Is the EU Closing the Gap on Health Inequities?
The World Health Organization and European Union (EU) DETERMINE Consortium has acknowledged gaps in health equities within and between member countries. A variety of efforts are underway to help close those gaps.
To prepare for this Discussion, review your Learning Resources, particularly the readings from the DETERMINE Consortium and European Commission and the National Social Marketing Centre video programs. Select two EU countries on which to focus. (It is advised to select two countries from the list of EU members and avoid repeating the same ones mentioned in the required media of this week resources). Look at efforts in those countries designed to reduce health inequities and inequality and examine appropriate outcomes for those efforts. Evaluate the performance of the health systems in those countries as reflected in population health data for each of the countries. Be sure to access the CIA country profiles (found within the CIA World Factbook) and WHO websites provided earlier for the most current resources.
By Day 4
Post a brief comparison of the health status of the two EU countries you selected with that of the U.S. Then, describe two efforts in those EU countries to reduce health inequities. Explain what lessons can be learned from the EU efforts you selected that can be implemented in the U.S. nationally or by individual states. Explain how the community you live in might adapt these interventions. Expand on your insights utilizing the Learning Resources.
Use APA formatting for your Discussion and to cite your resources.
By Day 6
Respond to your colleagues’ postings. Provide a substantive reply to your colleagues in one or more of the following ways and expand on your insights utilizing the Learning Resources:
- Validate an idea with your own experience.
- Offer polite disagreement or critique, supported with evidence.
In addition, you may also respond as follows:
- Offer and support an opinion.
- Make a suggestion or comment that guides the discussion.
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2 days ago
RE: Discussion – Week 8
When looking at the European Union (EU), we see that health outcomes have a lot to do with political policies, rules, and regulations that govern a society (Laureate Education, 2011). For the purpose of this assignment, we will explore how health outcomes in Poland and Sweden are impacted by public health policies and programs.
Poland has only recently begun to place a strong emphasis on public health. Prior to 2015, little money was spent on public health programs in Poland, and they did not have a concrete definition of “public health” in the country until the 2015 Act on Public Health (Topor-Madry, Balwicki, Kowalska-Bobko & Wlodarczyk, 2018). In Poland, the infant mortality rate is 4.3 deaths/ 1000 live births, which is slightly lower than in the United States (Central Intelligence Agency, n.d.).After the passing of the 2015 Act on Public Health, the life expectancy in Poland has started to slowly increase; the infant mortality rate has started to decrease and, tobacco consumption among men has begun to decrease. Poland has also started to implement programs addressing HIV prevention and encouraging vaccines against preventable diseases (Topor-Madry, Balwicki, Kowalska-Bobko & Wlodarczyk, 2018). Overall, Poland’s total health expenditure is 6.5%, compared to 17.1% in the United States, yet, we see that they have significantly lower rates of maternal mortality (2/100,0000 live births vs. 19/100,000 live births, respectively), a lower infant mortality rate and a lower rate of obesity (23.1% vs. 36.2%) (Central Intelligence Agency, n.d.).
So, why is it that the United States ranks lower in important health indicators than a country that only started focusing on public health five years ago and spends a great deal less on health every year? An important factor to consider when comparing health outcomes between Poland and the United States is the issue of income inequality. Although Poland is significantly less wealthy than the United States, income inequality within a country is a much greater predictor of health status than overall wealth (Wilkinson & Pickett, 2010). Wealth inequality in Poland is lower when compared to other EU countries and significantly lower than in the United States (Brzezinski, 2017). When looking at these data, we can see that there is possibly an association between the income inequality and these differences in health outcomes. To properly address poor health outcomes, the United States needs to focus on the underly systematic issues that lead to these poor outcomes. When looking at our health expenditure, we see that simply throwing money at the problem is not going to work, if we do not address the root cause of the problem.
When looking at Public Health data for Sweden, most of their health outcomes are better than the United States. Sweden has a much lower maternal mortality rate (4/100000 live births vs. 19/100000 live births), a lower infant mortality rate (2.6/1000 vs. 5.3/1000 live births), and a lower rate of obesity (20.6% vs. 36.2%) (Central Intelligence Agency, n.d.). As with Poland, Sweden has a much lower health expenditure (10.9%) when compared to the United States (17.1%) (Central Intelligence Agency, n.d.).
