Health Inequalities: a Challenge for Europe

  • Judge K
  • Platt S
  • Costongs C
 et al. 
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Aims Health inequalities are increasingly recognised as an important public-health issue throughout Europe. As a result of the growing recognition of the problem, many countries are responding by developing public policies in a wide variety of ways. The primary aim of this independent report, which was commissioned by the UK Presidency of the EU, is to review national-level policies and strategies – that either have been or are in the process of being developed to tackle health inequalities – and to reflect on the challenges that lie ahead. In doing so, it primarily focuses on socio-economic inequalities in health. Social and economic determinants The report begins by reviewing the importance of the wider social determinants of health inequality and the challenges associated with integrating attempts to promote social justice and social inclusion and policies to reduce health inequalities. The fight against poverty and social exclusion is crucial for tackling health inequalities. One of the reasons is that the size of the problem of health inequality is very much related to the numbers of people disadvantaged by different forms of social exclusion. There is a wealth of data showing how many of the wider social determinants associated with health outcomes are unequally distributed in all member states. The fact that so much emphasis is being given to anti-poverty and social inclusion policies across the EU, therefore, is potentially good news in terms of reducing health inequality, provided that policy can be translated into meaningful and proportionate action. In developing such policies it is important to note that, although policy entry points legitimately vary from country to country, there is great value in having a clear and measurable focus on health inequalities as part of wider concerns with social justice. Such an approach is not yet evident in many parts of Europe. Policy frameworks The next section considers the overall framework within which national policies to reduce health inequality are being developed, paying particular attention to the role of the World Health Organization (WHO) and the European Union (EU). There is considerable variation in the public policy goals and targets being set in different countries. Individual countries have chosen to respond to WHO recommendations and European Union initiatives in a wide variety of ways. • Most countries subscribe to the equity principles and values articulated by the WHO and the EU. • Most are explicitly concerned with the socioeconomic dimension of health inequalities but several (such as Hungary) focus on ethnic differences. • Some, such as Sweden, Denmark or Poland, emphasise their equity commitments in the context of broader public health strategies. • Others, such as the Czech Republic or Latvia, choose to express their domestic commitment to the Health21 targets specified by the European Regional Office of the WHO. • Countries such as Finland and the Netherlands have a single health inequality goal specified in quantitative terms. • Whereas Ireland and the four constituent countries of the UK each have a number of more detailed quantitative targets. Some countries that do not have national targets do have examples at a regional or local level. • Most countries with quantitative targets have set them in terms of reducing gaps between the poorest and the more affluent, but Scotland and Wales appear to be unique in terms of emphasising the importance of improving the position of the poorest groups per se. • None of the countries considered have explicit goals or targets related to the gradient between socio-economic position and health status across the whole population. National approaches There are three useful ways of distinguishing between the different approaches to health inequality currently in place in member states of the EU. The first relates to those countries that have clear references to tackling health inequalities included in legislation. The second is whether or not explicit goals or principles to promote health equity are mentioned in national policy documents. The third is whether such objectives are associated with quantitative targets, by which we mean that they have identified a specific aspect of the problem of health inequality as a priority and made a commitment to reduce it by a specified amount by a particular date. A number of EU countries have not formally articulated principles or goals to guide their actions at the national policy level in relation to promoting population health equity or reducing health inequalities. But the lack of national level policy statements does not necessarily mean that concerns about health inequalities are absent within a particular country. Responsibility for action It is typically the Department (Ministry) of Health (or umbrella department in which Health is located) that is responsible for action to tackle health inequalities. In nearly all countries this responsibility is shared with other departments. However, there is a considerable variation in the extent to which there is a concerted effort to co-ordinate action on health inequalities between government departments and/or successful implementation of such action. In one group of countries there is a general commitment across government to equality issues but no formal mechanism for co-ordinating implementation of policy on health inequalities across government departments. In a second group of countries co-ordinated national action on health inequalities, while evident, is less extensive or formalised than that found in a third group of countries. Co-ordinated and comprehensive national action on health inequalities is evident in a small number of countries in this final group. Action and implementation Four main ways that action programmes to reduce health inequalities are being implemented have been identified. One group of countries has wellintegrated and co-ordinated action plans. Countries in the second group have very clear concerns about, and some have commitments to, promoting health equity as part of more general public health policies. In a third group of countries it is possible to identify various actions to reduce health inequalities, but these are not necessarily related to a ‘master plan’. Countries in the final group appear to lack any distinctive focus on health inequalities per se, but like other member states they have examples of action in relation to the social determinants of health at national and local levels. One important implication of the review is that the more focused and integrated is the cross-government strategy for action, the greater is the probability that health outcomes will change in the desired direction. In addition, policies to reduce health inequalities are likely to be more successful when there is a clear action plan – that can be implemented and monitored – focused on specific targets within realistic timeframes. Monitoring and evaluation There is little evidence to suggest the widespread adoption of systematic evidence-based approaches to policy making across all areas of government. Even in a specific area, such as health improvement or the reduction of health inequalities, we have been able to locate only a few relevant frameworks. Nevertheless, several European countries appear to have developed a method to measure progress towards achieving health inequalities targets. In one group of countries monitoring is limited or not fully comprehensive. In keeping with the detailed specification and quantification of their health inequalities targets, countries in the second group have established systematic frameworks for monitoring and evaluation. (In a third group of countries there is no specific tool to monitor progress because no health inequalities targets have been set.) Conclusions This paper represents the first attempt to review and bring together in one place the experiences of those member states of the European Union that are in the process of developing national policies to tackle health inequalities. It shows that much progress has been achieved. But many challenges remain. No EU member state has yet made a concerted effort to implement the most radical approach to health inequalities, namely a reduction in the health gradient, whereby health is related to the position of social groups (and individuals within these groups) at every level within society. We suggest that EU member states should consider the potential advantages to society as a whole that might result from the adoption of this wider frame. One of the many issues that needs further thought in the future relates to the value of targets in national policy-making related to health inequality. Answers are needed to questions such as: • Is sufficient thought given by policy makers to the rationale for focusing targets on particular aspects of the problem of health inequality? • Should EU countries be working towards a common understanding of what type of target should be measured (which implies also a common understanding of what is meant by ‘health inequalities’ and what should be the focus of remedial action)? • Does the formulation of targets help or hinder the implementation of effective action to reduce health inequalities? Although there are many legitimate entry points for policy initiatives to tackle health inequalities, it is important that those selected are supported by financial and political commitment. It is equally important that steps are taken to ensure that adequate capacity and infrastructure are put in place to allow policies to be implemented in a sustainable way. One of the biggest challenges facing all member states is to assess the impact of their policies on health inequalities. Several developments are critical. One is the importance of assessing the potential impacts of non-health sector policies on health inequalities. Another is to recognise that monitoring of progress is crucial at a

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  • Ken Judge

  • Stephen Platt

  • Caroline Costongs

  • Kasia Jurczak

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