The World Health Organization

The World Health Organization (WHO) was one of the first actors to put social inequalities in health on the agenda. A key starting point was the Alma Ata declaration from 1978, which underlined that «The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable…» Since then, the goal of reducing social inequalities in health has been included in a number of WHO documents. For example, WHO Europe aimed for a 25 % reduction in social inequalities in health by the year 2000 as one of its «Health for all by the year 2000» goals in 1985. In 1998, the WHO Regional Office for Europe published a new health policy: Health 21– Health for all in the 21^st century, the second target of which deals with social inequalities in health: «By the year 2020, the health gap between socioeconomic groups within countries should be reduced by at least one fourth in member states, by substantially improving the level of health of disadvantaged groups.»

Although these WHO initiatives served to put social inequalities in health on the agenda in a number of Western countries, the WHO recognises there is still much work to be done, not least with regard to developing countries. In March 2005, the Director-General of WHO Lee Jong-Wook set up a Global Commission on Social Determinants of Health. In its explanation of the background to the formation of this commission, the WHO pointed out that there is a large need in some countries for documentation that can be used in the development of measures to reduce social inequalities in health. The Commission has a three-year mandate period (2005–2008) in which to produce this kind of documentation. The Commission is also intended to function as a spearhead in the work to bring about political processes of change in the area. The Commission consists of 20 commissioners from different countries, social sectors and academic disciplines.

EU

EU work related to social determinants of health and inequalities in health spans many policy areas, including economic, labour and social policy; regional policy; research and public health. One of the main goals of the EU programme of Community action in the field of public health for 2003–2008 is reducing inequalities in health. This is to be achieved by developing strategies and measures aimed at socioeconomic determinants of health. An expert group on social determinants and inequalities in health has been set up under the Council of Europe’s Public Health Committee, in which Norway is represented.

Sweden

Sweden has adopted an explicit equality and fairness perspective in all its public health policies. In 1995 a government committee was formed – the National Public Health Committee – to compile national objectives for developments in public health. According to the Committee’s brief, the objectives and the strategies were also supposed to contribute to a reduction in inequalities in health between socioeconomic groups and other groups. The Committee’s assessments and recommendations were presented in the Official Government Report «Health on Equal Terms – national public health objectives», which set up 18 national objectives for public health work. These objectives spanned from broad, socio-political areas such as «Strong solidarity and social community «, via lifestyle (for example «Greater physical activity»), to more specialised health-policy fields such as «Factual health information».

In December 2002, this report formed the background for a bill called «the Public Health Objective Bill», with the overall national public health objective «to create the social conditions to ensure good health on equal terms for the entire population». The inequality perspective was central and in addition to social inequalities also included gender, ethnicity and sexual inclination. The bill emphasised how social structures on different levels can create ill-health and put less emphasis on the individual’s choice of lifestyle as a determinant. This can be illustrated by the eleven domains of objectives for public health work defined in the bill:

• Participation and influence in society

• Economic and social security

• Secure and favourable conditions during childhood and adolescence

• Healthier working life

• Healthy and safe environments and products

• Health and medical care that more actively promotes good health

• Effective protection against communicable diseases

• Safe sexuality and good reproductive health

• Increased physical activity

• Good eating habits and safe food

• Reduced use of tobacco and alcohol, a society free from illicit drugs and doping, and reduced harmful effects of excessive gambling

The Swedish Parliament adopted the Government’s public health objectives in April 2003, and the Swedish National Institute of Public Health was commissioned to coordinate the national follow-up within the eleven domains of objectives. The National Institute of Public Health has developed concrete, quantifiable determinants and indicators for the various health policy objectives. The results will be reported in public health policy reports every four years. The first report was published in 2005.

Denmark

In 1999, the Danish Government presented The Danish Government Programme on Public Health and Health Promotion 1999–2008, An action oriented programme for healthier settings in everyday life. The formulated targets are partially based on WHO’s Health 21. The Programme formulated targets for risk factors, target groups (age groups and health-promoting environments) and organisation/structure.

In September 2002, the Programme on Public Health and Health Promotion was replaced by the new Government’s programme, called Healthy throughout Life – the targets and strategies for public health policy of the Government of Denmark, 2002–2010. This programme paves the way for «a broader and more comprehensive approach to efforts to promote health and prevent disease, which increases the coherence in relation to major preventable diseases and disorders between primary prevention; individual self-care and health initiatives; and counselling, support, rehabilitation and other measures in relation to patients.»

Healthy throughout Lifealso stresses the objective of increasing life expectancy free of disability or illness for everyone at all ages:

• Life expectancy should be increased substantially

• The number of years with high quality of life should be increased

• Social inequality in health should be minimized

The Programme also operates with a number of targets linked to four main elements: risk factors (such as smoking, working environment, physical activity), environments (such as school and the workplace), target groups (such as pregnant women and chronically ill people) and major preventable diseases and disorders (such as cancer and mental disorders).

