Tackling the wider determinants of health : effective policy change

Health inequalities reached a high point at the European level with the European Commission’s Communication on Health Inequalities released on 20 October 2009. This Communication provides an opportunity to interact with European policy makers to mitigate health inequalities by translating commitment into action.

Through the workshop "Tackling wider determinants of health: effective policy change," EPHA facilitated discussion on appropriate actions to reduce health inequalities and how to implement these actions.

Monika Kosinska, EPHA Secretary General, welcomed participants to the workshop. Monika Kosinska explained the role of the Commission’s Communication on Heath Inequalities and its context in the European Union. The Communication is an indication that the European Commission wants to engage in dialogue with stakeholders on the issue of health inequalities. This is an opportunity for the public health community to be involved in EU action on health inequalities.

The first speaker was Charles Price, Policy Office for Health Determinants from DG Sanco. Charles Price presented the Communication on Health Inequalities.

Charles Price - Comminication on Health Inequalities

The second speaker to address the participants was Dr. David Stuckler from the University of Oxford. Dr. David Stuckler is a social epidemiologist and presented a summary of his recent research on the impact of financial crisis’ on health.

The third speaker to address the participants was Tanja Dimitrijevic. Tanja Dimitrijevic described the situation of the Roma community in Serbia, drawing on her experiences.

Tanja Dimitrijevic Presentation - Roma and their rights to healthcare

Issues that were highlighted in the discussion included:

 the institutionalisation of problems;
 the importance of considering the most vulnerable groups when making policy;
 the role of the training of health professionals in combating discrimination;
 the EU influence on Member States;
 the importance of key documents at European and national level;
 the inclusion of vulnerable groups into health professions and the health system.

The full workshop report is below:

Report on EPHA Workshop ’Tackling wider determinants of health: effective policy change’

25 November 2009

Introduction

Participants were welcomed to the workshop by Monika Kosinska, Secretary General of the European Public Health Alliance. Ms. Kosinska explained the importance of the unique European political environment at present, with the European Commission’s Communication on Heath Inequalities. The Communication is a clear indication that the European Commission wants to engage in a dialogue with stakeholders other than national governments on the issue of health inequalities. Ms. Kosinska emphasised the need for the public health community to take advantage of this opportunity.

Need to strengthen the social dimension of the Lisbon Treaty

The first speaker to address the audience was Charles Price from the European Commission. Mr. Price presented the European Commission’s Communication on Health Inequalities that was released on 20 October 2009.

The workshop was one of the first opportunities that the European Commission has had to discuss the implementation of the Communication since its release in October. The Communication was an important step for the European Commission and the input of advocacy organisations , NGOs and groups, such as the Roma community, in this process was vital. The Communication builds on European Commission funded projects such as ’Closing the Gap’ and DETERMINE.

The European Commission is only partly able to address the large and complex problem of health inequalities in the EU, as a number of actions and solutions lie at Member State level. The Commission will do what it can to support and complement actions to reduce health inequalities, as they are a problem for all Member States. There are some deficiencies in basic health service provisions such as water provision and sanitation across the EU but there is still insufficient social data available at present.

Health inequalities as an indicator for the Lisbon Agenda is not fully utilised, and as a European consultation on the post Lisbon Agenda is open now therefore health civil society is strongly encouraged to respond. The Healthy Life Years indicator is currently the only health related indicator in the Lisbon Agenda. This indicator is not very reliable as it is based on fairly culturally sensitive questions.

European money is available to help reduce health inequalities in Europe. The European Commission encourages Member States to spend more money on reducing health inequalities through the Cohesion Fund and CAP funding mechanisms, the Public Health Programme and PROGRESS.

The next step for the European Commission is to call for a Joint Action with Member States in December 2009 and develop actions with stakeholders. DG Research will release a call in 2010 related to health inequalities.

Discussions following the presentation related to the direct involvement of vulnerable groups in the Joint Action of the Member States and research and the social dimension of the Lisbon Treaty. Mr. Price confirmed that including vulnerable groups directly is on the European Commission’s agenda.

