THE MARMOT REVIEW 10 YEARS ON AND ITS IMPLICATIONS FOR A HEALTHY EUROPEPOSITION PAPER

July 2020

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ContentsBackground 4

Introduction 4

HealthInequalitiesintheEuropeanUnion 6

1.Socialdeterminantsofhealth 6

1.1Accesstoqualityhealthandpreventivecare-an7indispensablestepforreducingdisparitiesbetweenpopulationgroups

1.2Inter-relationsbetweenpovertyandhealthinequalities9

2.Investinginearlychildhooddevelopmenttocombathealth12inequalitiesfromtheearliestageoflife

3.Accesstoqualityeducation-astrongfactorforreducing16inequalitiesinsociety

4.Ensureahealthystandardoflivingforall18

5Createanddevelophealthyandsustainableplacesand20communities

6.COVID-19andhealthinequalitiesacrossEurope23

Conclusion 25

Background

In2008theUKSecretaryofState forHealthcommissionedareviewaimingtoaddresshealthinequalitiesinEnglandfrom2010.Thereview,entitled“FairSociety,HealthyLives”1 providedananalysisofexistingdisparitiesinhealthfo-cusingonthefactorsresponsibleforinequalitiesbetweenpopulationgroups.Itidentifiedsixpivotalareasforreducingthegapinhealthandprovidedrec-ommendations for a comprehensive strategy to improvehealth and reduceinequalitiesbasedonactionstotackleholistically,thesocialdeterminantsofhealth.Strongerinvestmentinearlychildhooddevelopment,fairemployment,higherstandardsofliving,effectivehealthpreventionandhealthyandsustain-ableplacesandcommunitieshavebeenidentifiedasmajorfactorsforachiev-ingpositiveandsustainableresultsoncommunitiesandsocietiesaffectedbyhealthinequalities.

TheMarmotReviewanditsfollow-up,publishedinFebruary2020advancesapolicyapproachtowardsthegapinhealthlookingbeyondindividualbehaviourandaccesstohealthcarethatcanbesuccessfullyappliedtoEuropeanandna-tionalcontexts.Providingacomprehensivepolicyresponsetothedisparitiesinhealth,proportionaltothechallengesfacedbyaffectedgroupscanpromotehealthequityandsocialjusticeacrossEurope..

Introduction

The“MarmotReview:10YearsOn,”2 publishedinFebruary2020presentedaprogressreviewofhealthinequalitiesinEnglandoverthepasttenyears.ThereportfocusingonpoliciesimplementedinEnglandandtheirimpactonhealthdisparities,assessestheprogressachievedinthestrategicpolicyareasidenti-fiedinthefirstMarmotReviewpublished10yearsearlier.

The “Marmot Review: 10 Years On” presents a holistic and comprehensiveapproachtohealthaddressingstrategicsocialdeterminantssuchasemploy-ment,income,housing,andchildpoverty,underliningthestronglinkbetweensocial inequalities andhealthdisparities. The reportnotonlydemonstratedthathealthdisparitieshavecontinuedtorise,butalsoprovidedsolidevidenceabouttheinterrelationsbetweensocio-economicvulnerabilityandill-health.Moreover,itaccentuatesthedisproportionateexposuretopoorhealthofvul-nerablegroups,which impactsseveral socialoutcomesandmaintains thesegroupsatthemarginsofsociety.

InEnglandthelackofsignificantcommitmenttoreduceinequalitiesbetweenregionsandpopulationgroupsinthepasttenyearshasresultedinanalarmingtrendoflifeexpectancy-amajorindicatorforhealth.Forthefirsttimesincethebeginningof20thcentury,lifespanisstagnatinginEnglandanddecliningforcertainpopulationgroups.Increasedlevelsofchildpoverty,lossofincomeand employment precariousness are other factors of utmost importance in

1 https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

2 https://www.health.org.uk/sites/default/files/upload/publications/2020/Health%20Equity%20in%20England_The%20Marmot%20Review%2010%20Years%20On_full%20report.pdf

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causinghealthdisparitiesbetweenpopulationgroupsandthisisalsovalidforthedeclineof lifeexpectancynoticedinEngland.Asmightbeexpected,thereportdiscoveredthatpeopleexperiencingpoverty,vulnerablegroups,ethnicminorities have shorter lives and spendmore years in ill-health,which cor-relateswiththelevelofinequalitiestheyfaceinmanyareasoflife.Lifespanstronglydependsonsocialfactorssuchas livingandworkingconditions,ac-cess toqualityhealthcareandprevention services, includingtimelymedicaltreatment.Thus,inEnglandwomenlivinginthemostdeprivedareaslive12-18yearsless,demonstratingthelinkbetweenpoorlivingconditionsandlon-gevity.Also,theyaremorevulnerabletopoorhealthcomparedwithpeopleliving inbetterhousingconditions.Prematuredeaths followsimilar trends -theyhavealsoriseninEnglandforpeopleaged45-49linkedtoworsenedsocialandeconomicconditionsunderminingindividual’sandcommunities’health.

Vulnerable groups aremore severely hit by health inequalities but also bypovertyandsocialexclusion leadingtopooraccesstohealthandsocialser-vices,producinglongtermeffectsonphysicalandmentalhealth.Thenegativeresults inhealtharestrongly influencedbythelackofsustainablemeasurestoreducehealth inequalities,whichhasan impacton individuals’andcom-munities’capacitiestocombatpovertyandemploymentprecariousnessandimprovetheiraccesstohealthandsocialservices.Moreover,itcauseslossofproductivityandsocialandeconomiccompetitivenessofentirecommunitiesandsocio-economicgroups,affectingfurtherthewidereconomyandsociety.

The2020MarmotReviewshows thesocio-economiccostsofpoorcommit-menttocombatinequalities,aswellasthelackofholisticandcomprehensiveapproachinhealthpoliciesconcerningthosemostaffectedbyhealthdispari-ties.TheimportanceofeffectivepolicymeasureswereunderlinedinthefirstMarmotReviewandremainsvalidnotonlyforEnglandbutalsoforotherEuro-peancountries,alsofacingsignificantlevelsofinequalitiesinhealth.Tenyearsago,theMarmotReviewcalledonpolicymakerstoreducehealthinequalitiesbystrengtheningtheireffortsinsixpolicyareasaddressingsocialdeterminantsofhealthbutthefindingsin2020clearlyindicatethatpolicymakershavenotachievedsignificantprogressinreducinghealthdisparities.Vulnerablegroupsremaindisproportionatelyaffectedby ill-health, inparallelwithpovertyandsocialexclusioninstrategicareasdeterminingtheirqualityoflife,healthandwell-being.Theeffectsof the lackofprogress incombatinghealth inequali-tiesreflectsthepoorachievementsinsocialjustice,andbecamegreatlyvisiblewhentheCOVID-19pandemicreachedEuropeandrevealedthealarmingpub-lichealth,socialandeconomicconsequencesofpoorinvestmentinimprovingvulnerablegroups’healthandwell-being.

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Health Inequalities in the European Union

DespitethefactthatMarmotReviewpresentsthestateofhealthinequalitiesinEngland,itsfindingsarerelevantfortheEuropeanUnionasawhole.ItsholisticapproachisalsoapplicabletoEuropeanandnationalcontexts,raisingtheroleandresponsibilityofdecisionmakerstoprovideaneffectivepolicyresponsetohealthdisparitiesbasedontheproportionalitybetweensocialgradientsandthelevelofinequalitiesexperiencedbyvulnerablegroups.ThisisakeysolutionforbothclosingthegapinhealthandachievingsocialfairnessinEurope.Improvingaccesstohealthcareandpreventionservices isnotasufficientmeasureon itsowntoachievepositiveoutcomesinhealth,althoughhealthcareremainsapiv-otalareaforreducinghealthdisparities.Comprehensivemeasuresstartingfromtheearliest ageof lifeandaddressing themain factors responsible forhealthinequalitiesarestronglyrequiredtoachievepositiveandsustainableresultsforindividuals’andcommunities’healthandfortherealizingsocial justice.Basedontherelationshipbetweenhealthequityandsocial fairness,reducinghealthinequalitiesbecomesamilestoneforcreatingsustainableandequitableecono-miesandsocieties.

1. Social determinants of health

“The health of the population is not just a matter of how well the health service is funded and functions, important as that is. Health is closely linked to the conditions in which people are born, grow, live, work and age and inequities in power, money and resources.”3

EvidenceshowsthathealthdisparitiesbetweenpopulationgroupsexistinEuro-peancountriesregardlessoftheireconomicsituation.SignificantinequalitiesareobservedbetweenvulnerablegroupsandtherestoftheEuropeanpopulation,includingthoselivingintherichestEUcountries.AreviewpublishedbytheWorldHealthOrganization(WHO)analysingthesocialdeterminantsofhealthandthehealthdivideacrossEuropehasdemonstratedsystematicgapsinhealthbetweensocio-economicgroupsemphasisingtheresponsibilitiesofpolicymakersforim-provinghealthasasocialoutcome.4 TheWorldHealthOrganizationunderlinestheneedforholisticpolicymeasurestacklingthedisparitiesinworkingandlivingconditions,socialandeconomicsituations,accesstohealthandpreventionser-vicesbutalsohumanrightsprotectionwhichisnecessarytoaddressthemargin-alisationofcertainpopulationgroups.WhileEUMemberStatesclearlyhavetheresponsibilityforimprovingnationalpublichealthandsocialsystems,Europeanpolicymakersmustshowleadershipinpromotingstrongerpublichealthsystemsandequalityprovisions,advancingsocialjusticeandhealthequityacrossEuropeasawhole.

