Europe’s governments should set targets to reduce health inequalities

BMJ 2009; 338 doi: (Published 21 May 2009) Cite this as: BMJ 2009;338:b2075
  1. Tessa Richards

    The failure of European governments to tackle increasing inequalities in health in their populations is due to lack of political will and limited knowledge of what policy interventions work, speakers agreed at a recent meeting in London.

    The meeting was organised by the London School of Economics and the European Commission, which is due to launch a new initiative to tackle health inequalities across the European Union later this year.

    Few governments, take health inequalities seriously enough, speakers emphasised. Governments should follow the lead of the Netherlands, which in 1989,adopted a national policy to reduce health inequalities and is shortly to adopt objective targets by which progress can be measured.

    Health inequalities in the Netherlands are below the EU average, but the gap in life expectancy between those in the highest education groups and those in the lowest is still six years for women and seven and seven years for men, said Mariel Droomers, an epidemiologist at the Dutch National Institute for Public Health and the Environment.

    Initiatives to tackle health inequalities need to extend well beyond the health sector, said Dominique Poulton, of the French National Health Insurance fund for Salaried Workers. France had focused mainly on improving access to health care among deprived and socially excluded groups. Although this was an important objective, more could be achieved by introducing wider social and welfare policies.

    Several speakers, including Owen O’Donnell, from the University of Macedonia, Thessaloniki, drew attention to the methodological difficulties of measuring health inequalities. Although several EU wide surveys are suitable for analysis of inequalities, most have limitations, particularly those that include measures of subjective well being and unmet need.

    Patchy data collection is a further problem. Income and social inequalities in health have been rising steadily since 1989 in Central and Eastern European countries, said Martin Brobank, an epidemiologist from University College London, but investigation and documentation of these inequalities have been “slow and unsystematic.”

    Citing the example of Robin Hood, robbing the rich to help the poor, Martin McKee, professor of European Health at the London School of Hygiene and Tropical Medicine, drew attention to the central message from the Commission on Social Determinants of Health, which WHO established in 2005 to provide advice on how to reduce health inequalities: that the way to reduce them is to tackle the inequitable distribution of power, money and resources (BMJ 2007;335:522-3, doi:10.1136/bmj.39328.478044.80).

    But he underlined that while there is a clear relationship between per capita income and life expectancy in poorer countries in Europe, that did not hold true for richer ones.

    Research has shown that inequality in health stems from a wide range of factors beyond socioeconomic ones. These include individual life style factors, social and community networks, sex, age, occupation, education, income, social class, ethnicity, religion, disability, and even language. Defining appropriate policy responses was not easy, he said, for “context is all and evidence on what works sparse.” Governments seemed to have “an aversion to evaluating policy interventions.”

    Measures to tackle immediate causes of ill health, including smoking, alcohol consumption and poor nutrition, were obviously important, he said, but more research was needed to inform action outside the health sphere and adapt it to national regional and local conditions.

    The Campbell Collaboration (, he suggested, provides a rich source of information in this respect, by conducting systematic reviews of the effect of social interventions in the areas of welfare, education, crime and justice.

    The importance of taking “a life course approach to health inequalities” was emphasised by several speakers. Differentials in health by employment status vary over time, for example; and as Julian Le Grand pointed out, more than 40% of premature mortality in people aged over 75 is due to unhealthy life styles adopted many years previously. Influencing individual behaviour in the early years of life was critical, he said.


    Cite this as: BMJ 2009;338:b2046

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