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1. FOREWORD


The main objectives of this Report, consisting of the executive summary, the extended summary and the full report, are:

  • Assessment of the status of health through selected indicators and their trends mainly over the last 10 years and, when possible, over a longer period;

  • Analysis of the health determinants underlying the evolution of health indicators, and related Community and National policies;

  • Provision of data and information to facilitate the identification of priority issues for future investigations or actions and, when possible, of valuable relevant practicable approaches and policies.

This Report, therefore, does not intend to identify priorities in public health on behalf of the European Commission and/or Member States nor to recommend them the adoption of specific policies and control tools to address emerging needs, but only to provide a reliable and scientifically-sound picture of what is the status of health in the European Union, the nature of health determinants and relevant information gaps, what are the main policies and control tools adopted so far and, whenever possible, the extent of their success or failure.

So far, two related Reports have been published:

a) in 2003, “The Health Status of the European Union - Narrowing the Health gap”;

b) in 1996, “The State of Health in the European Community”.

However, this comprehensive Report considers a very different Institution than those addressed in the two above-mentioned Reports. Not only the number of Member States and the size of the overall population of the European Union has remarkably increased following the enlargement to 25 countries in 2004 and to 27 countries in 2007, but also previously-identified health-related trends have developed fast, while new trends have brought new challenges. In the meantime, civil society involvement and mobilization have been considerably strengthened and many new institutional and policy developments have taken place both at EU and Member States levels.

This very comprehensive Report has been: (i) financially supported by the D.G. "Health and Consumers" of the European Commission (Grant Agreement n. 2005115) (ii) produced through a 3-year process (from 15 November 2005 to November 2008), begun by the Steering Committee (Peter Achterberg, Yves Charpak, Pietro Folino Gallo, Paola Di Martino, Donato Greco, Nata Menabde, Antoni Montserrat, Zsuzsanna Jakab, Arun Nanda, Walter Ricciardi, Stefania Salmaso, Emanuele Scafato, Benedetto Terracini, Lorenzo Tomatis) who met in one occasion to set the overall guidance for the Report development; ii) with the participation of more than 60 experts from most European Member States and of several international Organizations (Appendix 1); (iii) reviewed by the experts listed in Appendix 2; (iv) supervised by officers designated by the Ministries of Health (or by the Scientific Institutions appointed by them) of all the EU Member States, Croatia, Turkey, Iceland and Norway(1) as well as of several Intergovernmental and International Organizations and EU Agencies (Appendix 3); and (v) considered by the Drafting Committee (Appendix 4).

The Report covers most relevant diseases and disorders as well as health determinants and main policies developed at Community and Member State level. The adopted approach takes into account the four-dimensional character of the interactions between human beings with their highly-specific intrinsic characteristics (e.g. genome and age) and biological, chemical, physical and socio-economic factors through a number of exposure routes and many different kinds of environment. This kind of approach is fundamental to understand well how the health status of each individual at a given time in his/her life is the result of the many interactions occurred until that time. However, due to the complexity of these interactions and of their development throughout life, there is an obvious need for developing much more complex interpretative models than those currently available to fully understand and predict the impact of the different stressors on public and individual health.

It is important to highlight at the outset that while this Report adopts a European comparative perspective, there are considerable difficulties and limitations associated with making such comparisons. For instance, definitions and measurement of key indicators and data coverage inevitably vary across countries, due to cultural, technical, political and social factors. Cross-country comparisons should, therefore, always be interpreted with caution. A European public health goal should therefore seek convergence or mapping between local variations of measurement, if comparisons are to be strengthened.

The process used to collect all the available data (see Appendix 5) for preparing the Report clearly highlights a practicable approach on how to make optimal use of the available data previously collected by European, Intergovernmental and International Organizations within their mandates and on how to obtain additional data and information from Member States or other sources, including relevant EU-funded projects. This kind of approach could be adopted also for producing future reports on the status of health in the European Union as it provides for a wide participation and allows considerable resource savings.

Apart from a few exceptions, each Chapter of this Report, constituting its 5 Parts, has been structured into 8 sections: (i) Introduction; (ii) Data sources; (iii) Data description and analysis; (iv) Risk factors; (v) Control tools and policies; (vi) Future developments; (vii) References; and (viii) Acronyms.

