Proposal for the Joint Action on

Health Inequalities (and Migration)

Giuseppe Costa

on behalf of the Italian consortium of the Joint Action

lead by the National Institute of Health (ISS)

Comparison among the size of health inequalities and policies aimed at tackling them

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6

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15% 20% 25% 30% 35% 40% 45% 50% 55% 60%

Weight of health ineiqualities on total male mortality

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http://www.euro-gbd-se.eu/fileadmin/euro-gbd-se/public-files/EURO-GBD-SE_Final_report.pdf

% of mortality explained by educational inequalities

The impact of health inequalities and the performance in tackling them in 21 European populations during the 2000s

Adva

ncem

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of a

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redu

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Do better

Do more

Do some

Grafico1

0.24

0.3

0.31

0.32

0.32

0.34

0.34

0.35

0.35

0.37

0.39

0.44

0.45

0.49

0.54

0.54

0.57

Weight of health ineiqualities on total male mortality

Livello di avanzamento sviluppo politiche di contrasto

Comparison among the size of health inequalities and policies aimed at tackling them

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Foglio1

MF

SpainES24%1618%SpainES18%16

ItalyIT30%1115%ItalyIT15%12

NetherlandsNL31%1326%NetherlandsNL26%13

EnglandEng32%1929%EnglandEng29%19

SwedenSW32%1633%SwedenSW33%16

AustriaAT34%826%AustriaAT26%8

DenmarkDK34%1332%DenmarkDK32%13

BelgiumBE35%1529%BelgiumBE29%15

NorwayNO35%1732%NorwayNO32%17

FinlandFI37%1630%FinlandFI30%16

ScotlandSc39%1735%ScotlandSc35%17

LithuaniaLT44%1035%LithuaniaLT35%10

FranceFR45%1030%FranceFR30%10

EstoniaEE49%1241%EstoniaEE41%12

HungaryHU54%1132%HungaryHU32%11

PolandPL54%943%PolandPL43%9

Czech RepCZ57%750%Czech RepCZ50%7

0.391764705912.9411764706

SpainES24%1618%

ItalyIT30%1115%

NetherlandsNL31%1326%

EnglandEng32%1929%

SwedenSW32%1633%

AustriaAT34%826%

DenmarkDK34%1332%

BelgiumBE35%1529%

NorwayNO35%1732%

FinlandFI37%1630%

ScotlandSc39%1735%

FranceFR45%1030%

ES-15%3

IT-9%-2

NL-8%0

Eng-7%6

SW-7%3

AT-5%-5

DK-5%0

BE-4%2

NO-4%4

FI-2%3

Sc-0%4

LT5%-3

FR6%-3

EE10%-1

HU15%-2

PL15%-4

CZ18%-6

MF

ES24%1618%

IT30%1115%

NL31%1326%

Eng32%1929%

SW32%1633%

AT34%826%

DK34%1332%

BE35%1529%

NO35%1732%

FI37%1630%

Sc39%1735%

FR45%1030%

34%14.25

ES-10%2

IT-4%-3

NL-3%-1

Eng-2%5

SW-2%2

AT0%-6

DK0%-1

BE1%1

NO1%3

FI3%2

Sc5%3

FR11%-4

SpainES-29%12%

ItalyIT-12%-23%

NetherlandsNL-9%-9%

EnglandEng-6%33%

SwedenSW-6%12%

AustriaAT-0%-44%

DenmarkDK-0%-9%

BelgiumBE3%5%

NorwayNO3%19%

FinlandFI9%12%

ScotlandSc15%19%

FranceFR32%-30%

DONNE

SpainES18%16

ItalyIT15%11

NetherlandsNL26%13

EnglandEng29%19

SwedenSW33%16

AustriaAT26%8

DenmarkDK32%13

BelgiumBE29%15

NorwayNO32%17

FinlandFI30%16

ScotlandSc35%17

LithuaniaLT35%10

FranceFR30%10

EstoniaEE41%12

HungaryHU32%11

PolandPL43%9

Czech RepCZ50%7

Foglio1

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Foglio2

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Foglio3

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England1619

Wales1518

Scotland1417

Norway1517

Spain1316

Finland1416

Irlanda1416

Sweden1516

Belgium1215

Denmark1113

Germany1113

Netherlands1113

Italy912

Estonia1112

Hungary1011

Portugal710

France810

Lithuania910

Poland79

Latvia89

Austria78

Czech Rep57

ItalyIT15%11

SpainES18%16

NetherlandsNL26%13

AustriaAT26%8

EnglandEng29%19

BelgiumBE29%15

FinlandFI30%16

FranceFR30%10

DenmarkDK32%13

NorwayNO32%17

HungaryHU32%11

SwedenSW33%16

ScotlandSc35%17

LithuaniaLT35%10

EstoniaEE41%12

PolandPL43%9

Czech RepCZ50%7

ItalyIT15%11

SpainES18%16

NetherlandsNL26%13

AustriaAT26%8

EnglandEng29%19

BelgiumBE29%15