3 https://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/the-marmot-review-10-years-on-executive-summary.pdf

4 ReviewofsocialdeterminantsandhealthdivideintheWHOEuropeanRegion,2014:https://www.euro.who.int/__data/assets/pdf_file/0004/251878/Review-of-social-deter-minants-and-the-health-divide-in-the-WHO-European-Region-FINAL-REPORT.pdf

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1.1 Access to quality health and preventive care - an indispensable step for reducing disparities between population groups

WhileArticle35oftheEuropeanCharterforFundamentalRightsguaranteestherighttomedicaltreatmentandpreventiveservicesaimingtoensurethehealthprotectionofEuropeanpopulations,equalaccesstoqualityhealthcareremainsasignificantchallengeformanysocio-economicgroups.Therightto“timelyac-cesstoaffordable,preventiveandcurativecareofgoodquality”isalsooneoftheprinciplespromotedbytheEuropeanUnionthroughtheEuropeanPillarofSocialRights-apolicyinstrumentseekingtoadvancesocialandeconomicrights.However,healthcaredependsonnationalpolicyand legislativeframeworksaswellascapacitiesofnationalpublichealthsystemstomeetpeople’sneedsbyensuringtheavailability,accessibilityandaffordabilityofrelevantservices,high-lightingthelimitationsoftheEuropeanUnioninhealthpolicy.

Althoughnationalhealthsystemsofferfullyorpartiallycoveredhealthcarepack-ages,includingprevention,primary,specialistandhospitalcaretheymaynotbeaccessibleforalliftheiravailabilityisdisproportionatecomparedwithpeople’sneeds.ManyEuropeancountrieshaveintroducedUniversalHealthCoverageintheirpublichealthsystems,enablingpeopletoenjoycertainpackagesofhealth-care;however,insomeEuropeancountrieshealthprotectionstilldependsonthesocialprotectionsystemandemploymentbenefits.Thus,severalsocialandeco-nomicgroups,suchasinactivepeoplewhoarenotentitledtosocialprotectionandemploymentbenefits;undocumentedpeople,includingmigrantsandstate-lesspersons;seasonalworkersandself-employedaswellasthosewhoarenotle-gallyemployed,struggletoenjoyequalandtimelyaccesstohealthcare.Astudy5

ofnationalpoliciesreleasedbytheEuropeanCommissionin2018demonstratedthatbetween5%and20%ofthepopulationincertainEUMemberStatesdonothavehealthcoverage(e.g.Bulgaria,Cyprus,Hungary,Romania,Poland),whichisamajorbarrierpreventingeffectivehealthprotection.ThistrendisobservedalsoincountrieswhereUniversalHealthCoveragehasbeenadopted.Somepopula-tiongroupsdonothaveaccesstoitbecauseofadministrativerequirementssuchastheneedforapostaladdressorpermanentresidence.Asaresult,patientswithouthealthcoveragecanonlyaccessurgentlynecessaryhealthcareorout-of-pocketpaymentcare,reducingopportunitiesforregularmedicalfollow-upandqualityandtimelytreatment.

The lack of healthcare coverage, or provisions for Universal Health Coveragewithinnationalpublichealthsystemsleadtoincreasedfinancialcostsofhealthandprevention,raisingfurtherissuesofaccessibilityandaffordabilityofessentialservices.Accordingly,unequalaccesstohealthcarecanbeobservedinEUMem-berStates,affectingpeoplefacingunemploymentandemploymentprecarious-nessorthoselivinginpovertyincreasinginequalitiesinhealth.

ArecentEuropeanCommissionreport6addressinghealthinEurope,statedthat62%ofthosewhoareself-employedinGreece,France,LatviaandRomaniaaremoreoftenconfrontedwithunmetmedicalneedscomparedwithemployeesinthese countries. In some sectors such as agriculture, the greater vulnerabilitytoemploymentprecariousness,becauseof theseasonal, informalandtempo-rarynatureof theirworkandhigh levelsofout-of-pocketpaymentsalso less-entheirabilitytoaccesshealthcare.Morebarrierstoenjoyingsocialprotectionandhealthcoverage,andreducedaccesstohealthcareinfluencesinturntheir

5 Inequalitiesinaccesstohealthcare-Astudyofnationalpolicies,EC,2018:https://ec.eu-ropa.eu/social/main.jsp?catId=738&langId=en&pubId=8152&furtherPubs=yes

6 https://ec.europa.eu/health/sites/health/files/state/docs/2019_companion_en.pdf

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health,well-beingandeconomiccompetitiveness.

ArecentWHOreportcriticisesthehigherlevelsofout-of-pocketpaymentspaidbythepooresthouseholdsandthisunacceptablesituationisasignificantobsta-cletohealthequityinEurope.7Similarly,vulnerablegroupssuchasethnicminori-ties,includingRoma;migrants,peoplewithphysicalandmentaldisabilities,olderpersons,maybedisproportionatelyexposedto increasedspendingpreventingthemfromqualityandtimelyhealthcareandpreventionservices.

AccordingtoanEUreport8analysingtheaccessibilityofhealthcareinMemberStates,thehighestspendinghasbeenregisteredinBulgaria-thepoorestcountryoftheEuropeanUnion–andconcernsmainlyout-of-pocketpaymentsrelatedtomedicines.Additionally,patientspayhighusercharges,especiallythosesufferingfromchronicandmentaldiseases,whichrequireregularmedicalchecks,timelyinterventionsandlong-termmedicaltreatment.AsimilarsituationisoccurringinAustria,Germany,Estonia,Hungary,Lithuania, theNetherlands,PolandandSlovakia.Itshouldbenotedthatthesegroupsfacegreatervulnerabilitytopoorhealth,povertyandexclusionthatcumulatemultiplefactors,wideninghealthin-equalities.Peoplewithmentalandphysicaldisabilities,olderpersons,andthosesufferingfromchronicdisease,includingcancer,areparticularlydisadvantaged.Theirvulnerabilitymaybeincreasediftheyliveinisolatedareas,duetoloweravailabilityofhealthandpreventionservicesaswellasthelackofmedicalspe-cialists.

Out-of-pocketpaymentsexacerbatefinancialhardship forpeopleexperiencingpovertywhen thosepayments aredisproportionate to their income, affectingtheircapacitytoaffordmedicaltreatment,especiallyiftheysufferfromchronicormentalhealthdiseases,requiringlong-termtreatment.Furthermore,afford-abilityofout-of-pocketpaymentsmaydrivepeopletomakeachoicebetweenmedicaltreatmentandbasicneedssuchasaccommodationandfood,directlyinfluencinganindividual’shealthandwell-being.

Inequalitiesinhealthcoverage,affordabilityofhealthservicesandmedicinesaf-fectnotonly individuals,butalsoentirecommunitiespreventingsustainabilityofhealthprotectionandtheeconomyasawhole. Inthisregard,the2030UNAgendaforSustainableDevelopmentunderlinestheimportanceofaddressingfi-nancialprotectioninparallelwithhealthprotectionmeasuresasmainindicatorsforUniversalHealthCoverage.

7 Canpeopleaffordtopayforhealthcare?,WHO2019: https://apps.who.int/iris/bit-stream/handle/10665/311654/9789289054058-eng.pdf?sequence=1&isAllowed=y

8 Companionreport,EC2019:https://ec.europa.eu/health/sites/health/files/state/docs/2019_companion_en.pdf

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“Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential

medicines and vaccines for all.”9

Improving access to healthcare and prevention cannot be efficient if people do not enjoy stronger protection against poverty and social exclusion that have long-term implications

on their health and health inequalities as a whole.

UniversalHealthCoverageisapolicyresponsetopooraccesstohealthcaresinceitguaranteeshealthandpreventionservicepackagesforall. It isamechanismpreventingfinancialhardshipcausedbyout-of-pocketpaymentsleadingtoun-metmedicalneeds,especiallyforthoseatriskofpoverty.Suchameasureisanecessaryprotection for vulnerable groups anda concrete step for improvingpublichealthsystemsinaccordancewiththeprinciplespromotedbytheEurope-anPillarofSocialRights.Therefore,introducingUniversalHealthCoverageisaninstrumentforboostingeconomicgrowthandsocialprogressaswellasawaytoensurebetterprotectionofpopulationgroupsagainstpovertyandsocialexclu-sionwhichimpacthealthinequalities.

1.2 Inter-relations between poverty and health inequalities

Incomeisamajorsocialdeterminantofhealthandthelackoffinancialresourceshasadirect influenceoninequalitiesbetweenpopulationgroups.Thesesocialgapsaresignificantobstaclesforachievingalong-termandsustainableimpactonsocialcohesion,aswellasinattainingtheUNSustainableDevelopmentGoals.Insuchconditions,reducingpoverty,achievinggenderequality,ensuringgoodhealthandwell-beinganddecreasinginequalitiesbetweenandwithinEurope-ancountriesbecomechallengingambitions,dependingstronglyonthepoliticalcommitmentofEuropeanandnationalpolicymakers.10

Giventhatpovertyandsocialexclusiondisproportionatelyaffectcertainpopu-lationgroupsandarethemaincausesofill-health,bothphysicalandmental,itiscruciallyimportanttobetteridentifythegroupsfacingincreasedriskofpov-ertyorsocialexclusion,analyseandaddressholisticallythefactorsresponsiblefortheirvulnerabilitybyproposingtargetedmeasuresproportionatetothein-equalitiestheyexperience.Improvingtheiraccesstohealthcareandpreventionwhereforestronglydependsoncomprehensivemeasuresforeffectivelyreducingpovertyandsocialinequalities.

9 https://www.who.int/sdg/targets/en/10 https://sdgs.un.org/goals

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1.3 Population groups experiencing higher risk of poverty and health inequalities

Although poverty reduction, with a specific focus on vulnerable groups hasbeenatthetopoftheEuropeanpoliticalagendaforthepasttenyears,manysocio-economiccategoriesandcommunitiesremainfrequentlyexposedtopov-ertyandsocialexclusion,influencingtheirhealthstatus.AccordingtoEurostat11

in2017,113millionpeople, counting for22.4%of theEuropeanpopulation,wereexperiencingpovertyor socialexclusionandone infiveEuropeans lackssufficientincome,impactinghealthandwell-being.WhileEuropeisoneoftherichestregionsoftheworld,thenumberofpeopleexperiencingdeepandgen-erationalpovertyremainshighandpersistent.AccordingtoEurostatdata, themostvulnerabletopovertyandexclusionarewomen,children,youngpeople,peoplewithdisabilities,theunemployed,single-parenthouseholds,andpeoplewithlowereducationallevels,thoselivinginruralareas.However,theEUdataisnotdisaggregatedbyethnicity,whichcancontributetofailurestoaddresssys-temicdiscrimination,oneofthemajorcausesofinequalities.

