INEQUALITIES IN HEALTH: AN ESTONIAN CASE

1
INEQUALITIES IN HEALTH AN ESTONIAN CASE

• Anu Kasmel
• Estonian Centre for Health Education and
  Promotion

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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.

3
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.

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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

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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 1990s social inequalities in
  mortality, and most types of health related
  behavior have widened.

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Average life expectancy at birth among men and
women from 1959 to 2000 in Estonia
80
Men
Women
75
70
Life expectancy at birth in years
65
60
55
1959
1970
1979
1989
2000
1959
1970
1979
1989
2000
7
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.
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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
70
60
Percent
50
40
30
20
Men
Women
2544
4559
6079
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The percentage of respondents reporting bad
general health or depression (age group 2579),
or reporting mobility limitations (age group
6079) in different personal income quartiles
1 (low)
2
3
4 (high income quartile)
25
20
15
Percent
10
5
0
'Bad' general health
Depression
Mobility limitations
10
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 2559.
Employed
Unemployed
25
20
15
Percent
10
5
0
Men
Women
2544
4559
Tallinn
Other
Rural
urban
11
Age-standardised mortality rate among people with
a university and lower secondary education in
19871990 and 19992000 by gender. Ages 20 years
and above included
University
Lower secondary
3500
Men
Women
3000
2500
ASMR per 100 000
2000
1500
1000
500
19871990
19992000
19871990
19992000
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The proportion of respondents who use fresh
fruits 0-2 days a week, according to the
education and study year.
13
The proportion of respondents who smoke daily, in
different personal income quartiles
14
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
University
Upper secondary
Lower secondary
50
45
40
35
30
Proportion ()
25
20
15
10
5
0
specialist
Visit to a
Visit to a
dentist
Visit to a
Telephone
consultation
with a doctor
general doctor
Hospitalisation
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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.

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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.

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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.

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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).
• 
  
  

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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.

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Understanding of health determinants

• It has appeared that societys 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.

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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.

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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.

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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.

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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).

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What we have learned from transition

• The political deliberation in the 1980s , 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.

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Assumptions of success

• Peoples 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
  communitys competence to collaborate and solve
  health problems
• Empowerment education interventions promote
  actual improvement in environmental and health
  conditions.

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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.