Europe’s challenge in reducing health and health care inequities

Eurohealth LOOKING FORWARD Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 34 EUROPE’S CHALLENGE IN REDUCINGHEALTHANDHEALTH CAREINEQUITIES By: Walter Ricciardi Summary: The European Public Health (EPH) Conference was about promoting excellence in public health in Europe. Europe is a tremendously rich place for health research and this conference was an opportunity to bring everyone up to the level of the best, as well as creating the opportunity for networking and bringing people together to exchange ideas on good practices and on further research and collaboration. Inspired by the exclamation “mind the gap”, the conclusions of the 7th EPH Conference provided governments with real policy options to address the challenge of reducing inequalities in health and health care. Keywords: EPH Conference, Health Inequalities, Health Policy Walter Ricciardi is Past President, European Public Health Association and Professor of Hygiene and Public Health, Catholic University of the Sacred Heart, Rome, Italy. Email: wricciardi@rm.unicatt.it Introduction Health inequalities are a persistent problem in European countries. Although health in Europe has improved in recent decades, inequalities in health have also widened. ‘Health inequalities’ refer to the differences in people’s health and life opportunities amongst different population groups, and are strongly related to the conditions in which people live, such as their income or the area in which they reside. Health inequalities exist not only between countries but also within countries and, crucially, they are still increasing in many places. They represent a waste of human potential, as well as a huge potential economic loss–conservatively estimated at between 1.5% and 9.5% of GDP. 1 Are we on track in tackling health inequalities in Europe? Population health professionals, researchers and other stakeholders came together at the 7th European Public Health (EPH) Conference to discuss how health inequalities can be effectively reduced. The evidence presented at the conference was extensive. Equity in health research and large scale interventions Public health refers to all organised measures put in place to prevent disease, promote health and prolong life among the population as a whole. Modern public health has many successes to claim in terms of population-targeted interventions, whose merit is largely due to extensive underlying research. However, as pointed out by the World Health Report 2013, 2 research is not Eurohealth LOOKING FORWARD Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 35 a prerogative of some countries and persistent geographical inequalities exist also in research output and research capacity. For example, research output, estimated through the number of published papers per capita, varies greatly across regions, with countries from the Former Soviet Union among the worst performers, where coincidently, mortality has actually risen over the past few decades. To overcome these inequalities funders and governments could develop national health research strategies in order to identify research areas and priorities; make rational use of resources; and increase financial contributions to health research, for instance by also using innovative financing sources such as lottery revenues. ‘‘ remarkably similar paths towards eventual success Large scale interventions also comprise projects that improve factors such as accessibility, equipment, social integration and perception of security. Such interventions are effective in improving the health of the resident population. For example, the Neighbourhoods Law, implemented by the Government of Catalonia (Spain) between 2004 and 2011, led to large-scale urban renewal interventions across Catalonia. The results show that the health perceptions of both women and men improved in the neighbourhoods in which intervention programmes were developed within the framework of the Neighbourhoods Law. Another inspiring project presented at the EPH conference is the Demetriq Project by the European Commission, aimed at developing, evaluating and refining methodologies for assessing the effects of social, economic and health policies on the pattern and magnitude of health inequalities. Examples of findings from the project include: policies that promote the financial security of individuals who are worst off in society by increasing their employment chances, such that better job security reduces the adverse effects of recession; smart public investment in health and social protection can save up to €3 for every €1 spent; and fairer pay strategies reduce mental health inequalities. Governments possess real policy options to promote health equity, by prioritising social and labour policies that strengthen sustainable employment in national budgets. Disease: old challenges, novel solutions Some communicable diseases are chronic (HIV/AIDS, tuberculosis, etc.), meaning that their control is quite similar to that of non-communicable diseases (NCDs), yet at the same time, some NCDs are in part transmissible (e.g. some infectious agents can cause cancer). A better understanding of the relationship between infectious and chronic diseases can affect health across populations, creating opportunities to reduce the impact of chronic diseases by preventing or treating infections. It is necessary to also consider the potential benefits of minimising infections that increase the morbidity of pre-existing chronic conditions during the process of care. This is an important, cross- cutting clinical and public health issue and a tremendous opportunity to reduce long-term illness and disability by implementing new models of care, new treatment regimens and public health programmes that substantially reduce and even prevent chronic diseases and related conditions. Political will and health investments are needed at a global level. In 2012, NCDs accounted for 38 million of 56 million total global deaths. Cardiovascular Disease (CVD), mainly heart disease and strokes, contributed 40% of all NCD deaths (17 million deaths each year, perhaps rising to 22 million deaths in 2030). The NCD burden of death and disability is immense, but most NCDs have only four major risk factors. Poor diet generates a bigger contribution (about 40%) than the combined effects of tobacco, alcohol and inactivity. 