AtthispointtheMarmotReviewprovidesvaluableanalysisdemonstratingthelink between poverty, health inequalities and systemic discrimination againstethnic minorities. In England the number of children from ethnic minoritiesexperiencingpoverty is twotimeshigher (45%)comparedwith those living in“whiteBritish”households(20%).12 Thesefindingsshowintersectionallinksbe-tweenpovertyanddisadvantageexacerbatedbyethnicdiscrimination,causinglong-termconsequencesonhealthaffectingentirecommunities.TheEU-MID-IS-IIsurveyconductedbytheFundamentalRightsAgencydemonstratedthatinmanyEUcountriesthepercentageofRoma-thelargestethnicminorityinEu-rope-experiencingpovertyandsocialexclusionmayreach80%andtheriskofpovertyfacedbythesecommunitiesisfourtimeshigherthantheaveragerateintheEuropeanUnion.ThehighestpovertyratesaffectingRomacommunitieshavebeennoticedinSpainreachingthealarmingrateof98%,followedbyGreeceandCroatia,whererespectively96%and93%ofRomaarelivingbelowthepovertyline.IntheCzechRepublic58%ofRomaexperiencepoverty–butthereisstillanotablegapbetweenRomapeopleandthegeneralpopulationinthiscountry.ThesefigureshighlightthesevereinequalitiesbetweenRomaandnon-Romaintermsofincomeandpovertyproducingnegativeeffectsonheathandotherso-cialoutcomes.Moreover, the surveyshowed thatone in threeRomachildrenliveinhouseholdsexperiencinghunger,whichisparticularlyworryingintermsofhealth,physicalgrowthandoptimalchilddevelopment,whichrequiresadequatenutrition,qualityhealthcareandaccesstopreventionservices.13Thesefindingsprovethatinequalitiesbasedonethnicityhavedeeprootsanddifferentdimen-sions.Beyondthepurelysocialandeconomicreasonsforgreaterpovertyratesamongethnicminorities,thereisalsoahumanrightsaspectwhichneedsspecificattentionfrompolicymakers.

Disparitiesinhealthcanbewideraccordingtotheageandsexofthevulnerablepopulationgroups.Ageandsexaremajor indicators formeasuring thegap inincomeandhealth,aswellasbeingusedtomonitortheprogressandeffective-nessofimplementedpolicymeasuresaimingtoachievegenderequality.Despite

11 Europe2020indicators-povertyandsocialexclusion:https://ec.europa.eu/eurostat/sta-tistics-explained/index.php/Europe_2020_indicators_-_poverty_and_social_exclusion#-General_overview

12 https://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/the-marmot-review-10-years-on-full-report.pdf

13 https://fra.europa.eu/en/publication/2016/second-european-union-minorities-and-dis-crimination-survey-roma-selected-findings

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thehighnumberofwell-qualifiedwomenacrossEurope,femalelabourmarketparticipation is still lowercompared tomen’semployment ratesalthough thisgaptendstodecreaseinEurope.14AccordingtoEurostat,fortheagegroup20to64,theemploymentgapis11.5%,whichcanbeexplainedbyfactorssuchasfamilyandsocialsupportservices,workingconditions,butalsosocialattitudestowardsmotherhoodandpregnancy.Theseinequalitiesarehigheramongolderpersons,withwomenoftenreceiving lowerpensions thanmen,which in turnleadstoincreasedhealthrisksandlowercapacitiestoaffordtimelyandqualityhealthcare,especiallyinthecaseoflong-termtreatment,chronicdiseasesordis-abilities.Retirementisacrucialperiodwhentheconsequencesofloweraccesstoemploymentandunevenwealthdistributionbetweenmenandwomenareespeciallyvisiblereaching5.4percentagepoints(Eurostat).Genderinequalitiesareevenmoreexacerbatedforretiredwomenfromvulnerablegroups,suchasthosebelonging toethnicminorities.Theyaremore likely toexperiencebothpovertyandill-healthcumulatingmultiplefactorsincreasingtheirexposuretoin-equalities.Thesecomplexissuesshowtheneedforstrongandefficienttargetedpolicyactionstotacklehealthdisparitiesinparallelwithgendergapsinemploy-mentandincome,whilealsoimprovinghumanrightsprotectionofwomenfromvulnerablegroups.

Disabilityisanotherfactorwhichincreasesthevulnerabilitytopovertyandex-clusionaswellaspoorhealth.Giventheaccumulationofmultiplecomponentsincreasingthevulnerabilitytoill-healthofpeoplewithdisabilities,bothmentalandphysical, comprehensivepolicymeasuresare required toeffectivelymeettheirneeds.In2017,theriskofpovertyandsocialexclusionfacedbydisabledpeoplewasalmosttwotimeshigherthanthegeneralpopulationacrosstheEu-ropeanUnion-36.0%ofdisabledpeopleaged16ormorecomparedwith19.9%ofthosewithnoactivitylimitations(Eurostat).

Anothersocio-economiccategoryatparticularriskaresingleparents:47.0%ofthemareexperiencingpovertyorsocialexclusionandtheriskofdeprivationforthemistwotimeshigher.Otherfactorssuchasgender,employment,ethnicityanddisabilitycanfurtherrisetheirvulnerabilityandhavelong-termconsequenc-esonsingleparents’physicalandmentalhealth.

The correlationbetweenhealth andpoverty is even stronger for peoplewithlowereducationallevels.AccordingtoEUdata,34.3%ofpeoplewithsecondaryeducationorlessareatriskofpovertyorsocialexclusioncomparedtoonly11.0%ofthosewithuniversitydegrees.Accesstoqualityeducationisthereforeade-cisivefactorincombatingpoverty,empoweringvulnerablegroupsandreducinginequalitiestheyfaceinhealthandemployment.

Levelsofpoverty,andthusgoodhealtharealsoinfluencedbylivingareasandaccess todecenthousing,withgreatdisparitiesbetweenregions.Onaverage,peoplelivinginisolatedandruralareasaremorelikelytoexperiencebothpov-ertyand ill-healthcomparedwithresidents living inurbanzones.TheEurope-anCommissionhasidentifiedfourmajorcategoriesoffactorsdefiningtheriskofpovertyorsocialexclusioninruralareas-demography(populationageing),lackofinfrastructureandservices,insufficienteducationalfacilitiesandeconom-icopportunities.Precarityofemploymentamongstseasonalworkers isanoth-erreasonforthegreaterexposuretobothpovertyandill-healthinruralareas.Nonetheless,thistrendcanbereversedinsomeNorthern,CentralandWesternEuropeancountries,bybetteropportunitiesforon-farmconsumptionandlow-erhousingcosts.Atthesametime,whileurbanareaspresentmoreeconomicopportunitiesandgreateravailabilityofsocialandhealthservices,theyarealsocharacterisedby awide rangeof inequalities in living andworking conditionsresponsibleforpoorhealth.

14 Eurostat,Peopleatriskofpovertyorsocialexclusion,2019

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2.Investinginearlychildhooddevelopmenttocombathealthinequalitiesfromtheearliestageoflife

Health inequalitieshavedeeproots reachingback to theearliestyearsof life.Manychildren,especiallythoseatriskofpoverty,socialexclusionorthoseinavulnerablesituationaredeprivedofequalopportunitiestogrowanddevelopinasafeandhealthyenvironment.Earlychildhoodhasbeenrecognisedasbothadriverfordisparitiesandacrucialperiodforinterventionsaimingtocombatexistinginequalitiesandpreventtheirimpactinadulthood.In2010theMarmotReviewaddressedearlychildhoodde-velopmentasan integralpartofasustainablestrategy for reducinghealth in-equalitieslinkingittosocialinjustice.Acommonapproachtotacklehealthinequalitiesaffectingcertainsocio-econom-icgroups, communities, regionsandcountries isnecessary forensuring socialcohesionwithintheEuropeanUnion,requiringgreatercommitmentofMemberStates,whichplaya crucial role for achievingadurable impactonhealthdis-parities.Initsrecommendationsissuedin2013theEuropeanCommissionem-phasisedtheneedforjointeffortsofMemberStatestoendinequalitiesexistinginsociety.15 TheEuropeanCommissioncalledonMemberStatesto implementintegratedpoliciesagainstchildpovertyandsocialexclusiontoachievepositiveresultsinchild’shealthandthus,lesseninequalitiesbetweendifferentsocio-eco-nomicgroupsandtakeastepforwardtowardssocialcohesion.However,theso-cialandeconomicsituationofvulnerablechildrenacrossEuropehasnotenjoyedasignificantimprovement.Childpovertyremainsanobstacleformanychildrento grow in a healthy environment, preventing their optimal development andimpactingothersocialoutcomesduringtheirlifecourse.ThesecondandmostrecentMarmotReviewclearlyshowsthefailureofpolicymakersinEnglandtoreducethegapinhealthaffectingvulnerablechildren,whichreflectsthefailuretorealizehealthequityinwidersociety.Thereporthighlightsthe impactofEnglishausteritymeasuresonearlychildhooddevelopment, in-creasingstillfurtherlevelsofchildpoverty,homelessnessandexacerbatingtheexistinghousingcrisis.SimilarmeasuresweretakeninmanyMemberStatesfol-lowingthe2008economicandfinancialcrisis,leavingmanycommunitieslivinginpoorsocialandeconomicconditions,withlessopportunitiestomaintaingoodphysicalandmentalhealth.WorsenedsocialandeconomicconditionsacrossEu-ropeproduceddirecteffectsonearlychildhooddevelopmentcreatingmultipledisadvantagesforchildrenfromvulnerablefamilies.TheMarmotReviewhighlightsthelackofpositiveresultsinchildpovertyreduc-tionand itseffectsonearlychildhooddevelopment,risingthevulnerabilityofcertainsocio-economicgroupstopovertyandsocialexclusion.InEngland,since2010thehighestratesofchildpovertyareexperiencedbychildreninsinglepar-enthouseholds-with47%ofchildrenatriskofpovertyfacinghigherriskofpoorhealth.Moreover,43%ofchildrenlivinginfamilieswiththreeormorechildrenwerelivinginpovertyintheUKin2018.Childrenfromethnicminoritiesarepar-ticularlyaffectedbyinequalitiesinincomeandhealth,raisingfurtherquestionsaboutequalopportunitiesforoptimalearlychildhooddevelopment.Thefigures16illustratingchildpovertyanddeprivationinEUMemberStatesare

