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CHAPTER 2 - Health and health care policy: inequality and the risks of exclusion
Table of content:
INTRODUCTION
I - THE HEALTH CONTEXT: CHANGES IN MORTALITY AND MORBIDITY
1) Cross-national trends in mortality rates
2) Infant mortality
3) Determinants of the increase in mortality
4) Health inequalities within countries
II - EXPLANATIONS OF HEALTH INEQUALITIES
1) Behavioural and cultural factors
2) Structural factors
3) Inégalité dans la répartition des revenus
III - TRENDS IN HEALTH CARE SYSTEMS
1) The constitution and the legal framework
2) Health care reforms
3) Funding systems
4) Squeeze on spending
5) Coverage
6) Decentralisation
7) Privatisation and commercialisation
8) Access to, and utilisation of, health services
IV - CONCLUSION : INCREASED RISKS OF MARGINALISATION AND EXCLUSION FROM HEALTH AND HEALTH CARE
1) Poorer health for poorer people and poorer countries
2) Need for better information and regular monitoring
3) A strong legal framework for health and health-care is not in itself sufficient to sustain good health for the least advantaged
4) Problems of implementing the new framework for health care
5) Problems in patient choice and access
6) Rationing
7) Caution about marketisation
8) Complex determinants of health
9) Social cohesion and health
10) Pervasive inequality and social cohesion
APPENDIX: FIGURES AND TABLES REFERRED TO IN THE TEXT
Figure 1: Eastern Europe death rate 55-59 males. Albania, Bulgaria, Croatia, Czech Republic, Hungary, Poland and Slovenia
Figure 2: Eastern Europe death rates 55-59 males. Estonia, Latvia, Lithuania, Romania, Russia and the Ukraine
Figure 3: Male death rate age 55-59 for various western European countries
Table 1: Death Rates: Ages 0-19 in bands
Table 2: Death Rates: Ages 20-49 in bands
Table 3: Death Rates: Ages above 49 in bands
Table 4: Infant mortality: deaths during first year per 1000 live births
This chapter contains four parts. Part 1 introduces the context of cross-national trends in mortality rates. It points to the stagnant trend in mortality in central European countries and the increase in mortality in some countries of the former Soviet Union.
Part 2 then goes on to raise the issue of health inequalities within countries, to note the lack of data on which groups are most at risk of poor health, and the implications for effective health policy of this lack of data. Part 3 discusses trends in health care systems, including financial reforms, the squeeze on expenditure, and the potential impact on coverage of the population. It goes on to review trends in decentralisation and privatisation and the potential impact on access to, and utilisation of, health care services. Part 4 (conclusion) summarises the main points of the chapter and draws some conclusions on the potential links between social cohesion and good health.
INTRODUCTION 
The aim of this chapter is to indicate how trends in health care provision may increase the risk of exclusion from health care for the poorest and least advantaged people. As in all of the chapters, the reports of the network of correspondents, and their responses to the questionnaires (which formed the initial structure for their reports), are the basis of the information for the perspective presented in this chapter. The reports themselves must be consulted for the sources used by the correspondents. Given that what has been constructed through the network is a ‘signalling mechanism’, the conclusions in this chapter are indicative only. Their value lies in suggesting some issues that will require further investigation, research and action, focused on the impact on the least advantaged, who have not been a top priority in most countries in the first phases of transition.
The central theme of this chapter is its concern with what is happening to the World Health Organisation goal of equity in health and health care. Equity has been defined by the World Health Organisation along these two dimensions:
Equity in health: ‘ideally everyone should have a fair opportunity to fulfil their full health potential, and more pragmatically, none should be disadvantaged from achieving this potential if it can be avoided’
Equity in health care: ‘leads to equal access to available care for equal need, equal utilization for equal need and equal quality of care for all’ (Townsend et al 1992: 223).
To set the context in which changes in health care are taking place, the first part of this chapter illustrates the trends in mortality in the former communist countries, which indicate the pressing need for action to stem the increasing mortality and morbidity in many countries. It must be stressed however, that within the overall trend in mortality in the former communist and state-socialist countries, experience has varied greatly. The worst experience has been in countries of the former Soviet Union. Within European former state-socialist countries, there are broad variations between the trends in Baltic, Balkan, and central European countries (these broad groupings are also evident in the other chapters, in housing, social protection, education and employment).
Research on health trends has not yet conclusively determined the relationship between economic and environmental change and decline, policy change, behavioural factors and trends in mortality and morbidity across countries. Indeed, the causal chain remains a very contentious issue. Further, the causes of health inequalities within countries are, if anything, more contentious, and, in former communist countries, little researched. Clearly, serious pursuit of the goal of equity in health requires further research, particularly concerning inequalities within countries, between groups and between regions. This will require improvements to the infrastructure of data-gathering in many countries.
The second part of this chapter indicates some trends in health care systems in the eleven countries for which correspondents reported, and concludes, that although experience varies between countries, there is a trend to declining equity in access to health-care. This is in principal an unattractive outcome, but its importance also depends on the extent to which access to health care impacts on mortality and morbidity for those groups adversely affected by changes in the health care systems. The chapter notes that there is disagreement on the importance or otherwise of health care systems in health outcomes, reinforcing the need for more research on health inequalities within countries.
I - THE HEALTH CONTEXT: CHANGES IN MORTALITY AND MORBIDITY
1) Cross-national trends in mortality rates
The present chapter can only provide a general perspective on the trends in health and health-care, but it is sufficient to indicate the severity of the situation confronting the least advantaged. Two basic indices of trends in health inequalities are considered: cross-national and intra-country inequalities in mortality.
For this report, recent (1987-1995) World Health Organisation (WHO) figures of deaths of males and females in several age brackets, and the populations of males and females in these age ranges, were used to compile a death rate for both sexes for each age range (deaths in a year as a percentage of population) (see Appendix to this chapter, Tables 1-3). There are many reservations and qualifications concerning reliability and comparability of such figures, but the consensus is that they reliably indicate the general patterns (Kunst et al 1996, UNICEF 1994).
Trends in western Europe are presented in the tables in order to highlight the situation in central and eastern Europe. Three illustrative figures in the Appendix to this chapter demonstrate recent trends in the death rates for one of the worst affected groups, males aged 55-59.
Figure 1 shows countries that have had little or no increase in death rates. Figure 2.2 shows countries that have had a sharp worsening in the death rate. Note that all of the countries started from a similar range of rates, around two per hundred of the relevant population. In general the countries with the stable rates are central European countries. The countries with the worsening rates were part of the former Soviet Union. Figure 2.3 illustrates death rates in western Europe, which are lower and have generally declined over the period1.
Key changes in mortality for ‘transition’ countries are:
· a sharp rise in death rates from the late 1980s has continued after 1994 in many countries;
· prime-age men are most affected;
· infant mortality is high in some countries but shows least change post-’transition’ (circa 1989).