We hope that this Report and the approaches it has used can be useful for EU D.G. “Health and Consumers” and Health Authorities of European Countries for fulfilling their task of collecting, analyzing and disseminating data and information related to health status, health determinants, health systems and health policies as well as to facilitate the cooperation among the EU Member States and with the European Commission. Furthermore, the Report may be an information tool for the Member States to establish in an efficient manner public health priorities as well as adopt and implement adequate policies and control tools to further improve the health conditions of their citizens. The Summaries and the Report are available at the EUGLOREH project website (www.eugloreh.it) and will be linked to the homepage of the European Commission D. G. Health and Consumers (http://ec.europa.eu/dgs/health_consumer/index_en.htm).

The value of this Report largely depends on the contributions of many experts who have kindly accepted to collaborate by providing manuscripts with high-quality scientific analyses and comments on specific subjects. On the other hand, integrations and amendments have been often made to the original contributions in order to take into account comments and suggestions received by other partners for improving the comprehensiveness and coherence of the Report as a whole. Therefore, in some cases, the Report may not completely reflect the views of the original contributions.

We wish to express our sincere appreciation and thanks to all those who have contributed and made possible this undertaking. While it is not possible to mention all of them, we wish to acknowledge the kind help of the colleagues at the Ministry of Health and at the National Health Institute: Nicola Begini, Francesca Belli, Antonella Calabrò, Marina D’Avanzo and Paola Marini for financial matters, Gaetano Guglielmi for taking care of website matters, as well as Susanna Conti, Carlo Donati and Colomba Iacontino for different scientific and administrative aspects. Finally, we wish to acknowledge the invaluable assistance of Beniamino Cislaghi, seconded from the World Health Organization - European Regional Office, in the management of the project.

Vittorio Silano Luciano Vittozzi

Project Coordinator Project Manager

October 2008

(1) These Countries will be referred collectively as the “EUGLOREH Countries” and will be listed in Tables and Figures according to the official order adopted by the European Union.

PART I – THE CONTEXT FOR HEALTH

2.

THE CHANGING CONTEXT FOR HEALTH IN THE EUROPEAN UNION


Acronyms

CIP

Competitiveness and Innovation Framework Programme

EURIPA

European Rural and Isolated Practitioners Association

FGM

Female Genital Mutilation

FP6

Sixth Framework Programme

GDP

Gross Domestic Product

HTA

Health technology assessment

ICT

Information and Communications Technology

ISCED

International Standard Classification of Education

NMS

New Member States

PHG

Public Health Genomics

RFID

Radio Frequency Identification

SMEs

Small and medium-sized enterprises

SNP

Single Nucleotide Polymorphism


2.1. Introduction

This Chapter deals with a number of demographic, socio-economic, environmental, scientific, technological and institutional developments and their trends that occurred with large regional variations in the European Community and Union during the last decades of the 20th Century and the first years of the 21st Century, resulting in major changes of the context in which citizens health has been and will be pursued. These developments had fundamental effects on society, on population size and ageing, family structure, labour market population and minority populations. For example, currently the EU is characterized by low and late fertility, as well as by low and late mortality. Most EU citizens still opt for marriage, although increasingly after a period of non-marital cohabitation. The age at marriage is high in some countries, even after a child is born. Divorce has become kind of normal, but the majority of marriages still end with death. Households are small, also as an effect of population ageing. One person households have become ‘popular’. Moreover, the EU has turned into an immigration continent. These processes started, roughly spoken, in the Northern part of the EU, ‘travelled’ to the Western, and then to the Southern part. After the fall of the Berlin wall, also the Eastern parts ‘adopted’ similar patterns together with the change to a free market economy.

The other fundamental character dominating the world scene is globalization that has substantially changed travel and trade, facilitating contacts and exchanges among parts of the world that were previously isolated. Globalization has increased travel, especially by air, connecting in hours extremes of the world with their different social environments and microbiological ecosystems. Globalisation of trade in food and animals has broadened human exposure to a variety of micro-organisms and made the prevention and control of zoonoses and food borne diseases much more difficult.

