Commission staff working document - Impact assessment accompanying the communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions -  Solidarity in health: Reducing health inequalities in the EU {COM(2009) 567 final} {SEC(2009) 1397}
Date: 2009-10-20
Institutions: European Commission
Subjects: health policy, impact study, public health, social inequality

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COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 20.10.2009 
SEC(2009) 1396 final 

COMMISSION STAFF WORKING DOCUMENT 

IMPACT ASSESSMENT 

accompanying the 

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

Solidarity in health: Reducing health inequalities in the EU 

{COM(2009) 567 final} 
{SEC(2009) 1397} 

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Introduction and policy background........................................................................................... 5 

1. 

1.1. 

1.2. 

2. 

Procedural issues and consultation of third parties ...................................................... 7 

Organisation and timing ............................................................................................... 7 

Consultation and expertise ........................................................................................... 8 

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 causes) of health inequalities ............................................. 11 

2.2.  What Member States are doing and consider effective to address health 

inequalities ................................................................................................................. 14 

2.3. 

2.4. 

Existing EU action and links to other relevant EU policies....................................... 16 

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 data, monitoring and reporting.  Lack of 

knowledge on the determinants and the effective policies to implement .................. 21 

2.4.3. 

Insufficient concerted EU approach to health 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. 

3.1. 

3.2. 

4. 

4.1. 

4.2. 

4.3. 

5. 

5.1. 

5.2. 

5.3. 

6. 

Objectives................................................................................................................... 27 

General Objectives ..................................................................................................... 27 

Specific Objectives..................................................................................................... 27 

Policy options............................................................................................................. 27 

Option I: Continue current activities, no new initiative:............................................ 28 

Option II: Current plus ............................................................................................... 29 

Option III: Far reaching efforts to enhance EU policy priorities in relation to 
health inequalities....................................................................................................... 33 

Analysis of impacts .................................................................................................... 41 

Social Impacts ............................................................................................................ 41 

Economic impacts ...................................................................................................... 43 

Costs regarding data collection .................................................................................. 44 

Comparison of the Options ........................................................................................ 44 

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6.1. 

6.2. 

6.3. 

7. 

8. 

8.1. 

8.2. 

8.3. 

8.4. 

8.5. 

8.6. 

9. 

Option I – Baseline – Continue current activities, no new initiatives........................ 45 

Option II – Current Plus ............................................................................................. 45 

Option III – Far reaching efforts to enhance EU policy priorities in relation to 
health inequalities....................................................................................................... 47 

Monitoring and evaluation ......................................................................................... 49 

ANNEX 1 Consultation and expertise ....................................................................... 53 

Targeted written consultation..................................................................................... 53 

Summary of responses ............................................................................................... 57 

Consultation during the development of previous communications.......................... 63 

Consultation with key groups convened by the European Commission .................... 64 

Consultation with EU institutions .............................................................................. 68 

Expertise  69 

ANNEX 2: Health inequalities in the EU .................................................................. 71 

9.1. 

Background and context: Nature and scale of health inequalities in the EU ............. 71 

9.1.1. 

Inequalities in health outcomes between Member States........................................... 71 

9.1.2.  Determinants (drivers or causes) of health inequalities ............................................. 82 

9.2.  What Member States are doing and consider effective to address health 

inequalities ............................................................................................................... 100 

9.3. 

9.4. 

10. 

11. 

Existing EU action and links to other relevant EU policies..................................... 104 

Additional information on why health inequalities between and within countries 
are a problem and a policy concern to the EU? The legal and political basis for 
action and subsidiarity.............................................................................................. 108 

Bibliography............................................................................................................. 111 

List of abbreviations................................................................................................. 113 

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Key concepts 

The  term  "health  inequalities"  taken  literally  means  differences,  variations  or  disparities  in 
health status between individuals or groups.   

The term inequity refers to differences in health which are not only unnecessary and avoidable 
but, in addition, are considered unfair and unjust.1 Health inequities are systematic differences 
in health outcomes across different population groups (often defined 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  environmental  variables  that  are 
largely beyond individual control yet can be addressed by public policy.    

In common usage and in many policy circles, the term health inequality is used as a synonym 
for  health  inequity.  This  is  partly  because  health  inequalities  is  a  much  more  readily 
understandable  term  by  the  general  public  and  partly  because  in  terms  of  measurement 
"inequalities", i.e. measured differences in health 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 translation 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  unfair  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. 

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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  Strategy2  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 State and EU levels.  It outlines a rationale for 
action and proposes a number of options and related policy actions which are then appraised.  
The report commits only the Commission's services involved in its preparation and does not 
prejudge the final form of any decision 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 explores 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 improvements in the health of the 
whole population, but with particular emphasis on reducing avoidable and unfair gradients in 
health  between  social  groups,  protecting  the  health  of  vulnerable  groups  and  contributing, 
where appropriate, to more rapid improvements in the health of populations for those regions 
of the EU that are lagging behind – i.e. a 'levelling-up' approach.   

A legal basis for action is provided by the EC Treaty.  The EU has a responsibility to ensure 
that  all  its  policies  and  activities  provide  a  high  level  of  health  protection.    It  also  has  a 
responsibility  to  strengthen  economic  and  social  cohesion.    There  is  also  a  "political" 
background for action. In June 2006 the Council adopted 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 Council adopted conclusions on 
health in all policies recognising the importance of health determinants and calling for inter-
sectoral and broad societal action on those determinants5.  Policy action on health inequalities 
was foreseen in the Commission White Paper “Together for Health, a strategic approach for 
the  EU  2008-2013”  of  October  2007  (the  EU  Health  Strategy)6  which  stressed  the  need  to 
reduce health inequity between and within Member States involving exchange of best practice 
and  health  promotion.    The  European  Parliament,  the  Council  and  the  Committee  of  the 
Regions, in their opinions on the Health Strategy, 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 

a 

for 

Health, 

strategic 

"Together 

2 
approach 
http://ec.europa.eu/health/ph_overview/Documents/strategy_wp_en.pdf  
3  "Renewed  Social  Agenda:  Opportunities,  Access  and  Solidarity".  COM(2008)  412 
http://ec.europa.eu/social/main.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 
EU 
approach 
http://ec.europa.eu/health/ph_overview/Documents/strategy_wp_en.pdf  

"Together 

strategic 

Health, 

EU 

the 

the 

for 

for 

for 

a 

2008-2013" 

final  at 

2008-2013" 

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States.7    Finally,  in  July  2008  the  Commission  Communication  on  a  Renewed  Social 
Agenda8,  highlighted  the  principles  of  opportunity,  access  and  solidarity  and  announced  a 
Commission Communication dedicated to the issue of health 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 Coordination for Social Protection and Social 
Inclusion  (social  OMC)10.    Reducing  health  inequalities  within  and  between  Member  States 
was  also  agreed  in  2006  as  an  operational  objective  of  the  renewed  EU  Sustainable 
Development  Strategy11.    The  persistence  of  health  inequalities  has  been  highlighted  in  the 
annual Joint Report on Social Protection and 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  inequalities  and  called  for  concerted  action  at  all  levels  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  field  should  be  seen  as  part  of  the  general  EU 
commitment to increase the welfare and living standards 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,  employment  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  recognition  that  further  and 
dedicated  EU  action  in  support  of  Member  States'  efforts  to  tackle  health  inequalities  is 
needed.   

The possibility of EU action should also be considered in the context of the economic crisis 
that the EU is currently facing.  It is not yet known to what extent the economic situation will 
impact  on  health  inequalities,  but  unemployment  is  fast  increasing  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 worsen the observed health disparities between and 
within Member States and highlights the need for action to mitigate the negative health effects 
of  the  crisis.    Moreover,  in  a  context  of  rising  strains  between  resources  and  needs,  it  is 
particularly important to protect the health of EU citizens and to improve the understanding of 
how economic, social, regional and other policies impact 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,  Access  and  Solidarity".  COM(2008)  412 
http://ec.europa.eu/social/main.jsp?catId=547&langId=en  
9 http://ec.europa.eu/employment_social/spsi/common_objectives_en.htm  
10 See http://ec.europa.eu/social/main.jsp?catId=448&langId=en  
11 Review of the EU Sustainable Development Strategy.  Council of the European Union. Document 10117/06. 9 

final  at 

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_determinants/final_report/en/index.html  

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and  on  the  various  subgroups  within  them.    The  current  economic  crisis  through  posing  a 
financial  pressure  on  health  systems  can  motivate  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-General for Employment Social Affairs and Equal 
Opportunities  (DG  EMPL)  and  the  Directorate-General  for  Health  and  Consumers  (DG 
SANCO).  

Exploratory work on the impact assessment began 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 SANCO 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 services to participate in the impact assessment 
inter-service  steering  group  (IA  ISSG).  The  first  IA  ISSG  meeting  took  place  in  November 
2008.    Three  further  meetings  of  the  group  took  place  in  February,  March  and  April  2009.  
The  following  Directorates-General  participated:  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  contributions  and  discussed 
important aspects of the document notably the options and the actions within these as well as 
the  need  to  relate  this  initiative  to  the  economic  crisis.    The  IA  ISSG  allowed  the  initiating 
DGs to take stock of what the 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 meeting 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  improvements.  This  version  of  the  document 
consolidates all changes in response to the comments and observations of the IAB. The four 
points below set out the changes that have been introduced. Adjustments following the second 
opinion of the IAB appear in italics. 

(1) The objectives for EU action were reformulated 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 proposed.  A decision was taken to use the term 'health inequalities' 
throughout  the  whole  document  and  an  explanation  of  this  decision  is  provided  in  the 
beginning of the document.  To achieve greater explicitness on the competence 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  emphasis  has  been  put  on  better  data  collection  and 
strengthening  the  knowledge  base  which  is  included  as  a  specific  objective  (section  3.2).  
Some information previously in section 2 was moved to the annex for the sake of conciseness.   

(2)  The  problem  definition  was  reworked  to  clarify  the  drivers  of  health  inequalities.  
Additional evidence and clarification on issues relating to causation of health inequalities was 
to section 2.1.3 (and further elaborated after the 2nd IAB opinion), highlighting that evidence 
on causality, albeit growing, is limited and indeed improving the knowledge pool is one of the 
aims of this initiative.  This helps distinguish to what extent causal links have been estimated 

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or only inferred from statistical correlation.  More use is made of evidence on existing actions 
at Member States and EU level.  An additional section (section 2.2) was included containing a 
list  of  effective  Member  States  actions.    Additional  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  State  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  and  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  initiative  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  proportionality  extra  detail  and  examples  was  added  to  section 
2.6. 

(4) Additional information on the consultation carried out by the Committee of the Regions 
was added in section 1.2 and the consultation section in the Annex adjusted to take account 
comments  received  following  publication  of  a  separate  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  working  with  DG  EMPL  and  DG  SANCO,  inviting 
written  contributions,  was  launched  on  3  February  2009  with  a  closing  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  national  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, healthcare 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 forums and processes were consulted including the 
Social  Protection  Committee  (SPC)  in  March  2009,  the  EU  Expert  Group  on  Social 
Determinants of Health and Health Inequalities (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 part of linked initiatives such as the Renewed Social Agenda 
(2008) (consultation ended February 2008, Social Agenda Forum of 5/6 May 2008), and the 
EU Health Strategy (2007) (consultation 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  inequalities  within  and 
between Member States, and perceived these as increasing even prior to the crisis.  EU action 
was  seen  as  providing  added  value.    Several  causes  of  health  inequalities  were  mentioned 
such as employment and working conditions, poverty and environment.  Respondents did not 
see the problem as just rooted in the character and extent of healthcare.   

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Regarding concrete actions better measurement, monitoring, reporting and exchange of best-
practices were suggested by nearly all stakeholders.  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 targeting of EU funds and special 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  actions  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 appraised 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  Monitoring  Network  during  February  and  March  2009  and 
received  13  responses.    Health  inequalities  were  also  perceived  as  a  problem.    Factors 
mentioned as drivers included: (i) socio-economic conditions; (ii) lifestyle; (iii) geographical 
features of the territory; and (iv) cultural heritage.  Action at Community level was considered 
necessary  particularly  in  relation  to  improving  comparability  of  information  and  assessment 
of the state-of-the-art processes 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  universal  coverage  health  systems  across  the  EU; 
(iv) improving mechanisms for monitoring inequalities in health across Europe, (v) promoting 
research and exchange of best practice.  In more specific terms and stressing the particularities 
of  remote  areas,  like  islands,  EU  support  for  health  information  technology  was  seen  as  an 
added value for these regions.  The COR highlighted 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 outcomes between Member States 

Substantial  differences  in  population  health  between  different  EU  Member  States  can  be 
observed in a wide range of health indicators15.  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  national  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  been  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 
at 

for 
http://ec.europa.eu/employment_social/spsi/reports_and_papers_en.htm. 

analysis 

detailed 

data 

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 cultural differences.  

17 See also Jagger et al. (2008) that suggest that the gap between East and West 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.  

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found in infant mortality, in premature and treatable and preventable mortality, in subjective 
measures  of  health  such  as  self-perceived  general  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  during  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  manual  and  professional  occupations;  people 
with primary level and post-secondary education; low and high income 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,  mortality  and  infant  mortality  are  higher  in  the 
lowest  socio-economic  groups  and  relative  inequalities  have  increased  in  several  countries.  
See annex 2.1.1 for detail. 

Rates of disease and disability also vary substantially by socio-economic 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 observed in that those in the lowest (poorest) 
income quintiles more often report very bad health than those in the highest (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 chewing 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  mortality  and  disease22.    These 
include some migrant groups and ethnic minorities, people living in deprived urban and rural 
areas  and  in  poverty,  the  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 pensions, and single parents.  For example, the Roma can expect to 
live 10 years less than the majority population in some countries23.   

19 Mackenbach J. "Health inequalities: Europe in profile". 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  Protection  and  Social  Inclusion  and  social  OMC  and  equal 
opportunities 
at 
http://ec.europa.eu/employment_social/spsi/the_process_en.htm,  the  Handbook  on  Integration  for 
policy-makers 
at 
http://ec.europa.eu/justice_home/doc_centre/immigration/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. 

practitioners 

networks 

studies/ 

related 

and 

23 See the European Monitoring Centre on Racism and Xenophobia http://eumc.eu.int/  

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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 association 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  (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  contribute  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

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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)

2.1.3.  Determinants (drivers or causes) of health inequalities 

Source: EUROSTAT 

Determinants of health inequalities 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) which indicates a causal relationship between the 
set of factors in the figure and measures of health 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  

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Figure 2: WHO Commission on Social Determinants 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, adequate washing and toilet facilities, affordable 
energy, appropriate housing, heating, new clothes, 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 geographic 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 individuals independently of 
each individual characteristics.  Health is also determined by health-related  behaviours (e.g. 
diet, physical activity, tobacco and alcohol use).  Some studies (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  utero  which  increases  the  risk  of  cardiovascular 
disease, stroke, respiratory diseases and lung cancer in middle age (Baker, 1992).  There are 
large  variations  between  EU  Member  States  and  between  socio-economic  groups  in  the 
consumption  of  fruit  and  vegetables  and  the  prevalence  of  smoking,  alcohol  consumption, 
obesity  and  physical  activity  (Figures  A10-A12).    Countries  with  high  rates  of  smoking 
combined with low rates of exercise and unhealthy diet are also countries with the lowest life-
expectancy 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  influenced  by  socio-economic  and  cultural 
factors  (SHARE;  Stronegger  et  al.,  1997;  Lundberg,  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/  comparison  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 higher mortality and disease.  Unemployment is associated with 
increased poor mental health and suicide (Kessler et al. 1987; Warr 1987; Blakely, 2003).  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 physical pressure and 
stress, high decision ability and possibilities to develop new skills, a correct monetary reward 

25 See http://www.eurofound.europa.eu/pubdocs/2008/52/en/1/EF0852EN.pdf 

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and having prospects for personal progress lead to good health status whereas lack of support 
at  work  and  the  feeling  of  job  insecurity  increase  the  risk  of  depression  and  bad  health.    In 
addition, occupational health risks vary across sectors 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  statistically  more  likely  to  suffer  from  accidents  at 
work  and  occupational  diseases.    In  general,  one  can  observe  disparities  in  employment/ 
unemployment  rates  and  differences  in  poverty  and  income  inequality  across  and  within 
Member  States    which  might  also  help  explain  part  of  the  differences  in  health  between 
countries. Notwithstanding the range of studies in this area much of this evidence remains at 
the  level  of  association  and  suggestion  rather  than  providing  clear  explanations  or 
mechanisms  of  causality.    A  growing  number  of  academic  studies  are  contributing  to 
understanding  of  the  causality  between  education  or  income  and  health  because  better  data 
panels and econometric techniques are becoming available.  In some cases it is now possible 
to  use  Census  information  and  link  it  to  mortality  data,  or  through  specialised  surveys  to 
follow  cohorts  of  individuals,  examine    the  relation  between  parents  and  their  children  or 
compare  siblings  (including  twin  studies)  as  techniques  to  improve  understanding  of    the 
effect  of  socio-economic  determinants  of  health.    While  such  evidence  is  contributing  to 
understanding  of  the  factors  involved  there  is  a  lack  of  studies  evaluating  initiatives  and 
actions in this area which could inform policy.   