Some common features emerge that reflect the findings of earlier studies :
· the increases are predominately in former Soviet Union countries;
· the same countries are manifesting increases in each band, especially Estonia, Latvia and Lithuania;
· males are affected more than females, though in some countries for some age groups there is no marked difference in the trend (Estonia and Latvia); however the absolute values are always higher in males;
· all age ranges are affected, but it is the young and middle-aged who show the largest trends upward. In line with findings of other studies, older persons and the retired have been affected to a lesser extent than prime-age males, especially those under age forty, although the absolute number of deaths of people of pensionable age is of course much higher.
These results confirm those of UNICEF (1994). A study of nine countries of central and eastern Europe, it found that the crude death rate ‘soared’ between 1989 and 1993 in seven of the nine countries studied (1994: 35). Only the Czech Republic and Slovakia did not show marked increases. Albania may have had a better initial post-transition experience, but data problems make this difficult to determine.
The study by UNICEF identified three generalised patterns of diversity in mortality trends in the former communist and state-socialist countries. There was a rise in mortality immediately following transition, which in the Czech Republic, Slovakia and Poland (after 1993) was reabsorbed. Where the crude death rate (CDR) rose more slowly, it stabilised, for example in Hungary after 1991/2. Where the CDR rose most initially, it accelerated (although it stabilised eventually in Romania). Life expectancy at birth fell most drastically in countries not covered by this study, such as Russia and Ukraine. For example, in Russia, there was a 5.2 years decline between the years 1989-1993, and 6.1 for the years between 1987-1993. The most dramatic changes have all been in countries of the former Soviet Union, most of which are not covered by the HDSE project. Sixteen of the eighteen countries of the former Soviet Union have experienced large increases in mortality, especially amongst males aged 20-59 age (Cornia, 1995).
Some part of the total rise in the crude death rates in central and eastern Europe can be accounted for by the ageing of the population, which is also causing a small upturn in mortality in some west European countries. A further factor in the recent ageing of the population has been the rapid fall in fertility; population growth in ‘transition’ countries is negative, whether low or highly negative (for example Estonia and Latvia), whereas in general, western Europe (whether central, southern or northern countries) has experienced slightly positive population increases (Turkey is the only large-country exception with a high population growth rate, of 1,68 % in 1996 (COE 1997b: 8)).
The UNICEF (1994) study also found that the gap between male and female life expectancy was at its highest ever in the nine countries studied. Consequently, there has been a rise in incomplete families, despite the fact that, in a number of central and eastern European countries, divorce rates have fallen since transition. Therefore there may be long-term social policy implications, even as the transition process itself is completed.
2) Infant mortality
Infant mortality rates (IMR) in the European Community have continued to decline in the last twenty years from over 20 per 1000 live births in 1970 to 10 per 1000 in 1992 (CEC 1995: 10). In ‘transition’ countries, in contrast to crude death rates for adults, infant and child mortality generally has generally continued to decline, particularly in central as opposed to eastern Europe (five out of nine countries in the study conducted by UNICEF (1994) and see also table 2.4).
Since infant mortality rates (IMR) are generally thought to be more closely connected to the quality of health care systems than are adult mortality rates, it would be important to know to what extent these out-turns reflect key features and trends in health care systems. Further, one might also raise the question of whether the decline in fertility rates, which may be selective amongst groups more or less affected by transition, has contributed to preventing a rise in infant mortality in some countries.
3) Determinants of the increase in mortality
Clearly, poorer countries and those with incomplete health care systems have worse mortality figures of various kinds. However, the explanation is not simple. In Europe, the main proximate causes of death can be classified into heart, respiratory, infectious diseases, accidents, homicides and suicides. While in countries of the European Community mortality rates have been falling, the major causes of death are similar to central and eastern Europe. The difference in mortality rates lie in the average level, the direction of trend, the rank order of heart disease, cancers, infectious diseases and external causes, and the major causes within these. Thus, across west and east Europe, the most important proximate cause varies.
The pattern of disease in the Slovak Republic is typical of central Europe. Five disease groups accounted for 94% of deaths: cardio-vascular (circulatory) disease (52.6%), oncological diseases (tumours) (20.1%), injuries & poisonings (6.9%), respiratory tract (6.5%) and digestive tract (4.3%) (Radicová, 1997: 15). UNICEF (1994) has pointed in eastern Europe, to an ‘epidemic’ of heart disease (and smaller rises in heart disease in central Europe), a trend rise in smoking-related cancers, and in some countries, a rapid rise in infectious diseases and violent deaths, the latter concentrated amongst young men. In contrast to former state-socialist countries, between 1970 and 1992 standardised death rates from ischaemic heart disease continued to decline in European Community countries. T (the average decline is 29.2 per cent, although the decline in the UK is little over 5%; it remains very elevated compared to other European Community countries, except Ireland, which has the highest rates of heart disease in Europe (CEC 1995: 68)).
In the European Community, cancers account for four out of ten deaths in those aged 35-64 years, three deaths are from cardiovascular disease, and one from external causes, mainly suicides and accidents. Suicides vary four-to-five fold between European Community countries, and were rising in five of the European Community twelve in the latter part of the 1970s and into the 1980s (CEC 1995: 19). Suicides have also risen in the majority of countries in central and eastern Europe. Everywhere, external causes are the main cause of death in young adults. In the European Community, for those aged 15-34, deaths from external causes account for more than half of all deaths in this age group, but whereas the average proportion of homicides has remained stable in all but two European Community countries, it has risen in many countries in transition (CEC 1995: 13).
While in transition countries the biggest absolute rise has been in heart disease, the fastest relative rise has been in infectious diseases. Infectious diseases are also most clearly a post-1989 phenomenon, as the outlook for heart disease and cancer had ceased to show improvement prior to transition. A major difference in cause of death amongst transition countries is the rapid rise in infectious diseases in countries of the former Soviet Union. It is significant that although infectious diseases are also a major cause of death at younger ages in Turkey (OECD 1994c: 303), there is no evidence of a recent rapid rise. While there has been an increase in cases of tuberculosis in some countries of the former Soviet Union, tuberculosis notifications have generally been falling in European Community countries, though the decline has ceased in some countries and is rising again in Spain in the 1990s (CEC 1995: 18). It seems likely that the process of transition to a market economy is implicated in the recent developments in mortality and morbidity in many former communist and state-socialist countries, but most particularly for infectious diseases, which are most susceptible to public health measures and structures.
4) Health inequalities within countries
While life expectancy is higher in most western European countries in comparison to former communist and state-socialist countries, western European countries up till now have demonstrated large mortality and morbidity differences between socio-economic groups within each country. These are not well explained, and show no sign of narrowing, indeed there have been recent reverses in some countries, particularly Nordic countries and the UK. While mortality has declined in all social classes in the UK up until 1981, the gap between professional and manual classes has increased (CEC 1995: 8), and indeed in the early 1990s it ceased to decline for the lowest social group (Wilkinson 1996).
