The European Commission's Directorate-General for 'Health and Consumers' (DG SANCO) launched a consultation on EU action to reduce health inequalities which closed on 15 April 2009. 

The aim of the consultation was to collect views on how the European Union can contribute to reducing health inequalities both within and between member states. 

Access the consultation paper here

Access the IPH response below:

IPH Submission to DG SANCO - EU action to reduce health inequalities

Introduction

The Institute of Public Health in Ireland
The Institute of Public Health in Ireland (IPH) is an all-island body which aims to improve health in Ireland, by working to combat health inequalities and influence public policies in favour of health.  The Institute promotes co-operation between Northern Ireland and the Republic of Ireland in research, training, information and policy to contribute to policies which tackle inequalities in health.

IPH acknowledges and appreciates the benefits of information sharing and joint action in relation to policy and practice between European countries and we are proud to have been the Irish/Northern Irish partner in several projects, most recently as Work Package Leader for DETERMINE, coordinated by EuroHealthNet and as collaborating partner for I2SARE, coordinated by Federation National des Observatories de Sante (FNORS).  Both projects are funded by the European Commission.

In recognition of the importance of health inequalities and the unjust ways in which the lives and health of Europeans are harmed by health inequalities IPH is delighted that the Commission has decided to take this initiative on Solidarity in Health.  We consider it to be key to a fairer, healthier and more just Europe.   We welcome the Commission’s aim to support the reduction of health inequalities in the EU between and within Member States and the Commissions request for inputs to the development of the Commission communication.
 
Key points
The Institute wishes to make the following summary points prior to responding to specific questions:

•    Reducing health inequalities must be a policy priority area and embedded and integrated within all directorates. DG Sanco must be prepared to play a lead role in this drive for coordination and integration.

•    The paper quite rightly highlights the importance of socio economic inequalities in health. It is essential that other key dimensions of health inequalities including geographical, gender and ethnic inequalities are also acknowledged and acted on.

•    A fundamental requirement in addressing health inequalities is that the concept of “levelling up” be applied.  The goal should be to improve the health of all sections of the population to that which is currently experienced by the better off in society.  This aspiration is not specifically referred to and consequently efforts to address inequalities could be understood as efforts to “level out” rather than “level up”.  It is important to apply this concept between countries as well as within countries.

•    As well as addressing the gap between the poorest and the richest within countries there is a need to alter the steep gradient which exists.  This is well argued in the Commission on Social Determinants of Health Report (CSDH)1, and IPH supports this analysis.

IPH supports the recommendations of the CSDH, and urges the Commission to take action on the 3 key recommendations:

(1)    to improve the lives of the most vulnerable.  This is especially important in the recession.  The current economic climate poses a significant threat as the evidence shows that in economic downturns it is the disadvantaged and marginalised who suffer most.  Special efforts must be made to ensure that this historical pattern is not repeated

(2)    to tackle the inequitable distribution of power, money and resources

(3)    to measure the problem, evaluate action and expand the knowledge base.

•    It is important to emphasise the links between healthy populations and productive sustainable economies.  The communication should highlight how reducing health inequalities can contribute to the Lisbon Agenda and Sustainable Development Strategies.

Questions

On general data:
The adoption of standardised reporting mechanisms on mortality, morbidity, lifestyle and health related behaviour and health inequalities by the EU25 would greatly assist comparative analyses.  The EU should vigorously pursue a course of action to secure agreement amongst Member States about the content of these datasets and produce regular reports to facilitate policy and practice comparisons.  For example an annual reporting system for health inequalities in Europe that was standardised across countries would be very valuable.  The comprehensive National Health Equity Surveillance Framework in “Closing the Gap in a generation” could serve as a template1.

