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Health inequalities: underlying factors and different ways of

addressing them

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• health is unequally distributed in Europe – between and within countries

• focus here on health inequalities within countries, between socioeconomic groups

• highlight 5 key points

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1. Health inequalities exist in all European countries

4

0

5

10

15

20

death

rate

Mortality rates (per 1000 person years) of lower & higher educated groups, women aged 60-69

Source: unpublished estimates by M. Huisman, A.E. Kunst and J.P. Mackenbach for the EU Working Group on  Socioeconomic Inequalities in Health

high

low

5

0

5

10

15

20

25

30

35

death

rate

Mortality rates (per 1000 person years) of lower & higher educated groups, men aged 60-69

Source: unpublished estimates by M. Huisman, A.E. Kunst and J.P. Mackenbach for the EU Working Group on  Socioeconomic Inequalities in Health

highlow

6

2. Health inequalities take the form of a social gradient

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0

5

10

15

20

25

30

35

40

higher secondary basic

educational level

%

men women

Sweden: rates of limiting longstanding illness by educational level, 1994-5

Source: Lungberg et al, 2001

8

0

5

10

15

20

25

30

35

I II IIInm IIIm IV V

socioeconomic group

%

men women

England: rates of limiting longstanding illness by socioeconomic group (based on occupation), 1998

Source: General Household Survey, 1998

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3. Health inequalities reflect inequalities in the distribution of

health determinants

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Health strategy of the European community 2001-06

• ‘addressing health determinants, the underlying factors which affect people’s health’

• ‘life-style related health determinants’ : cigarette smoking, diet etc

• ‘socio-economic determinants’: life chances (childhood circumstances, education, employment), working & living conditions, health & welfare services

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What is important about these determinants for health inequalities is

their social distribution

• health determinants display a socioeconomic gradient

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0

10

20

30

40

poor play space poor adult workenvironment

adult smoking

I/II IIInm IIIm IV/V

Risk factors by social class at birth, 1958 birth cohort

Source: Power 1997

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4. Multiple understandings of what it means to tackle health inequalities

• improving the health of disadvantaged groups

• reducing health differences between socioeconomic groups

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improving the health of disadvantaged groups

• focus on marginal & minority groups (immigrant communities, homeless people)

• sets boundaries around ‘the problem’

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improving the health of disadvantaged groups

• absolute improvements in their health may not narrow the gap between them & the wider population (because overall health is improving at a faster rate)

• obscures health inequalities across the population

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social class proportion death rates

of pop (%) (per 100000)

I 7282

II 27302

IIInm 9432

IIIm 31496

IV 14500

V 5816

54

Source: Drever and Whitehead, 1997

Deaths among men aged 20-64, England and Wales, 1991-3

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reducing health differences between socioeconomic groups

• encompasses goals of improving poor & poorer health of most disadvantaged

• tackling health inequalities is a population-wide strategy

• policies which equalise the distribution of health determinants

• too ambitious - or in line with welfare policy?

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Effect of major fiscal reforms on disposable household income, 1997 to 2002

0

2

4

6

8

10

12

14

poor

est t

enth 2 3 4 5 6 7 8 9

riche

st te

nth

all h

ouse

hold

s

% gain

Source: IFS, 2001

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5. Tackling health inequalities requires multi-sectoral commitment

• health inequalities reflect the unequal distribution of health determinants

• broader social and policy changes are often widening inequalities in key determinants

• new interventions & existing policies will have an impact on the distribution of health determinants

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Getting and keeping health inequalities on the policy agenda is a key challenge

for an enlarged Europe

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Proportion of households with pre-transfer incomes below 50% of average income, circa 1990

0 20 40 60 80 100

USA

UK

Australia

Sweden

Norway

Finland

Denmark

% poor

Source: Bradshaw & Chen, 1997

23

Proportion of households with post-transfer incomes below 50% of average income, circa 1990

0 20 40 60 80 100

USA

UK

Australia

Sweden

Norway

Finland

Denmark

% poor

Source: Bradshaw & Chen, 1997

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Percentage of lone parent households with pre-transfer incomes below 50% of average income,

circa 1990

0 20 40 60 80 100

USA

UK

Australia

Sweden

Norway

Finland

Denmark

% poor

Source: Bradshaw & Chen, 1997

25

Percentage of lone parent households with post-transfer incomes below 50% of average income,

circa 1990

0 20 40 60 80 100

USA

UK

Australia

Sweden

Norway

Finland

Denmark

% poor

Source: Bradshaw & Chen, 1997

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Benefits in kind for non-retired households by income quintile groups, UK, 1998-99

0

25

50

75

100

bottom 2nd 3rd 4th top all householdsb

enef

its

in k

ind

1 as

% o

f p

ost

-tax

inco

me

income quintile

Source: Harris, 2000

1education, NHS, housing, travel subsidies, school meals and welfare milk

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Cigarette smoking among women aged 16 and over by socioeconomic group 1958-2000, Britain

Sources: Wald and Nicolaides-Bouman, 1993; Bridgewood et al, 2000

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

ye ar

% smoke rs

professional

unskilled manual

all women