Kunst et al (1996) used micro data from national health interview surveys in European Union countries to examine self-reported morbidity; they also used data on mortality from national longitudinal studies and ‘unlinked’ cross-section studies, for ten causes of death2. In contrast to many studies which have relied on data from the 1970s, their study relies on data from the 1980s and early 1990s. This can make a considerable difference to results; as is evident from eastern Europe, the health situation of countries can deteriorate rapidly3. In every country for which data was available, morbidity rates were higher in what they describe as lower socio-economic groups. This inverse relationship held for each age group, sex, socio-economic indicator and morbidity indicator (1996: 132). In every country for which data was available, they also found mortality rates were higher amongst people of lower occupational classes (study of men only) and with lower education levels.
The differences in mortality and morbidity are quite shocking. Economically inactive men have three times the risk of premature death observed for employed men. While strong health selection increases the risk of exclusion from the labour market, it seems likely that there is also reverse causation due to social isolation and stress. Finland and Norway were used to illustrate the concept of healthy life-expectancies. Norwegian and Finnish men with post secondary education live 3-4 years longer than men with basic education, and 10-12 years more of healthy life, that is, without chronic debilitating illness (1996: 133). One important change between the 1970s and the 1980s is that Sweden, Norway and Denmark have lost their relatively favourable international position in terms of the size of mortality differences between classes (1996: 148). There are some other striking findings; French men in lower socio-economic groups had much greater excess mortality than the European average, which Kunst et al suggest may be due to the level of alcohol consumption; and while Nordic countries show large morbidity differences by education level, Great Britain shows large mortality differences by income (1996: 134).
These results, if repeated in former communist and state-socialist countries, would have very significant implications for intra-country inequalities in health. In particular, one would expect inequalities between groups to deepen, because of increases in unemployment and in inequalities such as access to housing and health, which are indicated elsewhere in this report.
However, Kunst et al. doubt that such factors play a major role in intra-country health inequalities. In general, rankings by country in the European Union varied by different socio-economic and health indicator, so that no country had consistently the best or worst performance4. Kunst et al conclude that their results support the view that inequalities in health are a generalised phenomenon in western Europe; and imply from this that neither high living standards nor universal access to health care have minimised the problem of inequalities in health. This conclusion would tend to diminish the likely impact of negative trends in access to health care.
According to HDSE correspondents, the kind of data available to Kunst for the European Union appears not to be available for former communist and state-socialist countries. Until the late 1980s there was little open debate about health inequalities. From 1990, WHO studies became available, but social structure could not be measured in the same way, in that privileged access was as important as money in determining social status. Further the general deterioration in living standards and environmental degradation mask the impact of inequalities. However Whitehead notes that the first four studies found variations in IMR by education for Hungary and Poland, and variations for adults in self-reported ill health by education, but not income. The greatest inequalities by education and occupation are for infant mortality, respiratory disease, infectious and parasitic diseases. Regional variations were high in republics of the former Soviet Union, but also in Hungary and Bulgaria (Townsend et al 1992: 294).
The HDSE correspondents reported on political awareness of health inequalities and the extent of evidence about them. The reports suggest that information and awareness of problems are both in need of development. In response to the question "Is there awareness among leading political forces that there are groups whose health status is worse than health of others, and who are under-served?" it was reported that while politicians were aware of this problem in five countries, other institutions in seven countries had diagnosed this problem. In only two countries (Romania and Moldova) was it stated that the politicians were aware, but other institutions had not made a diagnosis. However in Estonia and Lithuania the opposite was true, i.e. other institutions had made a diagnosis, but not the politicians (Question 54, Section 3 of the health questionnaire responses). However, the political situation is changing rapidly; for example in September 1996, the Latvian government presented a comprehensive strategy document on health-care. Nevertheless, as spending on health care remains very low, implementation is likely to be delayed.
Italy and Turkey are examples of western countries with severe regional variation in mortality and morbidity, which they are trying to address (OECD 1994b). Regional variation appears also to be important in former communist and state-socialist countries. The correspondents from Poland gave regional variation and rural dwellers as having poorer indicators for IMR and disability from chronic conditions, Hungary and Estonia also identified regional variation for IMR but there is no information available for Hungary or Estonia for rural dwellers. Morbidity rate due to tuberculosis seems to be regional, but, it is also is associated with unemployment; two (Hungary and Poland) of the four countries citing regional variation also cite unemployment, and it is likely that regional unemployment and poverty in the heavy industry areas is closely connected to the higher tuberculosis rates.
In six cases HDSE correspondents reported that the official agencies had made no diagnosis of which groups are most at risk of exclusions and disadvantages in health status and access to health care. Nevertheless, nine of the eleven corespondents reported social groups whose health status is significantly worse than the health of the rest of the society (the groups identified are shown in Section 2 of the questionnaire)5. Without better intra-country data on variation by group, region and locality, it will not be possible to track the relationship between inequalities, health and health care reforms, nor will it be possible to target limited resources effectively.
II - EXPLANATIONS OF HEALTH INEQUALITIES
This is a complex and contentious area. Potential causes of death are usually classified into behavioural, environmental or ‘external’ factors and structural factors. The former include health risk-taking behaviour such as smoking, heavy drinking and substance abuse. Environmental factors include road traffic and pollution (risk-taking behaviour by others). Structural factors include failures in the medical care and health protection systems and economic and social inequality.
1) Behavioural and cultural factors
Behavioural factors make a contribution to explaining international inequalities in mortality from some specific causes of death; but they do not appear to explain the overall excess death between countries or between classes or income groups in the same country. Whitehead reviews a number of studies on smoking, alcohol, diet and exercise as explanatory factors for differences by socio-economic group in mortality rates for various causes of death. She concludes that differences in life-style account for some but not all of the observed gap, and in some cases most of the difference in health is not explained. (Townsend et al 1992: 326).
Public health initiatives focusing on behaviour may have a significant impact. For example some believe that the Gorbachov anti-alcohol campaign reduced mortality and morbidity (Rajevska 1997: 15), though others believe that prohibitions are linked to higher morbidity and mortality.
It is noteworthy that heart disease has been more amenable to prevention and treatment in North America than in Europe. Behavioural factors take place in cultural and socio-economic contexts. In transition countries, a key cultural change that is difficult to adjust to, is personal responsibility for health status. Citizens may now have a duty to keep their health rather than a right to health care. The Polish National Health Programme, adopted in 1993, assumes as a basic principle that each citizen shares a responsibility for their health with the state, and the state is responsible for the creation of conditions to encourage good health. A failure to be responsible in self-care can have catastrophic results for some individuals.