Public policies including income distribution and access to health care: Public policies belong 
among the structural determinants of health inequalities as they influence the distribution of 
the  above  factors  (e.g.  education,  income)  and  the  degree  of  stratification  in  society.    The 
extent  of  redistribution  and  social  protection  (pensions,  sickness  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  (Jen 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  distribution  policies,  which  have  been 
estimated  to  reduce  the  risk  of  poverty  in  the  EU  by  38%  are  therefore  potentially  very 
important (2008 OMC Monitoring Report27).   

Healthcare  influences  the  likelihood  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. Country differences in the availability, access and quality of care 
contribute to differences in treatable mortality28 (Newey et al., 2003, 2008).  EU Statistics on 
income  and  living  conditions  suggest  an  income  gradient  in  unmet  need  for  medical  care: 
those  in  the  lowest  income  quintiles  more  often  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 adjusting for different levels of  need, the rich are significantly more 
likely to see a specialist and a dentist 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_prevention/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.  

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identified  the  following  as  barriers  to  healthcare  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 and care use.  In general, inequitable access to care appears to 
be associated with higher health inequalities.   

The current economic crisis can impact on  health  and increase health inequalities  through a 
deterioration  of  social  determinants  of  health,  especially  for  those  with  lower  qualifications 
and  savings,  and  who  are  already  vulnerable.    The  loss  of  job  and  thus  income  can  lead  to 
worse  living  conditions  and  life-styles,  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  countries  to  review  their  policy  mix  on  health 
determinants  in  search  for  higher  effectiveness  and  efficiency.    Evidence  (WHO  World 
Report, 200830) shows that countries with different levels of economic performance and social 
protection (notably health) expenditure can achieve similar health outcomes.  

The  analysis  in  2.1.1  and  2.1.2  is  in  line  with  the  2006  Council  Conclusions  that  "health 
determinants  are  unequally  distributed  among  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 within-country health inequalities may influence the overall health 
status  of  that  country’s  population.    The  analysis  provides  a  general  outline  of  the  various 
socio-economic  determinants  of  health  inequalities  between  countries  and  between  social 
groups,  including  living  and  working  conditions,  health-related  behaviour  and  social 
protection  policies  including  healthcare.    Robust  evidence  exists  in  a  number  of  areas  but 
more  detailed  and  specific  information  is  required  on  the  effect  (causality)  and  weights  of 
several  of  those  health  determinants  in  order  for  Member  States  to  choose  and  implement 
effective action in relation to particular population groups and determinants. 

2.2.  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 comprehensive 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  

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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 list 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 also needs to be intensified and targeted at 
specific  groups  (e.g.  to  mothers  and  children,  young  parents,  and  those  over  50)  in 
disadvantaged  areas,  in  vulnerable  families  and  in  lower  socio-economic  groups.    This  is 
particularly  the  case  for  health  promotion  and  disease  prevention  programmes.    Indeed, 
according  to  some  evaluation  studies  untargeted  health  promotion  information  campaigns 
may increase health inequalities because of a tendency to be more effective in affluent groups.   

Secondly,  a  number  of  Member  States  argue  that  regional  and  local  action,  supported  by 
national and EU actions, is very important to achieve results.  Building partnerships between 
the  public  and  the  voluntary/  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 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  first  step  towards  effective  action.    Such  information  allows  for 
awareness-raising  activities;  enables  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 and 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 innovation elsewhere is also deemed crucial and 
several  Member  States  suggest  that  initiatives  linking  cities  and  regions  have  been  very 
effective in disseminating information (e.g. the Healthy Cities Network in DK).  Taking stock 
of  increasing  body  of  evidence  on  the  causes  of  health  inequalities  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 applied to policies across  the  board is an effective 
way to generate inter-sectoral awareness. 

More specific examples of policies 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  decrease  infant  mortality  and  increase  life 

31 See http://ec.europa.eu/health/ph_determinants/socio_economics/keydo_socioeco_en.htm 

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expectancy  in  these  groups  it  is  effective  to  a)  ensure  smoking-cessation  during 
pregnancy,  b)  stop  parental  smoking  and  c)  reduce  smoking  in  general  for  those 
groups.  Studies have shown that the widespread provision of stop smoking services 
was effective in reducing the number of smokers 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 duration rates in deprived areas and lower socio-
economic groups which are currently lower than those of more affluent 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 socio-economic differences in tooth decay in 

children as shown when comparing different counties of 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-school  day  care  for  lower  socio-economic  groups  as  this 

• 

• 

increases education and employment attainment, 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 significant 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  and  affordable  heating  for  lower  socio-
economic  groups  and  measures  to  reduce  accidents  at  home  (smoke  alarms,  hand 
rails).  A review of UK "area regeneration initiatives" shown that these lead to better 
education  and  employment  rates,  higher  household  income  and  housing  quality  and 
contributed to improving health.  

Income support (NL, SE) 

•  Seat belt and speed legislation (UK, BE),  
• 
•  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,  local  strategies,  partnerships  or  actions  to  reduce  health 
inequalities has been effective to motivate policy development. 

•  Health infrastructure investment e.g. through 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  awareness  raising,  data  development,  monitoring, 
research,  dissemination  of 
legislative 
frameworks  for  environment,  health  and  safety  and  equal  opportunities.    A  collaborative 
approach  is  important  to  help  optimise  resources  and  tackle  common  challenges  within  the 
EU. 

information  and  best-practice  exchange,  and 

2.3.  Existing EU action and links to other relevant EU policies.   

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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.  Structural  Funds,  Health  Programme) 
can be used to develop targeted health promotion 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  relevant  for  action  to  contain  and  reduce  health 
inequalities include the following (see 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 living standards and thus 
health.  Healthy life years has been agreed as one of the structural indicators, thus indicating 
this strategy has paid a growing attention to the health dimension.   

Similarly,  under  the  Employment  Strategy  the  overarching  Employment  Guidelines  and  the 
associated common indicators provide 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  worse  working  conditions  is  an  objective  under 
Guideline 17.  Guideline 18 puts emphasis on improving occupational health status with the 
aim of reducing sickness burdens, 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 skilled and those at the margins of the labour market 
to  cope  with  a  working  life  that  is  becoming  more  complex,  diverse  and  irregular  and 
therefore  demanding.    A  set  of  common  indicators  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  objective  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  reporting  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 reports.  In 2008 a set of common indicators (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  published  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. 

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In  a  similar  manner,  following  the  2006  adoption  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  attention  to  social  determinants  as  part  of  the 
implementation  of  existing  EU  health  activities,  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  collaborative  projects  addressing  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 instrumental in improving understanding of the problem 
as well as promoting the sharing of information 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  range  of  initiatives  which  are 
conducive  to  reducing  the  health  impact  of  environmental  factors.    For  example,  a  study 
(Health and Environment Alliance) shows that 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 support via the European Social Fund (ESF), the 
European Regional Development Fund (ERDF), the cohesion fund, the European Agricultural 
Guarantee Fund (EAGF), the European Agricultural Fund for Rural Development (EAFRD), 
and  the  Research  Framework  Programmes  (currently  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 health inequalities such as living conditions (water 
and  sanitation),  training  and  employment  services,  transport  and  technologies.    Moreover, 
additional dedicated funding has been allocated to health infrastructure, capacity building and 
training of health staff through the Structural funds 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  promotion  and  disease  prevention.  
Significant investments in health systems have been supported by the structural funds.  The 
total allocated investment in the current programming period is € 5.2 bn.  Countries such as 
HU,  SK  and  LV  have  indicated  in  their  responses  that  the  structural  funds  have  helped 
address  inequalities  in  access  to  health  care,  notably  geographic  disparities  in  health 
provision, through investment in poorer/ deprived regions.  In the past, countries such as PT 
and EL have also used the funds 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  distribution  of  agricultural  products  to  most 
deprived people. Rural development policy includes measures to improve the quality of life in 
rural  areas  through    the  provision  of  basic  services  for  the  economy  and  rural  population 
(including  social  and  health  care  services  and  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 

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potential  to  contribute  to  narrowing  health  inequalities  which  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-related"  infringement  procedures 
for  example  on  the  freedom  of  establishment  and  provision  of  services,  restrictions  to 
ownership of pharmacies and their location, restrictions to ownership of laboratories and their 
opening  hours,  which  may  lead  to  sales  monopolies  and  constitute  barriers  to  access,  can 
contribute  to  lower  prices  of  care  and  thus  particularly  benefit  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 Community 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 contribution to the reduction of health inequalities 
in  the  European  Union.    The  improvements  in  the  protection  of  worker's  health  and  safety 
represents a significant contribution reducing health inequalities in Europe through reducing 
the negative impact of some of their determinants.  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 stressful 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. tobacco advertising, and food labelling amongst others) 
and  harmonisation  of  technical/  regulatory  standards  have  raised  public  health  related 
standards  in  many  Member  States  and  have  potentially  contributed  to  reducing  health 
inequalities  between  and  within  Member  States.    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 inequalities.  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 description suggests a lack of mainstreaming health 
inequalities across all relevant EU policies.  The 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  national  level,  to  taking  effective 
action to address health inequalities33.   

33 The Joint Report on Social Inclusion and Social Protection, 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. 

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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  Protection  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 that 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 their wish to adopt a "Health 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 principle 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 socio-economic dimensions of health only a smaller 
group  had  coordinated  national  policies  to  tackle  health  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  makers  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  options  that  can  be  implemented  by  national, 
regional  and  local  administrations  (as  well  as  schools,  workplaces,  local  health  and 
community  services,  community  organizations  and  other  stakeholders).    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  existing  good  practice  and  that  which  will  become 
available through best-practice exchange and information sharing mechanisms.   

Moreover, there is a need to better involve other 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 responses.  The 2009 Joint Report on SPSI indicates 
that in general it is not clear how stakeholders are consulted on the NSRs SPSI and how the 
results from any consultations are taken into consideration.  The EU could facilitate exchange 
of  information  and  knowledge  to  assist  stakeholders  to  take  action  that  contributes  to  the 
reduction of health inequalities,  as a number of consultation responses called for. 

Finally,  some  Member  States  and  respondents  to  consultations  have  argued  that  attention 
should be paid to a perceived lack  of targets and benchmarks in  the areas of inclusion and 
healthcare in order to  strengthen 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  may  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, proper heating, inadequate diet, lack of access to 
healthcare,  housing  or  education,  exclusion,  stigmatisation  and  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; 

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income  and  low  rates  of  employment.    For  these  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 nationality 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  determinants  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 varies widely by Member State thus contributing to 
policy  makers’  lack  of  awareness  on  the  extent,  causes  and  consequences  of  the  problem.  
Information  regarding  the  differences  in  health  outcomes  and  some  determinants  of  health 
between and within countries is not routinely collected 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,  developed  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  (Community  Statistics  on  Income  and  Living 
Conditions)  are  key  elements.    To  these  households  surveys  are  added  the  collection  of 
administrative  data  (Health  care  data  including  expenditure  and  non-expenditure,  causes  of 
death,  morbidity  statistics).    Some  of  the  health  and  healthcare  related  data  is  currently 
provided to EUROSTAT on the basis 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 remarked 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; (alcohol, tobacco, physical exercise) 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 determinants of health.  For 
example, the three-yearly Cohesion Report on the outcomes of the Structural Funds does not 
provide  an  assessment  of  the  impact  of  the  use  of  funds  in  reducing  regional  differences  in 
health.  Furthermore there is no dedicated and regular reporting on health 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 the degree of causality 
and  the  relative  weight  of  different  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 
the  age  of  migration"  at  http://www.eu2007.min-
well  as  "Challenges 
saude.pt/PUE/en/conteudos/programa+da+saude/Publications/Relat%C3%B3rio+Sa%C3%BAde+e+Mi
gra%C3%A7ao.htm, 
at 
http://www.iom.int/jahia/webdav/site/myjahiasite/shared/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 

for  health 

"Migration 

health", 

IOM, 

right 

and 

the 

to 

in 

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-  poor  water,  housing  and  environment  conditions); other causes  are much  more difficult to 
determine  -  for  example,  how  the  different  ways  that  jobs  are  organized  can  have  such 
markedly different health impacts.  More evidence 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 policies 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 small number of interventions that impact on health 
have been evaluated for their differential impacts on particular social groups or in particular 
areas.  Hence, more research is needed to provide such 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  policies/  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  contribute  directly  or 
indirectly to contain or reduce health inequalities this policy outcome is very rarely an explicit 
goal.    In  other  words,  promoting  the  reduction  of  health  inequalities  has  not  been 
mainstreamed in an explicit manner in EU policies and activities tools and most of them do 
not take the dimension of health inequality into account.  For example, few EU policies are 
evaluated  after  implementation  (ex-post)  in  relation  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 Strategy and associated Employment Strategy, while there has been a 
growing  attention  to  health  and  the  economic  benefits  of  good  health  (employment, 
productivity). The analysis on the impact of growth and jobs on health and health inequality 
or  on  the  impact  of  working  conditions  on  health  and  health  inequality  is  more  limited.    In 
addition,  while  the  healthy  life  years  indicator  can  allow  for  assessing  gender  and  between 
country  disparities  in  health  outcomes  it  does  not  allow  for  assessing  socio-economic 
differences in health.  The common employment indicators on quality of work and working 
conditions could also be further developed in this respect.    
Under  the  current  social  OMC,  full  delivery  on  common  objectives  remains  a  challenge36.  
Despite  the  common  objective  of  addressing  health  inequalities,  the  issue  has  not  yet  been 
taken  up  as  a  policy  priority  by  all  Member  States.    In  addition  to  the  improvement  and 
greater use of the common indicators, more regular monitoring and improved evidence within 

36 See Com(2008)418 at http://ec.europa.eu/social/main.jsp?catId=550&langId=en for more detail.  

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the  OMC,  it  has  been  argued  that  there  is  a  need  for  a)  developing  quantitative  targets  to 
achieve  more  and  faster  progress  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  involvement  of  regional  and  local  administrations 
and stakeholders is still 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  related  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  protection  of  more  vulnerable  groups  as  well  as  children  and  young 
people  as  well  as  the  potential  for  further  improvements  in  coordination  with  international 
agencies (e.g. WHO).   

the  GAP,  DETERMINE) 

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 relevant projects co funded by the 
EU  (Closing 
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.    Despite  the  potential  for  using  the  Structural 
Funds to address disparities in healthcare, the planned investment in healthcare 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  investments  are  likely  to  be  lower  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 national policy departments and 3) lack of technical 
capacity to propose / allocate investment in the field.  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 operational 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 staff 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  makes  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 addressing health and health inequality 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  reduce  health  inequalities.    Several  stakeholders 
suggested  in  their  consultation  responses  improving  the  exchanges  of  knowledge  and  good 
practice between recipients of Structural Funds with the aim of maximising their added value 
for improving the overall health of the population and narrowing health inequalities. 

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Finally,  while  this  paper  focuses  on  health  inequalities  in  the  EU,  the  2008  WHO  CSDH 
report highlighted the enormous health inequalities which exist at global level and called for 
sustained,  comprehensive,  action  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 (through aid and development funds and the provision of technical 
capacity) and has an interest that health inequalities are addressed globally.  The EU and its 
Member  States  are  important  partners  in  the  global  effort  to  attain  the  Millennium 
Development  Goals  and  work  together  with  other  international  organisations  such  as  the 
WHO  and  the  UN.    Hence,  it  would  be  important  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  comparable  EU  data  and  research  knowledge 
poses an obstacle to rethink policy priorities, establish comparisons, derive best-practices, and 
reallocate  resources  where  they  are  most  needed.    Better  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 for 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  persistence  of  such  inequalities  in  health  suggests  a  possible 
discrepancy between the existing situation and some of the overarching goals of the European 
Union such as strengthening of economic and social cohesion, ensuring equal opportunities, 
promoting  the  reduction  of  inequalities  and  the  promotion  of  equality  between  men  and 
women  and  solidarity  among  Member  States  (Art.  2  of  the  EU  Treaty  and  Art.  2  of  EC 
Treaty).  See annex 2.3 for more detail.    