15 Investinginchildren:breakingthecycleofdisadvantage,ECrecommendations,20February2013:https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX-:32013H0112&from=EN

16 Eurostat,Childrenatriskofpovertyorsocialexclusion: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Children_at_risk_of_poverty_or_social_exclusion#-General_overview

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alsoalarming. In2018,23.4%ofEurope’s childrenwereat riskofpovertyorsocialexclusion,withthehighestrate(38,1%)recordedinRomania,followedbyBulgariaandGreece.17HouseholdstructurehasalsonotableeffectsonpovertyintheEU,withsingleparenthouseholdsandthosewithlargefamiliesthemosthit.AccordingtoEurostat,suchhouseholdsarealmostthreetimesmoreexposedtotheriskofpoverty(42.8%)orsocialexclusion,comparedwith15.6%ofhouse-holdswithtwoadults.Childpovertyisalsocloselylinkedtoparents’educationalattainment,theirem-ploymentstatusand incomeand followssocialgradients. Ingeneral,apersonwithalowereducationaldegreehaslessopportunitiestoaccessbetterpositionsandregularincome.Also,theriskofpovertytendstoincreasewheneducationalattainmentdecreases.AccordingtoEuropeandata,in2018,51.5%ofchildrenatriskofpovertywerelivinginhouseholdswith lowersecondary levelswhilstonly7.4%ofchildrenwhoseparentshadhigherlevelsofeducationwereatriskofpoverty.InsomecountriessuchasRomania,LithuaniaandSlovakiathisgapreaches70points.Onechildintwo(51.5%)whoseparentshavelowereduca-tionallevelsexperiencepoverty,materialormonetarydeprivation.Lowereducationalattainmenthasfurtherconsequencesonparents’capacitytomaintainemployment,whichcanbeadecisivefactorforearlychildhooddevel-opmentandthechild’slifeasawhole.Parents’labourmarketparticipationde-finestheircapacitytomeetchild’sneedsintermsofhealthynutrition,learningactivities,accesstoqualityhealthcareandprevention,decenthousingandasafeandhealthylivingenvironment.AccordingtotheMarmotReviewfindingschildpovertyishighestforchildrenlivinginworklessfamilies-inexcessof70percentof children in these families are inpoverty,up fromover60percent in2010,affecting1.3millionchildren.Childrencontinuetofacepovertywhenoneoftheparentsisnotworkingorworkingparttime,and1.6millionchildrenarelivinginsuchasituationinEngland.Achildwhoseparentshavehigherlevelsofeducationcanalsobeatriskofpover-tyaslongasdiscriminationinaccessingemploymentcontinuestoexistinsociety.ThishasbeenconfirmedbyEuropeanstatistics18comparingemploymentratesofnative-bornpopulationsandthosewithmigrantbackground,bothgroupshavingtertiaryeducation.InmostoftheEuropeancountriesthenative-bornpopulationhas greater employment rates thanpeoplewithmigrant background.Accord-ingtotheannualreportonintraEULabourMobilitypublishedbytheEurope-anCommissionin2018,peoplewithmigrantbackgroundaremoreoftenrepre-sentedinsectorswheretheyareoverqualifiedfortheirjobs.Frequently,peoplewithmigrant backgroundwith high educational levels get access to positionsthatrequireuppersecondaryeducation,suchasclerks,crafts,elementaryoccu-pations,machineoperatorsetc.Therateofoverqualifiedworkerswithmigrantbackgroundishighestamongclericalsupportworkers,wherearound55%ofthepeoplewithmigrantbackgroundholdanuniversitydegree,comparedtoapprox-imately30%ofnationals.Disparitiesbetweennative-bornpeopleandthosewithmigrantbackgroundhavingtertiaryeducationraiseissuesofinequalitiesinac-cesstoemployment.Consequently,childrenwithmigrantbackgroundfacetwotimeshigherriskofpovertythanchildrenwithnative-bornparents (Eurostat).Childrenwith at least one foreign-born parentwere at higher risk of poverty(17.5pphigher),thegreatestdisparitieshavebeenobservedinBelgium(+28.5pp),Spain(+29.5pp),Sweden(+29.9pp)andFrance(+30.3pp).DisparitiesareevenwiderwhenitreferstoRomachildren.Evidenceshowsthat90%ofthemliveinhouseholdsbelowthenationalpovertythresholdandapproximately40 %ofRomachildrenexperiencemalnutritionorhungerhavingsevereconsequences

17 Eurostat18 Eurostat,Migrantintegrationstatistics–labourmarketindicators

| 13 EPHA | HEALTH INEQUALITIES

onchild’shealthanddevelopment,aswellaseducationalattainmentandem-ploymentcompetitivenessinadulthood.19

Childpoverty isamajorsocialconcernpreventingoptimalearlychildhoodde-velopment,whichremainschallengingforchildrenfromvulnerablegroupssuchasethnicminorities,migrants,childrenwithdisabilities.Deepandgenerationalpovertyexperienced in theearliest yearsof life, results inhigherexposure tohunger,malnutrition,poorhealth,bothphysicalandmental.Moreover,itraisestheissueofadequatechildprotectionagainsthumanrightsviolationstrengthen-ingtheirvulnerabilitytopovertyandsocialexclusion.The2020MarmotReviewhighlightstheeffectsofpovertyandmaterialdepriva-tiononearlychildhooddevelopment,providingevidenceaboutthepoorcondi-tionsinwhichmanychildrenliveandgrow,andthegrowingratesofchildpovertyand the social andeconomic disparities they are facing since 2010.Wideninghealth inequalities have long-term negative consequences for these children,theirfamiliesandcommunities.Therefore,reducingchildpovertyisanimpera-tiveforpromotingequalopportunitiesandachievingequityinsociety.

“Child poverty is not an inevitability, but largely the result of political and policy choices in areas including social protection, taxation rates, housing and income and minimum wage

policies.” (Marmot Review: 10 Years On)

Livingatriskofpovertyanddeprivationisnotwithoutconsequencesforchildhealthandwell-being,especiallyinthefirstyearsoflifecharacterisedbyinten-sivephysicalgrowthandcognitivedevelopment.The2020MarmotReviewsendsan alarmingmessage topolicymakers and society about child abuse, neglectanddomesticviolenceunderdifferentformsorplacement inchildcare institu-tions,whichcanleadtoseverechronicillness,suchasheartandlungdisease,hypertension,diabetesorevencancer.Mentalhealthdisorderscanalsobeduetoadversechildhoodexperiences,highly influencedbypoverty, job insecurity,deprivationandsocialexclusion.Wherefore, early childhooddevelopment requires strong child protection sys-temsandsocialandfamilysupportservices,whichisfundamentalforpreventingfurtherdisadvantageinadulthood.Providingchildrenwithbetteropportunitiestogrowinasafeandhealthyenvironmentneedsanumberofactionstoeradi-catepovertyandofferbettersupporttofamilieslivingindeprivation.Singlepar-enthouseholds,migrants,ethnicminoritiesandothervulnerablegroupsmustbeofferedspecificmeasuresproportionatetotherisksandchallengestheyface.Reducingfundingforsocialservicestargetingvulnerablegroupsandfamilieshasadverseeffectsontheprocess:theMarmotReviewhasshownthatdecreasingfundingforfamilyservicesalsogeneratesincreasesinchildpoverty.Raisingchil-dreninpovertyanddeprivationisnotonlyharmfulforearlychildhooddevelop-mentandchild’shealthbutalsoinfluencesothersocialoutcomes,harmingourwidersocietiesandeconomies.Furthermore,leavingbehindentirecommunitiesofpeoplewithmigrantbackground,ethnicminorities,anddisabilitiesshouldnotbetoleratedacrosstheEuropeanUnionwhichpromotesvaluesofequalityandsocialfairness.Europeshouldbetterprotectitschildrentoensuretheygrowupinthebestconditionsforrealizingtheirfullpotential.TheMarmotReviewrecommendationsarevalidnotonlyforEnglandbutalsoforEUMemberStateswheremanychildrenliveindisadvantage:

19 Povertyandemployment:thesituationofRomain11EUMemberStates,FRA2014:https://fra.europa.eu/sites/default/files/fra_uploads/fra-2014-roma-survey-dif-employ-ment-1_en.pdf

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“Comprehensive whole-systems approaches that take effective and sustained action on the causes, prevalence and impacts of ACEs [adverse childhood experiences] and impacts of deprivation across all of children’s frontline services is necessary to improve health, reduce inequalities in health, prevent the transmission of disadvantage and inequality across generations and improve the quality of life of children, young people and adults”.

Increasingsocialinvestmentinearlychildhooddevelopmentisacrucialandin-dispensablephaseofaprocessforpreventingfurtherhumanandfinancialcostsgeneratedbyhealthinequalitiesacrossEurope.