As elsewhere, alcohol abuse is a common phenomenona in former communist and state-socialist countries; and people under the influence of alcohol (for example in Estonia) are held responsible for their actions, and can be refused medical care (Narusk 1997:?). Rationing of treatment on the basis of lifestyle seems set to become more common, and is an open subject of debate in the UK. Given the higher rates of smoking and diet-related risk behaviour in lower socio-economic groups, it is possible that access to treatment for the least advantaged may become less equitable if lifestyle and ability to benefit from treatment become criteria for health rationing. Inequality in health may be exacerbated by inequality in access to health care. It is to this point that the chapter now turns.
2) Structural factors
The least advantaged groups are dependent on the state sector for access to health care and therefore the HDSE initiative was primarily concerned with key policy trends in health systems. The following Part reports, firstly, on the potential impact of poverty and inequality in income; then secondly, on trends in health-care that may have a negative impact on the health care opportunities of the least advantaged.
3) Inégalité dans la répartition des revenus
Although Judge (1996) and Kunst et al (1996) have raised doubts, the degree and rate of change of inequality in income distribution have been shown to be related to mortality in a number of studies including Rodgers, 1979; Flegg, 1982; Le Grand, 1987; Waldmamn, 1992; Wennemo, 1993, 1994b, 1996; (Wilkinson 1997). In the studies by Wilkinson, it is the younger and poorer who show the largest mortality rises (Wilkinson, 1993, 1994a).
On the basis of evidence from a number of research projects, Wilkinson has strongly argued that the inequalities in health both between countries, and within countries, between social groups, are not explicable in terms of individual risk-behaviour factors such as smoking, drinking and other substance-abuse etc. He has argued that ‘what matters is the nature of economic and social life’ (Wilkinson 1996: 2). In wealthy western countries heart disease is becoming a disease of poverty. In the UK, heart disease is increasingly related to socio-economic status, lower socio-economic groups are now three times as likely to die of heart disease (Dorling 1997), and health campaigns have not been so successful with poorer groups. Within developed countries in general poorer groups have two to four times the annual death rates of richer groups.
However if poverty was itself the cause, then health inequalities should decline as living standards rise, and this has not been the case. Wilkinson argues that the key is the ‘social capital’ which is part of the character of egalitarian societies, and the cause of higher death rates amongst the relatively poorer groups is the psycho-social stress of relative poverty and low social status. He points to the differences between Japan and Sweden, both in terms of family structures and social expenditure (they are at opposite ends of the OECD spectrum for each), yet they have rather low income inequality and the highest life expectancy (Wilkinson 1996: 80). Further, after controlling for a number of other factors in fifty states of the USA, Waldmann found that mortality and inequality are closely related (Wilkinson 1996: 81). A number of other studies indicate that the main direction of causation is from income inequality to health inequality, rather than the reverse.
The explanation for the decline in health in most transition countries is complex. The former state-socialist countries have low absolute levels of income per head, but per se, this is clearly not sufficient reason for the mortality and morbidity figures. As an example, in 1991, Portuguese and Greek mortality rates were very similar to those in the USA, yet Portuguese GNP per head was about $6000 compared to the USA, at $23000, and the USA spent more than twice the proportion of GNP on health care (14% vis-à-vis 6%) (OECDc 1994).
There is evidence for a relationship between levels of income and health cross-nationally for ‘less-developed countries’ but not for ‘developed countries’. This may be explained with reference to the ‘epidemiological transition’, which implies that above incomes of around $6000 per capita, absolute poverty ceases to be a major impact on health, and faster increases in income per head are not related to life-expectancy at birth cross-nationally (Wilkinson 1996). Incomes in Turkey and in most transition countries are in general below the $6000-$8000 per head generally considered to indicate passage through the ‘epidemiological transition’. European former state-socialist countries experienced rapid improvements in health after World War II, and had completed the ‘epidemiological transition’ by the late 1960s or early 1970s; they then experienced the slowdown in improvements that occurs when the ‘diseases of affluence’ begin to be important causes of death. This chapter suggests that it is possible that the worst affected former state-socialist countries now find themselves on the ‘wrong side’ of the epidemiological transition, following a collapse in incomes and public services, and a rise in infectious diseases.
A UNICEF report (1994) suggested that the cause of the mortality increase in former Soviet countries is associated with a massive fall in output (in Russia and the Ukraine, following transition, output fell by 50%) and the psycho-social stress of very rapid and massive change. The pace of change appears to be crucial, as the income collapse in some Latin American countries in the 1980s did not result in a similar collapse in life expectancy, or increase in morbidity. The UNICEF report (1994) (unlike Wilkinson ), also considered the fall in health care funding and in some cases, the collapse of public health infrastructure, to be important factors in the recent fall in life expectancy in many countries of the former Soviet Union.
Other state-socialist countries, particularly some of those in central Europe, which have better retained public health infrastructure and sustained employment and personal incomes, may face the impact of what were the diseases of affluence (for example the epidemic of heart disease) but without the means, post-transition, to shift from extensive to intensive health intervention, and from a focus on child health to include morbidity in adults, particularly prime age adults. For example, Poland would have to grow at 5% a year for twenty years to reach the current income of Greece, which has the lowest income per head in the European Community (Eatwell 1997)W(Eatwell et al 1997).
The first ‘epidemiological transition’ occurs when countries achieve a combination of a given level of national income and the implementation of extensive health-care systems, particularly to tackle infant and childhood diseases. It may be that more developed countries face a second ‘epidemiological transition’, which will require a new approach to tackling socio-economic inequalities in health, particularly for cardio-vascular and oncological causes. Tackling the degree of inequalities in income may be part of this (and may be the most effective way to tackle lifestyle causes of differences in health status); it may be necessary in addition to make the health care systems more inclusive and responsive for the adult disadvantaged. It is with this in mind, that this last Part of the chapter indicates some of the trends in health care systems that may make it difficult for such countries (and others in western Europe too) to pass through the posited second epidemiological transition.
III - TRENDS IN HEALTH CARE SYSTEMS
This part reviews some features of health care systems and recent trends that may impact on the health care entitlements and access for the least advantaged. These include reforms to funding systems, coverage, decentralisation, privatisation and commercialisation.
1) The constitution and the legal framework
European health policy is characterised by broad entitlement to both protection of health and health care, and is in general amongst the most inclusive anywhere.
The legal formula introducing this right is different in different countries. It seems that the tradition establishing health policy in particular countries determines which formula is accepted. Countries with new constitutions, such as the Netherlands, Spain and Portugal, have this right stated in the constitutions. There are however certain important exceptions. Ireland, France and Italy also have constitutional statements. On the other hand, Great Britain, the country which provided a universal right to health care in its classical form, has no written Constitution. In the majority of western European countries the right to health protection and health care is established on the level of legal resolutions. Characteristic features of health care systems determine the framework in which the right is applicable. As far as insurance systems are concerned (Austria, Belgium, Germany, Iceland, Switzerland) this right is defined by health insurance acts. In the countries with tax-funded national health services, this right is formulated as health care acts (e.g. the Health and Medical Care Act in Sweden, or Finnish Public Health Act) (Wlodarczyk 1997).