Sweden fares particularly well in terms of child wellbeing (Wilkinson & Pickett, 2010), which is an essential component of a health society. It is critical that children are healthy and well because that can impact the society as a whole. The United States scores extremely low on the UNICEF child wellbeing scale, when compared to similar countries. In Sweden, the government provides a generous parental leave program, which can be delegated between both the mother and father. This program provides parents with 80% of their wages for the first 18 months, an additional three months can be taken at a set pay rate, and an additional three months can be taken on top of that, for a total of 24 months (Wilkinson & Pickett, 2010). The United States has a notoriously poor parental leave program, which does not allow for parents to spend an adequate amount of time with their children during the initial critical years of their lives. If the United States could take one thing away from Sweden, it should be the critical importance of proper parental leave programs. Transforming the parental leave programs in the United States could prove to have positive impacts on infant mortality rates, maternal health, and child wellbeing, which are all critical public health indicators.
Central Intelligence World Factbook. (n.d.). Europe: Poland. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/pl.html
Central Intelligence World Factbook. (n.d.). North America: United States. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/us.html
Laureate Education (Producer). 2011.Global Health and Issue s in Disease Prevention Multimedia file].Retrieved from https:// class. Waldene.edu
Topór-Mądry R, Balwicki Ł, Kowalska-Bobko I, et al. Poland. In: Rechel B, Maresso A, Sagan A, et al., editors. Organization and financing of public health services in Europe: Country reports [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2018. (Health Policy Series, No. 49.) 8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507318/
Wilkinson, R., & Pickett, K. (2010). The spirit level: Why greater equality makes societies stronger. New York, NY: Bloomsbury Press.
RE: Discussion – Week 8
European Union Health Status
The European Union (E.U.) currently consists of 27 unique nations, amongst which France and Austria have been member countries since 1958 and 1995, respectively. France is a semi-presidential republic with a permanent representation of the E.U. According to Eurostat, France has a population of about 67,012 883 million inhabitants as of January 1, 2020, with a gross domestic product (GDP) of per capita in purchasing power standards (PPS) of 104. France also has a life expectancy of 81.90 and an infant mortality rate of 3.20 (2017 estimate).
Austria is a federal parliamentary republic and also a permanent representative to E.U. According to statistics from Eurostat, Austria has a population of 8 858 775 million inhabitants as of January 1, 2020, with a GDP of per capita in PPS of 128, with a life expectancy of 80.80 and infant mortality rate of 3.40 (2017 est.).
The U.S. practices a federal system of government, with a life expectancy of 80.00, an infant mortality rate of 5.80 (2017 est.), and a population of 332,639,102 million people (July 2020 est.). The U.S. per capita GDP is $59,500 (CIA site redirect — Central Intelligence Agency, 0154).
Strategies to reduce inequalities in France and Austria
Europe, just like other regions of the world, has social inequalities that affect the health and wellbeing of the population (Saurel-Cubizolles et al., 2009). This is why members of the E.U. signed the WHO-Europe 1985 health declaration, which was aimed at reducing inter-countries health disparities by 25% by the year 2000. However, unfortunately, the various countries are still at different stages of implementation (Mackenbach & Bakker, 2003).
France had one of the highest premature mortality rates in Europe (Kunst et al., 2000). The strongest predictor of premature mortality and morbidity worldwide is low levels of socioeconomic status. In 1994, the high committee on public health focused its attention on the reduction of social inequalities to address the issue of premature mortality. But the 1998 law against exclusion was focused mainly on access to health care, even though it has been proven that health care has a limited role. This law’s main objective was to improve access to curative and preventive health care to needy citizens (Fourcade et al., 2004). This law led to the Universal Medical Coverage (UMC) in 2000, in which approximately five million people were covered (Boisguérin, 2005). Also, people of low socioeconomic status were exempted from co-payments. Even though the 1998 law against exclusion and 1999 health conference didn’t include social inequality (Lang et al., 2002), the scientific communities published documents which emphasized the importance of addressing social disparities to improve health outcomes, including premature mortality (Leclerc et al., 2000; Joubert et al., 2001). So, on August 9, 2004, a public health law was established that recognized social inequalities as a significant determinant in health outcomes. Hence, France instituted policies to reduce social disparities such as reduction of the financial burden to obtain insurance for those whose income was slightly above the minimum requirements for UMC, etc.