FinlandFI30%16

FranceFR30%10

DenmarkDK32%13

NorwayNO32%17

SwedenSW33%16

ScotlandSc35%17

0.18

0.15

0.26

0.29

0.33

0.26

0.32

0.29

0.32

0.3

0.35

0.35

0.3

0.41

0.32

0.43

0.5

ES

IT

NL

Eng

SW

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DK

BE

NO

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FR

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PL

CZ

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Background

• Persisting health inequalities (between and within countries)

• New challenges (recession and migration…)• Available evidence on (distal and proximal)

mechanisms and their avoidability• Wide gap in Europe in terms of political response

Background • The new Joint Action: joint effort of EC and MSs

(resources, tool, expertise) (existing alliances and partnerships: global work, SDG, EU pillar of social rights…)

• Bringing together the available knowledge on what works and what does not to address both the distal (socio-economic) and proximal (lifestyle) determinants (even knowledge gaps)

• MS need to make an analysis of their capacity in tackling health inequalities, which the gaps are and what further action can be taken

• JA flexibly designed to enable MS with strong expertise in a specific area to support weaker MSthat have chosen to work on that same topic

Aims

• help halting or moderating the rise of health inequalities in Europe (relative everywhere and absolute in the Eastern regions)

• encouraging decision makers to make the issue of health inequalities a priority in the public agenda

• implementing concrete local/national actions through practical guidance/examples for more experienced MSs

Needs for assistance (and how substantive WP will contribute)

• Its not our concern (evidence, description)• We don’t know what to do (evidence, links)• We don’t know how to do it (delivery, networks)• We don’t want to (levers, incentives, regulations)• We really don’t want to (ideology, no pressure)• We cant afford to (cost efficacy, cross sectoral,

prevention and other things matter more)

Target groups • improving the health of those that are worse or

worst off at a faster rate than those who already have better health

• a combination of universal and targeted measures (proportionate universalism)

• that meets proportionally with greater intensity the growing needs of vulnerable groups (children in poverty, rural areas, phys/mental disabled, unemployed, in-work poor, older, victim of violence, homeless, prisoners)

• a specific focus on migrants

Deliverables and desired outcomes

• Policy framework for Action on reducing Health Inequalities in EU and Member States.

• Country assessments and country specific recommendations to reduce health inequalities in the participating Member States

• Report with learning from case studies on actions to tackle health inequalities and on actions overcoming challenges for health equity – reports per WP and one final summary report

• Material useful to policy makers and politicians and stakeholders, such as effective policy briefs, info-graphics, video’s and communication of evidence from EU to local levels, in all EU languages

Title and WP leader (Co-leaders to be decided)Red mandatory Green substantive

1 Coordination ITALY (National Inst. Health)

2 Dissemination EUROHEALTHNET (TBC)

3 Evaluation WP LEADER TO BE DECIDED

4 Integration and sustainability ITALY (TBC)

4 Health and Equity in All Policies – Governance FINLAND (National Inst Health)

5 Monitoring SWEDEN (Public Health Ag.)

6 Healthy Living Environments GERMANY (Health promotion)

7 Migration and health NORWAY (Centre for Migrat)

8 Improving equality in access to health services SPAIN (TBC)

WP1-4General country assessmentPolicy framework for actions

WP4-8 Specific policy framework

Specific menu of EB actions Specific country assessment Choice of actions to prioritize

Implementation: feasible/complex

Clustering actions/countriesfor substantive WPs

Lessons learned and recommendations

A preliminary country assessment : actions and WP

Actions

0%10%20%30%40%50%

Governance Monitoring Living Migrants Health care Healthaccess

Countries A Countries B Countries C Countries DComprehensive

cross government

Public health and Isolated cross-

governmentHealth sector

direct

Health sectorindirect

Grafico1

GovernanceGovernanceGovernanceGovernance

MonitoringMonitoringMonitoringMonitoring

LivingLivingLivingLiving

MigrantsMigrantsMigrantsMigrants

Health careHealth careHealth careHealth care

Health accessHealth accessHealth accessHealth access

Countries A

Countries B

Countries C

Countries D

Actions

0.4025974026

0.3394495413

0.3760683761

0.3571428571

0.1428571429

0.1651376147

0.0427350427

0.0476190476

0.0779220779

0.1467889908

0.1196581197

0.119047619

0.038961039

0.0458715596

0.0598290598

0.0476190476

0.1428571429

0.2752293578

0.2905982906

0.3333333333

0.1948051948

0.0275229358

0.1111111111

0.0952380952

Risultati

1. Paesi per numero di azioni censite (divise in azioni su disuguaglianze e azioni in genere su salute), numero di bisogni di salute censiti (somma delle voci 1.3 challenges, 3.3 Gaps in evidence regarding Health inequalities at Member State level e 3.4 N

CountriesRankingActionsNeedsTotal

HIHealthAll

FinlandA180181331

GermanyA13013821

NorwayA729615

SwedenA16622628

BelgiumB10010717

EstoniaB34649655

ItalyB23023831

CroatiaC81220626

CyprusC444481159

Czech RepublicC61420727

HungaryC13417522

BulgariaD4711415

PolandD30347

RomaniaD437310

SlovakiaD628614

2. Paesi, divisi in cluster, secondo colonna B di tabella 1, per numero di azioni censite (divise in azioni su disuguaglianze e azioni in genere su salute), numero di bisogni di salute censiti (somma delle voci 1.3 challenges, 3.3 Gaps in evidence regardi

CountriesRankingActionsNeedsTotal% HI on actions% actions% needs

HIHealthAll

Countries A54862339587.1%65.3%34.7%

Countries B3646822110343.9%79.6%20.4%

Countries C31741052913429.5%78.4%21.6%

Countries D171229174658.6%63.0%37.0%

3. Paesi, divisi in cluster, secondo colonna B di tabella 1, per tipologia di voci di azione (c'è da considerare che molti Paesi inserivano la stessa policy/azione più volte nel template, ma noi l'abbiamo considerata solo una volta, all'interno della voic

