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Equality  of  opportunity  in health in Europe
The long term impact of social background and
parents longevity on health status
Florence JUSOT, Université Paris-Dauphine (LEGOS)
IRDES Sandy TUBEUF, Academic Unit of Health
Economics Leeds Institute of Health Sciences
(GB) Alain TRANNOY, EHESS-IDEP-GREQAM
Health, inequalities, risk and public policy
2008 September 26-27 University Paris-Descartes
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Aims

• To explore the impact of family background on
  health status of adults
• Family background
• Parents occupations
• Health status of parents as measured by their age
  at death
• (1) To assess intergenerational inequality of
  opportunity in health in Europe
• Inequality of opportunity in health the
  distribution of health status of descendants
  depends on the family background
• (2) To contribute to the understanding of
  determinants of health status in adulthood
• (3) To compare intergenerational inequality of
  opportunity between European countries

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Context

• Several studies suggest
• An influence of social background on health
  status in adulthood (Barker 1996 Blane 1999
  Case 2005 Hyde et al. 2006 Melchior et al.
  2006a) through several mecanisms
• Direct impact of childhood conditions on health
  status in adulthood (Latency and accumulation
  models) 
• Indirect impact of childhood conditions on health
  status in adulthood through the determination of
  life trajectories and in particular socioeconomic
  status (Pathway model)
• An influence of parents health status on
  descendants health
• Correlation between parents health status and
  childs health status (Case et al. 2000
  Llena-Nozal 2007 Ahlburg 1998)
• Correlation between longevity accross generations
  (Cournil Kirkwood 2001)
• Impact of the parents relative longevity on
  descendants health status in France(Devaux et
  al. 2008)

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Inequality of opportunity in health

• Social background and parents' health represent
  circumstances independent of individual
  responsibility
• The distribution of health in adulthood
  conditional on these circumstances will describe
  inequalities of opportunities in health
  (Dworkin,1981 Roemer, 1998 Fleurbaey, 1994
  Dias and Jones, 2007)
• Three steps are used to analyse intergenerational
  inequalities of opportunity in health due to
  parental circumstances
• non parametric approach
• parametric approach
• counterfactual analysis

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Data and descriptive statistics
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Data

• 2003 SHARE Survey of Health, Ageing and
  Retirement in Europe
• 11 countries concerned Austria, Belgium,
  Denmark, France, Germany, Greece, Italy, the
  Netherland, Spain, Sweden, (Swizerland)
• 24 000 individuals, 49 years old and more, whose
  both parents are deceased and who answered both
  to
• self-assessed health Would you say your health
  is very good, good, fair, bad, very
  bad
• education level
• own (last) job
• parents last job
• parents age at death

ISCO Classification
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Respondents health status distribution
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Parents health status distribution
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Non-parametric approach
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Non-parametric approach

• Analysis of equality of opportunity in health
• Comparisons of distributions of respondents
  health in terms of stochastic dominance at first
  order based on a conjunction of
  Kolmogorov-Smirnov unilateral tests
• We compare distributions of health status
  according to
• The longevity of each parent
• The social status of each parent

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Inequality of opportunities in health according
to the fathers health
Belgique
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Inequality of opportunities in health according
to the mothers health
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Inequality of opportunities in health according
to the parents health

• There are inequalities of opportunities in
  health according to parents health in all the
  European countries
• The distribution of health of individuals born
  of parents who are still alive dominates the
  other two distributions of health
• The distribution of health of individuals born
  of a father who died in older ages dominates the
  distribution of health of individuals born of a
  father who had died prematurely in Austria,
  Germany, Sweden, Netherland and France
• The distribution of health of individuals born
  of a mother who died in older ages dominates the
  distribution of health of individuals born of a
  mother who had died prematurely in Austria, Italy
  and Belgium
• There is no control for age so younger
  descendants are more likely to have alive parents

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Health status in adulthood according to the
fathers social status
Différences significatives
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Health status in adulthood according to the
mothers social status
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Inequality of opportunities in health status
according to social background

• There are inequalities of opportunity in health
  according to social background in Europe
• according to the fathers social status
• The distribution of health of sons of Senior
  managers and professionals, Technicians and
  associate professionals and armed forces
  significantly dominates the distribution of
  health of sons of Skilled agricultural and
  fishery workers, Craftsmen and skilled
  workers, Elementary occupations and unskilled
  workers in Austria, Germany, Sweden, France,
  Denmark and Belgium
• according to the mothers social status
• The distribution of health of sons of Senior
  managers. professionals and technicians, Office
  clerks and service workers significantly
  dominates the distribution of health of sons of
  Skilled agricultural and fishery workers,
  skilled and unskilled workers, Elementary
  occupations and Homemakers in Austria,
  Germany, Sweden, Spain, France, Denmark and
  Belgium
• Individuals born to a Homemaker mother
  significantly report a better health than
  individuals born to a mother Elementary
  occupations and unskilled workers in Germany,
  France and Belgium

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Inequality of opportunities in health status
according to social background