At the same time, the national health policies and services of European countries have evolved to meet the growing challenges and health needs; the European (Economic) Community and, then, the European Union were established to provide the opportunity of a new institutional and collaborative context in order to promote health and well being of the European population. Social policies, renowned for their major impact on health outcomes, have become more and more necessary. Interventions need to adopt a health-in-all policies approach. Social protection should ensure access for all to quality healthcare and long-term care and promote prevention, including for those most difficult to reach. A major challenge is how to ensure access for all to technological progress while ensuring sustainability.

While the increasing demand of health implies higher and higher investments, it is very important to keep in mind that health is not only a cost for Society, but may largely contribute to economic outcomes in high-income countries such as the EU Member States through four main channels: (i) higher productivity; (ii) higher labour supply;(iii) improved skills as a result of greater education and training; and (iv) increased savings available for investments in physical and intellectual capital. There is a significant amount of evidence to support the economic importance of health in the labour market in rich countries, while country-level historical studies exploring the role of health in a specific country over one or two centuries have shown that a large share of today’s economic wealth is directly attributable to past achievements in health. In addition to the direct effect of health on economy, there is also an impact of the health system on the economy irrespective of the ways in which the health system affects health. As one of the larger service industries, health represents one of the most important sectors in developed economies, with a current output of about 7% of GDP in the EU15, larger in EU15 than the roughly 5% accounted for by the financial services or the retail trade sector. Around 9% of all workers in the EU25 are employed in the health and social work sector. Moreover, the performance of the health sector will affect the competitiveness of the overall economy via its effects on labour costs, labour market flexibility and the allocation of resources at macroeconomic level (Figure 2.1).

The analysis of the underlying factors which deeply influence the context in which interventions and actions to preserve and improve health take place in the EU is important to understand the existing challenges and constraints. There are several features and trends to be taken into account when addressing the background conditions underlying health developments in the EU. They are considered to be useful background information to help the understanding of the analyses developed in subsequent chapters.



2.2. Globalisation, travel and trade

Liberalisation of trade controls on manufacturers, an easing of restrictions on foreign direct investments and other capital movements, as well as sharply reduced costs of transportation and telecommunications, have fostered the emergence of a global market economy. More businesses face fiercer competition in their domestic and export markets. As a result of these changes, intensified global competition for products and services feeds through into pressures to adapt workplaces and match the efficiency and quality of market leaders – or close down. The EU25 share of world trade (import and export) was 19% in 2005 (the same as in the USA and double that of Japan or China). Asia is the main world partner region of the EU25, with trade of more than 700 billion euro in 2004 followed by the US, with almost 550 billion euro. Maritime transport was by far the most frequently used mode of transport for imports of agricultural products and live animals (61%) and foodstuffs and animal fodder (89%) into the EU during 2004 (Eurostat).

The progressive reduction of barriers that first took place between local and national, then regional and now intercontinental markets is a dominant economic topic in recent economic history (globalisation). Continued globalisation, through increased trades, travels, capital movements and services, in addition to offering new important opportunities, also broadens human and animal exposure to a variety of biological hazards and makes zoonoses and food-borne diseases as well as of other problematic issues much more difficult to control. Globalization has also increased travel, especially by air, connecting in hours extremes of the world.

