Transcript Probability of dying between the 45th and 65th birthday

INEQUALITIES IN HEALTH:
AN ESTONIAN CASE
Anu Kasmel
Estonian Centre for Health Education and
Promotion
Social inequalities in health as an issue
• came to the policy arena in Estonia in the end of
ninetieth after a period of the extensive and
profound societal changes.
• Discussions concerning health policy have been
focused to the social determinants of health and to
the most vulnerable groups in society.
• In spite of improvements during recent years, the
health situation in Estonia is still not favourable in
comparing with other northern countries and
social inequalities in health are growing.
Estonian Public Health Policy Document,
April,2002
“The public health strategies should be
directed towards diminishing inequalities in
health between different social groups.
All sectors and levels in society should direct
their health policies to support disadvantages
groups.”
Study of social inequalities in health, 2001
• Cause-specific
mortality
• Self-reported
morbidity
• Health related
behavior
• Health care utilization
• Mortality Database
• Health Interview
Survey
• Bi-annual Health
Behavior Surveys
1990-2000
• Living Condition
Surveys 1994, 1999
• Health Insurance Fond
The main results demonstrates that:
• Morbidity, mortality, health related behaviors and patterns
of health care utilization strongly vary between subgroups
of the population;
• People from lower socio-economic groups live shorter,
more ofter suffer from health problems, engage more often
in health damaging behavior and have less favourable
health care utilization pattern;
• Large differences in some outcome indicators are observed
between men and women, non-ethnic and ethnic Estonians
and by place of residence;
• During the 1990’s social inequalities in mortality, and most
types of health related behavior have widened.
Average life expectancy at birth among men
Life expectancy at birth in years
and women from 1959 to 2000 in Estonia
80
Men
Women
75
70
65
60
55
1959 1970 1979 1989 2000
1959 1970 1979 1989 2000
Probability (%) of dying
Probability of dying between the 45th and 65th
birthday. Men with high and low educational level in
Estonia compared to Norway and Finland in the late
1980s.
50
40
30
High education
20
Low education
10
0
Norw ay
Finland
Estonia
The percentage of respondents reporting 'bad or
average' general health in different educational levels
by gender and age groups, 1994
University Upper secondary Lower secondary
90
80
Percent
70
60
50
40
30
20
Men
Women
25–44
45–59
60–79
The percentage of respondents reporting ‘bad’
general health or depression (age group 25–79), or
reporting mobility limitations (age group 60–79) in
different personal income quartiles
1 (low) 2
3
4 (high income quartile)
25
Percent
20
15
10
5
0
'Bad' general health
Depression
Mobility limitations
The percentage of respondents having emotional
distress among the employed and unemployed by
gender, three age groups and place of residence in
the age range 25–59.
Employed Unemployed
25
Percent
20
15
10
5
0
Men
Women
25–44
45–59
Tallinn
Other
urban
Rural
Age-standardised mortality rate among people with a
university and lower secondary education in 1987–
1990 and 1999–2000 by gender. Ages 20 years and
above included
University
Lower secondary
ASMR per 100 000
3500
3000
Men
Women
2500
2000
1500
1000
500
1987–1990
1999–2000
1987–1990
1999–2000
The proportion of respondents who use
fresh fruits 0-2 days a week, according to
the
education and study year.
University
Upper secondary
Low er secondary
100
Percent
80
60
40
20
0
1990
1992
1994
1996
Year
1998
2000
The proportion of respondents who
smoke daily, in different personal income
quartiles
40
35
Percentage
30
25
20
15
10
5
0
3001 -
2001-3000
1001-2000
Income
-1000
The proportion of respondents 1999, who have had telephone
consultation with a doctor, visit to a doctor, visit to a
specialist, visit to a dentist (all during last 6 months) or have
been hospitalised during last 12 months, according to
educational level
Upper secondary
Lower secondary
Hospitalisation
Visit to a
dentist
Visit to a
specialist
Visit to a
general doctor
50
45
40
35
30
25
20
15
10
5
0
Telephone
consultation
with a doctor
Proportion (%)
University
To most of us, inequality is the state of
being unequal
• Inequalities in health describe the differences in
health between the groups. Inequities refer to a
subset of inequalities that are assessed as unfair.
