WHO Report: Take Action as Efforts to Curb Health Inequity Stall Across Europe

Becky McCall

September 11, 2019

LONDON – Progress in health inequities has stalled or even worsened across Europe despite efforts to tackle them, says a World Health Organisation (WHO) report launched this week that identifies leading risk factors but also provides tools to kickstart improvement. The report is the first from WHO on health inequities.

Being among society’s most disadvantaged shortens life expectancy – by 7 years in women and 15 years for men, finds the report; and in 75% of the 53 countries in the WHO European Region, the differences in life expectancy between the most and least disadvantaged regions have not changed in over a decade. As of 2016, life expectancy across the region is 82 years for women and 76 years for men.

The report is as much about enabling governments to take action as presenting data, said Christine Brown, lead author and head, WHO European Office for Investment in Health and Development. She told Medscape News UK "

During development of the report, Christine Brown has asked various policymakers and politicians for their thoughts on its value. "One said it’s empowering because it’s like having a set of keys to unlock what we’ve known is a problem that can’t be resolved," recalled Brown.

In fact, she emphasised that by providing governments with the data and tools to tackle health inequities it would be possible to produce visible results within a national government mandate of 4-5 years.

Health Inequities in the Least Affluent 20% Versus the Most Affluent 20% 

Key findings across the WHO European Region that underpin the report include that in comparison to the most affluent 20% of the population, almost twice as many people in the least affluent 20% report illnesses that limit their freedom to carry out daily activities; in 45 of 48 countries providing data, people with least education report higher rates of poor or fair health compared to those with most education; and in the most deprived areas, 4% more infants die in their first year compared to more affluent areas.

Not only is the health gap evident during infancy, but it widens with age. A total of 6% more girls and 5% more boys report poor health in the least affluent households, compared to those in the most affluent households, and the gap rises to 19% more women and 17% more men during working age. By 65 years and over, this gap peaks with 22% more women and 21% more men reporting poor health in the least affluent households compared to the most affluent households.

Non-communicable diseases show that women among the 20% least affluent have twice the risk of developing diabetes as those in the most affluent 20%; men are 1.5 times as likely to develop diabetes across these groups. Obesity and cardiovascular disease (CVD) show a similarly increased risk across the least compared to most affluent groups in both men and women.

Also, a woman in the 20% least affluent group compared to the most affluent, has 1.5 times higher poor mental health, 2.5 times higher poor life satisfaction, and twice higher incidence of illness limiting daily life. The equivalent increased risks in men are twice, three times and twice respectively. "It’s not just the individual with the illness that is life-limiting who is affected by it but the family too, and those dependent on that person," stressed Brown.  "There is also the wider impact in cost to society of not working and contributing to the economy."

Five Risk Factors Across the Region Identified

Behind the health inequities lie five risk factors which are: income security and social protection (making a 35% contribution to overall burden of inequity); living conditions (29%); social and human capital (19%); access to and quality of healthcare (10%); and employment and working conditions (7%).

"We see that 10% is due to inequality in access to, affordability, and quality of healthcare and waiting times for healthcare. This is compounded by access to healthcare professionals with better off areas having greater access," said Christine Brown, commenting on the drivers of inequality. "It’s no surprise that financial insecurity undermines health equity. Likewise, because it isn’t just a place to live but provides a sense of security, and we also find that the wider environment can contribute to this by provoking a sense of fear in some neighbourhoods, which can drive poor health including mental health," she said.

"Social and human capital refers to feelings of isolation, low levels of trust in others and the sense of having no one to ask for help leading to isolation."

The report finds that many of the critical factors driving health inequities are not being sufficiently addressed by countries across the European Region. For example, while 29% of health inequities stem from precarious living conditions, 53% of countries in the Region have disinvested in housing and community services in the last 15 years.

Potential solutions presented by the report include investing in the essential conditions needed to be able to live a healthy life; implementing progressive universal policies; and incentivising growth and development that equalises health and life chances. "A 50% reduction in gaps in life expectancy would provide monetised benefits to countries ranging from 0.3% to 4.3% of GDP, and the equivalent to $60bn in a country of 60 million population in central Europe," explained Christine Brown.

Complacency Among Policymakers

Christine Brown highlighted a problem with complacency among policymakers in many high-income countries where they believe they are on top of health inequalities and tend to shift their focus. "Slight, but prolonged changes can cause these gaps to reappear, and this is happening in some countries."

She noted that health inequity had to take its place outside of mainstream party politics for sustainable improvement. "Scotland, for example, has taken action to guard against this," noted Christine Brown. "It has an all-party group on inequalities because they recognise that this is beyond party politics. It’s about Scotland and society. As long as countries look at this from a non- [political] party perspective then it can be sustained."

New and Emergent Health Inequities

Importantly, the Health Equity Status Report also identifies new and emerging groups at risk of falling into health inequity. Specifically, Brown highlighted that in the UK, as well as in other European countries, youth, aged 18-28 years, comprised a "massive" health problem linked to inequity and "a mental health epidemic waiting to happen".
"Youth experience high unemployment, insecure working conditions and unsafe neighbourhoods. Add these socio-economic factors with other issues such as gender stereotyping and the mental health issues become huge," she emphasised. "We know this can predict drinking, risk-taking behaviour and poor participation in the workforce as well as early onset of cardiovascular disease." 

Jan Peloza, from the International Youth Health Organisation, Slovenia, who attended the launch event, told Medscape News UK about the significance of this report for youth in Slovenia. "This report confirms our fears about the drivers of inequalities but it helps us to prioritise where to invest," he said. "In Slovenia, there’s been high investment in employment schemes for young people which has greatly reduced unemployment in this group, however, the mental health of young people has trailed behind. Having short-term contracts within the gig economy might be good for the country overall, but young people lack the necessary security and money to live well. This brings anxiety, stress and mental health issues."

Ben Barr, PhD, senior clinical lecturer in applied public health research, University of Liverpool, lead the analysis of the report. "Inequalities in life expectancies are wider in eastern compared to western Europe, but in eastern Europe with their improved economy and increased investment in social protection, we are seeing progress in reducing the gap. In western European countries we are not seeing this progress, and in the UK, for example, we see that gap [between rich and poor] is widening," he remarked. "In the UK we’ve seen disinvestment in social protection and the effects of a prolonged period of austerity with cuts in social services, which hit the poorest hardest."

Dame Margaret Whitehead, professor of Public Health at the University of Liverpool, and head of the WHO Collaborating Centre for Policy Research on Determinants of Health Equity, also addressed the press briefing. 

"National and regional policies really do make a difference," she said, providing an example of how investing in reducing health inequity can pay dividends. She cited a longitudinal ecological study carried out within the NHS between 2001-2011 that informed the report. "Allocating more resources to areas of greater need can reduce inequalities. This conclusion comes from a 10-year experiment in the NHS on resource allocation."

In 2001, the NHS introduced a policy of increasing NHS funding to a greater extent in deprived areas compared to more affluent areas to reduce avoidable health inequalities. "This strategy reduced health inequities in causes amenable to healthcare," she recounted. The intervention resulted in a reduction in the gap between deprived and affluent areas in male mortality of 35 deaths per 100,000 population and female mortality of 16 deaths per 100,000 population. 

A set of 10 companion products accompany the report including a policy tool, an advocacy and media toolkit and case studies to show how reducing health inequity has been successfully carried out. There are links between data and policy tools that can be localised to a country’s particular needs, according to Christine Brown.

Published on 10th September 2019 on the WHO website. 
COI: No authors have declared any conflicts of interest. 



Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: