European Commission
Summary Report on the Seminar on Health Inequalities, London School of
Economics and European Commission DG Employment and Social Affairs,
London, May 7 2009
Key messages I: Measurement of health inequalities
 Health inequalities across socioeconomic, geographic, ethnic, and other groups are a health and public policy concern in all countries; although, the extent of relative and absolute inequalities varies across countries, as do overall levels of population health.
 There exist robust methodological tools from the epidemiological and economics disciplines to measure inequalities in health; there also exists a great deal of evidence on the level of inequalities in health across countries in addition to documentation of how inequalities have changed over time.
 There is general agreement that we need to move beyond measuring inequalities to taking policy actions to reducing inequality and to evaluate these policy interventions.
 The study of inequalities in health in the central and eastern European countries is very important due to the high level of inequalities that can be seen since the transition. Particular methodological challenges are raised with regards to the quality and comparability of the health data, and the collection of socioeconomic and ethnic information (in particular of Roma people and migrant populations).
 There are some data limitations in terms of incomplete death registries and the unavailability of health care insurance and hospital databases, the extension of existing European-level surveys to this region, such as
SHARE and EU-SILC, offers new opportunities for comparative research.
 Numerous methodological advances have taken place that have responded to the challenges and opportunities of the data that are available (on health and socioeconomic status), including the ‘corrected’ concentration index that accounts for the bounded nature of health indicators, and the use of longitudinal data sources to examine the causal pathways that lead to health inequalities across the life course.
 Self-reported unmet need for health care and forgone care provide some insight into people’s perceived access problems; however, disaggregation of unmet need into the stated reasons is required to aid interpretation, in addition to further research investigating the longterm effects of unmet need and the association between the reported access problems and the actual use of health services.
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Key messages II: Policies to reduce health inequalities
 Empirical evidence on strategies to reduce health inequalities is extremely limited; however we have evidence about how to address the causes of ill health that disproportionately affect the poor, in particular smoking related diseases, and how to improve the conditions in which poorer people live.
 To tackle inequalities in health we need to address the determinants of health at the individual (e.g. healthy lifestyles) and community level
(e.g. environmental health, education), to improve access to essential services for underserved populations, and, more fundamentally, to encourage macroeconomic and cultural change in order to address broader inequalities in income and power in society.
 Welfare policies, namely those that support dual-earning families, are associated with lower rates of child poverty and infant mortality.
 Relative health inequalities appear to persist irrespective of social polices or welfare state regimes; however, absolute inequalities, and in particular the levels of mortality among the lower strata (blue collar workers) may be linked to the type of welfare policies adopted.
 In the CEE region, health inequalities are significant, and will likely worsen under the current economic crisis.
Country experiences
 In Hungary, in the context of the current economic downturn, it is important to consider vulnerable populations such as those who are near to low income and are at risk of losing their jobs. Other vulnerable groups include the Roma and migrant populations and particular geographical regions such as the deprived population residing near the Ukraine border.
 In England there is a comprehensive national strategy in place to reduce inequalities in health, along with an explicit inclusion of goals to reduce avoidable inequalities in the formula that is used to allocate resources to the regional health care purchasing organizations; however, these policies have had limited success to date.
 In the Netherlands, there was considerable effort to measure and understand inequalities in health in the 1990s, along with the development of interventions to reduce inequalities. Recent renewed interest in reducing inequalities can be seen at the national level, with a focus on supporting existing interventions, the continual evaluation of these programmes, and a new focus on ethnic minorities.
 In France, there is no national policy to reduce inequalities in health, and the large part of the policy attention has been limited to the role of the health care system; these efforts have focused on reducing financial barriers to access, strengthening the role of GPs, and targeting specific diseases, although with limited evidence of their effects on inequalities.
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Summary Report
As stated by Sarah Worthington in her welcome address, the London School of
Economics is in a particularly favourable position to host a seminar on health inequalities. LSE has a long history of producing innovative research in this area, from the 1960s with Peter Townsend and 1970s with Julian Le Grand, both senior experts in the social policy community who were able to attend this seminar in 2009. This history of research and policy analysis continues to this day with a new generation of academics who are motivated by similar goals: to improve our understanding of the extent of the problem of health inequalities and to find realistic policy solutions.