3 Population-wide policies are powerful, more powerful than pills. They have prevented more CVD deaths than all medical and surgical interventions combined. Safeguarding prevention policies Prevention politics are challenging, not least because prevention policies tend to reflect political compromises. Quite often, scientific evidence risks being overcome by powerful vested interests: for example, the reality for food is that ten corporations control almost everything we buy. Unsurprisingly, these commercial companies prioritise profit, not public health. 4 They behave the same way, use the same marketing and lobbying strategies and often hold views that are contrary to the available scientific evidence. This phenomenon, known as denialism, is becoming more elaborate and widespread, and poses threats to public health. 5 However, public health can celebrate a long tradition of successes, including safe drinking water, clean air, sanitation, seatbelts, immunisation, and smoke- free public spaces. These public health triumphs all demonstrate remarkably similar paths towards eventual success. They begin with scientific evidence, gain traction as public issues, then eventually overcome oppositional vested interests to become consolidated by regulation, legislation and fiscal policies. We might therefore learn useful lessons from the great public health pioneers who preceded us. European Action Plan for Strengthening Public Health Capacity and Services Health has improved markedly across the European Region, yet not sufficiently nor equally: the great progress of gaining five years of life expectancy is scarred by profound inequities in health that are striking and unacceptable. Inequities in health outcomes also persist within countries, even in those that are known to promote equity in governmental policies. What can we do to steer towards more equity in health? There is much to be done. Much potential for improving health equity lies outside the health Eurohealth LOOKING FORWARD Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 36 sector. As suggested in Health 2020, the policy framework for the WHO European Region, more equitable health gains might result from making health a shared goal of governments and societies. The contribution of the health sector is vital in supporting economic, labour, environmental and social policies that are conducive to health. To contribute to equitable health gain, the health sector needs to move away from merely reactive models of treating diseases. It requires more proactive approaches in tackling the root causes of disease through population health interventions. This requires strengthened public health capacity and services in all Member States. Public health is presently too weak and its potential far from realised. For this reason, the WHO Regional Committee for Europe (62nd session) adopted the European Action Plan for Strengthening Public Health Capacities and Services 6 as a main implementing pillar of Health 2020. It is a comprehensive statement of strategic actions necessary to support and develop modern public health practice. Reaching the most at risk populations There are significant disparities in terms of access to health care and health status among population groups across the European Union (EU). Socially disadvantaged and vulnerable groups are exposed to greater lifestyle and environmental health risks, and carry a higher burden of chronic disease and co-morbidities. Chronic diseases are responsible for 86% of all deaths in the region and are the main cause of disability and morbidity, costing more than €700 billion a year – a number destined to grow year after year. 6 At the same time, chronic diseases contribute to increasing socioeconomic inequalities, due to disability, loss of productivity, and risk of poverty. There are still health systems within the EU that do not provide access to health insurance and necessary services to all on a universal basis, or that present forms of discrimination or prioritisation of patient groups according to reasons unrelated to health. Integration of care is an important approach to improve access to high quality care for patients, including the most vulnerable ones. In order to provide integrated services there should be a learning culture and a readiness to provide care through joint collaborative forces and partnerships between health care professionals, service users and wider communities. The European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) is an excellent example of the mobilisation of knowledge and of critical groups working together in partnerships in order to obtain integrated health care in Europe. Empowered individuals and communities are also key drivers of the change and transformation in health and social care delivery. Advancing health equity implies the need to shift from the current bureaucratic management philosophy towards a true clinical citizen/patient centred approach that enables people to become healthier and more aware of the decision-making processes. Improving health literacy – as well as Information Technology (IT) literacy – is a major factor in empowering citizens to take more responsibility for their own health, to obtain a greater level of choice, control and confidence in their care and well-being regardless of age, gender, and place of residence, and facilitate self- management. Furthermore, the use of technology in telehealth and telecare is playing a vital role in transforming the way health care is delivered to people and in organising health services in a more productive way. Population-group challenges in public health The European economic crisis has fuelled an ideology of fiscal austerity, which has contributed to the widening of health inequalities in the EU between migrants and