Health is both a medical and a social issue. Health status and inequalities are linked to factors which individuals cannot address alone. It is estimated that 80-85% of what is important in tackling health inequalities sits outside the control of health systems. In this section we briefly cover policy actions that help address the underlying causes of inequality and promote health and well-being for all.
Taking action to reduce inequalities in health does not require a separate health agenda, but action across the whole of society (…) A debate about how to close the health gap has to be a debate about what sort of society people want.
- Professor Sir Michael Marmot
Policy to reduce and prevent health inequalities
Policies to reduce health inequalities are policies that aim to deliver the essential conditions for a healthy life for all. Since the causes of health inequalities are complex, there is no single solution to address the challenge. Governments, and those working in different government sectors, -financial, economic, social, health etc., as well as private actors and citizens must work together.
Health inequalities are partly caused by inequalities in income, power and wealth across the population. We can reduce them by improving the conditions in which we are born, grow, live, work, and age. These are the determinants of health.
The World Health Organization (WHO) has identified five essential conditions for a healthy life:
- Health services
- Income security and social protection
- Living conditions
- Social and Human capital
- Employment and working conditions
The WHO Health Equity Policy Tool (2019) links these five essential conditions for a healthy life to policy areas where there is strong evidence for action. The Tool accompanies the WHO Health Equity Status Report (HESRi 2019). It was developed to support countries in efforts to monitor, take and strengthen policy action in these areas, and to reduce health inequalities.
These five areas are exactly those that are covered by the European Pillar of Social Rights (EPSR). The ‘Social Pillar’ is a commitment from Member States to address social challenges in their systems and guarantee a minimum set of social rights. Importantly, the 'Social Scoreboard' monitors EU Member States' progress. It indicates where countries must invest to reduce or prevent health inequalities.
The European Commission plans to integrate the EPSR into the European Semester process, the EU’s annual cycle of economic and social policy coordination. Naturally, this reflects a significant opportunity to address health inequalities in a holistic way.
Are you looking for more information on EU policy action?
The page on European Institutions explains each body's role in addressing health equity.
Looking for more information on EU action on health equity? Our EU Action section explains the European Semester, The European Pillar of Social rights, as well as Joint Actions and initiatives on Health Inequalities
Key principles and factors
Factors like policy coherence, accountability and participation are also very important to drive health equity. To ensure these factors are in place in turn depends on strong approaches to monitoring health inequalities and evaluating actions to address them.
New approaches to financing across sectors can help to optimise the allocation of existing resources and their impact on reducing health inequalities1Financing across sectors for sustainable development, UNDP, 2019. In addition, evidence and recommendations have started to emerge on how to create ‘political will’ for action on health equity, since many acknowledge that ‘Health is a political choice’.
The principle of proportionate universalism means resourcing and delivering universal services at a scale and intensity proportionate to the degree of need. It has been proposed as a solution to reduce health inequalities. While the principle is attractive in theory, it is seldom implemented in practice.2Francis-Oliviero, F., Cambon, L., Wittwer, J., Marmot, M., Alla Francois. Theoretical and practical challenges of proportionate universalism: a review Rev Panam Salud Publica. 2020; 44: e110.
It is more common to apply a combination of universal and targeted measures to reduce health inequalities.
For example, universal measures such as regulatory and marketing measures can help to reduce health inequalities by making essential commodities like water, sanitation services and energy available to everyone. Measures like tobacco bans, or food reformulation policies to reduce salt or sugar levels can also make it easier for people to make healthy choices.
At the same time, targeted actions are also needed to ensure people in more disadvantaged situations have access to the essential conditions for a healthy life. Such measures can include for example non-stigmatising approaches which ensure children from low-income families receive a healthy and nutritious meal at school, or subsidised housing for those on low income.
Health in All Policies
The health sector cannot reduce health inequalities on its own. However, it can take the lead in highlighting the importance of the issue. The public health sector can also ensure that monitoring and public reporting systems are in place to drive political and public concern.
To reduce health inequalities, health professionals should also take a ‘Health in all Policies’ approach. This means working with other sectors to encourage and enable them to play their role in addressing this challenge. The public health sector should ensure that others consider how their policies and actions impact different groups of people as well.
Examples of Health in All Policies in action
The Dutch National Heath Policy (2020-2024) encourages health professionals to look beyond their own areas of expertise to identify how to achieve the most health gains. It has an explicit ambition to reduce health inequalities, by addressing the determinants of health. For example, the Ministry of Health supports the ‘Healthy In’ Programme that is active in 150 municipalities across the Netherlands and brings together a wide range of stakeholders. It aims to stimulate and strengthen local approaches to reducing health inequalities, by encouraging participation, considering people’s behaviours and abilities, and addressing the physical and the social environment as well as prevention and care issues.
