INEQUALITIES IN HEALTH: AN ESTONIAN CASE

1. INEQUALITIES IN HEALTH: AN ESTONIAN CASE Anu Kasmel Estonian Centre for Health Education and Promotion

2. Social inequalities in health as an issue • came to the policy arena in Estonia in the end of ninetiethafter a period of the extensive and profound societal changes. • Discussions concerning health policy have been focused to the social determinants of health and to the most vulnerable groups in society. • In spite of improvements during recent years, the health situation in Estonia is still not favourable in comparing with other northern countries and social inequalities in health are growing.

3. Estonian Public Health Policy Document, April,2002 “The public health strategies should be directed towards diminishing inequalities in health between different social groups. All sectors and levels in society should direct their health policies to support disadvantages groups.”

4. Cause-specific mortality Self-reported morbidity Health related behavior Health care utilization Mortality Database Health Interview Survey Bi-annual Health Behavior Surveys 1990-2000 Living Condition Surveys 1994, 1999 Health Insurance Fond Study of social inequalities in health, 2001

5. The main results demonstrates that: • Morbidity, mortality, health related behaviors and patterns of health care utilization strongly vary between subgroups of the population; • People from lower socio-economic groups live shorter, more ofter suffer from health problems, engage more often in health damaging behavior and have less favourable health care utilization pattern; • Large differences in some outcome indicators are observed between men and women, non-ethnic and ethnic Estonians and by place of residence; • During the 1990’s social inequalities in mortality, and most types of health related behavior have widened.

6. Average life expectancy at birth among men and women from 1959 to 2000 in Estonia 80 Men Women 75 70 Life expectancy at birth in years 65 60 55 1959 1970 1979 1989 2000 1959 1970 1979 1989 2000

7. Probability of dying between the 45th and 65th birthday. Men with high and low educational level in Estonia compared to Norway and Finland in the late 1980s.

8. The percentage of respondents reporting 'bad or average' general health in different educational levels by gender and age groups, 1994 University Upper secondary Lower secondary 90 80 70 60 Percent 50 40 30 20 Men Women 25–44 45–59 60–79

9. The percentage of respondents reporting ‘bad’ general health or depression (age group 25–79), or reporting mobility limitations (age group 60–79) in different personal income quartiles 1 (low) 2 3 4 (high income quartile) 25 20 15 Percent 10 5 0 'Bad' general health Depression Mobility limitations

10. The percentage of respondents having emotional distress among the employed and unemployed by gender, three age groups and place of residence in the age range 25–59. Employed Unemployed 25 20 15 Percent 10 5 0 Men Women 25–44 45–59 Tallinn Other Rural urban

11. Age-standardised mortality rate among people with a university and lower secondary education in 1987–1990 and 1999–2000 by gender. Ages 20 years and above included University Lower secondary 3500 Men Women 3000 2500 ASMR per 100 000 2000 1500 1000 500 1987–1990 1999–2000 1987–1990 1999–2000

12. The proportion of respondents who use fresh fruits 0-2 days a week, according to the education and study year.

13. The proportion of respondents who smoke daily, in different personal income quartiles

14. The proportion of respondents 1999, who have had telephone consultation with a doctor, visit to a doctor, visit to a specialist, visit to a dentist (all during last 6 months) or have been hospitalised during last 12 months, according to educational level University Upper secondary Lower secondary 50 45 40 35 30 Proportion (%) 25 20 15 10 5 0 specialist Visit to a Visit to a dentist Visit to a Telephone with a doctor consultation general doctor Hospitalisation

15. To most of us, inequality is the state of being unequal • Inequalities in health describe the differences in health between the groups. Inequities refer to a subset of inequalities that are assessed as unfair. • Evans (2001) have said that the unfairness qualification invokes assessment of whether the inequalities are avoidable as well as more complex ideas of distributive justice as applied to health.

16. Equity • Equity concerns a special subset of health disparities that are particularly unfair because they are associated with underlying social characteristics, such as wealth, that systematically put some groups of people at a disadvantage with respect to opportunities to be healthy. • Equity is linked to human rights, as it calls for reduction in discrimination in the conditions required for people to have equal opportunity to be healthy. • Attaining optimal health ought not to be compromised by the social, political, ethnic, or occupational group into which one happens to fall.

17. Social justice The fully articulated effort to redress inequities in health must inevitably work in tandem with wider efforts towards social justice – such as the provision of safety nets; protection against medical impoverishment; provision of education, jobs training, and environmental risk reduction; and efforts to ensure peace and political voice for all.

18. William Farr “No variation in the health of the states in Europe is the result of chance; it is the direct result of physical and political conditions in which nations live” (1866).

19. The question is: How to promote factors, which create equitable society? What are the most influential interventions and policies, what could best contribute to reducing inequalities in health. There is no clear answer to this question. Until now the convincing evidence about the likely impact of specific policy initiatives or interventions on reducing health inequalities is highly elusive.

20. Understanding of health determinants It has appeared that society’s understanding of the determinants of health has an important influence on the strategies it uses to sustain and improve the health of its population. The increased understanding of the social causes of ill health is a critical component of health equity agenda.

21. The nature of political system • As demonstrated in many studies, the nature of the political system, its values and processes for participation, define the frontiers of opportunity for health equity. Societies with flourishing democracies, respect for human rights, transparency and opportunities for civic engagement – high social capital – are more likely to be equity enhancing.

22. Policies Macroeconomic and social policies may either limit or enhance health opportunities for different groups in the population. In the era of liberal macroeconomic policy “progrowth” strategies tend to provide enhanced opportunity to those with resources and high levels of education while large segments of the population without these assets are unlikely to be beneficiaries of economic transition. Just focusing to the economic growth policies that pay no attention to social investments or to compensatory educational and labor policies, these transitions have exacerbated the extent of inequity in health.

23. Human capital and social capital Diderichsen (2001) have declared that if we want to understand and intervene against social inequalities in health, we should look both upstream into the mechanisms of society and downstream into the mechanisms of human biology and coping skills.

24. Community development • Many studies have demonstrated that interventions, directed to the development of the human and social capital are leading to the increase of empowerment of community. • An empowered person/community can critically analyse the social and political environment and to make their own choices. • Community development has been suggested as offering “the most promising approach to reducing health inequalities” (Labonte, 1988).

25. What we have learned from transition • The political deliberation in the 1980’s , the time of ‘singing revolution’ synchronized with tremendous increase in social capital and also improved health data. • Rapid political, social and economical changes, which followed to the transition moment, caused in the initial period of transition the wide lose of control and disempowerment of large sectors of population. • Step by step empowerment is growing and people get back control over their life.

26. Assumptions of success: • People’s participation in community change promotes changes perceptions of self-worth and a belief in the mutability of harmful situations, which replaces powerlessness; • The experience of mobilizing people in community groups strengthens social networks and social support between individuals and enhances the community’s competence to collaborate and solve health problems; • Empowerment education interventions promote actual improvement in environmental and health conditions.

27. Tackling inequalities in health - needs for commitment and needs for concrete legislative acts • If communities are commited to create and governments are commited to support systems and structures (”social system for health”), that establish networks, norms, social trust and develops people capacities; if these structures facilitate co-ordination and cooperation between different sectors and levels, we are able to make changes in health of our populations, to deminish social inequalities in health.