Health inequalities and public health in Finland

1. Health inequalities and public health in Finland Seppo Koskinen and Eila Linnanmäki Berlin, 8 May 2009

2. Contents 1. Background 1.1. Wide health disparities in Finland 1.2. Advantages and challenges in addressing health inequalities in Finland 2. Rationale: Why should health inequalities be reduced? 3. Aims 2.1. Monitoring 2.2. Explore determinants 2.3. Develop means to tackle disparities • National Action Plan to Reduce Health Inequalities 2008–11 • Conclusion: Health inequalities can be reduced

3. 1.1. Background:- wide health disparities in Finland • Gender: women live 7 years longer than men • Region: residents of the west coast and Åland live 2–4 years longer than persons living in the northeastern regions • Marital status / living arrangements: one third of all deaths in the working-aged population would be avoided if mortality of the non-married could be reduced to the level achieved by the married • Ethnicity: very little information on health of immigrants • SOCIOECONOMIC POSITION: Persons with high level of education, working in white-collar occupations and enjoying a good income have better health and functional capacity and live longer than persons with a low level of education, those working in blue-collar occupations and having a small income

4. Striking differences in life expectancy between occupational classes Life expectancy of a 35-year-old in 1981-2000 in Finland Difference in life expectancy 3.2 yrs Difference 2.2 years Difference 6.0 years Difference 4.7 years Higher non-manual Lower non-manual Farmer Manual Source: Valkonen et al. 2003

5. Difference in remaining life years of a 35-year-old between high and low level of education • A Finnish 35-year-old man can expect to reach the age of 80 years if he has completed a university degree but only the age of 74 years if he has not completed any degree beyond the basic education How much longer does a 35-year-old person with tertiary level of education live compared with a person with no more than basic education • Since the 1980s this difference has increased from 4.7 to 6.2 years in favour for men with high education Men Years Women 6.2 years 4.7 years 3.6 years • In women the corresponding difference has increased from 2.7 to 3.6 years 2.7 years Year Source: Valkonen T et al. 2007

6. Mortality increases continuously as income diminishes Mortality of men aged 30 or over in the lowest income decile is 2.4 times higher than in the highest decile, among women the difference is 1.7-fold Women Men Highest Lowest Source: Martikainen P. et al. Int J Epid 2001;30:1397-1405

7. Self-rated health is also strongly associated with socioeconomic position Self-rated health average or worse,18–29-years-olds by level of education (p<0,001) (p=0,002) Upper Lower Secon- Basic tertiary tertiary dary Upper Lower Secon- Basic tertiary tertiary dary Source: Martelin et al. 2005

8. 16 % Higher 14 Secondary Basic 12 10 8 6 4 2 0 Women Men Wide inequalities in functional capacity according to level of education For instance moving difficulties are more common among those with lower education Below is the proportion (%) of those experiencing difficulties in walking 500 m by education among those aged 30 and over. Source: Martelin et al. 2004

9. 1.2. Good basis for addressing the social determinants of health inequalities in Finland (1) • Great improvements achieved in population health • Health and equity are highly valued by Finnish authorities as well as by citizens • Reducing health inequalities is a stated national policy goal, addressed in all health policy documents • National Action Plan 2008-2011 (Ministry of Social Affairs and Health 2008) • Growing awareness and activity around health inequalities in municipalities and regions

10. Good basis for addressing the social determinants of health inequalities in Finland (2) • Excellent research and knowledge base: • e.g. Palosuo H, Koskinen S, Lahelma E et al. Health inequalities in Finland: Time trends in socioeconomic health differences 1980-2005. MSAH 2009:9 • Registers covering living conditions, mortality, use of services and benefits (analysed e.g. by Valkonen et al., Keskimäki et al.) • Health (examination) surveys, e.g. AVTK, FINRISKI, Health 2000, Helsinki Health Study (analysed by e.g. THL research groups, Lahelma et al.) • New possibilities • Immigrant health study • Regional surveys on health and welfare (ATH) • Growing use of combinations of survey and register data