EPHA | HEALTH INEQUALITIES| 15

3. Access to quality education - a strong factor for reducing inequalities in society

AccesstoeducationisafundamentalrightguaranteedbyEuropeanandnationallegislationsaimingtoinsurebetterprotectionofchildren’srightsacrosstheEu-ropeanUnion.Article14oftheEuropeanUnionCharterofFundamentalRightsstipulatesthat“everyonehastherighttoeducationandtohaveaccesstovoca-tionalandcontinuingtraining.Thisrightincludesthepossibilitytoreceivefreecompulsoryeducation.”20

Equalaccesstoqualityeducationisessentialforbuildingsustainable, inclusiveandequitablesocietiesandeconomiesandisamajordriverforcombatingpov-ertyandsocialexclusionacrossEurope.Thishumanrightisindispensablefortheempowermentofpopulationgroupspushedatthemarginsofsociety. Ithasavitalroletoplayinensuringwomen’srightsprotection,protectionagainstdis-criminationaswellastherealizationofmultiplesocialandeconomicrightswhichareparticularlyrelevantforachievingapositivechangeinhealthinequalities.Despiteexistingnationalpoliciesandlegallybindinginstrumentsaimingtoen-sureequalaccesstoqualityeducationforall,manychildrenstillfacebarriersinaccesstoeducationandcannotfullyenjoytheirrights.Certainsocialandeco-nomicgroupsoftenexperiencelessaccesstoeducation,whichisbothadriverandaresultoftheirvulnerability.Somefaceparticularvulnerabilitieswithinna-tionaleducationsystemswhichcorrelateswithothersocialandeconomicdisad-vantages.TheMarmotReviewemphasisestherelationshipsbetweensocio-economicfac-torsandeducationalattainmentandtheirimpactonhealth.Socialandeconomicdisparitiesexperiencedbypupilsandstudentshavelong-termeffectsintermsofqualityofwork,income,healthandcanleadtogenerationalpovertyandmateri-aldeprivation.Theyaffectparentsandchildrenfromtheearliestageoftheirlifeanddefinechildren’saccesstoqualityeducationandeducationalachievement.Socialandeconomicdisparitiesgenerateagapineducationwhich,accordingtothe2020MarmotReview,tendstowideninprimaryandsecondaryschoolleav-ingtheaffectedpupilswithlessopportunitiestoachievetertiaryeducation.Inparallel,schooldrop-outcanbeobserved,whichisalsoaresultandadriverofin-equalities.Childrenfromsociallydisadvantagedfamiliesaremorelikelytoleaveschoolprematurelyandfaceschoolexclusion.ThefindingsoftheMarmotreviewhavedemonstrated,since2010,asignificantriseinschoolexclusionsinbothpri-maryandsecondaryschoolsaffectingchildrenindisadvantagedsocio-economicsituations,inparticular,resultinginpoorsocialoutcomes.Childrenwithdisabili-ties,ethnicminorities,andmigrantsaremorelikelytobeaffectedbyeducationaldisparities,schooldrop-outandschoolexclusioncomparedwiththoseinbettersocialandeconomicsituations.EthnicgroupssuchasBangladeshi,ChineseandIndianchildrenfacetwotimesgreaterrisktoleaveschoolbecauseofexclusionthan“whiteBritishchildren”.Pupilsfromotherethnicgroupsarealsoconcernedbysuchdisparities,inparticularBlackCaribbean,Gypsies,RomaandTravellersandthosehavingamixedbackground.IntheEU-27,Romaareparticularlydisadvantagedinaccessingqualityeducationand enjoy less protectionof their right to education. Romapupils experiencemoreoftengenerationalanddeeppovertyandsocialexclusionwhichmanifestsitselfindifferentforms,includingethnicsegregationinschools,preventingequalaccess to quality education. Furthermore, the placement of Roma children inschools formentallydisabled students is a commonpractice inmanyEurope-

20 https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:12012P/TXT&from=EN

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an countries, depriving themof the opportunity to realize their full potentialthroughadequatelearningopportunitiesandimprovetheirsocialandeconomicconditions.DespitehavingbeendeclaredillegalbytheEuropeanCourtofHumanRights,whichconcludedthatethnicsegregationinschoolsisdiscriminatoryandviolatesRomachildren’srighttoeducation,ethnicdiscriminationinschoolper-sistsinmanyEuropeancountries.ItcausessevereconsequencesforthesocialandeconomicrightsofRomaandfurthercontributestotheirhighervulnerabil-itytopoorhealth.21TheEuropeanCommissionhas initiated infringementpro-ceduresagainstCzechRepublic(2014),Slovakia(2015)andHungary(2016)forethnic segregation towhichRomachildrenare subjected in these countries.22 Nevertheless,thereisnotasignificantprogressincombatingethnicsegregationwideningthegapineducationbetweenRomaandnon-Roma.Childrenwithdisabilitiesareanothercategoryexperiencinghigherexposuretoinequalitiesineducation.Accesstoqualityeducationremainsamajorconcernand thepersistent lackof adequate learningopportunitiesprovidedbyhighlyqualifiedstaffiswideningacrossEurope.ArecentEuropeanCommissionreportrevealedthatchildrenwithspecialneeds ineducationhave lessopportunitiesto securehigh-level education, and consequently aremore vulnerable to em-ploymentprecariousness,povertyandexclusion.Approximatelyhalfofdisabledpersons intheEuropeanUnionexperienceunemployment-this isparticularlyconcerninginHungarywhereonly24%ofpeoplewithdisabilitiesarelegallyem-ployed.23

Childrenwithdisabilitiesfacedifferentchallengesinaccessingqualityeducationbecauseoftheaccessibilityandavailabilityofadaptedsettingsandqualifiedstaff.AlthoughinclusiveeducationisgreatlypromotedbytheEuropeanInstitutions,it requires higher costs compared tomainstreameducational settings, includ-ing investment in infrastructure, facilities and learningopportunities. Effectivein-schoolsupportforchildrenwithdisabilities isneededtoprovidethemwithquality education and learning,which rises the costs formainstream schools,includingprovisionofspecialisedstaff,aswellasadditionaleducationalandpsy-chologicalsupportfordisabledchildren,whoareoftenexposedtodiscriminationandharassmentinschool.AccesstoeducationofdisabledchildrenhasbeenfullyintegratedintotheEuro-peanDisabilityStrategy24 2010-2020establishingapolicyframeworkforinclusiveeducationaimingtoincreasetheprotectionofchildrenwithdisabilitiesandsafe-guardthattheyhaveequalaccesstoeducationandtraining.However,asedu-cationisaMemberStatecompetence,theoutcomesininclusiveeducationvaryconsiderablyduetothedifferencesinnationaleducationalpoliciesandsystems.Therefore, inclusiveeducationprovidingequalopportunities forall, regardlessofethnic,social,economicandhealthstatusremainsanunreachedgoalacrossEurope.

21 CaseofLavidaandothersv.Greece(Applicationn°7973/10)22 Romaandtheenforcementofanti-discriminationlaw,EC,DGJust,201723 Accesstoqualityeducationforchildrenwithspecialeducationalneeds,EuropeanCom-

mission201824 EuropeanDisabilityStrategy(2010-2020):https://eur-lex.europa.eu/legal-content/EN/

TXT/?uri=LEGISSUM%3Aem0047

EPHA | HEALTH INEQUALITIES

4. Ensure a healthy standard of living for all

Income and financial resources are essential conditions formaintaining goodhealthstatusbecausetheydefineanindividual’scapacitytoafforddecenthous-ing,healthynutrition,andtosomeextent-accesstotimelyandqualityhealthcareandpreventionservices.Thoseonlowincomesaremorelikelytobeconfrontedbybarriersinhealth,housingoreducation.Unevendistributionofresourcesin-creasesstillfurtherthelevelofinequalitiesbetweensocio-economiccategories,exacerbatingindividualsandcommunities’vulnerabilitytoill-health.The2020MarmotReviewclearlyshowsthatEnglandisnoexception.Between2010and2020levelsofin-workpovertyhaverisen,mainlyduetolowsalaries,inflation,higherhousingcostsandcutsinsocialbenefitsprovokedbyausteritymeasures.TheMarmotReviewdemonstratesthatthemostdeprivedhouseholdsarethosewhosufferedthemostfromausterityduringthelastdecade.SimilartrendshavealsobeenobservedacrossEUMemberStates.While inequalitiesbetweenandwithincountrieshavebeen identifiedasase-riousimpedimenttosustainabledevelopment,andareanessentialgoalofthe2030UNAgendaforSustainableDevelopment,disparitiesinwealthdistributioncontinuetowidenacrossEuropeancountries.ThepoorresultsfrompoliciestoreducepovertyacrossEuropehaveledtoagrowingdividebetweenEuropeancountriesandupperandmiddleclasseswithincountries.Theprocessofimpov-erishment ishighly influencedbyunemploymentandemploymentprecarious-ness,thein-workpovertyobservedacrosstheEUduetolowwages,increasedhousingandaccommodationcostsandausteritymeasuresaffectingsocialpro-tectionsystemsandfamilybenefits.WhilemanyEUcountrieshaveintroducedaminimumwageasameasureofem-ployeeprotection,aguaranteedminimumsalaryremainsimpossibleforEurope-anslivinginDenmark,Italy,Cyprus,Austria,FinlandandSweden.Also,significantdisparitiescanbeobservedbetweencountries-nationalminimumwageratesvarybetweenEUR312inBulgariatoEUR2142inLuxembourg.In Latvia, Romania and Hungary nationalmonthlyminimumwages are lowerthanEUR500permonth,reflectingthehigherpovertyratesrecordedinthesecountries.25 Often,theminimumwagedoesnotprovidesufficientresourcestomeetpeople’sneeds,especiallyforfamilieswithchildren,singleparentsorlargefamilies.Tobeefficient,theminimumwageshouldnotonlybeguaranteedbynationallegislationbutalsofulfilcertainconditionssuchasadequacy,pricelevelsintherespectivecountriesandprovidesufficientresourcestoenablepeopletomeettheirneedsinhealth,housing,educationandleadhealthylives.Adequateminimumwage rates stronglydependon social andeconomic factors suchaslabourmarketparticipation,theeconomicsituationofthecountry,butalsoonhousehold composition. According to a report26 commissioned by the Euro-peanCommissionthesectorswithhighconcentrationofminimumsalariesareaccommodationandfoodservices(16%)followedbyagriculture(15%),asectorwhereinequalitiesarefrequentlyobserved,includinghigherriskofemploymentprecariousness.Principle6oftheEuropeanPillarforSocialRightsstipulatesthat“workershavetherighttofairwagesthatprovideforadecentstandardofliving.”Adequacyofminimumwagesshouldcorrelatewithworkers’needsaccordingtoeconomicandsocialsituations ineachrespectivecountry.Adequacyofminimumwagemust

25 https://ec.europa.eu/eurostat/statistics-explained/index.php/Minimum_wage_statis-tics#General_overview

26 Minimumwagesin2020:AnnualReview,Eurofound2020:https://www.eurofound.euro-pa.eu/sites/default/files/ef_publication/field_ef_document/ef20005en.pdf

