European Public Health Conference, Ljubljana 28.11.2018 Preconference on Health Inequalities; JAHEE Health inequalities and public policy - selected experiences from Finland Seppo Koskinen

Health inequality has been a central issue in Finnish healthy public policy for more than 30 years 28.11.2018 Koskinen

Government’s health policy report to the Parliament, 1985 -”Differences in morbidity between population groups must be decreased." -”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." -”Measures needed to reduce behaviourally determined health problems in the population groups at highest risk will be untangled". -"Alcohol consumption will be reduced and the ability to control alcohol use in diferent subgroups of the population will be strengthened". -”Wide differences between socioeconomic groups in morbidity and mortality constitute a central research problem." 28.11.2018 Koskinen

Government’s report to the Parliament on public health, 1996 -”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." -”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." -”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." -”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) 28.11.2018 Koskinen

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) 28.11.2018 Koskinen

National action plan to reduce health inequalities, 2008–2011 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. 28.11.2018 Koskinen

Has health inequality decreased? 28.11.2018 Koskinen

Increasing inequalities in life expectancy at age 25 by level of education Women, higher Difference 4.2 years Difference 2.7 years Women, basic Difference 5.1 years Men, higher Difference 4.5 years Men, basic Source: www.terveytemme.fi/kuolleisuuserot/ 28.11.2018

Increasing inequalities in life expectancy at age 25 between income quintiles Men Women 4. & 5. quintile 4.6 4. & 5. quintile 3.0 1. quintile 9.0 6.4 1. quintile Source: www.terveytemme.fi/kuolleisuuserot/ 28.11.2018

*) Potential years of life lost between ages 25 and 80 /100 000 Wide regional differences in potential years of life lost (PYLL) in lower socieoconomic groups – but not in higher groups by level of education by income quintile Basic Higher Lowest Two highest *) Potential years of life lost between ages 25 and 80 /100 000 Source: www.terveytemme.fi/kuolleisuuserot/ 28.11.2018

Inequalities in mortality have increased rapidly largely due to growing disparities in deaths caused by alcohol, but also deaths from other causes of death Wide inequalities also in health and functional status, but no significant time trends 28.11.2018

Time trends in determinants: 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 28.11.2018

Time trends in determinants: living conditions Income and wealth growing inequality Unemployment 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 much more hazardous in manual than in non-manual occupations, but time trends in these inequalities are not well known 28.11.2018

Time trends in determinants: health services Occupational health services wide inequalities persist Private services very wide inequalities persist Distribution of surgical and other treatment according to need marked inequalities The limited supply and high price of new health technologies reduces possibilities of less advantaged groups to benefit from them 28.11.2018 Koskinen

Why are health inqualities not decreasing? Reduction of health inequality has been one of the main aims in all major health policy documents during more than 30 years These general health policy documents represent a quite well developed understanding of the causal network behind health inequalities Why are health inqualities not decreasing? Public policy decisions and measures have often been guided more by other aims than the commitment to reduce health inequalities. Example from alcohol policy: tax reduction in 2004  price of alcohol lowered  marked increase in alcohol deaths in lower socioeconomic groups – as predicted 28.11.2018

Need for committed action in all sectors of public policy Inequalities in health are not inevitable, and therefore, not acceptable ethically 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 the population ages Poor health is a factor in social exclusion Health inequalities have negative economic effects Public health will improve more effectively when the health of the (large) groups with accumulating problems is promoted 28.11.2018

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 28.11.2018 Source: Koskinen & Martelin 2007 17

Tackling health inequalities in municipalities: lessons learnt There is no uniform way to operate in different cities, municipalities and regions Information about health inequalities in the “own” population (not only national) is needed to awaken decision-makers Arguments which start from decision-makers’ point of view (e.g. economic effects, sufficiency of labour force) are needed for motivation The aim has to be incorporated into local and regional strategies in order to legitimate and lead to actions Effective intersectoral work is needed, health sector has an important role as an advocate 28.11.2018 Koskinen 18

Tackling health inequalities, lessons learnt on the national level: We need (also) Long-term policies/actions – not just 2–4-year programmes Healthy public policy – not just health services policy Partners from a number of different sectors A high-level intersectoral body to plan, monitor and prioritize interventions and policies in different sectors (The National Advisory Board for Public Health – including representatives of ministries, NGOs, academia, trade unions etc. – no longer exists after 2015) Active search of effective win-win situations: Which political initiatives tend to lead to action? Can we find shared aims with these supposedly successful initiatives / lines of policy or interventions? Can we produce convincing evidence that these initiatives or lines of policy significantly benefit from cooperation with policies aiming to reduce health inequalities 28.11.2018 Koskinen 19

Thank you!