11. Challenges in addressing the social determinants of health inequalities (1) • Social determinants of health show unfavourable development • high unemployment after the recession in 1991-1993,recently rapid negative development due to current recession • increase in income differences and relative poverty rate • cuts in social welfare benefits were made in the 1990s that have not been fully returned

12. Challenges in addressing the social determinants of health inequalities (2) • Recession health promotion and tackling health inequalities are not seen as priorities, already signs of plans to cut resources to health promotion and preventive health services in municipalities • Interests of economic life and other sectors may contradict those of health sector • Abundance of ongoing short-term programmes and projects within various policy sectors • Long-term development and prioritization difficult in this jungle of projects and programmes • The Action Plan comprises suggestions for action but does not oblige actors

13. Challenges in addressing the social determinants of health inequalities (2) easy availability and low prices ofalcoholincrease alcohol consumption and the related harms particularly in the underprivileged groups disparities insmokingcontinue to increase inequalities in health and its determinants tend to be steepest among the young adults = tomorrow’s middle-aged and elderly people the new effectivemedical technology is not likely to be similarly available for everyone due to limited resources 13

14. 2. Why should inequalities in health be reduced? (1) • Inequalities in health are not inevitable, and therefore, not acceptable ethically • Health inequalities present a major problem for any modern welfare state committed to values of equality • Public health will improve more effectively when the health of the (large) groups with accumulating problems is promoted • If health of other population groups could be raised to the same level as those who are in the best position, the nation as a whole would be in significantly better health

15. 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 (%) of cases avoided 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 15

16. Why should inequalities in health be reduced? (2) • 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 population ages • Poor health is a factor in social exclusion • Health inequalities have negative economic effects

17. 3. AIMS 3.1. Monitoring: national and regional level • Making health inequalities and their time trends visible • Providing information needed for decision making: targeting activities according to need • Evaluation of the effects of efforts to reduce health inequalities • Promoting research into causes and ways to reduce health inequalities • Production of up-to-date information by socioeconomic position on • different dimensions of health and functional capacity across age groups • living and working conditions and behavioral factors affecting health • need for care • coverage, contents and effects of treatment and prevention of diseases as well as health promotion and health-related social security • attempts to reduce health inequalities and the effects of these attempts

18. Proposals to improve monitoring in the national action plan Up-to-date information on level of education and occupation (and on other relevant social factors when feasible) to be linked from the registers of Statistics Finland to • other registers used in health monitoring, annually • surveys used for health monitoring, at the stage when the sample is drawn • client information systems of the health sector, annually Socioeconomic position and living arrangements to be included as routine background variables in health monitoring reports, in addition to the generally used age, gender and region

19. 3. AIMS 3.2. Explore determinants of health disparities and their trends • Prerequisite for developing means to act on health disparities

20. Pathways from socioeconomic position to health • Education affects knowledge and values related with health and one’s occupational career • Occupation influences working and living conditions, shapes behaviour and affects income • Income and economic position influence e.g. housing conditions and possibilities to make healthy choices • Behavioural factors are important in the generation of health inequalities • excessive alcohol use (accounts for ¼ of mortality differences in men) • smoking (accounts for another ¼ of mortality differences in men) • diet • lack of exercise • High socioeconomic position improves the knowledge and economic prerequisites – as well as motivation – to choose healthy behaviour patterns • Behavioural choices are influenced by e.g. economic possibilities, values, norms, fashion and marketing • Factors operating during all phases of the life course affect health inequalities }→ obesity and consequent health problems

21. % 60 Men Women 50 40 30 20 10 0 Basic Secondary. Higher vocational educ Higher Basic Secondary Higher vocational educ. Higher educ. educ. university educ. educ. educ. university educ. Smoking in young adults Significant differences between educational groups in young adults’ smoking. Figure shows age-adjusted prevalence (%) of daily smoking among those aged 18–29 in different educational levels. Men Women Source: Martelin et al. 2005

22. Contribution of intermediary factors to educational differences in stair climbing in women aged 55+ (relative decline in excess risk*, %). Obesity and osteo-arthritis of the knee and hip are the most important factors contributing to educational mobility differences in women Source: Sainio et al. 2007

23. 3. AIMS 3.3. Develop means to tackle health disparities Level of action • Local and regional • National • International

24. Aim: more equal distribution of health When the aim is to improve health of the whole population, the greatest benefit is gained through advancing health of the less fortunate groups. Population’s health Target: more equal distribution of health Present state: inequalities in health are large Social status (education, income, etc.)

