EN    EN EN 
EN    EN  COMMISSION OF THE E UROPEAN COMMUNITIES 
Brussels, 20.10.2009 
SEC(2009) 1396 final 
COMMISSION STAFF WORKING DOCUMENT 
   
IMPACT ASSESSMENT  
 
accompanying the 
COMMUNICATION FROM THE CO MMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMI TTEE OF THE REGIONS 
 
Solidarity in health: Reducing health inequalities in the EU  
   
{COM(2009) 567 final} 
{SEC(2009) 1397} 
EN ii   EN Introduction and policy background........................................................................................... 5 
1. Procedural issues and consultation of third parties ...................................................... 7 
1.1. Organisation and timing............................................................................................... 7 
1.2. Consultation and expertise ........................................................................................... 8 
2. Problem definition........................................................................................................ 9 
2.1. Background and context: nature and scale of health inequalities in the EU ................ 9 
2.1.1.  Inequalities in health outcomes between Member States............................................. 9 
2.1.2.  Inequalities in health outcomes between social groups within Member States. ........ 10 
2.1.3.  Determinants (drivers or cause s) of health inequalities ............................................. 11 
2.2. What Member States are doing and c onsider effective to address health 
inequalities ................................................................................................................. 14  
2.3. Existing EU action and links to other relevant EU policies....................................... 16 
2.4. Problems and barriers in taking action on inequalities in health – and possible 
role of the EU. ............................................................................................................ 19 
2.4.1.  Lack of awareness and insufficient policy priority and commitment by Member 
States 20 
2.4.2.  Absence of comparable and regular da ta, monitoring and reporting.  Lack of 
knowledge on the determinants and the effective policies to implement .................. 21 
2.4.3.  Insufficient concerted EU approach to h ealth inequalities (lack of mainstreaming 
at the EU level)........................................................................................................... 22 
2.5. Why are health inequalities between and within countries a problem and a 
policy concern to the EU? .......................................................................................... 24 
2.6. Legal and political basis for action and subsidiarity.................................................. 24 
3. Objectives................................................................................................................... 2 7 
3.1. General Objectives ..................................................................................................... 27 
3.2. Specific Objectives..................................................................................................... 27 
4. Policy options............................................................................................................. 27 
4.1. Option I: Continue current act ivities, no new initiative:............................................ 28 
4.2. Option II: Current plus ............................................................................................... 29 
4.3. Option III: Far reaching efforts to enha nce EU policy priorities in relation to 
health inequalities....................................................................................................... 33 
5. Analysis of impacts .................................................................................................... 41 
5.1. Social Impacts ............................................................................................................ 41 
5.2. Economic impacts ...................................................................................................... 43 
5.3. Costs regarding data collection .................................................................................. 44 
6. Comparison of the Options ........................................................................................ 44 
EN iii   EN 6.1. Option I – Baseline – Continue curre nt activities, no new initiatives........................ 45 
6.2. Option II – Current Plus............................................................................................. 45 
6.3. Option III – Far reaching efforts to en hance EU policy priorities in relation to 
health inequalities....................................................................................................... 47 
7. Monitoring and evaluation ......................................................................................... 49 
8. ANNEX 1 Consultation and expertise ....................................................................... 53 
8.1. Targeted written consultation..................................................................................... 53 
8.2. Summary of responses ............................................................................................... 57 
8.3. Consultation during the developmen t of previous communications.......................... 63 
8.4. Consultation with key groups convened by the European Commission.................... 64 
8.5. Consultation with EU institutions .............................................................................. 68 
8.6. Expertise 69 
9. ANNEX 2: Health ineq ualities in the EU .................................................................. 71 
9.1. Background and context: Nature and scal e of health inequalities in the EU ............. 71 
9.1.1.  Inequalities in health outcomes between Member States........................................... 71 
9.1.2.  Determinants (drivers or cause s) of health inequalities ............................................. 82 
9.2. What Member States are doing and c onsider effective to address health 
inequalities ............................................................................................................... 100 
9.3. Existing EU action and links to other relevant EU policies..................................... 104 
9.4. Additional information on why health ine qualities between a nd within countries 
are a problem and a policy concern to th e EU? The legal and political basis for 
action and subsidiarity.............................................................................................. 108 
10. Bibliography............................................................................................................. 111 
11. List of abbreviations................................................................................................. 113 
  
EN iv   EN  
Key concepts 
The term "health inequalities" taken literally m eans differences, variations or disparities in 
health status between individuals or groups.   
 
The term inequity  refers to differences in health wh ich are not only unnece ssary and avoidable 
but, in addition, are considered unfair and unjust.1 Health inequities are systematic differences 
in health outcomes across differe nt population groups (often defi ned by place of residence or 
on a socio-economic basis) which arise not from  chance or from the decision of the individual 
but from avoidable differences  in social, economic and envi ronmental variables that are 
largely beyond individual control yet can be addressed by public policy.    
In common usage and in many polic y circles, the term health in equality is us ed as a synonym 
for health inequity. This is partly because health inequalities is a much more readily 
understandable term by the general public an d partly because in terms of measurement 
"inequalities", i.e. measured differences in heal th outcomes, can be used as a proxy for health 
inequities.  There are also practical reasons  for the use of "inequalities" rather than 
"inequities": it is suggested by some academic researchers and other stakeholders that the 
term "health inequities" does not find a direct tran slation in all languages.  In consideration of 
these points, this document uses the term health  inequalities rather than health inequities. 
Clearly not all health inequalities are unfai r and unjust, nor are all health inequalities 
amenable to public policy.   
 
                                                 
1 Health21, the health for all policy for the European Region.  World Health Organization Regional Office 
for Europe.  Copenhagen 1999. 
EN 5   EN INTRODUCTION AND POLICY BACKGROUND 
This impact assessment considers policy options for a possible EU initiative "Solidarity in 
Health: Reducing Health Inequalities in the EU ", launching work in this field while building 
on existing measures and mechanisms.  The Commission identified the need for policy action on health inequalities in the EU Health Strategy
2 and announced an EU initiative on health 
inequalities in the 2008 Renewed Social Agenda3.  This document considers options for what 
such an initiative should be.  
This report provides information on health inequalities in the EU and some of their causes, as 
well as on the current actions taken at Member St ate and EU levels.  It outlines a rationale for 
action and proposes a number of options and rela ted policy actions which are then appraised.  
The report commits only the Commission's servi ces involved in its preparation and does not 
prejudge the final form of any deci sion to be taken by the Commission. 
Principal responsibility for action to address health inequalities rests with Member States, but 
EU policies could also have a role both through their indirect impact on health and by helping 
to overcome some of the current obstacles to action as identified in this report .  EU action 
appraised here therefore explor es options to support and complement the efforts of Member 
States and stakeholders and to  mobilise EU policies towards reducing health inequalities, in 
full respect of subsidiarity.  
The aim of EU action on health  inequalities should support impr ovements in the health of the 
whole population, but with particular emphasis on reducing avoidable and unfair gradients in 
health between social groups, protecting the he alth of vulnerable groups and contributing, 
where appropriate, to more rapid improvements in the health of populat ions for those regions 
of the EU that are lagging behind – i.e. a 'levelling-up' approach.   
A legal basis for action is provid ed by the EC Treaty.  The EU has a responsibility to ensure 
that all its policies an d activities provide a high level of health protection.  It also has a 
responsibility to strengthen ec onomic and social cohesion.  There is also a "political" 
background for action. In June 2006 the Council adopt ed conclusions on Common values and 
principles for health systems stating that they  aim to reduce the gap in health, which is a 
concern of EU Member States”4 and in November 2006 the C ouncil adopted conclusions on 
health in all policies recognisi ng the importance of health dete rminants and calling for inter-
sectoral and broad societal action on those determinants5.  Policy action on health inequalities 
was foreseen in the Commission White Paper “Toge ther for Health, a strategic approach for 
the EU 2008-2013” of October 200 7 (the EU Health Strategy)6 which stressed the need to 
reduce health inequity between and within Memb er States involving exch ange of best practice 
and health promotion.  The European Parl iament, the Council and the Committee of the 
Regions, in their opinions on the Health Strateg y, have all underlined the need for EU action 
to help address inequalities  in health. In June 2008 the European Council underlined the 
importance of closing the gap in health and in  life expectancy between and within Member 
                                                 
2 "Together for Health, a strategic approach for the EU 2008-2013" 
http://ec.europa.eu/health/ph_overview/Documents/strategy_wp_en.pdf   
3 "Renewed Social Agenda: Opportunities, Acce ss and Solidarity". COM(2008) 412 final at 
http://ec.europa.eu/social/m ain.jsp?catId=547&langId=en   
4 OJ C 146 of 22.06.2006, p.01. 
5 See http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/91975.pdf  page 10 
6 "Together for Health, a strategic approach for the EU 2008-2013" 
http://ec.europa.eu/health/ph_overview/Documents/strategy_wp_en.pdf   
EN 6   EN States.7  Finally, in July 2008 the Commissi on Communication on a Renewed Social 
Agenda8, highlighted the principles of opport unity, access and solidarity and announced a 
Commission Communication dedicated to the issue of h ealth inequalities for 2009.   
In 2006 Member States agreed on the objective of addressing inequities in access to care and 
in health outcomes,9 within the Open Method of Coordina tion for Social Protection and Social 
Inclusion (social OMC)10.  Reducing health inequalities within and between Member States 
was also agreed in 2006 as an operationa l objective of the renewed EU Sustainable 
Development Strategy11.  The persistence of health inequa lities has been highlighted in the 
annual Joint Report on Social Protection a nd Social Inclusion (Joint Report SPSI)12.  
In the international arena, in addition to Member States' adoption of the 2008 Tallinn 
Charter13, that establishes as health systems goals  "improving the level and distribution of 
health, equity in finance and equity of  access to care", the 2008 report of the WHO 
Commission on the Social Determinants of Health (WHO CSDH)14 described the global 
burden of health inequa lities and called for con certed action at all leve ls of government to 
address them.   
This background demonstrates increasing attention to the large and persistent inequalities in 
health between and within Member States  and growing concerns  about the negative 
consequences for health, social cohesion and economic development if they are not 
effectively addressed.  EU action in this fiel d should be seen as part of the general EU 
commitment to increase the welfare and living st andards of all as set out in the Treaties and 
reiterated in the Renewed Social Agenda, as well as in the international arena.  The means to 
achieve this goal include existing economic, empl oyment and social strategies, such as the 
strategy for growth and more and better jobs .  However, the Council Conclusions and the 
consultation for this communication indicate an increasing recogni tion that further and 
dedicated EU action in support of Member States ' efforts to tackle h ealth inequalities is 
needed.   
The possibility of EU action shou ld also be consider ed in the context of  the economic crisis 
that the EU is currently facing.  It is not yet known to what ex tent the economic situation will 
impact on health inequalities, but unemployment is fast incr easing and poverty is likely to 
increase as many households lose jobs.  At the same time, some countries are beginning to cut 
social and health care budgets.  This may wors en the observed health disparities between and 
within Member States and highlights the need fo r action to mitigate the negative health effects 
of the crisis.  Moreover, in a context of risi ng strains between resour ces and needs, it is 
particularly important to protect  the health of EU citizens a nd to improve the understanding of 
how economic, social, regional and other policies im pact on the overall health of populations 
                                                 
7 See http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/ec/101346.pdf  , page 13. 
8 "Renewed Social Agenda: Opportunities, Acce ss and Solidarity". COM(2008) 412 final at 
http://ec.europa.eu/social/m ain.jsp?catId=547&langId=en   
9 http://ec.europa.eu/employment_social/spsi/common_objectives_en.htm   
10 See http://ec.europa.eu/social/m ain.jsp?catId=448&langId=en   
11 Review of the EU Sustainable Development Strategy.  Council of the European Union. Document 10117/06. 9 
June 2006 http://register.consilium.europa.eu/pdf/en/06/st10/st10117.en06.pdf  
12 http://ec.europa.eu/employment_social/spsi/joint_reports_en.htm   
13 http://www.euro. who.int/document/hsm /6_hsc08_edoc06.pdf   
14 "Closing the gap in a generation: health equity through action on the social determinants of health."  
Commission on Social Determinants of Health Final Report. World Health Organization, Geneva 2008.  http://www.who.int/social_determin ants/final_report/en/index.html
  
EN 7   EN and on the various subgroups within them.  The current economic crisis through posing a 
financial pressure on health systems can moti vate countries to review their policy mix on 
health and health determinants in search  for higher effectiveness and efficiency. 
1. PROCEDURAL ISSUES AND CONSULTATION OF THIRD PARTIES 
1.1. Organisation and timing  
This work is jointly led by the Directorate-Ge neral for Employment Social Affairs and Equal 
Opportunities (DG EMPL) and the Directorat e-General for Health and Consumers (DG 
SANCO).  
Exploratory work on the impact assessment bega n in early 2008 when an  initial roadmap for 
the Communication was drafted.  This was finalised and agreed jointly by the two Directorates General DG EMPL and DG SANC O in July 2008.  Following the inclusion of 
the Communication on health inequalities in the Commission's legislative and work plan for 
2009 an invitation was sent to all Commission servi ces to participate in the impact assessment 
inter-service steering group (IA ISSG). The firs t IA ISSG meeting took place in November 
2008.  Three further meetings of the group to ok place in February, March and April 2009.  
The following Directorates-General particip ated: AGRI, AIDCO also  representing DEV, 
EAC, ECFIN, EMPL, EUROSTAT, INFSO, JLS, MARKT, REGIO, SANCO, SG, and RTD.  These Commission Services made very useful  and active contribu tions and discussed 
important aspects of the documen t notably the options and the actions within these as well as 
the need to relate this initia tive to the economic crisis.  The IA ISSG allowed the initiating 
DGs to take stock of what th e other Commission services are doing and can do in relation to 
addressing health inequalities.  The IA ISSG positively reviewed the draft impact assessment document circulated for the 1 April meeting and found it suitable for submission to the Impact 
Assessment Board (IAB) subject to  taking account of the (small) comments then provided.   
The IAB considered the document at its meetin g of 13 May and provided its initial opinion on 
25 May 2009. Following resubmission,  the IAB issued a positive opinion on 15 July 2009 
with a number of further suggestions for im provements. This version of the document 
consolidates all changes in response to the comm ents and observations of the IAB. The four 
points below set out the changes that have b een introduced. Adjustments following the second 
opinion of the IAB appear in italics. 
(1) The objectives for EU action were reformulat ed with the aim of ensuring an appropriate 
level of ambition for the policy context and to  be appropriately linked with the problems 
identified and the actions propose d.  A decision was taken to use the term 'health inequalities' 
throughout the whole document and an explanati on of this decision is provided in the 
beginning of the document.  To achieve greater explicitness on the comp etence of the EU and 
the scope of this initiative changes have  been made throughout the whole document but 
especially in section 2 (problem definition) , section 3 (the objectives) and section 6 
(comparison of the options).  More emphasi s has been put on better data collection and 
strengthening the knowledge base which is in cluded as a specific objective (section 3.2).  
Some information previously in section 2 was move d to the annex for the sa ke of conciseness.   
(2) The problem definition was reworked to clarify the drivers of health inequalities.  
Additional evidence and clarificat ion on issues relating to causati on of health inequalities was 
to section 2.1.3 (and further elaborated after the 2
nd IAB opinion),  highlighting that evidence 
on causality, albeit growing, is limited and ind eed improving the knowledge pool is one of the 
aims of this initiative.  This helps distinguish to wh at extent causal links have been estimated 
EN 8   EN or only inferred from statistical correlation.  More use is made of evidence on existing actions 
at Member States and EU level.  An additi onal section (section 2.2) was included containing a 
list of effective Member States actions.  A dditional information was added to section 2.3 
"Existing action and links to other relevant EU policies" on the current contribution of various 
EU policies.  Attention is drawn to the fact that consistent and comprehensive evaluation of 
policy actions both at Member St ate and EU level is limited.  A table to illustrate the 
relationship between national and EU level actions was added to end of section 4.  
(3) Information on costs was reworked a nd expanded including in a new subsection 5.3. 
Further points on costs have been provided, particularly in section 5.2 with the aim of 
clarifying that this is an in itiative aimed only at encouraging  Member States to take action 
without any obligatory compliance costs.   A separate section on subsidiarity and 
proportionality, section 2.6 was added and in  addition, issues of subsidiarity and 
proportionally added under the analysis for each option (6.1, 6.2, 6.3).  To further improve the 
analysis of subsidiarity and pr oportionality extra detail and examples was added to section 
2.6. 
(4) Additional information on the consultation carried out by the Comm ittee of the Regions 
was added in section 1.2 and the consultation secti on in the Annex adjust ed to take account 
comments received following publication of a se parate report on the consultation in July 
2009 .   
Beyond that the document was generally reworked to ensure consistency with the new 
sections and to improve readability.  
1.2. Consultation and expertise 
A targeted consultation of stakeholders wo rking with DG EMPL and DG SANCO, inviting 
written contributions, was launched on 3 Febr uary 2009 with a closi ng date of 1 April, 
subsequently extended by a further two weeks.  This was placed on the Commission's website 
providing an opportunity for other stakeholders to respond.  Altogether 125 responses were 
received. Responses included natio nal and regional authorities; EU level representations of 
regions and local governments; umbrella NGOs and networks in the domain of social policy; 
EU level organisations representing health insurers, heal thcare providers and pharmaceutical 
industries; the social partners; EU Agencies; national/regional/local providers and insurers; 
national agencies and researchers active in the domain of social  policy; political parties and 
international organisations.  A number of foru ms and processes were consulted including the 
Social Protection Committee (SPC) in Ma rch 2009, the EU Expert Group on Social 
Determinants of Health and Health Inequali ties (Expert Group SDH) in December 2008 and 
March 2009, and the EU Open Health Forum (December 2008).  The Committee of the Regions (COR) undertook a consultation process on health inequalities and provided input 
during the development of this impact assessment.   Prior to this, consultation on the issue of 
health inequalities took place as pa rt of linked initiatives such as the Renewed Social Agenda 
(2008) (consultation ended Febr uary 2008, Social Agenda Forum of 5/6 May 2008), and the 
EU Health Strategy (2007) (con sultation in early 2007).  A list of consultations and a more 
elaborated summary on positions is given in the Annex.   
The vast majority of respondents reported the existence of health in equalities within and 
between Member States, and perceived these as increasing even prior to the crisis.  EU action was seen as providing added value.  Several ca uses of health inequalities were mentioned 
such as employment and working conditions, po verty and environment.  Respondents did not 
see the problem as just rooted in the character and extent of healthcare.   
EN 9   EN Regarding concrete actions better measurement,  monitoring, reporting a nd exchange of best-
practices were suggested by nearly all stakeholde rs.  As the causes for health inequalities are 
so manifold, respondents indicated that they should be taken into  account in all EU policies.  
A majority proposed a better ta rgeting of EU funds and speci al focus on vulnerable groups.  
Targets/ milestones were suggested by a quarter of respondents.  A small number of responses 
(notably national authorities) remarked that EU  action should respect subsidiarity principles. 
The responses were used to include some actio ns and confirm the inclusion of some of the 
initial ideas for action in section 4.  They also influenced the way that actions were organised 
under the three options, how the options were a ppraised and how the final option was chosen.  
The Committee of the Regions (COR) carried out an impact assessment consultation among 
the partners of the Subsidiarity Monitori ng Network during February and March 2009 and 
received 13 responses.  Health  inequalities were also per ceived as a problem.  Factors 
mentioned as drivers included: (i) socio-economic conditions; (ii)  lifestyle; (iii ) geographical 
features of the territory; and (iv) cultural heri tage.  Action at Community  level was considered 
necessary particularly in relation to improving comparability of information and assessment of the state-of-the-art processe s at national and regional level.   Other suggestions for action 
included: (i) promoting ‘Health equality in all policies’ (ii) developing an equality-focused 
health impact assessment; (iii) promoting unive rsal coverage health systems across the EU; 
(iv) improving mechanisms for monitoring inequa lities in health across Europe, (v) promoting 
research and exchange of best practice.  In mo re specific terms and stre ssing the particularities 
of remote areas, like islands, EU support for h ealth information technology was seen as an 
added value for these regions.  The COR high lighted the EU’s role for agenda setting. 
2. PROBLEM DEFINITION 
2.1. Background and context: nature and scale of health inequalities in the EU 
This section summarises the nature and causes of health inequalities in the EU.  Annex 2 
contains a detailed presentation of the issues including graphs and references to data sources. 
2.1.1.  Inequalities in health outco mes between Member States 
Substantial differences in population health be tween different EU Member States can be 
observed in a wide range of health indicators
15.  Individuals in many new Member States live 
shorter lives than their Western counterparts.   In 2007 there was an 8-year gap between 
Member States in life expectancy for women and a 14-year gap for men (Figures A1-A5 in 
annex).  In several Member States the gap between nationa l life expectancy and the EU 
average has increased in the last two decades (Table A1 in annex).  There are also large 
differences, of up to 20 years,  in the number years lived in good health (Healthy Life Years) 
(Table A2)16,17,18 and recent negative trends have be en observed especially for women who 
already spend a higher proportion of their lives with limitations.  Large differences are also 
                                                 
15 See the Annual Monitoring Report from the European Observatory on Social Situation & Demography 
for detailed data analysis at 
http://ec.europa.eu/employment_soci al/spsi/reports_and_papers_en.htm . 
16 A word of caution is necessary as by construction this indicator is based on self-perceived limitations in 
activities and this measure may be prone to cross-country cu ltural differences.  
17 See also Jagger et al. (2008) that s uggest that the gap between East and We st in both life expectancy and years 
spent in good health is considerable. 
18 See http://ec.europa.eu/health/ph_information/indicators/lifeyears_en.htm  for more detail.  
EN 10   EN found in infant mortality, in premature and trea table and preventable mortality, in subjective 
measures of health such as self-perceived ge neral health, long-standing illness and activity 
limitations (Figures A6-A7, tables  A3,A4).  In some countries, contrary to the general EU 
trend, some mortality rates have grown duri ng the last decade.  See annex 2.1.1 for more 
detail. 
2.1.2.  Inequalities in health outcomes between social groups within Member 
States. 
Major differences in health exist between social  groups in all EU countries (for a review, see 
the report by Mackenbach for the 2005 UK Council Presidency Conference19).  These start at 
a young age and persist and widen in older ages (Survey of Health Ageing and Retirement in 
Europe - SHARE20).  Differences in life expectancy at birth between the lowest and the 
highest socio-economic groups (e.g. between ma nual and professional occupations; people 
with primary level and post-sec ondary education; low and high in come quintile) range from 4 
to 10 years for men and 2 to 6 years for women.  In some countries the gap has widened in the 
last decades.  Despite an overall decline, mo rtality and infant mortality are higher in the 
lowest socio-economic groups and relative inequalities have incr eased in several countries.  
See annex 2.1.1 for detail. 
Rates of disease and disability also vary s ubstantially by socio-economic group.  People with 
lower education live shorter lives and spend more  time in poorer healt h.  For ‘self-perceived 
general health’ a clear income gradient can be ob served in that those in the lowest (poorest) 
income quintiles more often report very bad heal th than those in the hi ghest (richest) quintile 
(Table A3).  In some countries the percentage reporting very bad health in the lowest quintiles 
has gone up since 2005.21  SHARE data shows that individuals with lower education or 
income are more likely to experience limitations with arm or motor functions and have a higher prevalence of eyesight, hearing and chew ing problems (Figure A8).  Education-related 
inequalities in common chronic diseases and in height are also observed for European 
Countries (Dalstra et  al., 2005; Cavelaar  et al., 2000).   
Vulnerable groups suffer a particularly greater burden of mo rtality and disease
22.  These 
include some migrant groups and ethnic minoritie s, people living in deprived urban and rural 
areas and in poverty, the long-term unemploye d, those informally employed, seasonal/daily 
workers and subsistence farmers, those furthe r from the labour market, jobless households, 
the homeless, the disabled, those suffering fr om mental or chronic illnesses, elderly 
pensioners on minimum pensions, and single parents.  For exampl e, the Roma can expect to 
live 10 years less than the major ity population in some countries23.   
                                                 
19 Mackenbach J. "Health inequalities: Europe in pr ofile". COI for Department of Health, London 2006 
http://ec.europa.eu/health/ph_determinants/socio_economics/documents/ev_060302_rd06_en.pdf  
20 See http://www.share-project.org/  
21 A word of caution is needed when looking at these conclusions, as current information covers a maximum of 
three years and hence the changes observed may not be a significant sign of a trend. 
22 As indicated in the Joint Report on Social Prot ection and Social Inclusion and social OMC and equal 
opportunities related studies/ networks at 
http://ec.europa.eu/employment_social/spsi/the_pro cess_en.htm, the Handbook on Integration for 
policy-makers and practitioners at http://ec.europa.eu/justice_home/doc_centre/immigr ation/integration/doc/2007/handbook_2007_en.pdf, 
the Health and Migration in the EU work under the 2007 PT Presidency , and the work of the 
International Organisation of Migration. 
23 See the European Monitoring Centre on Racism and Xenophobia http://eumc.eu.int/   
EN 11   EN The June 2006 Council Conclusions on Women's Health24 recognised a gender dimension in 
health.  For example, although women live longer than men, they suffer a greater burden of 
unhealthy life years, and a higher incidence and prevalence of certain diseases.   
Importantly, there appears to be a strong asso ciation between within country socio-economic 
inequalities in health and th e overall population health i.e.  the higher the socio-economic 
inequality in health, the poorer the overall popul ation health (Figure 1).  This adds to the 
analysis under the 2006 Finnish Presidency and the 2008 Joint Report on Social Protection 
and Social Inclusion that addressing health inequalities can cont ribute to important 
improvements in overall population health. 
Figure 1:  
Within country socio-economic inequalities in health versus 
aggregate population health
y=-0,18+0,51x
0123456
02468 1 0 1 2
Socio-economic (income) inequalities in health measured by the gap 
(absolute terms) in the % of those reporting very bad health between the 
highest and the lowest income quintile (S80-S20)% of total population stating very 
bad health
 
Source: EUROSTAT 
2.1.3.  Determinants (drivers or caus es) of health inequalities 
Determinants of health inequa lities can be summarised in the recent framework used by the 
WHO CSDH (Figure 2, see Annex 2.1.2 for a detailed  analysis).  Note that, while there is a 
substantial amount of evidence on association (i.e . when we look at measures of health across 
population groups based on education, we find a systematic socio-economic gradient in 
health), there is limited but growing evidence (as longer data series and more sophisticated 
econometric techniques become available) whic h indicates a causal relationship between the 
set of factors in the figure and measures of heal th status both at the country level and within 
countries between socio-economic groups.  This  is why improving the data and knowledge 
base for action is one of the objectives of this initiative. 
                                                 
24 See http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/89830.pdf   
EN 12   EN Figure 2: WHO Commission on Social Determ inants of Health conceptual Framework . 
 