However, the examples from central and eastern Europe demonstrate that a legal framework is not itself a sufficient framework to ensure access to health-care, or to sustain improvements in health. In most of the eleven central and east European countries for which correspondents reported, there is a constitutional right to access to health care for citizens. In answer to the question "Are there equal rights to health/right to health care set out in the constitution or in a specific clause of the law?" almost all countries (ten) stated equal rights were in the constitution, but only eight had a specific clause of the law. While most gave health rights to citizens (ten) and insured (ten), only six stated all those in need were covered in law. Five countries have had recent changes to the law, and certain specific groups were identified as not being covered in law (see Section 1 of the health questionnaire results). It is noteworthy that three countries which had among the worst health deterioration, Latvia, Lithuania and Estonia, all had access to health care firmly laid down in the constitution, all three had specific laws concerning equal rights to health care, and two of these (Estonia and Lithuania) covered all in need in the legislation. Constitutional rights and specific laws may be necessary, but are clearly not sufficient.
There needs to be a political strategy and will to implement health care. According to the correspondents, eight governments stated the principle of equality in health, and eight had a strategic document (see Section 1.2 of the health questionnaire results). Estonia, one of the worst affected countries with respect to increases in mortality, has neither a strategic document nor a statement from government on the principle of equal access to health care. However Albania, Lithuania and Romania all had both, yet all show poor health indicators. Political will would appear also to be insufficient to prevent health deterioration.
2) Health care reforms
‘The most remarkable feature of the health care system reforms across the seventeen countries is the degree of emerging convergence’ (OECD 1994c: 45).
There are common concerns with reforms in western countries, in the face of sluggish growth rates, ageing populations and health technology costs, though changes in government perspectives on the cost and effect of welfare systems have also had an impact. Many of the former communist and state-socialist countries have also engaged in reforms of health services, in the context of wider policies of ‘de-statisation’ and privatisation.
In western Europe, in countries as disparate as Sweden and Turkey, reforms have been aimed at micro-efficiency and cost-containment (OECD 1994c). Equity may be interpreted in terms of funding, access and outcome. Equity and universal coverage improved in many countries following the WHO ‘Health for All’ policy of the 1970s. Despite a continuing concern for equity, it has been in the past implemented through administrative control, which is now giving way to market processes (Wlodarczyk 1997). The period of increasing concern with equity and solidarity in health seems to be drawing to a close everywhere, to be replaced with concerns about consumer choice and efficiency. Two key developments in OECD countries have been user charges, and cuts in hospital provision, with a shift to alternative sources of health care (OECD 1994c). These have been mirrored in central and eastern European countries.
In the opinions of the correspondents of the HDSE initiative, eight of the eleven central and eastern European countries in the study had reform proposals. In five countries the principle of equal rights and access was weakening, compared with four where it was strengthening. A new interpretation was put forward in seven; in all cases health care reform proposals were stated to be influenced by the ideas of broader marketisation of the economy, and eight correspondents stated there was a conception of the rationing of health care that appeared in discussions of reform proposals (see Section 1, questions 10-17 of the responses to the health questionnaire). The impact of marketisation and new forms of rationing based on price or lifestyle are likely to disproportionately affect the access to health care of poorer and disadvantaged groups.
3) Funding systems
Whereas the level and quality of service in some cases may have been low, the post-war health service in communist and state-socialist countries was more or less universal, and, until the 1970s, coincided with more rapid increases in life expectancy than any western country. Wilkinson quotes Amartya Sen noting that in the post war period, given the experience of the Soviet Union and eastern Europe, ‘communism was good for your health’ (Wilkinson 1996: 122). However, in many countries, improvements in health had slowed or ceased by the 1970s.
Many of the health reforms in central and eastern Europe have been aimed at replacing or supplementing central state-funded systems with insurance-based systems6. In some countries in central Europe, for example those that were part of the Hapsburg empire, the insurance model represents a return to the type of system in operation before 1940, and indeed some countries had retained elements of an insurance system.
Slovakia is one example of the new systems of health care (introduced in 1989). The reform has been characterised by denationalisation, de-monopolisation and decentralisation. Financing of the medical system has since been revised and is now based on two components, a capitation fee and the remaining 60% is given for performance (Radicová, 1997: 14). From 1 January 1995 a premium payable to the General Health Insurance Company (VsZP) was built from employees (3.7% of incomes), employers (10% of workers’ incomes), self-employed (13.7 of income), voluntarily unemployed, or unemployed not registered with the labour office (13.7% of the minimum wage) and others, for example refugees (13.7% of 54% of the minimum wage) (Radicová, 1997: 15).
However, although Slovakia has completed the transformation to a pluralistic system of health care, it is an example of the possibility that equity has been compromised: because of the ceiling on contributions, they are in effect regressive. Further, private insurers have the possibility to ‘cherry-pick’ ‘good risks’, leaving the state insurer responsible for the more expensive patients, but with less resources (WHO 1996d, Slovakia). Germany and Switzerland are two countries that have introduced regulations to counteract risk-selection by health organisations.
4) Squeeze on spending
The impact of the shift in the financial structure of health-care systems is difficult to tease apart from the short-term impact of low overall expenditure. Total expenditure on health is greater in wealthier countries and wealthier regions. Western European countries on average spend 7.8% of GDP. However whereas Austria spends 9.4%, Turkey spends 4.2% and Greece 4.6%. In the World Health Organisation categories of countries, the central European average is 5.9%, but Slovenia spends 7.9% and Romania 3.6% and Albania 2.8%. The average in the Common wealth of Independent States is even lower, at 4.1%, but the Russian Federation spends only 2.3% of GDP (WHO, 1996a). The impact on total spending is greater than the varying proportions suggest, because in transition countries these are proportions of declining GDPs.
Low pay for health professionals is not confined to central and eastern Europe. However, in transition countries, state budget difficulties and new priorities are such that public sector professionals’ incomes are usually below average for the country concerned. In the Slovak Republic this has lead to a migration of medical and nursing staff abroad or to other professions. Those who stay in health care often take a second job, with a corresponding potential for reduced work performance. 70% of the medical staff in the Slovak Republic are prepared to go on strike (Radicová, 1997:).
Poland is an example of the impact of low resources on services and morale. Public health providers in Poland have charged for services that should be officially free, and there is also a trend to ‘informal’ payments. One estimate suggests that the average informal payment to doctors for a consultation is PLZ 1.7 million, that 11% of patients pay a ‘proof of gratitude’ and that only 2% of the doctors refused such a proof. It is also commonplace to have to pay other health workers. The average salary of a health worker is 85% of the national average. There are insufficient beds in residential treatment homes and hospices, and these centres tend to be poorly furnished and equipped. Funding of health fell by 8.8% in real terms from 1992 to 1994. The introduction of VAT in 1993 worsened the picture further, and material expenditure decreased by 12% from 1992 to 1993 (Dziewiecka-Bokun, 1997: 17).