The importance and scale of health inequalities has been addressed in Ireland, North and South, by the Institute of Public Health in many of its publications.  These include Inequalities in Mortality 1989-1998: A report on all-Ireland mortality data2 (to be updated this year); Inequalities in Perceived Health: A report on the all-Ireland social capital and health survey3; Tackling Health Inequalities: An all-Ireland approach to social determinants4; and recently published local health and well-being indicators for the island5.  The EU should support similar efforts to identify the extent of health inequalities amongst all Member States so the scale and scope of inequalities becomes clear throughout Europe.  In addition to having comparable national data available it is important to link this national data to sub-national information initiatives to allow sub-national efforts to tackle health inequalities thus complementing national and EU wide efforts.

Q. What do you think will be the trends regarding health inequalities? - are they increasing or decreasing – please supply evidence if possible.

A.  Findings from analysis of data in Ireland and Northern Ireland demonstrate that health inequalities on the island of Ireland are substantial.  Despite a decade of economic growth, most particularly in Ireland, the available data suggests no reduction in the extent of health inequalities.

Information relating to data in Ireland and Northern Ireland and an overview of the impact of social determinants on health in the Ireland/Northern Ireland context can be sourced in Tackling Health Inequalities: An All-Ireland Approach to Social Determinants4.

In Northern Ireland mortality data has been analysed according to the Statutory Equality duty on Public Authorities (Section 75 of the Northern Ireland Act 1998) and the poverty and social inclusion concerns reflected in an anti-poverty and social inclusion strategy for Northern Ireland (OFMDFM, 2008)6.  In the Republic of Ireland, data on mortality was last comprehensively analysed by IPH for the decade 1988-1999 and this analysis will be updated in 2009 (IPH, 2001).

In addition, an update of the Health and Social Inequalities Monitoring System in Northern Ireland provides an extensive overview of inequalities in mortality, morbidity and service usage in Northern Ireland (DHSSPS, 2007)7.  Furthermore, data on inequalities in child health and well-being outcomes are routinely monitored by the Office of the Minister for Children in the Republic of Ireland and through the Children’s Strategy in Northern Ireland (Office of the Minister for Children, 2008)8.  In this context, it is notable that international policy documents, backed by a wealth of epidemiological and intervention based evidence, emphasise the importance and benefits of tackling inequalities in child health. Indeed, ‘equity from the start’ is enshrined within the WHO Closing the Gap in a Generation framework for tackling health inequalities (CSDH, 2008)1.  In this regard, we would recommend that child health priorities be afforded special attention within the EU Commissions programme to support the reduction of inequalities in the EU.

In Northern Ireland, a geographic area based approach is often used to document health inequalities.  For example a range of health outcomes including mortality, life expectancy and morbidity can be examined using small-area analysis and the Northern Ireland Multiple Deprivation Measure ranks Census-based Super-Output areas within Northern Ireland along combined dimensions of social need (NISRA, 2005)9.  While geographic approaches are useful particularly in targeting resources to deprived areas, a combination of individual and geographic-based measures is recommended to develop a comprehensive picture of health inequalities within and between European states.

A summary of key statistics relating to inequalities in health in Ireland and Northern Ireland are provided below:

In Northern Ireland:
In 2004-06, the difference between male life expectancy in deprived areas and that in Northern Ireland overall stood at 3.8 years and 2.6 years respectively.  Between 1999-01 and 2004-06, the life expectancy gaps for the most deprived areas (compared with Northern Ireland as a whole) remained fairly steady10.

The highest mortality rates are found among the 20% of males and females living in the most deprived areas.  By contrast the lowest mortality rates are found among the 20% of the population living in the least deprived areas6.  [Data for years 2002-2005]

The Age Standardised Mortality Rate (per 100,000 persons) of those in higher professional occupations was 283.9 (CI 254.9-313.3) compared to 657.0 for those in routine occupations (CI 633.33-680.8) and 1010.0 for those who had never worked or were long-term unemployed (CI 952.9-1067.1)6.  [Data for years 2002-2005]

In 2007/08 35% of the unskilled manual socio-economic group were smokers, compared to 12% of the professional socio-economic group11.