25. Tackling health inequalities in municipalities: lessons learnt in TEROKA (www.teroka.fi) joint projects • Close collaboration between research institutes, policymakers and professionals is needed • Cities, municipalities and regions differ from each other, there is no uniform way to operate • Information about health inequalities in the “own” population (municipal or regional, not only national) is needed to awaken decision-makers • Simple and adapted terminology is necessary • 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, not only in national plans, in order to legitimate and lead to actions • Effective intersectoral work is needed, health sector has an important role as an advocate • Decision makers need enough time (= several years) to understand, digest and start concrete actions

26. 4. National Action Plan to Reduce Health Inequalities 2008–2011

27. Planning and drafting the Action Plan Preparation initiated in April 2006 by the ministerial group for social policy issues of the previous Government Coordinated by the Advisory Board for Public Health appointed by the Government members from several admininstrative sectors, local government, health services, NGOs, professional organisations, research institutes Preparatory work carried out by the sub-committee for national cooperation of the Board Large number of experts from various organisations participated in drafting Linked closely with the Government Policy Programme for Health Promotion 27

28. General principles of the Action Plan Long-term objectives, but measures mostly for the present Government term Covers measures within other programmes and projects that have effects on health inequalities to add impetus to their work Health in all policies as a strategic approach Emphasis on both the whole social gradientand on vulnerable/marginalised minorities Universal services as well as measures targeted at the most disadvantaged Not necessarily new, separate structures and resources, but focusing and mainstreaming ongoing activities 28

29. Strategies of the programme • General social policy actions to reduce health inequalities and prevent social exclusion: • poverty, poor education, unemployment, homelessness • Influencing lifestyles through policy • Developing social welfare and health care services • Developing systems to monitor health inequalities • Strengthening the information base and communications

30. Measures of the Action Plan:General social policy actions to reduce health inequalities and prevent social exclusion • Promote the health and well-being of youth in vocational education • Making health promotion a permanent feature at the workplace, emphasis on fields and sectors with health risks and harmful lifestyles

31. Measures of the Action Plan:Influencing lifestyles through policy • Alcohol tax to be raised • Substance abuse prevention incorporated into the structures of health and well-being promotion in municipalities • Tobacco tax to be raised gradually Inclusion of tobacco and nicotine addiction withdrawal drugs in health insurance coverage • Availability of mass catering services that comply with nutritional recommendations, particularly at small workplaces • A Government resolution on health promoting nutrition and physical activity; adaquate excercise and healthy diet for the most socioeconomically disadvantaged

32. Measures of the Action Plan:Developing social welfare and health care services • Social and health care services to be developed and allocated on the basis of monitored health needs • Analysis of the allocation of rehabilitation services • Health services that support the working ability among the long-term unemployed on a permanent basis in the municipalities • Study on the health and service needs of the immigrants

33. Measures of the Action Plan:Developing systems to monitor health inequalities, strengthening the information base and communications • Development of the data on health inequalities of registers, surveys, statistics etc. • Development of separate assessments and population research • Research into health inequalities to be continued and strengthened • Distribution of data to municipalities and other local actors

34. 5. Conclusion: Health inequalities can be reduced • The magnitude of health inequalities varies markedly between societies and time periods → there is no natural law which inevitably leads to a certain level of inequality! • Positive examples of reducing health disparities between subgroups of the population in Finland: • reduction of health disparities between northeastern and southwestern Finland • Reduction / eradication of regional and socioeconomic differences in health among children →Health inequalities can be reduced, but achieving results requires determined intersectoral work