CountriesCountries

VoiceABCDTotale%A%B%C%D

1.2 Health Inequalities Policy161636117924.6%19.5%35.0%37.9%

1.5 Health in all Policies approach for reducing health inequalities601079.2%0.0%1.0%0.0%

1.6 Evaluation of health inequalities policies103041.5%0.0%2.9%0.0%

2.1 Key actions to reduce health inequalities10112424715.4%13.4%23.3%6.9%

2.2 Key actions to make access to health system more equitable39187374.6%11.0%17.5%24.1%

2.3 Key actions addressing social determinants514124357.7%17.1%11.7%13.8%

2.4 Key action to support vulnerable groups1521604223.1%25.6%5.8%0.0%

2.5 Evaluation of implementation activities7101910.8%1.2%0.0%3.4%

3.2 Good practices reducing health inequalities identified by competent authorities21034193.1%12.2%2.9%13.8%

658210329279100.0%100.0%100.0%100.0%

4. Azioni dei Paesi, divisi in cluster, per tipo di WP di riferimento

WP5WP6WP7WP8WP9WP9

GovernanceMonitoringLivingMigrantsHealth careHealth access

Countries A40.3%14.3%7.8%3.9%14.3%19.5%

Countries B33.9%16.5%14.7%4.6%27.5%2.8%

Countries C37.6%4.3%12.0%6.0%29.1%11.1%

Countries D35.7%4.8%11.9%4.8%33.3%9.5%

Totale36.8%10.4%11.9%4.9%25.8%3.0%

5. Bisogni dei Paesi, divisi in cluster, per tipo di WP di riferimento

GovernanceMonitoringLivingMigrantsHealth careHealth access

Countries A33.3%53.3%3.3%3.3%0.0%6.7%

Countries B40.7%29.6%11.1%7.4%7.4%3.7%

Countries C41.4%31.0%6.9%3.4%10.3%6.9%

Countries D41.2%17.6%0.0%0.0%35.3%5.9%

38.8%35.0%5.8%3.9%10.7%3.0%

Risultati

Countries A

Countries B

Countries C

Countries D

Actions

Countries A

Countries B

Countries C

Countries D

Needs

Governance

Monitoring

Living

Migrants

Health care

Health access

Actions

Governance

Monitoring

Living

Migrants

Health care

Health access

Needs

A preliminary country assessment : challenges and WP

Needs

0%10%20%30%40%50%60%

Governance Monitoring Living Migrants Health care Healthaccess

Countries A Countries B Countries C Countries D

Grafico2

GovernanceGovernanceGovernanceGovernance

MonitoringMonitoringMonitoringMonitoring

LivingLivingLivingLiving

MigrantsMigrantsMigrantsMigrants

Health careHealth careHealth careHealth care

Health accessHealth accessHealth accessHealth access

Countries A

Countries B

Countries C

Countries D

Needs

0.3333333333

0.4074074074

0.4137931034

0.4117647059

0.5333333333

0.2962962963

0.3103448276

0.1764705882

0.0333333333

0.1111111111

0.0689655172

0

0.0333333333

0.0740740741

0.0344827586

0

0

0.0740740741

0.1034482759

0.3529411765

0.0666666667

0.037037037

0.0689655172

0.0588235294

Risultati

1. Paesi per numero di azioni censite (divise in azioni su disuguaglianze e azioni in genere su salute), numero di bisogni di salute censiti (somma delle voci 1.3 challenges, 3.3 Gaps in evidence regarding Health inequalities at Member State level e 3.4 N

CountriesRankingActionsNeedsTotal

HIHealthAll

FinlandA180181331

GermanyA13013821

NorwayA729615

SwedenA16622628

BelgiumB10010717

EstoniaB34649655

ItalyB23023831

CroatiaC81220626

CyprusC444481159

Czech RepublicC61420727

HungaryC13417522

BulgariaD4711415

PolandD30347

RomaniaD437310

SlovakiaD628614

2. Paesi, divisi in cluster, secondo colonna B di tabella 1, per numero di azioni censite (divise in azioni su disuguaglianze e azioni in genere su salute), numero di bisogni di salute censiti (somma delle voci 1.3 challenges, 3.3 Gaps in evidence regardi

CountriesRankingActionsNeedsTotal% HI on actions% actions% needs

HIHealthAll

Countries A54862339587.1%65.3%34.7%

Countries B3646822110343.9%79.6%20.4%

Countries C31741052913429.5%78.4%21.6%

Countries D171229174658.6%63.0%37.0%

3. Paesi, divisi in cluster, secondo colonna B di tabella 1, per tipologia di voci di azione (c'è da considerare che molti Paesi inserivano la stessa policy/azione più volte nel template, ma noi l'abbiamo considerata solo una volta, all'interno della voic