Living conditions and health related behaviour:   Living conditions affect  health through direct 
and indirect physical and psychological mechanisms .  There are sections of the EU population 
which do not have access to running water, adequa te washing and toilet facilities, affordable 
energy, appropriate housing, heating, new clot hes, or safe environment (e.g. EUROFOUND – 
2008 European Quality of Life Survey25).  Some studies (e. g. Trannoy and Tubeuf, 2008; 
Tubeuf et al., 2008) show suggest  a negative effect of geographi c environment (pollution) and  
neighbourhood/area (deprivation defined as high unemployment rates, single parent families, 
high share of individuals with lower education) on the health of indivi duals independently of 
each individual characteristics.  Health is also determined by health-related behaviours (e.g. 
diet, physical activity, tobacco and alcohol use).  Some studi es (e.g. Stronegger et al., 1997; 
van Lenthe, F. J., C. TM Schrijvers, et al. 2004 based on GLOBE NL; Mackenbach, 2007) 
suggest that individual health behaviour can explain from 25%  to 35% of differences in 
people's health.  Other studies hypothesise that maternal smoking and poor diet during 
pregnancy cause impaired development in uter o which increases the risk of cardiovascular 
disease, stroke, respiratory di seases and lung cancer in middl e age (Baker, 1992).  There are 
large variations between EU Member States  and between socio-eco nomic groups in the 
consumption of fruit and vegetables and the prevalence of smoking, alcohol consumption, 
obesity and physical activity (Figures A10-A 12).  Countries with high rates of smoking 
combined with low rates of exercise and unhealt hy diet are also countries with the lowest life-
expectancy in the EU (LV, LT, EE, BG, RO, PL, SK, HU, CZ).  St udies also show that health 
related behaviour is itself a nd to a large extent influenced  by socio-economic and cultural 
factors (SHARE; Stronegger et al., 1997; Lun dberg, 1991).  Note that the above academic 
studies showing causality are often restricted to specific countries,  regions or even cities in a 
country and there is no EU coverage/ compar ison on the causality of this sub-set of 
determinants. 
Education, occupation and income/wealth  are other important determinants of health (even 
after adjusting for risk factors - SHARE) shown to explain 40-50% of observed health 
differences (van Lenthe, F. J., C. TM Schrijvers, et al. 2004 based on GLOBE, NL).  Living 
in poverty is associated with hi gher mortality and disease.  Unem ployment is associated with 
increased poor mental health and suicide (K essler et al. 1987; Warr 1987; Blakely, 2003).  A 
number of studies have suggested that job qual ity and working conditions affect health to a 
great extent (e.g. Debrand and Lengagne, 2008; Ju sot et al., 2007): low physical pressure and 
stress, high decision ability and po ssibilities to develop new skill s, a correct monetary reward 
                                                 
25 See http://www.eurofound.europa.eu/pu bdocs/2008/52/en/1/EF0852EN.pdf  
EN 13   EN and having prospects for personal  progress lead to good health st atus whereas lack of support 
at work and the feeling of job insecurity incr ease the risk of depressi on and bad health.  In 
addition, occupational health risks vary across s ectors and not all workers are equally exposed 
(European Agency for Safety and Health at Work)26: e.g. workers with a fixed- duration or 
temporary employment relationship are statistica lly more likely to suffer from accidents at 
work and occupational diseases.  In general,  one can observe disparities in employment/ 
unemployment rates and differenc es in poverty and income ine quality across and within 
Member States  which might also help explai n part of the differenc es in health between 
countries. Notwithstanding the range of studies in this area much of this evidence remains at 
the level of association and suggestion rath er than providing clear explanations or 
mechanisms of causality.  A growing number of academic studies are contributing to understanding of the causality be tween education or income a nd health because  better data 
panels and econometric techniques are becoming av ailable.  In some cases it is now possible 
to use Census information and link it to mort ality data, or through sp ecialised surveys to 
follow cohorts of individuals, examine  the re lation between parents and their children or 
compare siblings (including twin studies) as techniques to improve understanding of  the 
effect of socio-economic determinants of hea lth.  While such evidence is contributing to 
understanding of the factors invol ved there is a lack of studi es evaluating initiatives and 
actions in this area which could inform policy.   
Public policies including income di stribution and access to health care:
 Public policies belong 
among the structural determinants of health ineq ualities as they influence the distribution of 
the above factors (e.g. education, income) and th e degree of stratifica tion in society.  The 
extent of redistribution and so cial protection (pensions, sickne ss and health care, disability, 
family and child, unemployment, housing and social exclusion benefits), which vary 
significantly across Member States, may contribute to the observed health  gaps.  A number of 
research studies indicate that income inequality is one of the factors explaining differences in 
health between countries and individuals  (J en et al, 2009; Babones,  2008; Leigh and Jenks, 
2007; Wilkinson and Picket, 2006; Cantarero et  al., 2005; van Doorslaer and Koolman, 2004; 
Asafu-adjaye, 2004; Gravelle et  al, 2002).  Income distributi on policies, which have been 
estimated to reduce the risk of  poverty in the EU by 38% ar e therefore potentially very 
important (2008 OMC Monitoring Report27).   
Healthcare influences the likel ihood of overcoming disease and avoiding mortality thus its 
availability and quality  between and within Member States  can help explain some of the 
health disparities observed. Count ry differences in the availab ility, access and quality of care 
contribute to differences in treatable mortality28 (Newey et al., 2003, 2008).  EU Statistics on 
income and living conditions sugge st an income gradient in unmet need for medical care: 
those in the lowest income quintiles more of ten report unmet need (Table A9).  Evidence 
suggests that lower income families have further to  travel to hospital or family doctor (Figures 
A24,A25) and that, after ad justing for different levels of  ne ed, the rich are significantly more 
likely to see a specialist and a de ntist than the poor. (e.g. Jusot et al., 2008;  Couffinhal et al., 
2004; van Doorslaer and Masseria, 2004 for the OECD).  Joint Reports on SPSI have 
                                                 
26 See e.g. http://osha.europa.eu/en /topics/accident_p revention/risks 
27 See http://ec.europa.eu/employment_social/spsi/docs/social_inclusion/2008/omc_monitoring_en.pdf   
28 There are over 30 conditions considered treatable, some examples are: cancer of the colon, skin, cervix, testis 
and breast; diabetes mellitus; epilepsy; pneumonia; appendicitis; thyroid disease; measles.  A similar 
picture can be found for preventable mortality.  
EN 14   EN identified the following as barriers to h ealthcare access: lack of health insurance29, direct 
financial costs of care (Figures A26 andA27), geographical disparities in provision, waiting 
times, lack of information, discrimination, language barriers, health literacy and socio-cultural 
expectations in relation to life a nd care use.  In general, inequ itable access to care appears to 
be associated with higher health inequalities.   
The current economic crisis can impact on health and increase  health inequa lities through a 
deterioration of social determinants of healt h, especially for those with lower qualifications 
and savings, and who are already vulnerable.  Th e loss of job and thus income can lead to 
worse living conditions and life-st yles, especially if social protection mechanisms are not 
present.  Unemployment or job insecurity lead to  increased levels of stress and greater risk of 
health damaging behaviours (e.g. harmful patterns of alcohol consumption) and contribute for 
example to depression,  immune disturbances or  accidents and have possible consequences 
on other family members.  The negative impact on health can be long lasting.  In addition, a 
deep economic crisis can impact on health and increase health inequalities through a 
deterioration of the access to quality health and social care by those in lower socio-economic 
groups.  This is the case if access to care depends on being employed, having financial means, or Member States cutting the resources allocated to the health and social  care sectors resulting 
in lower coverage or quality of care.  The current economic crisis through posing a financial 
pressure on health systems can motivate coun tries to review thei r policy mix on health 
determinants in search for higher effectiv eness and efficiency.  Evidence (WHO World 
Report, 2008
30) shows that countries with different le vels of economic performance and social 
protection (notably health) expenditure can achieve si milar health outcomes.  
The analysis in 2.1.1 and 2.1.2 is in line with  the 2006 Council Conclu sions that "health 
determinants are unequally distributed am ong population groups resulting in health 
inequalities".   
In summary  the above description indicates that inequalities in health both between and 
within Member States across socio-economic population groups can be substantial.  It 
suggests that the extent of with in-country health inequalities may influence the overall health 
status of that country’s population.  The anal ysis provides a general outline of the various 
socio-economic determinants of health inequa lities between countries  and between social 
groups, including living and working conditi ons, health-related behaviour and social 
protection policies including healthcare.  Robus t evidence exists in a number of areas but 
more detailed and specific information is requi red on the effect (causality) and weights of 
several of those health determ inants in order for Member States to choose and implement 
effective action in relatio n to particular population groups and determinants. 
2.2. What Member States are doing and co nsider effective to address health 
inequalities   
While about half of the EU Member States have  activities which address inequalities in health 
only a small number have developed comprehensiv e inter-sectoral strategies and even fewer 
have fully assessed their impact.  Hence, information based on comprehensive assessment and evaluation of the effectiveness of actions and strategies is limited.  General examples of 
reductions in gaps in health between regions of Member States include those achieved by FI 
                                                
 
29 See 2008 OMC Monitoring Report where data and analysis of national strategy reports shows that in several 
EU Member States – NL, PL, SK, AT, BE, ES, LU, DE, FR, SI, LT and EE – non-negligible numbers 
of the population are not covered by public or primary private insurance 
30 See http://www.who.int/whr /2008/en/index.html   
EN 15   EN in the North Karelia project and by DE with a reduction in the mortality rates between new 
and old Länder since reunification.  The UK has recently reported some encouraging signs of 
narrowing of health gaps between areas and social groups following a period were these 
inequalities widened.  
Despite the limited knowledge31, it is possible to establish a li st of policy actions (see annex 
2.2 for more detail) which have been judged by Member States to be effective in tackling 
health inequalities.  Member States assessments  suggest a number of broad conclusions.   
First, that in addition to maintaining universal  access to a number of key services such as 
education, social protection and healthcare, access al so needs to be intensified and targeted at 
specific groups (e.g. to mothers and child ren, young parents, and those over 50) in 
disadvantaged areas, in vulnerable families an d in lower socio-econo mic groups.  This is 
particularly the case for health promotion and disease prevention programmes.  Indeed, 
according to some evaluation studies untargete d health promotion information campaigns 
may increase health inequalities beca use of a tendency to be more effective in affluent groups.   
Secondly, a number of Member States argue th at regional and local action, supported by 
national and EU actions, is very important to ach ieve results.  Buildi ng partnerships between 
the public and the volunt ary/ third sector and businesses can  also be effective in raising 
general awareness and developing  action.  For example, in DE the health insurance BKK and 
the Ministry of Work Health and Social Affair s concluded a partnership to improve the health 
of the unemployed (JobFit).  
Thirdly, it is widely accepted that measuremen t and regular reporting of  health inequalities 
indicators is an essential first step towards effective action.  Such information allows for awareness-raising activities; en ables policy makers to identify the extent of the gap and 
possible causes;  and to inform the development of strategies to achieve  faster decreases in 
disease prevalence and mortality for areas a nd groups with high needs.  A good example of 
the impact of available information and reporting is that of NL where data analysis of the socio-economic gradient in health identified a 6 year gap for women and a 7 year gap for 
men.  The publication of the report has motivated the development of a policy strategy for 
tackling health inequalities.  Data collection, analysis and monitoring, it is argued, must then 
be accompanied by building scientific knowledge for action and which is gathered and disseminated through a coordination centre (e .g. the policy coordination centre for health 
inequalities in BE).  Learning quickly from i nnovation elsewhere is also deemed crucial and 
several Member States suggest that initiatives linking cities and regions have been very 
effective in disseminating inform ation (e.g. the Healthy Cities Network in DK).  Taking stock 
of increasing body of evidence on the causes of health inequa lities and how they can be 
influenced is therefore seen as a fundamental and effective step for devising policy action 
Fourthly, several Member States (UK, BE, IE ) state that health impact assessment/health 
inequalities test/ health inequalities audit appl ied to policies across the board is an effective 
way to generate inter-sectoral awareness. 
More specific examples of polic ies considered effective by Member States or research review 
studies are mentioned below(see annex 2.5 for a longer list and more detailed explanation): 
 
• Improve access to smoking cessation services for those in deprived areas and in lower 
socio-economic groups (UK, NL).  To decr ease infant mortalit y and increase life 
                                                 
31 See http://ec.europa.eu/health/ph_determinants/socio_economics/keydo_socioeco_en.htm 
EN 16   EN expectancy in these groups it is effective to a) ensure sm oking-cessation during 
pregnancy, b) stop parental smoking and c)  reduce smoking in general for those 
groups.  Studies have shown that the wide spread provision of stop smoking services 
was effective in reducing the number of smoke rs living in more disadvantaged areas.  
• Improve antenatal care, post natal care and parent support for those in less affluent 
areas / lower socio-economic groups (UK, PL) or migrants (NL) to reduce the gap in 
infant mortality.  Specific actions include the multidisciplinary Sure Start child centres 
in the UK or the ONE centres in BE.   
• Increase breastfeeding initiation and durati on rates in deprived areas and lower socio-
economic groups which are currently lower than those of more afflue nt areas /groups.  
A specific action is the baby-friendly hospital initiative in several Member States. 
• Improve child immunisation rates and follow- up of children's health in lower socio-
economic group. A specific action is the school U-programme (U1-U9) in DE. 
• Fluoridation of water which reduces the soci o-economic differences in tooth decay in 
children as shown when compari ng different counties of UK.  
• Providing meals, fruit and milk at school s (DK, UK, HU), which can reduce socio-
economic differences in nutrition (i.e. impr ove child nutrition in deprived areas and 
lower socio-economic groups notably in terms of healthy foods). 
• Provide affordable pre-school day care fo r lower socio-economic  groups as this 
increases education and employment atta inment, income level and thus health. 
• Improving work organisation (FI, SE, DE). For example, improving work organisation 
in a bus company in DE lead to a signifi cant reduction of sick leave and employees' 
turnover of bus drivers (e .g. Greiner & Syme 1994). 
• Improve the physical environment through clean air legislation, green spaces and 
encouraging more walking and cycling ( UK, NL).  Improving housing quality (UK, 
EE) through improved building standards an d affordable heating for lower socio-
economic groups and measures to reduce ac cidents at home (smoke alarms, hand 
rails).  A review of UK "area regeneration in itiatives" shown that these lead to better 
education and employment rates, higher household income and housing quality and 
contributed to improving health.  
• Seat belt and speed legislation (UK, BE),  
• Income support (NL, SE) 
• Using of Health Status Targets (UK, NL, CZ, FI, Basque Country in ES) has been 
effective in raising awareness and motivating policy action.  An award system to 
recognise local authorities, lo cal strategies, partnerships or actions to reduce health 
inequalities has been effective to motivate policy development. 
• Health infrastructure investment e.g. thr ough Structural Funds (HU, EL, PT, LV, SK)  
In summary  it can be seen that Member States are implementing some actions but in general 
comprehensive strategies are lacking.  Also, policies implemented lack assessment/ evaluation 
which limits knowledge on policy effectiveness and can thus hinder policy development by 
other Member States.  Finally, several areas can  be identified where the EU can support and 
complement Member States such as awarene ss raising, data development, monitoring, 
research, dissemination of information and best-practice exchange, and legislative 
frameworks for environment, health and safety and equal opportunities.  A collaborative 
approach is important to help optimise resour ces and tackle common challenges within the 
EU. 
2.3. Existing EU action and links to  other relevant EU policies.   
EN 17   EN From the above analysis of the determinants of  health inequalities, one can see that while 
many are potentially amenable to policies which are of national competence, they can also be 
influenced to a certain extent, by EU economic,  employment, environment, health, education, 
social and cohesion policies.  For example, national health promotion and disease prevention 
strategies can be influenced by EU actions  on health promotion, disease prevention and 
consumer protection.  While healthcare delivery is the responsibility of  Member States, EU 
action through the social OMC,  the health strategy, the Structural Funds and anti-
discrimination legislation can complement and support Member States actions in addressing 
inequalities in access to care.   Financial support (e.g. Struct ural Funds, Health Programme) 
can be used to develop targeted health promo tion and disease prevention interventions and to 
improve the geographic distribution of primary care, for example.  Such examples can be 
found in areas other than healthcare. 
Examples of existing EU policies that are rele vant for action to contain and reduce health 
inequalities include the following (s ee annex 2.3 for more detail).   
The Lisbon Strategy on growth and jobs  can be expected to positively contribute to improve 
health outcomes as growth and more and better jobs improve overall livi ng standards and thus 
health.  Healthy life years has been agreed as on e of the structural indi cators, thus indicating 
this strategy has paid a growing atte ntion to the health dimension.   
Similarly, under the Employment Strategy  the overarching Employment Guidelines and the 
associated common indicators pr ovide a vehicle to motivate policy and allow monitoring of 
some important determinants of health and health inequalities.  For example, reducing 
accidents at work, occupational diseases and work-related illnesses for all workers and in particular for workers suffering from the wo rse working conditions is an objective under 
Guideline 17.  Guideline 18 put s emphasis on improving occupationa l health status with the 
aim of reducing sickness burde ns, increasing labour productivity  and prolonging working life.  
Guidelines 21 and 23 call for the implementation of flexicurity approaches and new skills for 
new jobs with the aim of helping the low skille d and those at the margin s of the labour market 
to cope with a working life that is beco ming more complex, diverse and irregular and 
therefore demanding.  A set of common indicat ors related to quality of work/ working 
conditions, occupational health and health and safety in the work place, active ageing, and 
flexicurity has been agreed to monitor progress in these areas. 
Following the adoption in 2006 of the common obj ective of addressing health inequalities 
under the social OMC
, Member States have submitted the first National Strategies Reports on 
Social Protection and Social Inclusion (NSRs on SPSI) which included a chapter on 
healthcare and long-term care with some repor ting on their policies to tackle health 
inequalities.  A number of in-depth discussions  in the SPC followed and the topic was part of 
the analysis of several joint re ports.  In 2008 a set of common i ndicators (including on health 
status and healthcare) was agreed to measure progress towards that objective.  As a follow up, 
the first social OMC monitoring report was pu blished which presented some analysis of 
health inequalities between and within Member States.  The social OMC has regularly called 
for the need to have indicators broken down by socio-economic status.  Some reviews (e.g. 
EuroHealthNet Closing the Gap and Determine) indicate that the social OMC has help stimulating debate and some action in Member States to tackle health inequalities.  PROGRESS has funded a number of health  related peer reviews and studies. 
EN 18   EN In a similar manner, following the 2006 adopti on of the objective of addressing health 
inequalities between and within Member States and related indicators32 the Sustainable 
Development Strategy  report has highlighted differences in  health between Member States.  
This report is to be discussed by the European Council. 
The EU Health Strategy  (2008-2013) promotes the tackling of  health inequalities as a key 
value among other objectives and calls for attenti on to social determinan ts as part of the 
implementation of existing EU health activit ies, such as those on tobacco, obesity and 
alcohol, young people and mental health.  The EU public health programme 2002-2008 
provided funding for around ten co llaborative projects addres sing aspects of health 
inequalities.  Health Inequalities is a priority  of the current Health Programme 2008-2013.  In 
2005 the Commission established an EU Expert Group on Social Determinants of Health and 
Health Inequalities and this has been instru mental in improving understanding of the problem 
as well as promoting the sharing of informa tion and good practice.  The Health Information 
Strategy has also led to the development of a list of health indicators the European Community Health Indicators.  
Under the Environment Strategy
 the EU supports a wide ra nge of initiatives which are 
conducive to reducing the health impact of envi ronmental factors.  For example, a study 
(Health and Environment Alliance) shows th at a 30% cut of greenhouse gases by 2020 would 
result in health savings of up to €25 billion per year.  
The EU also provides significant financial s upport via the European Social Fund (ESF), the 
European Regional Development Fund (ERDF), th e cohesion fund, the European Agricultural 
Guarantee Fund (EAGF), the European Agricult ural Fund for Rural Development (EAFRD), 
and the Research Framework Programmes (cu rrently FP7), which has allocated funding to 
some health related studies.  
Under the Cohesion Policy  funds are directed to less well-off regions in the EU and which can 
be used to invest in key determinants of hea lth inequalities such as living conditions (water 
and sanitation), training and employment serv ices, transport and t echnologies.  Moreover, 
additional dedicated funding has be en allocated to health infrastructure, capacity building and 
training of health staff through the Structural f unds and health has become one of the top ten 
priority spending areas in 2007.  The EU poorest regions can now  use structural funding to 
invest in healthcare provision  and support health promoti on and disease prevention.  
Significant investments in health systems have  been supported by the structural funds.  The 
total allocated investment in the current pr ogramming period is € 5.2 bn.  Countries such as 
HU, SK and LV have indicated in their respons es that the structural funds have helped 
address inequalities in access to health care,  notably geographic disparities in health 
provision, through investment in poor er/ deprived regions.  In the past, countries such as PT 
and EL have also used the f unds to the same effect.   
The Common Agricultural Policy (CAP) has elements that may contribute to the reduction of 
health inequalities such as ensuring a fair standard of living for farmers, assuring the 
availability of supplies and reasonable prices  for consumers.  The CAP also supports the 
School Fruit and School Milk Scheme and the di stribution of agricultur al products to most 
deprived people. Rural development policy include s measures to improve the quality of life in 
rural areas through  the provision of basic se rvices for the economy and rural population 
(including social and health care services an d infrastructure). Such investments have the 
                                                 
32 Since 2006 – See Review of the EU Sustainable Development Strategy.  Council of the European Union. 
Document 10117/06. 9 June 2006 http://register.consilium.europa.eu/pdf/en/06/st10/st10117.en06.pdf  
EN 19   EN potential to contribute to narrowing health inequalities wh ich exist in some Member States 
(deprived) rural areas. 
Internal market work  has the potential to contribute to a reduction in health inequalities by 
stimulating economic growth, lowering prices, generating employment opportunities and thus 
improving standards of living.  More specifically, "health-relat ed" infringement procedures 
for example on the freedom of establishment and provision of services, restrictions to 
ownership of pharmacies and their location, restri ctions to ownership of  laboratories and their 
opening hours, which may lead to sales monopo lies and constitute barriers to access, can 
contribute to lower prices of ca re and thus particularly bene fit citizens from lower social-
economic groups.   
The EU also provides a substantial legislative framework  in various areas.  It has established 
Community labour law and Community legislation in  the field of health  and safety at work .  
The implementation in the Member States of Co mmunity Legislation on Health and Safety at 
Work, as well as all the actions foreseen in the Community Strategy on Health and Safety at 
Work 2007-2012 constitutes an important contribu tion to the reduction of  health inequalities 
in the European Union.  The improvements in the protection of worker's health and safety 
represents a significant contri bution reducing health inequalities in Europe through reducing 
the negative impact of some of their determinan ts.  The Impact Assessment to the Community 
Strategy 2007-2012 showed that occupational health  strategy reduces work accidents, helps 
accident victims or chronically ill to retain their job or return to  work, is a main platform for 
integrating migrant workers and can reduce st ressful and monotonous working conditions that 
cause early deterioration of health, and hence, an early exit from working life. 
In broader terms, EU regulations (e.g. tob acco advertising, and food labelling amongst others) 
and harmonisation of technical/ regulatory standards have rais ed public health related 
standards in many Member States and have potentially contributed to reducing health 
inequalities between and within Member St ates.  The Commission has highlighted the 
importance of health to achieve the goals set out in the Lisbon Agenda (e.g. more 
employment, longer working lives) and considers health as a dimension in the framework of 
its impact assessments of new policy proposals.   
In summary , through its policy processes and support, the EU has gradually given the issue 
of health inequalities higher priority in the policy agenda and there are a large number of EU 
policies which potentially can and are impacting on health inequali ties.  However, while these 
initiatives may have made a positive contribution to the issue, it has been difficult to establish 
and quantify the impact.  Moreover, the descript ion suggests a lack of mainstreaming health 
inequalities across all relevant EU policies.  Th e next section therefore analyses some of the 
weaknesses in the current approach.   
2.4. Problems and barriers in taking action  on inequalities in health – and 
possible role of the EU. 
There are a number of  barriers and obstacles at EU and nationa l level, to taking effective 
action to address health inequalities33.   
                                                 
33 The Joint Report on Social Inclusion and Social Pr otection, the work under the SPC and its Indicators Sub-
Group, the work of the EU Expert Group on SDH, the report of the WHO CSDH. 
EN 20   EN 2.4.1.  Lack of awareness and insufficient  policy priority and commitment by 
Member States  
Analysis of the 2008-2010 National Strategy Reports on Social Pr otection and Social 
Inclusion (NSRs SPSI) shows that  addressing health inequalities is regarded as the most 
important health policy challenge for 2 Member  States (FI and UK) and a major goal for 6 
Member States (LT, IE, AT, EE, SI and SK).  For others (BE, HU, ES, DK and MT) reducing 
health inequalities receives some policy emphasis.  Over half of all Member States do not refer to the issue at all in spite of the fact th at addressing inequalities in health outcomes is a 
common objective under the social OMC and in spite of the 2008 Council conclusions.  Table 
A16 shows that many Member States that show large health disparities have not allocated 
particular policy priority  to their reduction.   
Moreover, while Member States have affirmed th eir wish to adopt a "H ealth in All Policies 
approach" (2006 Council conclusions), only a minority have so far put this into place.  While 
Member States have now subscribed to the prin ciple of reducing health inequalities, the level 
of awareness and the extent to which action is being taken to achieve it varies substantially.  
A review carried out for the 2005 UK Presidency (Judge et al., 2005)
34 reported that while 
most EU countries express concerns with soci o-economic dimensions of health only a smaller 
group had coordinated national polic ies to tackle hea lth inequalities.  The few which have 
implemented a range of dedicated policies are still far from having made a major 
breakthrough.  This may relate to policy make rs lacking awareness of the extent and the 
economic and social consequences associated with  health inequalities.  It may also reflect a 
lack of awareness of the effective policy op tions that can be implemented by national, 
regional and local administrations (as well as schools, workplaces, local health and 
community services, community organizations and other stake holders).  Evidence suggests 
that the right policy mix can achieve reductions in  disparities and thus improve general health 
by optimising the health gain for the resources available (section 2.1.3).  Thus, further work is 
needed to disseminate knowledge of existin g good practice and that which will become 
available through best-practi ce exchange and information sharing mechanisms.   
Moreover, there is a need to better involve othe r levels of government and other stakeholders 
that which have the potential to take action on various determinants and thus influence health 
outcomes as indicated in the consultation res ponses.  The 2009 Joint Report on SPSI indicates 
that in general it is not clea r how stakeholders are consulted on the NSRs SPSI and how the 
results from any consultations are taken into c onsideration.  The EU coul d facilitate exchange 
of information and knowledge to assist stakeholders to take action that contributes to the 
reduction of health inequalities,  as a numb er of consultation responses called for. 
Finally, some Member States and respondents to  consultations have argued that attention 
should be paid to a perceived l ack  of targets and benchmarks in the areas of inclusion and 
healthcare in order to  stre ngthen policy prioritisation. 
There is also a problem of policy priority and awareness of special groups.  The analysis in 
section 2.1 indicated that the vulnerable groups ma y need special attention as they face the 
highest burden of disease and mortality and the highest risk: lack of basic requirements for 
health such as clean water, safe sanitation, pr oper heating, inadequate diet, lack of access to 
healthcare, housing or educati on, exclusion, stigmatisation a nd discrimination, inadequate 
                                                 
34 "Health Inequalities: a Challenge for Europe", Judge K., Platt S., Costongs C. and Jurczak K., 2005, at 
http://www.eurohealthnet.eu/images/publications/pu_2.pdf ; 
EN 21   EN income and low rates of employment.  For th ese groups, the barriers to access to general 
services are more severe.35  As the 2007 Council Conclusions on Health and Migration in the 
EU highlight there is a need for more data and knowledge of these groups' health (notably by 
gathering information by national ity or place of origin) and its determinants and a need to use 
a "Health in All Policies" approach. 
2.4.2.  Absence of comparable and regular  data, monitoring and reporting.  
Lack of knowledge on the determi nants and the effective policies to 
implement 
While the measurement of health inequalities is a fundamental first step to take effective 
action, the availability of this information vari es widely by Member Stat e thus contributing to 
policy makers’ lack of awareness on the exte nt, causes and consequen ces of the problem.  
Information regarding the differences in health  outcomes and some determinants of health 
between and within countries is not routinely co llected in a comparable manner across the EU 
Member States (year of data  collection, age-group, socio- economic classification do not 
correspond across Member States as illustrated by the graphs/tables in the  annex).  To monitor and assess progress on health inequalities in the EU, Eurostat has in recent years, 
together with the European Statistical System, de veloped a system of statistics in this field. 
This system is firstly composed of household surveys, of which the EHIS (European Health 
Interview Survey) and the EU-SILC (Commun ity Statistics on Income and Living 
Conditions) are key elements.  To these house holds surveys are added the collection of 
administrative data (Health care data includi ng expenditure and non-ex penditure, causes of 
death, morbidity statistics).  Some of the hea lth and healthcare related data is currently 
provided to EUROSTAT on the basi s of informal agreements and is not necessarily available 
for all Member State for the same years using fully comparable definitions (e.g. on staff and 
hospital beds).  Many consultation responses re marked on the need for improvements in the 
accuracy and comparability of  measures of health status; (mortality, life expectancy, 
premature mortality, avoidable mortality, mental illness), healthcare use; (visits to doctor, 
dentists, hospitals) and risk behaviour; (alcoho l, tobacco, physical ex ercise) by geographical 
area and by social-economic group  in order to  enhance the existing indicators base.   
Moreover, while the EU produces a variety of reports these do not necessarily take into 
account the health and health inequality dimensions  or the social determin ants of health.  For 
example, the three-yearly Cohe sion Report on the outco mes of the Structural Funds does not 
provide an assessment of the im pact of the use of funds in reducing regional differences in 
health.  Furthermore there is no dedicated and regular reporting on hea lth inequalities across 
and between countries, though there is some limited reporting through the Joint Report on 
SPSI.  
There is also a lack of evidence and knowledge  on the causes of health inequalities.  In 
relation to some factors there is a need to have  more information on th e degree of causality 
and the relative weight of differe nt determinants of health inequalities.  While some of the 
causes of health inequalities are well understood (e .g. lack of access to basic needs or services 
                                                
 
35 See various Joint Reports on Social  Protection and Social Inclusion and other social OMC related studies, as 
well as "Challenges for health in the age of migration" at http://www.eu2007.min-
saude.pt/PUE/en/conteudos/programa+da+saude/Publications/Relat%C3%B3rio+Sa%C3%BAde+e+Mi
gra%C3%A7ao.htm , "Migration and the right to health", IOM, at 
http://www.iom.int/jahia/webdav/site/myjahiasite/sha red/shared/mainsite/published_docs/serial_publica
tions/IML12-MRH%20dec07.pdf  and "Quality in and equality of access to healthcare services" at 
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare  
EN 22   EN - poor water, housing and environment conditions);  other causes are much more difficult to 
determine - for example, how the different wa ys that jobs are organized can have such 
markedly different health impacts.  More ev idence is needed on the relation between unequal 
access to healthcare and the health status of  the population and on the capacity of health 
systems to provide equal, timely and appropriate  diagnosis and treatment.  Further work is 
also needed to identify those factors which are causative from the wealth of information on 
association. Obtaining such information requires better availability of data and the development and use of more sophisticated (e .g. epidemiological) modelling to establish the 
independent effect and weight of  the various determinants.  It may also require a more regular 
use of health inequalities impact assessment and ex-post evaluation to elucidate the possible 
impacts of existing and planned policie s on the health of particular groups. 
Knowledge on the effectiveness of  interventions and policies to tackle inequalities is also 
lacking.  This is in part because only a sma ll number of interventions that impact on health 
have been evaluated for their differential impact s on particular social groups or in particular 
areas.  Hence, more research is  needed to provide su ch knowledge.  As this  is an area where 
Member States can learn from each other when devising their own policy strategies, existing 
knowledge, and that which will be built, needs to be disseminated. 
2.4.3.  Insufficient concerted EU approach to health inequalities (lack of 
mainstreaming at the EU level) 
Section 2.3 presented an overview of the EU polic ies/ tools that directly or indirectly have 
been underpinning efforts in Member States to address health inequalities.  The issue is 
however, that while EU policies include current  actions that may cont ribute directly or 
indirectly to contain or reduce h ealth inequalities this policy outco me is very rarely an explicit 
goal.  In other words, prom oting the reduction of health  inequalities has not been 
mainstreamed in an explicit manner in EU po licies and activities tools and most of them do 
not take the dimension of health inequality into account.  For exampl e, few EU policies are 
evaluated after implementation (ex-post) in rela tion to their impact on health and health 
inequality.  This  reduces understanding of how  effective EU policies are in reducing (or not) 
health inequalities.  Analysis and reporting on the relation between such policies and health inequality is also limited.  
The following illustrates some of the  limitations and potentials of relevant EU policies to 
deliver a more effective contribution in this area.  
In relation to the Lisbon Strate gy and associated Employment St rategy, while there has been a 
growing attention to health and the econom ic benefits of good health (employment, 
productivity). The analysis on the impact of grow th and jobs on health and health inequality 
or on the impact of working cond itions on health and health inequality is more limited.  In 
addition, while the healthy life years indicato r can allow for assessing gender and between 
country disparities in health outcomes it does not allow for a ssessing socio-economic 
differences in health.  The common employme nt indicators on quality of work and working 
conditions could also be further de veloped in this respect.    
Under the current social OMC, full delivery on common objectives remains a challenge
36.  
Despite the common objective of addressing health inequalities,  the issue has not yet been 
taken up as a policy priority by all Member St ates.  In addition to  the improvement and 
greater use of the common indicators, more re gular monitoring and im proved evidence within 
                                                 
