Background of the study
In 2003, the Swedish Parliament adopted a comprehensive public health policy that covered all the important health determinants, ranging from societal conditions to lifestyles. In order to compare the mechanism established there, and to make up for the lack of research into public health matters, a group of Swedish scientists decided to ask their European counterparts working in eight different countries – Sweden, Norway, Denmark, Finland, England, the Netherlands, Italy and Spain – to speak about their own public health policies with an equity-oriented perspective. The focus of this article will be on the remarks and recommendations resulting from the study.
Concluding remarks and recommendations
Some commonalities and important differences were noted during this study but the authors mentioned the difficulty of comparing and transferring knowledge when each country is different. these difficulties were compounded by the lack of a satisfactory set of established indicators to follow developments in social determinants. Many social indicators were proposed, but no follow-up systems.
Health equity policies have a better chance of surviving shifts in parliament and government if adopted through a broad consensus across the political party lines. Without this, the sustainability and follow up of the programme can be threatened.
There is a general trend of reduced mortality rates and prolonged life expectancy in all countries. Nevertheless, there can be great differences between high and low socio-economic groups. For example, in Denmark life expectancy has not improved as much as in the other countries of the studies, despite a high GNP. In Italy, there are measurable differences between men and women and between the North and South of the country.
At present, most national public health policies concentrate on lifestyle factors but social determinants have been taken into account in recent public health policies. Health equity appears very rarely in non-health-sector policies (except for Sweden and Finland).
Access to healthcare is fairly equal, however the increase of fees for primary healthcare and the privatisation of it show that there is still some work still to be done.
Interventions on tobacco smoking have been successful in all countries even if the lower socio-economic groups still smoke more. The study showed that this was related to living conditions, which is why smoking reduction programmes must take into account living conditions to improve results.
Although average alcohol consumption is uniform across Europe, an increase in levels of consumption has been noticed in Finland and Sweden. An explanation for this is tax cuts on alcohol in these counties.
Overweight and obesity: sugar tax and responsible initiatives from the food industry can have positive effects on the prevalence of obesity in general but this would probably have no effect on the most vulnerable social groups.
Most countries have a national public health reports published every 4 or 5 years by a national agency.
Local and regional actors are given the same level of importance in most public health interventions, except the NHS in the UK. Collaborative bodies negotiate the responsibility between the different administrative levels that deal with health issues, but equity aspects do not seem to be present. The example of Italy and Spain is an interesting one: public and political interest in health inequalities is greater. There is a greater availability of data with a more focused approach to geographical area or ethnic group than social aspects. The problem is one of underestimation of the differences: interventions may be incorrectly targeted.
Networks of healthy cities and "New Deal" programmes for communities in England dedicated to deprived areas are intensive intervention programmes incorporating several themes including health. Similar schemes have also been carried out in Sweden and Norway. The idea is to improve the living conditions of people in deprived areas. Such programmes included housing, education, health and others. These interventions are providing interesting results but there is a limit to repeat this on a national scale as most deprived persons in the countries in the study leave once their conditions have improved.
Disease-specific strategies have rarely been equity-oriented although there is some potential if attempted. Group-specific strategies have mostly been applied to children and mothers or marginalised and vulnerable groups. It is important to understand why marginalised groups have become marginalised in order to have better preventive measures for the generation to come.
Recommendations:
Establish one or several governmental agencies to collect data on health inequalities and disseminate that information.
Commission experiments or evaluation of “natural experiment” research design should be used more
Development of ways of assessing clusters of intervention or policy systems because the multiplicity of intervention is necessary to tackle health inequalities
More research into the potential of and best practices for the primary healthcare sector and more collaboration between health and non-health actors is necessary
Underprivileged and ethnic groups should be included in population surveys
Further research is needed on social determinants of health inequalities including a better understanding of the variety of factors and their impact on one another.
More research on gender inequalities related to health taking into account socio-economic conditions
Continued comparisons and analyses of successes and problems with the implementation and monitoring of health equity policies are warranted and should include more countries.
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