In Finland, multi-sectoral ‘health and well-being’ groups at different levels of government have been given the statutory task of processing and considering information on socio-economic differences in health. On the basis of that information, they engage in cross-sectoral cooperation in health. Finland, a front-runner in this field, is leading work on Health in all Policies for the EU Joint Action on Health Inequalities (JAHEE) and investigating how the approach is being implemented in two municipalities in Finland, as well as others across the EU. Some Finish municipalities and other JAHEE partners are also exploring how to measure health inequalities at the local level, to determine the best courses of action.
COVID-19 and health inequalities policy
COVID-19 is not just a pandemic, it is a syndemic. That is to say that it interacts with and exacerbates existing social inequalities in chronic disease and the social determinants of health. It has made existing social, economic and political inequalities more apparent to all.
Policies are needed to support those groups that were already struggling, and whose situation has deteriorated further due to the primary and secondary impacts of the disease. These include:
- children in low income or otherwise vulnerable families
- older people
- people in low-paid caring or other essential service professions
- platform workers
- women juggling work and (unpaid) care duties
- those with mental health problems.
Funds are being invested and policy measures taken to ‘build back better’. Those measures must address the underlying structures causing the inequities affecting such groups. This is essential to avoid a further widening of already persistent health gaps, and the additional damage to individual and social capital.
Examples of work on policy and COVID-19
The report Build Back Fairer: The Covid-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England (2020 ) examines inequality in COVID-19 mortality. It also looks at the effects on social and inequalities of the pandemic and the societal responses to it, and makes recommendations.
Many governments, agencies and other stakeholders are exploring and taking the actions needed. The Finish Institute of Public Health (THL) is for example providing guidance on how municipalities can support health and well-being during the pandemic, which highlights what groups need special attention and what can be done.
The Ministry of Health in Spain has also issued a report on Health Equity and COVID-19: Analysis and proposals to tackle epidemiological vulnerability related to social inequities that focuses on social vulnerability, clinical vulnerability and additional epidemiological vulnerability and their inter-relation. The full report, and a summary are also available in Spanish.
Sustainable development and economies of wellbeing
Efforts to address health inequalities are an essential part of the urgent need for economies and societies, particularly highly industrialised ones, to become sustainable. The concept of sustainable development means more than simply achieving economic development without depleting natural resources. It also includes ensuring that this development benefits everyone. This is reflected in the 17 interconnected United Nations Sustainable Development Goals.
Our goal is to position health at the top of the political agenda within the Sustainable Development Goals, and to strengthen the resilience of health and social care systems
- Dr Hans Kluge, WHO Regional Director for Europe
Linked to the concept of ‘inclusive growth’ is that of ‘economies of well-being’. Economies of wellbeing emphasise investments in health, education, employment, gender equality and social protection. They aim to create more trust, civic engagement, and social cohesion in society. This is a sounder pathway to economic growth than the current focus on measures like Gross Domestic Product (GDP). This is partly because they can improve productivity, financial and political stability, and enhance resilience to adverse shocks. Working towards economies that emphasise well-being as an end-goal can contribute significantly to a reduction of health inequalities.
The Pan-European Commission on Health and Sustainable Development
The WHO Regional Office for Europe established the Pan-European Commission on Health and Sustainable Development. It is an independent and interdisciplinary group of leaders to rethink policy priorities in the light of pandemics. Its mandate is to draw lessons from the ways in which European countries' health systems have responded to the COVID-19 pandemic and make recommendations on investments and reforms to improve the resilience of health and social care systems. This should aid to elevate health and social care as societal and political priorities, which are critical to both sustainable development and social cohesion.
In March 2021 the Commission called on governments, economic and social stakeholders, and international organizations to rethink their broad policy priorities, to step up investments and reforms in health- and social-care systems, and to upgrade global governance of public goods, such as health and the environment. You can read more about the Commission's call on this link.
In September 2021 the Commission will publish a report with recommendations on investments and reforms to improve health and social care systems.
The EuroHealthNet Policy Platform
EuroHealthNet’s Policy Platform advocates for effective evidence-based policies and interventions to improve health and reduce inequalities. It identifies, informs about, and aims to influence EU level policies that can have an effect on health inequalities. Social and health systems are for the most part a competence of EU Member States. In recent years more people have become aware of the inter-relationship between health and social policies, economic outcomes, and the EU’s objective of improving people’s well-being.
There is potential for more EU action and influence in this area, for example through:
- An Action Plan to implement the European Pillar of Social Rights (a set of 20 principles and rights to support fair and well-functioning labour markets as well as social protection and inclusion). Learn more about it here.
- Plans following the COVID-19 pandemic to move towards a closer European Health Union. Learn more about it here.
EuroHealthNet will continue to advocate, enable, and mediate to strengthen awareness and action for health equity in EU level policies and programmes that influence the essential conditions for a healthy life for all.
The platform helps organisations understand and anticipate policy changes at the European level, and make their voices heard on the European stage.
To find out more about the work of the platform and about being part of the platform visit our website.