36 See Com(2008)418 at http://ec.europa.eu/social/m ain.jsp?catId=550&langId=en  for more detail.  
EN 23   EN the OMC, it has been argued that there is a n eed for a) developing quantitative targets to 
achieve more and faster progre ss in relation to the objectives and b) a better integration 
between social and other policies such as environment, health, economic and employment 
policy.  The use of peer reviews and the invo lvement of regional and local administrations 
and stakeholders is stil l too limited (Joint Report SPSI).  PROGRESS could be better used as 
the basis for local policy innovation.  
While the Environment Strategy takes the impacts on health into account more attention could 
be paid in relation to environmentally relate d health inequalities as  more vulnerable groups 
are often more exposed to environmental hazards (e.g. pollution).  More attention could also be  paid to the health prot ection of more vulnerable groups  as well as children and young 
people as well as the potential for further im provements in coordination with international 
agencies (e.g. WHO).   
Although it is difficult to establish the impact of  EU public health initiatives on the reduction 
of health inequalities, it has been argued by a number of rele vant projects co funded by the 
EU (Closing the GAP, DETERMINE) that  some may have unintended negative 
consequences.  Thus, stakeholders should there should be greater emphasis on health 
inequality audit or health inequalities "proofing" of EU policies.  Regarding the Health Information Strategy, several ECHI indicators would equally benefit from a social-economic 
breakdown. 
Large health inequalities between and within Member States present a challenge to the EU 
objectives of economic and social cohesion.  De spite the potential for using the Structural 
Funds to address disparities in healthcare, the planned investment in h ealthcare infrastructure 
is only a relatively small amount of the total funds.  Furthermore Member States do not always use these to their full potential.  So far,  funds allocated for health related infrastructure 
investment (ERDF) represent about 1.5% of the total Structural Funds investment (ca. €5 bn 
for the period 2007-13) and actual investment s are likely to be lo wer based on proposed 
interventions.  Possible reasons are 1) lack of knowledge of the opportunity to use funds in 
this area, 2) lack of coordination between natio nal policy departments and 3) lack of technical 
capacity to propose / allocate investment in the fi eld.  Indeed, health is not a traditional area of 
support for Cohesion Policy and there may be need  to increase capacity building in the area.  
The current or proposed investment in the ope rational programmes does not  necessarily relate 
to the priorities identified in the Joint Report and NSRs on SPSI and is not necessarily 
allocated to areas where larger gains in health or larger reductions in health disparities could be attained.  For example, many regions in the newer Member States do not have enough 
health facilities and trained st aff in some areas and this is preventing them from responding to 
population needs.  This suggests a need for more investment in health equality, notably in the 
poorest regions in the next programming period.  Additionally, a) no structured data is available on ESF spending on health, which ma kes monitoring difficult and b) health and 
health inequality is not used as  an outcome measure of the use of  funds.  All this  is of more 
concern because some countries that have used the funds on health such as PT have attained 
positive outcomes.  
A greater emphasis on addr essing health and health inequalit y problems in the EU's Cohesion 
Policy – including better monitoring of health  outcomes for all EU funds - could help 
overcome barriers to their effective use to redu ce health inequalities.  Several stakeholders 
suggested in their consultation responses im proving the exchanges of knowledge and good 
practice between recipients of Structural Funds  with the aim of maxi mising their added value 
for improving the overall health of the population and narrowing health inequalities.  
EN 24   EN Finally, while this paper focuses on heal th inequalities in th e EU, the 2008 WHO CSDH 
report highlighted the enormous health inequali ties which exist at global level and called for 
sustained, comprehensive, acti on globally, nationally and locally  to tackle them.  Health 
inequalities in third countries are a concern to the EU because the EU is an important 
contributor to development (thr ough aid and development funds a nd the provision of technical 
capacity) and has an interest that health ine qualities are addressed globally.  The EU and its 
Member States are important partners in th e global effort to attain the Millennium 
Development Goals and work together with ot her international organi sations such as the 
WHO and the UN.  Hence, it would be import ant to ensure that any evidence and best-
practices that result from the actions in EU  Member States are disseminated to other 
countries.  It remains for the future to think how this policy priority can be linked to the 
policies addressing health inequalities in  the EU's development and aid agenda. 
In summary , lack of routinely available and compar able EU data and research knowledge 
poses an obstacle to reth ink policy priorities, es tablish comparisons, deri ve best-practices, and 
reallocate resources wh ere they are most needed.  Bett er and shared evidence and a good 
understanding of the rationale for action can provide the political commitment and 
momentum which is currently lacking from a wide range of stakeholders. 
2.5. Why are health inequalities between and within countries a problem and a 
policy concern to the EU?   
Although the major responsibility fo r addressing health inequalities rests with Member States, 
the problem is nevertheless one of potential policy concern for the EU for a number of 
reasons.   
Firstly, the pervasiveness and pe rsistence of such inequalities  in health suggests a possible 
discrepancy between the existing situation and some of the overa rching goals of the European 
Union such as strengthening of economic and social cohesion, ensuri ng equal opportunities, 
promoting the reduction of ine qualities and the promotion of  equality between men and 
women and solidarity among Member  States (Art. 2 of  the EU Treaty a nd Art. 2 of EC 
Treaty).  See annex 2.3 for more detail.    
Secondly, high levels of poor health in sec tions of the EU population imply substantial 
opportunity costs for the Union and thus provide  an economic reason for promoting action to 
address them.  High levels of population health are important in the context of an ageing 
population to allow longer working lives and support higher productivity, competitiveness and employment levels (Community Strategic Guidelines on Cohesion)
37.  Reducing 
unnecessary losses due to ill health and premature death can thus make a contribution to meeting the Lisbon goals and achieving Europe's full potential for prosperity.  Avoidable ill-
health also leads to large co sts for health systems and puts unnecessary pressure on public 
budgets.  
2.6. Legal and political basis for action and subsidiarity 
The above sections have  identified 3 sets of problems which the EU could help addressing:  
• Lack of awareness and insufficient policy priority and commitment by Member States 
• Absence of comparable and regular data , monitoring and reporting and lack of 
knowledge on the determinants and the effective policies to implement 
                                                
 
37 See http://ec.europa.eu/employment_social/esf/docs/TP_files_update/tp_health_EN.pdf   
EN 25   EN • Insufficient concerted EU approach to health  inequalities (lack of mainstreaming at the 
EU level) 
There is a legal basis for action.  Under Arti cle 152 of the EC Treaty the Community should 
ensure that all its policies and activities provide a high le vel of health protection.  
Strengthening economic and social cohesion by reducing disparities between the least 
favoured regions, including rural areas is a goal expressed in Art. 158 of the EC Treaty.  Art. 
159 states that the formulation and implementa tion of Community policies and actions shall 
take into account those ob jectives and that the Community shall also support the achievement 
of those objectives through the Structural Funds .  Art. 125 and related articles state that 
"Member States and the Community shall work towards developing a coordinated strategy for 
employment and particularly for promoting a skilled, trained and adap table workforce" and 
that " the Community shall encourage cooperati on between Member States and support and 
complement their actions in relation to achieving a high l evel of employment ".  Arts. 136 and 
137 and related articles indicat e that the Community and Memb er States, having in mind 
fundamental social rights, shall have as their objective the promotion of employment, 
improved living and working conditions, proper  social protection, de velopment of human 
resources and the combating of exclusion, and thus " the Community shall support and 
complement the activities of Me mber States in various fields " including working conditions 
and health and safety at wor k, social security a nd social protection, in tegration of people 
excluded from the labour market, equality between women and men in relation to employment and the combating of social exclus ion.  Finally, arts. 12 and 13 form the basis for 
EU directives on anti-d iscrimination e.g. in employment and social protection that are 
relevant to addressing he alth inequalities.   
This legal basis for action is reinforced by a "political mandate" for action with several EU 
bodies calling for further EU action which has recently been expressed by the Commission in 
the 2008 Renewed Social Agenda (see introductory section). 
Member States have the main responsibility for the policy changes needed to address most of 
the determinants of health inequalities and can  make the biggest contribution.  Most of the 
policy areas described above are areas where the EU has only competence to carry out actions 
to support, coordinate or supplement the actions of the Member States.  EU action and a more 
pro-active role at EU level can be considered only where the objectives  of the proposed action 
cannot be sufficiently achieved by the Member  States acting indivi dually and where for 
reasons of scale or the effect s of the proposed action, they can be better achieved by the 
Community.  For example Community research fr ameworks allow the building up of a richer 
pool of research knowledge than  individual country level fram eworks (knowledge could be 
restricted in less weal thy countries).  Community framewor ks can facilitate the exchange of 
information and best-practice across 27 Member States so that all co untries but especially 
those countries in a disadvantageous position can benefit from learning from the experience of 
others and develop their own st rategies.  EU level action can facilitate and support Member 
States' cooperation.  Community action can act as a catalyst in relation to the development of 
national strategies to address he alth inequalities and can help Member States improve the use 
of the various financing mechanisms currently at  their disposal to better support and reinforce 
those actions.  Moreover, in various areas the EU undertakes  actions which can indirectly 
impact on the socio-economic determinants of hea lth at national level.  It would therefore be 
important to understand if the Community can be  more effective in the way it supports and 
complements Member States' efforts in this  field.  These considerations explain why 
Community action may produce faster and la rger results than individual action.  
EN 26   EN In this context, the necessity of EU action can be found in relation to tw o areas.  A first area 
relates to  the need for EU-wide harmonised data collection and monitoring which is a 
fundamental step prior to putting forward any acti on.  Lack of reliable socio-economic data on 
health status is a common challenge in a larg e number of Member St ates.  The Community 
(through EUROSTAT) working together with Member  States  is better pl aced then individual 
Member States working alone to ensure EU wide  availability, reliability and comparability of 
data that is needed.  
Another area is  Cohesion policy through which th e EU provides financial support to Member 
States, especially less well-off regi ons, that can be used to invest in key determinants of health 
inequalities such as living conditions, traini ng and employment services, and more recently 
healthcare (promotion, prevention and treatment)  through training and infrastructure (in 
convergence regions).  Enlargement has increased  the economic and social disparities which 
exist between EU regions.  European Regiona l Policy provides tools (including funding) to 
create potential (cond itions and factors) in the least-deve loped Member States and regions so 
that they can achieve greater growth and competitiveness and real convergence. These 
conditions and factors conducive to convergence  include more and better jobs and better 
health by improving accessibility and ensuring ad equate quality of serv ices.  An EU level 
policy,  which includes support to some measures  in the health field and can lead to a 
leveling-up (in terms of health, employment a nd growth) of poorer regions,  is seen as 
necessary to tackle the disparities which would otherwise remain substant ial or even widen.  
By improving health services, employment and growth it can contribute to reducing health 
inequalities across EU areas.  
Looking at the problems identified the EU can al so provide added value (both in terms of 
scale and effects) by raising awareness and reinforcing a focus on health inequalities, 
improving its own monitoring mechanisms, enha ncing research and k nowledge gathering, 
providing greater visibility of re levant actions through improving the sharing of experiences 
and good practices and capacity building and imp roving the linkages between EU policies, 
areas where weaknesses have been identified.   This has been suggested in the many 
consultations responses received and in various other research reviews.  Moreover, given the 
complex nature of the problem and the wide di vergence of experience and performance, this 
is an area where Member States can obtain clear  benefits from mutual learning and exchange 
with other Member States as this can provide  good ideas and avoid repeating the errors of 
others.  Member States have  expressed keen interest in  cooperating in this area. 
All the options examined in section 4 respect th e principle of subsidiarity as they respect 
national competences.  They are also proportional  in that the options considered here do not 
force or even suggest any specific measure to be  followed by Member States and in fact leave 
the choice, definition and implementation of po licy strategies in the hands of the Member 
States to best fit their nationa l setting, fully respecting their national arrangements.  Actions 
considered here are appropriate to the level of  EU objectives and responsibility and leave all 
the decision scope to Member States.  Fo r example, while the EU would encourage 
participation or reporting by Member  States and other stakeholders  these would be voluntary.  
Improving data collection by socio-economic stat us would be done together with Member 
States allowing for the best nati onal alternative.  In  addition, actions prop osed and appraised 
would be pursued within existing EU instrume nts (e.g. OMC, Health Strategy and existing 
financial tools) so that costs are minimised.  Many actions are about using existing EU tools 
in a more effective way to support and reinforc e Member States activi ties with a benefit to 
Member States. 
EN 27   EN 3. OBJECTIVES 
In broad terms the aims of EU action in relation to inequalities in health are to support and 
complement the actions of Member States in th is field and to continue to ensure that EU 
policies and activities provi de a high level of hea lth protection as set out in the Treaty.  As far 
as possible, the health prot ection provided by EU policies should extend to all citizens 
irrespective of where they live or their social  background.  In fulfilling these aims, EU action 
can make a contribution towards a reduction in health inequalities in the EU.   
3.1. General Objectives 
The general objective of this initiative is to support and complement the efforts of Member 
States and stakeholders and mobilise EU po licies towards reducing health inequalities. 
3.2. Specific Objectives  
Specific objectives are to: 
• Raise awareness, promote information, best -practice exchange a nd policy coordination 
and advocate the tackling of health inequalities as a policy priority; both at 
Community and Member States le vel and by other stakeholders. 
• Improve data availability and the mechan isms to measure, monitor and report on 
inequalities in health across the EU and improve the knowledge base on the causes of 
health inequalities and the evidence base for action. 
• Develop the contribution of relevant EU policies towards reducing inequalities in 
health, including better suppor t of Member States and stak eholders' efforts to tackle 
health inequalities and a specific focus on vulnerable groups and third countries.  
The objectives and their relation to the problems outlined in section 2.4 are summarised in the 
following table: 
Problem Specific Objective 
Lack of awareness and insufficient policy 
priority and commitment  Raise awareness, promote in formation and best-practice 
exchange and advocate the tackling of health inequalities as a 
policy priority; both at Community and Member States level 
and by other stakeholders 
Absence of comparable and regular data, monitoring and reporting.  Lack of 
knowledge on the determinants and the 
effective policies to implement Improve data availability and the mechanisms to measure, 
monitor and report on inequalities in health across the EU and 
improve the knowledge base on the causes of health 
inequalities and the evidence base for action 
Insufficient concerted EU approach to 
health inequalities (lack of mainstreaming at 
the EU level) Develop the contribution of relevant EU policies towards 
reducing inequalities in health, including better support of 
Member States and stakeholders ' efforts to tackle health 
inequalities and a specific focus on vulnerable groups and third 
countries 
4. POLICY OPTIONS 
Three options are put forward for analysis towa rds achieving these objectives.  Option I is the 
continuation of current activities ("business as  usual"). Option II "C urrent plus" builds on 
existing work which can be take n forward in a short time frame without the need for further 
or fundamental changes to current Commun ity instruments, and formulated in a 
Communication.  Option III "Far Reaching" requi res a longer time frame, involves deeper 
EN 28   EN changes in existing EU instruments, and in cludes a Council Recommendation in addition to 
the Communication.   
 
4.1. Option I: Continue current ac tivities, no new initiative:  
Under Option I, work to support the reduction of health inequali ties would continue under the 
social OMC and the Health Strategy, but there w ould be no new initiatives.  Equity in health 
is a guiding principle of the Health Strategy an d reducing inequalities in access to health care 
and health outcomes is a common objective u nder the social OMC.  Hence, work would 
continue to take place, mainly in the form of exchange of experience to assist Member States 
to translate this objective into national strategies.  Mechanisms would include National Strategy Reports and the Joint Report on Social Protection and Social In clusion, peer reviews 
and Social Protection Committee (SPC) meetings, as well as meetings of the EU Expert 
Group on Social Determinants of Health and Health Inequalities a nd the Council Working 
Party on Public Health at Senior Level (Counc il WPPH).  There would be continued support 
for initiatives in this ar ea through PROGRESS and the Health Programme 2008-2013.  
Likewise, Cohesion Policy would continue to support a limited range of activities in the 
public health and healthcare areas, while the Common Agriculture Policy and the Agricultural 
and rural Development funds would continue to s upport some initiatives.  In more detail, this 
option would include work in the following areas:  
Raising awareness, promoting information and best-practice exchange, and promoting 
the tackling of health inequalities as a policy priority:   
a) Addressing health inequali ties would remain a common object ive of the social OMC and 
the Sustainable Development Strategy.   
b) The SPC under the social OMC, the EU Expert Group on SDH and the Council WPPH in 
relation to the Health Strategy would provide mechanisms for information and best practice 
exchange.  Under these structures work w ould take place on topics related to social 
determinants of health inequalities such  as: housing (exclusi on, deprivation and 
homelessness), active inclusion (follow-up 2008 active inclusion recommendation) and 
measures to enhance employment of those furt her from the labour market; looking at social 
aspects of migration and ethnic minorities; the an alysis of child wellbeing; review inequalities 
in access to health and social care services in general and fo r people suffering from specific 
diseases (e.g. Alzheimer's disease); analysis of access to quality prim ary care; quality of 
health and social services.   
c) A greater use of social OMC p eer reviews to address social de terminants of health could be 
encouraged and a health inequalities dimensi on would be included in reviews of EU health 
strategies as appropriate.   
d) Presumably, the Commission would organise a first reflection on targets in the area of 
health status as announced in the st rengthening social OM C communication.   
Improve data availability and the mechan isms to monitor and report on health 
inequalities and improve the knowledge base on the cases and the evidence base for action:   
a) Healthy life years would remain a stru ctural indicator in the Lisbon strategy  
b) The social OMC common indica tors on health status would be  used to monitor progress in 
relation to health inequalities.  Under the Indicators sub-Group of the SPC, some indicators 
EN 29   EN would be developed including on poverty and material deprivation, social aspects of 
migration and child wellbeing; on pension ad equacy; on avoidable mortality, on access to and 
utilisation of health care and on health pr omotion and disease prev ention (risk factors/ 
behaviours, screening), as much as possi ble by age, sex, socio- economic status and 
region/geographic dimension.  This would be d one in connection with other statistical work 
notably further developments of the European health information system (incl. European 
Community Health Indicators). 
c) The agreed indicators of the sustainable development strategy would also be used to 
monitor progress between and within Member States 
d) The Health Strategy and social OMC reporting mechanisms would continue to be used for 
reporting.  Health inequa lities concerns reported by Member States (in the NSRs and in the 
Expert Group on SDH) would be analysed in public health reports from the EU health 
information system, in the Joint Report SPSI, the Monitoring Report on progress towards the 
common objectives on the social OMC, the monitoring report on the EU Sustainable 
Development Strategy and perhaps in the A nnual Social Situation and Demography Report. 
There would be no special monitoring of health  outcomes for the use of  EU Funds under this 
option. 
e) PROGRESS and the Health Pr ogramme (2008-2013) would provi de some financial support 
to policy development and innovation by Member Stat es and other stakeholders in this area.   
f) The 7th EU Research Framework Programme (FP7) funding for Research would only 
address health inequalities under existing, broader research sections  without a specific focus.   
Develop the contribution of EU policies:   
a) Cohesion Policy would continue to support a range of activities in the public health and 
healthcare areas.  
b) The CAP (market measures, agricultural and rural development funds) would continue to 
support some initiatives such as the school milk scheme, the school fruit scheme, food distribution for most deprived pe ople, social care and health care  infrastructure and services.  
c) The Commission would continue to monitor the implementation of labour law and health 
and safety legislation.  A report is to be dr afted in 2009 on the implementation of Directive 
91/383/EC, covering the period up to 2007 and attempt identify pot ential deficiencies in the 
Directive in order to give guidance for the futu re action of the Commission in this field.   
d) The Roadmap on Gender Mainstream ing would continue to be pursued 
d) Some support would be available for st akeholder actions through PROGRESS and the 
Health Programme. 
e) The 2010 European Year Against Poverty is being organised to  raise awareness and 
develop policy to tackle poverty, a main determinant of health inequalities. 
f) Other EU actions on specific vulnerable groups (e.g. Roma, migrants, disabled) would 
continue from the perspective of integratio n and non-discrimination but not specifically 
focusing on health inequalities. For example, the European Fund for the Integration of Third 
Country Nationals would continue  to be used and monitored. 
4.2. Option II: Current plus  
Under Option II, a Commission Communication woul d raise awareness on h ealth inequalities, 
highlighting their economic, political and ethical magnitude.  It would confirm the reduction 
EN 30   EN of health inequalitie s as a policy priority, increase dialogue  with other releva nt actors in the 
field and strive towards a bett er use of existing informati on and best-practice exchange 
mechanisms and existing financial support.  It  would support actions to build knowledge for 
effective action and strive to improve the existing measurement system on health inequalities between Member States and EU  Regions and between social groups across the EU.  Indeed, 
one of the problems identified as an important obst acle to action is the current limited data on 
the extent and consequences of health ine qualities and the current limited knowledge on the 
effective policies to implement.  Informati on and knowledge is a first step in policy 
development and this is why under Option II  the Commission would propose a number of 
actions to improve and disseminate information and knowledge.  These include actions to improve data and statistics available thr ough improving data colle ction by socio-economic 
status and geographic dimensi on, which would allow the EU and its Member States to 
measure the extent of health inequalities and to monitor them over time.  Improving data 
collection is to be done through EUROSTAT toge ther with Member States implementing EU 
surveys and reviewing existing data collection mechanisms and investigating how to improve 
them.  Other actions to improve information and knowledge include more regular monitoring 
and a more regular use of existing reporting m echanisms to assess the possible impact of 
policies and to monitor the evolution of health  inequalities.  Actions to improve knowledge 
also include using EU funds including Re search funds, the Health Programme and 
PROGRESS to fund scientific re search from which Member Stat es could benefit to develop 
their strategies.  It would enc ourage a first consideration by a ll relevant policy areas on what 
is their potential for futu re action in this field (as proposed by some national au thorities in the 
consultation).  It would announce a number of specific actions which would aim to strengthen 
existing activities, without requiring significant new policy development.  It will however be 
the principle responsibility of Me mber States’ to develop and im plement concrete policies.   
Activities would include the following: 
Raising awareness, promoting information and best-practice exchange, and promoting 
the tackling of health inequalities as a policy priority: 
a) A Communication would underscore Comm ission commitment to  tackling health 
inequalities as a policy prio rity.  This Communication coul d be seen as the Commission 
recognition at a high level that he alth inequalities are an importa nt issue for policy.  It would 
indicate that there is some evidence and know ledge on the extent, causes of and policies to 
address health inequalities but th ere are also important gaps in these domains that need to be 
filled.  The Communication would also indicate th at while the EU and Member States have 
increasingly acknowledged the problem and are pursuing some policies, more can be done at 
both levels and thus the Commi ssion would start to explore wh at could be done at the EU 
level to better support Member States' efforts and ensure a more effective contribution of 
relevant EU policies towards a reduction on health inequalities in full respect of subsidiarity; and, in this context,  the Communication would propose a se t of initial ac tions in that 
direction.   
b) The Commission would explore possibiliti es for including the reduction of health 
inequalities as an objective in the post 2010 Lisbon strategy. 
c) Strengthen the synergy between Member St ates and EU work on health inequalities to 
ensure a more effective sharing of information and best-practice via, for example, the Commission proposing to revise the terms of re ference of the existin g EU Expert Group on 
SDH with the aim of ensuring that it was able to add the maximum additional value in relation 
to work in this area feeding into th e work of the SPC and the Council WPPH. 
EN 31   EN d) Establish a mechanism for bringing social part ners and other relevant stakeholders together 
at European level (e.g. a stakeholder platform ) to promote commitment and the uptake and 
dissemination of good practice in reducing health inequalities at the local level – including 
through activities at the wor kplace, in schools and in local communities.  Many open 
consultation responses highlighted the importance to establish a stakeholder platform similar 
to what happen in other EU in itiatives (e.g. nutrition platform) and ensure that a wide range of 
stakeholders (not only NGOs and not only from the health field) participate.  This stakeholder 
platform will include NGOs which, as stated  in the open consultation, can provide an 
important channel to reach people in th e context of their everyday lives..   
e) The Commission would bring forward proposals with the aim of stimulating and focussing 
the reflection on targets on improve ments in health status and na rrowing of health inequalities 
to which it committed to in the strengthening social OMC communication, as wished for by 
many stakeholders in the open consultation. 
Improve data availability and the mechan isms to monitor and report on health 
inequalities and improve the knowledge base on the cases and the evidence base for 
action:  In addition to the work under the social  OMC and European health information 
system as described in Option I this option the Commission would: 
a) Develop a consistent methodology for measur ing and monitoring differences in health 
between social groups, Member St ates regions at the level of the EU using data provided to 
EUROSTAT.   
b) Undertake a feasibility study on the further development of indicators and collection of 
health data by age, sex, socio-economic status and geographic dimension (e.g. regions) at EU 
level (as suggested in some open consultati on responses) through EUROSTAT work together 
with Member States;  
c) Improve the availability and comparability of health data collected at national level by 
implementing and analysing EU-SILC and EHIS surveys and regulations on public health statistics.  Improve data compar ability and coherence with othe r international datasets (e.g. 
WHO, OECD) as requested in several responses to the open consultation.  
d) Orient relevant EU research program el ements towards closing knowledge gaps on the 
extent, causes, consequences of health inequaliti es and policies to address them such as Socio-
economic Sciences and Humanities of the 7
th EU Framework Programme for Research.  
Develop a consistent and rational EU public h ealth research agenda in future framework 
programmes to embed health inequalities researc h.  The need for more research and related 
financial support was also seen as one of ma in areas of added value of the EU by the 
responses to the open consultation.  
e) Propose inclusion of research on the reduction of health ine qualities in the work plans of 
relevant EU agencies (the European Foundation EU Framework Programme for the 
Improvement of Living and Working Conditions, the European Centre for Disease Prevention 
and Control and the European Ag ency for Health and Safety at  Work, the Fundamental Rights 
Agency).  
f) Develop regular reporting, monitoring and analysis notably  via publishing of a special 
Commission report on progress in ad dressing health inequalities  by 2012 with further reports 
envisaged in three to five years.  The report would be compiled by the Commission and 
consider data on health inequalities as well as  the contribution of EU and National policies.  
The 2012 report would be an input into the revision of the EU H ealth Strategy and the further 
development of EU specific actions on health inequaliti es for the period beyond 2013, 
EN 32   EN including the new budget framework.  Such a dedi cated EU level report was deemed essential 
by responses to the open consultation (e.g. national authorities) to attain progress in this field.  
Develop the contribution of EU policies:  
In addition to elements relating to the Research Framework and the EU statistical and 
monitoring system described above this would require actions to:  
a) Review how existing EU Stru ctural Funds (at current levels ) in area of health could be 
better used to address health inequalities by  
• Developing the assessment of the impact of th e structural funds on health inequality 
i.e. the Commission would initiate monitoring  of the use of the structural funds for 
health purposes and analyse the impact of th e use of funds on health  inequalities in the 
Cohesion Reports  
• Encouraging Member States to make a greater  use of health status indicators in the 
assessment of their operational programmes, 
• Improving Member States' capacity building in  health (i.e. guidance on investment) 
through seminars on how to use the funds for care infrastructure (ERDF) and to 
provide staff training on social determinants of  health and the social gradient in health 
(ESF),   
• Improving links between policy priorities id entified in the Joint Report on SPSI and 
the investment proposals in operational pr ogrammes, including creating an internal 
Working Group in DG EMPL connecting issue of  health inequalities with the use of 
funds;  
• Giving "RegioStarts" to good practices that help reduce health  inequalities thus 
encouraging investments in those health ca re sector services which make a greater 
contribution towards reducing health inequalities.   
b) Encourage Member States to exploit fu rther the existing options under the EU rural 
development policy and apply in full the exis ting schemes under CAP (school milk, food for 
most deprived, school fruit scheme). 
c)  Organise a forum on hea lth and restructuring in 2010,  
d) Establish a mechanism for health inequali ty audit (assessing the contribution of existing 
policies towards reducing hea lth inequalities) for example through work supported by the 
Health Programme to produce a methodology and provide technical support. Promote 
exchange of best-practice on using health inequality audits   at Member State level  
e) Undertake health inequality  audits (ex-post) with the ai m of strengthening the health 
equality focus of existing EU activities on h ealth determinants incl uding tobacco, alcohol and 
nutrition as well as other policy areas 
f)  Review possibilities for incr easing contributions to health in equality reduction in other EU 
policies such as public health, education; antidiscrimination, gender; environment etc, notably through the use of indica tors and reporting  
 Action to increase the protection of health  for vulnerable groups would include:  
a) Follow up on the 2007 Council Conclusion s on Health and Migration in the EU by 
improving knowledge of migrants' and ethnic minor ities health and its determinants through 
more EU funded research, better data collection,  considering the establishment of a network 
of national experts on health and migr ation, disseminating best-practices;  
EN 33   EN b) Adding focus on reducing health inequalities  to the 2010 Roma summit and the integrated 
platform for Roma inclusion and develop an init iative in collaboration wi th Member States, to 
raise awareness and improve the ability of actio ns to promote health and address inequalities 
to meet the particular needs of migrant and ethnic minority groups including Roma.  
c) Improve synergies between policies and an alyse and monitor access to basic goods and 
services which impact on health (shelter, wate r, sanitation, healthcare, and other factors)  
d) Adding focus on reducing health inequalitie s in the 2010 European Year Against Poverty 
and in the proposal for an European Year on active ageing and intergenerational solidarity 
2012,  
e) Increase the focus on reducing health inequalities in EU activ ities on the health of children 
and young people. 
 In addition the Commission would take the fo llowing actions to promote the tackling of 
health inequalities at a global level:  
a) Provide input to the development coopera tion work on poverty and health and work on 
developing social protec tion in health care in developing countries,  
b) Create a tool for assembling and dissemi nating relevant good practices on social 
determinants of health and health inequalities;  
c) Provide support for joint work  with WHO and other relevant international organizations to 
take forward recommendations of WHO Commissi on on Social Determinants of Health and  
d) Pursue the EU global health agenda  outlined in EU Health Strategy;  
e) Make full use of the potential of this polic y for sector policy dial ogue on health inequalities 
in the context of the European Neighbourhood Policy.  
4.3. Option III: Far reaching efforts to enha nce EU policy priorities in relation 
to health inequalities.  
In addition to the actions under option II a comp rehensive policy approach would be put in 
place including actions wh ich involve significant changes in pol ices at EU and national levels.  
Option III would include the actions in Opti on II and in addition proposes the following 
elements including a Council Recommendation: 
Raising awareness, promoting information and best-practice exchange, and promoting 
the tackling of health inequalities as a policy priority:  
a) A Council recommendation on health inequa lities would set a common agenda for Member 
States to address health inequalities, while respecting na tional responsibilit ies for determining 
health policy and health services.  This woul d be based on article 152 and has been requested 
by a number of consultation responses  including nationa l authorities. 
b) The Commission would propos e targets to reduce health inequalities across the EU. 
Conceivably they could relate to: - No Member State having an estimated life ex pectancy at birth for either men or women 
that is more than X% less than the EU average (measured through ECHI mortality data) by 2020 and/or 
- A reduction of X% in the gap in life expe ctancy between those EU Regions comprising 
1/5th of population with lowest  life expectancy and the EU  as a whole by 2020 (baseline 
2008) (measured through ECHI mortality data) and/ or 
EN 34   EN - A reduction of X% in the level of chronic il lness and disability between those with the 
lowest fifth of incomes and the rest of the EU population by 2020 (measured through EU 
SILC) 
Improve data availability and the mechan isms to monitor and report on health 
inequalities and improve the knowledge base on the cases and the evidence base for 
action:  In addition to proposing changes to the wo rk plans of relevant EU agencies (the 
European Foundation for the Improvement of Living and Working Conditions, the European 
Centre for Disease Prevention and Control and th e European Agency for Health and Safety at 
Work), the Commission would propose changes to the terms of reference of one of them to 
transform it into an independe nt and dedicated research agency on health inequalities (as 
proposed in consultation). 
Develop the contribution of EU policies, in cluding better support of Member States and 
stakeholders' efforts and a specific focus on  vulnerable groups and third countries:  
a) A high level inter-institutional advisory co mmittee would be proposed to review progress 
and provide advice to the Commi ssion on the future development of policy.  It would include 
members nominated by: Council, European Parliament, SPC, Committee of the Regions, 
Economic and Social Committee, EU Health Forum, European Social platform, WHO 
Regional Office for Europe with a secretariat provided by the Commissi on.  This would meet 
once per year and provide comment on: the trend and implications of health inequalities and 
the extent to which health inequalities are ta ken into account in EU policies.  A report would 
be presented to the Commission.  
b) As programmes and policies are renewed for the period beyond 20 13, the reduction of 
health inequalities would be made an explicit key priority and resources  would be reallocated 
or added accordingly.  These w ould include i) the Cohesion polic y ii) the research framework 
programme, iii) health policy, iv) policies on  employment, social protection and equal 
opportunities and v) development and aid policies.  This is in line with the findings of the 
WHO CSDH and many request s in the consultation.  
c) The Commission would  review the extent to which add itional community measures could 
contribute to ensuring that acce ss to basic needs for health (health care, shelter, food, water 
education) can be better define d and assured for all groups, but particularly for those who are 
vulnerable (section 2.1) – incl uding Roma, migrants and pe ople with disabilities. 
d) The Commission would propose a major international initiativ e to address global health 
inequalities.  It would consid er additional approaches to su pport countries neighbouring the 
EU to reduce health inequalities. 
A table spreading through the next two pages pr ovides an overview of the actions under each 
option and its relation with the objectives. 
It can be further illustrated how  the EU level actions proposed he re relate to Member States 
actions using some examples 
EU level action Member State level actions / Stakeholders actions 
Establish stakeholder platform to overcome current 
limited commitment by stakeholders: Commission 
provides the facilities for stakeholders to meet and, together with stakeholders, defines an agenda. The 
Commission organises the administrative running of 
the meetings of the platform (e.g. invitations, Stakeholders' representativ es define agenda with 
Commission and participate on a voluntary basis, 
providing evidence from th eir work / experiences / 
policies. Some travelling and accommodation costs 
involved. Stakeholders benefit from the information 
and knowledge generated and may use it to apply it in 
EN 35   EN secretariat) and provides a mechanism (web) to 
disseminate useful information that is built through the 
Platform. their fields.  
Target development to overcome current limited 
commitment by Member Stat es: under the social OMC 
the Commission will submit discussion papers to the SPC to generate debate and reach some specific 
proposals. Funding under the health Programme and 
PROGRESS may be used to fund specific research on what could be good targets. Based on this and once a 
consensus is reached at the SPC the Commission 
proposes a number of targets under the social OMC.  Member States participate in the debate in the SPC 
and discuss advantages and disadvantages and make 
proposals for what the targets should be based on the best information available. Awareness is raised 
especially by those countries which currently put a 
lower policy priority on health inequalities. 
Develop a consistent methodology for measuring and 
monitoring differences in health between social 
groups and regions at the EU level using data provided to EUROSTAT to overcome the fragmented 
knowledge and non-comparable methodologies that 
currently exist: using funding from the Health Programme commission studies that will provide 
suggestions for a methodology. The Commission will 
review such suggestions and will apply the 
methodology at EU level using EUROSTAT data. Member States will provide the data as usual on the 
basis of agreed surveys and regulations. Member 
States can use and benefit from such methodological developments if they so wish at national level as well 
as from the general and public knowledge that results 
from using the methodology. They can thus generate national information where it was not previously 
available. This contributes for more informed decision 
making. 
Develop collection of health data and health indicators 
by age, sex, socio-economic status (SES) and 
geographic dimension which is currently limited: a) 
continue working with Member States using existing exchange frameworks to im prove the implementation 
and comparability of relevant EU level surveys, whose 
data the Commission services will analyse; b) EUROSTAT together with Member States using 
existing exchange frameworks, reviews current 
practices and the potential for improving mortality and life expectancy data collection by SES in Member 
States and makes suggestions. Funding may also be 
used to commission a study to explore the feasibility to improve mortality and life expectancy data 
collection by SES. O n  a )  M e m b e r  S t a t e s  w o r k  w i t h  E U R O S T A T  t o  
implement the EU surveys some of which are EU 
regulations; on b) Member States provide information 
on their practices and discuss with EUROSTAT the proposals to improve mortality and life expectancy 
data collection by SES and then choose if and how to 
best obtain mortality and life expectancy data by SES. Member States can use and benefit from the improved 
information that results. They can establish more 
accurately the extent of national health inequalities especially in those countries where this information is 
currently non-availa ble. Again, this contributes for 
more informed decision making. 
Dedicated report on health inequalities in 2012 with 
further reports envisaged thereafter to overcome the 
irregular, fragmented knowledge that currently exists: 
Commission services will write the report on the basis of existing reporting by Member States, available 
EUROSTAT data at EU level and any other relevant 
reporting available at EU level and national level 
which is public information. Member States already produce the National Strategy 
Reports on social protectio n and social inclusion and 
will be encouraged to report on actions in the field 
although reporting on this topic will remain voluntary. Representatives to the Expert Group on social 
determinants of health and health inequalities may 
voluntarily produce reports on national actions in the 
field. Other expert networks (e.g. gender, social 
protection and social inclusion) may produce relevant information. There may be national research studies or 
studies by other organisations with relevance to this 
reporting.  Member States and other stakeholders may if they wish provide the Commission services through 
existing exchange frameworks and on a voluntary 
basis a report dedicated to  their actions to address 
health inequalities. Member States can use and benefit 
from the public knowledge that results. 
EN 36   EN Orient relevant EU research program elements 
towards closing current knowledge gaps on the extent, 
causes (causality), consequences of health inequalities and policies to address them: in the coming calls under 
the 7th EU Framework Programme for Research and 
for example under the Socio-economic Sciences and Humanities branch, space is made for research on 
health inequalities.
 Member States can use and benefit from the public knowledge that results notably in devising national 
strategies in this area.  
Establish a mechanism as far as possible for health 
inequality audit to improve ex-post assessment of the 
impact of relevant EU policies which is currently 
limited: use funding under the Health Programme to produce a methodology for health audit and to provide 
technical support. In a pilot manner apply the 
methodology developed to a small number of EU policies. Promote exchange of best-practice on using health 
inequality audits at Member State level by using 
existing exchange frameworks and dedicated seminars. 
Participation and the choice to develop and use this audit would remain voluntary. Developing and using 
health equity audit at national level also provides 
evidence base for policy development to overcome the current limited knowledge on policy effectiveness at 
national level.  
To address gaps in key services and determinants of 
health inequalities in those regions lagging behind a) 
Review how existing EU Structural and Cohesion 
funds investments (at current levels) could be better 
used to address health inequalities: see detailed 
information in the main text above. b) allocate additional funding to the health priority  Member States would be encouraged to use health 
inequalities related indicators in their assessment of 
the operational programmes but this would remain 
voluntary. Participation in the capacity building 
seminars would also be voluntary. Member States can 
benefit from the knowledge provided when developing their investment programmes. Any decisions on 
funding allocations would be approved by the Council. 
To improve assessment of the impact of EU policies 
use existing reporting mechanisms and indicators of 
the Lisbon, Employment, Cohesion, Social and Health 
strategies to analyse the relationship between those policies and health inequalities.  To a large extent reporting and indicator development 
is done in collaboration with Member States. They can 
benefit from the knowledge created to develop 
national strategies.  
 