The report by Rudiger Leidner (2007) entitled “The European Tourism industry in the Enlarged Community” updates the Commission’s first analysis of the European tourism sector and extends it to the tourism industry of the enlarged Community. It reveals that Europe is a very stable tourist destination compared to other large regions in the world. The enlargement process contributed to this by inducing international arrivals not only in the new Member States, but also between old and new Member States. The still existing gaps in income can be seen in the rapid growth in the new Member States – whilst the differences in travel habits open a tremendous number of business opportunities and offer incentives to improve competitiveness. In the first years of the 21st century – despite an international environment not friendly towards global tourism – Europe consolidated its position as tourist destination number one in the world. Whereas the growth rates of international arrivals worldwide even turned negative in 2001 and 2003 they continued growing in Europe. Since 2004 global international arrivals have accelerated again. The increase continued irrespective of the rise in oil prices. The enlargement process contributed to improving Europe’s position as a tourist destination. The Community’s accession policy and the market oriented policies in the new Member States facilitated very large increases in tourist flows between old and new Member States – a trend that is still continuing. The overnight stays in the nearest old Member States generated by the three largest new Member States (Poland, Hungary and Czech Republic) grew by 56% in the period 1997 to 2004 and 26% in the opposite direction. Thus, the importance of intra-European tourism increased during the process of enlargement. The process of demographic ageing is characterized by a growing share of people older than 65. Data show that, without significant differences between old and new Member States, tourists aged 65+ continue travelling and do not reduce their travel expenditure severely. Taking into account that this age group prefers domestic destinations, the shift in the demand structure caused by demographic ageing will open new markets in particular for the regionally-oriented smaller tourism companies as long as they meet the higher requirements of this age group concerning service quality and accessibility. Innovation is of crucial importance for tourism, as it has an impact on tourism demand as well as on supply. The 17.5% increase of international tourist arrivals since 1950 would not have been conceivable without the technological innovations in the transport sector that made car and air transport affordable to almost everybody. Innovation by the tourism enterprises themselves aims at lowering costs and improving service quality to increase competitiveness. The same is true with regard to the uninterruptedly increasing on-line travel which not only changes consumer habits, but also facilitates new marketing strategies in the tour operator sector. Indeed, tourism is a very innovative sector. Lots of new products (nature-based tourism, wellness, cultural tourism etc.) were developed to meet evolving demand. Product quality and innovation are important factors to avoid the decline of destination. Within the process of demographic ageing the number of tourists with activity limitations is also expected to rise. A recent study estimates that the figure amounts to about 260 million people. Since the share of tourism facilities meeting their needs is currently quite low in most Member States, the catering of this market will initiate increases of service quality resulting in improved competitiveness of the tourism industry in general.

World-wide travel and global trade is often a very important risk factor for the transmission of infectious diseases although there are severe limitations on the relevant surveillance data. Of particular concern is the adventure/eco tourism to remote areas all over the world, being travels that bring a steadily growing number of humans into contact with pathogens and their reservoirs. Another effect of this increased travelling is “airport malaria” that is sometimes reported in relation to the inadvertent transport of infected mosquitoes from endemic areas. Furthermore, the growing cooperation of Europe with low-income countries results in a regular flow of European professionals from different fields (healthcare, engineering, planning, etc.), enrolled in NGOs and national cooperation agencies. They are also exposed to (re-)emerging diseases and can be an involuntary vehicle for the entrance of these diseases in Europe. Environmental, ecological and climate changes contribute to the emergence, maintenance and transmission of vector-borne and other infectious diseases, some of them imported from regions where they are endemic. The effect of global warming on Europe in the years ahead could increase this danger. In particular, the potential for malaria re-introduction in countries where it has been eradicated is a growing concern also due to global climate change, as the malaria vectors are still present in those areas, including Europe. Moreover, with their different social environments and microbiological ecosystems and trade in food, animals and other goods broadened human exposure to a variety of hazardous agents and made the prevention and control of food-borne and other diseases much more difficult to carry out.


2.3. Migration

The impact of migration on overall growth varies very much by country, but generally in many countries its contribution has increased over time. However, it’s unrealistic to believe that migration can offset the enormous inertia of population ageing in the EU. Nevertheless, migration can smooth the ageing pattern providing extra time for the policies to adapt.

Migration to EU countries has been constantly increasing over the past 25 years. For the European population at large, the relevant net gain in international migrants accounts for 70% of the overall population growth. In the European Union, there are about 25 million migrants (non-nationals). Most of them originate from Mediterranean countries and former colonies. During the past 20 years, Europe experienced very important annual increases of inward migration and over the last 5 years, EU net migrant inflows reached an annual level of 2 million. Increased immigration flows are mainly due to strong and persisting push and pull factors related to globalisation and the North-South divide in terms of demographic trends and welfare standards.

The EU is set to remain a popular destination for migrants over the coming decades. Eurostat’s conservative projection is that around 40 million people will immigrate in the European Union between now and 2050. As many of them are working-age migrants they will bring down the average age of the population. However, the longer-term repercussions remain uncertain, as they depend on the more or less restrictive nature of family reunification policies and birth patterns of migrants. Despite the current flows, immigration can only partially compensate for the effects of low fertility and extended life expectancy on the age distribution of the European population.