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alsopreventin-workpoverty,whichhasincreasedfrom8.3%in2010to9.6%in2016withhighestratesobservedinRomania(18.9%),Greece(14.1%)andSpain(13.1%).27Nevertheless,thelackofcommonprovisionsforafair,sufficientandadequateminimumwagemakesitdifficulttosetcommonEUframeworkforde-finingnationalminimumwagewhichcancontributetopreventfurthergrowthofsocio-economicdivideacrosstheEuropeanUnion.TheneedforanadequateminimumincomehasalsobeenacknowledgedatEu-ropean levelasaminimumguarantee foradecent lifeandprotectionagainstpovertyanddeprivationforall.Itsuniversalcharacterprovidesaconcretemea-suretoreduceinequalitiescausedbythelackof,orlow,income,sothatpeoplecancovertheirbasic livingcosts relatedto food,accommodation,clothesetc.Guaranteedbasicincome schemeshavebeenintroducedinFranceandSpain,forexample,asanimportanttooltocombatpovertyandsocialexclusion,providingfinancialsecurityandstrongersocialprotectionforthoseinneed.Abasicincomeplaysacrucial role inredistributingwealthandresourcespromotingsolidaritybetweensocio-economicgroupsandisasteptowardssocialjustice.Ithasdirecteffectsonmacro-economymitigatingtheimpactofeconomicandsocialcrisesonthemostvulnerable.Abasicincomeprovideseconomicstabilitybygeneratingadditionalfinancialresourcesallowingpeopletomeettheirbasicneeds.Despitetheirprovenpositiveeconomicandsocialeffects,someMemberStateshavenottakenactionstointroduceabasicincomeintonationalsocialprotectionsystems.Furthermore,incountrieswhereabasicincomeexists,somesocialcat-egoriescanstillbeexcludedfromthismeasure.Despiteitsuniversalcharacter,abasicincomerequirespeopletofulfilsomeadministrativeproceduresandreplytosomeconditionssuchashavingapostaladdress,whichinpracticepreventsthosewithnofixedabodeor postal address frombenefitting from this socialsafetynet.Consequently,suchsolidarity instrumentsshouldbestructured inawaytobeinclusiveandaccessibleforall,inordertoreachallbeneficiariesatriskofsocialexclusion.Improvingtheaccessibilityofbasicincomeschemesautomaticallyin-creasestheireffectivenessandthepositivebenefitsforsocietiesandeconomiesaswellasformanycommunitiesparticularlyaffectedbyinequalitiesinwealth.

27 Eurostat,In-workpovertyintheEU

EPHA | HEALTH INEQUALITIES

5 Create and develop healthy and sustainable places and communitiesInequalitiesinincomeprovokedbysocialandeconomicfactorshaveimplicationsonaccesstohousingandhousingconditionsasawholeand,atthesametime,theycontributetofurtherincreasesuchgaps.DisparitiesinhousingareprofoundandpersistentregardlessofanindividualMemberState’seconomicandsocialprogress.Peoplewithlowerfinancialresources,especiallythoseatriskofpover-tyhavelessopportunitiestoaccessandmaintainqualityhousingcorrespondingtothecompositionoftheirhouseholdsandneeds.Wideningdisparities in income lead to issues concerning theaccessibility andaffordabilityofqualityhousingandaccommodationforcertainsocio-economicandpopulationgroups.Gapsinhousingdisproportionatelyaffectethnicminori-ties, includingRoma;homelesspeople;peoplewithdisabilities; singleparentsandwomendemonstratingaclear linkbetweenaccess tohousingand riskofpovertyandsocialexclusion.Atthesametime,thesystemiccharacterofinequalitiesbothinincomeandhous-ingimpactingcommunities’healthraisesissuesfromahumanrightsperspective,relatedtoadequateprotectionofthoseinvulnerablesituations.Thecorrelationbetweendisparitiesinhousingandsomesocialfactors,suchasage,sex,ethnic-ity,anddisabilityetc.pushfurtherthereflectionaboutpersistentdiscriminationagainstcertainpopulationgroups. Italsoshowsthat reducinggaps inhousingrequires strongpoliticalmeasures targeting vulnerablepopulationgroups andpolicy solutionsaiming toguarantee theirprotectionagainstdiscrimination inaccesstoqualityhousing.AnewreportreleasedbyFEANTSAandFondationAbbéPierreshowsthat700,000peopleintheEuropeanUnionexperiencehomelessness-a70%increasecom-paredto201028demonstratingtheseverityofthehousingcrisisacrossEurope.This isoneof themostextremeformsofdeprivationandexclusionwhere formanyreasons,securinghousingisnotpossibleforentirehouseholdsandcom-munities.Thereasonsforthissocialandeconomicissuearecomplexandgobeyondpov-erty itself. The loss of housingmaybe causedby the loss of incomebut alsocanbeprovokedby ill-health.Often,poorphysicalandmentalhealth isa fac-torexacerbatingindividuals’vulnerabilitiestounemploymentandemploymentprecariousness and result in less opportunities tomaintain and afford decenthousing.Moreover,discriminationinaccesstohousingbecomesmoreandmorefrequentacrossEuropeamongstethnicandreligiousminorities,peoplewithmi-grantbackground,thosewithdisabilities,singleparents.Spatialsegregationasaformofethnicdiscriminationalsopreventsindividualsandcommunitiesfromaccessingqualityhousing.Consequently,housingbecomesa crucial socialde-terminantofhealthandacomponentofhealthinequalitiesandvulnerabilitytopoorhealth.AsstatedintheFEANTSAreport,homelessnessaffectscertainvulnerablegroupsandtakesdifferent formsaccordingtophysical, socialand legaldimensionsofthe issue.FEANTSAproposesa classification including fourmain forms: “roof-lessness,houselessness,livingininsecurehousing”andthelackofdecenthous-ingandidentifiesfourmaincategoriesofpeoplethatcanbeaffected:rooflesspeoplewithnoaccess tohousingatall;homelesspeoplewhohaveaccess totemporary andemergency shelters; people in insecurehousing - those facingathreatofimmediateeviction.Thefourthsocialcategoryconcernspeopleex-periencingsubstandardhousingconditionsprovokingmultiplehealthrisksand

28 FifthoverviewofhousingexclusioninEurope,FEANTSAandFondationAbbéPierre,2020

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environmentalburdens.Commoncharacteristicsofallthementionedcategoriesareobstaclesconcerningtheaccessibility,availabilityandaffordabilityofhousingandaccommodation.According to theEuropeanCommitteeof SocialRightsdefinesaffordabilityofhousingdependsonthecapacityofconcernedhouseholdstocovertherelatedlivingcosts(monthlyrent,billsandcharges)withoutbeingdeprivedofminimumstandards of living. However, this is not achievable formany Europeans,whofacedisproportionatehousingcostscomparedtotheirincome.Increasedhous-ing costshavebeen recorded inEuropeancountries, resulting in loweracces-sibilityandaffordabilityofdecenthousing.This issueconcernstwooutoffivepeopleinGreece,oneinfiveinBulgaria,andoneinsixinDenmarkandGermany,accordingtoEurostat.In2018,17.1%oftheEuropeanpopulationlivedinover-crowdeddwellingswith4.3%exposedtoseverehousingdeprivation,29whichisaresultofaffordabilityandaccessibilityofadequatehousingcorrespondingtothehouseholds’compositions.ThehighestratewasrecordedinRomania(46.3%)illustratingthebarriersinaccesstodecenthousing-havingasufficientspaceforlivingbeingakeyindicatorforassessingitsquality.Asstatedinthe2020MarmotReviewa similar situationhasbeenobserved in Englandwherehousing costshavenotablyrisensince2010,withagreaterimpactonthemostvulnerableanddisadvantagedhouseholdsandcommunities.Althoughtheoverburdencausedbyhousingcostsconcernsmanysocialandeco-nomicgroups,theyhavesevereconsequencesforthosewhoalreadyexperiencedeprivation, including in-work poverty.30 Housing cost overburdens affectinghouseholdsatriskofpovertyhaveincreasedinmostoftheMemberStates inthelasttenyearsreaching90%inGreece,75%inDenmarkand50%inBulgaria.31 Asa result, thepooresthouseholds are thosemost concernedbyovercrowd-edhousing,withthehighestratesbeingrecordedinRomania(56.4%),Slovakia(54.9%),Bulgaria(48.7%)andPoland(47.7%).

TheMarmotreviewshowsthatethnicminoritiesarethosemostconcernedbyovercrowdedhousing inEnglandreaching30%ofBangladeshihouseholdsand15%ofBlackAfricanscomparedwithonlytwopercentof“WhiteBritishhouse-holds”affectedbythelackofenoughspaceforliving.

InEurope,Romaarealsodisproportionatelyaffectedbynon-decenthousing,in-cludingpoorhousingconditions,spatialsegregation,severematerialdeprivationandovercrowdedhousing,accommodatingseveralgenerationsandlargefami-lies.Poorinfrastructure,includingaccesstocleanwaterandsanitation,lackofpavedstreets,pavementsandtrafficregulationinsegregatedareasdepriveRomaofadequatelivingconditions.Romasettlementsoftenlackbasicpublicservicessuchas regular rubbishcollections, safeconnection toelectricitypowergrids,orpublictransportation,leadingtosevererisksofdomesticaccidents,epidem-icoutbreaksandcommunicablediseases.The lackofadequateandsafe livingconditionsmakesthemgreatlyvulnerabletopoorphysicalandmentalhealth,contributingto10-15yearsshorterlifeexpectancycomparedtothenon-Romapopulation.32

Poor housing conditions have a direct influence on an individual’s access to

29 Eurostat,Housingstatistics,2018:https://ec.europa.eu/eurostat/statistics-explained/index.php/Housing_statistics

30 HousinginequalityinEuropeTacklinginequalitiesinEurope:theroleofsocialinvestment,CouncilofEuropeDevelopmentBank,2017

31 EuropeanIndexforhousingexclusion,FEANTSA,201932 HealthstatusoftheRomapopulationDatacollectionintheMemberStatesofthe

EuropeanUnion,EC,2014:https://ec.europa.eu/health/sites/health/files/social_determi-nants/docs/2014_roma_health_report_es_en.pdf

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healthcare, prevention services, childcare and education, job opportunities -pivotal factors for reducinghealth inequalities. The 2020MarmotReviewhasshownaclearrelationshipbetweenpoorhousing,includingsubstandardlivingconditionsandpoorhealth.IfsomeimprovementshavebeennoticedinEnglandover the lastdecade, thereare still a largeproportionofhouseholds living inpoorhousingconditions,mainlyintheprivatesector,withovercrowdedhousing,damp, condensation ormould responsible formultiple chronic diseases,withlong-termeffectsonindividuals’andcommunities’health.Moreover,poorandovercrowdedhousingcreatesfavourableconditionsforthetransmissionofcom-municablediseasesandinfectionsandisassociatedwithhighermortalityrates.33

