“More action also needs to be directed at the determinants of health—improving living and working conditions and policies supporting more positive health-related behaviors.”

Disparities or inequalities in health are a matter of increasing concern in Europe. Although all twenty seven European Union countries have policies of universal access to health care, it is clear that this has not prevented major differences in health from arising. It is becoming increasingly apparent that, while universal access to health care is an essential part of creating a fairer distribution of health, health care alone is not enough. More action also needs to be directed at the determinants of health—improving living and working conditions and policies supporting more positive health-related behaviors.

EU statistical data show widespread differences in health among countries and among socio-economic groups. These start at a young age and persist and widen in older ages. Differences in life expectancy at birth, between the lowest and the highest socio-economic groups (e.g. between manual and professional occupations; people with primary level and post-secondary education; low and high income quintile), range from four to ten years for men and two to six years for women. In some countries the gap has widened in the last decades. Despite an overall decline, mortality and infant mortality are higher in the lowest socio-economic groups and relative inequalities have increased in several countries.

Rates of disease and disability also vary substantially by socio-economic group. People with lower education live shorter lives and spend more time in poorer health. In some countries, the percentage reporting very bad health in the lowest income groups has gone up since 2005.

Vulnerable groups suffer a particularly greater burden of mortality and disease. These include some migrant groups and ethnic minorities, people living in deprived urban and rural areas and in poverty, the long-term unemployed, seasonal/daily workers and subsistence farmers, jobless households, the homeless, the disabled, those suffering from mental or chronic illnesses, older pensioners on minimum pensions, and single parents. For example, people from the Roma ethnic minority, which is the single largest minority in Europe, can expect to live 10 years less than the majority population in some countries.

Older age often exacerbates other pre-existing inequalities based on race, ethnicity or gender. Inequalities experienced in earlier life in access to education, employment and health care, as well as those based on gender and race, have a critical bearing on status and well-being in old age. For older people who are poor, the consequences of these earlier experiences are worsened through further exclusion from health services, credit schemes, income-generating activities and decision-making.

The causes of health inequalities were recently summarized by the World Health Organization. Broadly speaking, around 40-50 percent of the differences in health between social groups are related to differences in income, living and working conditions, around 30 percent are due to health-related behaviors, and around 20 percent to health and related services.

States and among socio-economic groups in the consumption of fruit and vegetables and the prevalence of smoking, alcohol consumption, obesity and physical activity. Countries with high rates of smoking, combined with low rates of exercise and unhealthy diet, are also the countries with the lowest life-expectancies in the EU. However it is also clear that health-related behavior is itself influenced to a large extent by socio-economic and cultural factors.

Education, occupation and income/wealth are also important determinants of health, even after adjusting for other risk factors. Living in poverty is associated with higher mortality and disease. Unemployment is associated with increased poor mental health and suicide. Job quality and working conditions probably affect health to a greater extent than is currently appreciated. In addition, occupational health risks vary across sectors and not all workers are equally exposed: e.g., workers with a fixed duration or temporary employment relationship are statistically more likely to suffer from accidents at work and occupational diseases.

Health care availability and quality helps us explain some of the health disparities observed. Evidence suggests that lower income families have further to travel to a hospital or a family doctor and that, after adjusting for different levels of need, the rich are significantly more likely to see a specialist and a dentist than the poor. Barriers to health care access include lack of health insurance, direct financial costs of care, geographical disparities in provision, waiting times, lack of information, discrimination, language barriers, health literacy and socio-cultural expectations in relation to life and care use. In general, inequitable access to care appears to be associated with higher health inequalities.

The current economic crisis may also have an impact on health and increase health inequalities through a deterioration of social determinants of health, especially for those with lower qualifications and savings, and those who are already vulnerable. The loss of job and thus income can lead to worse living conditions and life-styles, especially if social protection mechanisms are not present. Unemployment or job insecurity lead to increased levels of stress and greater risk of health damaging behaviors (e.g. harmful patterns of alcohol consumption) and contribute, for example, to depression, immune disturbances or accidents and have possible consequences on other family members. The negative impact on health can be long lasting. In addition, a deep economic crisis can have an impact on health and increase health inequalities through a deterioration of the access to quality health and social care by those in lower socio-economic groups. This is the case if access to care depends on being employed or having financial means, or if the EU Member States cut the resources allocated to the health and social care sectors, leading to lower coverage or quality of care.

The European Union is committed to reducing inequalities in access to health care and in health outcomes. A number of EU Member States have produced integrated strategies involving policies in areas such as economic development, education and environment as well as health as a mechanism to tackle them. A few others have established targets for reducing health gaps between social groups. The European Commission has recently adopted a policy paper outlining its strategic approach to address health inequalities, which I developed together with the Commissioner in charge of employment and social policy. The aim is to support national, local and regional government and other bodies to tackle health inequalities more effectively. These actions seek to raise awareness about the need to reduce health inequalities and provide a framework for joint work between countries and stakeholders. Initiatives on the special health needs of vulnerable groups including migrants, Roma, children and young people will be instituted.

Further analysis on the impact of a range of policies on the distribution of health throughout the EU—a so called “health inequality policy audit”—will be conducted. Work will ensue to make better use of the possibilities for funding of initiatives to tackle health inequalities available through the EU’s regional policy and rural development policies. Action aimed at reducing the gap in health between the EU and developing countries will also be taken. Research and information sharing will be enhanced, and a consistent methodology for monitoring health inequalities shall be introduced. A first progress report will be published in 2012.

I am convinced that our initiative is an investment in the future of Europe: A Europe based on the values of peace, freedom, justice and solidarity, where health and well-being are respected and desired.



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