1 1

Why are health inequalities increasing in Finland?

Seppo Koskinen & working group: Satu Helakorpi, Tuija Martelin, Pekka Martikainen, Pia Mäkelä, Päivi Sainio, Lauri Tarkiainen

Inequality and the Nordic Welfare Model, Helsinki 07.11.2011

2

1. Time trends in health inequalities

a. Mortality

b. Self rated health

c. Functioning

2. Time trends in determinants of health inequalities

a. Health behaviour

b. Living conditions

c. Health services

3. Time trends in public policy affecting health inequalities

4. Conclusions

a. Have health inequalities increased?

b. Why?

c. What to do?

Contents

3

• Material well-being

– income, assets, housing conditions etc.

• Means to acquire material well-being

– education, occupation, employment status

• In addition to the material aspects, also life style and esteem

associated with e.g. education and occupation have great

importance in the background of health inequalities

Prologue: Dimensions of socioeconomic

position and their relation with health

4

Pathways from socioeconomic position to health • Education affects knowledge and values related with health and one’s

occupational career

• Occupation influences working and living conditions, shapes behaviour and affects income

• Income and economic position influence e.g. housing conditions and possibilities to make healthy choices

• Behavioural factors are important in the generation of health inequalities

– excessive alcohol use (accounts for ¼ of mortality differences in men)

– smoking (accounts for another ¼ of mortality differences in men)

– diet

– lack of exercise

• Behavioural choices are influenced by e.g. economic possibilities, values, norms, fashion and marketing

• High socioeconomic position improves the knowledge and economic prerequisites – as well as motivation – to choose health-promoting living conditions and behaviour patterns

• Factors operating during all phases of the life course affect health inequalities

} → obesity and consequent health problems

5

1 Time trends in health inequalities

→ Mortality Self-rated health

Functional capacity

6

30

35

40

45

50

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Figure 1. Life expectancy of men and women aged 35 by income quintile in

1988-2007

Women 5th quintile (highest)

Women 4th quintile

Women 3rd quintile

Women 2nd quintile

Women 1st quintile (lowest)

Men 5th quintile (highest)

Men 4th quintile

Men 3rd quintile

Men 2nd quintile

Men 1st quintile (lowest)

Difference

3.9 years

Difference

7.4 years

Difference

6.8 years

Difference

12.5 years

Source: Tarkiainen L,

Martikainen P,

Laaksonen M,

Valkonen T. JECH

2010

7

-1,20 -0,60 0,00 0,60 1,20 1,80

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lung

cancer

Oth

er

cancers

Ischaem

ic

heart

dis

ease

Cere

bro

va

scula

r dis

eases

Oth

er

circula

tory

dis

eases

Respirato

ry d

iseases

Alc

ohol-

rela

ted

causes o

f death

O

ther

dis

eases

Suic

ide

Accid

ents

and

vio

lence

35-64

65+

Contribution of selected causes of death and age groups to the change in life expectancy of 35-year-olds from 1988-92 to 2003-07 in lowest and highest income quintiles,

men

Source: Tarkiainen L,

Martikainen P, Laaksonen M,

Valkonen T. JECH 2010

8 -0,6 0,0 0,6 1,2

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lowest 20%

Highest 20%

Lung

cancer

Bre

ast

cancer

Oth

er

cancers

Ischaem

ic

heart

dis

ease

Cere

bro

vascula

r dis

eases

Oth

er

circula

tor

y

dis

eases

Respirato

ry

dis

eases

Alc

ohol-

rela

ted

causes o

f death

O

ther

dis

eases

Suic

ide

Accid

ents

and

vio

lence

35-64

65+

Contribution of selected causes of death and age groups to the change in life expectancy of 35-year-olds from 1988-92 to 2003-07 in lowest and highest income quintiles,

women

9

Time trends in health inequalities

Mortality

→Self-rated health Functional capacity

10

Age-standardized prevalence (%) good or fairly good self-rated health in 1979–2010 in education tertiles, 25–64-year-old men and women

10

Source: Health Behaviour and Health among the

Finnish Adult Population -surveys 1979-2010

* educational tertiles

0

10

20

30

40

50

60

70

80

79-82 83-86 87-90 91-94 95-98 99-2002

2003-06

2007-08

2009-10

%Men

Low Middle High

0

10

20

30

40

50

60

70

80

79-82 83-86 87-90 91-94 95-98 99-2002

2003-06

2007-08

2009-10

%Women

Education

11

Time trends in health inequalities

Mortality

Self-rated health

→ Functional capacity

12

Prevalence (%) of difficulties in walking 500 m

by level of education in 1978-80 and 2000-01

0

1

2

3

4

5

6

7

8

1978-80 2000-01 1978-80 2000-01

Alempi Ylempi

30-64-year-olds

Men Women

***

***

**

*

0

5

10

15

20

25

30

35

40

45

1978-80 2000-01 1978-80 2000-01

Alempi Ylempi

65+-year-olds

Men Women

**

***

**

Source: Koskinen et al. 2004

Low High Low High

13

Prevalence (%) of difficulties in walking outside home in age groups 65-74 and 75-84 by years of education