Austria has inequality in income and opportunity despite being ranked 8th and 10th in GDP per capita and income inequality index respectively amongst OCED countries (“GDP and spending – Gross domestic product (GDP) – OECD data,” 2019; “Inequality – Income inequality – OECD data,” 2019). In Austria, the top 20% of the population earns four times higher than the bottom 20%. About 1.5 million minorities living in Austria are poor and marginalized (Stavkova et al., 2012), majority of whom are women, immigrants, and unemployed people, etc. (Kessler, 2019).
But the Austrian government reduced its poverty and social exclusion risk below that of E.U. average to 18% from 2011 to 2016 (European Commission, 2018). Austria developed a comprehensive system that reduced social security and welfare to 14% (Statistics Austria, 2017), free social housing, public school system, and affordable transportation. The Austrian government spends more on health than most members of OECD, hence ensuring that all Austrian have access to quality health care (Bachner et al., 2018). Austrians also have access to the cleanest water in the world, and Austria was ranked as a high performer in the OECD Environmental Performance Review of 2013, even though they face ecological challenges (OECD, 2013).
Lessons for the U.S.
The goal of healthy people 2020 was to provide the highest quality of health to all people. Health equity can only be achieved if health disparities are eliminated. But, in the U.S. the current policy of achieving health equity has been focused solely on diseases and access to health care. There are many determinants of health, of which access to health care is even the least (McGinnis, 1993). The U.S. should focus more on improving the social determinants of health, such as socioeconomic, cultural, racial, and environmental, etc., especially on minorities and disadvantaged people. For instance, France, who enacted public health laws that established universal medical coverage, exempted people of low socioeconomic status from co-payments, etc. In Austria, all its citizens have access to high-quality education, nutritious food, quality, and safe housing, affordably reliable public transportation, culturally sensitive health care providers, affordable health insurance, clean water, non-polluted air, and safe neighborhoods, etc. These are examples worth emulating. These are proven methods, and that’s why they rank better than the U.S. in most of the measurable health outcomes.
Lessons for my community
I live in the Hamilton-county in Ohio, USA. In 2010-2012, both the county poverty rate of (16%) and the rate of children living in poverty (24%) were higher than those of the state, which were 15% and 21%, respectively. Living in poverty has an impact on the academic performances of students, and that’s why the average graduation rates of the schools in this county were less than 35% within that same time frame. The unemployment rate was 8.5%, and those uninsured was 11.5%. During this same period, 12% of the population didn’t have access to enough food. The infant mortality rate of 10% and life expectancy of 77.3%, were worse than the national average. (U.S. Census Bureau, 2014).
Apart from helping low-income earners and their families by providing them with supplemental nutrition assistance program (SNAP) and declaring racism a public health crisis, the county has not offered concrete solutions to the socio-economic inequalities facing the county. So, the county can also make plans, and implement inclusive policies for minorities, provide affordable free high public-schools. Tax reductions for individuals on low incomes, increase access to affordable social housing, provide free and reliable transportation for the disadvantaged people, and provide safe neighborhoods, etc.
There are health inequalities across Europe, and even though one of the objectives of the WHO-Europe 1985 health declaration was to reduce inter-country disparities by 25% by the years 2000, the various member states are still in different levels of implementation of the policies. But within the European Union, there are countries such as France, Austria, etc., that have realized that to achieve quality health and wellbeing of their population, the other determinants of health such as the socioeconomic, cultural, and environmental aspects of health, etc., needs to be addressed. Since these holistic methods are producing positive health outcomes in those nations, they are worth emulating in a country such as the U.S. and also in our local communities.