In relation to labour market status, the highest mortality rates are found amongst the unemployed and those who are economically inactive whilst the lowest rates are found among the unemployed6.

In the Republic of Ireland:
The death rate for all causes in the lowest occupational class was 100 to 200% higher than the rate in the highest occupational class2.  [Data 1988-1999]

People with no formal education qualifications were half as likely as those with third-level education to say they had excellent or very good health3.  [Data: 2002]

Almost half of those who were consistently poor and 38% of those who were income poor reported having a chronic illness, compared with 23% of the general population4. [Data 2004]

Travellers live on average ten to twelve years less than the general population12.  [Data: 1987]

8.1% of babies born to unemployed mothers were low birthweight in 2001 compared to 5.3% of babies born in the state overall8.  [Data: 2005]

A larger percentage of mothers in lower and higher professional groups (70.9% and 67.8% respectively) breastfeed compared with mothers who are semi-skilled workers or unemployed (29.8% and 30.3% respectively)8. [Data: 2005]

The percentage of children who reported smoking every week was higher among children in lower social classes (11.7% of children in social class 3-4 compared to 9.5% of children from social class 1-2)8. [Data: 2006]

Evidence from many countries including Ireland suggests that while overall life expectancy is increasing, the increase is more pronounced amongst higher socio economic groups.  This would suggest that inequalities are actually being exacerbated.  

In general, while data collection systems are improving, our understanding of the types of diseases that are causing differences in health outcomes for sub-groups of the population are poorly understood.  Thus we would support greater analysis of existing datasets, particularly longitudinal studies, to gain increased understanding of what is driving the picture of health inequalities.  For example in relation to the decrease in cardiovascular disease in the Republic of Ireland knowing what proportion of this decrease was due to increased economic prosperity or other factors could help to shape more effective policy.
 
It is also important to note that while life expectancy may be increasing, healthy life years may not be increasing correspondingly and in fact people are living longer with chronic illness.  Addressing inequalities for older people thus becomes a priority.

On scope of level of EU action/subsidiary:

Q. Do you think action at EU level could make a difference in addressing health inequalities?  Why?

A. EU action is important in highlighting the issue, making it a priority across programmes and ensuring that all its health programmes have an equity focus.  The Commission can lead by example, set targets and drive legislation.  For example it has been shown that child morbidity and mortality have decreased, most notably amongst lower socio economic groups, with the introduction of legislation on compulsory wearing of seatbelts.

EU can support coordinated action as it has done on smoking.  Overall, legislation is an important tool in tackling health inequalities and should be used in sectors where commercial activity involves products which can be harmful to health eg tobacco, certain foods and excessive alcohol consumption.

The EU also needs to protect against inadvertently damaging health and causing health inequalities, as it has been suggested that some policies such as the Common Agricultural Policy (CAP) are actually harmful.  Health Impact Assessment should be applied systematically to policies and programmes that have an impact on health.  Such an assessment would reduce the likelihood of a policy inadvertently damaging health.

Q. How should relevant stakeholders be supported and engaged at EU level in tackling health inequalities?

A. The development of better evidence on effectiveness is key to the engagement of stakeholders at EU level in tackling health inequalities.  A recent House of Commons enquiry into health inequalities described a catalogue of missed opportunities in terms of acquiring evidence from policy interventions designed to tackle health inequalities.  It is therefore vital that appropriate evidence on effectiveness is developed both within and between Member States on the health impacts of policies and programmes.  

The Commission can also support work in this area by the continued use of the health forum, promoting networks that address health inequalities and supporting projects in tackling health inequalities through its Programme of Community Action in the field of health (2008-2013).  The Closing the Gap and DETERMINE13 projects are exemplary models of work in this field.

Much experience has been gained over the last 15 years by cities which have been part of the European Healthy Cities Network.  The capacity of the European Healthy Cities to tackle health inequalities should be developed in the future (Tsouros and Farrington, 2003)14.