Source: Laitalainen et al. 2010

Men Women

0-8 years 0-8 years

9+ years 9+ years

all all

14

Summary

• Inequalities in mortality have increased rapidly

– largely due to growing disparities in deaths caused by alcohol, but also deths from other causes of death

• No significant time trends in inequalities in self-rated health or functional capacity

15

2 Time trends in determinants of health inequalities

→ Health behaviour

• Smoking

• Diet

• Alcohol use

• Physical excercise

Living conditions

Health services

16

Age-standardized prevalence (%) of daily smoking in 1978–2009 in education tertiles,

men and women aged 25–64 years

16

Source: Helakorpi S. et al. Health Behaviour and Health

among the Finnish Adult Population, Spring 2009. THL

Report 7/2010.

* educational tertiles

0

10

20

30

40

50

78-81 82-85 86-89 90-94 95-99 2000-

04

2005-

09

% Men

Low Middle High

0

10

20

30

40

50

78-81 82-85 86-89 90-94 95-99 2000-04

2005-09

% Women

Education

17

Age-standardized proportion (%) of 25–64-year-old men and women who eat fresh vegetables

daily in 1979–2010 in education tertiles

17

Source: Health Behaviour and Health among the

Finnish Adult Population -surveys 1979-2010

* educational tertiles

0

10

20

30

40

50

60

70

79-82 83-86 87-90 91-94 95-98 99-2002

2003-06

2007-08

2009-10

%Men

Low Middle High

0

10

20

30

40

50

60

70

79-82 83-86 87-90 91-94 95-98 99-2002

2003-06

2007-08

2009-10

%Women

Education

18

18

Prevalence (%) of risk consumption (>8/5 portions/ week) of alcohol in 1982–2007 in education tertiles, men and women aged 25–64 years

MEN WOMEN

LOW INTERMED

HIGH LOW INTERMED

HIGH

Source: Helakorpi et al. 2008

19

19

Alcohol mortality by level of education in 1987–2003 (Herttua et al. 2007)

MEN WOMEN

87-88 90-91 94-95 02-03 87-88 90-91 94-95 02-03

basic

basic

intermed

high

inter

med

high

basic

20

Physical excercise

• Inequalities in physical excercise have not been studied much

• In men, leisure time excercise is more common in the higher socioeconomic groups, but there is no evidence time trends in this difference

• In women, no marked socioeconomic differences in leisure time physical excercise have been reported

21

Summary on time trends in inequalities in health behaviour

• Smoking

– rapid increase in inequalities

• Diet and physical excercise

– apparently no marked changes in inequalities

• Alcohol use

– discrepant findings:

– survey results fail to show marked inequalities in alcohol use

– mortality (and morbidity) data reveal wide and growing inequalities

22

Time trends in determinants of health inequalities

Health behaviour

→ Living conditions

– income

– unemployment

– working conditions Health services

23

2 Time trends in determinants of health inequalities

→ Health behaviour

• Smoking

• Diet

• Alcohol use

• Physical excercise

Living conditions

Health services

Differences in disposable income in Finland

in 1995–2008 measured by Gini index

Source: Statistics Finland

Gini coefficient * 100

24

Median disposable income (€) per consumption

unit by socioeconomic position in 1990–2009

Upper non-manual

Entrepreneur

Farmer

Lower non-manual

Manual

All households

Pensioners

Other non-occupied

Unemployed

Source: Statistics Finland

25

Unemployment rate (%) by level of education

in 2005–2009, age group 15–74 years

Source: Statistics Finland

Level of education

2005 2006 2007 2008 2009

Higher 4.6 3.9 3.7 3.5 4.4

Secondary 8.8 8.1 7.1 6.5 9.3

Basic 13.9 13.6 12.3 11.9 13.8

All 8.4 7.7 6.9 6.4 8.2

26

Prevalence (%) of working life hazards by

occupational group in 2009, employed women

Source: Virtanen and Husman 2010

Hazard Upper non-

manual

Lower non-

manual

Manual Entre-preneur

Farmer

Risk of accident

2 11 17 14 25

Chemical hazards

11 18 31 20 44

Physically strenuous work

4 25 56 38 63

Noise 15 14 26 15 25

No occup. health care

4 5 11 74 38

27

Prevalence (%) of working life hazards by

occupational group in 2009, employed men

Source: Virtanen and Husman 2010

Hazard Upper non-

manual

Lower non-

manual

Manual Entre-preneur

Farmer

Risk of accident

1 11 28 18 32

Chemical hazards

8 18 39 21 66

Physically strenuous work

3 11 43 26 53

Noise 11 28 50 26 45

No occup. health care

7 7 9 58 46

28

Summary on time trends in inequalities in living conditions

• Income inequality is rapidly growing

• Unemployment is much more common in the

lower socioeconomic groups than in the higher

groups, but this difference does not seem to have

changed much recently

• Working conditions are much more hazardous in

manual than in non-manual occupations, but time

trends in these inequalities are not well known

29

Time trends in determinants of health inequalities

Health behaviour

Living conditions

→ Health services

30

Health services

• Coverage and contents of occupational health services tend to be worst in small enterprises and short term employment contracts – often among low-income employees

• Due to high out-of-pocket price, private services are used particularly by persons with high income

• Many surgical operations are not distributed according to need. Persons with high education and income tend to get most/best services

• There is evidence of similar inequality also in non-surgical treatments

• Many of these inequalities in health services don’t seem to have increased

• However, new – generally expensive – medicines and other technologies are developed. The limited supply and high price of new technology tends to reduce possibilities to benefit from them particularly in less advantaged population groups

31

3 Time trends in public policy affecting health inequalities

Health inequality has been a central issue in

healthy public policy for 25 years

32

Government’s health policy report to the Parliament 26.3.1985

-”Differences in morbidity between population groups must be decreased." (p.

6)

-”Emphasis must be put to taking care of the needs of the disadvantaged

individuals and groups and to equity between citizens so that economic

factors do not prevent appropriate use of health services." (p. 6)

-”Measures needed to reduce behaviourally determined health problems in

the population groups at highest risk will be untangled". (p. 9)

-"Alcohol consumption will be reduced and the ability to control alcohol use in

diferent subgroups of the population will be strengthened". (p. 11)

-”Wide differences between socioeconomic groups in morbidity and mortality

constitute a central research problem." (p. 24)

33

Public Health Report 1996: Government’s report to the Parliament on public health and its development, K6/1996vp.

-”We have not succeeded to reduce social inequalities in health in recent years although this has been one of the main goals of health policy." (p. 71)

-”Increasing knowledge. Health inequalities continue to be a major challenge to research. … we still need much new information in order to develop more effective measures." (p. 71)

-”Public policy to improve equity. Health inequalities are largely based on differences in living conditions and scholarly as well as material resources. They can therefore be influenced by persevering social, labour and educational policy which aims to reduce differences between population groups and attends to the groups in the poorest situation in particular." (p. 71)

-”Equity in health services.

-In the development of the service system and its funding, particular attention must be paid to equal use of health services according to need.

-In reducing risk factors, more emphasis must be given to improvement of living conditions and circumstances by public policy measures." (p. 72)

34

Goverment’s resolution on the Health 2015 public health programme, 2001

-”It is particularly alarming that some health inequalities have

increased" (p. 11)

-”A prerequisite for successful health policy is to prevent the

growth of health inequalities and more efficient action aiming

to reduce these inequalities" (p. 13)

-”The main aims up to year 2015: 8. …inequality will decrease

and the wellbeing and relative position of disadvantaged

population groups will improve. The aim is to reduce mortality

differences between the genders, education groups and

occupational groups by one fifth" (p. 18)

35

National action plan to reduce health inequalities 2008–2011 (Ministry of Social ffairs and Health, Publications 2008:15)

• Persistent, multisectoral work is needed to reduce health inequalities. Social determinants of health and the processes behind the inequalities must be addressed. … three priority areas:

– Social policy measures: improving income security and education, and decreasing unemployment and poor housing

– Strengthening the prerequisites for healthy lifestyles: measures to promote healthy behaviour of the whole population with special attention to disadvantaged groups where unhealthy behaviour is common

– Improving the availability and good quality of social and health care services for everyone

• To pursue these goals and monitor the attainment of them, reliable knowledge base and effective communication are needed. For this purpose,

– a follow-up system for health inequalities is developed

– knowledge about the scope of and trends in health inequalities is strengthened

– education and communication concerning health inequalities and their reduction is advanced.

36

• Health inequality has been seriously addressed in all

major health policy documents during at least

25years

• An indisputable aim in these documents is to reduce

inequalities

• These general health policy documents represent a

quite well developed understanding of the causal

network behind health inequalities

• Why are health inqualities not decreasing?

