Public Health in Europa

Soziale Ungleichheit

Joy Ladurner

Dornbirn, 11. Juni 2010

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Inequality and inequity Often used interchangeably, e.g.

„Inequality and inequity are synonymous terms, both carry thesame connotation of health differences that are unfair and unjust“

however Inequality

Broader term Unequal Different in size, degree or circumstances

Inequity Specific, moral term Lack of fairness or justice

Source: New Oxford dictionary of health in Donald, A. in Pencheon, D. et al (2008)

Source: Whitehead, Dahlgren (2007)

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Principles of equity

Equal access to health care for those in equal need of health care

Equal utilisation of health care for those in equal need of health care

Equal (equitable) health outcomes

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Equity

Horizontal equity Equals should be treated equally Equal care for equal need Absolute

Vertical equity Unequals should be treated appropriately unequally Unequal care for unequal need requiring value judgement

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Inequities are expressed by

Determinants of inequities in health, involving differences/disparities in: Health status Morbidity Life expectancy Mortality Access to (essential) health services

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Equity in health care

Fair arrangements that allow for equal geographic, economic and cultural access to available services for all in equal need of care

Closely matching services to the level of need, thereby allowing for differences in need for health services across different socioeconomic groups

potentially resulting in (large) differences in access and utilisation of services between socioeconomic groups, favouring the more disadvantaged groups in greatest need

Source: Whitehead, Dahlgren (2007)

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Access to health services

Access to (essential) health services as a human right

Can improve health, provide freedom from pain and suffering and improve human activities in general

Even across Europe access to care shows great variations and is inadequate for the needs of some population groups

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Types of access to care

Geographical access – location and physical availability of health services in different parts of a country

Economic access – affordability of health services, burden of payment for essential health services

Cultural access –acceptability, dignity and respect

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Barriers to care

Proportion of population covered with health insurance

Content of the health insurance benefit package

Cost sharing arrangement

Geographical barriers

Organisational barriers

Utilization of accessibleservices

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Equitable access to health care Almost all European countries provide universal, or near-universal

coverage to statutory health insurance, a precondition for access

However, barriers to access exist – e.g. financial, geographical, cultural, administrative – and are unequally distributed across the population

Barriers to access may be especially pronounced for asylum seekers and refugees

There is considerable variation across Europe in reported barriers to access – e.g. waiting times for elective surgery exist in some countries (mainly tax-funded) more than others (mainly SHI funded)

Analyses of income-related inequity in utilisation of health services using SHARE and ECHP surveys indicate: No inequity, or pro-poor inequity, in GP services in Europe Pro-rich inequity in specialist services in almost all European countries No inequity, or pro-rich inequity, in hospital care

Source: Mossialos, M. Allin, S., Ladurner, J. et al (2006)

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Horizontal inequity for a GP visit, 2000

Quelle: OECD Health Data 2009

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Horizontal inequity for a specialist visit, 2000

Quelle: OECD Health Data 2009

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Main reasons for unequal access and quality of care

Unequal distribution of money and services Macro: insurance coverage, central planning Micro: design of services, local planning

Different treatment of groups with the same health need Poor training Lack of knowledge Discrimination Different perceptions and preferences for care by

different social groups

Source: Donald, A. in Pencheon, D. et al (2008)

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Choice

Choice can be exercised with regard to Insurance vs. no insurance Public vs. private insurance Insurance fund Health provider (GP, specialist, hospital) Treatment

Choice can be restricted due to reasons related to legislation, reimbursement or

organizational matters various barriers to care

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Coverage

Quelle: http://www.who.int/whr/2008/whr08_en.pdf

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Direkter Zugang zu Gesundheitsleistungen in 18 europäischen Ländern

Quelle: Kroneman et al. (2006)

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Einschätzung der Qualität der Versorgung durch Praktische Ärzte durch Patienten im Vergleich zum Zugang zu diesen in 14 Ländern

Quelle: Kroneman et al. (2006)

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Equity of access and utilisation

In Austria for instance few people forgo treatment because of costs or unavailability

Probability and frequency of visiting different providers/health care institutions People with a lower income use more health services

but access less specialist care (van Doorslaer, E.Masseria, C. - 2004).

Exemptions may exist for certain user charges (e.g. prescription charge). The exempt population may cause higher insurance expenditure (elderly, co-morbidity, poor, etc.)

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Equity of access and utilisation cont.

Insurance fund affiliation may result in inequity

Those with a lower social status may have restricted access to information on health care and the provision of health services

Elderly use more health services and cause higher expenses for the health insurance funds

Socially disadvantaged people and people with a lower level of education make less use of (free) preventive health services

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Equity of access and utilisation cont.

