A recent European Commission-funded report provides recommendations for a policy approach to reduce inequalities in health through health promotion. These recommendations were presented to a Health Council meeting on 15 November 2001 and to a ministerial round table on 5 December 2001. The following article is based on the report and suggests key roles for health NGOs. It is written by John Middleton of Sandwell Health Authority, an EPHA member involved in projects aimed at reducing health inequalities.
Inequalities in health exist in all European countries. In many cases, the evidence that exists shows that the gap between rich and poor is increasing. Many European countries do not record deaths by socio-economic categories, but years in higher education is widely taken to be a proxy for social advantage. Take an example from the Netherlands. If the risk of dying from a heart attack is set at 1.00 for people with a university education, the relative risk for Dutch people without a secondary school diploma is 2.40.
The risks associated with social impoverishment are most starkly shown by comparing countries of Western with Central and Eastern Europe. An unfolding public health disaster is taking place in countries of the former Soviet Union. WHO has described the consequences for health of this structural adjustment in Europe. The collapse of organised health care took place in the context of the explosion of HIV/AIDS and other infectious disease, alcohol related disease, accidents and violence. All of these health calamities are preventable and classically poverty-related.
The role of health promotion
"Health Promotion" is the process of enabling people to increase control over, and to improve, their health. An environment that encourages healthy behaviour will make healthy choices a lot easier - and it is therefore the task of society, from the individual to the government, to shape this environment.
The European project entitled "The role of health promotion in tackling inequalities in health" has been co-ordinated by the Flemish Institute for Health Promotion (VIG) in collaboration with the European Network of Health Promotion Agencies (ENHPA). It has involved experts from 13 European Union countries and Norway and has produced a series of recommendations for policy approaches to tackling health inequalities at national and local level and examples of good practice from across Europe. The experts’ recommendations focused on targeting health promotion strategies at the socially disadvantaged as a way of reducing health inequalities.
The approaches include:
setting health inequality targets;
integrating health determinants in other policy areas;
involving people in community development approaches to health promotion;
ensuring and improving access for all to healthcare;
monitoring and evaluation;
health impact assessment of policy;
dissemination of good practice and research.
Political acknowledgement, priority and target setting
Reducing inequalities in health needs to be seen as an important objective for health and social policy. Without political commitment, no change is likely; with it, change is possible. Politicians need to see this as a cross-sectoral issue in which environmental and economic policies are as important as health service or social policies whether in European, national or local policy making. This understanding of the causes of ill health and health inequalities is not yet universally shared by Europe’s politicians. Where it is understood, inequality may not yet be regarded as a priority for health or health service policy.
One important means through which political priority can be expressed is via target setting on health inequalities. For example, in the UK the target on infant mortality is "to reduce by at least 10 per cent the gap in mortality between manual groups and the population as a whole, by 2010." The life expectancy target is "starting with Health Authorities, by 2010 to reduce by at least 10% the gap between the quintile of areas with the lowest life expectancy at birth and the population as a whole."
Where targets exist politicians can more readily be held accountable for the actions they are taking to address these inequalities.
Partnership
The role of multi-sectoral, local partnerships is highlighted with examples from the healthy cities programme in Germany, the English Health Action Zones and from other specific local partnerships in Norway, Austria, Holland and Italy. To reduce inequalities, policy needs to be co-ordinated across economic, social and environmental areas.
Non-governmental organisations (NGOs) have a clear and potentially powerful role in bringing about local and national partnerships to reduce health inequalities. For example, action is needed to improve housing conditions, increase incomes and secure welfare rights, and to improve working and social environments. NGOs are catalysts for this approach to health improvement - as lobbyists, activists, service providers and advocates.
Information systems and monitoring
Scandinavian practice is particularly strong in national data systems for identifying inequalities. Examples include the Finbalt health monitor, the Norwegian health information systems and the Swedish national survey of living conditions. Indicators and monitoring systems need to be developed which are comparable across European countries. The report lends weight to the formation of a EU public health observatory although some still consider this would be a duplication of the efforts at the World Health Organisation Regional Office for Europe. There is inevitably a call for more sharing of good practice and greater training in evaluative methods.
Fairer access to health services
Health services should be actively involved in addressing unequal provision, particularly with excluded groups. Outreach work, engaging peer educators and mentors, is seen as a powerful tool. Many NGOs are already involved in such work, particularly AIDS groups. More specific provision to address language and cultural and religious barriers to care is needed. The report provides examples from Portugal and Italy of efforts to work with minorities, refugees and prostitutes, using peer health promotion workers.
What is still needed?
We still need to see European policy guidance addressing interventions that work. Reducing inequalities in income is the biggest single means through which inequalities in health will be reduced. Given the weight of evidence that poverty and disadvantage are major causes of ill health, the reluctance to highlight economic inequality across the EU is disappointing. There is a need for improved housing, higher incomes for the less well off and better working conditions for all across all Member States. Early years family support and education as well as nutritional programmes appear to be promising interventions.
Reform of the CAP
The EU itself has a key role in reducing inequalities. Examples of good community nutrition programmes exist - including those from Greece, Germany and the Scottish Community diet project. But all these operate against the destructive EU Common Agricultural Policy - which prices healthy foods out of the reach of the poor, creates "food deserts" in our inner cities, and promotes consumption of carcinogenic and coronary-forming diets. No opportunity should be missed to highlight this iniquitous policy.
Strong anti-tobacco policies
The continuation of tobacco subsidies and the lack of a European ban on tobacco advertising are other examples of EU inactivity that are damaging the health of Europe’s most disadvantaged.
Tax harmonisation
Further debate is needed on the role of tax harmonisation in creating or reducing health inequalities.
Important steps forward
Health promotion is finding its feet in Europe. Only a few years ago, many European countries would not have accepted the suggestion that health inequality existed in their countries. Now, an EU report on health inequality has been published. The Belgian Presidency has created an opportunity to get health inequalities and health promotion firmly in the sights of Europe’s politicians. EPHA and its members can now play a key role in keeping this issue on the EU agenda by highlighting key mechanisms through which inequalities can be reduced.
Info:
John Middleton, Director of Public Health
Sandwell Health Authority
438, High Street
West Bromwich, B70 9LD
United Kingdom