Bachner et al. (2018). Austria. Health system review, European Observatory on Health Systems and Policies. http://www.euro.who.int/__data/assets/pdf_file/0009/382167/hit-austria-eng.pdf?ua=1 (20.02.2019)
Boisguérin, B. (2005). “Les bénéficiaires de la CMU au 31 décembre 2003”, Etudes et Résultats (381).
CIA site redirect — Central Intelligence Agency. (0154). https://www.cia.gov/library/publications/the-word-factbook/rankorder/2102rank.html
European Commission, Monitoring report on progress towards the SDGs in an E.U. context (38). (2018). https://ec.europa.eu/eurostat/documents/3217494/9237449/KS-01-18-656-EN-N.pdf/2b2a096b-3bd6-4939-8ef3- 11cfc14b9329 (20.02.2019)
Fourcade, M., Jeske, V., Naves, P., & IGAS. (2004). “Synthèse des bilans de la loi d’orientation du 29 juillet 1998 relative à la lutte contre les exclusions”, Paris : La documentation française, rapport 2004 054.
GDP and spending – Gross domestic product (GDP) – OECD data. (2019, February 20). the OECD. https://data.oecd.org/gdp/gross-domestic-product-gdp.htm
Inequality – Income inequality – OECD data. (2019, February 20). the OECD. https://data.oecd.org/inequality/income-inequality.htm
Joubert et al, M. (2001). “Précarisation, risques et santé”, Collection Questions en santé publique’,. Paris : Editions de l’INSERM..
Kessler, R. (2019). Soziale Ungerechtigkeit und intervention Gottes. Theologie und Soziale Arbeit im Gespräch, 3-21. https://doi.org/10.1007/978-3-658-24213-8_1
Kunst, A. E., Groenhof, F., Mackenbach, j. P., & EU Working Group on Socioeconomic Inequalities in Health. (2000). “Inégalités socials de mortalité premature: La France comparée aux Autres pays européens,” in Leclerc A., Fassin D., Grandjean H., Kaminski M., Lang T., Les Inégalités Sociales de Santé, Paris: La Découverte/INSERM.
Lang, T., Fassin, D., Grandjean, H., Kaminski, M., & Leclerc, A. (2002). “France,” in Mackenbach J.P., Bakker M. (Eds), Reducing inequalities in Health: A European Perspective, Routledge.
Leclerc, A., Fassin, D., Grandjean, H., Kaminski, M., & Lang, T. (2000). “Les Inégalités Sociales de Santé”, Paris: La Découverte/INSERM.
McGinnis, J. M. (1993). Actual causes of death in the United States. JAMA: The Journal of the American Medical Association, 270(18), 2207. https://doi.org/10.1001/jama.1993.03510180077038
OECD. (2013). Environmental country review: Austria (13). http://read.oecd-ilibrary.org/environment/oecd-environmental- performance-reviews-austria-2013_9789264202924-en#page15 (20.02.2019)
Saurel-Cubizolles, M., Chastang, J., Menvielle, G., Leclerc, A., & Luce, D. (2009). Social inequalities in mortality by cause among men and women in France. Journal of Epidemiology & Community Health, 63(3), 197-202. https://doi.org/10.1136/jech.2008.078923
Statistics Austria, Armutsgefährdung vor und nach sozialen Transfers nach soziodemographischen Merkmalen (1). (2017). https://www.statistik.at/web_de/statistiken/menschen_und_gesellschaft/soziales/armut_und_soziale_eingliederung/index. html (20.02.2019)
Stavkova, J., Birciakova, N., & Turcinkova, J. (2012). Material deprivation in selected EU countries according to EU-SILC income statistics. Journal of Competitiveness, 4(2), 145-160. https://doi.org/10.7441/joc.2012.02.10
US Census Bureau. (2014, October 13). US census Bureau/American Factfinder, 2010-2012 America Community Survey. https://factfinder2.census.gov
RE: Discussion – Week 8
1. Post a brief comparison of the health status of the two EU countrys you selected with that of the U.S.
The United States – the world’s leading “economic … superpower” – is one of the wealthiest and most technologically advanced societies on earth (BBC, 2012), and yet, amongst the world’s developed nations, it is also strikingly anomalous its non-universal health insurance coverage (Teitelbaum & Wilensky, 2013) and its high level of income inequality (Wilkinson & Pickett, 2010).