Since the least advantaged groups are most dependent on state services, they are clearly most at risk from deterioration in the quantity and quality of public health services.
Nevertheless, in the shift from finance through the state budget to insurance-based systems, some former state-socialist countries, for example the Czech Republic (based on ‘Act N. 550/1990’) and Slovak Republics (Law 273: 1994) have retained almost complete coverage in the new systems, and compulsory medical insurance (however, illegal immigrants are not covered by insurance). Other countries are still undertaking reforms. In Bulgaria, a draft law has been in preparation since 1992, but debate on the possible disadvantages of health insurance have held it up. As in many countries of central and eastern Europe, the current draft law is based on the German model, and is expected to be funded from payroll levies (Noncheva, 1995).
5) Coverage
Coverage is between 99% and 100% in most west European countries, whether tax-financed or state insurance systems. However, even countries with universal tax-financed systems exclude some marginal groups from equal coverage (see Wlodarczyk 1997). Denmark is one of the small number of countries that includes all residents in coverage. This includes emergency, chronic, and maternity care for illegal residents. Other countries exclude illegal residents, and in some countries citizenship is the basis of coverage, so that legal migrants are disadvantaged in access to health care.
Although benefits and choice may be greater for the insured than in many tax-financed health care systems, the trend to insurance-based systems in transition countries perhaps bears more risks for the least advantaged groups. There is the possibility of exclusion from insurance-based systems, particularly where these are voluntary. One extreme western example is the USA, in which 50% of persons have not been covered or are inadequately covered (OECD 1994c). Another example is Turkey, in which only 55% of the population are covered by public insurance, though the country is aiming for complete coverage (OECD 1994c: 17). In many central and eastern European countries, the insurance-based systems are occupation-based, and there is particular difficulty for the long term unemployed and those who cannot access the labour market, but are not in the categories insured by central government (usually mothers of small children, students, military personnel and some people with long-term disabilities). The uninsured are also likely to include relatively more self-employed and in some countries, non-tax-payers.
The poorest and least advantaged groups face greater problems in systems which are not free at the point of need. For example, although the municipalities in Belgium are obliged to provide free access to health for the least advantaged, the charity ATD has pointed to problems in getting and paying insurance, for youths, low-income self-employed, broken families and refugees. Further, interviews with poorer families indicate that parents will call doctors for children, but are less willing to call for themselves, because they have to pay the money out and recover it later (Council of Europe 1996a: 13). They also point out that some very poor people may not know what good health is, and that little is known about socio-cultural barriers to accessing good health (Council of Europe 1996a: 27). These same problems are likely to be present in former communist and state-socialist countries with similar systems. Lithuania has been one of the countries of the former USSR that has been least affected by rising mortality rates, though it is rising more than in central European countries. It has been claimed (Lazutka and Sniukstienne, 1995) that the continued free access to health care in Lithuania mitigated against more severe rises in mortality seen in other former USSR states. Nevertheless, shortage of resources is putting pressure on the principle of universal coverage. In Lithuania all citizens have been covered, but in 1997 a new law, the ‘law of health insurance’ will identify three groups, insured, citizens but not insured, and others (Alisauskiene, 1997: 8).
In transition countries, the means to implement and operate the new systems clearly differ, but there are some general questions that can be raised. These concern whether the reform has been implemented, whether the coverage is universal and whether the expected funding for the new system will materialise. Given the decline in real incomes in many countries and problems of tax evasion and avoidance in systems still in development, the ability and willingness of employees, employers and the non-employed to fund health insurance may be called into question. Least advantaged and poorer groups will suffer disproportionately.
6) Decentralisation
Decentralisation to local level has been part of the widespread process of ‘de-statisation’ in central and eastern Europe. OECD (1994b: 17) has pointed in transition countries to the devolution of administrative responsibilities, without an increase in resources. Those for whom the municipality is responsible, usually poorer citizens, may suffer from shortage of municipal resources. Further, ageing of the population means that in future, resources for care of the elderly will come under pressure. For this reason Finnish local authorities have resisted the transfer to them of the costs of elder care, although this is a widespread trend in other countries.
Central and eastern European countries have also experienced decentralisation in the nature of the provision of health-care, and in the responsibility for funding and implementing health care systems. Like many western countries, hospital provision has declined in most countries. In Estonia, for those people who are not insured, the cost is put on the municipalities. However there is no stated responsibility of the municipalities, and they often do not have the funds to cover such care. Emergency aid has however to be given by doctors, without finance, under law. In January 1992 the ‘Law of Hhealth Iinsurance’ was accepted, and amended in April 1994 to introduce cost control mechanisms, including doctors’ fees for visits. However, this case is also an example of the flux in many countries. In July 1995 vulnerable groups (pensioners, children, pregnant women, patients with chronic conditions etc.) were exempted from these fees (Narusk, 1997: 10).
While no systematic reform of the health service in Poland has occurred after transformation, a number of changes have occurred. The Act on Health Care Centres, of 30th August 1991, transferred primary health care services to local authorities. As elsewhere, there is a trend away from hospitals, where currently 50% of patients are treated, to general practitioners. To assist in this aim a training scheme for GPs has been introduced (Dziewiecka-Bokun, 1997:6). However, the effective implementation of a shift to primary care outside hospitals will require resources. Cuts to central state budgets have not been offset by the resources transferred to municipalities, which have many new responsibilities concerning implementation of employment and training programmes and social protection, as well as health.
Bulgaria still appears as an example of over-provision of hospitals and clinics. It has a network of clinics and hospitals covering both rural and urban areas. The figures for health care personnel look attractive compared with western European figures (120 hospital beds per 10,000, nineteen admissions per 100 population per annum, 1,300 medical professionals per 100,000 population). However, such a comparison neglects differences in the systems of primary care; furthermore, the resources may not be appropriately targeted (Noncheva, 1995).
7) Privatisation and commercialisation
The emphasis on cost-containment, which arose first in the 1980s, has increased emphasis on micro-efficiency, and has encouraged a shift away from ‘integrated’ models of health-care to ‘contract’ models (for example countries as disparate as New Zealand and Turkey) which in Sweden and the UK has resulted in a ‘purchaser-provider split’, about which both WHO (1996f) and OECD (1994b: 80) are cautious. Market-oriented systems lead to risk-selection problems, and make it difficult for unhealthy people to obtain services. On the other hand, a market for health services can result in ‘over-service’ (OECD 1994b: 79). Thus, it is not clear that micro-efficiency leads to macro-efficiency and global cost-containment.