People with a higher income tend to show a lower tendency towards risky behaviour

Individuals with a migrant background (in Austria) are more likely to use curative than preventive health

services undertake periodic health examinations, vaccinations less

often

Men welcome personal invitations and often come only after experiencing symptoms for a longer period of time

Elderly may go to check-ups less often than young people (e.g. gynaecologist)

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Equity of health status and outcomes

Poverty and level of education influence the subjective health status and health behaviour of individuals

Poor people show signs of chronic illness more frequently and have a greater tendency of experiencing health problems such as obesity, depression or headache

They may be more prone to engage in risky behaviour (e.g. smoking)

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Equity of health status and outcomes cont.

Long term unemployment has psychological implications on health as well as influencing physical stress

These individuals tend to report a lower subjective health status and are less active to maintain their health

They show a higher prevalence of cases of chronic diseases (anxiety, depression) as well as a higher prevalence of obesity and smoking

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Equity of health status and outcomes cont.

Migration background can lead to late access of health services and thus to a higher prevalence of chronic conditions

Migrants also tend to report a lower subjective health status and are more prone to engage in a risky lifestyle

Strong links with level of education and level of income may exist

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Equity of health status and outcomes cont.

Family composition may have an influence on health and health behaviour of children and young people (HBSC study)

Low income and a migration background may have negative implications on the health status of children

The elderly may suffer more from chronic conditions, multi-morbidities and health problems resulting from restricted mobility (falls), social isolation (depression) and over/under use of medication.

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Variations in health across Europe

Relations between life expectancy and GDP per capita in PPS (100=EU25), 2002a

Source: Mossialos (2009)

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At risk of poverty rate, 2006in %

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Health status and race

Source: https://www.census.gov/prod/2006pubs/p70-106.pdf

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Mortality and occupation

Source: Marmot M. Lancet 2006;368:2081-94

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Life expectancy and occupation

Source: WilkinsonR & Marmot M. The Solid Facts. Second edition. WHO 2003

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Health status and employment status

Source: WilkinsonR & Marmot M. The Solid Facts. Second edition. WHO 2003

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Diskussion

Wie könnten benachteilige Personengruppen identifiziert und durch gezielte Maßnahmen unterstützt werden?

Ausgewählte Initiativen

Vergangenheit und Gegenwart

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EU

DETERMINE (2007-2010) – establishment of an EU Consortium for Action on the Socio-economic Determinants of Health (SDH) European Portal on Action for Health Equity

http://www.health-inequalities.eu/

CLOSING the GAP (2004-2007) http://www.health-inequalities.eu

/?uid=5ad5e33d5fc512af1afc89274cb54bbd&id=Seite2113

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EU

PROGRESS programme EU‘s employment and social solidarity programme

(2007-20143) 5 areas:

Employment Social inclusion and protection Working conditions Non-discrimination Gender equality

http://ec.europa.eu/social/main.jsp?catId=327&langId=en

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EU

EC, European Commission. White Paper. Together for Health: A Strategic

Approach for the EU 2008-2013. COM (2007); 630 final.

Eurothine, Tackling Health Inequalities in Europe (DG SANCO, Final report published in 2007) http://survey.erasmusmc.nl/eurothine/index.php?id=112,0,

0,1,0,0

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EU

EC, European Council. DECISION No 1350/2007/EC OF THE EUROPEAN

PARLIAMENT AND OF THE COUNCIL of 23 October 2007 establishing a second programme of Community action in the field of health (2008-13). 200

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European Centre for Disease Prevention and Control, ecdc

Migrant health: Background note to the EDCD Report on migration and infectious diseases in the EU (July 2009) http://www.ecdc.europa.eu/en/publications/Publicatio

ns/0907_TER_Migrant_health_Background_note.pdf

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WHO

WHO-Europe Programme „Socioeconomic Determinants of Health“ http://www.euro.who.int/socialdeterminants

Commission on Social Determinants of Health - final report Closing the gap in a generation: Health equity through

action on the social determinants of health Http://www.who.int/social_determinants/thecommission/

finalreport/en/index.html

Health Inequalities WHO Health Equity Target

http://www.euphix.org/object_document/o5616n29797.html

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The World Economic Forum

The Global Gender Gap Report 2007 http://www.weforum.org/en/initiatives/gcp/Gender

%20Gap/index.htm

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UK

NHS, DH Department of Health Health equity audit

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084138

Tackling health inequalities – a programme for action http://www.dh.gov.uk/en/Publicationsandstatistics/

Publications/PublicationsPolicyAndGuidance/DH_4008268 Tackling health inequalities: 10 years on (2009)

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098936

Marmot-review: Post-2010 strategic review of health inequalities http://www.dh.gov.uk/en/Publichealth/

Healthinequalities/DH_094770

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UK cont.

London Health Observatory Health inequalities intervention tool

http://www.lho.org.uk/LHO_Topics/Analytic_Tools

/HealthInequalitiesTool.aspx

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Finland

National Action Plan to reduce health inequalities – TEROKA (2008-2011) http://www.teroka.fi/teroka/index.php?

option=content&pcontent=1&task=view&id=102&Ite

mid=135 http://pre20090115.stm.fi/pr1227003636140/

passthru.pdf

Danke für Ihre Aufmerksamkeit!