 
EN 37   EN Objective Option I – Business as usual 
Continue current activities, no new 
initiatives Option II – Current  plus 
Additionally to the actions under Option I, this 
Option includes: Option III –  Far reaching  
Additionally to the actions under Option I and 
II, this Option includes:  
Raise awareness, 
promote information and 
best-practice exchange; 
health inequalities as a policy priority - health inequalities remain objective of 
social OMC and health strategy 
- encourage greater use of peer reviews  
- some first reflection on targets possible  - use existing Health Strategy and social 
OMC structures for be st-practice exchange 
(OMC, SPC, Expert group, Council WPPH) 
 - Commission Communication 
- explore possibility to strengthen link between 
growth, jobs and health in Lisbon strategy 
- strengthen the EU expert group on SDH to inform 
WPPH and SPC 
-establish a stakeholder platform  
- stimulate and focus work towards the 
development of targets - Council recommendation 
- set clear targets 
 
EN 38   EN Improve data availability 
and the mechanisms to 
measure, monitor and 
report on inequalities in health across the EU and 
improve the knowledge 
base on the causes of health inequalities and 
the evidence base for 
action - continue development of Health 
information system 
- under social OMC, continue to develop 
indicators on poverty, utilisation of health care, where possible by socio-economic 
status  
- continue to use the EU sustainable 
Development Strategy and Lisbon Strategy 
indicators 
- use the existing monitoring and reporting 
mechanisms of the social OMC, health 
strategy plus the social Situation and Demography Report 
- use existing funding notably under: FP7, 
PROGRESS and public health programme to develop additional knowledge and 
evidence base for action - develop consistent methodology for measuring 
and monitoring health inequalities 
- explore the feasibility to improve data collection, 
and develop indicators by socio-economic status and regions;  
- ensure further comparability of data by 
implementing EU-SILC and EHIS and through the implementation regulations on public health 
statistics 
- ensure coherence with WHO and OECD datasets 
- review and orient FP7 to fill knowledge gaps  
- include special funding line on health inequalities 
in further FP 
- propose to change work plans of agencies  
- dedicated report on health inequalities in 2012 
with further reports envisaged thereafter 
 - propose to change terms of reference of an 
agency to transform into  dedicated HI agency 
(e.g. EUROFUND, ECDC, OSHA) 
 
EN 39   EN Develop the contribution 
of relevant EU policies 
towards reducing 
inequalities in health, including better support 
of Member States and 
stakeholders' efforts to tackle health inequalities 
and a specific focus on 
vulnerable groups and 
third countries - continue financial support through the 
structural and cohesion funds 
- continue financial and in-kind support 
(school milk) via CAP and rural development 
- some support for stakeholders 
(PROGRESS, Health Programme) 
- continue to monitor implementation of 
labour law and health and safety legislation 
- 2010 European Year Against Poverty 
- Continue existing work on determinants 
(housing, labour market) and specific groups (disabled, Roma) without 
necessarily a health inequality focus 
 - ensure better use of Structural Funds by 
- Assessing the impact of Cohesion funds on 
health inequalities through for example the 
cohesion report 
- Improving Member States capacity 
building to use the funds through user 
seminars  
- new Working group in DG EMPL 
coordinating ESF and HI 
- RegioStarts to reward and promote 
investment  
- forum o health and restructuring  - include a health inequalities audit in public health 
(tobacco, alcohol, nutrition) and other EU policies  
- review possibilities for more effective 
contribution of health, education, anti-
discrimination, gender, environment, social, etc. 
policies, notably through the use of indicators and reporting 
Vulnerable groups: 
- work on Council Conclusions on health and 
migrants and the requests to the Commission 
- add health inequalities focus in the 2010 Roma 
summit 
- review existing policies to analyse and monitor 
access to goods and services , in a joint exercise 
involving relevant DGs 
- add health inequalities focus in 2010 European 
Year of Poverty and in the 2012 Year of Ageing  
- add health inequalities focus to the Health 
Strategy for children 
Global dimension: - create an inter institutional advisory board 
- make health inequalities a priority in post 
2013 programmes and policies including. 
additional dedicated funding (e.g. Cohesion, FP8, CAP, Health, employment) 
- review how additional EU policy can ensure 
access to basic goods and services 
- propose new international initiative health 
inequalities  
- support Neighbouring countries reducing 
health inequalities 
 
EN 40   EN - provide information (assemble and disseminate 
best-practice information) to third countries 
- collaborate with other international organisations 
(e.g. WHO)  
- add a health inequalities focus to the European 
Neighbourhood Policy 
 
EN 41   EN 5. ANALYSIS OF IMPACTS 
This is a non-legislative ini tiative with the aim of strengthening action to support and 
complement the efforts of Memb er States and other stakeholde rs on a broad policy objective – 
reducing inequalities in health.  The options are cumulative representing different levels of 
Community institutional response (option III bui lds on option II which in turn builds on option 
I).  The actions proposed in options I, II and II I operate at two levels: they entail increasing 
degrees of effort to improve co -ordination and facilitation of the issues at EU level and, 
secondly, increasing degr ees of effort to raise awarenes s among Member States and other 
stakeholders of the importance of considering health and social issues notably though not only 
at this time of financial insecurity for many.  
The extent to which the activities addressed in this document make a contribution to assisting 
action at EU level and by Member States and othe r stakeholders to reduce inequalities in health 
is the main factor determining th e impact of these proposals.   
This initiative falls within the category of 'b road policy-defining documents' as described in the 
Impact Assessment Guidelines.  In line with th e guidance there, and ta king into account the 
type of measures proposed, the appraisal is br oad and qualitative rather  than quantitative. 
The impact on the actual health status in the EU or on the reduction in the economic burden as 
a result of actions at the EU level cannot be estimated with any precision and is not easily 
measured in quantitative terms.  It is difficult to  assess the direct impact of the actions listed in 
section 4 due to the multitude of contributing factors.  Indeed, the main effect of the actions proposed is to support efforts by Member States  and other actors, who will choose which policy 
strategies to implement.  For example, some measures to reduce health inequalities require 
investment (e.g. strengthening health and soci al protection systems) or reallocation of 
resources, others require little funding (e.g. le gislation on smoke free areas).  The actions 
proposed here do not go as far as indicating to Member States and others the specific measures 
to be taken.  Hence, the impact on health status  or the economic impact depends on the level of 
involvement and implementation by Member Stat es (in particular th e ones with no current 
health inequalities focus and the ones with the biggest health gaps) and other actors and the 
particular mix of initiatives followed by them.  In addition it is in general difficult to quantify the monetary value of health as this has a va lue in its own right over and above the additional 
economic output that a healthier population is ab le to generate.  The analysis below is thus 
more an assessment of potential qualitative impact s of the various options, regarding social and 
economic outcomes as these are the main impacts expected.  No direct environmental impacts 
are expected (and no option among those proposed would have a priori a negative impact on 
the environment) and they are therefor e not considered in the appraisal.  
5.1. Social Impacts 
None of the options and the actions within them  would be expected to have a negative social 
impact.  The actions listed under th e three options may be expected  to have a number of social 
impacts as listed below.  As said, option III builds on option II which in turn builds on option I so that as we move from Option I to Option II and then Option III we  may expect that an 
strengthening of activities unde r each of the key objectives can provide a larger positive 
indirect (via encouraging the development of effective policies to tackle health inequalities at all levels of government) contribution to soci al aspects such as health and employment. 
 
EN 42   EN Options II and III vis-à-vis option I by proposing stronger awareness raising, associated with 
better data collection and great er monitoring, more knowledge and better and more effective 
support to Member States (not only financial but  also in terms of enhanced policy exchange 
mechanisms including in the field of health and social inclusion), could lead to Member States: 
1) ensuring social protection support to all includ ing in the field of healthcare (access for all to 
insurance coverage for health promotion, dis ease prevention, care a nd rehabilitation); 2) 
improving the geographic location and availability of  services (facilities and staff) in areas 
where they are lacking; 3) look ing at the specific needs of vulnerable groups (including third 
country nationals) and developing  targeted social policy acti on.  Providing a focus on more 
equality-orientated use of the Structural Funds  and Cohesion Funds proposed in options II and 
III vis-à-vis option I could furthe r encourage Member States to l ook at those i nvestments that 
could make a greater contribution to reducing health inequalities.  This would be especially the 
case, if Member States' use of the Structur al Funds and Cohesion Funds resulted in an 
investment towards those areas requiring higher labour inputs both high a nd low skilled – such 
as health and social care in the community and notably in  deprived population areas.  As a 
consequence, positive employment and health e ffects can expected such as higher employment 
of those less skilled, a more equal access to care across socio-economic groups and thus more vulnerable groups, the protection of care recipients or their relatives from the financial costs of 
care (and thus protecting their fi nancial situation), and better health outcomes in deprived 
geographic areas / lower socio-eco nomic groups.  At EU-level this  could also contribute to a 
greater health convergence betw een Member States - as the link between within country 
inequalities and overall count ry health suggests.   
Option II and III vis-à-vis Option I may further enhance the contribution to mainstreaming 
gender equality issues by looking at gender differen ces in health and access to health care.   
A mechanism for involving social partners as in Options II a nd III, building on previous and 
positive Commission’s experience to involve stakehol ders in other areas, such as obesity and 
alcohol, sends a positive signal about the importance of partnerships and so cial responsibility.  
Options II and III can also bring an additional impetus to research and policy innovation when 
the potential of joint EU research will be  used for health inequalities issues.  
An important issue, both social and economic, is  that the present economi c crisis can translate 
into a deterioration of some of the determinants of health (employment, income, health behaviour) and thus an increase in  health inequalities, while stricter financial constraints on 
national authorities’ budgets can lead them to cut public budgets associated with health and 
social protection in general (as the first assessmen t of the recovery plans of EU Member States 
conducted by the SPC shows for some countries).  Option II and III, through stronger awareness raising activities rega rding the extent and economic c onsequences associated with 
the pervasiveness of health ine qualities and the gains attained by addressing them could ensure 
that, at a time of prioritisation, Member States  do not neglect this area for action and thereby 
risk incurring negative future economic and soci al consequences.  Further deterioration of 
health of certain groups now, can imply less em ployment and productivity of these groups in 
the future.  Furthermore, the economic crisis and the stricter financial constraints imply a need 
for greater efficiency and emphasis on effective measures that can be introduced to tackle 
health inequalities.  Hence, the crisis ma kes the need for better information and its 
dissemination more pertinent and pressing, sugg esting that actions un der Options II and III 
would be preferred to those in Option I.  Note  that, under option I, we start with a baseline 
scenario of large and widening health inequaliti es between and within Member States which the 
current economic crisis could poten tially further enhance.  In this  context, no new actions in the 
 
EN 43   EN light of the crisis notably in terms of awareness raising coul d represent a wasted opportunity 
with regards to possibilities for health and employment (which could be attained through a 
greater emphasis on developing commun ity health and social care).   
5.2. Economic impacts 
The cumulative nature of the options also implie s that Option III could create greater uptake of 
effective measures then Option II and consequen tly Option I and thus the economic impact of 
Option III could be greater than that of Option II, in its turn greater than that of Option I. 
Indirect economic costs of the persistence of la rge scale inequalities in health are potentially 
considerable.  Such losses cannot be estimated with any precision or reliability and even less 
for each option at stake.  One of the few studies that has attempted to do so estimated that the 
potential economic gain which would occur if it was possible to bring the health of the whole 
population up to the level of health experien ced by those with higher education would be 
between 1.2% and 9% of GDP (Mackenbach et al ., 2007).  Such a wide estimate highlights the 
difficulties in deriving monetary costs from ch anges in mortality and morbidity.  Similar 
estimates are not available for the gap between Me mber States.  However, to the extent that a 
country's aggregate population health is poorer the larger the within county socio-economic 
inequalities in health and the fact that death and disease rates of peopl e of working age are over 
twice as high in some Member States than others  clearly represents a loss of human capital and 
an obstacle the objective of reducing the gap in GDP between countries.  The positive economic implications estimated, although not preci se, indicate the possibi lity for investments 
in reducing health inequalities to have positive economic benefits.   
Reinforced action on health inequalities is likely to have overall positive economic effects with 
the reduction of unnecessary and premature losses (productivity, labour market participation) 
for health reasons (death or disability) to the labour market.  For example, Options II and III, by implying a greater EU focus on the mutual rela tionship between employment and health could 
lead to Member States focusing more strongly on health and safe ty at the workplace, resulting 
in a) fewer accidents and injuries in the workpl ace, b) longer working lives and greater labour 
participation of older workers, which have a positive economic impact (increased GDP).   
As this initiative is about encouraging  Member States to address health inequalities it does not 
impose any course of action. In this sense there are no compliance  costs for Member States. 
Potential savings and costs will depend on the  particular mix of initiatives and implementation chosen by Member States.  Indeed, awareness ra ising, best practice exchange, policy analysis 
and greater knowledge for example, can have di fferent economic impacts.  For example, , 
where Member States decide to strengthen inter-s ectoral policies to address health inequalities, 
there could be budgetary implications as a resu lt of such activities in Options II and III.  
Member States could allocate additional national investment for the stre ngthening of health and 
social protection systems (e.g. mo re resources devoted to fight poverty or to close gaps in 
health care provision).  Or there could be opport unity costs as a result of the reorientation of 
resources which could occur particularly in Memb er States that do not currently have a focus 
on health inequalities.  It is al so possible that in some countries  there is no change in national 
budgets as the right priorities are deemed to have been set.  And it is even possible that in some 
Member States, as a result of the activities pr oposed, there is a reallocation of resources/ 
reprioritisation and effici ency gains are achieved.
  Some measures may require more funding 
than others and it is difficult to prejudge whic h will be chosen by which Member State and thus 
the costs of those actions.  At th e EU level no actual changes in budget or priorities are foreseen 
 
EN 44   EN under these options and any future change woul d be subject to a speci fic impact (including 
cost) analysis. 
Overall, if the underlying determin ants of health and health inequalities continue to improve 
this would be likely to have a positive economic im pact.  In the longer term gains in health and 
reductions in loss of healthy life years may be eith er cost neutral or of overall economic benefit.  
The actions proposed here may prove  essential in ensuring that to be the case.  Indeed, as 
mentioned in section 5.1, the current economic crisis can have a negative economic impact.  
Severe economic downturns, such as those which occurred in some Eastern European countries 
in the early 1990s, were associat ed with marked deterioration in health and rising premature 
death rates, which some current  Member States are only just  emerging from.  The economic 
crisis of FI and SE in the 1990s also had impor tant health and employment consequences (e.g. a 
large increase in the long-term unemployment ra tes) which can still be  observed.  Hence, the 
crisis makes the need for action along the lines expressed in section 3 an d 4 more pertinent and 
pressing, so that, in a time when Member States  need to establish priorities, they do not 
overlook the possibility to  achieve economic and health gains through the tackli ng of health 
inequalities.  In this respect, additional action under Options II and III would be preferable to 
those in Option I.   
5.3. Costs regarding data collection 
Regarding the activities related to improving data  availability and comparability notably in 
terms of obtaining data by socio-economic stat us it is also difficult to identify the costs 
involved.  Following a very recent questionn aire by ESTAT to Member States on the 
possibility to obtain such data it was identif ied that: a) some countries can and provide 
mortality data by socio-economic status (education le vel, last occupation) so that for these there 
would not be additional costs; b) some countri es indicated that by law such an information 
would be difficult to obtain which also implies no  additional costs; c) fo r some countries there 
could be the possibility to easily link vari ous instruments (e.g. census data and death 
certificates) at a minimum cost; d) for some, su ch linkages would require  some more additional 
work and thus costs.  In gene ral, EUROSTAT in its work with Member States would aim for 
the most cost-effective way of obtaining the information.  EURO STAT is currently exploring 
and proposing a way to improve data collection a nd dissemination in general that can lead to 
lower economic and administrative costs.  Certai nly, any activity that would imply changes in 
data collection at EU level w ould be subject to its own imp act assessment (including cost) 
analysis.  
Some actions proposed are not expected to gene rate extra cost.  Option II and III would develop 
a simple mechanism to provide input to third countries which would not  involve any additional 
costs.  Some other actions may have a cost.  , By proposing a stronger mechanism to involve 
stakeholders, Options II and III  may impose some insignificant co sts on those who take part, 
but participation will not be mandatory.  The additional high profile inter-institutional committee in Option III would involve  some minor additional costs. 
6. COMPARISON OF THE OPTIONS 
This section examines, as relevant, the three opti ons and related actions fr om the perspective of 
effectiveness – the contribution of the options to  achieve the objectives; e fficiency – taking into 
account the amount of resources and effort involve d and feasibility – in relation to the time to 
achieve the objective and possible barriers to implementation.  Progress towards achieving the 
general objectives is regarded as a proxy towa rds supporting and complementing the efforts of 
 
EN 45   EN Member States and other stakeholders in ta ckling health inequalities and thus the EU 
contribution towards a reduction of health inequa lities in the EU, because it is not possible, 
with any degree of confidence to make an accurate assessment of the outcome in this area.  We 
finalise each option appraisal by looking at subsidiarity and proportionality issues. 
6.1. Option I – Baseline – Continue curren t activities, no new initiatives 
Effectiveness 
Option I is maintenance of the status quo and incl udes a number of activities which will help to 
achieve some of the objectives.  Under option I, it seems likely  that continuation of current 
activities can be expected to lead to some progress.   
While the current EU policy framework support s a certain amount of awareness raising and 
mechanisms for exchange of good practice betw een Member States, unde r Option 1 (status 
quo) and despite current activitie s, we see that only a small mi nority of countries has set the 
reduction of health inequalities as a main polic y priority and has impl emented a comprehensive 
inter-sectoral approach to tackle health in equalities.  The COR’s response to the public 
consultation also highlighted that the current ac tion was not sufficient to ensure that health 
inequalities would appear on al l national policy agendas.   
Similarly, while current activitie s support some development of information and knowledge in 
this area, weaknesses would remain in monitori ng the level of health inequalities between and 
within Member States due to lack of comparable data (e.g. health related indicators are not fully 
comparable and routinely available across Me mber States) and in lacking an accepted 
methodology for calculating health in equalities.  Without an agr eed way of monitoring health 
inequalities and without rec ognised dedicated reporting, know ledge at the Community level 
about the rate of progress and the effectiv e policies to implement would be weak.   
Continuation of EU activities as currently set would not necessarily  lead to a greater 
understanding of the contribution of EU policies to reducing hea lth inequalities, neither would 
it necessarily lead to greater awareness in relati on the protection of health of vulnerable groups 
such as Roma, nor would it provide an input to  a global agenda on heal th inequalities.   
Thus continuing with current level of activities is  likely to lead to some  but modest progress in 
relation to the objectives (i.e. some progress in raising awareness and encouraging further 
policy prioritisation by Member States, some  data and knowledge developments).   
Efficiency and Feasibility 
This option does not imply any additional admini strative costs, nor require re-orientation of 
funds from other po licies.  However, in political terms,  it would not respond to the requests by 
Member States and other stakeholders fo r additional EU action in this field. 
Subsidiarity and Proportionality. 
There are no subsidiarity issues at stake with this option as Member States' prerogative for 
health and other policies remains untouched.    
   