Q. Should there be a common commitment at EU level to reduce health inequalities for example by committing to common milestones and reduction targets?  If yes, what do you think these milestones or targets should be (what variables? what extent?)?

A. A basic target should be to reduce the gap in premature mortality between the lowest and highest socio economic groups.  The exact percentage should be discussed and agreed on by Member States so consequently there is greater ownership and commitment to achieving the target.  N.B. Bear in mind a “levelling up” principle to apply.  A reduction in the gradient is also required otherwise the tendency will be to address poverty issues only and avoid the wider issue of inequality across society.

Q. What would be the right tools to ensure that common goals are achieved on national and EU level (reporting, benchmarking, OMC, etc)?

A. Standardised data collection, regular monitoring and comparable reporting mechanisms and the systematic use of methodologies such as Health Impact Assessment can help achieve common goals.  However a stronger commitment to strengthening the knowledge base related to the effectiveness of interventions designed to tackle health inequalities through research and evaluation as part of routine monitoring and surveillance systems is required.  

Q. To what degree can health inequalities be addressed through health policy?  How?

A. The Commission on Social Determinants of Health identifies that an empowered public sector, based on principles of justice, participation and intersectoral collaboration must underpin action on health inequalities.  Ministers of Health must act as leaders as well as occupying a stewardship role in terms of other ministries roles in respect of health.

Health policy is of critical importance in addressing health inequalities, not least in whether health policies adopt a biomedical or social determinants approach, the former having a limited capacity to address health inequalities.  Health policy must have a two-fold focus (a) the development of policies, programmes and services that serve to reduce health inequalities among the patients or clients they serve, be that through aspects of service design on location or aspects of preferential resourcing and (b) the development of effective approaches to address the social determinants of health through intersectoral and cross-departmental partnerships and other means.

Q. Which and to what extent should other policy areas, such as social policy, contribute to reducing health inequalities.

A. Our understanding of the determinants of health makes it imperative that other policy areas recognise their role and responsibility in contributing to improved health and reducing health inequalities.  Other sectors can recognise this responsibility and respond by having dedicated resources and personnel in place with specific mandates to work on this area.  The key to better understanding and hopefully more effective action is understanding the ways in which the determinants of health are distributed unequally.  A key area appears to be income and its distribution between and within societies.  More data is needed on this across Europe.

Possible actions and impacts:
Q. Given the current economic situation can you think of any immediate action that EU or Member States could take to avoid an increase of health inequalities in the short term?

A. It has been estimated that in the EU, the unemployment rate will reach 9.5% in 2010 and about 20 million jobs will be lost15.

Evidence from past crises show that the poor and most vulnerable are likely to suffer most in times of crisis.  Indeed a significant proportion of the WHO European Region is already at risk of poverty (16%).

EU and Member States must recognise that marginalised and disadvantaged are particularly vulnerable in economic downturns and consequently they must place special emphasis on these groups so that inequalities are not exacerbated.   

Even in times of economic downturn, investing in health is good for social stability and for the economy.

In order to anticipate risks to health and health inequalities, it will be necessary to undertake regular analyses at national and international levels of the economic and social situation and its effects on health and health systems.

Q. Do you believe that investments through structural funds could help to reduce health inequalities.  If so how and why?

A. Structural funds can contribute to tackling health inequalities in that they are designed to support less well off regions but they are rarely used for specific health benefit.  The EU should communicate more widely that such funds are available for health infrastructure and support applications in this area.

Q. Where do you think should future investments through structural funds be mainly spent to be effective for reducing health inequalities and what would be the expected impact of that spending.

A. IPH has produced reviews on the links between the critical areas of employment, education, the built environment and transport and health16 17 18 19.  Investment in these areas can be an investment in health and can be effective in reducing health inequalities particularly if health impact assessments are carried out on policy and project proposals.

Q. What in your opinion are other areas that EU and Member States should be encouraged to focus on to achieve a reduction of health inequalities?

