Health inequalities and public health in Finland

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Health inequalities and public health in Finland

Seppo Koskinen and Eila LinnanmäkiBerlin, 8 May 2009

1. Background

1.1. Wide health disparities in Finland

1.2. Advantages and challenges in addressing health inequalities in Finland

2. Rationale: Why should health inequalities be reduced?

3. Aims

2.1. Monitoring

2.2. Explore determinants

2.3. Develop means to tackle disparities

4. National Action Plan to Reduce Health Inequalities 2008–11

5. Conclusion: Health inequalities can be reduced

Contents

• Gender: women live 7 years longer than men

• Region: residents of the west coast and Åland live 2–4 years longer than persons living in the northeastern regions

• Marital status / living arrangements: one third of all deaths in the working-aged population would be avoided if mortality of the non-married could be reduced to the level achieved by the married

• Ethnicity: very little information on health of immigrants

• SOCIOECONOMIC POSITION: Persons with high level of education, working in white-collar occupations and enjoying a good income have better health and functional capacity and live longer than persons with a low level of education, those working in blue-collar occupations and having a small income

1.1. Background:- wide health disparities in Finland

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40

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46

48

50

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001

Women

Men

Remaining life years

Difference 6.0 years


Difference in life expectancy 3.2 yrs


Higher non-manual

Lower non-manual

Farmer

Manual

Life expectancy of a 35-year-old in 1981-2000 in Finland

Source: Valkonen et al. 2003

Striking differences in life expectancy between occupational classes

Difference in remaining life years of a 35-year-old between high and low level of education

0

1

2

3

4

5

6

7

1971-75 1976-80 1981-85 1986-90 1991-95 1999-2000

Vuosi

Vu

ott

a Miehet

Naiset

Since the 1980s this difference has increased from 4.7 to 6.2 years in favour for men with high education

Source: Valkonen T et al. 2007

In women the corresponding difference has increased from 2.7 to 3.6 years

A Finnish 35-year-old man can expect to reach the age of 80 years if he has completed a university degree but only the age of 74 years if he has not completed any degree beyond the basic education

4.7 years

6.2 years

2.7 years

3.6 years

How much longer does a 35-year-old person with tertiary level of education live compared with a person with no more than basic education Men

Ye

ars

Year

Women

Mortality increases continuously as income diminishes

Relative mortality

0,0

0,5

1,0

1,5

2,0

2,5

1Suurituloisin

2 3 4 5 6 7 8 9 10Pienituloisin

Income deciles

Naiset

Miehet

Source: Martikainen P. et al. Int J Epid 2001;30:1397-1405

Mortality of men aged 30 or over in the lowest income decile is 2.4 times higher than in the highest decile, among women the difference is 1.7-fold

Women

Men

LowestHighest

24,5

13,6

87,8

11,1

87,1

27,2

0

5

10

15

20

25

30

Akat.korkea-

aste

Amm.korkea-

aste

Keskiaste Perusaste Akat.korkea-

aste

Amm.korkea-

aste

Keskiaste Perusaste

%

Women Men

(p<0,001)(p<0,001)

(p=0,002)(p=0,002)

Self-rated health average or worse, 18–29-years-olds by level of education

Self-rated health is also strongly associated with socioeconomic position

Source: Martelin et al. 2005

Upper Lower Secon- Basic tertiary tertiary dary

Upper Lower Secon- Basic tertiary tertiary dary

Wide inequalities in functional capacity according to level of education

For instance moving difficulties are more common among those with lower education

Below is the proportion (%) of those experiencing difficulties in walking 500 m by education among those aged 30 and over.


0

2

4

6

8

10

12

14

16

Women Men

% Higher

Secondary

Basic

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1.2. Good basis for addressing the social determinants of health inequalities in Finland (1)

• Great improvements achieved in population health

• Health and equity are highly valued by Finnish authorities as well as by citizens

• Reducing health inequalities is a stated national policy goal, addressed in all health policy documents

• National Action Plan 2008-2011 (Ministry of Social Affairs and Health 2008)

• Growing awareness and activity around health inequalities in municipalities and regions

Good basis for addressing the social determinants of health inequalities in Finland (2)• Excellent research and knowledge base:

– e.g. Palosuo H, Koskinen S, Lahelma E et al. Health inequalities in Finland: Time trends in socioeconomic health differences 1980-2005. MSAH 2009:9

– Registers covering living conditions, mortality, use of services and benefits (analysed e.g. by Valkonen et al., Keskimäki et al.)

– Health (examination) surveys, e.g. AVTK, FINRISKI, Health 2000, Helsinki Health Study (analysed by e.g. THL research groups, Lahelma et al.)