In relation to skill level, Europe attracts less high skilled immigrants and more low skilled immigrants compared to the USA, Australia and Canada, while vacancies in highly skilled jobs are increasing. In relation to labour market participation, participation/ employment rates of immigrants and their descendents remain low in many Member States. Illegal migration contributing to irregular work remains high. Almost in all Member States the integration of immigrants represents an important issue. Immigrants are among the most vulnerable groups. The fight against discrimination represents an important dimension of this issue.

The influx of migrants in the EU may impact on health services demand. Poverty and social uneasiness among non-EU immigrants together with the wide diffusion among immigrants coming from specific areas of diseases almost absent or assumed to be eradicated in the EU (e.g. tuberculosis, malaria, Hansen disease, leishmaniosis and filariasis) may lead to further problems. Migrants may have difficulties in accessing health care services, they may be unable to use them adequately and the quality of the health care services provided to them may be lower than in general. Migrants' cultural beliefs and language barriers may impact on attitudes to and use of health care services. On the other hand, health workers may be less able to observe problems among immigrants affecting the efficiency of care. This makes additional training necessary for healthcare personnel in order to make them able to respond sensitively to the needs of immigrant populations. The health status and the use of health services among immigrants may be improved by providing appropriate and qualified interpreting and translation services. A special concern is the descendents of migrants, which may face special health and social problems. Moreover, voluntary pregnancy termination shows that abortion rates are much higher for foreign than for European women.

Female Genital Mutilation (FGM) is not only an important issue in Africa, the Middle-East and Asia where it has been traditionally practised, but due to the arrival of immigrants, refugees and asylum seekers from these countries FGM has now also become a European concern. It is estimated that in the European Union alone, 500 000 girls and women are affected or threatened by the practice of FGM. The magnitude and serious medical and social consequences of this practice in Europe and, moreover, the human rights that might be violated by it, should not be underestimated.

The number of children born to immigrants usually reflects the cultural background these immigrant groups have lived with in the past. Over the last decades, first generation immigrants from Western Asia and Northern Africa had higher fertility rates than non-immigrants. However, their children, the second generation, have much lower rates, mostly only slightly more than the non-immigrants. Childlessness is rather rare among minority groups, although a bit rising. Fertility of immigrants from Western countries (EU Member States, Northern America, and Japan) does usually not deviate very much from non-immigrants.

Within the EU, a significant population movement is occurring from EUNMS to EU15 states, where in general they are economically active and fulfil and important skilled and unskilled workforce role. However, they (and their family dependants) may present specific challenges to health systems, not least if they are not fluent in the language of their new country of residence. Their outward movement may also reduce the healthcare workforce in their countries of birth and training



2.4. Socio-economic trends and inequalities

Europe continues to become wealthier. However, inequalities persist, not only between European countries, but also within the country’s towns and cities (especially less developed regions and neighbourhoods), between social groups and also between Europe and neighbouring countries.

As highlighted in the Joint Report on Social Protection and Social Inclusion (European Commission, 2008), social and economic policies can and should be mutually supportive. In recent years, social protection reforms and active inclusion policies have contributed to higher growth and more jobs. Still, more needs to be done to ensure that the benefits of an improved economic framework reach those at the margins of society and enhance social cohesion. Preventing and tackling poverty and social exclusion, as well as modernising social protection, combining both social adequacy and economic sustainability in a framework of sound fiscal policies, is therefore fundamental to Europe’s sustainable development. Policy consistency and coordination, including mainstreaming gender equality and solidarity between generations are essential to achieve the objective of fully including the most vulnerable in society. Sustained efforts will be required during, and beyond, the next cycle of the Lisbon strategy.

Good indicators of the wealth differences existing between countries are the per capita Gross National Income and the per capita Gross Domestic Product. The data reported in Figure 2.2 clearly show that large differences existing among EU Member States in terms of gross national income and gross domestic product per capita and, particularly, between the groups of the 15 countries already members of the EU before 2004 and of those who joined the EU in 2004.

Figure 2.2. Gross Domestic Product and Gross National Income per capita in EUGLOREH Countries, 2007.

GDP is defined as the produced value of all goods and services less the value of any goods or services used in their creation. The calculation of the annual growth rate of GDP per capita at constant prices allows comparisons of the dynamics of economic development both over time and between economies of different sizes. The growth rate is calculated from figures at constant prices since these give volume movements only, i.e. price movements will not inflate the growth rate. Table 2.1 provides an overview of the growth rate of real GDP over the last 10 years of all the EU member States and allows a comparison of the dynamics of economy in these countries.

