Health inequalities and public policy - selected experiences from Finland

1. European Public Health Conference, Ljubljana 28.11.2018 Preconference on Health Inequalities; JAHEE Health inequalities and public policy - selected experiences from Finland Seppo Koskinen

2. Health inequality has been a central issue in Finnish healthy public policy for more than 30 years Koskinen

3. Government’s health policy report to the Parliament, 1985 -”Differences in morbidity between population groups must be decreased." -”Emphasis must be put to taking care of the needs of the disadvantaged individuals and groups and to equity between citizens so that economic factors do not prevent appropriate use of health services." -”Measures needed to reduce behaviourally determined health problems in the population groups at highest risk will be untangled". -"Alcohol consumption will be reduced and the ability to control alcohol use in diferent subgroups of the population will be strengthened". -”Wide differences between socioeconomic groups in morbidity and mortality constitute a central research problem." Koskinen

4. Government’sreport to the Parliament on publichealth, 1996 -”Wehavenotsucceeded to reduce social inequalities in health in recentyearsalthoughthishasbeenone of the main goals of healthpolicy." -”Increasingknowledge. Health inequalitiescontinue to be a majorchallenge to research. … westillneedmuch new information in order to developmoreeffectivemeasures." -”Publicpolicy to improveequity. Health inequalitiesarelargelybased on differences in livingconditionsand scholarly as well as materialresources. Theycanthereforebeinfluencedbypersevering social, labour and educationalpolicywhichaims to reducedifferencesbetweenpopulationgroups and attends to the groups in the poorestsituation in particular." -”Equity in healthservices. -In the development of the servicesystem and itsfunding, particularattentionmustbepaid to equaluse of healthservicesaccording to need. -Inreducingriskfactors, moreemphasismustbegiven to improvement of livingconditions and circumstancesbypublicpolicymeasures." (p. 72) Koskinen

5. Goverment’s resolution on the Health 2015 public health programme, 2001 -”It is particularly alarming that some health inequalities have increased" (p. 11) -”A prerequisite for successful health policy is to prevent the growth of health inequalities and more efficient action aiming to reduce these inequalities" (p. 13) -”The main aims up to year 2015: 8. …inequality will decrease and the wellbeing and relative position of disadvantaged population groups will improve. The aim is to reduce mortality differences between the genders, education groups and occupational groups by one fifth" (p. 18) Koskinen

6. National action plan to reduce health inequalities, 2008–2011 • Persistent, multisectoral work is needed to reduce health inequalities. Social determinants of health and the processes behind the inequalities must be addressed. … three priority areas: • Social policy measures: improving income security and education, and decreasing unemployment and poor housing • Strengthening the prerequisites for healthy lifestyles: measures to promote healthy behaviour of the whole population with special attention to disadvantaged groups where unhealthy behaviour is common • Improving the availability and good quality of social and health care services for everyone • To pursue these goals and monitor the attainment of them, reliable knowledge base and effective communication are needed. For this purpose, • a follow-up system for health inequalities is developed • knowledge about the scope of and trends in health inequalities is strengthened • education and communication concerning health inequalities and their reduction is advanced. Koskinen

7. Has health inequality decreased? Koskinen

8. Increasing inequalities in life expectancy at age 25 by level of education Women, higher Difference 4.2 years Difference 2.7 years Women, basic Difference 5.1 years Men, higher Difference 4.5 years Men, basic Source: www.terveytemme.fi/kuolleisuuserot/

9. Increasing inequalities in life expectancy at age 25 between income quintiles Women Men 4. & 5. quintile 4.6 4. & 5. quintile 3.0 1. quintile 9.0 6.4 1. quintile Source: www.terveytemme.fi/kuolleisuuserot/

10. Wide regional differences in potential years of life lost (PYLL) in lower socieoconomic groups – but not in higher groups by level of education by income quintile Basic Lowest Two highest Higher *) Potential years of life lost between ages 25 and 80 /100 000 Source: www.terveytemme.fi/kuolleisuuserot/

11. Inequalities in mortalityhaveincreasedrapidly • largelydue to growingdisparities in deathscausedbyalcohol, butalsodeathsfromothercauses of death • Wide inequalitiesalso in health and functional status, but no significanttimetrends

12. Time trends in determinants: health behaviour • Smoking • rapid increase in inequalities • Diet and physical excercise • apparently no marked changes in inequalities • Alcohol use • discrepant findings: • survey results fail to show marked inequalities in alcohol use • mortality (and morbidity) data reveal wide and growing inequalities

13. Time trends in determinants: living conditions • Income and wealth • growing inequality • Unemployment • much more common in the lower socioeconomic groups than in the higher groups, but this difference does not seem to have changed much recently • Working conditions • much more hazardous in manual than in non-manual occupations, but time trends in these inequalities are not well known

14. Time trends in determinants: health services • Occupationalhealthservices • wideinequalitiespersist • Privateservices • verywideinequalitiespersist • Distribution of surgical and othertreatmentaccording to need • markedinequalities • The limitedsupply and highprice of new healthtechnologiesreducespossibilities of lessadvantagedgroups to benefitfromthem Koskinen

15. Reduction of health inequality has been one of the main aims in all major health policy documents during more than 30 years • These general health policy documents represent a quite well developed understanding of the causal network behind health inequalities • Why are health inqualities not decreasing? • Public policy decisions and measures have often been guided more by other aims than the commitment to reduce health inequalities. Example from alcohol policy: tax reduction in 2004  price of alcohol lowered  marked increase in alcohol deaths in lower socioeconomic groups – as predicted

16. Need for committed action in all sectors of public policy • Inequalities in health are not inevitable, and therefore, not acceptable ethically • 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 the population ages • Poor health is a factor in social exclusion • Health inequalities have negative economic effects • Public health will improve more effectively when the health of the (large) groups with accumulating problems is promoted

17. 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 education Health problem Proportion (%) avoided of cases Edentulousness 80 Respiratory deaths 50–75 Alcohol deaths 50–60 Need for daily help due to restrictions in functional capacity 50 Coronary heart disease deaths 30–50 Accidental/violent deaths 20–45 Diabetes 30 Back disorders 30 Osteoarthritis of knee/hip 30 Stroke deaths 20–40 Cancer deaths 20–30 Impaired vision/hearing 20 Source: Koskinen & Martelin 2007

18. Koskinen Tackling health inequalities in municipalities: lessons learnt • There is no uniform way to operate in different cities, municipalities and regions • Information about health inequalities in the “own” population (not only national) is needed to awaken decision-makers • 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 in order to legitimate and lead to actions • Effective intersectoral work is needed, health sector has an important role as an advocate 18

19. Koskinen Tackling health inequalities, lessons learnt on the national level: We need (also) • Long-term policies/actions – not just 2–4-year programmes • Healthy public policy – not just health services policy • Partners from a number of different sectors • A high-level intersectoral body to plan, monitor and prioritize interventions and policies in different sectors (The National Advisory Board for Public Health – including representatives of ministries, NGOs, academia, trade unions etc. – no longer exists after 2015) • Active search of effective win-win situations: • Which political initiatives tend to lead to action? • Can we find shared aims with these supposedly successful initiatives / lines of policy or interventions? • Can we produce convincing evidence that these initiatives or lines of policy significantly benefit from cooperation with policies aiming to reduce health inequalities 19

20. Thank you!