– New possibilities• Immigrant health study• Regional surveys on health and welfare (ATH)• Growing use of combinations of survey and register data

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Challenges in addressing the social determinants of health inequalities (1)

• Social determinants of health show unfavourable development– high unemployment after the recession in

1991-1993,recently rapid negative development due to current recession

– increase in income differences and relative poverty rate

– cuts in social welfare benefits were made in the 1990s that have not been fully returned

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• Recession health promotion and tackling health inequalities are not seen as priorities, already signs of plans to cut resources to health promotion and preventive health services in municipalities

• Interests of economic life and other sectors may contradict those of health sector

• Abundance of ongoing short-term programmes and projects within various policy sectors

• Long-term development and prioritization difficult in this jungle of projects and programmes

• The Action Plan comprises suggestions for action but does not oblige actors

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• easy availability and low prices of alcohol increase alcohol consumption and the related harms particularly in the underprivileged groups

• disparities in smoking continue to increase

• inequalities in health and its determinants tend to be steepest among the young adults = tomorrow’s middle-aged and elderly people

• the new effective medical technology is not likely to be similarly available for everyone due to limited resources

2. Why should inequalities in health be reduced? (1)

• Inequalities in health are not inevitable, and therefore, not acceptable ethically

Health inequalities present a major problem for any modern welfare state committed to values of equality

• Public health will improve more effectively when the health of the (large) groups with accumulating problems is promoted

If health of other population groups could be raised to the same level as those who are in the best position, the nation as a whole would be in significantly better health

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Proportion (%) of selected public health problems that would be avoided if the prevalence of the problem in the rest of the population would be as low as among those with tertiary level of educationHealth problem Proportion (%)

of cases avoided

Edentulousness 80Respiratory deaths 50–75Alcohol deaths 50–60Need for daily help due to restrictions in functional capacity 50Coronary heart disease deaths 30–50Accidental/violent deaths 20–45Diabetes 30Back disorders 30Osteoarthritis of knee/hip 30Stroke deaths 20–40Cancer deaths 20–30Impaired vision/hearing 20

Source: Koskinen & Martelin 2007

• Health inequalities endanger the sufficiency of labour force in the near future

• Persisting large inequalities imply a great need for services which the nation may not be able to supply as population ages

• Poor health is a factor in social exclusion

• Health inequalities have negative economic effects

Why should inequalities in health be reduced? (2)

3. AIMS

3.1. Monitoring: national and regional level • Making health inequalities and their time trends visible

• Providing information needed for decision making: targeting activities according to need

• Evaluation of the effects of efforts to reduce health inequalities

• Promoting research into causes and ways to reduce health inequalities

• Production of up-to-date information by socioeconomic position on • different dimensions of health and functional capacity across age groups

• living and working conditions and behavioral factors affecting health

• need for care

• coverage, contents and effects of treatment and prevention of diseases as well as health promotion and health-related social security

• attempts to reduce health inequalities and the effects of these attempts

Proposals to improve monitoring in the national action plan

Up-to-date information on level of education and occupation (and on other relevant social factors when feasible) to be linked from the registers of Statistics Finland to

• other registers used in health monitoring, annually

• surveys used for health monitoring, at the stage when the sample is drawn

• client information systems of the health sector, annually

Socioeconomic position and living arrangements to be included as routine background variables in health monitoring reports, in addition to the generally used age, gender and region

3. AIMS

3.2. Explore determinants of health disparities and their trends

• Prerequisite for developing means to act on health disparities

Pathways from socioeconomic position to health• Education affects knowledge and values related with health and one’s

occupational career • Occupation influences working and living conditions, shapes behaviour and

affects income• Income and economic position influence e.g. housing conditions and

possibilities to make healthy choices • Behavioural factors are important in the generation of health inequalities

– excessive alcohol use (accounts for ¼ of mortality differences in men)– smoking (accounts for another ¼ of mortality differences in men)– diet– lack of exercise• High socioeconomic position improves the knowledge and economic

prerequisites – as well as motivation – to choose healthy behaviour patterns

• Behavioural choices are influenced by e.g. economic possibilities, values, norms, fashion and marketing

• Factors operating during all phases of the life course affect health inequalities

} → obesity and consequent health problems

Significant differences between educational groups in young adults’ smoking. Figure shows age-adjusted prevalence (%) of daily smoking among those aged 18–29 in different educational levels.

Men Women


Men Women

0

10

20

30

40

50

60

Basic educ.

Secondary. educ.

Highervocationaleduc

Higher university educ.