Part I: Methodological issues in health inequalities measurement
What are we actually measuring (micro/macro/meso level; absolute/relative measures)? (Cristina Masseria, LSE Health)
There are numerous methodological issues that the study of health inequalities introduces. We are often concerned with inequalities in health by income, an association that can be measured at the macro, or national, level, and at the micro, or individual, level. At the macro level, there appears to be little relationship among high income countries between national income and aggregate levels of population health such as life expectancy and infant mortality, although this is more clearly seen among lower income countries. It does seem however that as national incomes increases, so too does population health; this is due to a complex and bidirectional relationship between income and health.
At the micro level, one can examine absolute and relative inequalities, the former is expressed in terms of the difference in absolute terms between high and low socioeconomic groups, the latter can take the form of a ratio between different socioeconomic groups or across the entire distribution. It is important to consider both absolute and relative inequalities since they both carry important information on the extent of the problem and to monitor effects of interventions.
Moreover, it appears that the relationship between overall health outcomes and inequalities is not straightforward: as overall health improves, relative inequalities in health may worsen if health improvements are disproportionately among higher socioeconomic groups, or they may improve if they are due to improvements among the more deprived populations.
Data availability and methodological issues in Central and Eastern European countries (Martin Bobak, Epidemiology & Public Health, University College London,
Division of Population Health)
The economic transition had a clear and measurable impact on income inequalities and social inequalities in health. A particular challenge that relates to the study of inequalities in this region is the limited representation of Roma populations in census and survey data, a population that is likely the most disadvantaged in socioeconomic and health terms. Also there is little
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information on the role of nationality (and migrant populations) in datasets in order to understand health inequalities, for example studies have shown that
Russian minorities in Baltic states have worse health than the national-born populations.
In terms of the data requirements for studying health inequalities, although there are some limitations in terms of incomplete death registries and the unavailability of health care insurance and hospital databases, the extension of existing European-level surveys to this region, such as SHARE and EU-SILC, offers new opportunities for comparative research. Future research could address the problem of urban/rural inequalities in health, an area that has received greater attention in western countries, the United Kingdom in particular.
The issues of data collection are not restricted to the CEE countries, and some countries are abandoning the census altogether in favour of population registries; however, these registries need to be significantly improved in order to ensure data accuracy and representativeness, and though census can have high levels of under-reporting (for example up to 15% of the population in the Czech
Republic) these should still be offered once every ten years.
Methodological issues in data analysis in Europe (Owen O’Donnell, University of
Macedonia, Greece)
There have been significant advances in the methodologies that we have available to measure inequalities in health; in large part these advances have responded to the particular challenges and opportunities that the available data present. In order to measure inequalities, we need accurate measures of socioeconomic status and health. Numerous surveys are available that have this information; however, the reliance on subjective measures of health status has raised particular methodological challenges that relate to the potential bias that can arise if the reporting of health status differs systematically across socioeconomic, or other population, groups. Research has shown that this bias can be addressed by making use of vignettes of health states; in some countries such adjustments increase the level of inequalities that is found, in others they decrease.
Methodological tools to measure inequalities range from simple rate ratios to more complex concentration indices that take account of the whole distribution of socioeconomic status (the former is used in epidemiological research, the latter in economics). The concentration index has recently been improved further to account for the bounded nature of health indicators (meaning that these indicators, e.g. self-assessed health, often have an upper and a lower limit).
Other methodological developments include the use of longitudinal data sources that enable a better understanding of health inequalities over the lifecycle as opposed to at a given age and time. This type of research also permits the investigation of the causal mechanisms of inequalities. In the United States and the Netherlands such research has found strong support for a mechanism that
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goes from health (i.e. poor self-assessed health or presence of disabilities) to work (i.e. job loss) to income (i.e. loss of income associated with job loss). Of course the effect of income and socioeconomic status on health is important as well, for example the effects of retirement (and reduction in income) on health, and the role of early childhood deprivation, and both directions play a role; however it appears that the other direction (health to income) is the stronger causal pathway that explains inequalities.