Secondly,  high  levels  of  poor  health  in  sections  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  costs  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  

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• 

Insufficient concerted EU approach to health inequalities (lack of mainstreaming at the 
EU level) 

There is a legal basis for action.  Under Article 152 of the EC Treaty the Community should 
ensure  that  all  its  policies  and  activities  provide  a  high  level  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 implementation of Community policies and actions shall 
take into account those objectives 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  adaptable  workforce"  and 
that  "the  Community  shall  encourage  cooperation  between  Member  States  and  support  and 
complement their actions in relation to achieving a high level of employment".  Arts. 136 and 
137  and  related  articles  indicate  that  the  Community  and  Member  States,  having  in  mind 
fundamental  social  rights,  shall  have  as  their  objective  the  promotion  of  employment, 
improved  living  and  working  conditions,  proper  social  protection,  development  of  human 
resources  and  the  combating  of  exclusion,  and  thus  "the  Community  shall  support  and 
complement  the  activities  of  Member  States  in  various  fields"  including  working  conditions 
and  health  and  safety  at  work,  social  security  and  social  protection,  integration  of  people 
excluded  from  the  labour  market,  equality  between  women  and  men  in  relation  to 
employment and the combating of social exclusion.  Finally, arts. 12 and 13 form the basis for 
EU  directives  on  anti-discrimination  e.g.  in  employment  and  social  protection  that  are 
relevant to addressing health 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  individually  and  where  for 
reasons  of  scale  or  the  effects  of  the  proposed  action,  they  can  be  better  achieved  by  the 
Community.  For example Community research frameworks allow the building up of a richer 
pool  of  research  knowledge  than  individual  country  level  frameworks  (knowledge  could  be 
restricted in less wealthy countries).  Community frameworks can facilitate the exchange of 
information  and  best-practice  across  27  Member  States  so  that  all  countries  but  especially 
those countries in a disadvantageous position can benefit from learning from the experience of 
others and develop their own strategies.  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 health 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 health 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 larger results than individual action.  

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In this context, the necessity of EU action can be found in relation to two 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 action.  Lack of reliable socio-economic data on 
health status is a common challenge in a large number of Member States.  The Community 
(through EUROSTAT) working together with Member States  is better placed 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 the EU provides financial support to Member 
States, especially less well-off regions, that can be used to invest in key determinants of health 
inequalities  such  as  living  conditions,  training  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  Regional  Policy  provides  tools  (including  funding)  to 
create potential (conditions and factors) in the least-developed 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  adequate  quality  of  services.    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  and  growth)  of  poorer  regions,    is  seen  as 
necessary to tackle the disparities which would otherwise remain substantial 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  also  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,  enhancing  research  and  knowledge  gathering, 
providing greater visibility of relevant actions through improving the sharing of experiences 
and  good  practices  and  capacity  building  and  improving  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 divergence 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  the  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  policy  strategies  in  the  hands  of  the  Member 
States to best fit their national 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.    For  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  status  would  be  done  together  with  Member 
States allowing for the best national alternative.  In addition, actions proposed and appraised 
would  be  pursued  within  existing  EU  instruments  (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  reinforce  Member  States  activities  with  a  benefit  to 
Member States. 

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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  this  field  and  to  continue  to  ensure  that  EU 
policies and activities provide a high level of health protection as set out in the Treaty.  As far 
as  possible,  the  health  protection  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 policies towards reducing health inequalities. 

3.2. 

Specific Objectives  

Specific objectives are to: 

•  Raise awareness, promote information, best-practice exchange and policy coordination 
and  advocate  the  tackling  of  health  inequalities  as  a  policy  priority;  both  at 
Community and Member States level and by other stakeholders. 
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. 

• 

•  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.  

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 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 

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 
Insufficient  concerted  EU  approach 
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 towards achieving these objectives.  Option I is the 
continuation  of  current  activities  ("business  as  usual").  Option  II  "Current  plus"  builds  on 
existing work which can be taken forward in a short time frame without the need for further 
or  fundamental  changes 
in  a 
Communication.    Option  III  "Far  Reaching"  requires  a  longer  time  frame,  involves  deeper 

instruments,  and  formulated 

to  current  Community 

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changes in existing EU instruments, and includes a Council Recommendation in addition to 
the Communication.   

4.1.  Option I: Continue current activities, no new initiative:  

Under Option I, work to support the reduction of health inequalities would continue under the 
social OMC and the Health Strategy, but there would be no new initiatives.  Equity in health 
is a guiding principle of the Health Strategy and reducing inequalities in access to health care 
and  health  outcomes  is  a  common  objective  under  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 Inclusion, 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  and  the  Council  Working 
Party on Public Health at Senior Level (Council WPPH).  There would be continued support 
for  initiatives  in  this  area  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 support 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 inequalities would remain a common objective 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  would  take  place  on  topics  related  to  social 
determinants  of  health 
inequalities  such  as:  housing  (exclusion,  deprivation  and 
homelessness),  active  inclusion  (follow-up  2008  active  inclusion  recommendation)  and 
measures to enhance employment of those further from the labour market; looking at social 
aspects of migration and ethnic minorities; the analysis of child wellbeing; review inequalities 
in access to health and social care services in general and for people suffering from specific 
diseases  (e.g.  Alzheimer's  disease);  analysis  of  access  to  quality  primary  care;  quality  of 
health and social services.   

c) A greater use of social OMC peer reviews to address social determinants of health could be 
encouraged  and  a  health  inequalities  dimension  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 strengthening social OMC communication.   

Improve  data  availability  and  the  mechanisms  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 structural indicator in the Lisbon strategy  

b) The social OMC common indicators on health status would be used to monitor progress in 
relation  to health inequalities.    Under  the  Indicators sub-Group of the SPC, some indicators 

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would  be  developed  including  on  poverty  and  material  deprivation,  social  aspects  of 
migration and child wellbeing; on pension adequacy; on avoidable mortality, on access to and 
utilisation  of  health  care  and  on  health  promotion  and  disease  prevention  (risk  factors/ 
behaviours,  screening),  as  much  as  possible  by  age,  sex,  socio-economic  status  and 
region/geographic dimension.  This would be done 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 inequalities 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  Annual 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 Programme (2008-2013) would provide some financial support 
to policy development and innovation by Member States 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 people, 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 drafted in 2009 on the implementation of Directive 
91/383/EC, covering the period up to 2007 and attempt identify potential deficiencies in the 
Directive in order to give guidance for the future action of the Commission in this field.   

d) The Roadmap on Gender Mainstreaming would continue to be pursued 

d)  Some  support  would  be  available  for  stakeholder  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  integration  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 would raise awareness on health inequalities, 
highlighting their economic, political and ethical magnitude.  It would confirm the reduction 

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of health inequalities as a policy priority, increase dialogue with other relevant actors in the 
field  and  strive  towards  a  better  use  of  existing  information  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 obstacle to action is the current limited data on 
the extent and consequences of health inequalities and the current limited knowledge on the 
effective  policies  to  implement.    Information  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  through  improving  data  collection  by  socio-economic 
status  and  geographic  dimension,  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 together 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  mechanisms  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  Research  funds,  the  Health  Programme  and 
PROGRESS to fund scientific research from which Member States could benefit to develop 
their strategies.  It would encourage a first consideration by all relevant policy areas on what 
is their potential for future action in this field (as proposed by some national authorities 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 Member States’ to develop and implement 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  Commission  commitment  to  tackling  health 
inequalities  as  a  policy  priority.    This  Communication  could  be  seen  as  the  Commission 
recognition at a high level that health inequalities are an important issue for policy.  It would 
indicate  that there is  some  evidence  and knowledge on the  extent, causes of  and policies to 
address health inequalities but there are also important gaps in these domains that need to be 
filled.  The Communication would also indicate that 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  Commission  would  start  to  explore  what  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  set  of  initial  actions  in  that 
direction.   

b)  The  Commission  would  explore  possibilities  for  including  the  reduction  of  health 
inequalities as an objective in the post 2010 Lisbon strategy. 

c)  Strengthen  the  synergy  between  Member  States  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 reference of the existing 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 the work of the SPC and the Council WPPH. 

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d) Establish a mechanism for bringing social partners 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  workplace,  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 initiatives (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 the context of their everyday lives..   

e) The Commission would bring forward proposals with the aim of stimulating and focussing 
the reflection on targets on improvements in health status and narrowing 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  mechanisms  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  measuring  and  monitoring  differences  in  health 
between social groups, Member States 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 consultation 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  comparability  and  coherence  with  other  international  datasets  (e.g. 
WHO, OECD) as requested in several responses to the open consultation.  

d)  Orient  relevant  EU  research  program  elements  towards  closing  knowledge  gaps  on  the 
extent, causes, consequences of health inequalities and policies to address them such as Socio-
economic  Sciences  and  Humanities  of  the  7th  EU  Framework  Programme  for  Research.  
Develop  a  consistent  and  rational  EU  public  health  research  agenda  in  future  framework 
programmes to embed health inequalities research.    The  need  for  more  research  and  related 
financial  support  was  also  seen  as  one  of  main  areas  of  added  value  of  the  EU  by  the 
responses to the open consultation.  

e) Propose inclusion of research on the reduction of health inequalities 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 Agency 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 addressing 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 Health Strategy and the further 
development  of  EU  specific  actions  on  health  inequalities  for  the  period  beyond  2013, 

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including the new budget framework.  Such a dedicated 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  Structural  Funds  (at  current  levels)  in  area  of  health  could  be 
better used to address health inequalities by  

•  Developing the assessment of the impact of the 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 the 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  identified  in  the  Joint  Report  on  SPSI  and 
the  investment  proposals  in  operational  programmes,  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  care  sector  services  which  make  a  greater 
contribution towards reducing health inequalities.   

b)  Encourage  Member  States  to  exploit  further  the  existing  options  under  the  EU  rural 
development policy and apply in full the existing schemes under CAP (school milk, food for 
most deprived, school fruit scheme). 

c)  Organise a forum on health and restructuring in 2010,  

d)  Establish  a  mechanism  for  health  inequality  audit  (assessing  the  contribution  of  existing 
policies  towards  reducing  health  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  aim  of  strengthening  the  health 
equality focus of existing EU activities on health determinants including tobacco, alcohol and 
nutrition as well as other policy areas 

f)  Review possibilities for increasing contributions to health inequality reduction in other EU 
policies such as public health, education; antidiscrimination, gender; environment etc, notably 
through the use of indicators and reporting  

Action to increase the protection of health for vulnerable groups would include:  

a)  Follow  up  on  the  2007  Council  Conclusions  on  Health  and  Migration  in  the  EU  by 
improving knowledge of migrants' and ethnic minorities health and its determinants through 
more EU funded research, better data collection, considering the establishment of a network 
of national experts on health and migration, disseminating best-practices;  

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b) Adding focus on reducing health inequalities to the 2010 Roma summit and the integrated 
platform for Roma inclusion and develop an initiative in collaboration with Member States, to 
raise awareness and improve the ability of actions 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  analyse  and  monitor  access  to  basic  goods  and 
services which impact on health (shelter, water, sanitation, healthcare, and other factors)  

d) Adding focus on reducing health inequalities 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 activities on the health of children 
and young people. 

In  addition  the  Commission  would  take  the  following  actions  to  promote  the  tackling  of 
health inequalities at a global level:  

a)  Provide  input  to  the  development  cooperation  work  on  poverty  and  health  and  work  on 
developing social protection in health care in developing countries,  

b)  Create  a  tool  for  assembling  and  disseminating  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 Commission 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 policy for sector policy dialogue on health inequalities 
in the context of the European Neighbourhood Policy.  

4.3.  Option III: Far reaching efforts to enhance EU policy priorities in relation 

to health inequalities.  

In addition to the actions under option II a comprehensive policy approach would be put in 
place including actions which involve significant changes in polices at EU and national levels.  
Option  III  would  include  the  actions  in  Option  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 inequalities would set a common agenda for Member 
States to address health inequalities, while respecting national responsibilities for determining 
health policy and health services.  This would be based on article 152 and has been requested 
by a number of consultation responses including national authorities. 

b)  The  Commission  would  propose  targets  to  reduce  health  inequalities  across  the  EU. 
Conceivably they could relate to: 
-  No Member State having an estimated life expectancy 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 expectancy 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 

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-  A  reduction  of  X%  in  the  level  of  chronic  illness  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  mechanisms  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  work  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 the 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  independent  and  dedicated  research  agency  on  health  inequalities  (as 
proposed in consultation). 

Develop the contribution of EU policies, including 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 committee would be proposed to review progress 
and provide advice to the Commission 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 Commission.  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 taken into account in EU policies.  A report would 
be presented to the Commission.  

b)  As  programmes  and  policies  are  renewed  for  the  period  beyond  2013,  the  reduction  of 
health inequalities would be made an explicit key priority and resources would be reallocated 
or added accordingly.  These would include i) the Cohesion policy 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 requests in the consultation.  

c) The Commission would review the extent to which additional community measures could 
contribute to ensuring that access to basic needs for health (health care, shelter, food, water 
education) can be better defined and assured for all groups, but particularly for those who are 
vulnerable (section 2.1) – including Roma, migrants and people with disabilities. 

d)  The  Commission  would  propose  a  major  international  initiative  to  address  global  health 
inequalities.    It  would  consider  additional  approaches  to  support  countries  neighbouring  the 
EU to reduce health inequalities. 

A table spreading through the next two pages provides 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 here 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 
invitations, 
the  meetings  of 

the  platform  (e.g. 

Stakeholders'  representatives  define  agenda  with 
Commission  and  participate  on  a  voluntary  basis, 
providing  evidence  from  their  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 

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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 States: 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 
is  raised 
especially  by  those  countries  which  currently  put  a 
lower policy priority on health inequalities. 

information  available.  Awareness 

Develop a consistent  methodology for measuring and 
in  health  between  social 
monitoring  differences 
groups and regions at the EU level using data provided 
to  EUROSTAT 
fragmented 
to  overcome 
knowledge  and  non-comparable  methodologies  that 
the  Health 
currently  exist:  using  funding  from 
Programme  commission  studies  that  will  provide 
suggestions for a methodology. The Commission will 
review 
the 
suggestions  and  will  apply 
methodology at EU level using EUROSTAT data. 

such 

the 

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  improve  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 
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 
life  expectancy  data 
collection by SES. 

improve  mortality  and 

frameworks, 

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  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. 

On  a)  Member  States  work  with  EUROSTAT  to 
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-available.  Again,  this  contributes  for 
more informed decision making. 

to 

Member  States  already produce  the  National  Strategy 
Reports  on  social  protection  and  social  inclusion  and 
will  be  encouraged  to  report  on  actions  in  the  field 
although reporting on this topic will remain voluntary. 
the  Expert  Group  on  social 
Representatives 
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. 

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relevant  EU 

Orient 
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. 

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. 

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  

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.  

Member  States  can  use  and  benefit  from  the  public 
knowledge  that  results  notably  in  devising  national 
strategies in this area.  

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.  

Member  States  would  be  encouraged  to  use  health 
inequalities  related  indicators  in  their  assessment  of 
the  operational  programmes  but  this  would  remain 
voluntary.  Participation 
the  capacity  building 
in 
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 a large extent reporting and indicator development 
is done in collaboration with Member States. They can 
benefit  from 
to  develop 
the  knowledge  created 
national strategies.  

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Objective 

Option I – Business as usual 

Option II – Current plus 

Option III –  Far reaching 

Continue 
initiatives 

current 

activities,  no  new 

Additionally  to  the  actions  under  Option  I,  this 
Option includes: 

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  best-practice  exchange 
(OMC, SPC, Expert group, Council WPPH) 

- Commission Communication 

- Council recommendation 

-  explore  possibility  to  strengthen  link  between 
growth, jobs and health in Lisbon strategy 

- set clear targets 

- strengthen the EU expert group on SDH to inform 
WPPH and SPC 

-establish a stakeholder platform  

- 
stimulate  and 
development of targets 

focus  work 

towards 

the 

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- propose  to change  terms  of  reference  of an 
agency to transform into dedicated HI agency 
(e.g. EUROFUND, ECDC, OSHA) 

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 
inequalities  and 
health 
the  evidence  base 
for 
action 

- 
continue 
information system 

development 

of  Health 

-  develop  consistent  methodology  for  measuring 
and monitoring health inequalities 

-  under  social  OMC,  continue  to  develop 
indicators  on  poverty,  utilisation  of  health 
care,  where  possible  by  socio-economic 
status  

to  use 

-  continue 
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 

- 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 

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Develop  the  contribution 
of  relevant  EU  policies 
reducing 
towards 
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 
rural 
development 

and 

some 

- 
support 
(PROGRESS, Health Programme) 

for 

stakeholders 

-  continue  to  monitor  implementation  of 
labour law and health and safety legislation 

- 2010 European Year Against Poverty 

-  Continue  existing  work  on  determinants 
labour  market)  and  specific 
(housing, 
groups 
without 
Roma) 
(disabled, 
necessarily a health inequality focus 

- ensure better use of Structural Funds by 

- 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 

- 

-  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  

of 

review 

for  more 

possibilities 

effective 
- 
contribution 
anti-
health, 
discrimination,  gender,  environment,  social,  etc. 
policies,  notably  through  the  use  of  indicators  and 
reporting 

education, 

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: 

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-  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 

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5.  ANALYSIS OF IMPACTS 

This  is  a  non-legislative  initiative  with  the  aim  of  strengthening  action  to  support  and 
complement the efforts of Member States and other stakeholders on a broad policy objective – 
reducing  inequalities  in  health.    The  options  are  cumulative  representing  different  levels  of 
Community institutional response (option III builds on option II which in turn builds on option 
I).    The  actions  proposed  in  options  I,  II  and  III  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  degrees  of  effort  to  raise  awareness  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 other stakeholders to reduce inequalities in health 
is the main factor determining the impact of these proposals.   