CountriesCountries

VoiceABCDTotale%A%B%C%D

1.2 Health Inequalities Policy161636117924.6%19.5%35.0%37.9%

1.5 Health in all Policies approach for reducing health inequalities601079.2%0.0%1.0%0.0%

1.6 Evaluation of health inequalities policies103041.5%0.0%2.9%0.0%

2.1 Key actions to reduce health inequalities10112424715.4%13.4%23.3%6.9%

2.2 Key actions to make access to health system more equitable39187374.6%11.0%17.5%24.1%

2.3 Key actions addressing social determinants514124357.7%17.1%11.7%13.8%

2.4 Key action to support vulnerable groups1521604223.1%25.6%5.8%0.0%

2.5 Evaluation of implementation activities7101910.8%1.2%0.0%3.4%

3.2 Good practices reducing health inequalities identified by competent authorities21034193.1%12.2%2.9%13.8%

658210329279100.0%100.0%100.0%100.0%

4. Azioni dei Paesi, divisi in cluster, per tipo di WP di riferimento

WP5WP6WP7WP8WP9WP9

GovernanceMonitoringLivingMigrantsHealth careHealth access

Countries A40.3%14.3%7.8%3.9%14.3%19.5%

Countries B33.9%16.5%14.7%4.6%27.5%2.8%

Countries C37.6%4.3%12.0%6.0%29.1%11.1%

Countries D35.7%4.8%11.9%4.8%33.3%9.5%

Totale36.8%10.4%11.9%4.9%25.8%3.0%

5. Bisogni dei Paesi, divisi in cluster, per tipo di WP di riferimento

GovernanceMonitoringLivingMigrantsHealth careHealth access

Countries A33.3%53.3%3.3%3.3%0.0%6.7%

Countries B40.7%29.6%11.1%7.4%7.4%3.7%

Countries C41.4%31.0%6.9%3.4%10.3%6.9%

Countries D41.2%17.6%0.0%0.0%35.3%5.9%

38.8%35.0%5.8%3.9%10.7%3.0%

Risultati

Countries A

Countries B

Countries C

Countries D

Actions

Countries A

Countries B

Countries C

Countries D

Needs

Governance

Monitoring

Living

Migrants

Health care

Health access

Actions

Governance

Monitoring

Living

Migrants

Health care

Health access

Needs

28 Countries Organisation's Full Name (red: ministerial body; grey: public health institute, green: regions)

Belgium Federal Public Service Health, Food Chain Safety and Environment

Bosnia and Herzegovina

Ministry of Civil Affairs of Bosnia and Herzegovina

Bulgaria National Center of Public Health and Analyses Croatia Croatian Institute of Public Health Cyprus Ministry of health Czech Republic The National Institute of Public Health Denmark Bridge to Better Health - Region Zealand

Estonia The National Institute for Health Development Finland National Institute for Health and Welfare France Santé Publique France Germany Bundeszentrale für gesundheitliche Aufklaerung / Federal

Centre for Health Education Greece 6th health region of Peloponnese, Ionian Islands, Epirus and

Western GreeceItaly The National Health Institute

28 Countries Organisation's Full Name (red: ministerial body; grey: public health institute, green: regions)

Latvia The National Health ServiceLithuania Sveikatos apsaugos ministerijaMalta Department Health Information and Research Moldova Institute of Mother and Child Netherlands Dutch Ministry of Health, Welfare and Sport Norway The Norwegian Centre for Migration and Minority Health Poland Ministry of HealthPortugal Directorate-General of Health Romania National school of public health, management and professional

developmentSerbia Institute of Public Health of Republic of Serbia "Dr Milan

Jovanović Batut"Slovakia Ministry of Health of the Slovak republicSlovenia National Institute of Public Health of the Republic of Slovenia Spain Escuela Andaluza de Salud PúblicaSweden Folkhälsomyndigheten, The Public Health Agency of Sweden United Kingdom Welsh Government

Preliminary exercise of country assessment

for helping WP leaders in clustering actions issues and countries for priority setting EU

COUNTRIES ACCORDING TO THEIR ADVANCEMENT IN TACKLING HEALTH INEQUALITIES AS REPORTED IN SOME COUNTRY ASSESSMENTS AVAILABLE