Analysing unmet need for health care (Sara Allin, University of Toronto)
Self-reported unmet need for health care is included in SHARE and EU-SILC, and therefore provides an opportunity for cross-country comparative research on
‘access’ to health care. The phrasing of the question in EU-SILC focuses on
“unmet need” for reasons such as cost, waiting times, wanted to wait to see if the problem got better on its own, didn’t know any good doctor, fear of doctors, and could not take the time; in SHARE the question is about forgone care specifically due to costs and unavailability. The diverse set of reasons for reporting unmet need (in EU-SILC) necessitates its disaggregation in order to gain meaningful information: for example the prevalence of unmet need in Sweden is 13% when all reasons are included, but is only 1.5% of the population when only costs and availability are included.
Among those reasons for unmet need that are arguably more policy relevant, it appears to be more prevalent among people in poorer health and lower income.
However, more research is needed to investigate the reasons for the higherthan-expected use of health services that preliminary research has found among those who report unmet need, and, using the longitudinal data from SHARE to examine the effects of reporting forgone care in one year on health outcomes and health care utilization in subsequent years.
Part IIa: Policy interventions for reducing health inequalities
Reducing health inequalities – What do we really know about successful strategies?
(Martin McKee, London School of Hygiene and Tropical Medicine)
Health inequalities exist across numerous population groups including, but not limited to, socioeconomic groups, language and nationality, gender, ethnic background. There is considerable knowledge on the extent of inequalities in health, however the empirical evidence on strategies to reduce health inequalities is extremely limited. Fortunately research is gaining ground in this area: there is a lot of evidence about how to address the causes of ill health that disproportionately affect the poor, in particular smoking related diseases
(although their impact on inequalities is less well understood), and the Campbell collaboration provides a rich source of evidence on how to improve the conditions in which poorer people live.
When inequalities relate to health conditions that should be avoided in the presence of timely and effective health care, as with the example of racial inequalities in the United States, the tools to reduce inequalities relate in part to
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the health system. Therefore, ensuring health insurance coverage is vital, in addition to providing such things as interpreter services, outreach workers, developing culturally sensitive policies, and encouraging the recruitment and retention of minority health workers.
According to the Dahlgren and Whitehead model of the social determinants of health, we need to address inequalities by a) strengthening individuals, b) strengthening communities, c) improving access to essential facilities and services, and d) encouraging macroeconomic and cultural change. On the side of the individual, we need to help people make healthy choices through legislation, fiscal policies, and empowerment. Smoking provides a good example of where to focus these activities, and where significant effort has been placed. Systematic reviews (from the Cochrane Collaboration) have identified that certain smoking policies work to reduce the prevalence of smoking, such as individually-targeted workplace interventions, smoking cessation programmes among pregnant women, intensive hospital-based interventions, and the provision of advice by doctors and nurses. Many of the individually-targeted and educational programmes however have shown greater success among higher socioeconomic groups and therefore may have the effect of widening social inequalities in health.
On the side of the community, there is some evidence of successful strategies in increasing job participation, improving educational outcomes, and improving living standards; all may have an effect on health inequalities, but this link has not yet been demonstrated empirically. With regards to education, studies have shown that parental involvement interventions can achieve significant improvements in reading and maths, and ‘head-start’, the American programme from the 1960s showed preschool education for poor families had an effect on numeracy and literacy in the short-term, and with beneficial long-term educational and occupational effects.
With regards to improving access to essential facilities among the underserved populations, and encouraging macroeconomic and cultural change, such changes are much more complex and difficult to bring about. However, there is an important role that welfare programmes and income redistribution can play to reduce income inequalities, and therefore potentially health inequalities as well.
In the context of high income countries, however, no study shows convincingly that, controlling for confounding factors, giving people money does not improve their health. Also, Marmot shows that inequalities worldwide are severe, but the prescriptions suggest a radically different society from that which we live in.
Perhaps the way forward it to target the immediate causes of health, such as smoking among the disadvantaged population groups. Also we need to develop more evidence from experiments to demonstrate what works in the quest to reduce inequalities in health.
How do welfare policies contribute to the reduction of health inequalities?