This initiative falls within the category of 'broad policy-defining documents' as described in the 
Impact  Assessment  Guidelines.    In  line  with  the  guidance  there,  and  taking  into  account  the 
type of measures proposed, the appraisal is broad 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  social  protection  systems)  or  reallocation  of 
resources,  others  require  little  funding  (e.g.  legislation  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  States  (in  particular  the  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 value in its own right over and above the additional 
economic  output  that  a  healthier  population  is  able  to  generate.    The  analysis  below  is  thus 
more an assessment of potential qualitative impacts 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 therefore 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 the 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  under  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 social aspects such as health and employment. 

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Options II and III vis-à-vis option I by proposing stronger  awareness  raising, associated with 
better  data  collection  and  greater  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 including in the field of healthcare (access for all to 
insurance  coverage  for  health  promotion,  disease  prevention,  care  and  rehabilitation);  2) 
improving  the  geographic  location  and  availability  of  services  (facilities  and  staff)  in  areas 
where they are lacking; 3) looking at the specific needs of vulnerable groups (including third 
country  nationals)  and  developing  targeted  social  policy  action.    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 further encourage Member States to look at those investments that 
could make a greater contribution to reducing health inequalities.  This would be especially the 
case,  if  Member  States'  use  of  the  Structural  Funds  and  Cohesion  Funds  resulted  in  an 
investment towards those areas requiring higher labour inputs both high and low skilled – such 
as  health  and  social  care  in  the  community  and  notably  in  deprived  population  areas.    As  a 
consequence, positive employment and health effects 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  financial  situation),  and  better  health  outcomes  in  deprived 
geographic areas / lower socio-economic groups.   At EU-level  this could also contribute to a 
greater  health  convergence  between  Member  States  -  as  the  link  between  within  country 
inequalities and overall country 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 differences in health and access to health care.   

A  mechanism  for  involving  social partners as in Options II and III, building on previous and 
positive  Commission’s  experience  to  involve  stakeholders  in  other  areas,  such  as  obesity  and 
alcohol, sends a positive signal about the importance of partnerships and social 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 economic 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 assessment 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  regarding  the  extent  and  economic  consequences  associated  with 
the pervasiveness of health inequalities 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  social  consequences.    Further  deterioration  of 
health of certain groups now, can imply less employment 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  makes  the  need  for  better  information  and  its 
dissemination  more  pertinent  and  pressing,  suggesting  that  actions  under  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 inequalities between and within Member States which the 
current economic crisis could potentially further enhance.  In this context, no new actions in the 

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light  of  the  crisis  notably  in  terms  of  awareness  raising  could  represent  a  wasted  opportunity 
with  regards  to  possibilities  for  health  and  employment  (which  could  be  attained  through  a 
greater emphasis on developing community health and social care).   

5.2.  Economic impacts 

The cumulative nature of the options also implies that Option III could create greater uptake of 
effective measures then Option II and consequently 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  large  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  experienced  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  changes  in  mortality  and  morbidity.    Similar 
estimates are not available for the gap between Member 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 people 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 precise, indicate the possibility 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 relationship between employment and health could 
lead to Member States focusing more strongly on health and safety at the workplace, resulting 
in a) fewer accidents and injuries in the workplace, 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 raising, best practice exchange, policy analysis 
and  greater  knowledge  for  example,  can  have  different  economic  impacts.    For  example,  , 
where Member States decide to strengthen inter-sectoral policies to address health inequalities, 
there  could  be  budgetary  implications  as  a  result  of  such  activities  in  Options  II  and  III.  
Member States could allocate additional national investment for the strengthening of health and 
social  protection  systems  (e.g.  more  resources  devoted  to  fight  poverty  or  to  close  gaps  in 
health care provision).  Or there could be opportunity costs as a result  of the reorientation of 
resources which could occur particularly in Member States that do not currently have a focus 
on health inequalities.  It is also 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  proposed,  there  is  a  reallocation  of  resources/ 
reprioritisation and efficiency gains are achieved.   Some  measures  may  require  more  funding 
than others and it is difficult to prejudge which will be chosen by which Member State and thus 
the costs of those actions.  At the EU level no actual changes in budget or priorities are foreseen 

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under  these  options  and  any  future  change  would  be  subject  to  a  specific  impact  (including 
cost) analysis. 

Overall,  if  the  underlying  determinants  of  health  and  health  inequalities  continue  to  improve 
this would be likely to have a positive economic impact.  In the longer term gains in health and 
reductions in loss of healthy life years may be either 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  associated  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 important health and employment consequences (e.g. a 
large increase in the long-term unemployment rates) which can still be observed.  Hence, the 
crisis makes the need for action along the lines expressed in section 3 and 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  tackling  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  status  it  is  also  difficult  to  identify  the  costs 
involved.    Following  a  very  recent  questionnaire  by  ESTAT  to  Member  States  on  the 
possibility  to  obtain  such  data  it  was  identified  that:  a)  some  countries  can  and  provide 
mortality data by socio-economic status (education level, last occupation) so that for these there 
would  not  be  additional  costs;  b)  some  countries  indicated  that  by  law  such  an  information 
would be difficult to obtain which also implies no additional costs; c) for some countries there 
could  be  the  possibility  to  easily  link  various  instruments  (e.g.  census  data  and  death 
certificates) at a minimum cost; d) for some, such linkages would require some more additional 
work and thus costs.  In general, EUROSTAT in its work with Member States would aim for 
the most cost-effective way of obtaining the information.  EUROSTAT is currently exploring 
and proposing a way to improve data collection and dissemination in general that can lead to 
lower economic and administrative costs.  Certainly, any activity that would imply changes in 
data  collection  at  EU  level  would  be  subject  to  its  own  impact  assessment  (including  cost) 
analysis.  

Some actions proposed are not expected to generate 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 costs 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 options and related actions from the perspective of 
effectiveness – the contribution of the options to achieve the objectives; efficiency – taking into 
account the amount of resources and effort involved 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 towards supporting and complementing the efforts of 

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Member  States  and  other  stakeholders  in  tackling  health  inequalities  and  thus  the  EU 
contribution  towards  a  reduction  of  health  inequalities  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 current activities, no new initiatives 

Effectiveness 

Option I is maintenance of the status quo and includes 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  supports  a  certain  amount  of  awareness  raising  and 
mechanisms  for  exchange  of  good  practice  between  Member  States,  under  Option  1  (status 
quo)  and  despite  current  activities,  we  see  that  only  a  small  minority  of  countries  has  set  the 
reduction of health inequalities as a main policy priority and has implemented a comprehensive 
inter-sectoral  approach  to  tackle  health  inequalities.    The  COR’s  response  to  the  public 
consultation  also  highlighted  that  the  current  action  was  not  sufficient  to  ensure  that  health 
inequalities would appear on all national policy agendas.   

Similarly, while current activities support some development of information and knowledge in 
this area, weaknesses would remain in monitoring 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  Member  States)  and  in  lacking  an  accepted 
methodology for calculating health inequalities.  Without an agreed way of monitoring health 
inequalities  and  without  recognised  dedicated  reporting,  knowledge  at  the  Community  level 
about the rate of progress and the effective 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 health inequalities, neither would 
it necessarily lead to greater awareness in relation the protection of health of vulnerable groups 
such as Roma, nor would it provide an input to a global agenda on health 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  administrative  costs,  nor  require  re-orientation  of 
funds from other policies.  However, in political terms, it would not respond to the requests by 
Member States and other stakeholders for 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 

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The actions listed under option II represent an additional 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 would provide additional input and value to the work of the SPC and the 
Council WPPH and thus strengthen the existing information sharing and best-practice exchange 
mechanisms  without  significant  administrative  or  economic  costs  to  the  EU  or  national 
administrations.    Mechanisms  for  involving  social  partners  create  additional  momentum  for 
action  to  achieve  the  objectives.    Building  on  previous  and  positive  Commission’s  work  to 
involve stakeholders in other areas, such as obesity and alcohol, they can 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  decision  making  by  Member  States  and  other 
stakeholders  on  policies  to  address  health  inequalities,  something  that  has  been  supported  by 
the majority of stakeholders.  

Option II could lead to more appropriate (“equality proof”) regional investments, making them 
responsive to the observed large and widening health inequalities and other challenges such as 
the current economic crisis or the future challenges of ageing 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  information  would  primarily  be  drawn  from  existing 
reporting mechanisms.   

In general this option is achievable within existing resources and highly feasible although there 
are some issues that need noting.  Policy priority under Option II would imply more in-depth 
work  on  targets.    Such  work  received  substantial  support  in  the  consultation  (some  national 
authorities  included).    While  support  for  this  has  been  building,  an  acceleration  may  still 
involve the risk of generating resistance from some Member States.  In addition, some actions 
to  improve  data  availability  and  comparability  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 extension of some EU activities and therefore proper consideration of 
whether such an extension is consistent with the principles of subsidiarity and proportionality.  
This  goes  beyond  the  simple  legal  basis  for  action  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 that 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; 

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•  added value of exchange of information and 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 policies but also including a wide range of other policy areas such 
as social, health and regional policy and activities 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 under Option II through health inequalities impact 
analysis,  would  have  the  potential  to  inform  future  EU  policy  development.    EU  wide  data 
collection  and  monitoring  will  provide  the  possibility  of  comparison  and  learning  between 
Member States which will be of benefit to policy makers in each country.  By reason of their 
greater  scale  and  opportunities  for  sharing  expertise  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  social,  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  intervention  of  the  EU  were 
highlighted by the COR’s response. 

The actions in Option II are relatively modest and proportional to the objectives defined in this 
impact assessment.  Option II represents a lighter implementation requirement for the EU and 
for Member States, in comparison with the activities listed under Option III.  

6.3.  Option III – Far reaching efforts to enhance 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  particular  added  value  of 
Option III is in relation to political commitment 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  tackling  of  health  inequalities  as  a  policy  priority.    Although  not  legally 
binding, a recommendation would be highly visible  and  would  ensure  ownership  by  Member 
States.    Experience  shows  that  the  status  of  recommendations  does  facilitate  the  uptake  and 
dissemination  of  measures  and  can  become  a  reference  document  for  all  actors  involved.    It 
could then be a useful tool to strengthen monitoring and evaluation.  A recommendation would 
also  be  a  good  opportunity  to  make  clear  how  a  package  of  measures  on  tackling  health 
inequalities  should  be  integrated  into  overall  social  and  economic  development  measures  as 
part  of  the  Lisbon  agenda.    Some  of  the  responses  to  the  open  consultation  including  by 
national authorities support the 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 

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Commission which have not previously had the opportunity for a developmental process with 
Member States and stakeholders.   

In  general,  the  possible  drawback  of  the  package  of  measures  in  Option  III  is  that  there  are 
currently  significant  uncertainties  regarding  causations  and  effective  measures.    This  means 
that,  while  such  deep  policy  changes  should  be  considered  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 advantages 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  measures  that  can  improve  access  to  basic  needs, 
would  also  require  the  support  of  other  EU  institutions  and  Member  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 health inequalities it is not clear that a Council Recommendation 
would  be  favoured  by  a  majority  of  Member  States  in  the  current  situation  and  given  the 
existing lack of information and knowledge. 

Proposing targets allows the Commission to test the strength of political interest and respond to 
the challenge created by the  economic 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 sufficient 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 stage such support has not been sufficiently gauged.  
Option  III  may  also  involve  some  opportunity  costs  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 consensus 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 further 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  activities  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 health.  Such a non binding recommendation would 
continue to fully respect the responsibilities of Member States to determine their health policies 
and organize and deliver health services.  However,  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, -- significant negative impact, --- major negative impact.  

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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  acceptance  /  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 

Investments  allocated  to  addressing  health  inequalities  for 
national authorities  

0 

- 

- 

-- 

-- 

--- 

Preferred Option 

All  three  options  would  help  to  achieve  the  specific  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  potential  for  some  additional  administrative  and 
opportunity costs, may suffer from knowledge uncertainty and may face some political barriers.  
Option  I  is  likely  to  make  a  modest  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.  Therefore, while actions under Option III are realistic 
potential  EU  actions,  the  current  situation  suggests  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  principle  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  involved.    To  some  extent  however,  there  is  a 
possibility for individual elements to be moved 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  inequalities38.    It  contains  several  proposals  to 
improve information, monitoring and reporting on the progress in relation to impact on health 
inequalities and related outcomes such as social protection and social inclusion.  These include 
the development of indicators based on current data and further progress on the development of 
EU wide indicators on related outcome measures.  

38  For  an  overview  table  linking  the  identified  problems  via  the  objectives  with  the  evaluation  see  Annex 

A17. 

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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  mechanisms.    That  is  through  reporting,  self 
monitoring and evaluation including through peer review.  Monitoring and evaluation will be 
on  the  basis  of  measurement  against  the  specific  objectives.    The  precise  mechanisms  for 
monitoring  and  evaluation  will  thus  depend  on  what  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 monitoring is identified in Option II – a report by 
the Commission on progress in tackling health inequalities.  This Option foresees that in 2012, 
the Commission will publish a report on the implementation of this initiative and the progress it 
has  had  on  addressing  health  inequalities  with  further  reports  envisaged  (including  an 
evaluation of the HI strategy). This 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  development  of  a  consistent  methodology  for 
measuring and monitoring differences in health between social groups, Member States regions 
at  the  level  of  the  EU  and  support  Member  States  to  collect  data  on  health  inequalities  and 
determinants of health.  These data will 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  Party  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 
best-practice 
and 
information 
exchange  and  advocate  the  tackling 
of  health  inequalities  as  a  policy 
priority 

Improve data availability and the 
mechanisms to measure, monitor and 
report and improve the knowledge 
base  

Develop  the  contribution  of  relevant 
reducing 
EU 

towards 

policies 

Number  of  Member  States  with  comprehensive  policy  approach 
which can be analysed in the social OMC NSR 2011-2013 (currently 
two) 

To  be  evaluated  by  the  Eurostat  Working  group  on  mortality  data, 
who is compiling the data  

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 

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inequalities in health 

how  many  EU  reports  address  the  influence  of  certain  strategies  on 
health and health disparities 

Additional  assessment  under  Option  II  and  III  in  dedicated  Health 
Inequality report 2012 

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Annexes to the Impact Assessment on "Solidarity in Health".  
1.  ANNEX 1 Consultation and expertise........................................................................ 53 

1.1. 

1.2. 

1.3. 

1.4. 

1.5. 

1.6. 

Targeted written consultation ............................................................................... 53 

Summary of responses.......................................................................................... 57 

Consultation during the development of previous communications. ................... 63 

Consultation with key groups convened by the European Commission .............. 64 

Consultation with EU institutions......................................................................... 68 

Expertise ............................................................................................................... 69 

2.  ANNEX 2: Health inequalities in the EU ................................................................... 71 

2.1. 

Background and context: Nature and scale of health inequalities in the EU........ 71 

2.1.1. 

Inequalities in health outcomes between Member States ..................................... 71 

2.1.2.  Determinants (drivers or causes) of health inequalities........................................ 82 

2.2.  What Member States are doing and consider effective to address health 

inequalities.......................................................................................................... 100 

2.3. 

2.4. 

Existing EU action and links to other relevant EU policies ............................... 104 

Additional information on why health inequalities between and within countries 
are a problem and a policy concern to the EU? The legal and political basis for 
action and subsidiarity ........................................................................................ 108 

3.  Bibliography ............................................................................................................. 111 

4.  List of abbreviations ................................................................................................. 113 

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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 stakeholders and organizations working with them on 
issues related to health inequalities to respond to a consultation document which contained a 
number of questions (Annex 1).    Altogether 148 requests for consultation 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 document 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  service  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, like women councils or regional authorities.   

