Inequalitites: The public health puzzle

Bettina Döbereiner continues her reports on theories, policy strategies and current projects aired in the Berlin conference Reducing Health Inequalities. What do we really know about successful strategies?

Finland is one of the classic social-democratic welfare states with good health status in general and vastly improved population health. Although health and equality are highly valued by Finnish authorities and citizens alike, and although there is an excellent research and knowledge base in Finland, a lot still needs to be done to abolish health inequalities. Seppo Koskinen from the National Institute for Health and Welfare provided examples of wide health disparities in Finland: generally, women live seven years longer than men. Residents of the west coast and Åland live two to four years longer than people living in the north-eastern regions. One third of all deaths in the working-age population would be avoided if mortality of the non-married could be reduced to the level recorded for married people. Koskinen also points out the importance of education: people with a high level of education, who work in white-collar occupations and enjoy a good income, have better health and functional capacity and live longer than those with a low level of education, who work in blue-collar occupations and have a small income. For example, a 35-year-old Finnish man can expect to reach the age of 80 years if he has completed a university degree, but only the age of 74 years if he has not completed any degree beyond basic education. Since the 1980s, this difference has increased from 4.7 to 6.2 years in favour of well-educated men, for women the corresponding difference has increased from 2.7 to 3.6 years.

He also reports wide inequalities in functional capacity correlated to level of education. For instance, difficulties with physical activities are more common among those with lower education. Almost 14% of Finnish women with a basic education, aged 30 and over, have difficulties in walking 500 m, for better educated women the percentage is just below 8%. According to Koskinen, selected health problems would be avoided if the prevalence of the problem in the rest of the population was as low as among those with tertiary level of education: loss of teeth 80%, respiratory deaths 50-75%, alcohol-induced deaths 50-60%, cancer deaths 20-30%, back disorders 30%. He also presented statistics that show the correlation between income and health in Finland. Mortality increases as income diminishes. Mortality of men aged 30 or over, in the lowest income deciles is 2.4 times higher than in the highest deciles; among women the difference is 1.7.

The reduction of health inequalities between population groups is a central goal of Finnish health policy and one of the key targets of the national public health programme Health 2015. Drafted in 2000, this programme outlines the objectives and targets of Finland’s national health policy for 15 years. The focus of the strategy is on health promotion.

In addition, and closely linked with the Government Policy Programme for Health Promotion, the government and especially the Ministry of Social Affairs and Health, implemented the National Action Plan 2008-2011 to reduce health inequalities. This was initiated in April 2006 by the ministerial group for social policy issues of the previous government, coordinated by the Advisory Board for Public Health, and appointed by the Government. Many experts from various organisations participated in drafting the plan, which focuses on long-term objectives and covers measures in other programmes and projects. The aim is to implement general social policy actions to reduce health inequalities and prevent social exclusion, for example to promote the health and well-being of young people in vocational training. Furthermore, the plan suggests measures to influence lifestyles through policy, for example by raising the alcohol tax, and to develop social welfare and healthcare services, such as health services that support the working ability of the long-term unemployed on a permanent basis in the municipalities. Furthermore, mechanisms to monitor health inequalities and to strengthen the information base and communications shall be developed, for example by strengthening the data pool on health inequalities based on registers, surveys, statistics, etc.

Koskinen also pointed out the challenges for Finnish healthcare policy. The Action Plan measures, which he deplored, are voluntary not mandatory. Due to the current global recession, there is a rapid negative development: employment rates fall and income differences and relative poverty rates increase. This development could trigger new policies that cut future budgets for health promotion. In conclusion, Koskinen stressed that health inequalities can be reduced - there is no natural law that inevitably leads to a certain level of inequality, but achieving results requires determined cross-disciplinary efforts.

‘FemmesTische’ – Women’s tables with expatriates in Switzerland

Maya Mulle, head of the Swiss association of parent education, realised a special public health strategy for women in Switzerland. FemmesTische - Women’s Tables with expatriates was invented 13 years ago and is one of the renowned offers for poor migrant and Swiss women. Six to eight women meet for a ‘FemmesTische’ at a host’s apartment. The hostess receives a small compensation for her hospitality so that the family budget will not be strained. A specially trained female moderator starts the meeting with a short movie (10-15 minutes) on a particular topic. Afterwards the women discuss their topic in their native language. Everybody’s opinion is important; every woman has the opportunity to voice her thoughts.

The female moderator belongs to the same ethnic group and is an important role model for successful integration. At FemmesTische, migrants get information on German language courses, on Swiss education, the social system and so forth. There are also discussion groups, where women from different cultures meet and talk in the local idiom. Often, at the end of the meeting, one woman offers to be the next host. Thus FemmesTische has spread, basically by word of mouth. The meetings are held neither regularly nor in the same place. Normally, every meeting is hosted by a different family. Some of the topics covered are women in Switzerland; prevention of substance abuse within the family; balancing work and family; healthcare; computer and TV addiction; learning – a child’s game?; growing up bilingual; nutrition and exercise; self-confidence; active childhood; multi-national marriages; mobbing – no child’s game.

In addition to the movies, moderators can spark a discussion with a photo series named ‘Be healthy – stay healthy’. The programme, which is funded by different health foundations, offers a low-threshold service, especially for migrants. 20% of the seven million inhabitants of Switzerland are migrants and many of them are low educated and live in difficult surroundings. In 2008, 712 FemmesTische, with 196 moderators, 4,360 participants and in more than 20 languages took place. In addition, 37 special FemmesTische talks with 233 participants where held. The majority of FemmesTische are for migrants, only a few are for Swiss women or mixed groups. The head of coordination of FemmesTische is the Suisse association of parent education.

In six regions in Germany, services such as FemmesTische are offered; in Austria there is one such project. The Austrians described their project as a ‘Tupperware Party’ combined with serious educational discussions.


For further information on European-wide research and policies on health inequalities visit the website of the project DETERMINE (2007-2010). An EU Consortium for Action on Socio-economic Determinants of Health).


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