INEQUALITIES IN HEALTH: AN ESTONIAN CASE

INEQUALITIES IN HEALTH: AN ESTONIAN CASE

Anu Kasmel Estonian Centre for Health Education and Promotion

Social inequalities in health as an issue came to the policy arena in Estonia in the end of ninetieth after a period of the extensive and profound societal changes. Discussions concerning health policy have been focused to the social determinants of health and to the most vulnerable groups in society. In spite of improvements during recent years, the health situation in Estonia is still not favourable in comparing with other northern countries and social inequalities in health are growing.

Estonian Public Health Policy Document, April,2002

The public health strategies should be directed towards diminishing inequalities in health between different social groups. All sectors and levels in society should direct their health policies to support disadvantages groups.

Study of social inequalities in health, 2001Cause-specific mortalitySelf-reported morbidityHealth related behavior

Health care utilization

Mortality Database

Health Interview SurveyBi-annual Health Behavior Surveys 1990-2000Living Condition Surveys 1994, 1999Health Insurance Fond

The main results demonstrates that:Morbidity, mortality, health related behaviors and patterns of health care utilization strongly vary between subgroups of the population;People from lower socio-economic groups live shorter, more ofter suffer from health problems, engage more often in health damaging behavior and have less favourable health care utilization pattern;Large differences in some outcome indicators are observed between men and women, non-ethnic and ethnic Estonians and by place of residence;During the 1990s social inequalities in mortality, and most types of health related behavior have widened.

Average life expectancy at birth among men and women from 1959 to 2000 in Estonia 5560657075801959197019791989200019591970197919892000Life expectancy at birth in yearsMenWomen

Probability of dying between the 45th and 65th birthday. Men with high and low educational level in Estonia compared to Norway and Finland in the late 1980s.

Chart1

14.820.8

17.526.5

24.140

High education

Low education

Probability (%) of dying

c-o-d

Contribution of causes of death

Source: HMP rapport

Country% contribution

cancercirculatoryother disinjuries

Nor17.839.119.523.5

Swe19.137.222.721

Den30.727.522.519.2

Fin11.43517.835.8

Eng25.251.715.87.3

Ita41.411.237.310.1

Den30.727.522.519.2

c-o-d

0000

0000

0000

0000

0000

0000

Cancer

CVD

Other

Injuries

estonia

Mortality rate by educational level

Source: HMP, thesis

Probability of death

High edLow ed

Norway14.820.8

Finland17.526.5

Estonia24.140

estonia

00

00

00

High education

Low education

public

publications per capita

landpublicatiesinwonerspubl/capita

doc.centrumin 1986 (*milj.)