Mr. Price agreed that the social dimension is weaker than the economic dimension in the Lisbon Treaty but stressed that there has been progress since it began. Mr. Price explained that President Barroso stated in his political guidelines that he saw the need to strengthen the social dimension of the Lisbon Treaty. Nothing is know as yet about the tools and instruments he will use to do this.

The European Commission was advised by a Roma participant to separate statistics by ethnic groups, drawing on his experiences of the difficulties the Roma community had in doing this in Macedonia and the benefits it can bring.

It was agreed that NGOs have an important role to play, they have limited capacity and the willingness of national governments and at the local level to engage these vulnerable groups is vital.

Social protection systems are key The second speaker to address the audience as Dr. David Stuckler from the University of Oxford. Dr. Stuckler is a social epidemiologist and presented a summary of elements of his recent research relating to the impact of financial crises on health.

Dr. Stuckler’s presentation outlined the patterns and trends of health outcomes during economic crises during the 20th century. Some clear conclusions can be drawn from the available data and specifically on the role of social policies and their positive health impact. He outlined how severe fiscal restrictions, such as those imposed by lenders like the International Monetary Fund, can have a devastating impact on health as can rapid privatisation and economic insecurity. Whereas, conversely, some crises had a positive impact on health outcomes by improving social cohesion and controlling inequality producing substances such as alcohol and drugs.

Combating discrimination is crucial to tackle inequalities The third speaker to address the audience was Tanja Dimitrijevic. Ms. Dimitrijevic described the situation of the Roma community in Serbia, drawing on anecdotal experiences. The inclusion of specific examples from the Roma community into this workshop was important to highlight the perspective of Europe’s most vulnerable group. When discussing health inequalities, and inequalities in general, this is not just a matter for the broader population and the distribution of equity within it. In order to really tackle the inequalities faced by Europe’s most vulnerable, it is necessary to address the issues from their perspective. This is not just a ’Roma issue’, this is a failing of our whole society.

Ms. Dimitrijevic’s presentation highlighted that Roma are the largest ethic minority in Europe, as well as her country, Serbia. There is a 25 year difference in average life expectancy of a Roma Serbian and a non-Roma Serbian. Although Serbia has laws, strategies, action plans and documents dedicated to helping the Roma these words do not translate into action and institutionalised discrimination is rampant.

The healthcare system is a vital tool to deliver health outcomes, and institutionalised discrimination is a massive barrier to reducing inequity. Working environments create a culture and all levels within the structure need to be addressed - discrimination must be denormalised in order for a new acceptable working culture to develop. Institutional change is difficult but not impossible.

It is easy to get lost in the ’words’ and lose sight of most vulnerable groups. It is easiest to make policy for the majority and/or the most vocal where the noise of the majority can dominate. It is important to recognise the role that the training of health professionals plays in combating discrimination and address health inequalities to ensure the theory becomes reality.

It is important to hold authorities accountable for the health related commitments that they made towards the Roma population and it is crucial to involve the Roma in designing, implementing and monitoring health policies that affect them.

The local level cannot be reached with a top down approach only. It needs to be countered by a bottom up approach. The EU can have an important influence on how Member States organise themselves and that key policy documents are an important part of the process; measures need to ensure that they monitor the outcomes of inclusion strategies and not simply the creation of policies processes. The monitoring and evaluation of the strategies and action plans should be pre-determined and include the groups it is trying to address. Medical student exchanges could be an opportunity to explore to force health professionals into a wider medical environment.

The inclusion of vulnerable groups into health professions and the system in general is very important in tackling institutionalised discrimination and bringing about a new social norm.

Health inequalities are magnified in the Roma community, but this is not simply a Roma issue, it is a problem for individuals and all vulnerable groups in the EU. The Roma are amongst our most vulnerable and discriminated group and their challenges represent the greatest challenges for tackling inequalities.

Related EPHA articles

EPHA welcomes first steps and calls for bold action on health inequalities

2nd European Public Health Conference - EPHA holds three workshops

*Updated* Working with Communities to Reduce Health Inequalities

Commission Health Inequalities Consultation