non-migrants, and between ethnic minorities and the majority population. Migration is a high priority on the political and policy agenda of most Member States of the WHO European Region. The complexity of the issue poses challenges within and beyond the health sector, especially with regard to the health needs of undocumented migrants and of political asylum seekers. Migrants often bear an unfair accumulation of disadvantages throughout life and migration can be in itself a determinant of inequities, unhealthy lifestyles, exposure to infections, limited access to care, social stigmatisation and of mental and physical health challenges. Furthermore, the adoption by some migrants of specific risky health behaviours that are characteristic of the receiving society, can ulteriorly contribute to the deterioration of health over time. ‘‘ both political will and health investments are necessary The Roma people are Europe’s largest ethnic minority. Many Roma in the EU are victims of prejudice and of social exclusion and consequently face barriers in accessing good quality housing, health care and education. A sixteen year difference in the age at death between the Roma population and the general population in Romania underlines the dramatic disparity in relation to health status and health outcomes; in Romania the average time between first diagnosis of a condition and death is 3.9 years in the Roma population, while it is 6.8 years in the general population. 8 The poor and unequal health outcomes of Europe’s Roma population reflect the contemporary political and social trends on the continent. Moreover, the lack of disaggregated data poses an obstacle to monitoring the success or failure of the policies targeted for the Roma population. Disaggregated data should be collected through the exchange of good practices, the dissemination of information regarding relevant data protection rules (i.e., EU Directive 95/46/EC on data protection) and the support of pilot projects that can serve as models. However, the real mistake would be to fail to harness the imagination Eurohealth LOOKING FORWARD Eurohealth incorporating Euro Observer — Vol.21 | No.1 | 2015 37 and energy of the communities in finding solutions to the above-mentioned problems. In fact, communities often know what works best for them. It would be a tragic failure of our system if we failed to capture and support these opportunities, not just for the benefit of the Roma but also for the whole population’s health. Conclusions In conclusion, keeping health inequalities high on European and Member State agendas at a time of great economic strain will be no mean feat. This challenge needs to be met if both population health and social solidarity across Europe are to be protected. 9 In order for this to be done, both political will and health investments are necessary. The principal responsibility for action in addressing health inequalities rests with the Member States, but EU policies should also have a role in helping to overcome some of the current obstacles to action. References 1 Mackenbach JP, Meerding W, Kunst A. Economic implications of socio-economic inequalities in health in the European Union. Brussels: Directorate-General for Health and Consumers, 2007. Available at: http:// ec.europa.eu/health/ph_determinants/socio_ economics/documents/socioeco_inequalities_en.pdf 2 WHO. World Health Report 2013. Available at: http://www.who.int/whr/en/ 3 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012;380(9859):2224–60. 4 Moodie R, Stuckler D, Monteiro C, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. The Lancet 2013;381(9867):670 – 9. 5 McKee M, Diethelm P. How the growth of denialism undermines public health. BMJ 2010; 341:c6950. 6 WHO Regional Office for Europe. European Action Plan for Strengthening Public Health Capacities and Services. Malta: WHO, 2012. Available at: http://www.euro.who.int/__data/assets/pdf_ file/0005/171770/RC62wd12rev1-Eng.pdf?ua=1 7 Busse R, Blümel M, Scheller-Kreinsen D, Zentner A. Tackling chronic disease In Europe. Strategies, interventions and challenges. Copenhagen: European Observatory on Health Systems and Policies, 2010. Available at: http://www.euro.who.int/__data/ assets/pdf_file/0008/96632/E93736.pdf 8 European Roma Rights Centre. Hidden Health Crisis. A Report by the European Roma Rights Centre. Health Inequalities and Disaggregated Data, 2013. Available at: http://www.errc.org/cms/upload/file/ hidden-health-crisis-31-october-2013.pdf 9 Makara P. Policy actions to tackle health inequalities in Hungary arising from the economic crisis. Measuring and tackling health inequalities across Europe. Eurohealth 2009;15(3):28 – 9. Available at: http://www.euro.who.int/__data/assets/ pdf_file/0020/80435/Eurohealth15_3.pdf?ua=1 International Award to Professor Martin McKee Martin McKee, Professor of European Health Policy at the London School of Hygiene & Tropical Medicine, Research Director of the European Observatory on Health Systems and Policies and president-elect of the European Public Health Association has been awarded the 2015 Donabedian International Award. Each year the Avedis Donabedian Foundation honours leaders in the field of quality in health care, both individuals and institutions, which have made a substantial contribution to health care excellence. The Foundation notes how Professor McKee has an impressive record in health systems analysis and evaluation, especially in drawing attention to the challenges that all countries in Europe face in integrating health and social care and the responses that will be needed in the future. Professor McKee is a world leader in health systems and his leadership is evident in his crucial contributions that have provided new insights into the adverse health consequences of rapid social transition and his major research activities on the health effects of the financial crisis. His contributions on strategies for changing health care enlighten quality programmes all over the world, making him an outstanding leader and advocate for quality in health care. Many congratulations to Martin!