6.2. Option II – Current Plus 
Effectiveness 
 
EN 46   EN The actions listed under option II represent an ad ditional strengthening of activities under each 
of the key objectives.  Overall they would lead  to a greater and more rapid change in the 
direction of achieving the objectives.  
For example, Option II (as well as Option III), through improving the work of the current EU 
Expert Group on SDH woul d provide additional input and value to the work of the SPC and the 
Council WPPH and thus strengthen the existing in formation sharing and best-practice exchange 
mechanisms without significant administrative or economic co sts to the EU or national 
administrations.  Mechanisms for involving soci al partners create a dditional momentum for 
action to achieve the objectives.  Building on  previous and positive Commission’s work to 
involve stakeholders in other areas, such as ob esity and alcohol, they ca n create a greater policy 
focus for example on effective policies to improve  the health of specific and vulnerable groups 
such as migrants.  Option II could also bring an additional impetus to research and policy 
innovation.  Indeed, Option II (as well as Option III) compared to Option I could produce better information and knowledge to inform deci sion making by Member States and other 
stakeholders on policies to address health ineq ualities, something that has been supported by 
the majority of stakeholders.  
Option II could lead to more a ppropriate (“equality proof”) regi onal investments, making them 
responsive to the observed large and widening hea lth inequalities and othe r challenges such as 
the current economic crisis or the future  challenges of ag eing societies.   
Efficiency and Feasibility 
Option II builds on existing work, does not require any significant shifts in policy, and there 
will be no changes in budgetary allocations.  No new obligatory reporting would be required 
from Member States by this option, as info rmation would primarily be drawn from existing 
reporting mechanisms.   
In general this option is achievable within ex isting resources and highl y feasible although there 
are some issues that need noting.  Policy prio rity under Option II would imply more in-depth 
work on targets.  Such work received substa ntial support in the c onsultation (some national 
authorities included).  While support for this  has been building, an acceleration may still 
involve the risk of gene rating resistance from some Member States.  In addition, some actions 
to improve data availability and comparabilit y could require the modification of current 
information systems in some Member States as explained in section 5.3 which could raise some 
resistance.  This work would however be coordinated through the working groups with 
Member States convened by EUROSTAT as is  done with all areas of statistics.   
Subsidiarity and Proportionality 
This option envisages an extensi on of some EU activities and th erefore proper consideration of 
whether such an extension is consistent with the principles of subsidiarity and proportionality.  
This goes beyond the simple legal basis for acti on which has been set out in section 2.6, to 
consider whether the proposed actions meet in addition all the following criteria – necessity and 
added value of EU level action in addition to th at of Member States and proportionality.  The 
issues relating to the necessity and added value of EU action on health inequalities focus on 3 
elements: 
• harmonised EU-wide data collection and monitoring to allow for comparison of 
performances; 
 
EN 47   EN • added value of exchange of information a nd knowledge facilitated by the EU and use of 
EU Research Programmes.  
• in addition to this, the EU has a role in determining and monitoring EU level policies 
such as labour market policies, cohesion policies and others which influence HI;  
The section on the causes of health inequalities has outlined the multitude of influences starting 
with overall macroeconomic polic ies but also including a wide ra nge of other po licy areas such 
as social, health and regional policy and activi ties combating discrimination and ensuring equal 
rights.  EU policies are important  in all these areas in supporting and complementing the efforts 
of Member States and other stakeholders.  A better understanding of how  EU policies affect 
health inequalities, which would be obtained un der Option II through hea lth inequalities impact 
analysis, would have the potential to inform fu ture EU policy development.  EU wide data 
collection and monitoring will provide the po ssibility of comparis on and learning between 
Member States which will be of benefit to polic y makers in each country.  By reason of their 
greater scale and opport unities for sharing expe rtise between countries  the EU research 
programme can add additional value to national efforts in this area.  Finally there is considerable experience from the OMC in soci al, educational and other policy areas of the 
added value of exchange of information and knowledge between Member States facilitated 
through EU mechanisms.  These benefits of  a supportive interventi on of the EU were 
highlighted by the COR’s response. 
The actions in Option II are relativ ely modest and proportional to th e objectives de fined in this 
impact assessment.  Option II represents a light er implementation requirement for the EU and 
for Member States, in comparison with th e activities listed under Option III.  
6.3. Option III – Far reaching efforts to enha nce EU policy priorities in relation 
to health inequalities  
Effectiveness 
As options are cumulative it is conceivable that Option III is evaluated as the package of 
measures likely to have the greatest impact on the objectives.  The par ticular added value of 
Option III is in relation to political commitme nt and monitoring and evaluation.  Under Option 
III, a Council recommendation, EU wide targets and high profile inter-institutional committee, 
as well as the additional focus on reducing health  inequalities from key EU policies described 
under Option III, are likely to have the biggest effect in terms of raising awareness and 
establishing the tacklin g of health inequalities as a po licy priority.  A lthough not legally 
binding, a recommendation would be highly visi ble and would ensure ownership by Member 
States.  Experience shows that the status of  recommendations does faci litate the uptake and 
dissemination of measures and can become a re ference document for all actors involved.  It 
could then be a useful tool to strengthen monitoring and ev aluation.  A recommendation would 
also be a good opportunity to make clear how  a package of measur es on tackling health 
inequalities should be integrat ed into overall social and ec onomic development measures as 
part of the Lisbon agenda.  Some of the re sponses to the open co nsultation including by 
national authorities support th e proposal for a Council Recommendation for these reasons.   
Efficiency and Feasibility 
Option III however is likely to take longer to achieve the objectives and carries additional 
"risks" – particularly in relation to possible lack of acceptance of measures proposed by the 
 
EN 48   EN Commission which have not previously had the opportunity for a develo pmental process with 
Member States and stakeholders.   
In general, the possible drawback of the packag e of measures in Option III is that there are 
currently significant uncertainties regarding caus ations and effective measures.  This means 
that, while such deep policy changes should be c onsidered as realistic future actions, in the 
current context, there is a risk that we propose an incomplete and ineffective set of changes.  
There are therefore advant ages in taking an intermediate set of steps as proposed in Option II to 
build up information, knowledge and experience before we suggest larger actions.   
Moreover, some of the actions proposed in Option III such as a Council Recommendation and 
additional work in relation to community meas ures that can improve access to basic needs, 
would also require the support of  other EU institutions and Memb er States and at this stage 
such level of support has not been determined.  While it is true that the Council has requested 
further EU action to address he alth inequalities it is not cl ear that a Council Recommendation 
would be favoured by a majority of Member St ates in the current s ituation and given the 
existing lack of information and knowledge. 
Proposing targets allows the Commis sion to test the strength of po litical interest and respond to 
the challenge created by the econom ic crisis to reorient Member  States actions around health 
and social actions.  Although the majority of consultation responses supported the idea of 
targets, they also feel that setting quantitative EU targets would not be possible at this moment 
due to data and knowledge limitations and large differences between Member States.  
Introducing targets without suffici ent preparation may result in them being ignored, and waste 
the political potential of this  action for the future.   
Hence, the implementation of the package of measures outlined in Option III requires the 
support of other EU institutions and at this stag e such support has not been sufficiently gauged.  
Option III may also involve some opportunity cost s and risks associated with too ambitious 
actions on the basis of current knowledge and experience which could be reduced through the 
intermediate information/ knowledge and experience building exercise of Option II. Many stakeholders wished for parts of Option III, but  agreed that not all are feasible right now.  
Concluding, while there is a general political co nsensus for additional EU action under the lines 
of Option II, going further, along the lines of Option III, may bring a split between those 
Member States who wish to go fu rther and those who do not and thus  there is a risk of creating 
political resistance which is counterproductive.  
Subsidiarity and Proportionality 
Option III represents a further extension of EU level activiti es beyond those in Option II.  
However the main points discussed under Option II  are also valid.  By introducing a Council 
Recommendation Option III would seek to create  a common approach and impetus amongst all 
Member States to addressing inequalities in he alth.  Such a non bindi ng recommendation would 
continue to fully respect the re sponsibilities of Member States to  determine their health policies 
and organize and deliver health services.  Howe ver,  it is questionable whether at the current 
state of knowledge the setting of targets for HI reduction at EU would still meet the objective of 
proportionality. 
The following table summarises the impact of the three options on the specific objectives as 
defined in section 3.2.  In the table "+" indicates some positive impact, ++ indicates significant positive impact, +++ major positive impact, impact  "0" indicates no change and "-" some 
negative impact, -- signif icant negative impact, -- - major negative impact.  
 
EN 49   EN Contribution towards Objectives Option I Option II Option III 
Raising awareness and promoting the tackling of health 
inequalities as a policy priority + ++ +++ 
Enhance mechanisms to monitor and report on inequalities in 
health and improve the knowledge on the causes of health 
inequalities and the evidence for action + ++ +++ 
Develop the contribution of relevant EU policies towards 
reducing inequalities in health + ++ +++ 
Feasibility  Option I Option II Option III 
Political risks / lack of acceptan ce / lack of Member States' 
support / counterproductive No No Yes, some 
Costs of achieving the objectives  Option I Option II Option III 
Administrative cost development of information systems 0 - -- 
Investments allocated to addressing health inequalities for 
national authorities  - -- --- 
Preferred Option 
All three options would help to achieve the speci fic objectives albeit to a different extent.  
Option III is expected to achieve most in terms of the specific objectives and positive social and economic impacts.  However, it also has the po tential for some addition al administrative and 
opportunity costs, may suffer from knowledge uncer tainty and may face some political barriers.  
Option I is likely to make a mo dest contribution.  From the effectiveness and feasibility 
perspective, the costs involved and the ability to  act quickly in relation to the current crisis, 
Option II is the one which is preferred.  Theref ore, while actions under Option III are realistic 
potential EU actions, the current situation su ggests that we should follow an intermediate 
Option II.  Option II can be seen as a stepping  stone to further EU level work on health 
inequalities.  This option fully respects the princi ple of subsidiarity.  Note that actions have 
been grouped together under the different options  according to the level of additional policy 
content and support from other institutions invo lved.  To some extent however, there is a 
possibility for individual elements to be m oved between Options II and III if so decided. 
7. MONITORING AND EVALUATION 
This document has identified a number of gaps  in information and lack of comparable 
indicators across Member States on health inequalities
38.  It contains several proposals to 
improve information, monitoring and reporting on th e progress in relation to impact on health 
inequalities and related outcomes such as social  protection and social in clusion.  These include 
the development of indicators based on current da ta and further progress on the development of 
EU wide indicators on rela ted outcome measures.  
                                                 
38 For an overview table linking the identified problems via the objectives with the evaluation see Annex 
A17. 
 
EN 50   EN The key elements for monitoring and evaluation  are: impact on national policymaking, impact 
on EU policy and on policy outcomes.  Impact on national policy will be monitored firstly 
through the existing OMC and health strategy m echanisms.  That is through reporting, self 
monitoring and evaluation includ ing through peer revi ew.  Monitoring and evaluation will be 
on the basis of measurement against the specif ic objectives.  The precise mechanisms for 
monitoring and evaluation will thus depend on wh at measures are chosen in the eventual 
communication.  The table below should therefore be regarded as indicative of the kind of 
approach that will be taken to  monitoring and evaluation of activities on health inequalities in a 
future communication. 
An additional mechanism for reporting and mon itoring is identified in Option II – a report by 
the Commission on progress in tackling health ine qualities.  This Option foresees that in 2012, 
the Commission will publish a report on the implemen tation of this initiative and the progress it 
has had on addressing health  inequalities with further re ports envisaged (including an 
evaluation of the HI strategy). Th is report will give elements for the revision of the EU Health 
Strategy and the further development of specific actions on health inequalities for the period 
beyond 2013.  Option II also provides for the de velopment of a consistent methodology for 
measuring and monitoring differences in health between social groups, Me mber States regions 
at the level of the EU and s upport Member States to collect data on health inequalities and 
determinants of health.  These data w ill be used for monitoring and evaluation. 
Impact on EU policy could also be monitored through the newly configured EU Expert Group 
reporting to the SPC and the Council Working Part y on Public Health at Senior Level.  The 
Commission will provide expert support for regular analyses of  EU policy developments for 
discussion with relevant groups  through existing mechanisms.  These include the Observatory 
on the Social Situation and the Observatory on Health Systems and Policies. 
The Commission will also contribute to analysis  which could form the basis for discussion at 
the EPSCO Council.  
     
Objective Indicator 
Raise awareness, promote 
information and best-practice 
exchange and advo cate the tackling 
of health inequalities as a policy priority Number of Member States with  comprehensive policy approach 
which can be analysed in the so cial OMC NSR 2011-2013 (currently 
two) 
To be evaluated by the Eurostat Working group on mortality data, 
who is compiling the data  Improve data availability and the 
mechanisms to measure, monitor and report and improve the knowledge 
base  To be evaluated by DG Research by number and quality of studies, 
and amount of distribution platforms (internet portal), publications 
(available in all languages) 
Develop the contribution of relevant 
EU policies towards reducing how many relevant EU policy strategies have an indicator of health 
status inequalities 
 
EN 51   EN how many EU reports address the influence of certain strategies on 
health and health disparities inequalities in health 
Additional assessment under Option II and III in dedicated Health 
Inequality report 2012 
 
 
 
EN 52   EN  
Annexes to the Impact Assessment  on "Solidarity in Health".  
1. ANNEX 1 Consultation and expertise........................................................................ 53 
1.1. Targeted written consultation ............................................................................... 53 1.2. Summary of responses.......................................................................................... 57 1.3. Consultation during the developmen t of previous communications. ................... 63 
1.4. Consultation with key groups convened by the European Commission .............. 64 1.5. Consultation with EU institutions......................................................................... 68 
1.6. Expertise ............................................................................................................... 69  
2. ANNEX 2: Health ineq ualities in the EU................................................................... 71 
2.1. Background and context: Nature and scal e of health inequalities in the EU........ 71 
2.1.1. Inequalities in health outcomes between Member States ..................................... 71 2.1.2. Determinants (drivers or cause s) of health inequalities........................................ 82 
2.2. What Member States are doing and c onsider effective to address health 
inequalities.......................................................................................................... 100 
2.3. Existing EU action and links to other relevant EU policies ............................... 104 
2.4. Additional information on why health ine qualities between a nd within countries 
are a problem and a policy concern to th e EU? The legal and political basis for 
action and subsidiarity ........................................................................................ 108 
3. Bibliography ............................................................................................................. 111  
4. List of abbreviations ................................................................................................. 113 
 
 
EN 53   EN  
8. ANNEX  1 CONSULTATION AND EXPERTISE  
8.1. Targeted written consultation 
Consultation process. 
A targeted written consultation of  stakeholders was carried out as  part of the preparation for a 
Commission Communication on Health  Inequalities.   The Health and Consumers Directorate-
General (DG SANCO) and the Employment, Social policy and Equal Opportunities   
Directorate-General (DG EMPL) invited stakeholde rs and organizations working with them on 
issues related to health ine qualities to respond to a consulta tion document which contained a 
number of questions (Annex 1).    Altogether 148 requests for consultati on were sent it.  The 
consultation was launched on 3 February 2009 with  a closing date of 1 April subsequently 
extended until 15 April.  The consultation docum ent was also placed on the Commission's web 
site giving an opportunity  for others to reply39.   
Composition of respondents 
127 answers were received of which 13 came from  Member States or national governmental 
organizations within Member States. A number of  regional health servic e organisations also 
gave their input. A significant share of answers (52) came from  EU umbrella organisations, 
therefore summarising a broader range of national organisations. One third of the respondents 
came not directly from the health sector, lik e women councils or regional authorities.   
Responses from EU Member States and nati onal governmental orga nizations in Member 
States :  
Belgium, Cyprus, Czech Republic, Finland, Fr ance, Germany, Hungary, Ireland (national 
public health institute), Latvia, Lithuania, Ma lta, Sweden, United Kingdom, (Department of 
Health) 
 
Responses from national governmental  organizations in other countries : 
Norway   European Bodies outside the Commission@
 
Committee of the Regions,  European Centre for Disease Prevention and Control,  CEN - European Committee for Standardization.  Responses from the regional level
,  
Assembly of European Regions AER 
                                                 
39 See http://ec.europa.eu/social/main.jsp?langId=en&catId=89&newsId=462&furtherNews=yes  and 
http://ec.europa.eu/health/ph_determinants/socio_economics/cons_inequalities_en.htm  
 
EN 54   EN European Regional and local Health Authorities platform - EUREGHA  
Bayrisches Staatsministerium für Umwelt und Gesundheit Cornwall health service Glasgow health service Kent & Medway health service Limburg (NL) Local Government Association - Wales and England Scottish health service Skane County Council Västernorrland County Council Västra Götaland health service Verbindungsstelle der Bundesländer (AU) 
Western Investing for Health (Northern Ireland)  From health service systems responses were  received both from providers and insurers
:  
BKK (DE) Bundesarbeitsgemeinschaft der Freien Wohlfahrtspflege Bundesärztekammer und Kassenärztliche Bundesvereinigung Caritas (DE) Eurodiaconia European Social Insurance Platform HOPE European Hospital and Healthcare Federation Mutualité Française Mutuelle générale de l’ Education nationale (FR) 
 
European wide networks of health professionals
 of several disciplines replied as well: 
Standing Committee of European Doctors British Dental Association British Medical Association Council of Occupational Therapists  for the European Countries 
European Association of Intellect ual Disability Medicine - MAMH 
European Association of Service provider s for Persons with Disabilities – EASPD 
European Society of In tensive Care Medicine 
European Union Geriatric Medicine Society - EUGMS 
 
EN 55   EN International Association of  Gerontology and Geriatrics 
 European umbrella organisations (ENGOs)
: 
AIDS action Europe AVERROES Network (migrants' health) Central and Eastern European Women's Networ k for sexual and reproductive Health and 
Rights - ASTRA 
Confederation of Family Organisations in the European Union EuroCare - European Alcohol Policy Alliance Eurochild Eurocities EuroHealthNet (Public Health) European Child Safety Alliance European Disability Forum - EDF European Federation for Street Children European Federation of Re tired and Elderly People 
European Forum for Primary Care European health and Fitness Association European Health Management Association European Institute for Women’s Health European Men's Health Forum European Network against racism European Network for Smoking Prevention - ENSP European Network of Occupational Th erapy in Higher Education - ENOTHE 
European Network of Regions Improving Citizens Health 
European Older People's Platform - AGE 
European Patients' Forum European Public Health Alliance European Respiratory Society European Social Network - ESN European Volunteer Center - CEV European Womens Lobby European Youth Forum FEANTSA the European Federation of Nationa l Organisations working with the Homeless 
 
EN 56   EN International Association for the Study of Obesity IASO 
International Planed Parenthood Federation National Heart Forum (UK) / European Heart Network  Smokefree Partnership Social Platform  Trade Unions
  
UEAPME (European Association of Craft,  small and medium-seized enterprises) 
Confédération Européenne des Syndicats Indépendants (CESI) European Federation of Public Service Unions European Trade Union Confederation ETUC  Among the stakeholders are natu rally also representatives of the Industry / companies:
 
European Diagnostic Ma nufacturers Association 
European Federation of Pharmaceutical  Industries and Associations EFPIA 
Alliance Boot  Eucomed - medical technology European Association of Service provider s for Persons with Disabilities - EASPD 
Insurers of Europe - CEA Novartis Gilead Science  National Non Governmental Organizations 
 
Actuarial Profession UK  Dental Health Foundation Ireland 
Home Safety Scotland 
La Confederacion Espanola de Agrupaciones de Familiares y Personas con Enfermedad 
Mental - FEAFES 
National Pensioners Convention UK NIVEL & PHAROS - Centre of expertis e on refugees and newcomers' health 
Romanian Association Against AIDS Zminijietna - Voice of the Left (MT) IOGT-NTO (SE, Alcohol) Connections - Integrated responses to drugs an d infections across European criminal justice 
systems 
 
EN 57   EN ver. E.A.T.R.G. 
National Roma Centrum Macedonia Fundación Secretariado Gitano  Women's Health Council IR  Research institutes and individual scientists
:  
Association of Schools of Public Health in the European Region  
Health Monitor Research HU Health and Social Development Foundation, BG Kosice Institute (SK) Landesinstitut für Gesundheit und Arbeit NRW Royal College of Nursing UK And individually: Dr. Margaret Douglas, G. Costa, Prof. Str onegger, James Scanlan, Dr. Mc 
Hugh Mike, Gerardo Zamora-Monge and, Tor-Kristian Rønneberg. 
 Other responses included 
 
International Organiza tion for Migration  
The European Office for Investment for Health  and Development of the WHO (please note 
that this is not an offi cial WHO communication)  
the Women of the Green Party (SE)  Alternattiva Democratica party (MT). 
8.2. Summary of responses 
Nature and scale of the overall problem 
The vast majority of respondents recognised he alth inequalities within  and between member 
states as a serious problem. The current economic crisis is expected to aggravate the gap as on 
the one hand raising unemployment deteriorat es the health status and on the other hand 
decreasing tax revenues might lead to cut-back s in health care expenditures. For example, 
groups concerned with mental illness expected an increase in such problems due to the 
economic crisis. 
Some pointed out, that there is no common definition of the scope of the problem yet, it varies 
between unequal access to care to the so cial gradient in health status.  
Several stakeholders noted the economic valu e of improving population health status. One 
health service organization propos ed not to focus on increasing gross domestic product (GDP) 
to raise healthy life-expectancy, but the othe r way around arguing that one  year increase in 
average life expectancy leads to 4% increase of GDP.  
Inequalities between and within Member States 
 
EN 58   EN While life-expectancy is on the rise all over Eur ope, health inequalities tend to widen as well. 
The existence of differences in life-expectancy and healthy life-y ears was reported in nearly all 
responses and for all Member States.  
The gap between Member States was reported to have increased and was expected to increase 
further. For example decrease mortality rates fo r coronary heart diseases in the old Member 
States, whereas they increase in the EU-10. 
Differences in Socio-Economic Status (SES) wi dened in Central and Ea stern Europe following 
the introduction of a market ec onomy. While the gap remained st able in the 80s and 90s in 
Western Europe it increased in the 2000s. Some st akeholders stressed that in the new Member 
States gaps tend to be wider.  
Injuries are also more prevalent among groups w ith low socio-economic status (SES): injury 
prevalence is five times higher among the lowest income quintile.  People with multiple and chronic diseases, most prevalent among the very  old (80+), most often lack access to the 
appropriate coordinated services.  
It was noted that disparities within cities are deepening as  some neighbourhoods accumulate 
multiple problems. 
Determinants 
Several social umbrella organisations stresse d the close connection between socio-economic 
status and health status. A scientific study pres ented a hierarchy of cause s, identifying physical 
and physical working conditions as the most in fluential, followed by childhood conditions and 
risk behaviour. All these factors were regard ed as being more prev alent among lower socio-
economic strata. 
Several responses underlined the importance of th e early ages for a health y life. Life-styles are 
acquired in the early life years,  policy therefore has to focus on children and young people, 
who can not determine their living environmen t, nutrition and housing themselves and are 
susceptible to outside influences. 
Among respondents there was a difference of opini on on whether the higher risk behaviour can 
be solved by education and information campaigns alone or whether additional measures are required addressing socio-economic factor s and living conditions more broadly.  
Huge differences in access to and quality of treatment received, both between Member States 
and between different groups of patients within a country, were also remarked on as another 
determinant of health inequalities. The worst access to health care was reported for highly 
vulnerable groups including ment ally disabled people, unaccom panied minor immigrants and 
trafficked women. The increasing liberalisation in the health care sector is a source of concern 
to social umbrella organisations as they report this is increasing health inequalities and it is 
feared that this might lead to a two tier system. 
A minority of respondents did not regard th e scientific evidence  on the link between 
determinants and outcomes as sufficient. However, the majority appeared to take a different view summarised by one health ministry whic h concluded: "We alr eady know enough to take 
action". 
The EU added value 
The overwhelming majority of responses welcom ed further action by the European Union. The 
appreciation of EU added value was linked to  respondents views on the definition of health 
inequalities. Stakeholders, which focussed on  health care access stressed Member States' 
 
EN 59   EN responsibility, whereas those which focusse d on health outcomes welcomed further 
Community action. An organization representing insurers underlined that inequalities in health 
care access are subject to Member  State regulations and best so lved at the regional or even 
local level. EU added value was welcomed in th e areas of data collection, agenda setting and 
funding. 
Responses from the national level took quite dive rging positions on the desired involvement of 
the EU in principle. Whereas some saw a need fo r the EU to take a lea d, others were of the 
view that actions tackling hea lth inequalities should be the so le responsibility of Member 
States. Despite this general divergence, consensu s existed in relation to  a range of concrete 
actions. All national level responses were of th e view that better indicators and exchange of 
best practices can add value to the nationa l policies to tackle health inequalities. 
The role of the EU in providing leadership in relation to the ec onomic crisis was also identified 
as an added value. The possibl e contribution of the following EU policies was mentioned also 
in relation to improving working conditions, ph armaceuticals, food safety, housing, education, 
environment and employment. 
Awareness  
The suggestion of a Commission communication was welcomed by nearly all stakeholders. 
Especially among NGOs this would be seen as ra ising the issues salience  and thereby assisting 
their work in Member States. Whereas all national  responses agreed that health inequalities are 
to be tackled there was recogni tion that concrete actions face obstacles. A renewed European 
discourse is expected to help to overcome these. 
One health ministry and the professional asso ciation from the same country saw a Council 
recommendation as best way to ensure a high commitment to the health inequity problem. 
A patients group proposed establishing an Ombu dsman monitoring health inequality. Another 
respondent asked for a white paper on Health Inequality. 
A very small number of responses preferred to  see the actions of th e Commission limited to 
information campaigns. 
Umbrella NGOs concerned with womens' health and mental illness expected added value from 
a Commission communication which would raise issue salience. 
Measurement, Monitoring, Reporting 
Providing comparable data on health inequalities and its determinants along with exchange of 
best practices was identified in nearly all re sponses as a necessary action on behalf of the 
Commission. 
Many recommendations were made for improvement of the current indicators. Several health 
ministries proposed improving reporting by socio-economic st atus, gender and geographic 
area. Respondents commented that many of the proposed indicators are al ready included in the 
Open Method of Coordination (OMC ) health indicators, but cohe rent data are not available 
yet. The need to raise data on the determinants  to better suit policy re sponses was underlined 
repeatedly. One national response raised concerns  about comparability of subjective indicators 
(unmet need) as these are influenced by cultura l expectations rather then real provision. 
Two European umbrella Non Governmental Or ganizations proposed a further reporting by 
private or public f unded care / insurance. 
A health inequalities index was pr oposed a few times, but also explicitly rejected by others. 
 
EN 60   EN Some responses proposed more research on indi cators and special works hops for stakeholders 
including on how to use existing datasets.  
A number of non-governmental organizations suggested expa nding the concept of Socio-
Economic Status measured by income, educat ion and occupation by measures of sexual 
orientation, ethnicity and neighbourhood. 
Many suggestions concerning indicators were qu ite detailed and were forwarded to the 
relevant statistical units. 
One response suggested a dedicated institu tion to monitor heal th inequalities.  
There were diverging views among national le vel responses regard ing on how to pursue 
further reporting and monitoring. Whereas  one called for much more reporting on 
determinants, following the model of the Town send Score of Social deprivation, others 
stressed the need to carefully design further repor ts, to avoid duplication of  work, in particular 
with the WHO and not to overload nati onal bureaucracy with reporting burdens. 
One health ministry proposed the production of a special reporting section on health inequality 
once every three years and have a five-year report on trends and best practices. Another health 
ministry proposed annual reports on indicators. A thir d health ministry suggested inclusion of 
ministries of social affairs, interior affairs and education into the OMC process. Inclusion of 
the European and national parliaments was also suggested. 
One forum of regional authorities did not regard the OMC and reports as an adequate measure, 
as national situations are too diverse. 
Comments from the national level of some new Member States asked for special support to be 
able to provide data and reporting. While a nu mber of older ones under lined the need not to 
overburden Member States with reporting obligations and theref ore include health inequalities 
into other reporting exercises like the public health . 
Policy coordination at EU level 
A stakeholder platform following the example of the nutrition forum, to  coordinate actions on 
health inequalities was proposed several times. Interregional collaboration among social NGOs 
would require more support from the EU. 
The Open Method of Coordination (OMC) was s een a key forum for reports and exchange of 
best practices. Nearly all NGOs ca lled for a better incorporation of  stakeholders into the OMC. 
Next to the OMC; the Open Health Forum and th e Social Platform were mentioned as Forums 
for the exchange of best pr actices on stakeholder level. 
One Member State called for coordination of  Health Strategy and social OMC to reduce 
double work. Furthermore it stressed the need to work in existi ng forums without creating new 
reporting obligations for Member States. 
EU policies 
Most contributions noted that although the EU do es not have competence in health care, many 
of its policies affect the determinants of Hea lth Inequalities. In a ddition to the demand for 
better measurements, was therefore the call for ta king health inequalities into account in all 
policies. Additional Health Impact assessmen t was proposed by some.  Health Inequality 
Impact Assessment at EU level was rega rded as an importa nt activity by some. 
One women's NGO recommended including a sec tion on health inequalities into the gender 
mainstreaming process. 
 
EN 61   EN EU policies on working conditions, labour market , education and growth were regarded as 
important for their positive impact on health and health inequalities. Some respondents identified the Lisbon Strategy as important al so in relation to health inequalities, as 
unemployment is a major determinant of bad health. Some stakeholders identified the 
proposed directive on patient mobility as a so urce for increasing health inequalities within 
Member States. 
The increasing introduction of supplementary pr ivate health insuran ces was regarded as 
negatively affecting vuln erable groups, next to the econ omically disadvantaged, also old 
women, disabled and people with low health li teracy. Also social assistance schemes may 
offer free health care for this groups, the shame associated with means-testing could prevent some of them from looking for care. 
Some documents explicitly asked for better interservice communication.  
Resources 
The majority of respondents re garded the Structural Funds as  a valuable s upport to tackle 
health inequalities at the local level and spread  best practices. Howeve r more information was 
needed on behalf of the local stakeholders to be  able to fully implement these funds. Structural 
funds should also support regiona l cross-boarder health care. Th e regional funds were widely 
seen as useful to support innovative projects at th e local level. Also it was criticized, that this 
could lead to further disparitie s between regions, which are able  to recruit funds  and the ones, 
who are not. It was therefore called for a more simple application procedure. 
The proposals how the EU funds could support training for medical professionals were 
manifold: specialized care for the very old vu lnerable people, disabled, chronicle ill or in 
general patients with lowe r socio-economic status, were also mentioned. 
The support of the funds would also be needed to increase capacities for data generation, 
reporting, health impact assessments a nd participation in EU level forums. 
Poor housing as a cause of bad health stat us should also be included in the funding 
programme, as suggested by a few stakeholders. 
The funding for research (FP7) was mentioned many times. More evidence about the causal 
relationships between determinants and health  outcomes is needed. Some also called for 
scientific evaluation of programmes tackling health inequalities and for special research focussing on the particularities of Eastern Europe. 
The areas mentioned for investment in health care were: primary care networks, risk groups 
and complex treatments. 
A regional organization proposed an excha nge programme for health professionals. 
Some national responses provided positive examples of how the ERDF and ESF funding has 
been employed to improve health infrastructu re, ensure access for all and improve health 
promotion. A few noted that investment shoul d always be a combination of EU and MS 
funding and will contribute to an increased wo rkforce. A minority were firmly against 
expansion of the budget line following 2014 and reca lled that funding for health projects can 
just be increased by reshuffling budget lines. 
Most vulnerable groups 
 
EN 62   EN Plenty of responses regarding the special need s of different vulnerabl e groups were received 
including on those mentally di sabled, trafficked women, HI V infected, homeless, street 
children, elderly, Roma, migrants, prisoners. 
Equal access to health care was regarded as a co re element to tackle health inequalities. 
However, several stakeholders noted that such a right is not sufficient for the most vulnerable 
groups. Targeted approaches taking their special needs and cultures into account are called for. 
Health mediators have been proven a succe ssful approach for Roma and migrants. 
Health literacy is a central con cept in their concerns. Reform policies are too often targeted at 
the educated middle-class, leaving the ones most in need of care aside. 
Also for data generation, an approach to identify these most vul nerable groups without 
stigmatising them is called for by NGOs active in  this field. They also stressed the need for 
inclusion of vulnerable groups  in the policy formulation. 
The special needs of women, who suffer from uns afe abortions and teenag e pregnancies, have 
been brought to our attention by several women NGOs. 
It was suggested to break down data on migrant h ealth by country of origin to develop tailor 
made programmes. A group which also deserves special attention is the Roma minority. NGOs 
representing Roma called for sp ecial EU support to tackle the huge gap in health status 
between Roma and the majority population. Health inequalities should become a topic of the 
next Roma summit.  
Many advocacy groups of disabled people responded to the consul tation. Their main point was 
that also suffering from their specific impairme nt, disabled people can still enjoy good health, 
when treated in the right way. 
In general, several NGOs working with vulnerabl e groups, asked for a better exchange of best 
practices and experien ces at EU level. 
On the current crisis, some responses noted th at experiences from pr evious crises were 
relevant. 
Targets and Benchmarks 
The majority, were supportive of the idea of setti ng targets and milestones at EU level.  Some 
remained sceptical about the f easibility of implementation. Two respondents were against the 
idea of setting targets and mile stones. Data limitations were the most mentioned obstacle. 
Furthermore a small majority regarded the diffe rences in health status between the Member 
States as too big to come up w ith real targets. One national re sponses called for guidelines of 
recommendatory nature and also su pported the idea of common targets. 
Targets were proposed for injuries and concrete groups of people.  
Milestones were seen a little bi t more positive, as th ey would allow social NGOs to pressure 
the national governments. Targets should also  be set at a national level. 
Overall summary of targeted consultation 
Overall the vast majority of respondents supported  further action by the EU to address health 
inequalities. Many respondents also expressed will ingness to participate ac tively as partners in 
future initiatives. In additi on there was positive support for a ll the key areas of action which 
were specifically mentioned in the consulta tion document, though there were a number of 
reservations as reported above. 
 
