijntje Bakker

Content

I IntroductionII Interventions and policies to reduce socio-

economic inequalities in healthIII National experiencesIV Evaluation issuesV ReflectionsVI Key messages

SEIH in Europe

• Morbidity

• Mortality

Morbidity (1) (Kunst et al., 2000)

Morbidity (2) (Kunst et al., 2000)

Mortality (1) (Kunst,1997)

Mortality (2) (Kunst et al., 2000)

How do countries in Europe deal with socio-economic inequalities

in health?

The Action spectrum

Situation in 8 European countries

• Greece: pre-measurement

• Spain: denial/ indifference

• France, Italy: concern

• Lithuania: will to take action

• The Netherlands, Sweden: more structured developments

• England: comprehensive coordinated policy

An explanatory model

Examples of comprehensive packages (1)

• British Independent Inquiry into inequalities in health (1998)• 39 main recommendations (123 with sub-clauses)• Seven policy areas reviewed: Taxation and social security, Education,

Employment, Housing and environment, Mobility, transport and pollution, Nutrition and the common agricultural policy, National Health Service

• Demographic factors over the life course considered, including: Mothers, children and families, Young people and adults of working age, Older people, Ethnicity, Gender

• Three priority areas emphasized:– 1. Health inequalities impact assessment– 2. A high priority for the health of families with children– 3. Reduction in income inequalities and improvement of living standards

of poor households

Examples of comprehensive packages (2)

• Swedish National Public Health Commission (2000)• 18 health policy objectives • Six overarching themes:

– 1.        Strengthening social capital2.        Growing up in a satisfactory environment3.        Improving conditions at work4.        Creating a satisfactory physical environment5.        Stimulating health-promoting life habits6.        Developing a satisfactory infrastructure for health

• Development of ‘indicators for achievement’ recommended.

Examples of comprehensive packages (3)

• The Dutch program committee on socio-economic inequalities in health (2001)

• 26 recommendations• Four specific strategies:

– 1. Reduction of inequalities in education, income and other socio-economic factors2. Reduction of the negative effects of health problems on socio-economic position

– 3. Reduction of the negative effects of socio-economic position on health– 4. Improve access and quality of healthcare for lower socio-economic

groups

• 11 quantitative targets relating to intermediate outcomes.• Strong emphasis on continuation of research, development, monitoring

and evaluation.

An example: health care

• Access to healthcare– Financial– Physical– Cultural

Access to primary care

• UK: inequalities in access and provision of care (Goddard & Smith, 1998)

• Spain: no clear picture (De La Hoz and Leon, 1996)• NL: more GP contacts for low SES (Van der Meer et al.,

1996)• Sweden: more GP contacts for high SES (Whitehead et al.,

1997)• Germany: more GP contacts for low SES (Bormann &

Schreuder, 1994)• Finland: high SES: private practices and occupational

healthcare; low SES: GP’s at municipal health centres (Keskimäki, 1997)

Access to hospital care

• In general, access seems equitable• However, this might not be true for access to and

quality of care in specialist or intensive services• Examples:

• UK: specialist cardiac services, survival cancer treatment (Goddard, Smith, 1998)

• Finland: coronary bypass operations, hip replacement operations, cataract surgery (Keskimäki, 1997)

Review

• 36 interventions (aimed at low SES groups, or aimed at general population with results reported by SES)

• Aims: cancer screening, hypertension or substance abuse treatment programs, improving maternal and child outcomes

• Interventions: hospital-based education programs, community outreach activities, personalised contacts with target groups by healthcare personnel

Starting Well, Glasgow

• Early intervention program• Target group: children up to 5 years in deprived

areas• Aim: Improving health and well-being• Activities:

– Intensive home support to families with a new baby– Improved network of community services– Stronger linkages between families and support

structures and services

Nurse practitioners, NL

• Target group: Patients with COPD/ Asthma in deprived areas

• Aim:compliance with therapy, reduced complications

• Activities: Counseling of COPD/ Asthma patients by nurse practitioner in GP practice