Comparison of USA’s health outcomes in relation to other, European Union (EU) nations can help inform population health scholars how societies might intelligently seek out desirable states of population health. Two such nations (chosen arbitrarily, on account of my being the least familiar with them) are: 1) Slovakia and 2) Estonia.
A brief comparison follows (The World Bank, n.d.a; The World Bank, n.d.b ; HDRO, 2019; CIA World Factbook, n.d.).
USA has GDP per capita (in current international $ – PPP) of $65,280.70 and a Gini index of 41.4. It has a Life Expectancy at Birth (LEaB) of 78.9 years, an Infant Mortality Rate (IMR) (number of deaths of infants aged under one year, per year per 1,000 live births) 5.8 infant deaths, and Human Development Index (HDI) of 40.8. This set of observations paints for USA a profile of excellent relative wealth profile and of moderate relative health.
Slovakia (i.e., the Slovak Republic) has a GDP per capita of $34,178.00 and a Gini index of 25.2. Overall, this means that Slovakia is only about half as wealthy as USA but that its overall share of income is distributed almost twice as equally. Its LEaB is 77.4, its IMR is 5.1, and its HDI is 25.8. HDI notwithstanding, its general health profile seems comparable or nearly comparable to USA’s, despite its lower overall wealth.
Estonia (i.e., the Republic of Estonia) has a GDP per capita of $38,811.10 and a Gini of 30.4. This makes Estonia slightly more wealthy than Slovakia and also slightly more unequal in income, functioning as a kind of intermediate between Slovakia and USA on both counts. Its LEaB is 78.6, its IMR is 3.8, and its HDI is 36.0. This suggests perhaps a slightly superior health profile to that of USA’s.
Each of these EU countries has a universal public health insurance system, unlike USA (SSA, 2018a; SSA, 2018b).
2. Describe two efforts in those EU countries to reduce health inequitys.
To begin, the Estonian constitution “enshrines” a right among its people to universal health care (EC, 2018). However, the nation falls conspicuously short of realizing this ideal. As of 2017, the nation spends only 6.0% of GDP on health (among the lowest in OECD countries) (OECD, 2017a) and has the EU’s greatest health inequalities by income (OECD, 2017b). Unsurprisingly then, Estonia has one of the highest rates of unmet medical needs in the EU (Habicht et al., 2018).
Estonia’s recent Health Insurance Act marks one effort by the Estonian government to reduce health inequalities (Habicht, Habicht, & Ginneken, 2015). Estonia’s Estonian Health Insurance Fund (EHIF) is the governmental agency which buys up insurance policies, designed to then cover the entire population. This recent legislation’s four main changes to purchasing criteria include: 1) redefining access criteria to be based on population need rather than on historical supply, 2) more optimal work load criteria to increase specialist care, 3) greater consideration of patient movement, and 4) re-emphasizing quality (Habicht, Habicht, & Ginneken, 2015). If carried out well, this effort could mark the latest success in Estonia’s 20(+) years of slowly but surely improving population health outcomes and may help counties most in need, such as Ida-Viru (Lai & Leinsalu, 2015).
Like Estonia, the Slovakian government begins from the premise that all Slovak citizens have a right to health care (IOM, n.d.). Also like Estonia, Slovakia fails to deliver on this ideal, with noticeable systemic deficiencies that result in health inequity by ethnicity and by spatial distribution (IOM, n.d.).
One particular ethnic group – the Roma – is striking in its disproportionate share of poor health outcomes (IOM, n.d.). This is true of the Roma not only in Slovakia but indeed across much of Europe, with Roma having lower LEaB, higher IMRs, higher rates of infectious disease, and lower rates of vaccination uptake almost wherever in Europe they are found (e-RR, n.d.; EC, 2014).