EN 63   EN 8.3. Consultation during the development of previous communications. 
Considerable consultation took place on the br oad elements of possible future Commission 
action on health inequalities prior to the comm encement of the impact assessment exercise.  
Proposals for Commission action on health ine qualities were included as part of the 
development of the EU Health Strategy (2007) a nd the Renewal of the Social Agenda (2008).  
These consultations are documented in the impact assessments accompanying these communications and included both written consultation and via key meetings which included 
the Social Protection Committee and the EU Expert Group on Social Determinants.  
Renewed social agenda   
A wide public consultation took place during 2007 on Europe’s Social Reality which is 
relevant to this communication.  The consul tation was launched in February 2007.40  The 
initial results of this consultation re sulted in the November 2007 Communication 
"Opportunities, Access and Solidar ity: Towards a New Social Vi sion for 21st Century Europe" 
setting out a range of possible re sponses to the societal challe nges at work in the EU. The 
consultation process involved 150 contributions from a wide range  of sources su ch as public 
authorities, a national parliament committee, so cial partners, non-govern mental organisations 
(NGOs), various interest groups, universities and research institutions, religious groups and 
churches as well as individual ci tizens.  Improving health receives considerable attention in 
most of the contributions, thus confirming the cruc ial role attributed to this area of action in 
the consultation document. In a number of c ontributions, health wa s seen as a factor 
influencing virtually all domain s of the social reality of in dividuals.  A second consultation 
followed (ending in February 2008 ) and the Social Agenda Forum, was organised on 5/6 May 
2008, with a view to provide a platform for stak eholders — representatives of EU institutions 
and the national authorities of Member States, not ably representatives of national, regional and 
local authorities, social partne rs, NGOs, international organisations , networks in the domain of 
social policy, researchers active in the domain of  social policy — to discuss the outcome of the 
social reality stocktaking exercise and the br oad policy orientations for a renewed Social 
Agenda.  Once again improving health and reduc ing health inequalities was part of the 
discussions held. The Commission closed the conference with the announcement of future 
action in the field of health  inequalities including a Comm unication.  The Commission then 
launched the Renewed Social Agenda in July 2008, part of which relates to ensuring longer 
and healthier lives and a nnounces a Communication on heal th inequalities for 2009. 
EU Health strategy 
The consultation process in early 2007, which aime d to gain stakeholder input with regard to 
the EU Health Strategy (adopted in Octobe r 2007) involved nationa l, regional and local 
authorities, NGOs, associations, co mpanies, universities and indi vidual citizens. The majority 
(54%) of the more than 150 respondents consider ed reducing health ineq ualities, both between 
and within Member States or regions, as a very  important objective for the Health Strategy and 
said that EU activity should be enhanced in this area.  
Committee of the Regions 
                                                
 
40  See http://ec.europa.eu/citizens_agenda/social_reality_stocktaking/index_en.htm   
 
EN 64   EN The Committee of the Regions conducted a cons ultation of its members on the "Assessment of 
Territorial Impacts of EU Action to  Reduce Health Inequalities". It has to be noted that just 13 
regions replied, out of which five from Spain and none fr om the new Member States. 
The drivers of inequalities identified in the su rvey complement the list given in this impact 
assessment (socio-economic factors and lifes tyle) by geographical f eatures (remoteness, 
fragmentation, islands and mount ainous environments, presenting concrete barriers to the use 
of services) and cultural heritage  (peoples perception of health systems and issues according to 
local traditions, organi sation and ethnic group). 
Desirable Community action includes: mainst reaming, equity-focused health impact 
assessment, promoting universal coverage, improve monitoring and standardisation of 
indicators, research, learning and training, exch ange of information and best practices.  
Additionally the actions outlined in the health inequalities impact assessment stakeholder 
consultation, the CoR calls for the funding of telemedicine. Assessment of the impact of 
Community funding is difficult, because finances are channelle d through various national or 
regional structures. 
Mainstreaming is deemed necessary especially in the policy fields of social policy (incl. social 
housing and poverty reduction), education, la bour market (safe working conditions and 
reduction of job insecurity), urban planning a nd transport (reducing ineq ualities between rural 
and urban areas), environment (food safety) and immigration (special support to border 
regions). 
8.4. Consultation with key groups conv ened by the European Commission 
Social Protection Committee (SPC) 
Specific consultation took place with the SPC during the impact assessment process on the 
possible objectives and action which are included  in this document. 
Prior to that, in early 2007 a peer review on health  inequalities in the context of health care 
reform took place in Hungary within the progr amme of peer reviews organized through the 
SPC.  It brought together representatives of 8 EU Member States, who shared their policy 
experiences with each other and with a sm all number of relevant non governmental 
organizations, academic researchers and Commission staff.  The peer review showed that differences in health status and access to care can  be substantial within each country depending 
on place of residence and socio-economic status.  Member States exchanged views in terms on policies particularly in relation to the design of h ealth services in order not to deter those more 
vulnerable from accessing necessary care and thus  to avoid a negative impact on health from 
delayed treatment (e.g. cost-s haring, health insurance).  
In the spring of 2007, the Commission presented a discussion paper on he alth inequa lities in 
the EU to the Member State delegates to the SPC.  This paper reviewed existing evidence of 
health status inequalities within Member Stat es using published research papers, SHARE data 
and EU-SILC data.  It reviewed existing policies or policy pr oposals by Member States as put 
forward in the National Strategy Reports (NSRs)  on Social Protection and Social Inclusion 
2006-2008.  The paper was well received by Member  States who consider ed this to be a 
priority area for health and social policy.  
Several Joint Reports have also hi ghlighted the issue of health in equalities as a crucial area for 
policy (Joint Report on Social Inclusi on 2004, the JRSPSI 2006, the JRSISP 2007 and the 
JRSISP 2008).  The JRSISP 2008 provided an entir e chapter on health inequalities within 
 
EN 65   EN countries, across population groups. NSRs 2008- 2011 and Joint Report 2009 in addition to 
above mentioned reports.  
An indication of the policy interest in this area is that Member States have agreed to a regular 
monitoring of health status  inequalities under the social OMC using a set of common 
indicators (life expectancy, heal thy life years and self-perceived  measures of general health 
and activity limitations).  The Indicators sub-Gr oup (ISG) of the SPC ha s in several occasions 
highlighted the need to improve data comparabilit y in this area and the need to have data and 
indicator by sub-categories such  as age, sex and socio-economi c status.  The ISG has also 
called for further improvements in the collectio n of mortality data by socio-economic status.  
The development of indicators of health status and access to care are an important part of its 
work.   
On the SPC meeting of 18 March 2009 there was a dedicated agenda item whether and what 
additional EU level action was needed to addre ss health inequalities between and within EU 
Member States.  The outcomes of th at discussion are as follows.   
Member States strongly welcomed additional acti on by the Commission as they deemed this is 
a very important/pertinent topic, central to human development.  They held a social 
determinants perspective of the issue i.e. heal th inequalities are the result of many factors 
(social determinants) that lead to unhealthy living conditions (e.g. life-styles, income, employment) in addition to acc ess to quality health care (promotion, preventi on and treatment).  
Thus health inequalities relate to policy areas other than healthcare su ch as education, income 
distribution, housing, and social protection for example.  Thus, they support a "health in all 
policies /inter-sectoral" approach to addressing the issue and welcome the fact that additional 
actions are joint initiatives by DGs EMPL and SANCO and other Co mmission services.  
Moreover, they suggest that, from this perspec tive, it is necessary to look at both member 
States competences and work and at EU competences and work and mobilise resources at the 
two levels, where they can impact on those factor s.  Member States claimed that the issue does 
not pertain to vulnerable groups only but is in fact about a social gradient and thus action 
should address this social gradient.  However,  if these actions do not help improve e.g. access 
to services by those more vulnerable then special actions may be needed.  Additional actions were proposed along the following lines: 
• Conduct reviews of Member States actions to  address health ine qualities e.g. assess 
equal access to health services, quality and effectiveness of health systems in 
addressing health inequalities; Conduct studies based on an SPC questionnaire. 
• Fund research studies on the quality and pr actical implication and consequences of 
actions. 
• Conduct more extensive and intensive excha nge through peer revi ews but especially 
in-depth reviews on the ba sis of a questionnaire / consultation structure.  
• Organise a high profile conference every 2 ye ars to see what has been the progress in 
the area. 
• Create a platform approach with stakeholder involvement. 
• Support and follow experiments better thr ough PROGRESS and publ ic health action 
programme.  
• Conduct analysis of specific types of diseases  and mortality rates as  it may be "easier" 
to identify good promotion and prevention st rategies. Monitor evolution of specific 
diseases and in certain groups (e.g. children).  
• Complement this with looking at specific groups and their access to care (e.g. disabled, 
elderly, profession, gender). 
 
EN 66   EN • Work on improving the common social OMC i ndicators already agreed to, notably in 
terms of comparability. Continue work to have life expectancy, mortality rates and 
healthy life years by age, se x and socio-economic status. 
• Investigate whether more resources could be  made available to healthcare through the 
Structural Funds and to re duce health inequalities 
• Ensure the visibility of the issue i.e. of the existing inequalities in health, of the actions 
to improve it and look for political commitm ent (especially from other policy areas).  
Finally, assess the impact of the crisis on healthcare and health in the SPC assessment and the 
crisis should not halt the work on hea lth inequalities, quite the contrary  
EU Expert Group on Social Dete rminants and Health Inequalities 
The EU Expert Group on health inequalities and social determinants of health is an 
informal group convened by the Commission in cluding representative s nominated from 
Ministries of health of Member States as well as officials from several Commission services, the WHO, OECD and the Council of  Europe.  The Comm ission's Communication 
on health inequalities was a main agenda it em at meetings of the group in December 2008 
and March 2009.  
The group commented favourably on the review of the evid ence and expressed strong 
support for the main ideas for further action. Pa rticipants saw the crisis as adding extra 
urgency to the initiative and offered a number  of suggestions for how  to tackle various 
methodological, procedural and political issues. 
 The group identified a range of ideas for how to  progress EC work on  health inequality 
reduction which will be further elaborated in written responses . Particularly useful were 
suggestions for how to approach methodologica l problems of measurement and monitoring 
and political dilemmas of priority setting and sequencing of actions. There was a wide-
ranging discussion on the pros and cons of target  setting. Several par ticipants made clear 
that they would welcome support for countries who wished to set targets for themselves. 
However, they did not support the European Commission setting targets at country level. 
There was considerable discussion about targets for the European Commission e.g. on 
'equity-proofing' EU policies, with more disc ussion necessary. Participants from a number 
of Member States expressed in terest in the possibility of a joint action through the Health 
Programme to support implementation mechan isms for the forthcoming Communication. 
 Other points included:  
¾ The health impact of the crisis adds new urgency to action aimed at containing and 
reducing health inequalities – there is  a danger that these will increase. 
¾ Reduction of health inequalities is neith er just about health promotion nor 
primarily about poverty avoidanc e; it concerns health in all policies with a definite 
equity emphasis. 
¾ At this stage more is known about policies to  tackle gaps in health rather than the 
gradient in health in equalities. While better  data might be usef ul to understand how 
the steepness of the gradie nt plays out across social  groups in different MS, a 
 
EN 67   EN greater concentration should be  given to identifying policies which help to level the 
gradient, as well as addressing the gap.  
¾ Delivering benefits for the working and mi ddle classes are important for securing 
broad political support for acti on on health inequalities.  
¾ At the same there needs to be special attention to those groups particularly 
disadvantaged by socially determined poor  health. In this work it would be 
important to draw on knowledge and expe rience from the EU’s work on social 
inclusion. 
¾ Delivery mechanisms in present health services can increase socially determined 
health inequalities  sometimes in a ve ry significant way. A ddressing the health 
sector from a social determinants a nd equity perspective would both make a 
contribution to reducing HI s, and set the lead for action by other sectors. . 
¾ Need to include elements on pub lic health capacity building. 
¾ Additional work at the EU level on health equity impact assessment of both 
existing and future policies would be welcome. 
¾ Improved mechanisms for collaboration on h ealth inequalities between the Social 
Protection Committee the EU Expert Group and the Council Working Party on 
Public Health would be a good idea.  
¾ In addition to support from the structural funds more work should be done to see, 
among other policies how the Agriculture and Rural Development and internal 
market policies could assist , and consider the impact of EU policies on health 
inequalities globally, particular ly in low income countries.. 
 
Open Health Forum 
A session of the EU Open Health Forum held a plenary session in December 2008 on 
health inequalities chaire d by the Director General of DG SANCO with around 400 
participants.  A background paper describe d the proposed communication and invited 
comment on a number of key questions.  Th e rapporteur summarised the discussion as 
follows: 
Making a difference in health inequalities at the local level will only be possible through 
the active involvement of a very wide range of stakeholders.  EU action should be across 
all relevant policies and enable engagement at all levels with a wide range of civil society 
actors as well as governments.  The EU shoul d contribute to alle viating poverty and 
improving the living conditions – with an emphasis on the mo st vulnerable. Rural and 
urban deprivation should be addressed  U ltimately all action must impact locally and 
involve local people, which will require m easures to enable relevant networks and 
stakeholders to have an impact on people as part of their everyday lives – at work, at 
leisure, at  home, in schools and universities  in hospitals in  care institutions and in 
communities.  Equity orientated health poli cies on chronic disease prevention are needed 
with greater emphasis on tackling major health  determinants such as tobacco, alcohol, 
obesity, physical activity and accidents.  Actio n should aim to create the biggest impacts 
amongst areas, communities and groups with the greatest need.    
 The EU should be active in: proposing targets and benchmarks; suggesting what action is 
needed by which actors; monitoring progress towards targets; carrying out analyses and 
impact assessment of its policies to determ ine their impact on equity between social 
 
EN 68   EN groups and regions; facilitating exchange of  good practice and engaging with governments 
and stakeholders; using its f unding instruments to support ac tion on inequalities in ways 
which are easier for disadvantaged people to benefit and creating a genuine health in all 
policies approach.  It is particularly important  to do this now in orde r to protect and make 
fundamental values of solidarity, social cohesi on and human rights a reality at a time of 
economic difficulties  
 
European Health Policy Forum 
The European Health Policy Forum meeting in  January 2009 discussed the possible actions 
which would be desirable in a future Commu nication on health inequalities and were 
invited to provide further i nput on several key questions. 
Participants strongly welcomed the Co mmission initiative to bring forward a 
communication on health inequali ties. Participants commented that more work should be 
done to encourage and support countries which had not yet carried out any analyses on the distribution of health by area and by social group to do so. There was qualified support for 
target setting at the EU level and the idea of health inequality impact assessment of existing and planned policies was strongly suppo rted.  More work was needed to involve 
disadvantaged and vulnerable groups in contri buting to policy development which affects 
them. The EU work on health literacy coul d be a useful and re levant input to the 
development of the Communication.   Further work by the EU to support regions to 
improve health and address health inequalitie s both directly through the structural funds 
and by encouraging exchange of good practic e via networking and other arrangements, 
would be very welcome. 
 
8.5. Consultation with EU institutions 
The Committee of the Regions included a c onsultation on the Communication on health 
inequalities as part of its work for 2009.  A targeted consultation took place through the 
subsidiarity platform.    
In order to facilitate di alogue and provide input into  the development of the 
Communication the European Economic and So cial Committee established a study group 
and selected a rapporteur in an ticipation of the Communication. 
Committee of the Regions 
The Subsidiarity Platform of the Committee of  the Regions conducted a consultation on the 
"Assessment of Territorial Imp acts of EU Action to Reduce H ealth Inequalities". Thirteen 
regions participated, five of which were from  Spain and none from the new Member States. 
The drivers of inequalities identified incl uded socio-economic and life-style factors; 
geographical features such as remoteness, fragmentation, islands and mountainous 
environments which present concrete barriers to the use of services; and cultural heritage 
(people's perception of health systems and issu es according to local traditions, organisation 
and ethnicity).. 
Desirable Community action in cluded: mainstreaming, equity -focused health impact 
assessment, promoting universal coverage, improve monitoring and standardisation of 
indicators, research, learning and training, exch ange of information a nd best practices.  
 
EN 69   EN Additionally the actions outlined in the health inequalities impact assessment stakeholder 
consultation, the CoR called for the funding of telemedicine. Assessment of the impact of 
Community funding is difficult, because finances are channelle d through various national or 
regional structures. 
Mainstreaming is deemed necessary especially in the policy fields of social policy (incl. social 
housing and poverty reduction), education, la bour market (safe working conditions and 
reduction of job insecurity), urban planning a nd transport (reducing ineq ualities between rural 
and urban areas), environment (food safety) and immigration (special support to border 
regions). 
The Committee of the Regions (COR) carried out  an impact assessme nt consultation among 
the partners of the Subsidia rity Monitoring Network during February and March 2009 and 
received 13 responses.  Health in equalities were perceived as a pr oblem.  Factors mentioned as 
drivers included: (i) socio-economic conditions; (ii)  lifestyle; (iii) geograph ical features of the 
territory; and (iv) cultural heritage.  Action at Community level was considered necessary 
particularly in relation to im proving comparability of information and assessment of the state-
of-the-art processes at national and regional level.  Other sugge stions for action included: (i) 
promoting ‘Health equality in al l policies’ (ii) developing an equality-focused health impact 
assessment; (iii) promoting universal coverage health systems across the EU; (iv) improving 
mechanisms for monitoring inequalities in heal th across Europe, (v) pr omoting research and 
exchange of best practice.  In  more specific terms and stressing the particularities of remote 
areas, like islands, EU support fo r health information technology was seen as an  added value 
for these regions. More broadly, the COR high lighted the EU’s role for agenda setting. 
 
8.6. Expertise  
Expert input to the development of the Communication came from a number of projects 
funded by the Second Programme of Community Action in the Field of  Health 2008-2013 and 
before by the Public Health Programme (2003-2008) and by DG EMPL PROGRESS and the 
previous Social Inclus ion Action Programme.  
EuroHealthNet and the German Federal Centre for Health Education (BZgA) coordinated a 
project entitled “Closing the Gap: Strategies  for Action to tackle Health Inequalities in 
Europe” (June 2004- June 2007), co-funded by the European Commission, under the EU Public Health Programme. A final Closing the Gap Conference, 'Action For  Health Equity' 
took place in Brussels on 8 May, 2007 and was followed by a publication ‘Taking Action on 
Health Equity’
41 which presents an overview of what each  of the countries that participated in 
the project are currently doing to ta ckle health inequalities, and furt her actions that they plan to 
take. It also includes a series  of key conclusions and recommenda tions for priority actions in 
this area.  Four areas in wh ich action was most needed: a) Awareness Raising and Advocacy; 
b) Health in All Policies and H ealth Impact Assessment (HIA); c) Support to the Regional and 
Local Level and d) Evidence and Evaluation  
EuroHealthNet and the Czech National Institute of  Public Health are coordinating a three year 
initiative (2007-2010) that focuses on mobilising all relevant collective forces within the EU to 
generate action on improving health by addressing  the socio-economic determinants of health. 
                                                 
41  See 
http://www.eurohealthnet.eu/images/publicati ons/taking%20action%20on%20health%20equity.pdf   
 
EN 70   EN DETERMINE is co-funded by the European Co mmission Public Health Action Programme. 
Building on the work of the WHO Commission on So cial Determinants of Health the objective 
is to generate greater understa nding and to change conception s and approaches amongst policy 
makers and practitioners, so that improving health and health equity is considered in all policy 
sectors. See also the European Portal for Action on Health Equity42. Previously EuroHealhtNet 
and NHS Health Scotland (PHASE II) and the Neth erlands Institute for Health Promotion and 
Disease Prevention (Phase I) conducted a project entitled "T ackling Health Inequalities and 
Social Exclusion in Europe", funded by th e European Commission Action Programme to 
Combat Social Exclusion. The associated report43 highlights the exchan ge of good practices 
between health professionals addressing social ex clusion across Europe, th at is, the wide range 
of ways in which the health field can contribut e to reducing social excl usion and poverty.  This 
work has highlighted that areas for develo pment include the need for monitoring and 
evaluation, evidence based policies, policy coor dination and the establishment of targets. 
A study commissioned by the European Commission Public Health Programme regarded the 
"Economic implications of soci o-economic inequalities in health  in the European Union" and 
was conducted by the Erasmus MC, Department of  Public Health, The Netherlands. The study 
argues that health inequalities ar e one of the main challenges fo r public health and have a large 
negative economic impact: the es timates suggest that the econo mic impact of socioeconomic 
inequalities in health is lik ely to be substantial: about €1,000 billion, or 9.5% of GDP. The 
study concludes that there is a great potenti al for improving average population health by 
reducing the health disadvantage of lower soci oeconomic groups. This requires an active 
engagement of many policy sectors,  not only of the public health and health care systems, but 
also of education, social securit y, working life, city planning, etc. 
Previously, " The health status of the European  Union - narrowing the health gap , 2003" came 
as an outcome from a pr oject of the health moni toring programme (1997-2002)  
Finally, the project "EUROTHINE  - Tackling Health Inequalitie s in Europe: an integrated 
approach" was conducted by the EMC (Erasm us MC) Universitair Medisch Centrum 
Rotterdam - University Medical Centre Rotterdam44   
 
                                                 
42  At http://www.health-inequalities.eu/   
43 See http://www.eurohealthnet.eu/images/publications/pu_1.pdf . Other related documents include 
"Promoting social inclusion and tackling health inequalities in Europe, an overview of good practices from the health fi eld" and "The role of the health care sector in tackling poverty and social 
exclusion in Europe" at  http://www.eurohealthnet.eu/images/publications/pu_3.pdf  and 
http://www.eurohealthnet.eu/images/publications/pu_4.pdf   
44 See http://ec.europa.eu/health/ph_projects/2003/action1/action1_2003_16_en.htm#3  
 
EN 71   EN 9. ANNEX  2: HEALTH INEQUALITIES IN THE EU 
This section provides additional detail on the nature and scale of the problem of health 
inequalities in the EU.   
9.1. Background and context: Nature and scale of health inequalities in the EU 
9.1.1.  Inequalities in health outco mes between Member States 
Substantial differences in life  expectancy at birth can be observed across the EU Member 
States, with individuals in ma ny new Member States living shor ter lives than their Western 
counterparts (Figure A1-A5).  An  8-year gap for women (between ES, FR and IT, and BG, on 
one hand, and LV and RO on the other) and a 14-year gap for men (between CY and SE, on 
one hand, and LT and LV on the other) can be see n.  In BG, LV, LT, RO, SK, DK, EL and LU 
the gap between national life expectancy and the EU average has actually increased in the last 
two decades (Table A1).  Moreover, while the ge nder gap in New Member States is still large 
(e.g. 11 years in LV and LT).  
Figure A1: Life expectancy at birth, 2006  
0102030405060708090
BE BG CZ DK DE EE IE EL ES FR IT CY LV LT LU HU MT NL A T PL PT RO SI SK FI SE UK
men women 
Source: Eurostat, UK 2005, IT 2004. 
 
EN 72   EN Figure A2:  
Female life expectancy at birth - differences from the EU average
-7,0-6,0-5,0-4,0-3,0-2,0-1,00,01,02,03,0
BE BG CZ DK DE EE IE EL ES FR IT CY LV LT LU HU MT NL AT PL PT RO SI SK FI SE UKyears
2006 
Source: Eurostat, UK 2005, IT 2004 
 
Figure A3:  
Female life expectancy at birth - differences from the best three 
performers (FR, ES, IT)
-14,0-12,0-10,0-8,0-6,0-4,0-2,00,0
BE BG CZ DK DE EE IE EL CY LV LT LU HU MT NL AT PL PT RO SI SK FI SE UKyears
2006 
Source: Eurostat, UK 2005, IT 2004 
 
 
EN 73   EN Figure A4:  
Male life expectancy at birth - differences from the EU average
-12,0-11,0-10,0-9,0-8,0-7,0-6,0-5,0-4,0-3,0-2,0-1,00,01,02,03,04,0
BE BG CZ DK DE EE IE EL ES FR IT CY LV LT LU HU MT NL A T PL PT RO SI SK FI SE UKyears
2006 
Source: Eurostat, UK 2005, IT 2004 
 
Figure A5:  
Male life expectancy at birth - differences  from the bes t three performers  
(CY, SE, IT)
-14-12-10-8-6-4-20BE BG CZ DK DE EE IE EL ES FR LV LT LU HU MT NL A T PL PT RO SI SK FI UK
2006 
Source: Eurostat, UK 2005, IT 2004 
 
EN 74   EN  
Table A1: Differences in female national life expectancy and the EU average, 1986, 1996 and 2006  
 Life 
expectancy 
1986 difference t o
EU average Life 
expectancy 
1996 difference to 
EU average Life 
expectancy 
2006 difference to 
EU average 
AT 77,8 -0,2 80,2 0,9 82,8 0,8 
BE 78,2 0,2 80,7 1,4 82,3 0,3 
BG 74,8 -3,2 74,5 -4,8 76,3 -5,7 
CY     82,4 0,4 
CZ 74,7 -3,3 77,5 -1,8 79,9 -2,1 
DE 77,7 -0,3 80,1 0,8 82,4 0,4 
DK 77,7 -0,3 78,3 -1,0 80,7 -1,3 
EE   75,6 -3,7 78,6 -3,4 
ES 79,9 1,9 82 2,7 84,4 2,4 
FI 78,9 0,9 80,7 1,4 83,1 1,1 
FR 79,8 1,8   84,4 2,4 
GR 78,8 0,8 80,2 0,9 81,9 -0,1 
HU 73,3 -4,7 75 -4,3 77,8 -4,2 
IE 76,4 -1,6 78,7 -0,6 82,1 0,1 
IT 79,1 1,1 81,8 2,5 83,8 1,8 
LT 76,4 -1,6 75,9 -3,4 77 -5,0 
LU 78,7 0,7 80,2 0,9 81,9 -0,1 
LV 75 -3,0 76,8 -2,5 76,3 -5,7 
MT   79,6 0,3 81,9 -0,1 
NL 79,7 1,7 80,5 1,2 82 0,0 
PL   76,6 -2,7 79,7 -2,3 
PT 76,8 -1,2 79 -0,3 82,3 0,3 
RO 72,8 -5,2 72,8 -6,5 76,2 -5,8 
SE 80,2 2,2 81,7 2,4 83,1 1,1 
SI 76,4 -1,6 79 -0,3 82 0,0 
SK 75,1 -2,9 77 -2,3 78,4 -3,6 
 
EN 75   EN UK   79,5 0,2 81,1 -0,9 
EU avera g 78,0  79,3  82,0  
Source: Eurostat, UK 2005, IT 2004 
There are also large differences (of up to 20 ye ars) in the number years lived in good health 
(Healthy Life Years) (Table A2 )45,46,47  Recent negative trends have been observed: Since 
2006 the number of Healthy Life Years has decr eased in many countries (FI, AT, ES, IT, IE, 
BE and all EU12 countries), es pecially for women who alrea dy spend a higher proportion of 
their lives with limitations.  Data in Table A2 suggests that, in general, people in Central and 
Eastern Europe live fewer years of their lives in good health (without lim itations) esp ecially in 
the case of men; the difference between the best  and lowest performing states in the EU can 
reach 20 years!48  While men in EE live only 71% of th eir lives in good health, in DK men can 
expect to live 90% of their li ves in good health (EUROSTAT 2006)49.   
  
Table A2: Life expectancy and healthy life years, 2005  
                                                 
45 A word of caution is necessary as by construction th is indicator is based on se lf-perceived limitations in 
activities and this measure may be prone to cross-country cu ltural differences.  
46 See also Jagger et al. (2008) that also suggests that the gap between Ea st and West in both life expectancy 
and years spent in good h ealth is considerable. 
47 See http://ec.europa.eu/health/ph_information/indicators/lifeyears_en.htm  for more detail.  
 
49 See http://ec.europa.eu/health/ph_information/indicators/lifeyears_en.htm  for more detail.  
 
EN 76   EN 
 
 
Substantial differences are found in infant mort ality, which is higher in  Central and Eastern 
Europe, in premature mortality, in avoidable mortality and in more subjective measures of 
health such as self-perceived general health, long-standing illness or activity limitations in the past 6 months (Figures A6-A7).   
Figure A6: infant mortality  
02468101214
BE BG CZ DK DE EE IE EL ES FR IT CY LV LT LU HU MT NL AT PL PT RO SI SK FI SE UK
2006 
Source: Eurostat, BE 2005, UK 2005, IT 2004. 
 