• The dignified general policy goals are not

(always) materialised in practical policy

decisions: an example from alcohol policy …

37

Impact of reduction in alcohol tax in 2004 on alcohol deaths by level of education: change in alcohol mortality from 2001–03 to 2004–5

Level of education

MEN WOMEN

Number of additional deaths

/100 000 %

Number of additional deaths

/100 000 %

1. Highest 5 8 6 56

2. 15 16 2 12

3. 33 20 12 40

4. Lowest 40 16 15 34

Source: Herttua et al. AJE

38

Impact of reduction in alcohol tax in 2004 on alcohol deaths by employment status: change in alcohol mortality from 2001–03 to 2004–5 in age group 30–59 years

MEN WOMEN

Number of additional deaths

/100 000 %

Number of additional deaths

/100 000 %

Employed 2 3 1 8

Unemployed<25m 101 30 46 81

Unemployed>25m 166 21 109 50

Retired 168 27 59 37

Source: Herttua et al. AJE

39

4 Conclusions

a. Have health inequalities increased? b. Why?

c. What to do?

40

Have health inequalities increased?

Yes and no

• Inequalities in mortality have increased rapidly

• No significant time trends in inequalities in self-rated health or functional capacity

41

Future prospects Inequalities in health may well increase because/if

• long-term unemployment remains at a high level

• income inequalities increase

• the growing number of immigrants can not integrate in the society

• the reduced resources of preventive services, such as maternity and child health clinics and student health care, are not increased

• easy availability and low prices of alcohol increase alcohol consumption and the related harms particularly in the underprivileged groups

• disparities in smoking continue to increase

• inequalities in health and its determinants tend to be steepest among the young adults = tomorrow’s middle-aged and elderly people

• the new effective medical technology is not likely to be similarly available for everyone due to limited resources

42

Conclusions

a. Have health inequalities increased?

b.Why? c. What to do?

43

Mortality inequalities have increased because

• Inequalities in health behaviour (alcohol and

smoking in particular) have increased

• Inequalities in material living conditions have

increased

• Inequalities in the use and quality of health services

may partly have increased

• Public policy decisions and measures have

sometimes been guided more by other aims than the

commitment to reduce health inequalities

44

Conclusions

a. Have health inequalities increased?

b. Why?

c.What to do?

45

Should something be done? (1)

Jäljellä olevia elinvuosia

Työntekijät

Maanviljelijät

Alemmat toimihenkilöt

Ylemmät toimihenkilöt

Työntekijät

Maanviljelijät

Alemmat toimihenkilöt

Ylemmät toimihenkilöt

32

34

36

38

40

42

44

46

48

50

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Vuosi

Ero 4,7v

Ero 2,2v

Ero 3,2v

Ero 6,0v

Naiset

Miehet

• Inequalities in health are not inevitable, and therefore, not acceptable ethically

Health inequalities present a major problem for any modern welfare state committed to values of equality

• Public health will improve more effectively when the health of the (large) groups with accumulating problems is promoted

If health of other population groups could be raised to the same level as those who are in the best position, the nation as a whole would be in significantly better health

46 46

Proportion (%) of selected public health problems that would be avoided if the prevalence of the problem in the rest of the population would be as low as among those with tertiary level of education

Health problem Proportion (%) avoided of cases Edentulousness 80

Respiratory deaths 50–75

Alcohol deaths 50–60

Need for daily help due to restrictions in functional capacity 50

Coronary heart disease deaths 30–50

Accidental/violent deaths 20–45

Diabetes 30

Back disorders 30

Osteoarthritis of knee/hip 30

Stroke deaths 20–40

Cancer deaths 20–30

Impaired vision/hearing 20

Source: Koskinen & Martelin 2007

47

Jäljellä olevia elinvuosia

Työntekijät

Maanviljelijät

Alemmat toimihenkilöt

Ylemmät toimihenkilöt

Työntekijät

Maanviljelijät

Alemmat toimihenkilöt

Ylemmät toimihenkilöt

32

34

36

38

40

42

44

46

48

50

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Vuosi

Ero 4,7v

Ero 2,2v

Ero 3,2v

Ero 6,0v

Naiset

Miehet

• Health inequalities endanger the sufficiency of labour force in the near future

• Persisting large inequalities imply a great need for services which the nation may not be able to supply as population ages

• Poor health is a factor in social exclusion

• Health inequalities have negative economic effects

Should something be done? (2)

48

Health inequalities can be reduced

• The magnitude of health inequalities varies markedly

between societies and time periods → there is no

natural law which inevitably leads to a certain level of

inequality!

• Positive examples of reducing health disparities

between subgroups of the population in Finland:

– reduction of health disparities between northeastern and

southwestern Finland

– Reduction / eradication of regional and socioeconomic

differences in health among children

→ Health inequalities can be reduced, but achieving

results requires determination

49

• There is no lack of high level policy declarations

emphasizing the importance to reduce health

inequalities in Finland

• These declarations should be adequately reflected in

practical policy decisions

• It seems that the aim to reduce health inequalities has

been disregarded in favour of other, more important,

political aims

• Commitment to reduce health inequalities may

sometimes mean that this aim must be prioritized at

the expense of other aims/commitments

HOW?