A. The area of agriculture, food production and pursuit of a sustainable environment can make a significant contribution.  Also relevant are the rights of the unemployed and social protection measures for the poor, marginalised, disadvantaged and ethnic minorities.

Q. What could be possible actions in other EU policy areas on health inequalities and what could be their impact?

A. Getting other sectors eg agriculture, education, employment and environment to appreciate the impact of their policies on health and health inequalities is a major challenge but one that must not be avoided.  The Health and Consumer Protection, Directorate General has a pivotal role to play in leading in this area but also by encouraging and working with other Directorates to get them to appreciate and address their responsibilities in providing better opportunities for health for all.

Q. What shall be done by the EU in order to facilitate the exchange of experiences between Member States, regions and cities?

A. Systematic engagement with health inequalities is essential.  The EU can create and support constructive partnerships and support for projects to exchange best practice.

Work undertaken as part of the DETERMINE project13 shows that actions are increasingly being taken in policy areas outside health systems that address the Social Determinants of Health Inequalities but such actions are not systematically or routinely undertaken throughout Europe.  The EU can support exchange of specific examples of good practice from this and other similar projects such as Closing the Gap which identified good practice at local level.

Q. How should EU policies be stream-lined in order to reach targeted beneficiaries in the best way? (Disadvantaged, women, migrants, children).

A. All policies should be systematically assessed with regard to their impact on inequalities.

Q. To what extent do you think is the improvement of research capacities advantageous for fighting HI?  Can you name any concrete examples?

A. The development of knowledge, monitoring and skills in the area of health inequalities is viewed as the ‘backbone of action’ by the Commission on Social Determinants of Health (CSDH, 2008)1.

In this regard we would stress the importance of several capacities in fighting health inequalities:

(i)    The development of basic data systems including vital registration and Census data, national surveys, population health and health service information systems to the level where they can comprehensively monitor health inequalities

(ii)    The development of research methodologies and actors to monitor the impact of social, economic, cultural and political change on health with a particular emphasis on evaluating the impact of changes in social and fiscal policy

(iii)    The development of funding streams that support research on policy impacts and the social determinants of health to the same level as funding available for biomedical type research

(iv)    The support of mechanisms to bridge the research-policy divide supporting knowledge dissemination from research to policy and facilitating policy-makers to input into research priorities on the social determinants of health and health inequalities

(v)    Research capacities must focus on documenting health inequalities above and beyond the documentation of mortality figures and encompass aspects of child development as well as health and well-being across the life course

(vi)    The appropriate integration of guidelines produced by systematic reviews and meta-analyses such as the NICE guidelines with health inequalities concerns.

It is important that people in all departments or directorates that have an impact on health inequalities have the skills to assess the impact of their policies and projects on health.  If they don’t, training should be provided to up-skill them in this area.

Other points:

Q. Do you know of any examples of good practice in addressing health inequalities which would be helpful to share with the Commission or other stakeholders?  If yes, please supply details.

A. The Institute of Public Health in Ireland’s work has a particular focus on reducing inequalities in health.  We provide up to date, accessible information and through our population health observatory (INIsPHO) produce and disseminate health intelligence and strengthen the research and information infrastructure on the island of Ireland.

We support individuals, organisations and processes involved in improving public health on the island.  Specifically we have strengthened partnerships, developed health impact assessment and established an all-island leadership programme.

We inform and support policy making and implementation in a wide range of areas which impact on health inequalities.  Further information on all our activities is available on www.publichealth.ie.  

In Northern Ireland, the Investing for Health strategy represents an example of good practice.  Rather than developing a separate health inequalities strategy, Investing for Health adopts a social determinants approach and makes tackling health inequality the core concern of national health policy.  A number of structures were developed to support the implementation of Investing for Health including Investing for Health partnerships within each of the Health and Social Services Boards.  These partnerships operate a number of intersectoral groups acting on social determinants of health at local level.  Strong links with community groups and representatives have allowed for the integration of national policy with work on the ground and such a community development approach is proving very successful.  In a European context we particularly refer to the Closing the Gap and DETERMINE project coordinated by EuroHeatlhNet.

