October 2013

Sustainable Health Systems for Inclusive Growth in Europe:
Session III Overview

A conference organised by the Lithuanian Presidency of the Council of the European Union, Vilnius, 19-20 November 2013.

Taking Stock: health and health care inequalities in Europe

Across Europe as a whole, life expectancy is increasing. However, health inequality remains: in Newcastle, UK, 55-year olds whose homes are eight miles apart can have eleven years difference in healthy life expectancy. Such huge inequalities are repeated in other European cities.

The differences between countries are even starker: for males there is a difference of 19 years between the average number of healthy life years in Slovakia at 52.1 years, and Sweden at 71.1 years. For women there is an 18.4 year gap between average healthy life years of 52.3 in Slovakia, and Malta, where women have a healthy life span of 70.7 years.

On average, the gap in healthy life years in 2011 was 11.8 years for men and 7.9 years for women, according to the latest data published by the European Commission in September.

Health inequality in Europe has been recognised as an important public health issue for the past 25 years, and a number of policies have sought to close this gap. But with health inequalities starting at birth and persisting into older age, the effects of policy instruments such as cutting tobacco and alcohol consumption, improving disease prevention or promoting social cohesion, inevitably take time to have an impact.

Social gradient in health status

Throughout the European Union a social gradient in health status exists where people with a lower level of education and lower income die younger and have a higher incidence of most types of health problem. Newcastle bears this out: between the high of 74.8 years and the low of 63.8 years, healthy life expectancy in other areas of the city varies from 71.5 years in South Gosforth, 70.1 years in Jesmond and 66.1 years in Fawdon.

The European Commission concluded in its latest update, ‘Report on health inequalities in the European Union’ published in September 2013, ⁽¹⁾ that although there has been some progress in reducing disparities, “sizeable gaps exist within and between member states of the European Union”.

And it is disturbing to find that the latest research implies that rather than decreasing, fall-out from the financial crisis, including increasing unemployment and cuts to health and social care budgets, means that health disparities are increasing.

All of which points to the need for renewed action to deal with health inequality: if everyone is living longer the benefits should be shared by all, so that the extra years of life are genuinely worth having. Session III of the conference will take stock of current understanding of the extent of health and health care inequalities, and raise awareness of the need for governments to reframe and reinvigorate policies aimed at closing these gaps.

Speaking at the European Health Forum in Gastein, Austria, early in October EU Health Commissioner Tonio Borg stressed his commitment to fighting discrimination in health in all its forms and to addressing the stigma and discrimination suffered by vulnerable groups who he said, sometimes “slip through the net”.

“To address continued inequalities in health, we need to focus on improving Europe’s health systems – making them more effective and sustainable, and more accessible to everyone,” Borg said. “Reducing these inequalities is in everyone’s interest,” because better healthcare for all, “Is a crucial component for social cohesion and vital to achieve Europe's 2020 goals of smart, sustainable and inclusive growth,” the Commissioner told delegates.

Lost years of healthy life expectancy are not only a significant cost to individuals, they are an affront to the European Union’s principles of solidarity, human rights, equality of opportunity and social cohesion. More than that, they also have major economic effects, as first highlighted by the research of Professor Johan P. Mackenbach, Chair of the Department of Public Health at Erasmus MC, University Medical Centre, who will be chair of Session III of the Vilnius conference.

In initial research in 2007, Mackenbach estimated that inequality-related losses to health amount to more than 700,000 deaths per year and 33 million cases of ill health in the European Union as a whole. This accounted for 20 per cent of total health care costs and 15 per cent of social security payments. Furthermore, inequality-related losses to health reduce labour productivity, cutting 1.4 per cent, or €141 billion per year from Europe’s GDP.

Health in all policies

The World Health Organisation’s definition of the social determinants of health – “the conditions in which people are born, grow, live work and age” - could not present a wider canvas for policy intervention. Certainly it underlines the need for a whole-of-government approach to framing policy to reduce the health inequalities, with many contributing factors lying beyond the traditional scope of health ministries.

While health inequality is recognised as being the result of a complex mixture of socioeconomic influences, variation in health systems is an important contributory factor.  The Commission’s September report attributes some health inequality to the differences that exist in the quality and effectiveness of health services across the EU.

One European Union research project, ECHO (The EU collaboration for Health Optimisation) is studying unwarranted variation in the effectiveness, quality and safety of Europe’s health systems, drawing on patient-level data from hospitals in six member states. The question of whether differences in health care structures and incentives worsen or reduce health inequalities will be addressed in Session III.

Although equal access to health care is a necessary element in bridging the divide, the socioeconomic determinants highlight the need for a ‘health in all policies’ approach to tackle health inequality. This is the only way to break the vicious downward spiral of poor health that both results from - and perpetuates - poverty and exclusion. A whole-of-government perspective is also required to ensure that the combination of a longer life expectancy lived in poorer health does not fundamentally undermine the sustainability of health systems. 

The degree of autonomy a person has over their life and their decisions is incredibly important for wellbeing. Given this, a key to addressing health inequalities is to create the conditions for people to take control of their own lives. One way to do this is through patient empowerment, to help people living with chronic diseases – which are the major manifestation of health inequalities – to cope better with their conditions.

As Nicola Bedlington, Executive Director of the European Patients’ Forum says in the viewpoint accompanying this overview, “Empowered patients are not cost drivers. On the contrary, when patients are genuinely involved and their preferences are listened to and acted on, the result is better health outcomes, more engaged patients and lower costs.”    

Health inequality is preventable: if someone living in Ponteland in the north west of Newcastle can have a healthy life expectancy of 74.8 years, than so can someone eight miles away in Byker in the south east of the city, where currently the healthy life expectancy is 63.8 years. The same applies across the EU. Dealing with health inequality calls for improvements in housing, safer workplaces and access to healthcare to ensure people enjoy the good health that is biologically possible.

(1) COMMISSION STAFF WORKING DOCUMENT
Report on health inequalities in the European Union