With «Healthy throughout Life», Denmark has chosen a slightly different public health strategy to Sweden, focusing on factors that affect the population’s choice of lifestyle. The Danish Government Programme on Public Health and Health Promotionalso placed a great deal of emphasis on local actions and clearly defined its goal of using local arenas like primary and lower-secondary schools, the workplace, local communities and the health service. The idea was that individual follow-up in these arenas would afford greater possibilities for reaching more social strata in the population. Healthy throughout Lifecontinues this philosophy for the most part, also stressing the importance of involving voluntary organisations and establishing partnerships, but whereas The Programme on Public Health and Health Promotionattached importance to social inequalities in health and concrete strategies to reduce them, this aspect is less obvious in Healthy throughout Life. One exception is a special indicator programme, developed for the purpose of monitoring and documentation. The indicator programme operates with 14 key indicators, two of which are explicit measures of distribution of health («Social differences in mortality» and «Social differences in the quality of life»).

The United Kingdom

The first official study on social inequalities in health in Britain, the Black Report (after the chairman of the committee, Sir Douglas Black) was published in 1980. The report, which was commissioned by a Labour government, was not well received by the new Thatcher Government, which rejected the committee’s proposals as unrealistically expensive.

Since the Blair Government came to power in 1997, social inequalities in health have once again been high up on the British agenda. An important prelude was a new independent inquiry of social inequalities in health and proposals for measures to reduce these inequalities, chaired by former Chief Medical Officer, Sir Donald Acheson. The objective of this study was also to survey the situation and identify the most pressing challenges. The Acheson report showed that inequalities in health had increased steadily and that inequalities in material conditions were one of the main causes. It contained recommendations for reducing social inequalities in many areas, including, for example taxation policy, education, work, housing policy, the environment and transport in addition to health policy in a narrower sense.

In July 1999, the Minister for Public Health and 11 other ministers presented Saving lives: Our Healthier Nation. This white paper defined the following two main goals for health policy in the United Kingdom:

• improve the health of everyone

• and the health of the worst off in particular.

The report focuses primarily on four causes of death: cancer, coronary heart disease and stroke, accidents, and mental illness (suicide).

In 2001, the British Department of Health defined objectives for its work on social inequalities in health. Two objectives were given specific targets in terms of reductions to be achieved and time limits:

• starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between the routine and manual group and the population as a whole, and

• starting with local authorities, by 2010 to reduce by at least 10 per cent the gap in life expectancy between the fifth of areas with the worst health and deprivation indicators (the Spearhead Group) and the population as a whole.

In 2003, the UK Department of Health and 11 other ministries presented Tackling Inequalities in health: A Programme for Action. This three-year programme has two objectives: to meet the targets defined above and to function as a broad strategy for reducing social inequalities in health and factors that create the health gap. The UK efforts to combat social inequalities in health have a prominent geographical dimension, in that many of the resources and measures are aimed at defined geographical areas (Health Action Zones) with poor living conditions.

1 July 1999 saw the official opening of the Scottish parliament, and Scotland was granted authority over a number of policy areas, including health. The new Scottish public health policy also has a clear objective of reducing social inequalities in health.

The United Kingdom has been an active pioneer in getting inequalities in health higher up on the international agenda. In autumn 2005, during its presidency of the EU, the UK arranged a major conference on social inequalities in health, Tackling Health Inequalities.

The Netherlands

In the Netherlands, the focus on social inequalities in health increased gradually during the 1980s, partly as a result of a study into inequalities in health between different boroughs of Amsterdam in 1980, plus the process linked to the WHO Health for all targets. The Health 2000report published by the Ministry of Welfare, Health and Cultural Affairs in 1986 included a paragraph on social inequalities in health. A subsequent conference resulted in the establishment of a national research programme (1989–93) under the aegis of a committee that reported directly to the Minister. The programme was to investigate the scope and nature of socioeconomic inequalities in health and their determinants.

When the programme ended in 1994, the committee recommended establishment of a new research programme, but now with a focus on developing and evaluating measures designed to reduce socioeconomic inequalities in health. At the same time, developments were to be monitored, and earlier studies were to be followed up. This second programme ran from 1995–2000. Reducing social inequalities in health continued to be defined as a political objective in various government documents. In March 2001, the programme committee of the second national research programme published its report. This document proposes policies and concrete measures, as well as summarising experiences and lessons learned from the programme. Four types of intervention are afforded special attention:

• Improving conditions in terms of occupation, education or income among the people at the bottom of the social hierarchy

• Minimising the effects of health problems on (downward) social mobility.

• Limiting risk exposure in the lowest social strata

• Extra health services for these groups

A Dutch public health report from 2003 attaches importance to prevention in general and highlights three specific preventive areas: smoking, obesity and diabetes. Examples of policy instruments to be used include information campaigns in lifestyle areas, collaboration with local authorities, collaboration with trade and industry, incentives for health insurance companies and developing healthy schools. The equality perspective is less explicit in the Dutch public health policy.