Despite caution in the west about some aspects of marketisation, in former state-socialist countries, there have been widespread attempts to encourage both private health care provision and commercialisation of services. For example, the 1991 Act in Poland allowed health institutions to be run by non-state organisations. The decree of the Council of Ministers (Dz. U. of 1994, No. 131, item 657, January 1995) specifies state duties that can be contracted to the private sector. These include most non-emergency services (Dziewiecka-Bokun, 1997: 6). In most countries privatisation and commercialisation have been accelerated because of state budget difficulties. In Moldova, the financial difficulties are such that the state can no longer assure even the minimum guarantee of health care in the constitution (Danii, 1997: page 6 of health questionnaire). In these circumstances it is likely that the main focus of privatisation will be on cost-containment.
Thus, ‘defined packages’ of allowable treatments are an increasing feature of health provision in most countries, though they are usually quite broad. A draft proposal in Poland provides for unlimited services but with a waiting list, and with part and fully chargeable services, the latter to consist of health services not deemed vital, for example cosmetic surgery. In the Slovak Republic, Law 98: 1995 lists the diagnoses and treatments that requires patients to participate in financing (Radicová, 1997: 13). While emergencies and certain listed diseases in Lithuania will continue to be treated free of charge, other treatments may soon be charged (Alisauskiene, 1997: 8). Payments by patients at the point of need will clearly affect the willingness of poorer people to seek treatments.
Portugal, Iceland and Japan have introduced or reintroduced user charges in the 1990s (ibid: 17). The impact on the least advantaged is clearly more severe in countries where more people are living at or below subsistence. In much of Latvia since 1992, every visit to a doctor incurred a charge, and in July 1994 compulsory payments were introduced, of 0.2 Lats (0.37 USD) which equates to 0.5 kg of bread (Rajevska, 1997: 12), in a country where average incomes cover only food, fuel and rent. The Latvian correspondent noted that those on low incomes, especially the unemployed, had poor access to medical care due to the high cost of medicine and treatment. Rural dwellers face an additional problem as half need to travel 5 km or more, and 8% must travel in excess of 10 km. to reach the nearest health services.
In Poland, the better-off families typically spend 3-5 times more on health than those at the bottom of the scale (Dziewiecka-Bokun 1997). In Estonia, the impact on health ranges from more expensive transport, so rural dwellers and the poorest in particular may suffer more, to a reduction in the number of doctors, and medicines are more expensive and most are not subsidised (Narusk, 1997: 10,14).
Widespread changes have included the emergence of two or three-tier insurance systems, so that those able to pay for more than the ‘defined package’ guaranteed by the state sector can buy ‘luxury’ treatment. However, the scope for tiered insurance systems is limited in those countries which have low real incomes for the majority. ‘Opting out’ is another new development, for example in Italy and being considered in Portugal, whereby persons can opt out of the state system and pay for more costly private doctors, taking a rebate on their contribution to the state system. It breaks the principle of solidarity in the population, making it less likely that those opted-out will be willing to pay taxes to support services for the less advantaged (OECD 1994c).
8) Access to, and utilisation of, health services
Effective access must be related to need, and this is complex to assess by socio-economic group. Results vary by country and are difficult to compare cross-nationally because of different cultural habits in utilising doctors and health services (Townsend et al 1992; Wlodarczyk 1997). This kind of information, concerning frequency and appropriateness of usage and treatment, is not available from the HDSE project, which focused on the legal and policy environment.
HDSE correspondents identified the following groups as having weaker access to health care: those living in depressed regions, the unemployed, people with social problems and immigrants were all mentioned in three countries; HIV carriers and rural dwellers were mentioned twice, and the correspondent for Poland also mentioned the less educated. The homeless were stated to be the group most likely to suffer from lack of access to health services. Poland, Hungary, Latvia and Estonia identified this group. Lack of a domiciliary address may be the most important reason for failure to obtain medical care. The most disadvantaged group among the homeless would seem to be very young children, as among the homeless prenatal care and childhood immunisation are difficult to access. (See responses in Section 2 of the health questionnaire).
A group at severe risk in most countries are the long-term unemployed who have fallen out of the unemployment insurance system (only about one third or less of the unemployed are insured in most countries). It is likely that the population in regions of high unemployment, especially industrial areas in decline, find difficulty in paying user charges. Furthermore, in some countries health insurance is linked to possession of unemployment insurance.
IV - CONCLUSION : INCREASED RISKS OF MARGINALISATION AND EXCLUSION FROM HEALTH AND HEALTH CARE
1) Poorer health for poorer people and poorer countries
There are rises in death rates in eastern Europe, especially in countries of the former Soviet Union. There is also, in those countries with higher death rates, worsening morbidity figures, although it is difficult to get comparable data in all countries. Where death rates are raised, it is always that middle aged males are worst affected, though young males are often showing higher rates, and in some countries females show similar rises (though from a lower baseline). Though life expectancy has continued to increase in many western European countries, it has slowed, and not all socio-economic groups are benefiting from increased life-expectancy, and especially from healthy life-expectancy.
Indeed morbidity is increasing for poorer and lower-status people. We can expect the same phenomenon to develop in former communist and state-socialist countries as inequality increases and the behaviour of income and occupation classes, their housing and education, become more differentiated. However, it does not appear that the data at present available will support further investigation of the link between inequality and health within countries.
2) Need for better information and regular monitoring
The reports from the correspondents indicate that there is a need for systematic research into the relation between health care reforms, marketisation generally, and access by the least advantaged to health care. To do this, most countries will have to improve recording systems in such a way that groups most at risk can be better identified and targeted, if most effective use is to be made of limited resources, and if health care policy is to evolve in such a way that the needs and situation of the least advantaged are addressed.
3) A strong legal framework for health and health-care is not in itself sufficient to sustain good health for the least advantaged
The decline in health is occurring despite the fact that European countries have constitutional or legal rights to equal access to health care, and in many cases also, a stated and written political statement concerning equal access, and health systems designed to cover all citizens, or in some cases all residents of a country. In almost all countries there are groups legally excluded from equal access to health care (the uninsured, foreigners, illegal immigrants, or those considered to have caused their own illness) and who often have access only to emergency treatment. Other groups are not legally excluded but are unable to make effective use of available health care.
4) Problems of implementing the new framework for health care
In countries across Europe there are trends towards more plural health services. In former communist and state-socialist countries this has involved decentralisation of implementation, de-monopolisation of provision, de-budgetisation of central government funding and a shift in the locus of services (for example from hospitals to outpatient care in other forms). It is not clear how the impact of the change on least advantaged and poorer groups is being monitored.
Further, in countries in transition the legal framework is changing rapidly, frequently and sometimes incompletely, which may affect the implementation of services. Implementation of the legal framework is patchy in poorer countries, and in many countries particular regions as well as particular groups are under-served.
5) Problems in patient choice and access
In most countries, some people now have greater choice in doctor and their treatment, but others have no choice and may have no treatment if they have no funds, or are not sufficiently insured and are suffering from a disease which is not immediately life-threatening. The insurance systems are in the worst affected countries not financed sufficiently, and frequently limit care for those not on insurance schemes, for example the long-term unemployed or homeless. For working people on state health insurance, some restrictions apply in many countries, as health care systems are under financial pressure. While in most cases emergency treatment is given to those who are uninsured or otherwise out of the health service provision, this does not mean people do not die because of poor service provision. Untreated hypertension, missing ante-natal care, or a lack of preventive measures or diagnostic procedures will inevitably result in increased emergencies who either do not get to hospital, or are too ill to be treated on arrival.
