REDUCING SOCIAL INEQUALITIES IN HEALTH IN EUROPE

Abstract

Reducing inequalities in health between socioeconomic groups within a country is one of the greatest challenges for public health, even in the highly developed welfare states of Europe. Recognizing this, several countries and the World Health Organization have set quantitative targets for reducing these inequalities. Since these targets were set, reports have appeared suggesting that inequalities in mortality have widened instead of narrowed. However, a systematic analysis of progress in reducing health inequalities has not been made. We therefore collected data from 11 European countries to assess whether there has been progress, and if so how much, in reducing inequalities in mortality in the period 1990-2010.

Our findings show that remarkable mortality declines have occurred in lower socioeconomic groups in most European countries, but that whether or not progress has occurred is very much dependent on the perspective chosen. Absolute declines in all-cause mortality were often larger in lower than in higher socioeconomic groups (with absolute inequalities narrowing as a result) among men, but not among women. However, relative declines in mortality were almost always smaller in lower than in higher socioeconomic groups (with relative inequalities widening as a result). Narrowing of absolute inequalities was mainly driven by ischemic heart disease, smoking-related causes (men only), and causes amenable to medical intervention, whereas setbacks with widening inequalities can be seen in many countries for alcohol-related causes.

Although, as these results show, recent trends in inequalities in mortality in Europe are more encouraging than commonly thought, they also raise important questions, such as whether the observed narrowing of inequalities in mortality can be interpreted as a beneficial effect of explicit policies, e.g. of national programs to reduce health inequalities. Unfortunately, the evidence suggests that that is not the case, and that wherever a narrowing has occurred this has been a side-effect of population-wide behavioural changes and improvements in prevention and treatment of conditions like cardiovascular disease.

Another, more fundamental question is whether in public health we should aim for reducing absolute or relative inequalities in mortality. Quantitative targets are usually ambiguous and do not specify whether relative or absolute inequalities should be reduced. Our findings show that since 1990 no country has achieved a reduction of relative inequalities in mortality, but that in terms of absolute inequalities some countries have even surpassed the 25% reduction target that the World Health Organization proposed. Should we be satisfied with reducing absolute inequalities in mortality, or keep striving for a reduction of relative inequalities as well?