Health Inequalities in Europe: Setting the Stage for Progressive Policy Action by Timon Forster, Alexander Kentikelenis and Clare Bambra

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Executive Summary

By some measures, such as life expectancy at birth, the health of the European population is better today than ever before. However, substantial inequalities in health continue to exist:

  • Between European countries, life expectancy and mortality continue to be better in Western European countries than in Eastern European countries.
  • Within European countries, there are stark social gradients in morbidity, mortality, and life expectancy: the higher the social position (approximated by level of education, occupation, or position in the income distribution), the better the health. Such health inequalities are present in all countries, by gender, and across different age groups.

This report examines health inequalities in Europe—the extent of inequalities, their costs to society, their determinants, and what can be done by policymakers to reduce them. In Part A, we investigate these health inequalities both between and within different European countries—highlighting recent trends and key issues not only in health outcomes, but also in associated risk factors.

These health inequalities have multiple causes, outlined in Part B. We primarily focus on three major determinants: health systems; economic policy; and the wider social determinants of health. Firstly, we find that the cross-national variation in financing, resources, and coverage of healthcare may narrow or widen health inequalities. National health systems that provide universal healthcare can reduce health inequalities—particularly in terms of mortality amenable to healthcare.

Secondly, we emphasise two aspects of economic policy:

  • Labour market policy employment. Yet, insecure and temporary employment—on the rise in the EU since the global financial crisis—are associated with negative health consequences. Such forms of employment are concentrated amongst people of lower socioeconomic status. Thus, we find that in the absence of any protective measures, labour market deregulation may contribute to health inequalities.
  • Fiscal policy pertains to government resources and spending on social protection, public health policy, or sustainability. We show that cuts in government spending on social protection due to austerity have been linked to higher health inequalities in Europe (e.g., through rising unemployment or loss of public services). Yet, we also illustrate that fiscal policy and public health regulation can reduce health inequalities, as some European countries have shown through combatting unhealthy diets or providing sustainable energy.

Thirdly, we examine the wider social determinants of health—the conditions in which people are born, grow, live, work, and age. Specifically, we note:

  • The health benefits of higher levels of education are clear, as individuals with tertiary education are exposed to fewer risk factors, enjoy better opportunities in the labour market, and have increased health literacy.
  • Good work and employment conditions support health through multiple mechanisms—ranging from financial stability to social status, and from providing social networks to the protection Health Inequalities in Europe: Setting the Stage for Progressive Policy Action from psychosocial hazards. Bad work and employment conditions—often concentrated among populations in vulnerable situations—can have the opposite effect, thereby widening inequalities in health.
  • Income inequality is one of the most pressing issues of our time. Indeed, countries with higher income inequality levels tend to have lower life expectancy, higher infant mortality rates, as well as higher prevalence of mental illness and obesity. Put differently, more equitable societies tend to be healthier societies.

In Part C, we draw attention to the sizeable economic costs of health inequalities. In the European Union, they are estimated to cost €980 billion per year, or 9.4 percent of European GDP, as a result of lower productivity and higher healthcare and welfare costs. Increasing the health of the lowest 50 percent of the European population to the average health of the top half would improve labour productivity by 1.4 percent of GDP each year—meaning that within five years of these health improvements, the GDP of the European Union would be more than 7 percent higher.

Based on a comprehensive mapping of the multiple causes of health inequalities in Europe, we conclude by proposing a progressive agenda to act on their determinants:

  1. Reforms in health policy should include provisions to ensure universal health coverage, along with reforms that reduce barriers to accessing and utilising health services—such as lack of health literacy.
  2. In terms of economic policy, the regulation of labour markets and working conditions should provide individuals with healthy work. Further, fiscal policy measures should improve job and income stability of people in vulnerable situations.
  3. Public health policy interventions should address risk factors pertaining to health-related behaviour, such as regulating the consumption of tobacco and alcohol, as well as targeting advertising and the sale of unhealthy foods.
  4. Improving the social determinants of health is a key element for reducing health inequalities in Europe. Thus, governments should reduce barriers to accessing education and put redistributive measures in place to make societies more equitable.
  5. Along all policy dimensions, proposed reforms should be evaluated in advance of implementation to assess their health consequences. Thus, we advocate the use of health impact assessments, an established framework through which the potential health impact of policies can be systematically assessed.

In realising this agenda, policy interventions should be universal, but implemented at a level and intensity of action proportionate to need—an approach known as ‘proportionate universalism.’ In doing so, tackling health inequalities promises not only economic benefits at a national level, but—much more importantly—delivers on a basic human right: the right to the highest attainable standard of health, irrespective of place of birth, gender, ability, or socioeconomic background.

Authors

Timon Forster,

PhD candidate of the Berlin Graduate School for Transnational Studies, Freie Universität Berlin

Timon Forster is a PhD candidate of the Berlin Graduate
School for Transnational Studies, Freie Universität Berlin. His
research interests include the distributional consequences
of economic reforms, international political economy, and
global public health.

Alexander Kentikelenis

Assistant Professor of Sociology and Political Economy, Bocconi University

Alexander Kentikelenis is Assistant Professor of Sociology
and Political Economy, Bocconi University. He has published
extensively on the social and political consequences of
economic reforms.

Clare Bambra,

Professor of Public Health, Newcastle University.

Clare Bambra is Professor of Public Health, Newcastle
University. Her research examines the political, social, and
economic determinants of health and health inequalities.
She has published extensively in these areas, focusing on
how public policies and interventions can reduce health
inequalities

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