 
Contact details

For further information on this submission, please contact:

Owen Metcalfe
Associate Director
Institute of Public Health in Ireland
5th Floor
Bishop’s Square
Redmond’s Hill
Dublin 2

Tel: +353 1 478 6300
Email: owen.metcalfe@publichealth.ie

Dr Jane Wilde
Chief Executive
Institute of Public Health in Ireland
Forestview
Purdy’s Lane
Belfast   BT8  7ZX
Northern Ireland

Tel: +44 28 9064 8494
Email: jane.wilde@publichealth.ie

Acknowledgements
This response has been prepared by Owen Metcalfe, Helen McAvoy, Jane Wilde, Kevin Balanda and Teresa Lavin.

References

1.    CSDH, 2008.  Closing the gap in a generation: Health equity through action on social determinants of health. World Health Organisation.

2.    Balanda, K. and Wilde, J. (2001) Inequalities in Mortality 1989 – 1998: A Report on All-Ireland Mortality Data: Institute of Public Health in Ireland.

3.    Balanda, K. and Wilde, J. (2003) Inequalities in Perceived Health: A Report on the All-Ireland Social Capital and Health Survey: Institute of Public Health in Ireland.

4.    Farrell, C. McAvoy, H. Wilde, J. and Combat Poverty Agency (2008) Tackling Health Inequalities: An All-Ireland Approach to Social Determinants: Dublin: Combat Poverty Agency/Institute of Public Health in Ireland.

5.    Balanda K., Barron, S. and Fahy, L. (2008) Local Health and Well-Being Indicators: Institute of Public Health in Ireland.

6.    Office of the First Minister and Deputy First Minister (October 2008) Differences in Mortality Rates in Northern Ireland 2002-2005: A Section 75 and Social Disadvantage Perspective.

7.    DHSSPS, Health and Social Care Inequalities Monitoring System: Second Update Bulletin, (2007).

8.    Office of the Minister for Children (2008) State of the Nations Children.

9.    NISRA, Northern Ireland Multiple Deprivation Measure, (2005).

10.    DHSSPS 2008.  Northern Ireland Health and Social Care Inequalities Monitoring System Changes in the Northern Ireland life expectancy gap 1999/01 to 2004/06. NISRA Occasional Paper No. 29.

11.    Comptroller and Auditor General for Northern Ireland (2008) The Performance of the Health Service in Northern Ireland: Northern Ireland Audit Office.

12.     Barry, J., Herity, B., and Folan, K. (1987) The Travellers Health Status Study: Vital Statistics of Travelling People, Dublin: Health Research Board.

13.    EuroHealthNet (2008) DETERMINE Action Summary: Improving Health Equity via the Social Determinants of Health in the EU.

14.    Tsouros and Farrington (2003) WHO Healthy Cities in Europe: A compilation of papers on progress and achievements – a working document. WHO: Copenhagen.

15.    Health in times of global economic crisis – Discussion Paper (WHO Europe, Norwegian Ministry of Health and Care Services and Norwegian Directorate of Health, 2008).

16.    Doyle, C., Kavanagh, P., Metcalfe, O., Lavin, T (2005) Health Impacts of Employment A Review: Institute of Public Health in Ireland.

17.    Kavanagh, O., Doyle, C., Metcalfe, O., (2005) Health Impacts of Transport A Review: Institute of Public Health in Ireland.

18.    Lavin, T., Higgins, C., Metcalfe, O., Jordan, A., (2006) Health Impacts of the Built Environment: A Review: Institute of Public Health in Ireland.

19.    Higgins, C., Lavin. T., Metcalfe, O. (2008) Health Impacts of Education A Review: Institute of Public Health in Ireland.

 

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