IN THE EU EXPERT GROUP WORK (2015-16)

7 June, 2017

Action/country clusters for WP4 governance• Cooperation and participation enabling HI to be raised in

public agenda (stakeholder, supportive culture, comunication, leadership): – bottom up (Italy, Finland), – top down (Croatia), – advocacy (Cyprus), from health professional (Italy, UK)– policy framework: creating and sharing (Croatia, Cyprus, Slovakia)– intervention networks and communities of practice (Austria, Germany,

Italy)• How to keep HI in the agenda (accountability…):

– Role of health targeting and evaluation (Austria)– Role of legal duty for ensuring equity in essential level of care in NHS

(Italy)– structural funds at regional level (Bulgaria)

• Decentralization to local authorities and communities (Finland, Estonia, Sweeden, Italy, Netherlands)

• Capacity building– availability and dissemination of best practices (Hungary)– how to put HiAP in practice (Estonia)– Governance processes (Cyprus)

Action/country clusters for WP5 monitoring• Preliminary essential equity monitoring (Bulgaria, Cyprus,

Poland, Slovakia) • Profiling health inequalities (Croatia, Poland)

• Integrating social and health data in health information systems for equity audit at any level (Austria, Italy, Estonia)

• Best indicators: evaluation (Germany, Italy), unexplored health determinants (Ireland, Italy), material deprivation (Netherlands)

• Developing longitudinal studies for impact evaluation (Austria, Italy)

• HEIA tools: quality criteria for project funding (Austria), in practice (Cyprus, France)

• Knowledge gaps: a) evidence for effectiveness of actions and policies in the area of health systems and welfare (Norway, Finland, Sweedish commission?), b) assessing impact of actions on HI (relative, absolute…) (Belgium, Italy)

Action/country clusters for WP6 living conditions• Health equity audit in

– Housing for vulnerable: housing first (Belgium) (Norway)– School setting: whole of school (Hungary, Italy), school meals (Czech)– Workplace: workability and HP (Estonia, Italy), role of occupational safety (Italy)– GP setting HP (Italy)– Early life HP (Italy)– Environmental justice (Italy)– Obesity (Italy, UK, Ireland)– Mental health HP (Hungary, Italy, Denmark)

• HP among vulnerables– Excluded areas HP(Czech)– Hard to reach: men violence, HIV, sexual health (Sweeden)– Disabled HP (Czech, Estonia)

• Capacity building – Evidence on good practices: HP in general (Estonia), care, work, housing, living

conditions (Norway, Finland, Ireland)– Training health equity audit in HP (Spain)

• Knowledge gaps: a) lone parenthood and children (Czech), b) southern resilience to inequalities in nutrition, alcool.. (Italy), c) interaction of income education and work with proximal risk factors and implication for actions (Sweeden) d) good practice in EU facilitating collaboration on structural funds and social policies

Action/country clusters for WP7 immigration

• Health literacy in front of health care access and health promotion (Austria, Norway, Italy, Portugal)

• Health mediators (Belgium, Bulgaria, Romania, Italy)• Health examination guidelines for refugees , and training

for professionals and frontline workers (Croatia, Greece, Sweeden)

Action/country clusters for WP8 universal access to care for vulnerables

• Targeting vulnerable groups – tailor made in: dementia, cancer, nutrition, earlylife (Austria), rare

diseases (Croatia), pregnancy (Belgium), diabetes, cancer screening, mental health, occupational injuries (Italy)

– Affordability and inclusion in: sex workers, prisoners … (Belgium, Croatia, Cyprus), ethnic minorities (Bulgaria), disabled, victim of violence, Roma, (Croatia) (Denmark)

– Health literacy in health care access (Austria)

• Targeting remote areas (Italy)

• NHS reform: – coverage (Estonia) (France, Portugal)– capitation in allocation formula (Italy)– Equal access to GP (Denmark)– Use of structural funds (Slovenia)