Europe has become wealthier overall as it is shown by the fact that a steady economic growth has been experienced in the last 10 years. However, recent EUROSTAT estimates(1) indicate that GDP in the Euro Area and in EU27 declined in the third and forth quarter of 2008 (with respect to their respective previous quarters) and current forecasts are rapidly varying downward.

Table 2.1. Growth rate of real gross domestic product in EUGLOREH countries.

Inequalities persist, not only between European countries, but also within the country’s towns and cities (especially less developed regions and neighbourhoods), between social groups and also between Europe and neighbouring countries. Regions of relative wealth coexist with those less economically developed (Eurostat, 2005). Even broader gaps can be found inside the biggest European cities. Some 15% of European Union citizens are regarded as being poor. Relative poverty rates in the EU25 range from 8% in the Nordic countries, the Czech Republic and Slovenia to 21% in Greece, Ireland and Slovakia. There seems to have been some convergence in the extent of poverty across the EU15 since the mid 1990s, though no overall reduction can be observed (APPLICA, 2005; Table 2.2).

Table 2.2. At risk of poverty rate in EU27 and Croatia.

Out of the 78 million Europeans living at risk of poverty, 19 million are children. Ensuring equal opportunities for all through well-designed social policies, and strengthening efforts aimed at successful educational outcomes for each child, is necessary to break the transmission of poverty and exclusion to the next generation. Here, inclusion and anti-discrimination policies need to be reinforced, not least in relation to immigrants and their descendants and to ethnic minorities (Joint Report on Social Protection and Social Inclusion, 2008). When children are poor, it is because they live in jobless or low work-intensity households or because their parent’s jobs do not pay sufficiently and income support is inadequate to ward off the risk of poverty. Therefore, the implementation of balanced, comprehensive active inclusion strategies is an indirect but major element in promoting well-being of children and young people. This involves a combination of quality job opportunities, allowing parents to integrate and progress in the labour market, adequate and well-designed income support and the provision of necessary services for children and their families. The appropriate balance must be struck between helping families and targeting children in their own right. The best performers target the most disadvantaged children within a broader universal approach. Efforts to tackle poverty – of children and overall - will gain leverage from an evidence-based diagnosis of the main causes of poverty and exclusion in each Member States. within this context, national quantified objectives can be instrumental in making a decisive impact on the eradication of poverty. This can be further strengthened by the regular monitoring of policies’ impact and effectiveness and, where needed, by a reinforcement of the statistical capacity.

High risk populations in Europe, indicated by low level of education, occupational class, income level, or other groups such as migrants, differ in incidence and prevalence rates, treatment and cure rates, and access to health services (Report prepared by APPLICA, 2005; Semenza and Giesecke, American Journal of Public Health).

An independent comprehensive expert Report on “Health inequalities “, commissioned by, and published under the auspices of the UK presidency of the EU in October 2005, and other documents clearly indicate that:

  • in all countries with available data, rates of premature mortality are higher among those with lower levels of education, occupational class, or income;

  • inequalities in mortality exist from the youngest to the oldest ages and in both genders, but tend to be smaller among women than among men; and

  • inequalities in mortality can also be found for many specific causes of death, including cardiovascular disease, many cancers, and injury.

These inequalities in mortality lead to substantial inequalities in life expectancy at birth (4 to 6 years among men, 2 to 4 years among women). In many Western European countries, mortality differences between socio-economic groups widened during the last three decades of the 20th century. This continued into the 1990s, and has led to considerable increases of the relative excess risk of dying in the lowest socio-economic groups.

The explanation of this disturbing phenomenon is only partly known. One aspect which should certainly be taken into account, however, is that this widening of the relative gap in death rates is generally the result of a difference between socio-economic groups in the speed of mortality decline. While mortality declined in all socio-economic groups, the decline has been proportionally faster in the higher socio-economic groups than in the lower. The faster mortality declines in higher socio-economic groups were in their turn mostly due to faster mortality declines for cardiovascular diseases. In many Western European countries, the 1980s and 1990s were decades with substantial improvements in cardiovascular disease mortality. This was due to improvements in health-conducive behaviours (e.g. less smoking, modest improvements in diet and more physical exercise), and to the introduction of effective healthcare interventions (e.g. hypertension detection and treatment, surgical interventions and thrombolytic therapy). Apparently, while these improvements were to some extent taken up by all socio-economic groups, the higher socio-economic groups tended to benefit more from them.

