Reducing Health Inequalities in Europe; What can be done?

1. Reducing Health Inequalities in Europe; What can be done? Dr. Martijntje Bakker Public Health Fund the Netherlands

2. Content • Background • Inequalities in health in Europe • How do countries deal with SEIH • An example: healthcare

3. History of the Network • King’s Fund report (1995) • BMJ editorial (1995) • Malmö 1996, London, 1997, Rotterdam 1998 • EU funding, 1999 • Helsinki 1999, Barcelona 2000

4. Purposes of the network • To exchange the various national experiences with interventions and policies to reduce SEIH • To explore opportunities for developing comparative or collaborative research to evaluate such interventions and policies

5. Network members • 40 members • 13 European countries (Belgium, Denmark, Finland, France, Germany, Greece, Italy, Lithuania, the Netherlands, Norway, Spain, Sweden and UK) • WHO representatives • New-Zealand and USA

6. Reducing inequalities in healthA European perspectiveEdited by Johan Mackenbachand Martijntje Bakker

7. Content • I Introduction • II Interventions and policies to reduce socio-economic inequalities in health • III National experiences • IV Evaluation issues • V Reflections • VI Key messages

8. SEIH in Europe • Morbidity • Mortality

9. Morbidity (1) (Kunst et al., 2000)

10. Morbidity (2)(Kunst et al., 2000)

11. Mortality (1)(Kunst,1997)

12. Mortality (2)(Kunst et al., 2000)

13. How do countries in Europe deal with socio-economic inequalities in health?

14. The Action spectrum

15. Situation in 8 European countries • Greece: pre-measurement • Spain: denial/ indifference • France, Italy: concern • Lithuania: will to take action • The Netherlands, Sweden: more structured developments • England: comprehensive coordinated policy

16. An explanatory model

17. Examples of comprehensive packages (1) • British Independent Inquiry into inequalities in health (1998) • 39 main recommendations (123 with sub-clauses) • Seven policy areas reviewed: Taxation and social security, Education, Employment, Housing and environment, Mobility, transport and pollution, Nutrition and the common agricultural policy, National Health Service • Demographic factors over the life course considered, including: Mothers, children and families, Young people and adults of working age, Older people, Ethnicity, Gender • Three priority areas emphasized: • 1. Health inequalities impact assessment • 2. A high priority for the health of families with children • 3. Reduction in income inequalities and improvement of living standards of poor households

18. Examples of comprehensive packages (2) • Swedish National Public Health Commission (2000) • 18 health policy objectives • Six overarching themes: • 1.        Strengthening social capital2.        Growing up in a satisfactory environment3.        Improving conditions at work4.        Creating a satisfactory physical environment5.        Stimulating health-promoting life habits6.        Developing a satisfactory infrastructure for health • Development of ‘indicators for achievement’ recommended.

19. Examples of comprehensive packages (3) • The Dutch program committee on socio-economic inequalities in health (2001) • 26 recommendations • Four specific strategies: • 1. Reduction of inequalities in education, income and other socio-economic factors2. Reduction of the negative effects of health problems on socio-economic position • 3. Reduction of the negative effects of socio-economic position on health • 4. Improve access and quality of healthcare for lower socio-economic groups • 11 quantitative targets relating to intermediate outcomes. • Strong emphasis on continuation of research, development, monitoring and evaluation.

20. An example: health care • Access to healthcare • Financial • Physical • Cultural

21. Access to primary care • UK: inequalities in access and provision of care (Goddard & Smith, 1998) • Spain: no clear picture (De La Hoz and Leon, 1996) • NL: more GP contacts for low SES (Van der Meer et al., 1996) • Sweden: more GP contacts for high SES (Whitehead et al., 1997) • Germany: more GP contacts for low SES (Bormann & Schreuder, 1994) • Finland: high SES: private practices and occupational healthcare; low SES: GP’s at municipal health centres (Keskimäki, 1997)

22. Access to hospital care • In general, access seems equitable • However, this might not be true for access to and quality of care in specialist or intensive services • Examples: • UK: specialist cardiac services, survival cancer treatment (Goddard, Smith, 1998) • Finland: coronary bypass operations, hip replacement operations, cataract surgery (Keskimäki, 1997)

23. Review • 36 interventions (aimed at low SES groups, or aimed at general population with results reported by SES) • Aims: cancer screening, hypertension or substance abuse treatment programs, improving maternal and child outcomes • Interventions: hospital-based education programs, community outreach activities, personalised contacts with target groups by healthcare personnel

24. Starting Well, Glasgow • Early intervention program • Target group: children up to 5 years in deprived areas • Aim: Improving health and well-being • Activities: • Intensive home support to families with a new baby • Improved network of community services • Stronger linkages between families and support structures and services

25. Nurse practitioners, NL • Target group: Patients with COPD/ Asthma in deprived areas • Aim:compliance with therapy, reduced complications • Activities: Counseling of COPD/ Asthma patients by nurse practitioner in GP practice