Public health puzzle - inequalities in health

In almost all of the industrialised countries, the general health status - as indicated for example by infant mortality, prevalence of disease, subjective health and life expectancy - has improved during the last four decades. At the same time, however, there is a proven close correlation between good and poor health and high and low socioeconomic status.

Martin McKee, Professor of European Public Health at the London School of...
Martin McKee, Professor of European Public Health at the London School of Hygiene and Tropical Medicine, co-director of the European Centre on Health of Societies in Transition and Research Director of the European Observatory on Health Systems and Policies

For twenty years these inequalities in health in and among countries have been recognized and analysed, and in some regions of the world they have been addressed. Nevertheless, they remain a largely unsolved puzzle. The difference in life expectancy among the twenty-seven member states of the European Union and within these states is larger today than it was twenty years ago.
For most of the European welfare states, these inequalities contradict their aim to protect civil and human rights and offer equal opportunities for all. The conference “Reducing Health Inequalities. What Do We Really Know About Successful Strategies?” in Berlin addressed this phenomenon. On 8 and 9 May, close to 240 international guests attended the presentations of 22 speakers who analysed these inequalities in health, discussed recent research, lined out innovative policy strategies and showed current projects. The conference, which took place at IGES, a private R&D institute for health and healthcare, was co-funded by the Federal Centre for Health Education of Germany (BzgA) and initiated and organized by Hertie School of Governance, a school for public policy based in Berlin, and the School of Public Health in Bielefeld.

Theory debate – comparability of inequalities in health

The conference focused on Europe and, to some extent, the United States. The theoretical framework was provided by the concept of the so-called “three worlds of welfare capitalism“, a term which was introduced by Danish sociologist and political scientist Gøsta Esping-Andersen in the early 1990s. It was the first and still is the most widely used approach to distinguish between traditions and types of public policy. Based on historical analyses, Esping-Andersen defines three ideal types of welfare states - liberal, conservative and social democratic - which are mainly characterised by their different way of organizing social welfare. The social-democratic system is shaped by an extended de-commodification, that is an almost independent social security system granted by the state. The conservative welfare state relies on work-based insurance contributions, thus welfare benefits are closely linked to status. Liberal welfare states such as Great Britain emphasise market-based mechanisms to support the needy. In the social sciences, this welfare typology framework is being used to analyse cross-national differences in population health. Esping-Anderson’s original concept has been modified and expanded, but remains the foundation. Almost all studies concluded that population health is enhanced by the relatively generous and universal welfare provided by the social democratic Scandinavian countries. Despite their comparatively strong performance in terms of overall health, however, the social-democratic welfare states tend to show more pronounced inequalities in health than conservative countries such as Germany, which seem to have the least health inequalities. These unexpected research results were widely discussed at the conference.

Clare Bambra of Durham University called it a “public health puzzle“ which should be solved soon. She proposed further research on the interaction of macro-level welfare state characteristics and health inequalities within and between countries. Espen Dahl, Professor at Oslo University College, sees no evidence of a link between types of welfare states and health inequality and concludes that the welfare state typology does not particularly help to explain comparative data on health inequalities. He therefore suggested refining the typology. Klaus Hurrelmann, Professor at the Hertie School of Governance and main initiator of conference demanded a broader perspective on the phenomena of inequalities and thus suggested future research apply a wider European concept of social policy which includes not only healthcare but labour policy, social security, social housing, criminal justice, education policy, unemployment insurance. Overall, the speakers concluded that there is still no framework which allows identification of the factors that cause inequalities in health in a country and comparison of these factors across countries.

The life-course theory

Laura Kestilä from Finland described the life-course approach which suggests that long-term exposure to physical risks or adverse social and economic circumstances in childhood or concurrent adverse circumstances due to unfavourable living conditions in earlier life may lead to poor health, detrimental health behaviour, disease and even premature death. She also presented the results of her recent study “Childhood social circumstances as predictors of health and health behaviour - independent and mediated effects“ and concludes that childhood circumstances affect health and health behaviour of young Finnish adults. The study results indicate that the impact of childhood on early adult health varies according to the measure of health: childhood conditions are strongly associated with poor self-rated health and psychological distress, whereas somatic diseases and disorders typical of young adults show no or only weak associations with these factors. Kestilä assumes that childhood circumstances predict health-damaging behaviours. These indicators of health behaviour (smoking, heavy alcohol use and obesity) are shaped throughout the life-course. This corroborates the assumption that health differences related to education also develop throughout the life-course.