Finland1974.940.2

Sweden1968.423.3

Norway654.215.5

Denmark805.115.7

United Kingdom140356.624.8

France9355.41.7

Italy5957.21.0

Spain4938.81.3

Germany11960.72.0

Other EU123

Netherlands26814.518.5

Finland1974.940.2

Netherl.26814.518.5

Other123

Norway654.215.5

Denmark805.115.7

Germany11960.72.0

public

0

0

0

0

0

0

0

0

0

0

gini

0

0

0

0

0

0

0

0

0

0

0

elderly

Income inequalities

Source: book Kautto, page 25

countryGINIp90/p10

Norway24.32.8Nor

Sweden22.52.65Swe

Finland232.7Fin

Denmark24.22.85Den

Netherl.25.83.1NL

Germany26.23.2Germ

United K.354.6UK

elderly

0

0

0

0

0

0

0

SAH

Mortality by housing tenure; men

Bron: data van Martijn

Country

50-60-70-80-90+

Nor1.641.461.191.081.02

Fin2.171.891.471.211.06

Den2.271.671.391.231.15

Eng2.021.651.321.181.01

Bel1.661.441.241.080.97

Ita1.381.591.381.371.17

0.440.60.720.810.87

SAH

000000

000000

000000

000000

000000

Den

Fin

Eng

Nor

Bel

Ita

Age

mortality

Self assessed health

Bron: HMP project

Men educationWomen education

CountryOdds ratio0

midbovenondermidmidbovenondermid

Nor2.31.733.042.32.842.13.822.84

Swe2.371.73.32.373.062.224.233.06

Fin2.992.443.662.993.292.64.183.29

Den1.661.112.481.662.331.63.392.33

Eng3.082.573.683.082.662.213.192.66

Neth2.922.383.572.922.061.72.492.06

Ger1.761.442.141.761.911.52.441.91

Italy2.942.543.42.942.552.22.952.55

Spa2.591.813.672.593.12.184.413.1

Income

MenWomen

midbovenondermidmidbovenondermid

Fin3.092.423.943.092.431.863.182.43

Swe3.92.536.023.92.81.924.092.8

Eng3.272.644.043.273.572.964.313.57

Net4.793.736.154.793.242.564.13.24

Ger2.051.552.722.052.41.813.182.4

Fin2.431.863.182.43

Swe2.81.924.092.8

Eng3.572.964.313.57

Net3.242.564.13.24

Ger2.41.813.182.4

mortality

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

0000

men women

Sterfte naar beroep

Bron: HMP rapport

CountryMan/nm RRRate manual

midbovenondermid

Nor1.561.621.51.564.3

Swe1.641.681.591.644.1

Fin1.952.011.91.956.9

Den1.491.531.441.495.7

Eng1.511.671.361.514.6

Ire1.451.541.361.454.6

Italy1.431.541.331.434.3

0

0

0

0

0

0

0

0000

0000

0000

0000

0000

0000

0000

The percentage of respondents reporting 'bad or average' general health in different educational levels by gender and age groups, 1994

2030405060708090Men Women254445596079PercentUniversityUpper secondaryLower secondary

The percentage of respondents reporting bad general health or depression (age group 2579), or reporting mobility limitations (age group 6079) in different personal income quartiles

0510152025'Bad' general health DepressionMobility limitationsPercent1 (low)234 (high income quartile)

The percentage of respondents having emotional distress among the employed and unemployed by gender, three age groups and place of residence in the age range 2559.

0510152025MenWomen25444559TallinnOtherurbanRural PercentEmployedUnemployed

Age-standardised mortality rate among people with a university and lower secondary education in 19871990 and 19992000 by gender. Ages 20 years and above included

50010001500200025003000350019871990199920001987199019992000ASMR per 100 000UniversityLower secondaryMenWomen

The proportion of respondents who use fresh fruits 0-2 days a week, according to the education and study year.

Chart3

89.2987.190.83

89.5190.190.24

58.8869.9580.86

58.572.1484.38

45.363.878.36

36.756.466.7

University

Upper secondary

Lower secondary

Year

Percent

Sheet1

Education

ButterVegetFruitExecSmokSpiritCholBMISeatb

University21.952.842.650.216.318.256.636.79.2

Upper secondary29.961.159.950.531.820.363.340.714.6

Lower secondary2866.170.954.439.320.267.347.213.7

University

Upper secondary

Lower secondary

Sheet1

000

000

000

000

000

000

000

000

000

University

Upper secondary

Lower secondary

Percentage

Sheet2

199019921994199619982000

University89.2989.5158.8858.545.336.7

Upper secondary87.190.169.9572.1463.856.4

Lower secondary90.8390.2480.8684.3878.3666.7

Sheet2

000

000

000

000

000

000

University

Upper secondary

Lower secondary

Year

Percent

Sheet3

The proportion of respondents who smoke daily, in different personal income quartiles

Chart1

26.2

27.9

29.1

36.2

Daily smoking

Income

Percentage

Sheet1

199019921994199619982000

Daily smoking

3001 -26.2

2001-300027.9

1001-200029.1

-100036.2

Sheet1

0

0

0

0

Daily smoking

Income

Percentage

Sheet2

Sheet3

The proportion of respondents 1999, who have had telephone consultation with a doctor, visit to a doctor, visit to a specialist, visit to a dentist (all during last 6 months) or have been hospitalised during last 12 months, according to educational level

05101520253035404550Telephoneconsultationwith a doctorVisit to ageneral doctorVisit to aspecialistVisit to adentistHospitalisationProportion (%)UniversityUpper secondaryLower secondary

To most of us, inequality is the state of being unequalInequalities in health describe the differences in health between the groups. Inequities refer to a subset of inequalities that are assessed as unfair. Evans (2001) have said that the unfairness qualification invokes assessment of whether the inequalities are avoidable as well as more complex ideas of distributive justice as applied to health.