(Olle Lundberg, Universitet Stockholms)
From the perspective of the social determinants of health, it is important to look
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at the role of welfare policies on health and inequalities. Research shows that the institutional design of welfare policies as well as the levels of generosity may be related to public health outcomes. For instance family policies that support dual earning households are associated with lower levels of child poverty and infant mortality. With regards to health inequalities, however, relative inequalities appear to persist irrespective of social polices or welfare state regimes. However, absolute inequalities, and in particular the levels of mortality among the lower strata (the so-called ‘blue collar’ workers) may be linked to the type of welfare policies adopted.
More scientific attention could be addressed towards the question of the extent to which welfare policies can effectively reduce health inequalities. In particular these policies will have the most impact on improving health among disadvantaged populations. Since large-scale societal change may not be within our grasp, such as that which was proposed by the Commission on the Social
Determinants of Health final report, increasing support and expansion of welfare policies to the advantage of the most deprived populations is one tool by which inequalities in health could be more feasibly addressed.
Individual behaviour and public health: the role of incentives (Julian Le Grand, LSE)
Individual behaviours have been recognized as some of the most important determinants of health and health inequalities. Therefore, there is potential to reduce inequalities if lower socioeconomic groups adopt healthier lifestyles.
There have been advances in the behavioural economics literature where there is recognition that individuals do not have rationally, they have trouble processing information, and they aren’t able to project themselves into a different situation. Also the costs of undertaking unhealthy activities accrue a long time in the future, whereas the benefits are immediate, and moreover the benefits of undertaking healthy activities accrue a long time in the future, whereas the costs are immediate. Therefore incentives can be used to bring forward in time the benefits of healthy activities or the cost of harmful activities.
Some of the existing tools that are used to bring about behaviour change by changing incentives include regulation, taxation, and libertarian paternalism.
Regulatory actions in health include mandating vaccinations, safety belts in automobiles, helmets for motorcycles, and prohibiting unhealthy, unsafe behaviours such as drug use or alcohol consumption among youth. Taxation is widely used to limit consumption of cigarettes, alcohol, and may arguably reduce inequalities in health since the price elasticity of demand for poorer people is higher (they are more likely to reduce consumption in the face of higher prices).
A new area of research is in the area of libertarian paternalism, whereby policies are introduced that ‘nudge’ people to make healthier choices. An example of this theory in practice is with organ donation, whereby if individuals have to opt into organ donation there are very low levels of donation, however if they have to opt out (and the default is that everyone will donate organs in the appropriate circumstances), then much higher levels of donation take place.
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Some new applications of this theory in the context of health improvement include the permit to smoke, and the introduction of an ‘exercise hour’ for employees. These have their strengths and limitations, and their impacts on inequalities are unknown. For the case of smoking it is important to consider that the majority of long-term smokers start in their youth, at an age when purchasing cigarettes is illegal; therefore the permit would have no effect on the initiation of smoking among youth. Also one must consider consequences of regulatory policies such as smoking bans, given the example of the decline of smoking among doctors in the 1950s and 1960s that was mirrored by an increase in alcohol consumption. Finally, incentives are not only important at an individual level to bring about behavioural changes, but also at the supply side, for example by imposing regulations with regards to the labeling of health content on food packaging.
Part IIb: Policy interventions for reducing health inequalities: regional and
country case studies
Policy interventions to tackle health inequalities in Central and Eastern Europe
(Peter Makara, National Institute for Health Development, Hungary)
In Hungary the challenge of reducing health inequalities is particularly important given the likely increase in inequalities that will result from the current economic recession. The population that is at highest risk of poor health in
Hungary is that which is close to low income but is pushed into low income from economic recession, crisis, job loss. For these populations the health effects, both physical and mental, will be significant. Also, there are significant geographical inequalities in health, whereby there is a severely disadvantaged population that is located near the Ukrainian border with Hungary; there is a higher level of social exclusion, and average life expectancy is at the level of the
1920s and is declining.