Basic educ.

Secondary educ.

Highervocationaleduc.

Higheruniversity

educ.

%

Smoking in young adults

Contribution of intermediaryfactors to educational differences in stair climbing in women aged 55+ (relative decline in excess risk*, %).

Source: Sainio et al. 2007

Obesity and osteo-arthritis of the knee and hip are the most important factors contributing to educational mobility differences in women

3. AIMS

3.3. Develop means to tackle health disparities

Level of action• Local and regional• National• International

When the aim is to improve health of the whole population, the greatest benefit is gained through advancing health of the less fortunate groups.

Social status (education, income, etc.)

Population’s health

Target: more equal

distribution of health

Present state:

inequalities in health

are large

Aim: more equal distribution of health

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Tackling health inequalities in municipalities: lessons learnt in TEROKA (www.teroka.fi) joint projects

• Close collaboration between research institutes, policymakers and professionals is needed

• Cities, municipalities and regions differ from each other, there is no uniform way to operate

• Information about health inequalities in the “own” population (municipal or regional, not only national) is needed to awaken decision-makers

• Simple and adapted terminology is necessary

• Arguments which start from decision-makers’ point of view (e.g. economic effects, sufficiency of labour force) are needed for motivation

• The aim has to be incorporated into local and regional strategies, not only in national plans, in order to legitimate and lead to actions

• Effective intersectoral work is needed, health sector has an important role as an advocate

• Decision makers need enough time (= several years) to understand, digest and start concrete actions

4. National Action Plan to Reduce

Health Inequalities 2008–2011

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Planning and drafting the Action Plan• Preparation initiated in April 2006 by the ministerial group

for social policy issues of the previous Government

• Coordinated by the Advisory Board for Public Health – appointed by the Government– members from several admininstrative sectors, local

government, health services, NGOs, professional organisations, research institutes

• Preparatory work carried out by the sub-committee for national cooperation of the Board

• Large number of experts from various organisations participated in drafting

• Linked closely with the Government Policy Programme for Health Promotion

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General principles of the Action Plan

• Long-term objectives, but measures mostly for the present Government term

• Covers measures within other programmes and projects that have effects on health inequalities to add impetus to their work

• Health in all policies as a strategic approach

• Emphasis on both the whole social gradient and on vulnerable/marginalised minorities

• Universal services as well as measures targeted at the most disadvantaged

• Not necessarily new, separate structures and resources, but focusing and mainstreaming ongoing activities

Strategies of the programme

• General social policy actions to reduce health inequalities and prevent social exclusion:

– poverty, poor education, unemployment, homelessness

• Influencing lifestyles through policy

• Developing social welfare and health care services

• Developing systems to monitor health inequalities

• Strengthening the information base and communications

Measures of the Action Plan:General social policy actions to reduce health inequalities and prevent social exclusion

1. Promote the health and well-being of youth in vocational education

2. Making health promotion a permanent feature at the workplace, emphasis on fields and sectors with health risks and harmful lifestyles

Measures of the Action Plan:Influencing lifestyles through policy3. Alcohol tax to be raised

4. Substance abuse prevention incorporated into the structures of health and well-being promotion in municipalities

5. Tobacco tax to be raised gradually

Inclusion of tobacco and nicotine addiction withdrawal drugs in health insurance coverage

6. Availability of mass catering services that comply with nutritional recommendations, particularly at small workplaces

7. A Government resolution on health promoting nutrition and physical activity; adaquate excercise and healthy diet for the most socioeconomically disadvantaged

Measures of the Action Plan:Developing social welfare and health care services

8. Social and health care services to be developed and allocated on the basis of monitored health needs

9. Analysis of the allocation of rehabilitation services

10.Health services that support the working ability among the long-term unemployed on a permanent basis in the municipalities

11.Study on the health and service needs of the immigrants

Measures of the Action Plan:Developing systems to monitor health inequalities, strengthening the information base and communications

12.Development of the data on health inequalities of registers, surveys, statistics etc.

13.Development of separate assessments and population research

14.Research into health inequalities to be continued and strengthened

15.Distribution of data to municipalities and other local actors

5. Conclusion: Health inequalities can be reduced

• The magnitude of health inequalities varies markedly between societies and time periods → there is no natural law which inevitably leads to a certain level of inequality!

• Positive examples of reducing health disparities between subgroups of the population in Finland:

– reduction of health disparities between northeastern and southwestern Finland

– Reduction / eradication of regional and socioeconomic differences in health among children

→ Health inequalities can be reduced, but achieving results requires determined intersectoral work

Health inequalities and public health in Finland

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