Poorhousingconditions,includingdampandovercrowdedhousingalsocontrib-utestomentalhealthconditionssuchasstress,depressionandanxietyaswellasthefeelingofpowerlessnessandlossofcontroloverlife.Non-decenthousinghasdevastatingeffectson children, especially in thefirstyearsoflifewhenphysicalgrowthandmentaldevelopmentareparticularlyin-tensive.Childrenlivinginovercrowdedhomesaredeprivedofadequatespaceforliving,playingandlearningactivities;theybecomemorevulnerabletopoorphysicalandmentalhealthandhavelesschancestoachievetheirfullpotentialatschool.Efficientpolicymeasuresformakingqualityhousingaffordableandaccessibleforthemostdisadvantagedgroupsarethereforean imperativeforbothreversingthetrendsofpoorhealthofvulnerablegroupsandreducingsocialinequalities.TheEUdoesnothavelegislativecompetencesinthefieldofhousing;nationalgovernmentsareresponsibleforthedesignandimplementationoftheirrespec-tivehousingpolicies.However,thesimilarityofchallengesfacedacrossMemberStatesrequireacommonapproachandjointeffortstoresolvethehousingcrisis,includingimprovingtheavailability,accessibilityandaffordabilityofdecentandadequatehousing,withaspecificfocusonsocially-disadvantagedandvulnerablegroupssusceptibletohousinginequalities,housinginsecurityandhomelessness.TheEuropeanUnioncanprovidesignificantsupporttoMemberStatesthroughaninclusiveandcomprehensivepolicyframeworkandprogrammestoaddresscommonchallengesfacedbyEuropeancountries.Socialhousing,greatlypromotedbytheEUpolicymakersappearstobeanad-equatesolutiontothehousingcrisis.Article34oftheCharterofFundamentalRightsoftheEuropeanUnionrecognisesthemajorroleofsocialhousinginerad-icatingpovertyandsocialexclusionandsuchmeasurescan furthercontributetoreduceinequalitieswithinandbetweenEuropeancountries.However,itstillraisesquestionsofavailabilityandaccessibility,especiallyforthoseinvulnerablesituationsaswellasthelimitedroleoftheEuropeaninstitutionsinthisarea.Tacklinghealth inequalities throughdecenthousing requiresalsoactionsaim-ingtoaddressenvironmentalburdensandpollutionwhichworsen individuals’andcommunities’health.In2010theMarmotReviewcalledonpolicymakerstoimplementactionstomitigatetheeffectsofclimatechangeduetotheirprovenlinkswithhealthandsocial inequalities.Themostdisadvantagedcommunitiesarethemostexposedtoenvironmentalburdens,suchasair,groundandwaterpollution,oftenassociatedwithpoor livingareasandhousingconditions.Lesscapacitytoaffordqualityhousingpushessocially-disadvantagedgroupsandpeo-plewithlowincomestoareaswithunfavourableconditions,closertoindustrialzonesorfarmswheretheinhabitantsaremorefrequentlyexposedtomultipletypesofpollution,harmingchildandadulthealth.AccordingtotheWorldHealthOrganizationincreasedglobalairpollutionlevelsareleadingtotheprematuredeathofapproximately7millionpeopleeachyear,

33 MinistryofHousing.CommunitiesandLocalGovernment.EnglishHousingSurveyHead-lineReport,2016to2017.MHCLG;2018

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frompulmonaryandcardiovasculardisease,cancer,andotherchronicdiseases,respiratoryinfections,includingpneumonia.34Reducedaccesstoqualityhousing,healthandpreventionservices,aswellasthemoreharmfullivingconditionsex-periencedbyvulnerablegroups,environmentalburdenssuchasair,groundandwater pollution have stronger effects on disadvantaged communities, furtherincreasingthehealthriskstheyface.Acknowledgingtheirspecificvulnerabilitytoenvironmentalburdenswill contributetoeffectivelyaddressing the levelofinequalitiestheyfaceintermsofhealth,housingconditionsandlivingenviron-mentandmitigatetheimpactofclimatechangeonthem.

6. COVID-19 and health inequalities across Europe

TheMarmotReviewwasreleaseda fewweeksbeforetheCOVID-19pandem-icwasdeclaredinEurope.Thereportshowedthatlowcommitmenttoreducehealthdisparitiesbyaddressingholisticallysocialdeterminantsofhealth leadstoincreasedvulnerabilityofsocietiesandeconomies.Theunprecedentedpan-demicanditsstrongersocialandeconomiceffectsonthemostvulnerablehaveperfectlyillustratedtheconsequencesofpoorpolicycommitmenttotacklepub-lichealth,andthesocial,economicandhumanrightsissuescausinghealthin-equalities.Vulnerabilitytoill-health,includingnon-communicablediseases,accesstohealthandsocialprotectionservices,substandardlivingconditions,greaterexposuretopollutionarepre-existingconditionsincreasingtheparticularvulnerabilityofcer-tainpopulationgroupstothehealth,socialandeconomicimpactofCOVID-19.Thosealreadyexperiencingdifferentformsof inequalitiessuchaspovertyandsocialexclusion,reducedaccesstoeducation, ill-health,orworsehousingandlivingconditions,enjoyedlowerprotectionagainstCOVID-19andhavebeenhitthehardestbythepandemic’ssocio-economiceffects.Areview35releasedinJune2020byPublicHealthEnglandshowedsignificantdis-paritiesintheriskandoutcomesfromCOVID-19,whichreflecthealthinequali-tiesasawhole.ThereviewrevealedthatthoselivingindeprivedareasinEnglandfacedhigherrisksoffatalitiesfromCOVID-19comparedtothoselivinginbetterconditions,orfromhighersocio-economicgroups.Thepandemiccausedmorefatalitiesinthemostdeprivedregionswheretherecordeddeathratesweretwotimeshighercomparedtotheleastdeprivedareas,andthistrendisobservedinbothgenders.PublicHealthEngland’sanalysisalsodemonstratedthatCOVID-19mortalityrateswerehighestamongpeoplefromBlackandAsianethnicgroups;people with a Bangladeshi ethnic background faced risk of death two timesgreaterthanpeopleof“WhiteBritishethnicity”.PeopleofChinese,Indian,Pa-kistani,otherAsian,CaribbeanandotherBlackethnicityfacebetween10%and50%higherriskofdeathcomparedwith“WhiteBritish”.Thegreatermortalityratesobservedamong“Black,AsianandMinorityEthnicgroups”comparedto“White”ethnicgroupsisaresultofexistinghealthinequalitiesexperiencedbysuchgroups,underlinedinthe2020MarmotReview.Inthesameway,inEUMemberStatespopulationgroupsalreadyvulnerabletoill-healthfacedhighervulnerabilitytoCOVID-19 intermsofpublichealth,andthesocialandeconomicconsequencesofthepandemic.ThereportreleasedbytheFundamentalRightsAgencyaddressingthefundamentalrightsimplicationsofCOVID-19inEUMemberStates,confirmedthatvulnerablegroupswerethe

34 https://epha.org/wp-content/uploads/2018/07/Clean-air-briefing.pdf35 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach-

ment_data/file/892085/disparities_review.pdf

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mostseverelyhitbythepublichealthcrisis.Romapeoplehavebeenparticularlyatriskduetosubstandardlivingconditionsandovercrowdedhousing,accommodatinglargefamilies increasingtheriskofproliferationofthevirus.ThelackofcleanwaterandsanitationinahighnumberofRomahouseholdswasamajorbarrierformanyseekingtoprotectthemselvesagainstCOVID-19,withthehighlyrecommendedmeasureofwashingtocontrolthevirusspread,beingdifficulttoimplement.LockdownsofRomasettlements,withpolicecheckpointsattheirentrancehavebeenreported inmanyEasternandCentralEuropeancountries,raisingissues intermsofequalityandhumanrightsprotection.Suchmeasures,adoptedbynationalauthoritiesasanactiontopreventthevirusspread,restrictaccesstoandfromRomasettlementsandlimit-edaccesstoqualityandtimelyhealthcareduringthepandemic.Romacontinuetofacepoorhousingconditions,environmentaldiscrimination,pooror lackofpublicservicessuchasregularrubbishcollections,cleanwaterandsanitation,raisingthequestionofadequateprotectionagainstCOVID-19andequalaccesstopreventivemeasures. Ina jointstatement,theEUCommissionerforEquali-ty,HelenaDalliandMarijaPejčinovićBurić,CouncilofEuropeSecretaryGener-alstressedtheparticularvulnerabilityofRomacommunitiesinMemberStatesandtheneedforurgentmeasurestoensuretheirprotectioninCOVID-19.36TheCouncilofEuropeSecretaryGeneralexpressedherdeepconcernsaboutsomeofthemeasuresadoptedbymanyEUMemberStates“thatcouldresultinfurthercompromisingthehumanrightsofRomaandhamperingtheirequitableaccesstotheprovisionofbasicpublicservices,mostimportantlyhealthcare,sanitationandevenfreshwater.”CommissionerDallicalledforstrongereffortstoensure“equal access to thebasicneeds” toprotectRomaagainst theCOVID-19out-breakandtackletheadditionalchallengesthatRomacanface.Experiencing greater vulnerability to poor health, housing, poverty and exclu-sion,peoplewithdisabilitieshavealsobeendeeplyimpactedbythepandemicbecauseof thesignificantdisruptionofhealthandsocialservices, limitingtheaccesstothespecificsupportonwhichtheyrely.Theirgreaterexposuretoill-healthincreasestheeffectsofreducedaccessibilityofhealthandpreventionser-vicesashealthsystemsconcentratedontheirresponsetoCOVID-19.Pre-existinghealthconditions,reducedaccesstohealthcare,higherriskofpovertyandexclu-sionfurtherincreasetheriskofcomplicationsandmortalitycausedbyCOVID-19amongpeoplewithdisabilities. Pooraccessibilityofpublichealth informationandmainstreampublichealthprotectionmeasures,aswellas thecapacityofpublichealthauthorities toadaptsuchmeasures to theneedsofpeoplewithdisabilitiesandimplementspecificactionstargetingthisvulnerablegroupisan-otherexampleofthewayinwhichpeoplewithdisabilitieshavebeenadverselyaffected.Homeless people, already experiencing less protection against communicablediseasesduetothe lackofdecent livingconditions,accesstocleanwater,hy-gieneproductsetc.areanothergroupfacingparticularrisksofcontractingthevirus.FEANTSAcriticisedthereducedopportunitiesforhomelesspeopletopro-tectthemselvesas“stayingathomewasnotanoptionforhomelesspeople.”37 Manyofthemainstreamprotectionmeasuresaimingtocontroltheepidemic’sspreadsuchasconfinementand self-isolation,hand-washing,increasedhygiene