There is growing awareness in CEE of the need to tackle socioeconomic inequalities in health and to improve the accessibility and quality of health services. However, more effort needs to be taken at the national and EU levels to standardize data collection in the region, to share best practices, and to translate these to the different national and local contexts. Also important is to consider other inequalities than those that relate to socioeconomic groups, for instance gender differentials are significant in this region, although health policy and programmes have not given this issue sufficient attention. Health promotion and health education need to be targeted to those groups who are typically more difficult to reach, such as those with lower education, the poor and unemployed, migrants, older people and ethnic minorities.
There is also need for more health impact assessment of crisis management and development policies, in particular the impact of these policies on the health of disadvantaged or high-risk groups. Broader health equity impact assessment, such as that which is promoted by the WHO, should be incorporated into broader public policy. The health threats of particular population groups need to be addressed, such as Roma and migrant groups even though improvements in these areas may not translate to broader population-level reductions in inequalities.
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There has been significant progress in developing programmes to tackle poverty and social exclusion in the countries of CEE. These programmes offer opportunities to develop synergies between health and development, for instance in order to consider the health effects of development strategies. Furthermore, improving access to and management of care for health conditions that disproportionately affect lower socioeconomic groups could have an impact on narrowing the gap in health between the more and less deprived groups.
Resource allocation policies to reduce avoidable health inequalities between
Primary Care Trusts in England (Tom Hennell, Department of Health, UK)
England has one of the most comprehensive health strategies to reduce health inequalities in Europe. Included in this strategy is the explicit incorporation of health inequalities reduction into the formula that is used to allocate resources from the national level to the regional purchasing organizations (primary care trusts, PCTs). Since the 1970s the primary objective of the resource allocation formula was to achieve equal access to health care for equal need across the regions, and since 2002 there has been an additional objective of reducing avoidable health inequalities.
Historically there has not only been extensive research into the magnitude of the problem of health inequalities in England, both across social groups (e.g. the
Whitehall studies that document inequalities in health across different occupational grades of civil servants) and across regions (the so-called ‘inverse care law’ that states that wealthier regions also spend more on health care in spite of having better levels of health than poorer regions). Although over time there have been significant improvements in overall population health in
England, as with many other high-income countries, the levels of health inequalities have not improved and according to some indicators may have widened. It appears that even in the context of comprehensive strategies to reduce inequalities along with measurable targets, alongside the explicit link that is made between health care funding and the reduction of inequalities, these efforts have so far had little success. Perhaps further refinement of the resource allocation formula, for example that takes into account regional variations in unexpressed demand, or unmet needs may have some effect.
Policies to increase healthy life expectancy among lower social income groups in
the Netherlands (Mariel Droomers, National Institute for Public Health and the
Environment)
In the Netherlands the reduction of inequalities in health is on the political agenda. There has been a long-held concern in the Netherlands for health inequalities, in the 1980s this concern focused on the socially and economically marginalized groups, and in the 1990s the Dutch government pursued a research-based approach to tackle inequalities; this approach resulted in the development of several effective interventions. Since 2000 there was very little attention paid to inequalities until the change in government in 2007. This year also marks the first time data on educational inequalities in life expectancy and healthy life expectancy were compiled based on survey and mortality registry
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data: in terms of life expectancy there was a 6 and 7 year gap between the highest and lowest educational group for women and men, respectively, and a 16 and 19 year gap in healthy life expectancy for women and men.
The current policy, termed ‘Toward and Able-Bodied Society’ focuses on integrated policy across the different sectors, prevention and decentralized implementation. The prevention policy emphasizes individuals taking responsibility for their health, facilitating cooperation across public health, curative care and home care, and incorporating some preventive interventions into the basic health insurance coverage. Decentralized implementation relies on stimulating municipalities, schools and companies to work together to improve the health of their populations. The new policy has no measurable targets, it has no separate financial budget, and does not develop any new interventions except in the area of improving quality of health care for ethnic minorities.
However it does take a district approach to tackling the problems of housing, employment, education, safety and integration among the 40 most deprived districts in the country. Moreover, in half of these districts, healthy neighbourhood experiments will be introduced to improve the health of the residents by means of an integrated approach focussing on healthy residents, healthy living conditions, and the provision of coherent primary health care teamed up with prevention. Evaluation of these programmes will serve to inform future policies.