EquityEquity concerns a special subset of health disparities that are particularly unfair because they are associated with underlying social characteristics, such as wealth, that systematically put some groups of people at a disadvantage with respect to opportunities to be healthy. Equity is linked to human rights, as it calls for reduction in discrimination in the conditions required for people to have equal opportunity to be healthy.Attaining optimal health ought not to be compromised by the social, political, ethnic, or occupational group into which one happens to fall.

Social justice The fully articulated effort to redress inequities in health must inevitably work in tandem with wider efforts towards social justice such as the provision of safety nets; protection against medical impoverishment; provision of education, jobs training, and environmental risk reduction; and efforts to ensure peace and political voice for all.

William Farr No variation in the health of the states in Europe is the result of chance; it is the direct result of physical and political conditions in which nations live (1866).

The question is: How to promote factors, which create equitable society?

What are the most influential interventions and policies, what could best contribute to reducing inequalities in health. There is no clear answer to this question. Until now the convincing evidence about the likely impact of specific policy initiatives or interventions on reducing health inequalities is highly elusive.

Understanding of health determinants It has appeared that societys understanding of the determinants of health has an important influence on the strategies it uses to sustain and improve the health of its population. The increased understanding of the social causes of ill health is a critical component of health equity agenda.

The nature of political systemAs demonstrated in many studies, the nature of the political system, its values and processes for participation, define the frontiers of opportunity for health equity. Societies with flourishing democracies, respect for human rights, transparency and opportunities for civic engagement high social capital are more likely to be equity enhancing.

Policies Macroeconomic and social policies may either limit or enhance health opportunities for different groups in the population. In the era of liberal macroeconomic policy progrowth strategies tend to provide enhanced opportunity to those with resources and high levels of education while large segments of the population without these assets are unlikely to be beneficiaries of economic transition. Just focusing to the economic growth policies that pay no attention to social investments or to compensatory educational and labor policies, these transitions have exacerbated the extent of inequity in health.

Human capital and social capital Diderichsen (2001) have declared that if we want to understand and intervene against social inequalities in health, we should look both upstream into the mechanisms of society and downstream into the mechanisms of human biology and coping skills.

Community developmentMany studies have demonstrated that interventions, directed to the development of the human and social capital are leading to the increase of empowerment of community.An empowered person/community can critically analyse the social and political environment and to make their own choices.Community development has been suggested as offering the most promising approach to reducing health inequalities (Labonte, 1988).

What we have learned from transitionThe political deliberation in the 1980s , the time of singing revolution synchronized with tremendous increase in social capital and also improved health data. Rapid political, social and economical changes, which followed to the transition moment, caused in the initial period of transition the wide lose of control and disempowerment of large sectors of population.Step by step empowerment is growing and people get back control over their life.

Assumptions of success:Peoples participation in community change promotes changes perceptions of self-worth and a belief in the mutability of harmful situations, which replaces powerlessness; The experience of mobilizing people in community groups strengthens social networks and social support between individuals and enhances the communitys competence to collaborate and solve health problems; Empowerment education interventions promote actual improvement in environmental and health conditions.

Tackling inequalities in health - needs for commitment and needs for concrete legislative acts

If communities are commited to create and governments are commited to support systems and structures (social system for health), that establish networks, norms, social trust and develops people capacities; if these structures facilitate co-ordination and cooperation between different sectors and levels, we are able to make changes in health of our populations, to deminish social inequalities in health.