Responses  from  EU  Member  States  and  national  governmental  organizations  in  Member 
States:  

Belgium,  Cyprus,  Czech  Republic,  Finland,  France,  Germany,  Hungary,  Ireland  (national 
public  health  institute),  Latvia,  Lithuania,  Malta,  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 

See 

39 
http://ec.europa.eu/health/ph_determinants/socio_economics/cons_inequalities_en.htm 

http://ec.europa.eu/social/main.jsp?langId=en&catId=89&newsId=462&furtherNews=yes 

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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 Intellectual Disability Medicine - MAMH 

European Association of Service providers for Persons with Disabilities – EASPD 

European Society of Intensive Care Medicine 

European Union Geriatric Medicine Society - EUGMS 

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International Association of Gerontology and Geriatrics 

European umbrella organisations (ENGOs): 

AIDS action Europe 

AVERROES Network (migrants' health) 

Central  and  Eastern  European  Women's  Network  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 Retired 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 Therapy 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 National Organisations working with the Homeless 

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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 naturally also representatives of the Industry / companies: 

European Diagnostic Manufacturers Association 

European Federation of Pharmaceutical Industries and Associations EFPIA 

Alliance Boot  

Eucomed - medical technology 

European Association of Service providers 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 expertise on refugees and newcomers' health 

Romanian Association Against AIDS 

Zminijietna - Voice of the Left (MT) 

IOGT-NTO (SE, Alcohol) 

Connections  -  Integrated  responses  to  drugs  and  infections  across  European  criminal  justice 
systems 

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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. Stronegger, James Scanlan, Dr. Mc 
Hugh Mike, Gerardo Zamora-Monge and, Tor-Kristian Rønneberg. 

Other responses included  

International Organization for Migration  

The  European  Office  for  Investment  for  Health  and  Development  of  the  WHO  (please  note 
that this is not an official 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  health  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  deteriorates  the  health  status  and  on  the  other  hand 
decreasing  tax  revenues  might  lead  to  cut-backs  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 social gradient in health status.  

Several  stakeholders  noted  the  economic  value  of  improving  population  health  status.  One 
health service organization proposed not to focus on increasing gross domestic product (GDP) 
to  raise  healthy  life-expectancy,  but  the  other  way  around  arguing  that  one  year  increase  in 
average life expectancy leads to 4% increase of GDP.  

Inequalities between and within Member States 

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While life-expectancy is on the rise all over Europe, health inequalities tend to widen as well. 
The existence of differences in life-expectancy and healthy life-years 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  for  coronary  heart  diseases  in  the  old  Member 
States, whereas they increase in the EU-10. 

Differences in Socio-Economic Status (SES) widened in Central and Eastern Europe following 
the  introduction  of  a  market  economy.  While  the  gap  remained  stable  in  the  80s  and  90s  in 
Western Europe it increased in the 2000s. Some stakeholders stressed that in the new Member 
States gaps tend to be wider.  

Injuries are also more prevalent among groups with 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  stressed  the  close  connection  between  socio-economic 
status and health status. A scientific study presented a hierarchy of causes, identifying physical 
and physical working conditions as the most influential, followed by childhood conditions and 
risk  behaviour.  All  these  factors  were  regarded  as  being  more  prevalent  among  lower  socio-
economic strata. 

Several responses underlined the importance of the early ages for a healthy 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  environment,  nutrition  and  housing  themselves  and  are 
susceptible to outside influences. 

Among respondents there was a difference of opinion on whether the higher risk behaviour can 
be solved by education and information campaigns alone or whether additional measures are 
required addressing socio-economic factors 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 mentally disabled people, unaccompanied 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  the  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 which concluded: "We already know enough to take 
action". 

The EU added value 

The overwhelming majority of responses welcomed 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' 

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responsibility,  whereas  those  which  focussed  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  solved  at  the  regional  or  even 
local level. EU added value was welcomed in the areas of data collection, agenda setting and 
funding. 

Responses from the national level took quite diverging positions on the desired involvement of 
the EU in principle. Whereas some saw a need for the EU to take a lead, others were of the 
view  that  actions  tackling  health  inequalities  should  be  the  sole  responsibility  of  Member 
States.  Despite  this  general  divergence,  consensus  existed  in  relation  to  a  range  of  concrete 
actions.  All  national  level  responses  were  of  the  view  that  better  indicators  and  exchange  of 
best practices can add value to the national policies to tackle health inequalities. 

The role of the EU in providing leadership in relation to the economic crisis was also identified 
as an added value. The possible contribution of the following EU policies was mentioned also 
in relation to improving working conditions, pharmaceuticals, 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 raising 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 recognition that concrete actions face obstacles. A renewed European 
discourse is expected to help to overcome these. 

One  health  ministry  and  the  professional  association  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 Ombudsman 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 the 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  responses  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  status,  gender  and  geographic 
area. Respondents commented that many of the proposed indicators are already included in the 
Open  Method  of  Coordination  (OMC)  health  indicators,  but  coherent  data  are  not  available 
yet. The need to raise data on the determinants to better suit policy responses was underlined 
repeatedly. One national response raised concerns about comparability of subjective indicators 
(unmet need) as these are influenced by cultural expectations rather then real provision. 

Two  European  umbrella  Non  Governmental  Organizations  proposed  a  further  reporting  by 
private or public funded care / insurance. 

A health inequalities index was proposed a few times, but also explicitly rejected by others. 

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Some responses proposed more research on indicators and special workshops for stakeholders 
including on how to use existing datasets.  

A  number  of  non-governmental  organizations  suggested  expanding  the  concept  of  Socio-
Economic  Status  measured  by  income,  education  and  occupation  by  measures  of  sexual 
orientation, ethnicity and neighbourhood. 

Many  suggestions  concerning  indicators  were  quite  detailed  and  were  forwarded  to  the 
relevant statistical units. 

One response suggested a dedicated institution to monitor health inequalities. 

There  were  diverging  views  among  national  level  responses  regarding  on  how  to  pursue 
further  reporting  and  monitoring.  Whereas  one  called  for  much  more  reporting  on 
determinants,  following  the  model  of  the  Townsend  Score  of  Social  deprivation,  others 
stressed the need to carefully design further reports, to avoid duplication of work, in particular 
with the WHO and not to overload national 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 third 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 number of older ones underlined the need not to 
overburden Member States with reporting obligations and therefore 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 seen a key forum for reports and exchange of 
best practices. Nearly all NGOs called for a better incorporation of stakeholders into the OMC. 
Next to the OMC; the Open Health Forum and the Social Platform were mentioned as Forums 
for the exchange of best practices 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 existing forums without creating new 
reporting obligations for Member States. 

EU policies 

Most contributions noted that although the EU does not have competence in health care, many 
of  its  policies  affect  the  determinants  of  Health  Inequalities.  In  addition  to  the  demand  for 
better  measurements,  was  therefore  the  call  for  taking  health  inequalities  into  account  in  all 
policies.  Additional  Health  Impact  assessment  was  proposed  by  some.    Health  Inequality 
Impact Assessment at EU level was regarded as an important activity by some. 

One  women's  NGO  recommended  including  a  section  on  health  inequalities  into  the  gender 
mainstreaming process. 

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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  also  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  source  for  increasing  health  inequalities  within 
Member States. 

The  increasing  introduction  of  supplementary  private  health  insurances  was  regarded  as 
negatively  affecting  vulnerable  groups,  next  to  the  economically  disadvantaged,  also  old 
women,  disabled  and  people  with  low  health  literacy.  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  regarded  the  Structural  Funds  as  a  valuable  support  to  tackle 
health inequalities at the local level and spread best practices. However more information was 
needed on behalf of the local stakeholders to be able to fully implement these funds. Structural 
funds should also support regional cross-boarder health care. The regional funds were widely 
seen as useful to support innovative projects at the local level. Also it was criticized, that this 
could lead to further disparities 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  vulnerable  people,  disabled,  chronicle  ill  or  in 
general patients with lower 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 and participation in EU level forums. 

Poor  housing  as  a  cause  of  bad  health  status  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 exchange programme for health professionals. 

Some national responses provided positive examples of how the ERDF and ESF funding has 
been  employed  to  improve  health  infrastructure,  ensure  access  for  all  and  improve  health 
promotion.  A  few  noted  that  investment  should  always  be  a  combination  of  EU  and  MS 
funding  and  will  contribute  to  an  increased  workforce.  A  minority  were  firmly  against 
expansion of the budget line following 2014 and recalled that funding for health projects can 
just be increased by reshuffling budget lines. 

Most vulnerable groups 

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Plenty of responses regarding the special needs of different vulnerable groups were received 
including  on  those  mentally  disabled,  trafficked  women,  HIV  infected,  homeless,  street 
children, elderly, Roma, migrants, prisoners. 

Equal  access  to  health  care  was  regarded  as  a  core  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 successful approach for Roma and migrants. 

Health literacy is a central concept 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  vulnerable  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 unsafe abortions and teenage pregnancies, have 
been brought to our attention by several women NGOs. 

It was suggested to break down data on migrant health 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  special  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 consultation. Their main point was 
that also suffering from their specific impairment, disabled people can still enjoy good health, 
when treated in the right way. 

In general, several NGOs working with vulnerable groups, asked for a better exchange of best 
practices and experiences at EU level. 

On  the  current  crisis,  some  responses  noted  that  experiences  from  previous  crises  were 
relevant. 

Targets and Benchmarks 

The majority, were supportive of the idea of setting targets and milestones at EU level.  Some 
remained sceptical about the feasibility of implementation. Two respondents were against the 
idea  of  setting  targets  and  milestones.  Data  limitations  were  the  most  mentioned  obstacle. 
Furthermore  a  small  majority  regarded  the  differences  in  health  status  between  the  Member 
States as too big to come up with real targets. One national responses called for guidelines of 
recommendatory nature and also supported the idea of common targets. 

Targets were proposed for injuries and concrete groups of people.  

Milestones were seen a little bit more positive, as they 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 willingness to participate actively as partners in 
future initiatives. In addition there was positive support for all the key areas of action which 
were  specifically  mentioned  in  the  consultation  document,  though  there  were  a  number  of 
reservations as reported above. 

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8.3.  Consultation during the development of previous communications. 

Considerable  consultation  took  place  on  the  broad  elements  of  possible  future  Commission 
action  on  health  inequalities  prior  to  the  commencement  of  the  impact  assessment  exercise.  
Proposals  for  Commission  action  on  health  inequalities  were  included  as  part  of  the 
development of the EU Health Strategy (2007) and 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  

in 

this  consultation  resulted 

A  wide  public  consultation  took  place  during  2007  on  Europe’s  Social  Reality  which  is 
relevant  to  this  communication.    The  consultation  was  launched  in  February  2007.40    The 
initial  results  of 
the  November  2007  Communication 
"Opportunities, Access and Solidarity: Towards a New Social Vision for 21st Century Europe" 
setting  out  a  range  of  possible  responses  to  the  societal  challenges  at  work  in  the  EU.  The 
consultation process involved 150 contributions from a wide range of sources such as public 
authorities, a national parliament committee, social partners, non-governmental organisations 
(NGOs),  various  interest  groups,  universities  and  research  institutions,  religious  groups  and 
churches  as  well  as  individual  citizens.    Improving  health  receives  considerable  attention  in 
most of the contributions, thus confirming the crucial role attributed to this area of action in 
the  consultation  document.  In  a  number  of  contributions,  health  was  seen  as  a  factor 
influencing  virtually  all  domains  of  the  social  reality  of  individuals.    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 stakeholders — representatives of EU institutions 
and the national authorities of Member States, notably representatives of national, regional and 
local authorities, social partners, 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  broad  policy  orientations  for  a  renewed  Social 
Agenda.    Once  again  improving  health  and  reducing  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  Communication.    The  Commission  then 
launched  the  Renewed  Social  Agenda  in  July  2008,  part  of  which  relates  to  ensuring  longer 
and healthier lives and announces a Communication on health inequalities for 2009. 

EU Health strategy 

The consultation process in early 2007, which aimed to gain stakeholder input with regard to 
the  EU  Health  Strategy  (adopted  in  October  2007)  involved  national,  regional  and  local 
authorities, NGOs, associations, companies, universities and individual citizens. The majority 
(54%) of the more than 150 respondents considered reducing health inequalities, 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  

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The Committee of the Regions conducted a consultation 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 from the new Member States. 

The  drivers  of  inequalities  identified  in  the  survey  complement  the  list  given  in  this  impact 
assessment  (socio-economic  factors  and  lifestyle)  by  geographical  features  (remoteness, 
fragmentation, islands and mountainous environments, presenting concrete barriers to the use 
of services) and cultural heritage (peoples perception of health systems and issues according to 
local traditions, organisation and ethnic group). 

Desirable  Community  action 
impact 
assessment,  promoting  universal  coverage,  improve  monitoring  and  standardisation  of 
indicators, research, learning and training, exchange of information and best practices.  

includes:  mainstreaming,  equity-focused  health 

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  channelled  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,  labour  market  (safe  working  conditions  and 
reduction of job insecurity), urban planning and transport (reducing inequalities between rural 
and  urban  areas),  environment  (food  safety)  and  immigration  (special  support  to  border 
regions). 

8.4.  Consultation with key groups convened 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  programme  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  small  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 health 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-sharing, health insurance).  

In the spring of 2007, the Commission presented a discussion paper on health inequalities in 
the EU to the Member State delegates to the SPC.  This paper reviewed existing evidence of 
health status inequalities within Member States using published research papers, SHARE data 
and EU-SILC data.  It reviewed existing policies or policy proposals 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  considered  this  to  be  a 
priority area for health and social policy.  

Several Joint Reports have also highlighted the issue of health inequalities as a crucial area for 
policy  (Joint  Report  on  Social  Inclusion  2004,  the  JRSPSI  2006,  the  JRSISP  2007  and  the 
JRSISP  2008).    The  JRSISP  2008  provided  an  entire  chapter  on  health  inequalities  within 

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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,  healthy  life  years  and  self-perceived  measures  of  general  health 
and activity limitations).  The Indicators sub-Group (ISG) of the SPC has in several occasions 
highlighted the need to improve data comparability in this area and the need to have data and 
indicator  by  sub-categories  such  as  age,  sex  and  socio-economic  status.    The  ISG  has  also 
called for further improvements in the collection 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 address health inequalities between and within EU 
Member States.  The outcomes of that discussion are as follows.   

Member States strongly welcomed additional action 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.  health  inequalities  are  the  result  of  many  factors 
(social  determinants)  that  lead  to  unhealthy  living  conditions  (e.g.  life-styles,  income, 
employment) in addition to access to quality healthcare (promotion, prevention and treatment).  
Thus health inequalities relate to policy areas other than healthcare such 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  Commission  services.  
Moreover,  they  suggest  that,  from  this  perspective,  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 factors.  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  inequalities  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  practical  implication  and  consequences  of 

actions. 

•  Conduct  more  extensive  and  intensive  exchange  through  peer  reviews  but  especially 

in-depth reviews on the basis of a questionnaire / consultation structure.  

•  Organise a high profile conference every 2 years to see what has been the progress in 

the area. 

•  Create a platform approach with stakeholder involvement. 
•  Support  and  follow  experiments  better  through  PROGRESS  and  public  health  action 

programme.  

•  Conduct analysis of specific types of diseases and mortality rates as it may be "easier" 
to  identify  good  promotion  and  prevention  strategies.  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). 

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•  Work on improving the common social OMC indicators already agreed to, notably in 
terms  of  comparability.  Continue  work  to  have  life  expectancy,  mortality  rates  and 
healthy life years by age, sex and socio-economic status. 
Investigate whether more resources could be made available to healthcare through the 
Structural Funds and to reduce 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 commitment (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 health inequalities, quite the contrary  

EU Expert Group on Social Determinants and Health Inequalities 

The  EU  Expert  Group  on  health  inequalities  and  social  determinants  of  health  is  an 
informal  group  convened  by  the  Commission  including  representatives  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 Commission's Communication 
on health inequalities was a main agenda item at meetings of the group in December 2008 
and March 2009.  

The  group  commented  favourably  on  the  review  of  the  evidence  and  expressed  strong 
support  for  the  main  ideas  for  further  action.  Participants  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 methodological 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 participants 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 discussion necessary. Participants from a number 
of Member States expressed interest in the possibility of a joint action through the Health 
Programme to support implementation mechanisms for the forthcoming Communication. 

Other points included: 

(cid:190)  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. 

(cid:190)  Reduction  of  health  inequalities  is  neither  just  about  health  promotion  nor 
primarily about poverty avoidance; it concerns health in all policies with a definite 
equity emphasis. 

(cid:190)  At this stage more is known about policies to tackle gaps in health rather than the 
gradient in health inequalities. While better data might be useful to understand how 
the  steepness  of  the  gradient  plays  out  across  social  groups  in  different  MS,  a 

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greater concentration should be given to identifying policies which help to level the 
gradient, as well as addressing the gap.  

(cid:190)  Delivering benefits for the working and middle classes are important for securing 

broad political support for action on health inequalities.  

(cid:190)  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  experience  from  the  EU’s  work  on  social 
inclusion. 

(cid:190)  Delivery  mechanisms  in  present  health  services  can  increase  socially  determined 
health  inequalities    sometimes  in  a  very  significant  way.  Addressing  the  health 
sector  from  a  social  determinants  and  equity  perspective  would  both  make  a 
contribution to reducing HI s, and set the lead for action by other sectors. . 

(cid:190)  Need to include elements on public health capacity building. 
(cid:190)  Additional  work  at  the  EU  level  on  health  equity  impact  assessment  of  both 

existing and future policies would be welcome. 