What is the role of the health care system in France to reduce inequalities in
health? (Dominique Polton, CNAMTS)
France appears to have large and increasing inequalities in health. The approach that has been taken in France to reduce inequalities in health has focused on the role of the health system, in spite of evidence that demonstrates the small role that health care plays in explaining inequalities. To date there has been no national strategy developed to reduce inequalities in health.
Some important health care reforms have taken place that may have had some effect on inequalities. Three health care policies in particular were introduced with the expectation that they would have an impact on health inequalities: to improve access to health care among the poorest people, to revise the role of general practitioners to strengthen primary care and to improve continuity of care with voluntary gatekeeping, and for public health plans to focus on tackling specific diseases and risk factors. Improved access to services was facilitated with the introduction of universal coverage (CMU) in 2000, the extension of voluntary health insurance to low-income groups and subsidies for extended coverage for those families with incomes that exceeded the low-income threshold. These reforms were likely to have affected inequalities in access to care, although financial and geographical barriers are still a problem for some population groups, and the impact of these reforms on health inequalities are uncertain. As for the strengthened role of GPs, at present about 85% of the population has registered with a GP, however the effects of this change have not
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yet been evaluated. The focus of health plans on targeting specific diseases and risk factors may have an impact on reducing inequalities in health if those diseases are chosen that are disproportionately prevalent among lower socioeconomic groups.
Cancer is an important example of a disease with a highly unequal distribution, and it appears to be playing an increasing role in explaining inequalities in health. Two of the risk factors for cancer have been targeted: tobacco consumption and obesity. The Public Health Act aimed to reduce the prevalence of daily smoking in the adult population, through banning smoking in public places, schools, restaurants and bars, reimbursing smoking cessation programmes, and increasing the price of cigarettes. Among men the smoking prevalence fell from 33% to 30% between 2000 and 2006, and for women the decline was from 26% to 21%, which is close to the targets that were set for
2008. The Act also aimed to reduce the prevalence of overweight and obesity, although there has been little or no progress toward this goal, and in fact among women the prevalence of obesity actually increased from 11-13.6% between
2003 and 2006. Since inequality in obesity was greater than that for smoking, these trends suggest only minimal progress in reducing inequalities and a need for further integration of research on inequalities and policy development.
Conclusions
Research on health inequalities has been substantial, although more needs to be done to better inform policy. It is important to acknowledge that inequalities in health should not only be considered in relation to socioeconomic groups but across other dimensions as well, such as gender, ethnic background, and geography. The European Commission has made significant progress in collecting comparable data that enables the study of inequalities in health in the region, and the new European Health Interview Survey is an important positive development in this area. There is a need to go beyond the measurement of the socioeconomic inequalities in health, which is an important, but purely descriptive, exercise, to the study of the causes of these observed inequalities in order to inform policy development. The likely policy response should not be to increase income, per se, but to address the things that are related to income such as employment and living standards. Finally, research should take a life-cycle perspective to the analysis of health inequalities; such an approach provides insight into the causes of inequalities, and at what stages of life inequalities are more pronounced.
From a policy perspective, we have some knowledge about what policies may be effective in reducing health inequalities, although more research is needed to evaluate existing policies and to develop a more robust evidence base. Some effective policies include those that address individual behaviours, such as smoking, through incentives and regulations. Also important are communitylevel interventions such as through the strengthening of communities, local labour market policies, education and social policies. While individual behaviours are important focus for policy attention, it is important to recognize
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the role that structural and environmental changes can have on individual behaviour. To reduce inequalities there also has to be a dual focus on inequalities across the entire socioeconomic distribution, to reduce relative inequalities, but also to target the most deprived populations to reduce absolute inequalities. Finally, there is evidence from country experiences that there are some interventions that have shown to be effective in reducing inequalities, and perhaps the most effective would be to develop a constellation of local-level strategies in conjunction with, or in the place of, a broader national policy.
From the perspective of the European Commission, the 2009 work programme includes the reduction of inequalities in health between and within countries.
Toward this aim, the Commission is dedicated to improving data availability and comparability, for example with the new European Health Interview Survey, and is also concerned with generating evidence on what health and health care policies may be effective in reducing inequalities but that are also feasible to implement.
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