36 8April,InternationalRomaDay:“StepuphumanrightsprotectionforRomaandguar-anteetheiraccesstovitalservicesduringCOVID-19pandemic”-statement,CouncilofEurope,7April2020:https://www.coe.int/en/web/portal/-/8-april-international-roma-day-step-up-human-rights-protection-for-roma-and-guarantee-their-access-to-vital-ser-vices-during-covid-19-pandemic-?fbclid=IwAR0zznGjsLsEoTEDIsh6Lh8hoCr8CaXmNZ-rU-L4sw-GrlcE3vOI_F8oQuQ0

37 COVID-19:“StayingHome”NotanOptionforPeopleExperiencingHomelessness,FEANTSA,18March2020:https://www.feantsa.org/en/news/2020/03/18/covid19-stay-ing-home-not-an-option-for-people-experiencing-homelessness?bcParent=26

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andphysicaldistancingwerenotachievableforhomelesspeople.Sleepingroughor staying/living in temporaryoremergency shelters increased theirexposuretotheriskof transmission.Homelesspeopleareoneofthegroupsfacingdis-proportionatehealthinequalities,includingdisabilitiesmakingthemahigh-riskcategoryrequiringstrongerprotectionagainstCOVID-19.

Childrenhavealsobeendeeplyaffectedbythesocialandeconomicconsequenc-es of the pandemic, limiting the access to education and early childhood de-velopmentservicesformanyvulnerablechildren.Attendingonlineclasseswasnotpossible for thousandsof childrenat riskofpoverty,whoseparentswereunabletoaffordtheequipmentnecessarytohavelessonsathome.Thisissueex-acerbatedtheinequalitiesfacedbyvulnerablechildrenandwillhavelong-termimplications on their access to quality education and employment opportuni-tiesinadulthood.TheAllianceforInvestinginChildren38underlinedthespecificsocialandeconomicconsequences forchildren,especially those invulnerablesituationsandcalledforimmediatemeasurestoprotectthemandmitigatetheincreased risk of poverty and social exclusion they faceduring thepandemic,andinthelong-term.Inadditiontothesocialandeconomiceffects,childrenandwomenhavebeenexposedtoincreasedriskofdomesticviolenceandlowerac-cesstomeasuresaimingtoensureadequateandtimelychildprotection,whichwillhavespecificlong-termmentalhealthimpactonchildren.

Thepandemicinfluencedmanyofthesocialdeterminantsofhealth,exacerbatingexistinginequalitiesbetweenandwithinMemberStates.COVID-19hasgreatlyimpactedthe livesofnumerouspeopleacrossEurope,buthashaddispropor-tionateeffectsonvulnerablegroups,whenitcomestohealthandsocialprotec-tion,labourmarketparticipationandhumanrightsasawhole.IthasthreatenedtheemergenceofeconomicrecessionsinMemberStatesthroughlossofincome,reducedlabourmarketparticipationinmanysectors,increasingunemploymentandemploymentprecariousnessformanyduetothereductionineconomicac-tivities.Consequently,increasedpovertyrateswillimpactindividuals’andcom-munities’capacitytoaccessandaffordtimelyandqualityhealthcareandpreven-tion,affordqualityhousingandmaintaingoodlivingstandards.

Conclusion

The“MarmotReview:10YearsOn”demonstratesthathealthinequalitiespersistinEnglandandconcernmainlysocially-disadvantagedgroups.Thereportcon-firmsthegrowingdividebetweenpopulationgroupsinEngland,whichremainsfarfromreachingtherecommendationstoadvancesocialjusticeandhealtheq-uitymadeintheoriginalreview10yearsearlier.DecliningpopulationhealthandwideninghealthinequalitiesinEnglandprovideevidenceofmajorissuesexistinginsocietyfailingtoensurethesocialandeconomicprotectionofitspoorestandmostvulnerablemembers.

Similar issues havebeenobserved in EUMember Stateswhere themost dis-advantagedmembersofsocietyremaingreatlyexposedtohealth inequalities.Disparitiesbetweendifferentsocio-economicandpopulationgroupscontinuetorise,whichisaworryingsignofworseningpopulationhealthandthelittleprog-ressachievedinsocialfairness.

38 https://epha.org/wp-content/uploads/2020/04/eu-alliance-statement-covid19-crisis-16-april-2020.pdf

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In England, aswell as in EUMember States vulnerable groups, including eth-nicminoritieshavebeenparticularlyhit.Poorpolicycommitmenttocombatin-equalities inhealththroughnationalpolicies,haveresulted in increasedsocialandeconomicdisparities,includingincreasedchildpoverty.AusteritymeasuresadoptedinthelastdecadeinEngland,butalsoinmanyEuropeancountries,poorinvestmentinvulnerablegroupsandlowersocialprotectionhavepreventedpeo-ple’sneedsinhealth,housingandemploymentbeingmet,andtheirprotectionagainstpovertyensured.Highchildpovertyrates,employmentprecariousnessandin-workpoverty,lowerhousingaffordabilityleadingtoriseofhomelessnessofindividualsandfamilies,orlackofsufficientresourcesaresevereobstaclestoreducingdisparities inhealth.Consequently, vulnerablegroupshavebeende-privedofequalopportunitiestoimprovetheirlivingstandardsandleadhealthylives.

Disparitiesinhealthare“avoidableandpreventable”asithasbeendemonstrat-edinProfessorMarmot’sinitialreviewandtheworsenedhealthsituationinEn-glandprovesthatpolicymakershavenotbeencommittedenoughtoclosethegapbetweenpopulationgroupsinsocietyleadingtogreaterfinancialandhumancostsforthemostdeprived.Healthequityhasnotbeenprioritised,healthgapshavebeenpoorlyaddressedandthesituationofthosewhoalreadyexperiencedinequalitiesinhealthhasgotworsecomparedto2010,whichhasbeenconfirmedbythedeclineinlifeexpectancyofwomenlivinginthemostdeprivedareas.

Accordingtothe2010MarmotReviewreducinghealthinequalitiesrequiresac-tions inpivotal policy areas, including good cooperationand coordinationbe-tweenpolicymakers.Itproposedastrategybasedonsixpillarsaimingtoachieveapositivechangeinhealthbyinfluencingitssocialdeterminantsandputtingeq-uityandsocialjusticeattheheartofpolicyanddecisionmaking.Healthequityhasbeenidentifiedasacrucialindicatorofsocietalwell-beingandsocialprog-ressbutalsoasaprerequisiteforcreatingsustainablesocietiesandeconomies.Itdependsonmanyfactorsbeyondthehealthsectorandcanbeachievedthroughstrongerpolicycommitmentaddressingsocialdeterminantsofhealth,includingimprovedaccesstohealthcare.Strengtheningthehealthsystemwithaspecificfocuson thosewhoaredisproportionatelyaffectedbyhealth inequalities is acriticalsteptowardsbetterhealthprotectionbutactionstolesshealthinequali-tiesshouldnotonlybefocusedonimprovingpublichealthsystems.

The2020Reviewreiteratestheearlierrecommendationscallingonpolicymak-erstocreatean“ambitiousandworld-leadinghealthinequalitiesstrategy”thatcanpositively impactpeople’s lives,whichcouldequallyapply toEUMemberStates.Developingastrategyandconcreteactionplan,includingqualitativeandquantitativeindicatorsforsocialdeterminantsofhealth,monitoringmechanismsandaccountability isarequiredmeasureforachievingareal impactonhealthequityandsocialfairnessacrossEurope.Suchmeasureswillimprovetheresultsineconomy,environmentandsocialcohesionbutalsoresolvemanysocialissuessuchaschildpovertyanddeprivationthroughstrongerinvestmentinvulnerablepopulationgroupsfromtheearliestyearsoflife.

Reducinginequalitiesinearlychildhooddevelopmentdiminishestheexposuretoadversechildexperiences,havingadirect influenceonphysicalandmentalhealth in adulthood. Furthermore, early interventionswork towards reducingchildpoverty,reachingfairnessinemploymentandhousingwhichwillincreaseopportunitiesforpeopletoleadhealthylives.Closingthegapineducationwill

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alsoleadtoimprovementsinemployment,povertyreduction,workforceandtheeconomyasawhole.

Creatinghealthyenvironmentswillmitigatetheeffectsofclimatechangewhichalsodisproportionatelyaffectthemostvulnerablemembersofsociety.Further-more,thestrategyforreducinghealthdisparitiesmustincludeactionsinhous-ing,housingconditionsbeingamajorfactorformaintaininggoodhealthstatus.Specificmeasuresmustbetakenconcerningthosewhoalreadyexperiencedis-advantagesinaccesstoaffordablequalityhousingproportionatetotheirhouse-holdcompositionsandneeds.

MakinghealthequityandsocialfairnesscoreprinciplesofallrelevantEurope-anandnationalpolicies contributes toboostingsocialprogressandeconomicgrowthaswellassupportingthecreationofsustainablesocietiesandeconomieswhereeveryonecanenjoygoodhealthandwell-being,regardlessoftheirsocialstatus.Inthecontextoftheeconomicrecessionandpublichealthconcernspro-vokedbytheCOVID-19pandemic,acommonEuropeanstrategyandactionplanaddressingsocialdeterminantsofhealth,focusingonthehealth,economicandsocialprotectionofvulnerablegroups,isparticularlyrequiredtopreventafur-therincreaseofinequalitiesaswellasbuildingtheresilienceofMemberStatesagainstnewsocialandeconomiccrises.

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