Change instead of scientific analyses

The title of Martin McKee’s lecture was chosen as the title of the entire conference. Professor of European Public Health at the London School of Hygiene and Tropical Medicine, co-director of the European Centre on Health of Societies in Transition and Research Director of the European Observatory on Health Systems and Policies, McKee started out with a famous quote by Karl Marx “The philosophers have only interpreted the world, the point is to change it“ – a fitting motto for his presentation. In his opinion public health researchers have been remarkably good at measuring and understanding inequalities in health. However, they have been less successful in discovering what to do about them. All know what should be done; there is no need for more research. McKee considers the debate about the different types of welfare states and their comparability an academic amusement. For him, the causes of health inequalities are as clear as they are diverse. People, according to McKee, differentiated in many ways and these differences are mainly responsible for the very different causes for inequalities in health. His advice sounds provocative in its simplicity: give very poor people money, food, clean water, shelter, protection from violence, satisfying and rewarding jobs, build them safe environments, stop other people from killing them and make them vote. To underline the importance of this framework, McKee quoted a study which indicates that reducing crime can promote health. Swedes aged 35 to 64 living in violent neighbourhoods had higher incidence of coronary heart disease after adjusting for other factors. In addition, work contributes to health. In all countries studied so far, those in employment are in better health than those who are not, even when the unemployed get 100% salary replacement. McKee proposed to identify the disadvantaged groups, find out how they are disadvantaged, look how this impacts health and identify possible points of intervention. The main problem, McKee is convinced, is the lack of political will and foremost the lack of will to offer money for measures to reduce health inequalities. In the final discussion McKee was adamant that neither the German chancellor Angela Merkel nor the British Prime Minister are interested in reducing health inequalities for humanitarian or ethical reasons. Consequently, the argument that health equality will increase overall economic productivity is a more promising strategy. McKee’s critics were reluctant to “sell” their point rather than to convince with moral and ethical arguments. Moreover, there were doubts that politicians will indeed buy the economic argument. McKee, who said that his many conversations with politicians had led him to his conviction and disabused him of any ideals, pointed out that politicians have memories like goldfish, i.e. only thirty seconds. He also underlined the fact that in Europe, national health ministries are in general no stepping-stones for political careers, that there are many changes in staff and that in many countries, ministries are bound by weak coalition partners with little influence.


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, still a lot 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-aged population would be avoided if mortality of the non-married could be reduced to the level recorded for married persons. Koskinen also points out the importance of education: persons with a high level of education, working in white-collar occupations and enjoying a good income have better health and functional capacity and live longer than persons with a low level of education, working in blue-collar occupations and having a small income. For example, a Finnish 35-year-old 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 of wide inequalities in functional capacity correlated to level of education. For instance, difficulties with physical activities are more common amongst those with lower education. Almost 14% of Finnish women with 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 which 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. This programme, drafted in 2000, outlines the objectives and targets of Finland’s national health policy for fifteen 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 so-called “National Action Plan 2008-2011” to reduce health inequalities. It 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 like health services that support the working ability among 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, Koskinen deplored, are voluntary not mandatory. Because of 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 which cut future budgets for health promotion. By way of conclusion, Koskinen stressed that health inequalities can be reduced - there is no natural law which 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, realized 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 women 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 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 play?; growing up bilingual; nutrition and exercising; self-confidence; active childhood; multi-national marriages; mobbing – no child‘s play. In addition to the movies the moderators can spark a discussion with a photo series entitled “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 and 4.360 participants 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. Head of coordination of FemmesTische is the Suisse association of parent education. In six regions in Germany, services like 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 in Europe-wide research and policies on health inequalities please also see the website of the project Determine and Consortium for Action on Socio-economic Determinants of Health(2007-2010):


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