(cid:190)  Improved  mechanisms  for  collaboration  on  health  inequalities between the Social 
Protection  Committee  the  EU  Expert  Group  and  the  Council  Working  Party  on 
Public Health would be a good idea.  

(cid:190)  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, particularly 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  chaired  by  the  Director  General  of  DG  SANCO  with  around  400 
participants.    A  background  paper  described  the  proposed  communication  and  invited 
comment  on  a  number  of  key  questions.    The  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  should  contribute  to  alleviating  poverty  and 
improving  the  living  conditions  –  with  an  emphasis  on  the  most  vulnerable.  Rural  and 
urban  deprivation  should  be  addressed    Ultimately  all  action  must  impact  locally  and 
involve  local  people,  which  will  require  measures  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 policies on chronic disease prevention are needed 
with  greater  emphasis  on  tackling  major  health  determinants  such  as  tobacco,  alcohol, 
obesity, physical activity and accidents.  Action 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  determine  their  impact  on  equity  between  social 

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groups and regions; facilitating exchange of good practice and engaging with governments 
and  stakeholders;  using  its  funding  instruments  to  support  action  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 order to protect and make 
fundamental  values  of  solidarity,  social  cohesion  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  Communication  on  health  inequalities  and  were 
invited to provide further input on several key questions. 

initiative 

Participants  strongly  welcomed 
to  bring  forward  a 
the  Commission 
communication on health inequalities. 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 supported.  More work was needed to involve 
disadvantaged and vulnerable groups in contributing to policy development which affects 
them.  The  EU  work  on  health  literacy  could  be  a  useful  and  relevant  input  to  the 
development  of  the  Communication.    Further  work  by  the  EU  to  support  regions  to 
improve  health  and  address  health  inequalities  both  directly  through  the  structural  funds 
and  by  encouraging  exchange  of  good  practice  via  networking  and  other  arrangements, 
would be very welcome. 

8.5.  Consultation with EU institutions 

The  Committee  of  the  Regions  included  a  consultation  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  dialogue  and  provide  input  into  the  development  of  the 
Communication the European Economic and Social Committee established a study group 
and selected a rapporteur in anticipation of the Communication. 

Committee of the Regions 

The  Subsidiarity  Platform  of  the  Committee  of  the  Regions  conducted  a  consultation  on  the 
"Assessment  of  Territorial  Impacts  of  EU  Action  to  Reduce  Health  Inequalities".  Thirteen 
regions participated, five of which were from Spain and none from the new Member States. 

The  drivers  of  inequalities  identified  included  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  issues  according  to  local  traditions,  organisation 
and ethnicity).. 

Desirable  Community  action 
impact 
assessment,  promoting  universal  coverage,  improve  monitoring  and  standardisation  of 
indicators, research, learning and training, exchange of information and best practices.  

included:  mainstreaming,  equity-focused  health 

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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  channelled  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,  labour  market  (safe  working  conditions  and 
reduction of job insecurity), urban planning and transport (reducing inequalities 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  assessment  consultation  among 
the  partners  of  the  Subsidiarity  Monitoring  Network  during  February  and  March  2009  and 
received 13 responses.  Health inequalities were perceived as a problem.  Factors mentioned as 
drivers included: (i) socio-economic conditions; (ii) lifestyle; (iii) geographical features of the 
territory;  and  (iv)  cultural  heritage.    Action  at  Community  level  was  considered  necessary 
particularly in relation to improving comparability of information and assessment of the state-
of-the-art processes 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  universal  coverage health  systems  across  the  EU;  (iv)  improving 
mechanisms  for  monitoring  inequalities  in  health  across  Europe,  (v)  promoting  research  and 
exchange  of  best  practice.    In  more  specific  terms  and  stressing  the  particularities  of  remote 
areas, like islands, EU support for health information technology was seen as an added value 
for these regions. More broadly, the COR highlighted 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 Inclusion 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 tackle health inequalities, and further actions that they plan to 
take. It also includes a series of key conclusions and recommendations for priority actions in 
this area.  Four areas in which action was most needed: a) Awareness Raising and Advocacy; 
b) Health in All Policies and Health 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/publications/taking%20action%20on%20health%20equity.pdf  

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DETERMINE  is  co-funded  by  the  European  Commission  Public  Health  Action  Programme. 
Building on the work of the WHO Commission on Social Determinants of Health the objective 
is to generate greater understanding and to change conceptions 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 Netherlands Institute for Health Promotion and 
Disease  Prevention  (Phase  I)  conducted  a  project  entitled  "Tackling  Health  Inequalities  and 
Social  Exclusion  in  Europe",  funded  by  the  European  Commission  Action  Programme  to 
Combat  Social  Exclusion.  The  associated  report43  highlights  the  exchange  of  good  practices 
between health professionals addressing social exclusion across Europe, that is, the wide range 
of ways in which the health field can contribute to reducing social exclusion and poverty.  This 
work  has  highlighted  that  areas  for  development  include  the  need  for  monitoring  and 
evaluation, evidence based policies, policy coordination and the establishment of targets. 

A study commissioned by the European Commission Public Health Programme regarded the 
"Economic implications of socio-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 are one of the main challenges for public health and have a large 
negative economic impact: the estimates suggest that the economic impact of socioeconomic 
inequalities  in  health  is  likely  to  be  substantial:  about  €1,000  billion,  or  9.5%  of  GDP.  The 
study  concludes  that  there  is  a  great  potential  for  improving  average  population  health  by 
reducing  the  health  disadvantage  of  lower  socioeconomic  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 security, working life, city planning, etc. 

Previously, "The health status of the European Union - narrowing the health gap, 2003" came 
as an outcome from a project of the health monitoring programme (1997-2002)  

Finally,  the  project  "EUROTHINE  -  Tackling  Health  Inequalities  in  Europe:  an  integrated 
approach"  was  conducted  by  the  EMC  (Erasmus  MC)  Universitair  Medisch  Centrum 
Rotterdam - University Medical Centre Rotterdam44   

42 
43  See  http://www.eurohealthnet.eu/images/publications/pu_1.pdf.  Other 

 At http://www.health-inequalities.eu/  

include 
"Promoting  social  inclusion  and  tackling  health  inequalities  in  Europe,  an  overview  of  good 
practices from the health field" and "The role of the health care sector in tackling poverty and social 
exclusion 
http://www.eurohealthnet.eu/images/publications/pu_4.pdf  

in  Europe"  at    http://www.eurohealthnet.eu/images/publications/pu_3.pdf  and 

related  documents 

44 See http://ec.europa.eu/health/ph_projects/2003/action1/action1_2003_16_en.htm#3 

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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 outcomes between Member States 

Substantial  differences  in  life  expectancy  at  birth  can  be  observed  across  the  EU  Member 
States,  with  individuals  in  many  new  Member  States  living  shorter  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 seen.  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 gender gap in New Member States is still large 
(e.g. 11 years in LV and LT).  

Figure A1: Life expectancy at birth, 2006 

90

80

70

60

50

40

30

20

10

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 UK

men  women

Source: Eurostat, UK 2005, IT 2004. 

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Figure A2:  

Female life expectancy at birth - differences from the EU average

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, UK 2005, IT 2004 

Figure A3:  

Female life expectancy at birth - differences from the best three 
performers (FR, ES, IT)

BE BG CZ DK DE EE IE

EL CY LV LT LU HU MT NL AT PL PT RO SI SK

FI SE UK

s
r
a
e
y

3,0

2,0

1,0

0,0

-1,0

-2,0

-3,0

-4,0

-5,0

-6,0

-7,0

s
r
a
e
y

0,0

-2,0

-4,0

-6,0

-8,0

-10,0

-12,0

-14,0

2006

Source: Eurostat, UK 2005, IT 2004 

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Figure A4:  

Male life expectancy at birth - differences from the EU average

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

s
ar
e
y

4,0

3,0

2,0

1,0

0,0

-1,0

-2,0

-3,0

-4,0

-5,0

-6,0

-7,0

-8,0

-9,0

-10,0

-11,0

-12,0

2006

Source: Eurostat, UK 2005, IT 2004 

Figure A5:  

Male life expectancy at birth - differences from the best three performers 
(CY, SE, IT)

BE BG CZ DK DE EE IE EL ES FR LV LT LU HU MT NL AT PL PT RO SI SK FI UK

0

-2

-4

-6

-8

-10

-12

-14

2006

Source: Eurostat, UK 2005, IT 2004 

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Table A1: Differences in female national life expectancy and the EU average, 1986, 1996 and 2006  

Life 
expectancy 
1986 

difference 
EU average 

to

Life 
expectancy 
1996 

difference 
EU average 

to 

Life 
expectancy 
2006 

difference 
EU average 

to 

AT 

BE 

BG 

CY 

CZ 

DE 

DK 

EE 

ES 

FI 

FR 

GR 

HU 

IE 

IT 

LT 

LU 

LV 

MT 

NL 

PL 

PT 

RO 

SE 

SI 

SK 

77,8 

78,2 

74,8 

74,7 

77,7 

77,7 

79,9 

78,9 

79,8 

78,8 

73,3 

76,4 

79,1 

76,4 

78,7 

75 

-0,2 

0,2 

-3,2 

-3,3 

-0,3 

-0,3 

1,9 

0,9 

1,8 

0,8 

-4,7 

-1,6 

1,1 

-1,6 

0,7 

-3,0 

79,7 

1,7 

76,8 

72,8 

80,2 

76,4 

75,1 

-1,2 

-5,2 

2,2 

-1,6 

-2,9 

0,9 

1,4 

-4,8 

-1,8 

0,8 

-1,0 

-3,7 

2,7 

1,4 

0,9 

-4,3 

-0,6 

2,5 

-3,4 

0,9 

-2,5 

0,3 

1,2 

-2,7 

-0,3 

-6,5 

2,4 

-0,3 

-2,3 

82,8 

82,3 

76,3 

82,4 

79,9 

82,4 

80,7 

78,6 

84,4 

83,1 

84,4 

81,9 

77,8 

82,1 

83,8 

77 

81,9 

76,3 

81,9 

82 

79,7 

82,3 

76,2 

83,1 

82 

78,4 

0,8 

0,3 

-5,7 

0,4 

-2,1 

0,4 

-1,3 

-3,4 

2,4 

1,1 

2,4 

-0,1 

-4,2 

0,1 

1,8 

-5,0 

-0,1 

-5,7 

-0,1 

0,0 

-2,3 

0,3 

-5,8 

1,1 

0,0 

-3,6 

80,2 

80,7 

74,5 

77,5 

80,1 

78,3 

75,6 

82 

80,7 

80,2 

75 

78,7 

81,8 

75,9 

80,2 

76,8 

79,6 

80,5 

76,6 

79 

72,8 

81,7 

79 

77 

74 

EN 

   EN 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UK 

EU averag

78,0 

79,5 

79,3 

0,2 

81,1 

82,0 

-0,9 

Source: Eurostat, UK 2005, IT 2004 

There are also large differences (of up to 20 years) 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 decreased in many countries (FI, AT, ES, IT, IE, 
BE and all EU12 countries), especially for women who already 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 limitations) especially 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 their lives in good health, in DK men can 
expect to live 90% of their lives 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 this indicator is based on self-perceived limitations in 

activities and this measure may be prone to cross-country cultural differences.  

46 See also Jagger et al. (2008) that also suggests that the gap between East and West in both life expectancy 

and years spent in good health 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 

75 

   EN 

 
 
 
 
 
 
 
 
                                                 
 
Substantial  differences  are  found  in  infant  mortality,  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 

14

12

10

8

6

4

2

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 UK

2006

Source: Eurostat, BE 2005, UK 2005, IT 2004. 

EN 

76 

   EN 

 
 
 
 
 
Figure A7: Premature mortality - risk (probability) of dying before the age of 65, 2002 

Women

Men

7%
8%
8%
9%
9%
9%
9%
9%
10%
10%
10%
10%
11%
11%
11%
11%
12%
13%
13%
13%
15%
16%
16%
16%
17%
18%
18%

25%

Spain
Greece
Italy
Sweden
Austria
France
Finland
EU15
Germany
Luxembourg
Portugal
Ireland
Slovenia
Netherland
UK
Belgium
Czech Rep.
Denmark
Poland
Slovakia
EU10
Lithuania
Bulgaria
Estonia
Hungary
Latvia
Romania
Russia

Sweden
Italy
Netherland
Greece
UK
Spain
EU15
Ireland
Austria
Germany
Denmark
Luxembourg
Finland
France
Belgium
Portugal
Slovenia
Czech Rep.
Poland
Slovakia
Bulgaria
EU10
Romania
Hungary
Lithuania
Estonia
Latvia
Russia

14%
15%
16%
17%
17%
18%
18%
18%
18%
18%
19%
19%
20%
20%
20%
22%

25%
25%

31%
31%
33%
33%

36%
36%

41%
43%
44%

59%

100%

80%

60%

40%

20%

0%

0%

20%

40%

60%

80%

100%

Detailed analysis of the health gap (see Annual Report of the European Observatory on Social 
Situation and Demography50) between EU-15 (+ MT & CY), and the remaining new Member 
States  shows  that  differences  between  Member  States  are  explained  by  high  mortality  and 
morbidity in terms of cardiovascular disease, injuries and violence, cancer, and alcohol-related 
diseases  and  their  underlying  risk  factors:  smoking,  diet  and  alcohol  consumption.    In  some 
countries,  contrary  to  the  general  EU  trend,  some  mortality  rates  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  cerebrovascular  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  differences  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 rates have increased in 
the poorest Member States since 1996 (EUROSTAT): e.g. the mortality 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  health  outcomes  between  socio-economic  groups  within  Member 
States.  

50 See http://ec.europa.eu/employment_social/spsi/reports_and_papers_en.htm  

EN 

77 

   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 highest socio-economic groups (e.g. between manual 
and  professional  occupations;  people  with  primary  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 infant mortality are higher in the lowest socio-
economic  groups  and  relative  inequalities  have  increased  in  several  countries.    The  risk  of 
dying in the lowest socio-economic groups was found to be 25 to 50 to even 150% more than 
in  higher  groups  and  relative  inequalities  in  mortality  have  increased  in  several  countries. 
Inequalities  in  mortality  from  cardio-vascular  diseases  account  for  about  half  of  the  excess 
mortality  in  lower  socio-economic  groups,  who  also  register  lower  cancer  survival.    Also, 
despite  an  overall  decline,  infant  mortality  continues  to  be  higher  in  lower  social-economic 
groups.  In some countries this gap has increased. 

Rates of disease and disability also vary substantially by socio-economic 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 observed in that those in the lowest (poorest) 
income quintiles more often report very bad health than those in the highest (richest) quintiles 
(Table A3).  In some countries (DK, LT, and SK) the percentage reporting 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 likely to experience limitations with mobility, arm 
or motor functions and have a higher prevalence of eyesight, hearing and chewing problems.  
Several studies (Dastra et al., 2005; Huisman, Kunst et al., 2003; Huisman, Kunst et al., 2004) 
found socio-economic inequalities for a range of common chronic diseases such as  diabetes, 
arthritis, chronic respiratory and 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 reports for a review of the literature at 
http://ec.europa.eu/employment_social/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/Healthcare/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 

78 

   EN 

 
 
                                                 
Table A3: Self-perceived general health (very bad health), by income quintile  

Source: Eurostat based on EU-SILC 2006 data 

EN 

79 

   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 and moderate limitations separately. 

Source: SHARE 2005 

EN 

80 

   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  disease55.    These  include 
some migrant and ethnic minority populations, people 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  pensions,  and  single  parents.  In  rural  areas  of  RO  and  BG 
infant  mortality  is  3  times  higher  than  in  the  capital.    Inequalities  between  nationals  and 
migrants  persist  in  Europe,  in  terms  of  health  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  disease)  and  mental  health  problems  due  to  a 
combination of the socio-economic and environmental conditions in the origin, transit and host 
countries (2007 Council Conclusions on Health and Migration in the EU). 

55  As  indicated  in  the  Joint  Report  on  Social  Protection  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  

See 

also 

57 
at 
http://www.iom.int/jahia/webdav/site/myjahiasite/shared/shared/mainsite/published_docs/serial_publications
/IML12-MRH%20dec07.pdf  and  "Quality 
to  healthcare  services"  at 
http://ec.europa.eu/employment_social/spsi/studies_en.htm#healthcare  

in  and  equality  of  access 

"Migration 

health", 

IOM, 

right 

and 

the 

to 

EN 

81 

   EN 

 
 
 
 
                                                 
The  June  2006  Council  Conclusions  on  Women's  Health58    recognise  the  importance  of  the 
gender dimension in health.  Health inequalities are also a global issue (WHO CSDH, 2008).  

Importantly, there appears to be a strong association 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 addressing 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 Social Protection and Social Inclusion. 