 
EN 77   EN Figure A7: Premature mortality - risk (probability) of dying before the age of 65, 2002  
 
 
Detailed analysis of the hea lth gap (see Annual Repor t of the European Ob servatory on Social 
Situation and Demography50) between EU-15 (+ MT & CY), and the remaining new Member 
States shows that differences between Member  States are explaine d by high mortality and 
morbidity in terms of cardiovascul ar disease, injuries and viol ence, cancer, and alcohol-related 
diseases and their underlying risk  factors: smoking, diet and alcohol consumption.  In some 
countries, contrary to the gene ral EU trend, some mortality ra tes have grown during the last 
decade.  For example (EUROSTAT, 2006), death rates due to ischemic heart diseases for 
women are 12 times higher in LT than in FR  (263.2 vs 22.5 deaths per 100,000 inhabitants), 
death rates due to pneumonia varies 9 fold  for men (5.3 in EL vs 46.4 deaths per 100.000 
inhabitants in SK), and death rates from cer ebrovascular diseases for women are 6 times 
higher in RO than in FR (184.9 vs 25.9 deaths per 100.000 inhabitants).  Death rates from liver 
cirrhosis for men are 10 times higher in HU or RO  than in NL or EL (65 and 52 vs 4.4 and 5.3 
per 100,000 inhabitants).  Fatal injuries amongst men in the Baltic States (LT, LV, EE) are about 7 fold higher than in the NL and the UK (219, 210 and 206 deaths vs 31 and 33 deaths 
per 100,000 inhabitants).  There are also differen ces in disease incidence: e.g. the incidence 
rate of lung cancer for men varies 4.5 fold  between EU countries (GLOBOCAN 2002, IARC - 
International Agency on Research on Cancer).  In addition, mortality ra tes have increased in 
the poorest Member States sinc e 1996 (EUROSTAT): e.g. the mort ality rate due to pneumonia 
has risen in LT by 52%, in LV by 34%, and in PL by 13%, when many other Member States 
have actually reduced such mortality rates by up to 50%.  Moreover, LV, LT, HU, SK and PL 
have reduced mortality due to ischaemic heart disease and respiratory diseases by only 5% since 1996 (Inequalities in heal th outcomes between socio-economic groups within Member 
States.  
                                                
 
50 See http://ec.europa.eu/employment_social/spsi/reports_and_papers_en.htm   Women
25%18%18%17%16%16%16%15%13%13%13%12%11%11%11%11%10%10%10%10%9%9%9%9%9%8%8%7%
0% 20% 40% 60% 80% 100%RussiaRomaniaLatviaHungaryEstoniaBulgariaLithuaniaEU10SlovakiaPolandDenmarkCzech Rep.BelgiumUKNetherlandSloveniaIrelandPortugalLuxembourgGermanyEU15FinlandFranceAustriaSwedenItalyGreeceSpainMen
59%44%43%41%36%36%33%33%31%31%25%25%22%20%20%20%19%19%18%18%18%18%18%17%17%16%15%14%
0% 20% 40% 60% 80% 100%RussiaLatviaEstoniaLithuaniaHungaryRomaniaEU10BulgariaSlovakiaPolandCzech Rep.SloveniaPortugalBelgiumFranceFinlandLuxembourgDenmarkGermanyAustriaIrelandEU15SpainUKGreeceNetherlandItalySweden
 
EN 78   EN The literature showing socio-economic differences in health in the EU is extensive51.  These 
start at a young age and persist and widen in older ages (SHARE ).  An analysis (Mackenbach, 
2006)52 produced for the UK Presidency53 shows differences in life expectancy at birth and at 
higher ages between the lowest and the highe st socio-economic groups (e.g. between manual 
and professional occupations; people with prim ary level and post-secondary education; low 
and high income quintile) ranging from 4 to 10 years for men and from 2 to 7 years for women.  In some countries the gap has widened in the last decades.  
 Also, despite an overall decline, mortality and in fant mortality are higher in the lowest socio-
economic groups and relative ineq ualities have increased in seve ral countries.  The risk of 
dying in the lowest socio-economic groups was f ound to be 25 to 50 to even 150% more than 
in higher groups and relative inequalities in mo rtality have increased in several countries. 
Inequalities in mortality from cardio-vascular diseases account for about half of the excess mortality in lower socio-econom ic groups, who also register lower cancer survival.  Also, 
despite an overall decline, infa nt mortality continues to be higher in lower social-economic 
groups.  In some countries this gap has increased. 
Rates of disease and disability also vary s ubstantially by socio-econom ic group.  People with 
lower education live shorter lives and spend more  time in poorer health.  For ‘self-perceived 
general health’ a clear income gradient can be ob served in that those in  the lowest (poorest) 
income quintiles more often report very bad heal th than those in the hi ghest (richest) quintiles 
(Table A3).  In some countries (DK, LT, and SK ) the percentage reportin g very bad health in 
the lowest quintile has gone up since 2005.
54  Similar conclusions can be drawn when looking 
at self-perceived activity limitations (Table A4 ).  SHARE data shows that individuals with 
lower education or lower income are more lik ely to experience limitations with mobility, arm 
or motor functions and have a hi gher prevalence of eyesight, hearing and chewing problems.  
Several studies (Dastra et al.,  2005; Huisman, Kunst et al., 2 003; Huisman, Kunst et al., 2004) 
found socio-economic inequalities for a range of common chronic diseases such as  diabetes, 
arthritis, chronic respiratory a nd heart diseases (figure A8).   
                                                 
51 See the Health Status & Living Conditions part of the Monitoring Reports from the European Observatory 
on Social Situation and Demography repo rts for a review of the literature at 
http://ec.europa.eu/employment_soci al/spsi/reports_and_papers_en.htm   
52 See "Health inequalities: Europe in Profile" by Mackenbach (2006) at 
http://ec.europa.eu/health/ph_determinants/socio_economics/keydo_socioeco_en.htm . Previous 
important studies include van Doorslaer, Wagstaff et al. (1997), Cavelaars, Kunst et al. (1998), 
Mackenbach, Cavelaars et al. (2000); Mackenbach , Bos et al. (2003), Avendano, Kunst et al. 
(2005). 
53 See http://www.dh.gov.uk/en/Healthca re/International/EuropeanUnion/EUPresidency2005/DH_4119613   
54 A word of caution is needed when looking at these conclusions, as current information covers a maximum 
of three years and hence the changes observed may not be a significant sign of a trend. 
 
EN 79   EN Table A3: Self-perceived general health (very bad health), by income quintile  
 
Source: Eurostat based on EU-SILC 2006 data 
 
 
EN 80   EN Table A4: Self-perceived limitations in activities people usually do as a result of health problems and 
lasting for at least the last 6 months (severely hampered in activities), by income quintile  
 
Source: Eurostat based on EU-SILC 2006 data 
Note: DK does not report severe an d moderate limitations separately. 
 
   
Source: SHARE 2005 
 
 
EN 81   EN Figure A8: Odds ratios of having a chronic disease between 2004 and 2006 comparing low and middle 
with high wealth  
 
Source: SHARE 2007. NB: The odds are adjusted for age, gender, country, and the time-interval 
between waves 
 
 Some vulnerable groups suffer a greater  burden of mortality and disease
55.  These include 
some migrant and ethnic minority populations, peopl e living in deprived urban and rural areas 
and in poverty, the unemployed, especially long- term unemployed, those informally employed, 
seasonal/daily workers and subsistence farmers, those further from the labour market, jobless 
households, the homeless, the disabled, those suffering from mental or chronic illnesses, 
elderly pensioners on minimum pe nsions, and single parents. In rural areas of RO and BG 
infant mortality is 3 times higher than in th e capital.  Inequalities between nationals and 
migrants persist in Europe, in terms of hea lth status and in access to health services 
(promotion, prevention, treatment and care).56,57  Note for example that migrants may 
experience greater health  risk than the majority population due to greater vulnerability to 
communicable diseases (TB, HIV/AIDS, hepatitis ).  They may also face higher risks of non-
communicable diseases (cardiovascular diseas e) and mental health problems due to a 
combination of the socio-economic and environmen tal conditions in the or igin, transit and host 
countries (2007 Council Conclusions on Health and Migration in the EU). 
                                                 
55 As indicated in the Joint Report on Social Prot ection and Social Inclusion and social OMC and equal 
opportunities related studies/ networks, the Handbook on Integration for policy-makers and 
practitioners, the Health and Migration in the EU work under the 2007 PT Presidency, and the work 
of the International Organisation of Migration. 
56 See "Challenges for health in the age of migration" at http://www.eu2007.min-
saude.pt/PUE/en/conteudos/programa+da+saude/Publications/Relat%C3%B3rio+Sa%C3%BAde+e
+Migra%C3%A7ao.htm   
57 See also "Migration and the right to health", IOM, at 
http://www.iom.int/jahia/webdav/site/myjahiasite/share d/shared/mainsite/published_docs/serial_publications
/IML12-MRH%20dec07.pdf  and "Quality in and equality of access to healthcare services" at 
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare   
 
EN 82   EN The June 2006 Council Conc lusions on Women's Health58  recognise the importance of the 
gender dimension in health.  Health inequali ties are also a global issue (WHO CSDH, 2008).  
Importantly, there appears to be a strong asso ciation between within country socio-economic 
inequalities in health and the overall population health i.e.  the higher the socio-economic 
inequality in health, the poorer  the overall population health.  Addressing health inequalities 
within Member States could thus contribute to reducing differences in health outcomes 
between Member States.  The importance of addr essing health inequalities as part of overall 
socio-economic development was highlighted in  Council Conclusions under the 2006 Finnish 
Presidency59 and in the  2008 Joint Report on So cial Protection and Social Inclusion.  
9.1.2.  Determinants (drivers or caus es) of health inequalities 
Several models (varying in complexity and details) synthesize the re lation between various 
determinants (including socio-economic factors) and health (Figure A9).  They illustrate the 
“layered” view of the causation of health inequalities (Mackenbac h, 2002): health is not 
randomly distributed but the result of systematic differences in the distribution of those factors, 
in a variety of areas, which improve or harm health.   
According to these models, while biol ogical factors/ gene tic predispositions  may explain why 
one person is more likely to get ill than anothe r in the same circumstances, living and working 
conditions , as well as exclusion and ma rginalisation, affect health through direct and indirect 
physical and psychological mechanisms.  Some  factors operate over long periods: e.g. poor 
conditions in childhood can affect health late r in life.  Depending on where people live and 
what their situation is, people differ in their exposure to positive and negative factors which influence health.   
Indeed, individuals face differen ces in the quality of their phy sical and social environments
 (at 
home – central heating, insula tion, dampness, crowding, at  school, in the workplace – 
exposure to chemicals, accidents and physically hard work; social networks) and are more 
likely to be in poor health when they live in  poor housing/social en vironments (WHO World 
Report 2003, WHO CSDH).  In relation to housing , for example, people are significantly more 
likely to be in poor health when they live in housing characterised by poor conditions such as: insufficient protection against noise, vibrations, dampness, droughts, mould, and cold in 
winter; overcrowding; lack of light or no view  of the outside environment; impediments to 
socialisation (e.g. absence of parks and gardens); vandalism; and other factors which occur 
more often with low socioeconomic status, such  as fear of losing the dwelling, having bad 
image of the neighbours.  In terms of living c onditions, the exposure to noise in EU countries 
for example ranges from 3% up to 18% with po ssibly big regional/local  differences (Table 
A5).  There are sections of the EU populati on which do not have access to running water, 
adequate washing and toilet fa cilities, affordable energy, a ppropriate housing, heating, new 
clothes, or safe environment (e.g. EUROFUND  – 2008 European Quality of Life Survey
60).  
Some studies (e.g. Trannoy and Tubeuf, 2008;  Tubeuf et al., 2008) show a geographic 
environment (pollution) and a neighbourhood/area (deprivation defined as high unemployment 
rates, single parent families, high share of indivi duals with lower education) effect (negative) 
on the health of individuals independently  of each individual characteristics.   
                                                 
58 See http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/89830.pdf   
59 Council Conclusions on Health in All Policies (HIAP). 
http://ec.europa.eu/health/ph_projects/2005/action1/docs/2005_1_18_frep_a8_en.pdf  
60 See http://www.eurofound.europa.eu/pu bdocs/2008/52/en/1/EF0852EN.pdf  
 
EN 83   EN Figure A9: Determinants of health and health inequalities  
 
Health is also determined by health-related behaviours  (quality of nutrition, level of physical 
activity, tobacco and alcohol use, sexual behavi our), themselves influenced by socio-economic 
and cultural factors and can explain part of the differences  between social groups and between 
countries and areas (SHARE, 2007).  Some studies (e.g. Stronegger et al., 1997; van Lenthe, F. 
J., C. TM Schrijvers, et al. 2004 based on GLOBE, NL; Mackenbach, 2007) show that 
individual health behaviour can explain from 25% to 35% of di fferences in people's health.  
Other studies suggest that ma ternal smoking and poor diet dur ing pregnancy cause impaired 
development in utero which increases the risk of cardiovascular diseas e, stroke, respiratory 
diseases and lung cancer in middle age (Baker , 1992).  There are large variations between 
European countries and socio-economic groups  in nutrition (e.g. consumption of fruit and 
vegetables) and the prevalence of smoking, alcohol consumption, obesity and physical activity 
(Cavelaars et al., 1998; Mack enbach, 2006).  For example,  the prevalence of daily smokers for 
men varies 3 fold between EU countries a nd smoking rates are very high in Central and 
Eastern Europe.  Countries with high rates of smoking combined with low rates of exercise 
and unhealthy diet are also countr ies with the lowest life-expect ancy in the EU (LV, LT, EE, 
BG, RO, PL, SK, HU, CZ).  Studies also show that  health related behaviour is itself and to a 
large extent determined by socio-economic and cultural factors (SHARE; Stronegger et al., 
1997; Lundberg, 1991).  Note that the above studies  are often restricted to specific countries, 
regions or even cities in a country and there is no EU coverage/ comparison on the causality of 
this sub-set of determinants.  
Psychosocial factors  such as negative life events and a co mbination of high effort and demands 
with a low reward and low control also contribute to one's health.   
Past social positions influence individuals' hea lth status in that for example family socio-
economic status  (income, interest in education) can determine a child's education attainment, 
occupation, income and health.  Some studies  (e.g. Trannoy and Tube uf, 2008; Jusot et al, 
2007) show that a high family /parents socio-economic status  impacts on an individual's health 
reducing one's risk of stroke and of stomach  cancer in adulthood life.  Maternal socio-
economic deprivation is significan tly associated with low birth weight and thus the person's 
health throughout his life (MRC Scotland). 
 
EN 84   EN Table A5: Differences in life-styles and living and working conditions between EU Member States  
 
Source: Eurobarometer 283 
 
Figure A10: regular daily smokers in the population (%), age +15, WHO European Region  
 
EN 85   EN 
 
European Observatory of the So cial Situation and Demography 
 
Figure A11: pure alcohol consumption, litres per capita, WHO European Region  
 
European Observatory of the So cial Situation and Demography 
 
Figure A12: obesity rates in european countries  
 
EN 86   EN 
 
European Observatory of the So cial Situation and Demography 
 
Table A6: Differences in life-styles and living and working conditions by age, gender and socio-
economic status  
 
Source: Eurobarometer 283  
 
Table A7:. Socio-economic inequalities in daily smoking in Sweden  
  Number of daily smokers p
1,000 Relative difference Absolute difference
  1988-89 1998-99 1988-89 1998-99 1988-89 1998-99 
 Blue-collar 314 223 1.6 1.7 115 91 
 White-collar 199 132     
 
EN 87   EN Men        
 Poorly educated 327 265 1.6 3.4 118 186 
 Highly educated 209 79     
 Blue-collar 328 263 1.8 1.7 144 110 
 White-collar 184 153     
Women        
 Poorly educated 310 277 2.1 3.0 163 185 
 Highly educated 147 92     
Source: Boström & Rosén, 2003. 
 
 
Unemployment is associated with increased ch ance of poor mental health, social exclusion 
(Kessler et al. 1987; Warr 1987)  and suicide (Blakely, 2003).  Job quality and working 
conditions also affect health to a great exte nt.  A good working environment plays a crucial 
role in terms of ensuring peopl e's health: e.g. differences in exposure to physical, chemical, 
and biological agents at work l ead to differences in health stat us.  A number of studies have 
suggested that job quality and working conditions affect health to a great extent (e.g. Debrand 
and Lengagne, 2008; Jusot et al., 2007): low physic al pressure and stress, high decision ability 
and possibilities to develop ne w skills, a correct monetary re ward and having prospects for 
personal progress contribute to goo d health status whereas lack of support at work and the 
feeling of job insecurity increase the risk of ill health, including depression. Occupational 
health risks vary significantly across sector s and not all workers ar e equally exposed to 
occupational hazards (European Agency for Safety and Health at Work)61: e.g. young workers 
are usually less informed about occupationa l risks, which makes them overexposed, and 
workers with a fixed-duration or temporary em ployment relationship are more exposed to the 
risk of accidents at work and occupational diseases.  The Whiteha ll-Study (1984) of UK 
17.500 civil servants shows a clea r gradient between the lowest  and the highest professional 
level of civil servants.  The link between type of  work and health is related not only to income, 
but also to type of contract, method of work or ganization and occupational health and safety.   
We can indeed observe geographic disparitie s in employment, unemployment (Figures A13 
and A1) and long-term unemployment rates, in working conditions, in continuous life long-training and adult education, in health and safe ty and health at the workplace practices (e.g. 
Employment Report
62), which might also help explain part of the differences in health between 
countries.  GDP per capita and poverty rates vary across th e EU, and substantial income 
inequality persists (Table A8 and Figures A15-A16).  In 2006 th e total income received by the 
20% of the population with the hi ghest income was 4.8 times higher  than that received by the 
20% with the lowest income.   
                                                 
61 See e.g. http://osha.europa.eu/en /topics/accident_p revention/risks 
62 See http://ec.europa.eu/employment_social/employment_analysis/employ_en.htm   
 
EN 88   EN Figure A13: employment rates in the EU; total, women and older workers; 2007.  
.
  
 
Figure A14: Unemployment and youth unemployment; 2000 and 2007.  
 
 
EN 89   EN  
Table A8: GDP PPS per inhabitant  
 200
be Belgium 297 0
bg Bulgaria 95 0
cz Czech Republic 202 0
dk Denmark 303 0
de Germany 281 0
ee Estonia 176 0
ie Ireland 371 0
gr Greece 241 0
es Spain 265 0
fr France 276 0
it Italy 252 0
cy Cyprus 232 0
lv Latvia 144 0
lt Lithuania 152 0
lu Luxembourg 689 0
hu Hungary 158 0
mt Malta 192 0
nl Netherlands 329 0
at Austria 316 0
pl Poland 133 0
pt Portugal 186 0
ro Romania 101 0
si Slovenia 226 0
sk Slovakia 170 0
fi Finland 290 0
se Sweden 313 0
uk United Kingdom 291 0
Source: EUROSTAT 
  
 
EN 90   EN Figure A15: At-risk-of-poverty rate for the total population and for children (0-17) and elderly people (65+), in 
%, 2006   
 
 
Figure A16: Income inequality: S80/S20 income quintile ratio, confidence intervals7 at 95% —  
2006  
 
 
 
EN 91   EN Figure A17:   
Health inequalities versus income inequality
y=2,1+0,62x
024681012
234567
Income inequality using the S80/S20Health inequalities measured by the 
S80-S20 gap (absolute terms) in very 
bad health
 
Source: EUROSTAT 
 
In the background are some important  structural drivers such as the political context, biases, 
norms and values within society, and economic, social, education, environmental and health 
policy, as these can contribute to the degree of social stratificatio n in society (the magnitude of 
inequity along various dimensions).  Differen ces in average health status between Member 
States can relate to differences  in the economy of different areas , which in turns affects health 
through its impact on the quality of jobs, levels of income and quality of living conditions and 
services.  Economic growth and income distri bution policies for example appear to have a 
positive impact on health.   
Differences in levels of income (GDP per ca pita) across Member States (Table A8) may 
explain part of the difference in health between countries.  Across the EU on average higher 
levels of GDP per capita are associated with  higher average levels of population health 
(Figures A18-A19), through improvements in social determinants such as levels of income and 
the quality of jobs, living conditions, a nd public services.  High economic growth  in Member 
States with lower health levels by narrowing di fferences in GDP per ca pita would thus help 
reduce health inequities.  However the relati onship between economic gr owth and health is 
complex.  Evidence suggests that on its own economic growth may not deliver a reduction in 
health inequities.  To ensure that this w ill happen, it needs to be accompanied by other policy 
measures and attention to the distribution of  benefits.  Indeed, while many EU countries 
registered high economic growth in recent years, this has not necessarily translated into 1) a 
reduction of poverty rates, which have actually in creased in some Member States (Figure A20) 
and 2) a reduction in the health  gap within Member States (e .g. Table A1 shows that for BG, 
LT, LV, RO and SK the gap in has actually increa sed).  Moreover, health is not just a function 
of GDP levels; how economic re sources are used to improve  living conditions, promote 
solidarity and deliver services is also important.  The level of health inequalities is therefore 
linked to but is not a simple function of the le vel of GDP.  The translation of GDP per capita 
into health and health equity depends to a la rge extent on policy.  The right policy mix can 
 
EN 92   EN achieve reductions in disparities and thus impr ove general health by optimising the health gain 
for the resources available.  Gl obally there are examples of c ountries with high GDP and high 
health inequalities (USA) or lowe r health inequalities (Canada).  
 
Figure A18: Life expectancy versus real GDP per capita PPP$  
 
 
Figure A19: Trends in GDP per capita and life expectancy at bi rth in 133 countries  
grouped by the 1975 GDP, 1975-2005  
 
Source: WHO World Report 2008 
 0 10000 20000 30000 40000 50000 60000 70000606570758085 Aus tria
Belgium
Bulgaria
Cy pr us
Cz ech Republic
Denm ark
Est onia
Finland
France
Germ any
Greece
Hungary
I celand
I reland
Ita ly
Lat v ia
Lit huania
Lux em bourg
Malta
Net herlands
Nor way
Poland
Port ugal
Romani a
Slov akia
Slov enia
Spain
Sweden
Turkey
Unit ed KingdomY = 0.0002833X+70.04 Y
X
X - Real gross dom est ic product ,  PPP$ per capit a,  Last  av ailable
Y - Lif e ex pect ancy  at  birt h,  in y ears,  Last  av ailable
 
EN 93   EN Figure A20: Impact of economic growth on poverty: change in anchored poverty rate (income years 
2005/04), change in at-risk-of-poverty rate (incom e years 2005/04) — percen tage points; and average 
GDP growth (2004-05) — % 
 
 
 
Variations across the EU can also be observed in relation to the size/ exte nt of social protection 
systems  (Figure A21) including health care and long term care budgets and the protection of 
those outside of the labour market (pensions , sickness, disability, family and child, 
unemployment, housing and social in clusion benefits).  The extent  of redistribution and social 
protection, which vary significan tly across Member States, ma y contribute to the observed 
health gaps (Figures A 21-23).  Income distributi on policies (e.g. social tr ansfers) are estimated 
to reduce the risk of povert y in the EU by 38% (Figure A21, 2008 OMC Monitoring Report63).  
Several research studies suggest that income inequality is one of a number of factors 
explaining differences in health between countri es and individuals (Jen et al, 2009; Babones, 
2008; Leigh and Jenks, 2007; Wilkinson and Picket, 2006; Cantar ero et al., 2005; van 
Doorslaer and Koolman, 2004; Asafu-adja ye, 2004; Gravelle  et al, 2002). 
                                                 
63 See http://ec.europa.eu/employment_social/spsi/docs/social_inclusion/2008/omc_monitoring_en.pdf   
 
EN 94   EN Figure A21: social protection benefits, by function, in % of GDP — 2005  
 
 
Figure A22: Impact of social transfers (excluding pensions) on the at-risk-of-poverty rate for the total 
population and for children, 2006 — %  
 
 
Healthcare influences the like lihood of overcoming disease and avoiding mortality thus its 
availability and quality between and within Member States can  help explain some of the health 
disparities observed.  The size of health budgets can determine the health system capacity to 
meet the care needs of the populat ion: there is a tendency for t hose Member States reporting 
lower life expectancy64 to also report the lowest total health expenditure per capita and as a 
percentage of GDP (Figure A23)  and the highest proportions of unmet need for medical care 
(Table A9).  Also, private expenditure, wh ich can deter access to care by lower socio-
                                                 
64 BG, LV, RO, LT, HU, EE, SK, and PL 
 
EN 95   EN economic groups, may be a factor contributing to health  inequalities in  some countries (2008 
OMC monitoring report).   
 
Figure A23: total health expenditure as % of GDP, 2006 or most recent year  
Total health expenditure as % of GDP, 2006
0.02.04.06.08.010.012.0
fr
debe
pt
at
dk
nl
se
el
it
si
es
mt
uk
hu
fi
bg
ie
lx
sk
cz
lv
pl
cy
lt
ro
ee%
Public expenditure Private expenditure
Source: OECD Health Data 2008 and WHO, HFA-DB 
 
Table A9: Self-reported unmet need fo r medical care in the last year, 2006  
 
Source: Eurostat based on EU-SILC 2006 data 
 
Availability (infrastructure, equipment and health professionals), access and quality of 
healthcare are keys factors determining health and health inequalities as they influence the 
likelihood of overcoming morbidity  and avoiding mortality.  H ealth systems inadequacies 
 
EN 96   EN include under-resourcing (financial and human65) and uneven geographical coverage.  Quality 
distribution of resources and f acilities including poor coverage in some regions and for some 
disadvantaged social groups such as Roma (e.g. Joint Reports on Social Inclusion and Social 
Protection).  They affect the way diseases are diagnosed a nd treated and thus population 
health.  The size of national hea lth budgets can determine the capac ity of a given health system 
to meet the needs of the population.  The quality of healthcare plays a key role: e.g. every year 
3 million patients suffer from healthcare asso ciated infections and 50.000 die from them66.  
Differences in access to quality care translate into very large differences in treatable mortality  
i.e. conditions that respond to  healthcare intervention (Newe y, Nolte, McKee, & Mossialos, 
2003, 2008).  This is particularly acu te in some regions of new Me mber States which lack high 
quality health facilities with up to date  equipment and well trained staff.   
Moreover, socio-economic differences in access to care can be observed (e.g. Alter et al, 1999, 
2006).  There is a clear income gradient in unme t need for medical care : those in the lowest 
income quintiles more often report an unmet need  due to waiting, the dir ect financial cost of 
care and the distance to care (T able A10).  Evidence suggests that lower income families have 
further to travel to hospital or family docto r (Figures A24 and A25) and those with low 
incomes have a lower chance of being admitted to  hospital or be seen by a specialist. Several 
Joint Reports on Social Protection and Social Inclusion have iden tified barriers to access: lack 
of health insurance coverage67, direct financial costs of care, geographical disparities in service 
availability, waiting times, lack of informati on, discrimination and language barriers, health 
literacy and socio-cultural expectations in  relation to life and care services.   
For example, in most countries, doctors and facil ities tend to be concentr ated in the capital and 
richer regions (2009 Joint Report on Social Prot ection and Social Inclusion).  The current 
healthcare staff shortages, which may increase as a result of ageing, can  undermine the quality 
of healthcare systems68.  Finally, health staff may not be trained on issues of equity, social 
exclusion and discrimination or mental health problems.   
Access to healthcare is also affected by gender.  A gender-sensitive focus is critical when 
trying to reduce health inequalities as many ar e caused by social factors, such as education, 
employment and family life, where, again, gender has a significant impact. 
In general, inequitable access to care appears to  be associated with higher health inequalities 
(Figure A26).   
                                                 
65 When looking at resources, a 2-fold difference in the number of practicing physicians per 100,000 
population fold can be found between EU countries. 
66 See: The First European Communicab le Disease Epidemiological Report, 
http://www.ecdc.eu.int/pdf/Epi_report_2007.pdf , p. 319.  
67 See 2008 OMC Monitoring Report where data and analysis of national strategy reports shows that in 
several EU Member States – NL, PL, SK, AT, BE, ES, LU, DE, FR, SI, LT and EE – non-
negligible numbers of the population are not covered by public or primary private insurance 
68 See: Green Paper on the Europe an Workforce fo r Health, 2008, 
http://ec.europa.eu/health/ph_systems/docs/workforce_gp_en.pdf , p. 6. 
 
EN 97   EN  
Table A10: Self-reported unmet need for medi cal care in the last year, by income quintile  
Source: Eurostat based on EU-SILC 2006 data 
 
Figure A24: distance to hospital, income quintile  
 
 
Figure A25: distance to general practitioner/family doctor, income quintile  

 
EN 98   EN  
 
Figure A26:  
Health inequalities versus ineq uitable access to medical care
y=-0,76+1,06x
024681012
0 5 10 15 20 25
Socio-economic (income) inequalities in health measured by the gap (absolute 
terms) between the highest and the lowest income quintile (S80-S20) in the % of 
those reporting unmet need for medical careSocio-economic (income) inequalities 
in health measured by the gap 
(absolute terms)  between the highest 
and the lowest income quintile (S80-
S20) in the % of those reporting very 
bad health
Source: Eurostat based on EU-SILC 2006 data 
 

 
EN 99   EN Figure A27  
Health inequalities versus direct payments for care
y=2,04+0,15
024681012
0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0 40,0 45,0out-of-pocket payments as % of GDP Socio-economic inequalities in health m easured by the gap 
(absolute terms) between the highest and the lowest income 
quintile in the % of those reporting very bad health
 
Source: Eurostat based on EU-SILC 2006 data 
 
Finally, the current economic crisis can impact on health and increase health inequalities 
through a deterioration of social determinants of healt h, especially for thos e who are already in 
lower socio-economic groups with lower qualifica tions and savings.  The loss of job and thus 
income can lead to deterioration in living cond itions, including a poorer diet, especially if a 
safety net (social protection mechanisms includ ing unemployment benefits) is not present.  
Unemployment or job insecurity lead to increased levels of stress and risk behaviour (e.g. 
drinking, smoking) which harm health: depressi on and disturbed immune system, accidents, 
which possible health and educa tion consequences on the rest of  the family (e.g. children).  
Depending on the length of the cris is, the negative impact on heal th can be long lasting: e.g. 
burnout conditions appear years rather than week s or months after unemployment started.  In 
addition, a deep economic crisis can impact on h ealth and increase health  inequalities through 
a deterioration of the access to quality health and social care  especially by those in lower 
socio-economic groups.  This is the case if acces s to care depends on being employed, having 
financial means or on Member States cutting the resources allocated to the health and social 
care sectors resulting in lower coverage or quality of care.  The current economic crisis through posing a financial pressure on health sy stems can motivate countri es to review their 
policy mix on health determinants in search for higher effectiveness and efficiency.   
 
