1 Health inequalities: underlying factors and different ways of addressing them

2 health is unequally distributed in Europe – between and within countries focus here on health inequalities within countries, between socioeconomic groups highlight 5 key points

3 1. Health inequalities exist in all European countries

4 Mortality rates (per 1000 person years) of lower & higher educated groups, women aged Source: unpublished estimates by M. Huisman, A.E. Kunst and J.P. Mackenbach for the EU Working Group on Socioeconomic Inequalities in Health high low

5 Mortality rates (per 1000 person years) of lower & higher educated groups, men aged Source: unpublished estimates by M. Huisman, A.E. Kunst and J.P. Mackenbach for the EU Working Group on Socioeconomic Inequalities in Health high low

6 2. Health inequalities take the form of a social gradient

7 Sweden: rates of limiting longstanding illness by educational level, Source: Lungberg et al, 2001

8 England: rates of limiting longstanding illness by socioeconomic group (based on occupation), 1998 Source: General Household Survey, 1998

9 3. Health inequalities reflect inequalities in the distribution of health determinants

10 Health strategy of the European community ‘addressing health determinants, the underlying factors which affect people’s health’ ‘life-style related health determinants’ : cigarette smoking, diet etc ‘socio-economic determinants’: life chances (childhood circumstances, education, employment), working & living conditions, health & welfare services

11 What is important about these determinants for health inequalities is their social distribution health determinants display a socioeconomic gradient

12 Risk factors by social class at birth, 1958 birth cohort Source: Power 1997

13 4. Multiple understandings of what it means to tackle health inequalities improving the health of disadvantaged groups reducing health differences between socioeconomic groups

14 improving the health of disadvantaged groups focus on marginal & minority groups (immigrant communities, homeless people) sets boundaries around ‘the problem’

15 improving the health of disadvantaged groups absolute improvements in their health may not narrow the gap between them & the wider population (because overall health is improving at a faster rate) obscures health inequalities across the population

16 social classproportion death rates of pop (%) (per ) I 7282 II IIInm 9432 IIIm IV V Source: Drever and Whitehead, 1997 Deaths among men aged 20-64, England and Wales,

17 reducing health differences between socioeconomic groups encompasses goals of improving poor & poorer health of most disadvantaged tackling health inequalities is a population-wide strategy policies which equalise the distribution of health determinants too ambitious - or in line with welfare policy?

18 Effect of major fiscal reforms on disposable household income, 1997 to 2002 Source: IFS, 2001

19 5. Tackling health inequalities requires multi-sectoral commitment health inequalities reflect the unequal distribution of health determinants broader social and policy changes are often widening inequalities in key determinants new interventions & existing policies will have an impact on the distribution of health determinants

20 Getting and keeping health inequalities on the policy agenda is a key challenge for an enlarged Europe

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22 Proportion of households with pre-transfer incomes below 50% of average income, circa 1990 % poor Source: Bradshaw & Chen, 1997

23 Proportion of households with post-transfer incomes below 50% of average income, circa 1990 % poor Source: Bradshaw & Chen, 1997

24 Percentage of lone parent households with pre- transfer incomes below 50% of average income, circa 1990 % poor Source: Bradshaw & Chen, 1997

25 Percentage of lone parent households with post- transfer incomes below 50% of average income, circa 1990 % poor Source: Bradshaw & Chen, 1997

26 Benefits in kind for non-retired households by income quintile groups, UK, bottom2nd3rd4thtop all households benefits in kind 1 as % of post-tax income income quintile Source: Harris, education, NHS, housing, travel subsidies, school meals and welfare milk

27 Cigarette smoking among women aged 16 and over by socioeconomic group , Britain Sources: Wald and Nicolaides-Bouman, 1993; Bridgewood et al, 2000