The Roma (singular Rom, and informally called Gypsies) are a large, heterogeneous, traditionally itinerant ethnic group originating from northern India, now scattered throughout Europe (Encyclopaedia Britannica’s editors, 2020). Thus, the Roma’s presence in and comparatively poor health outcomes within the nation are by no means unique to Slovakia, but Slovakia has one governmental intervention formally aimed at addressing the Roma situation – a project called (or rather, translated as) “Healthy Communities” (Smatana et al., 2016). This is one of a few projects in Slovakia aimed at Slovakia’s 10% Roma minority (OECD, 2017c). The project, run now by Slovakia’s Ministry of Health, refers to disadvantaged groups as PPZZS (e.g., elderly persons, homeless persons, rural communities, etc.) and the Roma comprise it chiefly (WHO, n.d.; Smatana et al., 2016). The project reaches out to Roma communities in 239 locations, mostly around central and Eastern Slovakia, and it aims to promote preventive health care and health education (Smatana et al., 2016).
3. Explain what lessons can be learned from the EU efforts you selected that can be implemented in the U.S. nationally or by individual states.
Parts of Estonia’s Health Insurance Act are reminiscent of the United States’ Patient Protection and Affordable Care Act. In particular, the idea of restructuring reimbursement from more of a Fee-for-Service system to a Value-based seems familiar (Teitelbaum & Wilensky, 2013). The major difference, of course, is that in Estonia, the disadvantaged populations were already covered, in theory. The Estonian legislation is recent enough that long-term evaluation of its success is scarce, but, USA can take note of two things. First, USA should note that Estonia has far less wealth to spread around and spends far less of its budget on health care and yet has health outcomes that are nearly equal to USA’s. Regarding Estonia’s Health Insurance Act specifically, USA could also pay more attention to patient mobility. Since, in USA, many insurance programs are tied to one’s employer and/or to one’s recent residence in a given state, USA could do more to provide some safety net to persons in the midst of a transition either to a different job or to a different state.
Regarding Slovakia’s “Healthy Communities” Project, it’s difficult to say what, if anything, USA can learn. USA does not face the challenge of a 10% Roma population specifically, although it does have number of itinerant ethnic groups who sometimes have worse health outcomes than the average American and who can pose unique challenges in targeting for intervention. However, USA already provides stabilizing care in any of its Medicaid/Medicare-recipient emergency rooms, along with translation services, so emergency medical care for the indigent and/or marginalized ethnic groups is largely an already-met need. But, perhaps USA could do more in reaching out to certain communities to promote preventive care and uptake of vaccinations. After all, preventing people from needing to use the emergency room in the first place seems a more cost-effective stabilizing than ensuring stabilizing care once there.
4. Explain how the community you live in might adapt these interventions.
USA’s system leaves much discretion up to states and local governments. Here in Houston, TX, health officials might be able to find zip codes or neighborhoods with migrant ethnic groups of poor health outcomes and might try to find ways to educate them on preventive care or of taking up vaccinations more reliably. It sounds simple, but I think it’s pretty much always easier said than done, though.
Regarding Estonia’s restructuring of insurance, it’s a change closer to the heart of the central government. I don’t think that the Houston community has much power to change that on its own, except perhaps by participating in the governmental process to try to change the terms of reimbursement here in Texas or here in Harris county.
British Broadcasting Company [BBC]. (2012, January 10). United States of America Country Profile. Retrieved July 14, 2020, from http://news.bbc.co.uk/2/hi/americas/country_profil…
Electronic Roma Resource [e-RR]. (n.d.). Slovakia: Health. Retrieved July 14, 2020, from http://www.eromaresource.com/slovakia/health.html
Encyclopaedia Britannica’s editors. (2020, June 11). Roma. Retrieved July 14, 2020, from https://www.britannica.com/topic/Rom
European Union’s European Commission [EC]. (2014, August). Roma Health Report: Health Status of the Roma Population. Data collection in the Member States of the European Union. Retrieved July 14, 2020, from https://ec.europa.eu/health/sites/health/files/soc…
European Union’s European Commission [EC]. (
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