• Knowledge gaps: a) cost effectiveness of actions on health literacy (Austria), b) EB actions on unemployment and precarious jobs(Belgium) and on income and education and work and interaction with proximal factors (Sweeden)

Agenda Type Evaluation TargetDeaths

attributable to education

Countries

A High

Comprehensive cross-

government strategies

HighSocial

gradient30-35% M

30% F

Finland ● Ireland ●Norway ● Sweden ●Austria ● Germany ●(UK)

B Medium/High

Public health and Isolated

Cross-government

Medium/HighMostly

vulnerable

25-30%M 15-25% F

a part FR/ES males 45%

Belgium ● Denmark Spain ●Netherlands ●Italy ● France ●Estonia

C Medium Health sector Low/medium VulnerableRegional

45-55% M35-45% F

but CY 20-30

Croatia ● Cyprus ●Czech ● Hungary

D Low Health sector direct/indirect

LowSociety as

whole45-55% M35-45% F

Poland ● Romania ●Slovakia

EU COUNTRIES ACCORDING TO THEIR ADVANCEMENT IN TACKLING HEALTH INEQUALITIES ACCORDING TO THE E.G. COUNTRY TEMPLATE (2015-16)

E Missing 20-50% M15-45% F

Latvia● Greece ●Portugal ● UK

Widening of policy response on HI between member states since EC Communication on

solidarity• Do some

– Greece: little (crisis)– Eastern and Baltic countries plus Turkey:

prevention programs on lifestyles, and vulnerable groups (roma)

– Slovenia: structural funds– Slovachia: NHS reform

Widening of policy response between member states since EC Communication on solidarity

• Do more– Germany: new prevention law – Italy: equity focus in national prevention plan

and legal duty in health protection– Sweeden: whole of government, municipalities– Austria: whole of government– France: national strategy, regional

responsibilities– Spain: systematic training program – Belgium: health in all policies, inclusion– Portugal: NHS reform, lifestyles, migrants

Widening of policy response on HI between member states since EC Communication on

solidarity• Do better

– Denmark: less visible– Netherlands: municipalities– Norvay: new strategy– Sweeden: new strategy, whole of governmewnt,

municipalities– Finland: health in all policies– UK: strategy still in place, targeting obesity and

child poverty– Ireland: strategy still in place, targeting tobacco,

nutrition and crisis

Needs for assistance and how

• Its not our concern (evidence, description)• We don’t know what to do (evidence, links)• We don’t know how to do it (delivery, networks)• We don’t want to – (levers, incentives, regulations)• We really don’t want to - ideology, no pressure

– so public pressure• We cant afford to – (cost efficacy, cross sectoral,

prevention and other things matter more)

How are other countries doing it….?

•as a matter of fairness and social justice

•as a human right

•for achieving Social Cohesion

•as an approach for managing / reducing social and economic costs

•as an approach to social and economic sustainability

•as an enabler of inclusive growth & development

1. Putting (health) Equity ‘on’ the Agenda

Chris Brown, 2016

Current European agendas supporting joint investment in health equity

• Inclusive Growth agendasEU Targets– Poverty Reduction – Participation of Older People in the Workforce – CAP Inclusive growth through education & employment– EU Social Investment Package

• Costs associated with preventable disease and Inequities • Well being & Resilience• Social Sustainability • WHO Health 2020 Policy Framework

Chris Brown, 2016

How do we make joint investments for equity in Health work in practice ?

2. Keeping (health) Equity ‘in’ Policies

A Question of Governance . . . .

Chris Brown, 2016

PARTICIPATIONACCOUNTABILITY

COOPERATIONJoint Responsibility Shared Benefits

Co Production

Chris Brown, 2016

Incentivizing cooperation across sectors and stakeholders

COOPERATION

Partnership Platforms Formal Intersectoral & Inter-ministerial Working Groups & Task Forces Slovenia, Estonia, Denmark, Finland,

Financial & reward systems linked to team resultsShared/ Pooled Budgets, common Performance Indicators. England, Spain, Norway,

Joint Review of policies and interventions ensure shared understanding of problems & solutions e.g. Impact Assessments, Cross Sectoral Spending Reviews Slovakia, Lithuania, Latvia, Scotland, EU OMC;

Chris Brown, 2016

Hold decision makers to account for health & equity results

ACCOUNTABILITY

Laws, MoUs, Contracts make responsibilities explicit & hold decision makers to account for results.