• Evans (2001) have said that the unfairness
qualification invokes assessment of whether the
inequalities are avoidable as well as more complex
ideas of distributive justice as applied to health.
Equity
• Equity concerns a special subset of health
disparities that are particularly unfair because they
are associated with underlying social
characteristics, such as wealth, that systematically
put some groups of people at a disadvantage with
respect to opportunities to be healthy.
• Equity is linked to human rights, as it calls for
reduction in discrimination in the conditions
required for people to have equal opportunity to be
healthy.
• Attaining optimal health ought not to be
compromised by the social, political, ethnic, or
occupational group into which one happens to fall.
Social justice
The fully articulated effort to redress
inequities in health must inevitably work in
tandem with wider efforts towards social
justice – such as the provision of safety
nets; protection against medical
impoverishment; provision of education,
jobs training, and environmental risk
reduction; and efforts to ensure peace and
political voice for all.
William Farr
“No variation in the health of the states in
Europe is the result of chance; it is the
direct result of physical and political
conditions in which nations live” (1866).
The question is: How to promote factors,
which create equitable society?
What are the most influential interventions and
policies, what could best contribute to reducing
inequalities in health. There is no clear answer to
this question. Until now the convincing evidence
about the likely impact of specific policy
initiatives or interventions on reducing health
inequalities is highly elusive.
Understanding of health determinants
It has appeared that society’s understanding
of the determinants of health has an
important influence on the strategies it uses
to sustain and improve the health of its
population.
The increased understanding of the social
causes of ill health is a critical component
of health equity agenda.
The nature of political system
• As demonstrated in many studies, the nature
of the political system, its values and
processes for participation, define the
frontiers of opportunity for health equity.
Societies with flourishing democracies,
respect for human rights, transparency and
opportunities for civic engagement – high
social capital – are more likely to be equity
enhancing.
Policies
Macroeconomic and social policies may either limit or
enhance health opportunities for different groups in the
population.
In the era of liberal macroeconomic policy “progrowth”
strategies tend to provide enhanced opportunity to those
with resources and high levels of education while large
segments of the population without these assets are
unlikely to be beneficiaries of economic transition.
Just focusing to the economic growth policies that pay no
attention to social investments or to compensatory
educational and labor policies, these transitions have
exacerbated the extent of inequity in health.
Human capital and social capital
Diderichsen (2001) have declared that if we
want to understand and intervene against
social inequalities in health, we should look
both upstream into the mechanisms of
society and downstream into the
mechanisms of human biology and coping
skills.
Community development
• Many studies have demonstrated that
interventions, directed to the development of the
human and social capital are leading to the
increase of empowerment of community.
• An empowered person/community can critically
analyse the social and political environment and to
make their own choices.
• Community development has been suggested as
offering “the most promising approach to reducing
health inequalities” (Labonte, 1988).
What we have learned from transition
• The political deliberation in the 1980’s , the time
of ‘singing revolution’ synchronized with
tremendous increase in social capital and also
improved health data.
• Rapid political, social and economical changes,
which followed to the transition moment, caused
in the initial period of transition the wide lose of
control and disempowerment of large sectors of
population.
• Step by step empowerment is growing and people
get back control over their life.
•
Assumptions of success:
• People’s participation in community change
promotes changes perceptions of self-worth and a
belief in the mutability of harmful situations,
which replaces powerlessness;
• The experience of mobilizing people in
community groups strengthens social networks
and social support between individuals and
enhances the community’s competence to
collaborate and solve health problems;
• Empowerment education interventions promote
actual improvement in environmental and health
conditions.
Tackling inequalities in health needs for commitment and needs for
concrete legislative acts
• If communities are commited to create and
governments are commited to support systems
and structures (”social system for health”), that
establish networks, norms, social trust and
develops people capacities; if these structures
facilitate co-ordination and cooperation between
different sectors and levels, we are able to make
changes in health of our populations, to deminish
social inequalities in health.