• A peculiar result for sons of Skilled
  agricultural and fishery workers
• They significantly have a better health status
  than sons of Craftsmen and skilled workers,
  Elementary occupations and unskilled workers
  and even Office clerks and service workers and
  shop and market sales workers in Netherland,
  Denmark and Belgium
• They significantly have a worse health status
  than sons of Craftsmen and skilled workers,
  Elementary occupations and unskilled workers in
  Spain and Greece
• The distribution of health of individuals born
  to a mother who was Skilled agricultural and
  fishery workers dominates all the other
  distributions in Netherland
• - The distribution of health of individuals born
  to a mother who was Skilled agricultural and
  fishery workers is dominated by all the other
  distributions in Spain and Germany

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Parametric approach
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Parametric approach

• Analysis of intergenerational inequalities of
  opportunities in health in terms of conditional
  expectation controlled by age and sex
• Logistic regression models
• Explaining the probability of being in good or
  very good health status
• Regressors
• Age/Sex
• Parents longevity
• Parents SES
• Descendants SES
• Descendants education level
• The two last variables control variables

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Parametric approach

• Inequalities of opportunity according to the
  fathers SES
• in every countries except Netherland
• high in Germany, Austria, Belgium, Spain, France
  and Italy
• heterogeneity of the most advantaged social
  backgrounds
• Influence of social background more or less
  direct from one country to the other
• social reproduction Denmark, France, Greece and
  Sweden
• direct effect Germany, Austria, Belgium, Spain
  and Italy
• Inequalities of opportunity according to the
  mothers SES
• favoring agricultural workers Greece,
  Netherland
• disadvantaging agricultural workers Germany,
  Belgium, Italie
• favoring office clerks France
• favoring senior managers Sweden
• Inequalities of opportunity according to parents
  longevity in every countries

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A first pass to the measurement of inequalities
of opportunities in health counterfactual
analysis
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Counterfactual analysis

• Inequalities of opportunity in health are health
  inequalities explained by circumstances and not
  by effort
• We aim a measurement which takes into account the
  health differences due to the direct effect of
  circumstances on health and their indirect effect
  going through the descendants education and
  social status
• If we assume that the respondent's SES
  (educationsocial status) is the result of both
  circumstances and his effort, then the
  measurement should not take into account health
  differences explained by the share of education
  and social status due to individual effort
• We aim a measurement independent from health
  differences coming from demographic
  characteristics (age and sex), considered as
  legitimate differences

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Counterfactual analysis

• Measure based on the conditionnal probabilities
  of being in good health status
• Counterfactual analysis Comparison of the
  probability of being in good health status
  conditionnal to
• - the current characteristics of the individuals
• - for given circumstances
• Measure closed to the  fairness gap  (Fleurbaey
  and Schokkaert, 2008)
• To measure the counterfactual probabilities, we
  have to assess the full impact (direct
  indirect) of circumstances

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Counterfactual analysis

• Separated estimation of the impact of social
  background and parents' health on the
  descendants education and the respondents
  occupation (Probit models)
• Educ a1 b1xAge c1xSex d1xCirc u1
• SES a2 b2xAge c2xSex d2xCirc
  e2xEduc u2
• The generalized residuals E(u1/Xi) and E(u2/Xi)
  (Gourieroux et al., 1985) can be interpreted as
  effort, unobserved circumstances and luck
  for a given background.
• Assessment of the  full  influence of social
  background and parents' health on the
  respondents health status (Logit model)
• Health a3 b3xAge c3xSex
  d3xCircumstances
• e3x E(u1/Xi) f3x E(u2/Xi) u3

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Counterfactual Analysis

• The last model is used to predict the probability
  of being in good health status with
• - currents circumstances (current probabilities)
• - best circumstances (counterfactual
  probabilities)
• The Gini index of predicted probabilities gives a
  measure of health inequalities
• The difference between the Gini index of the
  current probabilities and the Gini index of the
  counterfactual probabilities gives a measure of
  the contribution of inequalities of opportunities
  to health inequalities

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Health inequalities in Europe
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Contribution of inequalities of opportunity to
health inequalities in Europe
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Contribution of inequalities of opportunity
according to social background to health
inequalities in Europe
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Contribution of inequalities of opportunity
according to parents longevity to health
inequalities in Europe
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Contribution of inequalities of opportunity
according to the fathers characterisitics to
health inequalities in Europe
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Contribution of inequalities of opportunity
according to the mothers characteristics to
health inequalities in Europe
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Inequalities of opportunities in health, Income
and income inequalities European comparisons
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Conclusion
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Conclusion

• Inequalities of opportunities in health in Europe
  according to
• social backgroud ()
• parents longevity
• Health status in adulthood is influenced by
• current social conditions
• social background indirect (pathway model) and
  direct influence (childhood conditions, parents
  education)
• parents longevity genetic inheritance ?
  health preferences and health-related behaviors
  (prevention, risk) ? common characteristics
  influencing health status of parents and children
  ?
• Differences between European countries have to be
  explained
• policies reducing social reproduction
• policies reducing intergenerational reproduction
  of health problems

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Conclusion

• Questions ?
• Some social statuses containing individuals who
  are socially different from one country to the
  other agricultural workers
• Is self-assessed health usable for international
  comparisons?
• Selection biais of the sample (49 years old and
  more)

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Thanks
Florence JUSOT, florence.jusot_at_dauphine.fr Sandy
TUBEUF, S.Tubeuf_at_leeds.ac.uk Alain TRANNOY,
Alain.Trannoy_at_eco.u-cergy.fr
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