9.1.2.  Determinants (drivers or causes) of health inequalities 

Several  models  (varying  in  complexity  and  details)  synthesize  the  relation  between  various 
determinants  (including  socio-economic  factors)  and  health  (Figure  A9).    They  illustrate  the 
“layered”  view  of  the  causation  of  health  inequalities  (Mackenbach,  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 biological factors/ genetic predispositions may explain why 
one person is more likely to get ill than another in the same circumstances, living and working 
conditions, as well as exclusion and marginalisation, 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  later  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 differences in the quality of their physical and social environments (at 
home  –  central  heating,  insulation,  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 environments (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 conditions, the exposure to noise in EU countries 
for  example  ranges  from  3%  up  to  18%  with  possibly  big  regional/local  differences  (Table 
A5).    There  are  sections  of  the  EU  population  which  do  not  have  access  to  running  water, 
adequate  washing  and  toilet  facilities,  affordable  energy,  appropriate  housing,  heating,  new 
clothes,  or  safe  environment  (e.g.  EUROFUND  –  2008  European  Quality  of  Life  Survey60).  
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 individuals 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 
on 

Council 
Policies 
http://ec.europa.eu/health/ph_projects/2005/action1/docs/2005_1_18_frep_a8_en.pdf 

Conclusions 

Health 

All 

in 

60 See http://www.eurofound.europa.eu/pubdocs/2008/52/en/1/EF0852EN.pdf 

(HIAP). 

EN 

82 

   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 behaviour), 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  differences  in  people's  health.  
Other  studies  suggest  that  maternal  smoking  and  poor  diet  during  pregnancy  cause  impaired 
development  in  utero  which  increases  the  risk  of  cardiovascular  disease,  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; Mackenbach, 2006).  For example, the prevalence of daily smokers for 
men  varies  3  fold  between  EU  countries  and  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 countries with the lowest life-expectancy 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 combination of high effort and demands 
with a low reward and low control also contribute to one's health.   

Past  social  positions  influence  individuals'  health  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  Tubeuf,  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  significantly  associated  with  low  birth  weight  and  thus  the  person's 
health throughout his life (MRC Scotland). 

EN 

83 

   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 

84 

   EN 

 
 
 
European Observatory of the Social Situation and Demography 

Figure A11: pure alcohol consumption, litres per capita, WHO European Region 

European Observatory of the Social Situation and Demography 

Figure A12: obesity rates in european countries 

EN 

85 

   EN 

 
 
 
 
 
European Observatory of the Social 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 

White-collar 

314 

199 

223 

132 

1.6 

1.7 

115 

91 

EN 

86 

   EN 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Men 

Women 

Poorly educated 

Highly educated 

Blue-collar 

White-collar 

Poorly educated 

Highly educated 

327 

209 

328 

184 

310 

147 

265 

79 

263 

153 

277 

92 

1.6 

3.4 

118 

186 

1.8 

1.7 

144 

110 

2.1 

3.0 

163 

185 

Source: Boström & Rosén, 2003. 

Unemployment  is  associated  with  increased  chance  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  extent.    A  good  working  environment  plays  a  crucial 
role  in  terms  of  ensuring  people's  health:  e.g.  differences  in  exposure  to  physical,  chemical, 
and biological agents at work lead to differences in health status.  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 physical pressure and stress, high decision ability 
and  possibilities  to  develop  new  skills,  a  correct  monetary  reward  and  having  prospects  for 
personal  progress  contribute  to  good  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  sectors  and  not  all  workers  are  equally  exposed  to 
occupational hazards (European Agency for Safety and Health at Work)61: e.g. young workers 
are  usually  less  informed  about  occupational  risks,  which  makes  them  overexposed,  and 
workers with a fixed-duration or temporary employment relationship are more exposed to the 
risk  of  accidents  at  work  and  occupational  diseases.    The  Whitehall-Study  (1984)  of  UK 
17.500 civil servants shows a  clear 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 organization and occupational health and safety.   

We  can  indeed  observe  geographic  disparities  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  safety  and  health  at  the  workplace  practices  (e.g. 
Employment Report62), which might also help explain part of the differences in health between 
countries.    GDP  per  capita  and  poverty  rates  vary  across  the  EU,  and  substantial  income 
inequality persists (Table A8 and Figures A15-A16).  In 2006 the total income received by the 
20% of the population with the highest 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_prevention/risks 
62 See http://ec.europa.eu/employment_social/employment_analysis/employ_en.htm  

EN 

87 

   EN 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
Figure A13: employment rates in the EU; total, women and older workers; 2007. 

.

Figure A14: Unemployment and youth unemployment; 2000 and 2007. 

EN 

88 

   EN 

 
 
 
 
Table A8: GDP PPS per inhabitant 

200

2970

950

2020

3030

2810

1760

3710

2410

2650

2760

2520

2320

1440

1520

6890

1580

1920

3290

3160

1330

1860

1010

2260

1700

2900

3130

2910

be Belgium 

bg Bulgaria 

cz Czech Republic 

dk Denmark 

de Germany 

ee Estonia 

ie Ireland 

gr Greece 

es Spain 

fr France 

it Italy 

cy Cyprus 

lv Latvia 

lt Lithuania 

lu Luxembourg 

hu Hungary 

mt Malta 

nl Netherlands 

at Austria 

pl Poland 

pt Portugal 

ro Romania 

si Slovenia 

sk Slovakia 

fi Finland 

se Sweden 

uk United Kingdom

Source: EUROSTAT 

EN 

89 

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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 

90 

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Figure A17:  

Health inequalities versus income inequality
y=2,1+0,62x

e
h
t

y
b

d
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12

10

8

6

4

2

0

2

3

4

5

6

7

Income inequality using the S80/S20

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 stratification in society (the magnitude of 
inequity  along  various  dimensions).    Differences  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  distribution  policies  for  example  appear  to  have  a 
positive impact on health.   

Differences  in  levels  of  income  (GDP  per  capita)  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, and public services.  High economic growth in Member 
States  with  lower  health  levels  by  narrowing  differences  in  GDP  per  capita  would  thus  help 
reduce  health  inequities.    However  the  relationship  between  economic  growth  and  health  is 
complex.  Evidence suggests that on its own economic growth may not deliver a reduction in 
health inequities.  To ensure that this will 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 increased 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 increased).  Moreover, health is not just a function 
of  GDP  levels;  how  economic  resources  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 level of GDP.  The translation of GDP per capita 
into  health  and  health  equity  depends  to  a  large  extent  on  policy.    The  right  policy  mix  can 

EN 

91 

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achieve reductions in disparities and thus improve general health by optimising the health gain 
for the resources available.  Globally there are examples of countries with high GDP and high 
health inequalities (USA) or lower health inequalities (Canada).  

Figure A18: Life expectancy versus real GDP per capita PPP$ 

Y   =   0 . 0 0 0 2 8 3 3 X + 7 0 . 0 4

Y

8 5

8 0

7 5

7 0

6 5

A u s tr i a
B e l g i u m
B u l g a r i a
C yp r u s
C ze c h  R e p u b l i c
D e n m a r k
E s to n i a
F i n l a n d
F r a n c e
G e r m a n y
G r e e c e
H u n g a r y
Ic e l a n d
Ir e l a n d
Ita l y
L a tvi a
L i th u a n i a
L u xe m b o u r g
M a l ta
N e th e r l a n d s
N o r w a y
P o l a n d
P o r tu g a l
R o m a n i a
S l o va k i a
S l o ve n i a
S p a i n
S w e d e n
T u r k e y
U n i te d  K i n g d o m

6 0 0 0 0

X
7 0 0 0 0

6 0

0

1 0 0 0 0

2 0 0 0 0

3 0 0 0 0

4 0 0 0 0

5 0 0 0 0

X  -   R e a l  g r o s s  d o m e s ti c  p r o d u c t, P P P $  p e r  c a p i ta , L a s t a va i l a b l e
Y  -  

L i fe  e xp e c ta n c y a t b i r th , i n  ye a r s , L a s t a va i l a b l e

Figure A19: Trends in GDP per capita and life expectancy at birth in 133 countries  

grouped by the 1975 GDP, 1975-2005 

Source: WHO World Report 2008 

EN 

92 

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Figure A20: Impact of economic growth on poverty: change in anchored poverty rate (income years 
2005/04), change in at-risk-of-poverty rate (income years 2005/04) — percentage points; and average 
GDP growth (2004-05) — % 

Variations across the EU can also be observed in relation to the size/ extent 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 inclusion benefits).  The extent of redistribution and social 
protection,  which  vary  significantly  across  Member  States,  may  contribute  to  the  observed 
health gaps (Figures A21-23).  Income distribution policies (e.g. social transfers) are estimated 
to reduce the risk of poverty 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 countries and individuals (Jen 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). 

63 See http://ec.europa.eu/employment_social/spsi/docs/social_inclusion/2008/omc_monitoring_en.pdf  

EN 

93 

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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  likelihood  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 population: there is a tendency for those 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,  which  can  deter  access  to  care  by  lower  socio-

64 BG, LV, RO, LT, HU, EE, SK, and PL 

EN 

94 

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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

Public expenditure

Private expenditure

%

12.0

10.0

8.0

6.0

4.0

2.0

0.0

r
f

e
d

t

e p
b

t
a

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l

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Source: OECD Health Data 2008 and WHO, HFA-DB

v p

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l

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Table A9: Self-reported unmet need for 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.    Health  systems  inadequacies 

EN 

95 

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include under-resourcing (financial and human65) and uneven geographical coverage.  Quality 
distribution of resources and facilities 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  and  treated  and  thus  population 
health.  The size of national health budgets can determine the capacity 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  associated  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  (Newey,  Nolte,  McKee,  &  Mossialos, 
2003, 2008).  This is particularly acute in some regions of new Member 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 unmet need for medical care: those in the lowest 
income quintiles more often report an unmet need due to waiting, the direct financial cost of 
care and the distance to care (Table A10).  Evidence suggests that lower income families have 
further  to  travel  to  hospital  or  family  doctor  (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 identified barriers to access: lack 
of health insurance coverage67, direct financial costs of care, geographical disparities in service 
availability,  waiting  times,  lack  of  information,  discrimination  and  language  barriers,  health 
literacy and socio-cultural expectations in relation to life and care services.   

For example, in most countries, doctors and facilities tend to be concentrated in the capital and 
richer  regions  (2009  Joint  Report  on  Social  Protection  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  are  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. 

The 

See: 

First 

European 

66 
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 

Epidemiological 

Communicable 

Disease 

Report, 

68 

See: 

Green 

European  Workforce 
http://ec.europa.eu/health/ph_systems/docs/workforce_gp_en.pdf, p. 6. 

Paper 

the 

on 

for 

Health, 

2008, 

EN 

96 

   EN 

 
                                                 
Table A10: Self-reported unmet need for medical 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 

97 

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Figure A26:  

Health inequalities versus inequitable access to medical care
y=-0,76+1,06x

s
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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 care

Source: Eurostat based on EU-SILC 2006 data 

EN 

98 

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Figure A27 

Health inequalities versus direct payments for care
y=2,04+0,15

12

p
a
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30,0

35,0

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out-of-pocket payments as % of GDP 

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 health, especially for those who are already in 
lower socio-economic groups with lower qualifications and savings.  The loss of job and thus 
income  can  lead  to  deterioration  in  living  conditions,  including  a  poorer  diet,  especially  if  a 
safety  net  (social  protection  mechanisms  including  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:  depression  and  disturbed  immune  system,  accidents, 
which  possible  health  and  education  consequences  on  the  rest  of  the  family  (e.g.  children).  
Depending on the length of the crisis, the negative impact on health can be long lasting: e.g. 
burnout conditions appear years rather than weeks or months after unemployment started.  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  especially  by  those  in  lower 
socio-economic groups.  This is the case if access 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 systems  can  motivate  countries to review their 
policy mix on health determinants in search for higher effectiveness and efficiency.   

EN 

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The  information  provided  above  supports  the  Council  Conclusions  of  November  200669  that 
"health  determinants  are  unequally  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 the health status of the population".  It shows 
that  health  inequalities  are  associated  with  socio-economic  inequalities  (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  required  to  be  able  to 
establish  the  effect  (causality)  and  weights  of  several  of  those  health  determinants  so  that 
Member States can choose and implement effective action in relation to a particular population 
group or in relation to a particular 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  comprehensive  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 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  knowledge,  it  is  possible  to  establish  a  list  of  policy  actions  which  have 
been judged by Member States as effective to tackle 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 "Health Inequalities: a Challenge for Europe"70, 
the Eurohealthnet coordinated project "Closing the Gap: Strategies for Action to tackle health 
inequalities", the ongoing Eurohealthnet coordinated project "Determine" and its related web 
site  (www.health-inequalities.eu),  which  gathers  Member  States  information  on  strategies  to 
tackle  health  inequalities.    The  largest  amount  of  evidence  comes  from  the  UK  where  
comprehensive  strategies to tackle health  inequalities have been developed over more than a 
decade and where several evaluations have taken place 71.   

Reviewing  available  evidence  indicates  that  many  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 and healthcare, access also needs to be intensified 
and targeted at specific groups (e.g. to mothers and children, young parents, and those over 50) 
in  disadvantaged  areas,  in  vulnerable  families  and  in  lower  socio-economic  groups.    For 

69 

Council 
Policies 
http://ec.europa.eu/health/ph_projects/2005/action1/docs/2005_1_18_frep_a8_en.pdf 

Conclusions 

Health 

All 

on 

in 

(HIAP). 

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/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D
H_098936 

EN 

100 

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example, health policy actions do not need to be new but redesigned i.e. we need to change the 
way  we  deliver  health  promotion,  disease  prevention  and  treatment  services.    This  is 
particularly the case for health promotion 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 and local authorities  must actively search for the 
individuals at risk of lower health status in their communities.  One effective way to reach those 
individual  is  to  build  neighbourhood  and  community  infrastructures  (e.g.  communities  for 
health programme in the UK).  Building partnerships with the voluntary / third sector and with 
business can also be effective in raising general awareness and action (e.g. in the UK a social 
enterprise partner foundation delivers a programme in some disadvantaged areas and 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).  

Thirdly  it  is  widely  accepted  that  measurement  and  regular  reporting  of  health  inequalities 
indicators is an essential first step towards effective action.  Building information through the 
development of regular monitoring of health indicators (e.g. the UK has even developed a quite 
complex composite indicator, the health poverty index), allows for awareness-raising 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  areas  /  lower  socio-economic  groups  vis-à-vis  the  more  affluent 
groups.    A  good  example  of  the  impact  of  available  information  and  reporting  is  that  of  NL 
where a detailed 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.    Similar  conclusions  come 
from  EE,  ES  and  BE  following  the  publication  of  their  first  report  on  socio-economic 
inequalities in health.  Data collection, analysis and monitoring must then be accompanied by 
building  scientific  knowledge  for  action  (notably  through  partnerships  between  national 
administration  and  universities),  which  is  gathered  and  disseminated  through  a  coordination 
centre (e.g. the policy coordination centre for health equity in BE, the national support team for 
health  inequalities  in  the  UK,  the  National  Institute  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  Health  Observatory  and  the  All-
Ireland Health Library, the Working Group on Health inequalities in the Trentino Region in IT, 
Inter-sectoral Coordination Commission 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 from innovation elsewhere is also deemed crucial 
and  several  Member  States  suggest  that  initiatives  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 Network in DK, the National Health Board in DK, 
the city links initiative in NL).  Taking stock of increasing body of evidence on the causes of 
health  inequalities  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) that health impact assessment/health equity test/ 
health  equity  audit  applied  to  policies  across  the  board  is  an  effective  way  to  generate  inter-
sectoral  awareness  of  health  inequalities  and  the  social  determinants  of  health  and  health 
inequalities. 

