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 health A European perspective Edited by Johan Mackenbach and Martijntje Bakker

7. Content lI Introduction lII Interventions and policies to reduce socio- economic inequalities in health lIII National experiences lIV Evaluation issues lV Reflections lVI 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 capital 2. Growing up in a satisfactory environment 3. Improving conditions at work 4. Creating a satisfactory physical environment 5. Stimulating health-promoting life habits 6. 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 factors 2. 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