Guidance, Audit and Regulation support systematic action & remedy poor performance

Rewards & Incentives make pro health action the easy option.

Common Targets Health & Equity as key indicators

Systematic & Transparent Monitoring

use a mix of hard and soft instruments

Chris Brown, 2016

Diversity of voices in decision making and implementation

PARTICIPATION

Bottom Up Planning

Capacity Building for Communities to Participate

Public Reporting of actions and engagement in review of progress e.g citizens juries, community panels, social networks and media)

Chris Brown, 2016

Warnings for Lifepath (Exworthy, Health Policy&Planning, 2008)

• Features of SDHs making it resistant to policy translation– Multiple causes ~ coordination barrier– Life-course perspective ~ misfit policy timetables– Inter-sectoral collaboration ~ misfit “modus

operandi” – Complex causality ~ attribution problems– Conflicting priority– Globalization ~ multi-level stakeholders hampers

governance– Data availability

Warning to Lifepath: attribution matters in agenda setting

(Causal stories and the formation of policy agendas. Stone PSQ, 1989)

“Complex causal explanations are not very useful in politics, precisely because they do not offer a single locus of control” (ibid pp289)

“Complex cause is sometimes used as a strategy to avoid blames and the burden of reform” (ibid pp 292)

Attribution “to push a problem into the realm of human purpose” = scientific presentation of risk and causality?

Agenda Type Evaluation TargetDeaths

attributable to education

Countries

A High

Comprehensive cross-

government strategies

HighSocial

gradient30-35% M

30% F

Finland ● Ireland ●Norway ● Sweden ●Austria ● Germany ●(UK)

B Medium/High

Public health and Isolated

Cross-government

Medium/HighMostly

vulnerable

25-30%M 15-25% F

a part FR/ES males 45%

Belgium ● Denmark Spain ●Netherlands ●Italy ● France ●Estonia

C Medium Health sector Low/medium VulnerableRegional

45-55% M35-45% F

but CY 20-30

Croatia ● Cyprus ●Czech ● Hungary

D Low Health sector direct/indirect

LowSociety as

whole45-55% M35-45% F

Poland ● Romania ●Slovakia

EU COUNTRIES ACCORDING TO THEIR ADVANCEMENT IN TACKLING HEALTH INEQUALITIES ACCORDING TO THE E.G. COUNTRY TEMPLATE (2015-16)

E Missing 20-50% M15-45% F

Latvia● Greece ●Portugal ● UK

Bildnummer 1Bildnummer 2Background Background Aims Needs for assistance (and how substantive WP will contribute) Target groups Deliverables and desired outcomes Bildnummer 9Bildnummer 10A preliminary country assessment : actions and WPA preliminary country assessment : challenges and WPBildnummer 13Bildnummer 14Bildnummer 15Action/country clusters for WP4 governanceAction/country clusters for WP5 monitoringAction/country clusters for WP6 living conditionsAction/country clusters for WP7 immigrationAction/country clusters for WP8 universal access to care for vulnerablesBildnummer 21Bildnummer 22Bildnummer 23Widening of policy response on HI between member states since EC Communication on solidarityWidening of policy response between member states since EC Communication on solidarityWidening of policy response on HI between member states since EC Communication on solidarityNeeds for assistance and how Bildnummer 28Bildnummer 29Bildnummer 30Bildnummer 31Incentivizing cooperation across sectors and stakeholders Hold decision makers to account for health & equity results Diversity of voices in decision making and implementation Warnings for Lifepath �(Exworthy, Health Policy&Planning, 2008)Warning to Lifepath: attribution matters in agenda setting�(Causal stories and the formation of policy agendas. Stone PSQ, 1989)Bildnummer 37