EN 

101 

   EN 

 
More specific examples of policies considered effective 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  rates  of  smoking  than  more  affluent  groups  (UK,  NL).    To 
decrease infant mortality and increase life expectancy 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' health throughout their lives – Kramer 2000), 
b) stop parental smoking (which research has shown is strongly associated with Sudden 
Infant Death Sindrome) and c) reduce smoking in general for those groups.  Smoking 
was  considered  by  the  UK  DoH  as  the  single  biggest  preventable  cause  of  socio-
economic gradient in infant mortality and life expectancy through lower birthweight and 
higher  mortality  from  Cardiovascular  disease,  stroke  and  respiratory  disease.    Studies 
have  showed  that  NHS  stop  smoking  services  were  very  effective  in  reducing  the 
number  of  smokers  living  in  more  disadvantaged  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 these, 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 (vitamin and folate) for pregnant women in 
lower socio-economic groups  
Improve  antenatal  care  (screening  and  immunisation)  and  post  natal  care  including 
neonatal  screening  and  parent  support  (information  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 the gap in neo-natal and infant mortality.  
This  has  been  done  through  working  with  family  doctors  and  hospitals  and  the  Sure 
Start  child  centres  in  the  UK  (multidisciplinary  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  duration  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 the likelihood of gastro and respiratory 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 groups. See instruments of previous point.  
Improve  child  immunisation  take-up  and  better  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  reducing  the  delays  to  see  a  GP  and  a  GP 
referral in deprived areas 

• 

• 

• 

•  Managing high blood pressure and reducing cholesterol levels through medical advise 
and medicines and advise on diet exercise and smoking for those in deprived areas 

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Increase flu vaccination of those 65+ 

• 
•  Reduce teenage pregnancy and STDs through comprehensive contraceptive advice. 
•  Ensure timely access to effective emergency services in more deprived areas.  
•  Address cultural barriers to care by a) adjusting 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  including  emergency  services  working  with  faith/ 
religious  representatives  (UK).    For  example,  in  the  UK  the  ambulance  service  is 
holding a summit with various faith and religious 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 outermost 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  socio-economic  differences  in  tooth  decay  in 
children  as  shown  by  comparing  different  counties  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-school  day  care  for  lower  socio-economic  groups  as  this 

increases education and employment attainment, 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  through  improved  house  building  standards  and 
through  affordable  heating  for  lower  socio-economic  groups  and  measures  to  reduce 
accidents  at  home  (smoke  alarms,  hand  rails).    A  review  of  UK  "area  regeneration 
initiatives"  showed  that  these  lead  to  better  education  and  employment  rates,  higher 
household income and housing quality and contributed to improving health.  

•  Child resistant containers 
• 
Improving transport links 
•  Seat belt and speed legislation (UK, BE),  
• 
•  Using  targets  (UK,  NL,  CZ,  FI,  Basque  Country  in  ES)  has  been  effective  in  raising 

Income support (NL, SE) 

awareness and motivating policy action.  

•  Partnerships  with  voluntary  sector  and  community  groups  including  faith  /  religious 

leaders  

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•  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  advocacy  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 authorities, 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  monitoring.    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 distribution 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 deliver 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 crucial element in attracting more people into the labour market, in 
particular in the light of ageing. Moreover, reducing accidents at work, occupational 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 active ageing including 
appropriate  working  conditions  and  improved  occupational  health  status.  It  also  calls  for 
promoting modern social protection systems including healthcare. The employment guidelines 
put  emphasis  on  improving  the  occupational  health  status  with  the  aim  of  reducing  sickness 
burdens, increasing labour productivity and prolonging 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  including  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, diverse and irregular and 
therefore demanding.  Finally Employment Guideline 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. 

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The EU can support Member States actions to address common challenges through the OMC 
(employment  OMC,  social  OMC)  by  facilitating  dialogue  and  the  exchange  of  best-practice 
and policy coordination with/between Member States and with stakeholder organizations, by 
supporting the development of innovative good practice through its funding programmes (e.g. 
PROGRESS).    Addressing  health  inequalities  is  a  common  objective  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 Public 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  coordination  of  health  policies  through  information  sharing  and 
exchange  of  good  practice.    The  2008  social  OMC  Communication72  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 implementation 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  policies  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  Determinants  and  Health  Inequalities  can  provide  a 
good basis for policy improvements.  Work on social determinants of health has started to map 
out health equity related policies, linking up with 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 together to map out the use of cohesion funds 
in the field of health. 

Common Basic Principles for immigrant integration policy in the EU have been agreed to by 
the Commission (COM(2005) 389) of which access to services, such as healthcare, is seen as a 
fundamental  elements.    The  Handbooks  on  Integration  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  supporting  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  European  Social  Fund  (ESF)  Structural  Funds 
according  to  the  Community  Strategic  Guidelines  for  Cohesion  2007-2013.73    Health 
promotion,  disease  prevention,  transfer  of  knowledge,  training  and  availability  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  contribute  to  healthcare 

72  "A  Renewed  commitment  to  social  Europe:  Reinforcing  the  Open  Method  of  Coordination  for  Social 
Protection 
at 
Inclusion". 
http://ec.europa.eu/social/main.jsp?catId=550&langId=en  
73 http://ec.europa.eu/regional_policy/sources/docoffic/2007/osc/l_29120061021en00110032.pdf 

COM(2008) 

Social 

418/4 

and 

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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 availability of supplies and reasonable prices of 
consumers.  The CAP supports the School Milk Scheme and the distribution of agricultural 
products to most deprived people. More recently, there was work and discussion on how 
the  CAP  could  contribute  to  a  more  healthy  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 supports investments and development of social 
and health care services, technologies and infrastructure in rural areas as well as training and 
information actions on health and social subjects.  

The EU Public Health Programme has been funding action networks, local initiatives, expert 
reviews, conferences, and policy innovations in the field of public health.  PROGRESS funds 
activities in the area of anti-discrimination (e.g. anti-discrimination training activities)  

The  European  Fund  for  the  Integration  of  Third  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 agreed with the Commission.   

The  EU  Framework  Programmes  for  Research  also  offer  possibilities  to  tackle  health 
inequalities in particular under the 3rd 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  necessary  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 including lifestyle and socio-economic 
and environmental factors75. 

Legislation: 

The  EU  has  established  Community  labour  law  and  Community  legislation  in  the  field  of 
health and safety at work and monitors its implementation, including some funding of research 
in  the  area  of  occupational  safety  and  health  in  order  to  improve  working  conditions.    The 
implementation in the Member States of the Community 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  important  contribution  to  the  reduction  of  health 
inequalities in the European Union.  The active working population is currently 48,3% percent 
of  the  total  population  of  the  EU.    Therefore  the  improvement  of  the  prevention  and  the 

74 See Annex: Table showing the allocated share of Structural Funds investment in health infrastructure per 

MS. 

75  COUNCIL  DECISION  (2006/971/EC)  of  19  December  2006  concerning  the  Specific  Programme 
"Cooperation" implementing the Seventh Framework Programme of the European Community for 
research, technological development and demonstration activities (2007 to 2013), OJ L400/127) 

EN 

106 

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protection  of  the  worker's  health  and  safety  represents  a  very  significant  contribution  to  the 
overall public health in Europe, and to the reduction of some of the main elements having an 
impact  on  health  inequalities  among  countries  and  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  order  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  strategy  reduces  work  accidents, 
helps  accident  victims  or  chronically  ill  to  retain  their  job  or  return  to  work,  is  a  main 
platforms  for  integrating  migrant  workers  and  can  reduce  stressful  and  monotonous  working 
conditions that cause early deterioration of health, and hence, an early exit from working life. 

Since  2000,  in  addition  to  laws  covering  the  equal  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 Europe. These laws are designed to ensure equal 
treatment  irrespective  of  racial  or  ethnic  origin,  religion  and  belief,  disability,  sexual 
orientation,  and  age  in  many  aspects  of  daily  life  -  from  the  workplace,  to  issues  covering 
education,  healthcare  and  access  to  goods  and  services.    In  2008  the  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-discrimination  measures,  validates 
good  practice  through  peer  learning  and  evaluates  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,  restrictions  to  ownership  of  pharmacies  and  their 
location, restrictions to ownership of laboratories and their opening hours, which may lead to 
sales monopolies and constitute barriers to access, may contribute to lower 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 groups 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 competences76, which invites Member States to 
develop the provision of key competences for all as part of their 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  and  of  the  Council  of  18  December  2006  on  key 
competences for lifelong learning (2006/962/EC). 

77 COM (2009)200 – 27/04/09 - An EU Strategy for Youth -Investing and Empowering –  

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9.4.  Additional  information  on  why  health  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 Treaty states that the EU shall "promote economic and social progress and 
a  high  level  of  employment,  a  balanced  and  sustainable  development  …through  the 
strengthening of economic and social cohesion …".  In the EC Treaty Article 2 states that "the 
Community  shall  have  as  its  task  …to  promote  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 living 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  Community  shall  include:  (…)  a  policy  in  the  social 
sphere (…), the strengthening of economic and social cohesion, (…) the promotion of research 
(…),  a  contribution  to  the  attainment  of  a  high  level  of  health  protection,  contribution  to 
education and training (…), a policy in development cooperation (…).  Arts. 2 and 3 thus refer 
to a number of objectives and policies which relate to the reduction of health inequalities in the 
EU.    In  addition,  art.  16  of  the  EC  Treaty  indicates  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  addition,  the  2008  Tallinn  Charter, 
adopted  by  EU  Member  States  establishes  as  health  systems  goals  "improving  the  level  and 
distribution of health, equity in finance 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  common  agricultural  policy  puts 
forward  the  goal  of  ensuring  "a  fair  standard  of  living  for  the  agricultural  community"  and 
"that supplies reach consumers at reasonable prices" and that "account shall be taken of (…) 
structural  and  natural  disparities  between  the  various  agricultural  regions".  Art.  98  indicates 
that Member States shall conduct their economic policies so as to achieve 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  cooperation  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. 

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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 imply 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  publications  on  the  European  Social  Fund).80    The 
Community  strategic guidelines on cohesion for example adopted by the Council in  October 
2006  underline  that  investment  in  health  promotion  and  disease  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  element  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  working  lives  and  induces  higher  productivity, 
competitiveness and employment levels (idem).  Avoidable ill-health also leads to large costs 
for  the  healthcare  system  and  puts  unnecessary  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  disease rates of those 
with lower educational attainment were the same as those with higher educational attainment.  
The consequent increase in the number of workers 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 for 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 

of 

awareness 

Lack 
and
insufficient  policy  priority  and
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  

Absence  of  comparable  and 
regular  data,  monitoring  and 
reporting.  Lack of knowledge 
on  the  determinants  and  the 
effective 
to 
implement 

policies 

and 

availability 

Improve  data 
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 

Monitoring and evaluation 
mechanisms / Indicator 

Number  of  MS  with  comprehensive 
policy  approach  which  can  be 
analysed  in  the  social  OMC  NSR 
2011-2013 (currently two) 

To  be  evaluated  by  the  Eurostat 
Working group on mortality 

To  be  evaluated  by DG  Research by 
number  and  quality  of  studies,  and 
amount  of  distribution  platforms 
publications 
(internet 
(available in all languages) 

portal), 

to 

Insufficient  concerted  EU 
health 
approach 
of 
inequalities 
mainstreaming  at 
the  EU 
level) 

(lack 

Develop  the  contribution  of  relevant  EU 
policies  towards  reducing  inequalities  in 
health, 
support  of 
Member  States  and  stakeholders'  efforts 
to tackle health inequalities and a specific 

including  better 

how  many 
relevant  EU  policy 
strategies have an indicator of health 
status inequalities 

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 

109 

   EN 

 
                                                 
focus  on  vulnerable  groups  and  third 
countries 

and health disparities 

Additional  evaluation  under  Option 
II  and 
in  dedicated  Health 
III 
Inequality report 2012 

EN 

110 

   EN 

 
 
10.  BIBLIOGRAPHY 

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Cardano, M., Harding, S., Borgan, J-K, Glickman, M., Reid, A., and Mackenbach, J. 
P.,  2005.  Trends  in  socioeconomic  disparities  in  stroke  mortality  in  six  European 
countries between 1981-1985 and 1991-1995. Am J Epidemiol 161 (1):52-61. 

Braveman P, Gruskin S., 2003. Defining equity in health. J Epidemiol Community 
Health. 2003;57:254–258. 

Breeze, E., A. E. Fletcher, et al., 2001. Do socioeconomic disadvantages persist into 
old age? Self-reported morbidity in a 29-year follow-up of the Whitehall Study. Am 
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Jagger,  C.,  Gillies,  C.,  Moscone,  F.,  Cambois,  E.,  Van  Oyen,  H.,  Nusselder,  W. 
Robine,  J.,  2008.  Inequalities  in  healthy  life  years  in  the  25  countries  of  the 
European  Union  in  2005:  a  cross-national  meta-regression  analysis.  The  Lancet, 
Volume 372, Issue 9656, Pages 2124 - 2131 

Cavelaars,  A.  E.,  Kunst,  A.  E.  et  al.,  1998.  Morbidity  differences  by  occupational 
class  among  men  in  seven  European  countries:  an  application  of  the  Erikson-
Goldthorpe social class scheme. Int J Epidemiol 27 (2):222-30. 

Cavelaars,  A.E.,  Kunst,  A.E.,  Geurts,  J.J.M.  et  al.,  2000.  Persistent  variations  in 
average height between countries and between socio-economic groups: an overview 
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Dalstra,  J.A.,  Kunst,  A.E.,  Borrell,  C.,  Breeze,  E.,  Cambois,  E.,  Costa  G,  Geurts, 
J.J.,  Lahelma,  E.,  Van  Oyen,  H.,  Rasmussen,  N.K.,  Regidor,  E.,  Spadea,  T., 
Mackenbach, J.P., (2005) Socio-economic differences in the prevalence of common 
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Eurohealthnet,  2007  Closing  the  Gap  –  Strategies  for  Action  to  tackle  Health 
Inequalities. Taking Action on Health Equity 

Huisman,  M.,  A.  E.  Kunst,  et  al.,  2003.  Socioeconomic  inequalities  in  morbidity 
among the elderly; a European overview. Soc Sci Med 57 (5):861-73. 

Huisman,  M.,  A.  E.  Kunst,  et  al.,  2004.  Socioeconomic  inequalities  in  mortality 
among elderly people in 11 European populations. J Epidemiol Community Health 
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Kunst AE, Bos V, Lahelma E et al.  Trends in socio-economic inequalities in self-
assessed health in 10 European countries.  Int.J. Epidemiol 2005; 34 295-305. 

Kutzin,  J.  (2008).  Health  financing  policy:  a  guide  for  decision-makers.  Geneva, 
World Health Organization. 

Lundberg,  O.,  1991.  Causal  explanations  for  class  inequalities  in  health  –  an 
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Mackenbach,  J.  P.,  2006  Health  Inequalities:  Europe  in  Profile,  2006,  An 
independent, expert report commissioned by the UK Presidency of the EU  

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Mackenbach,  J.  P.,  A.  E.  Cavelaars,  et  al.,  2000.  Socioeconomic  inequalities  in 
cardiovascular  disease  mortality;  an  international  study.  Eur  Heart  J  21  (14):1141-
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Newey,  C.,  E.  Nolte,  et  al.  2003.  Avoidable  mortality  in  the  enlarged  European 
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Stronegger,  W.J.,  Freidl  W.,  et  al.,  1997.  Health  behavious  and  risk  behaviour: 
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van  Doorslaer,  E.,  A.  Wagstaff,  et  al.,  1997.  Income-related  inequalities  in  health: 
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van  Oort,  F.  V.,  F.  J.  van  Lenthe,  et  al.,  2005.  Material,  psychosocial,  and 
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van Lenthe, F. J., C. TM Schrijvers, et al. 2004. Investigating explanations of socio-
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Whitehead M, 1990 The concepts and principles of equity and health. Copenhagen. 
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Annex HIs ImpactAssessment-postCIS19Spet 

EN 

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11.  LIST OF ABBREVIATIONS 

AGRI 

AIDCO 

CAP 

Agriculture and Rural development 

EuropeAid - Cooperation Office 

Common Agriculture Policy 

Council WPPH 

Council Working Party on Public Health at Senior Lev

DEV 

DG 

EAC 

EAFRD 

EAGF 

ECFIN 

ECHI 

EHIS 

EMPL 

EPSCO 

ERDF 

ESF 

EUROFUND 

EUROSTAT 

EU-SILC 

Development 

Directorate General 

Education and Culture 

European Agricultural Fund for Rural Development 

European Agricultural Guarantee Fund 

Economic and Financial Affairs 

European Community Health Indicators 

European Health Interview System 

Employment Social Affairs and Equal Opportunities 

Employment,  Social  Policy,  Health  and  Consum
Affairs Council 

European Regional Development Fund 

European Social Fund 

European  Foundation  for  the  Improvement  of  Livi
and Working Conditions 

European Statistical Office 

European Union survey on income and living conditio

Expert Group SDH 

EU Expert Group on Social Determinants of Health 

FP7  

GDP 

HI 

Research Framework Programme 7 

Gross domestic product 

Health Inequalities 

IA ISSG 

impact assessment inter-service steering group 

EN 

113 

   EN 

 
IAB 

INFSO 

JLS 

Impact Assessment Board 

Information Society and Media 

Justice, Freedom and Security 

Joint Report SPSI 

Joint Reports on Social Protection and Social Inclusion

MARKT 

Internal Market and Services 

MS 

NGO 

NSR 

Member States 

Non-governmental organisation 

National Strategy Report 

PROGRESS 

EU's employment and social solidarity programme 

REGIO 

RTD 

SANCO 

SG 

SHARE 

social OMC 

SPC 

WHO CSDH 

Regional Policy 

Research 

Health and Consumers 

Secretariat General 

Survey of Health Ageing and Retirement in Europe 

Open Method of Coordination for Social Protection a
Social Inclusion 

Social Protection Committee 

WHO  Commission  on  the  Social  Determinants 
Health 

EN 

114 

   EN