The available evidence suggests that during - the late 1980s, inequalities in mortality were in Eastern Europe at least as big, and perhaps even bigger than in Western Europe. For example, a study looking at differences in mortality by level of education in Finland, Norway, Italy, Hungary, the Czech Republic and Estonia in the late 1980s showed substantial inequalities in mortality in all countries, both among men and women. Among men, the excess mortality ranged between 50 and 78 per cent in the three Eastern European countries, as compared to between 25 and 41 per cent in the three Western European countries. Among women, however, relative inequalities in mortality were of similar magnitude in the Eastern compared to the Western countries. Since the political transition, mortality rates have changed dramatically in many countries in Eastern Europe, sometimes for the better (e.g. in the Czech Republic) but often for the worse (e.g. in Hungary and Estonia), particularly among men. This is probably due to a combination of (interlinked) factors: a rise in economic insecurity and poverty; a breakdown of protective social, public health and healthcare institutions; and a rise in excessive drinking and other risk factors for premature mortality. The available evidence clearly shows that these changes in mortality have not been equally shared between socio-economic groups: in the countries with available data, mortality rates have generally improved less, or deteriorated more, in the lower socio-economic groups. Apparently, people with higher levels of education have been able to protect themselves better against increased health risks, and/or have been able to benefit more from new opportunities for health gains. An example is provided by Estonia where a considerable rise of inequalities in mortality has occurred. Evidence from some other Eastern European countries suggests a similar widening of the gap in death rates. The fact that this is not seen in some other countries (e.g. the Czech Republic), however, suggests that a widening of the health gap in a period of important political and economic change is not inevitable.

As in the case with mortality, rates of morbidity are usually higher among those with a lower educational level, occupational class or income level:

  • substantial inequalities are also found in the prevalence of most specific diseases (including mental illness) and most specific forms of disability;

  • over the past decades, inequalities in morbidity by socio-economic position have been rather stable; and

  • together with inequalities in mortality, inequalities in morbidity contribute to large inequalities in 'healthy life expectancy' (number of years lived in good health).

Inequalities are also evident in the prevalence of self-reported chronic conditions by level of education among people aged 25-79 during the ’90s. Data indicate that most chronic diseases have a higher prevalence in the lower educational groups.

Moreover, the European Commission also released the Communication on “Unequal Welfare States, Distributive Consequences of Population Ageing in Six European Countries”. DG Employment and Social Affairs, 2004. As retired people generally have lower incomes than employed workers, ageing will lead to a slight rise in income inequality in Europe in the next 20 years. Larger numbers of people with lower incomes will in turn lead to higher poverty rates.

While healthcare systems have contributed to significant improvements in health across the EU, access to healthcare remains uneven across social groups. A major challenge is allowing access for all to high quality care reflecting recent technological progress while ensuring sustainability. Hence, Member States are implementing policies to reduce these inequalities, e.g. by: addressing risk factors through health promotion; reducing the prevalence and incidence of certain diseases; and ensuring more effective prevention activities in various settings (at home, school, work). Also important are the steps to increase population coverage, address financial barriers to care, emphasize promotion and prevention activities over curative care, and address cultural barriers to the use of services. The Structural funds will be used to support reform and capacity building mainly to improve access and develop human resources. A combination of general policies and those tailored to lower socio-economic groups is needed. Virtually, all Member States have implemented universal or almost universal rights to care and have adapted services to reach those who have difficulty in accessing conventional services due to physical or mental disability or to linguistic or cultural differences. Few have begun to address health inequalities systematically and comprehensively by reducing social differences, preventing the ensuing health differences, or addressing the poor health that results. This would ensure in practice equal access for equal needs. Finally, policies outside the health sector are also central to improving the health of the population and reducing the existing gaps in healthcare provision (Joint Report on Social Protection and Social Inclusion, 2008).




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