EN 100   EN The information provided above supports the Council Conclusions of November 200669 that 
"health determinants are unequa lly distributed among population groups resulting in health 
inequalities" and "that policies can have positive or negative impacts on health determinants 
reflected in the observed health outcomes and th e health status of the population".  It shows 
that health inequalities are associated with socio-economic in equalities (e.g. uneven 
distribution of resources and opportunities which translate into income, education, occupation 
and environmental differences between and within  countries).  The above description provides 
a general outline of the causes of inequalities in  health between countries and between social 
groups.  More detailed and specific information is nevertheless still re quired to be able to 
establish the effect (causality) and weights of several of those health determinants so that Member States can choose and implement effectiv e action in relation to a particular population 
group or in relation to a pa rticular determinant.   
9.2. What Member States are doing and consider effective to address health 
inequalities   
While about half of the EU Member States have  activities which address inequalities in health 
only a small number have developed comprehensiv e inter-sectoral strategies and even fewer 
have fully assessed their impact.  Hence, info rmation based on comprehensive assessment and 
evaluation of the effec tiveness of actions and strategies is limited.  General examples of 
reductions in gaps in health between regions of  Member States include those achieved by FI in 
the North Karelia project and by DE with a re duction in the mortality rates between new and 
old Länder since reunification.  The UK has recen tly reported some encouraging signs of 
narrowing of health gaps between areas and social groups following a period were these 
inequalities widened. 
Despite the limited knowledge, it is  possible to establish a list of policy actions which have 
been judged by Member States as effective to t ackle health inequalities. There are a number o f 
sources of information on effective policy initiatives including the report produced for the  
2005 UK Presidency on the topic and entitled "H ealth Inequalities: a Challenge for Europe"
70, 
the Eurohealthnet coordinated project "Closing the Gap: Strategies for Action to tackle health 
inequalities", the ongoing Eurohealthnet coordi nated project "Determine" and its related web 
site ( www.health-inequalities.eu ), which gathers Member States information on strategies to 
tackle health inequalities.  The largest am ount of evidence comes from the UK where  
comprehensive strategies to tackle health ine qualities have been developed over more than a 
decade and where several evaluations have taken place 71.   
Reviewing available evidence indicates that ma ny Member States reach a number of general 
conclusions.  Firstly, that in addition to maintaining universal access to a number of key services such as education, social protection an d healthcare, access also ne eds to be intensified 
and targeted at specific groups (e.g. to mother s and children, young parents, and those over 50) 
in disadvantaged areas, in vulnerable families and in lower socio-economic groups.  For 
                                                
 
69 Council Conclusions on Health in All Policies (HIAP). 
http://ec.europa.eu/health/ph_projects/2005/action1/docs/2005_1_18_frep_a8_en.pdf  
 
70 See http://ec.europa.eu/health/ph_determinants/socio_economics/documents/ev_060302_rd05_en.pdf   
71 See for example "Tackling Health Inequalities: 10 years on", Department of Health,  London 2009. 
http://www.dh.gov.uk/en/Publicationsandstatistic s/Publications/PublicationsPolicyAndGuidance/D
H_098936  
  
 
EN 101   EN example, health policy actions do not need to be new but redesigne d i.e. we need to change the 
way we deliver health promotion, disease pr evention and treatment services.  This is 
particularly the case for health promoti on and disease prevention programmes.   
Secondly, Member States argue that regional  and local action, supported by national and EU 
actions, is very important to achieve results an d local authorities must actively search for the 
individuals at risk of lower heal th status in their communities.  One effective way to reach those 
individual is to build neighbourhood and co mmunity infrastructures (e.g. communities for 
health programme in the UK).  Building partnershi ps with the voluntary / third sector and with 
business can also be effective in raising genera l awareness and action (e.g. in the UK a social 
enterprise partner foundation deliv ers a programme in some disadva ntaged areas and in DE the 
health insurance BKK and the Ministry of Work Health a nd Social Affairs concluded a 
partnership to improve the health of the unemployed -  JobFit).  
Thirdly it is widely accepted that measurement and regular reporting of health inequalities 
indicators is an essential firs t step towards effective action.  Building information through the 
development of regular monitori ng of health indicators (e.g. the UK has even developed a quite 
complex composite indicator, the health poverty index), allows fo r awareness-rais ing activities 
(e.g. conferences, seminars, pre and post graduate lectures in  CZ, DE, IE, PL) and allows 
policy makers to identify the extent of the gap and where it lays (types of diseases and causes 
of mortality).  They can then devise strategy to  achieve faster decreases in these diseases and 
mortality in the deprived area s / lower socio-economic groups vis-à-vis the more affluent 
groups.  A good example of the impact of availa ble information and reporting is that of NL 
where a detailed data analysis of the socio-economi c gradient in health id entified a 6 year gap 
for women and a 7 year gap for men.   The publication of the report has motivated the 
development of a policy strategy  for tackling health inequalities.  Similar conclusions come 
from EE, ES and BE following the publicati on of their first report on socio-economic 
inequalities in health.  Data collection, analys is and monitoring must then be accompanied by 
building scientific knowledge for action (not ably through partners hips between national 
administration and universities), which is gath ered and disseminated through a coordination 
centre (e.g. the policy coordination centre for hea lth equity in BE, the national support team for 
health inequalities in the UK, the National Ins titute of Public Health in DK, the National 
Institute for Health Development in EE, the National Institute for Health Education and 
Prevention in FR, the internet platform www.gesundheitliche-chancengleichheit  in DE, the 
Institute of Public Health in  IE comprising the Population H ealth Observatory and the All-
Ireland Health Library, the Working Group on Hea lth inequalities in the Trentino Region in IT, 
Inter-sectoral Coordination Commi ssion of Public Health in LV, Health Inequalities Monitor in 
NL, the National Institute of Public  Health in SE, ).  This entity can advise local authorities on 
what are effective actions.  Learning quickly fr om innovation elsewhere is also deemed crucial 
and several Member States suggest  that initiativ es linking cities and regions have been very 
effective in disseminating information (e.g. the city wide initiative in the UK, the Local Government Denmark, the Healthy Cities Networ k in DK, the National Health Board in DK, 
the city links initiative in NL).  Taking st ock of increasing body of evidence on the causes of 
health inequalities and how they can be influe nced is therefore seen  as a fundamental and 
effective step for devising policy action 
Fourthly, several Member States (UK, BE, IE) th at health impact assessment/health equity test/ 
health equity audit applied to policies across th e board is an effective way to generate inter-
sectoral awareness of health in equalities and the social determ inants of health and health 
inequalities. 
 
EN 102   EN More specific examples of policies considered e ffective by Member States or research review 
studies are as follows: 
• Improve access to information on the risk of smoking and access to smoking cessation 
services for those in deprived areas and in lower socio-economic groups which 
consistently show higher rate s of smoking than more afflue nt groups (UK, NL).  To 
decrease infant mortality and increase life expe ctancy in these groups it is effective to a) 
ensure smoking-cessation during pregnancy (which has been shown to be the most significant of very few know modifiable risk  factors in the prevention of low birth 
weight and as a consequence individuals' h ealth throughout their liv es – Kramer 2000), 
b) stop parental smoking (which  research has shown is stro ngly associated with Sudden 
Infant Death Sindrome) and c) reduce smoki ng in general for those groups.  Smoking 
was considered by the UK DoH as the singl e biggest preventable cause of socio-
economic gradient in infant mortality and life expectancy through lower birthweight and 
higher mortality from Cardiovasc ular disease, stroke and respiratory disease.  Studies 
have showed that NHS stop smoking services  were very effec tive in reducing the 
number of smokers living in more disadva ntaged areas when the access to those 
services was improved.  
• Banning smoking in work places and in public  places is effective in reducing smoking 
rates and passive smoking for all.   
• Evidence from the UK, BE, FI, SE and NL also indicate that the use of taxes can make 
unhealthy items more expensive and reduces  consumption while and subsidies for 
healthy food can increase consumption of thes e, and can contribute  to reducing health 
inequalities because increasinge the price of tobacco and alcohol for example reduces 
consumption by lower income groups as these are more price sensitive. 
• Improving access to food supplementation (vitam in and folate) for pregnant women in 
lower socio-economic groups  
• Improve antenatal care (screening and imm unisation) and post natal care including 
neonatal screening and parent support (i nformation on nutrition, parental smoking, 
sleeping positions etc) for those in less affluent areas and in lower socio-economic groups (UK, PL) or migrants (NL) to reduce th e gap in neo-natal and infant mortality.  
This has been done through working with fa mily doctors and hospitals and the Sure 
Start child centres in the UK (multidiscip linary professionals providing services for 
families and children of up to 5 years in deprived areas), home visits from early pregnancy till 2 years for vulnerable mothers (young, single, deprived areas) in the UK; 
through the ONE centres in BE, for example. 
• Increase breastfeeding initiation and durati on rates in deprived areas and lower socio-
economic groups which are currently lower than  those of more affluent areas /groups 
notably through food vouchers for pregnant women in disadvantaged areas/ groups.  
Breastfeeding reduces th e likelihood of gastro and respirat ory infections and obesity and 
mother's likelihood of developing breast and ovarian cancer, all with the exception of 
breast cancer higher in lower socio-economic gr oups. See instruments of previous point.  
• Improve child immunisation take-up and bett er follow-up of children's health in 
deprived areas and lower socio-economic  group.  An example is the school U-
programme (U1-U9) in DE in addition to the instruments of previous point.  
• Increase the up-taking of screening and re ducing the delays to see a GP and a GP 
referral in deprived areas 
• Managing high blood pressure and reducing ch olesterol levels through medical advise 
and medicines and advise on diet exercise and smoking fo r those in deprived areas 
 
EN 103   EN • Increase flu vaccination of those 65+ 
• Reduce teenage pregnancy and STDs thr ough comprehensive contraceptive advice. 
• Ensure timely access to effective emergenc y services in more deprived areas.  
• Address cultural barriers to care by a) adjustin g medical curricula to  look the topic of 
health inequalities (CZ, NL, PL) by b) using intercultural mediators in the primary and 
secondary care sector (BE, BG, RO, IT, FI , NL) and by using c) community health 
trainers (UK); d) medical services includ ing emergency services working with faith/ 
religious representatives (UK).  For exam ple, in the UK the ambulance service is 
holding a summit with various faith and religiou s services to foster  better understanding 
and better relationships and reduce discrimination 
• Address care supply gaps in some geographic areas by reinforcing primary care services 
which should work together with community social services and other stakeholders 
(BE, NL, UK, HU).  Investment in ICT in the field of healthcare has been effective to 
address healthcare gaps in the specific case of out ermost regions such as the Canaries in ES, 
bringing professionals and users closer together.   
• Making promotion and prevention interventions part of the basis packages of health 
insurance (e.g. exercising by prescription, smoking cessation services) in NL.  Cervix Mass 
screening Programme in HU which was accompanied by social marketing to ensure a boost 
of screening in lower socio-economic groups.  
• Fluoridation of water which reduces the soci o-economic differences in tooth decay in 
children as shown by comparing different c ounties in the UK; Providing meals, fruit 
and milk at schools (DK, UK, HU), which can reduce socio-economic differences in 
nutrition (i.e. improve child nutrition in deprived areas and lower socio-economic 
groups notably in terms of healthy foods). 
• Provide affordable pre-sc hool day care for lower socio-economic groups as this 
increases education and employment atta inment, income level and thus health 
• Ensure good physical education programmes in schools (UK, NL). 
• Decrease school drop-outs (IE, NO, FI, UK, NL ) notably through the Sure Start scheme 
in the UK 
• Improving work organisation (FI, SE, DE). For example, improving work organisation in a 
bus company in DE lead to a significant reduction of sick leave and employee turnover of 
bus drivers (e.g. Greiner & Syme 1994).  
• Improve the physical environment through clean air legislation, green spaces and 
encouraging more walking more cycling ( UK, NL).  Improving housing quality (UK, 
EE) to tackle cold and dampness thr ough improved house building standards and 
through affordable heating for lower socio-ec onomic groups and measures to reduce 
accidents at home (smoke alarms, hand rail s).  A review of UK "area regeneration 
initiatives" showed that these lead to be tter education and employment rates, higher 
household income and housing quality a nd contributed to improving health.  
• Child resistant containers 
• Improving transport links 
• Seat belt and speed legislation (UK, BE),  
• Income support (NL, SE) 
• Using targets (UK, NL, CZ, FI, Basque Count ry in ES) has been effective in raising 
awareness and motivating policy action.  
• Partnerships with voluntary  sector and community groups  including faith / religious 
leaders  
 
EN 104   EN • Partnerships with companies and having public sector giving example for health at work 
strategies (UK, BE, IE, DE).  In DE the health insurance BKK and the Ministry of 
Work Health and Social Affairs concluded a partnership to improve the health of the 
unemployed (JobFit). A public health advoc acy tool to help develop meaningful 
partnerships (IE) and training individuals who can raise awareness and advocate from 
within and beyond their sector (IE).  
• An award system to recognise local authoritie s, local strategies, partnerships or actions 
to reduce health inequalities has been effective to motivate policy development. 
From the above list, several areas can be identified where EU and national action are 
complementary.  The EU can support and complement Member States in the areas of awareness 
raising and advocacy, data development and mon itoring.  It supports research (Research and 
specific action programmes) and the dissemination of information and best-practice exchange 
(e.g. OMC mechanisms).  It provides financial support (e.g. Structural  Funds) which can be 
used for example to develop targeted health promotion and disease prevention interventions 
and to improve the geographic dist ribution of primary care.  More  generally, the EU is striving 
for better environment (cleaner air), health and safety at work and equal opportunities.  The 
need for a collaborative approach is important as it can help optimizing resources and contribute to tackling common challenges within the EU. 
9.3. Existing EU action and links to other relevant EU policies 
EU strategies: growth, employment , social and health strategies 
The Lisbon Strategy on growth and jobs can be expected to de liver some positive outcomes on 
health as growth and more and better jobs improve overall living standards and thus health.  
Healthy life years has been agreed as one of the structural indicators.   
The current European Employment Strategy ( EES) entails a number of policy areas that 
directly or indirectly addresses health inequalities. One of the key objectives in the overarching 
Employment Guideline 17 is to improve quality  and productivity at work and to modernise 
social protection systems. Health and safety at work is one of the main dimensions of quality 
at work. It also represents a cr ucial element in attracting more people into the labour market, in 
particular in the light of agei ng. Moreover, reducing accidents at work, o ccupational diseases 
and work-related illnesses for all workers and in particular for workers suffering from the 
worse working conditions is an important tool to address health inequalities.  Employment 
Guideline 18 on promoting a lifecycle approach calls for support for ac tive ageing including 
appropriate working conditions an d improved occupational health  status. It also calls for 
promoting modern social protection systems in cluding healthcare. The employment guidelines 
put emphasis on improving the occu pational health status with the aim of reducing sickness 
burdens, increasing labour productivity and prol onging working life.  Employment Guideline 
21 calls for the promotion and dissemination of innovative and adaptable forms of work 
organisation to improve quality  and productivity at work in cluding health and safety. The 
employment guidelines also calls  for the implementation of integrated flexicurity approaches 
with the aim of helping workers including low skilled and those at the margins of the labour 
market to cope with a working life that is becoming more complex, di verse and irregular and 
therefore demanding.  Finally Employment Guid eline 23 emphasises the need to focus on new 
skills for new jobs in order to promote access for all and ensure innovation and quality at work. 
 
EN 105   EN The EU can support Member States actions to  address common challenges through the OMC 
(employment OMC, social OMC) by facilitatin g dialogue and the excha nge of best-practice 
and policy coordination with/betwe en Member States and with stakeholder organizations, by 
supporting the development of innovative good practice through its f unding programmes (e.g. 
PROGRESS).  Addressing health  inequalities is a common object ive under the social OMC.  
Work under the employment and social OMC, supported by the ESF, has looked at how one can address long-term unemployment and bring those further from the labour market into 
work, looking at disadvantaged groups and the gender dimension.  Under the social OMC and 
the Council Working Party on P ublic Health meeting at senior  level, supported by the ongoing 
development of indicators (social OMC common indicators, ECHI) the EU has promoted the 
monitoring of health and coor dination of health policies th rough information sharing and 
exchange of good practice.  The 2008 social OMC Communication
72 proposed that the 
implementation of the objectives in the field of healthcare be supported by targets on access to 
healthcare and on health status.   
Under the EU Health Strategy, inclusion of equity in health as a key value of the and attention 
to social determinants as part of the implemen tation of existing EU health activities, such as 
those on tobacco, obesity and alcohol, young people and mental health.  : As some countries 
have begun to introduce policie s intended to reduce health inequalities, sharing of good 
practice on national and regional policies to address health inequalities such as for example 
through the EU Expert Group on Social Determin ants and Health Ine qualities can provide a 
good basis for policy improvements.  Work on social  determinants of hea lth has started to map 
out health equity related policies, linking up w ith international organisations such as WHO and 
the OECD, the Council of Europe  and research developments in this area.  Commission 
services (REGIO, SANCO, EMPL) are working t ogether to map out the use of cohesion funds 
in the field of health. 
Common Basic Principles for immigrant integrati on policy in the EU have been agreed to by 
the Commission (COM(2005) 389) of which access to se rvices, such as healthcare, is seen as a 
fundamental elements.  The Handbooks on Inte gration for practitioners and policymakers 
provide best-practice examples from a number of projects in this area.   
EU Funds:  
The EU's Cohesion Policy is financially suppor ting Member States to address regional 
imbalances.  Recently, health has been defined as  one of the areas of support by the European 
Regional Development Fund (ERDF) and Europ ean Social Fund (ESF) Structural Funds 
according to the Community Strategic Guidelines for Cohesion 2007-2013.73  Health 
promotion, disease prevention, transfer of kn owledge, training and av ailability of highly 
skilled staff and infrastructure in cohesion regions are some of  the topical areas qualifying for 
support.  The Guidelines note that  there are "major differences in  health status and healthcare 
between EU regions"... thus "it is important  for cohesion… to cont ribute to healthcare 
                                                 
72 "A Renewed commitment to social Europe: Reinforcing the Open Method of Coordination for Social 
Protection and Social Inclusion". COM(2008) 418/4 at 
http://ec.europa.eu/social/m ain.jsp?catId=550&langId=en   
73 http://ec.europa.eu/regional_policy/sources/docoffic/2007/osc/l_29120061021en00110032.pdf 
 
EN 106   EN facilities… Community based health improvement  and preventive actions have an important 
role to play in reducing inequalities".”.74   
While the Common Agricultural Policy (CAP) is  not a social policy in itself it has 
elements that may contribute to the reduction of  health inequalities such as ensuring a fair 
standard of living for farmers, assuring the ava ilability of supplies a nd reasonable prices of 
consumers.  The CAP supports the School Milk Scheme and the distri bution of agricultural 
products to most deprived people. More re cently, there was work and discussion on how 
the CAP could contribute to a more healt hy diet by putting more emphasis on fruit and 
vegetables.  To contribute more effectively to the children' s healthy diet, a School Fruit 
Scheme was agreed by the Council in 2008, and which is operational as  of the school year 
2009-2010.  
 In addition, the EU rural development policy su pports investments and development of social 
and health care services, technologies and infras tructure in rural areas as well as training and 
information actions on health  and social subjects.  
The EU Public Health Programme has been fundi ng action networks, local initiatives, expert 
reviews, conferences, and policy innovations in the field of public he alth.  PROGRESS funds 
activities in the area of  anti-discrimination (e.g. anti-discr imination training activities)  
The European Fund for the Integration of Thir d Country Nationals supports Member States 
efforts to facilitate the integration of migrants into European societies.  7% of the total budget 
of €825M is for Community Actions supporting pr ojects addressing different aspects of 
integration, including access to healthcare.  The remaining 93% is for the Member States to 
implement an Annual Programme ag reed with the Commission.   
The EU Framework Programmes for Research al so offer possibilities to tackle health 
inequalities in particular under the 3
rd pillar of the Health Theme of the specific Programme 
"Co-operation" of the 7th EU Framework Programme.  This new activity aims at developing 
new research methods and generating the necessa ry scientific basis to underpin informed 
policy decisions and more effective and efficient evidence-based strategies in such areas as health promotion and the wider determinants of health includ ing lifestyle and socio-economic 
and environmental factors
75. 
Legislation: 
The EU has established Community labour law and Community legislat ion in the field of 
health and safety at work and monitors its implementation, including so me funding of research 
in the area of occupational safe ty and health in order to imp rove working conditions.  The 
implementation in the Member States of the Co mmunity Legislation on Health and Safety at 
Work, as well as all the actions foreseen in the Community Strategy on Health and Safety at 
Work 2007-2012 is seen to constitute an importa nt contribution to th e reduction of health 
inequalities in the European Union.  The ac tive working population is currently 48,3% percent 
of the total population of the EU.  Therefor e the improvement of the prevention and the 
                                                 
74 See Annex: Table showing the allocated share of Stru ctural Funds investment in  health infrastructure per 
MS. 
75 COUNCIL DECISION (2006/971/E C) of 19 December 2006 concer ning the Specific Programme 
"Cooperation" implementing the Seventh Framework Programme of the European Community for research, technological development and demonstr ation activities (2007 to 2013), OJ L400/127) 
 
EN 107   EN protection of the worker's health and safety re presents a very significant contribution to the 
overall public health in Europe, and to the redu ction of some of the ma in elements having an 
impact on health inequalities among countries a nd citizens of the EU.  Directive 91/383/EC 
aims to ensure that fixed-term workers and temporary agency workers are afforded, as regards safety and health at work, the same level of protection as that  of other workers in the user 
undertaking and/or establishment. A report will  be drafted in 2009 on the implementation of 
Directive 91/383/EC.  The report which will cover the period up to 2007 will try to find 
potential deficiencies in the Directive in orde r to give guidance for the future action of the 
Commission in this field.  The Impact Assessment to the Community Strategy on health and safety at work 2007-2012 showed that occupational health stra tegy reduces work accidents, 
helps accident victims or chronically ill to re tain their job or return to work, is a main 
platforms for integrating migrant workers an d can reduce stressful and monotonous working 
conditions that cause early deterioration of hea lth, and hence, an early exit from working life. 
Since 2000, in addition to laws covering the e qual treatment of men and women, EU anti-
discrimination legislation has been in place to ensure minimum levels of equal treatment and protection for everyone living and working in Eur ope. These laws are designed to ensure equal 
treatment irrespective of raci al or ethnic origin, religion and belief, disability, sexual 
orientation, and age in many aspect s of daily life - from the wo rkplace, to issues covering 
education, healthcare and access to goods and services.  In 2008 th e Commission set up a 
governmental expert group in the field of non- discrimination and the promotion of equality 
which examines the impact of national and EU -level non-discriminati on measures, validates 
good practice through peer learning and evalua tes the effectiveness of non-discrimination 
policies. 
Internal Market 
Work on "health-related" infringement procedures for example on the freedom of 
establishment and provision of services, restri ctions to ownership of pharmacies and their 
location, restrictions to ownership of laborator ies and their opening hours, which may lead to 
sales monopolies and constitute barriers to access , may contribute to lowe r prices of care and 
thus particularly benefit citizens from lower social-economic groups.  
More broadly, at the EU level all Commission initiatives now undergo an assessment of its 
likely economic, social and environmental impacts, including in particular the impacts on different social and economic gr oups and on existing inequalities. 
Education and Youth 
Physical and mental health and healthy lifestyle are promoted as part of Social and civic 
competences in the Recommendation on key competences
76, which invites Member States to 
develop the provision of key comp etences for all as part of th eir lifelong learning strategies. 
The Commission has also proposed  a new EU Strategy for Youth77, which underlines the 
vulnerability of youth and identifies actions to improve their health, particularly for those at 
risk of social exclusion.  
 
 
                                                 
76  Recommendation of the European Parliament an d of the Council of 18  December 2006 on key 
competences for lifelong le arning (2006/962/EC). 
77 COM (2009)200 – 27/04/09 - An EU Strategy for Youth -Investing and Empowering –  
 
EN 108   EN  
9.4. Additional information on why heal th inequalities between and within 
countries are a problem and a policy concern to the EU? The legal and 
political basis for action and subsidiarity  
This section explains in more detail the articles  cited in section 2.5 of the main text and adds 
some more information on other articles that  also provide a legal basis for action.   
Article 2 of the EU Treat y states that the EU shall "promo te economic and social progress and 
a high level of employment, a balanced and sustainable development …through the 
strengthening of economic and soci al cohesion …".  In the EC Treat y Article 2 states that "the 
Community shall have as its task …to pr omote throughout the Community a harmonious, 
balanced and sustainable development, a high level of employment and social protection, 
equality between men and women,… the raising of  the standard of livi ng and quality of life, 
and economic and social cohesion and solidarity among Member States".  Art. 3 of the EC 
Treaty refers that "the activities of the Commu nity shall include: (…) a policy in the social 
sphere (…), the strengthening of economic and so cial cohesion, (…) the promotion of research 
(…), a contribution to the attainment of a hi gh level of health protection, contribution to 
education and training (…), a policy in developm ent cooperation (…).  Arts. 2 and 3 thus refer 
to a number of objectives and polic ies which relate to the reducti on of health inequalities in the 
EU.  In addition, art. 16 of the EC Treaty in dicates that "(…) given the place occupied by 
services of general economic interest in the shared  values of the Union as well as their role in 
promoting social and territorial  cohesion, the Community and the Member States, each within 
their respective powers and within the scope of application of this Treaty, shall take care that 
such services operate on the basis of principles and conditions which enable them to fulfil their 
missions".  These services can play an important  role in addressing health inequalities.   
In addition, Art. 35 of the Charter of Fundamental  Rights of the EU states that "everyone has 
the right of access to preventive health care and the right to benefit from medical treatment 
under conditions established by national laws and practices"78.  The 2006 Council Conclusions 
on Common Values and Principles Underpinning EU Health Systems79 highlight the 
overarching values of universality, access to  good quality care, equity and solidarity of 
healthcare systems as a central part of Europe's  high levels of social protection and a major 
contribution to social cohesion and social justice.  In add ition, the 2008 Tallinn Charter, 
adopted by EU Member States establishes as health systems goals "improving the level and 
distribution of health, equity in fina nce and equity of access to care".   
In additions to the articles in the main text  a legal basis for action can be found in other 
specific policies areas of the EC Treaty.  Art. 33 on the co mmon agricultural policy puts 
forward the goal of ensuring "a fair standard of living for the agricultural community" and "that supplies reach consumers at reasonable pri ces" and that "account sh all be taken of (…) 
structural and natural disparities between the various agricultural regi ons". Art. 98 indicates 
that Member States shall conduct their economic policies so as to achie ve the goals expressed 
in art. 2.  Art. 149 of the EC Treaty says "the Community shall contribute to the development of quality education by encouraging coope ration between Member States and (…) by 
supporting and supplementing action (…)." Art. 159 also states that the Commission shall 
submit a report on the progress made towards achieving economic and social cohesion which 
                                                
 
78 OJ C364, 18/12/2000 
79 OJ C 146 of 22.06.2006, p.01. 
 
EN 109   EN shall be accompanied by appropriate proposals if necessary.  Finally, arts. 163 to 166 
expressed the goal of strengthening research  capacity in the Community and establish a 
framework programme to support this goal. 
Moreover, health inequalities im ply substantial opportunity costs for the Union.  Good health 
is seen as a "tool and part of the solution to  the key challenges of population ageing and labour 
shortages"(e.g. European Commission publi cations on the European Social Fund).80  T h e  
Community strategic guidelines  on cohesion for example adopt ed by the Council  in October 
2006 underline that investment in  health promotion and diseas e prevention will help to 
maintain active participation in society (…), thus maintaining their economic contribution and 
reducing dependency levels.  This has a direct  effect on productivity and competitiveness”.  
Health is recognised as an important elemen t in meeting the Lisbon goals and achieving 
Europe's full potential for prosperity, solidarity  and security because improving health reduces 
early retirement, contributes to longer wo rking lives and induces higher productivity, 
competitiveness and employment levels (idem).  A voidable ill-health also leads to large costs 
for the healthcare system and puts unnece ssary pressure on public budgets. (European 
Commission publications on the European Social  Fund, Community Strategic Guidelines on 
Cohesion).81  This is confirmed by a study (Mackenbach et al., 2008)82 carried out for the 
Commission that estimates the potential economic impact if death and di sease rates of those 
with lower educational attainment were the same as those with higher educational attainment.  The consequent increase in the number of work ers the number of days worked, productivity of 
work and income levels and the reduction in premature death before retirement and chronic 
disease could lead to a minimum gain of 1.4% of  GDP with an estimate fo r the overall value of 
gain of around 9.5% of GDP or one trillion Euros per year.  
Table A17: Overview table, linking Problems, general and operational objectives to monitoring and evaluation 
mechanisms  
Problem General Objective Mo nitoring and evaluation 
mechanisms / Indicator 
Number of MS with comprehensive 
policy approach which can be 
analysed in the social OMC NSR 
2011-2013 (currently two) Lack of awareness an d
insufficient policy priority an d
commitment by Member States  Raise awareness, promote information 
and best-practice exchange and advocate 
the tackling of health inequalities as a 
policy priority; both at Community and Member States level and by other 
stakeholders  To be evaluated by the Eurostat 
Working group on mortality 
Absence of comparable and 
regular data, monitoring and reporting.  Lack of knowledge 
on the determinants and the 
effective policies to implement Improve data availability and the 
mechanisms to measure, monitor and report on inequalities in health across the 
EU and improve the knowledge base on 
the causes of health inequalities and the evidence base for action To be evaluated by DG Research by 
number and quality of studies, and amount of distribution platforms 
(internet portal), publications 
(available in all languages) 
how many relevant EU policy 
strategies have an indicator of health 
status inequalities Insufficient concerted EU 
approach to health 
inequalities (lack of mainstreaming at the EU 
level) Develop the contribution of relevant EU 
policies towards reducing inequalities in 
health, including better support of Member States and st akeholders' efforts 
to tackle health inequalities and a specific how many EU reports address the 
impact of certain strategies on health 
                                                 
80 See http://ec.europa.eu/employment_social/esf/docs/TP_files_update/tp_health_EN.pdf   
81 See http://ec.europa.eu/employment_social/esf/docs/TP_files_update/tp_health_EN.pdf   
82 See http://ec.europa.eu/health/ph_determinants/socio_economics/documents/socioeco_inequalities_en.pdf   
 
EN 110   EN and health disparities focus on vulnerable groups and third 
countries 
Additional evaluation under Option 
II and III in dedicated Health 
Inequality report 2012 
 
 
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Annex HIs ImpactAssessment-postCIS19Spet 
 
EN 113   EN 11. LIST OF ABBREVIATIONS  
AGRI Agriculture and Rural development 
AIDCO EuropeAid - Cooperation Office CAP Common Agriculture Policy Council WPPH Council Working Party on Public Health at Senior Le
v
DEV Development 
DG Directorate General EAC Education and Culture EAFRD European Agricultural Fund for Rural Development EAGF European Agricultural Guarantee Fund ECFIN Economic and Financial Affairs ECHI European Community  Health Indicators 
EHIS European Health Interview System EMPL Employment Social Affa irs and Equal Opportunities 
EPSCO Employment, Social Policy, Health and Consu
m
Affairs Council 
ERDF European Regional Development Fund ESF European Social Fund EUROFUND European Foundation for the Improvement of Liv
i
and Working Conditions 
EUROSTAT European Statistical Office EU-SILC European Union survey on income and living conditi
o
Expert Group SDH EU Expert Group on Social Determinants of Health FP7  Research Framework Programme 7 GDP Gross domestic product 
HI Health Inequalities 
IA ISSG impact assessment  inter-service steering group 
 
EN 114   EN IAB Impact Assessment Board 
INFSO Information Society and Media JLS Justice, Freedom and Security Joint Report SPSI Joint Reports on Soci al Protection and Social Inclusio
n
MARKT Internal Market and Services 
MS Member States NGO Non-governmental organisation NSR National Strategy Report PROGRESS EU's employment a nd social solidarity programme 
REGIO Regional Policy RTD Research SANCO Health and Consumers SG Secretariat General SHARE Survey of Health Ageing and Retirement in Europe social OMC Open Method of C oordination for Social Protection 
a
Social Inclusion 
SPC Social Protection Committee WHO CSDH WHO Commission on the Social Determinants 
Health