6) Rationing
At present, in practice, equity and universality are not strong features of the systems in many former state-socialist countries, and are weakening elsewhere. Everywhere, there is concern about cost containment, but there seems to be little debate about the relative merits of rationing access to health-care in various ways, for example by price (user charges etc.), clinical need, ability to benefit (affected by lifestyle / behavioural factors), fault (behavioural factors), queuing. Rationing by price, fault and ability to benefit, will adversely affect access by the least advantaged groups, and diminish the concept of equal entitlement to health-care.
7) Caution about marketisation
Given the deteriorating health in transition countries, and the OECD’s own concerns about the impact of aspects of the marketisation of health, such as the purchaser-provider split (OECD 1994c), caution should be exercised by countries considering further marketisation of their own systems. It seems that equity and universality are more difficult to achieve in insurance-based systems, and it is not evident that costs are easier to control, since the better-off may choose to over-provide themselves with health care. Rationing, problems of co-ordination, and the creation of two and three-tier systems of funding and entitlement, are all evident trends in health-care systems which may well disadvantage the poor and the vulnerable, who already experience the worst health.
It seems likely that for the least advantaged groups, morbidity, if not mortality, will worsen if a continued emphasis on choice and micro-efficiency are achieved at the expense of equity and solidarity, and at the risk of even greater exclusion for the least advantaged groups.
8) Complex determinants of health
Health care provision is not the only factor in maintaining good health; it may not be the most important factor. It seems likely that health outcomes and their determinants involve both behavioural and structural factors which are multi-dimensional, and multi-directional. Unemployment and homelessness are consistent predictors of ill health. Alcohol, tobacco and other drug dependencies, and injuries associated with drug dependency, are major killers of the young and middle-aged. Tobacco in particular is a major cause of oncological and cardiovascular disorders. The problems are inter-related, unemployment can lead to homelessness; homelessness is associated with tuberculosis, alcoholism, drug dependence and low self esteem. It seems that mortality of unemployed and manual males of working years is most affected by the reforms of Eastern Europe. These groups also have the worst life expectancy in western Europe.
Following Kunst et al and Wilkinson, it is not clear that greater country wealth, or correction of inadequacies in health care systems, or health promotion, will eliminate the gap in health status between socio-economic groups within any country, or between countries. The coincidence of unemployment (and rising inequality) with widening socio-economic differentials in mortality in the UK and Nordic countries, may be a salutary warning that if a less equitable distribution of wealth continues, as appears in all the trends, the excluded sections of society may not benefit significantly even in an improved macro-economic and health policy environment.
9) Social cohesion and health
Given the recent rise in mortality rates in many countries of central and eastern Europe, Wilkinson asks, what went wrong? He refers to research which seems to indicate that neither declining medical care nor environmental factors (except Chernobyl) have had a significant impact on mortality. The rise in mortality rates in eastern Europe is concentrated in adult men of working age; children, the elderly and women in general have so far had a better experience. For Wilkinson, as for UNICEF (1994), the pathway that translates income inequality into health inequality is psycho-social stress. Wilkinson argues that the psycho-social stress of system change is the key factor for men: unemployment or long hours of work, breadwinner responsibilities in a difficult economic environment, illegal activity, risk behaviour related to stress and social dislocation are seriously affecting health (Wilkinson 1996: 123-126). One hopeful feature of this analysis is that it would suggest that the upsurge in mortality in some countries is temporary, related to the stress of transition.
10) Pervasive inequality and social cohesion
However, both mortality changes and health system reform may reflect wider changes in societies concerning the importance of the principles of equity and solidarity. Wilkinson argues that communist and state socialist countries dissipated their social capital (defined in terms of social life networks, norms and trust (Putnam 1992)) in the later period of communism. Wilkinson quotes research on the health protective effects of participation in social networks (Wilkinson 1996: 185). According to Wilkinson, Kawachi, Kennedy et al (to be published in 1997) have demonstrated quantitatively that social cohesion provides the link between income distribution and mortality in the USA.
This kind of analysis would provide the basis for a unified explanation of inequalities in health status cross-nationally and between socio-economic groups. It implies that health is not primarily a ‘health’ problem in wealthy societies, but is strongly influenced by the social environment. Increasing income inequality may a symptom of deteriorating social cohesion.
Nevertheless, given the recent rises in mortality and morbidity in Russia and the Ukraine, looking at the rise in infectious diseases, rise in mortality from any cause, decline in immunisation and collapse of the public health system, Wilkinson’s assertions about these broader determinants of mortality must be ceteris paribus for the existence off a public health system which is efficient, effective and aims for universal access. The UNICEF report on mortality trends in transition countries (1994), suggests that under-funding of health-care systems was a factor, reducing both the preventative and curative efficiency of the public health systems. Further, Wilkinson’s data addresses variations in inequality in income distribution and life expectancy; it does not explain the secular rise in life expectancy in the period covered by his data. Public health systems surely played an important role. Current trends in health care systems are likely to increase inequalities in access, particularly where allocation of health-care is based on price (insurance, user charges) and not on clinical need. Further, in the context of scarce resources for health, better information is needed about the health condition and health requirements of least advantaged groups, though the evidence does not support the view that changes in behaviour of such groups, without a different economic and social context, will have much impact on healthy life expectancy. It is likely that inequality in access to health systems reflects wider social choices about inequality, which adversely affect the health and life-expectancy of the least advantaged in all societies. Combating inequality in health requires a multi-dimensional approach to combating social exclusion. Employment, education, housing and social protection are as important to health-protection as the health-care system. The following chapters consider the policy environment for each of these ‘basic goods’.
APPENDIX: FIGURES AND TABLES REFERRED TO IN THE TEXT
Figure 1: Eastern Europe death rate 55-59 males. Albania, Bulgaria, Croatia, Czech Republic, Hungary, Poland and Slovenia
Figure 2: Eastern Europe death rates 55-59 males. Estonia, Latvia, Lithuania, Romania, Russia and the Ukraine
Figure 3: Male death rate age 55-59 for various western European countries
Table 1: Death Rates: Ages 0-19 in bands
(latest figures available for each country, source WHO on-line mortality database)
Country
|
Year
|
Sex
|
0
|
1
|
2
|
3
|
4
|
5-9
|
10-14
|
15-19
|
Albania
|
93
|
Male
|
3.49
|
.17
|
.
|
.
|
.
|
.07
|
.06
|
.10
|
Albania
|
93
|
Female
|
3.32
|
.17
|
.
|
.
|
.
|
.05
|
.04
|
.04
|
Austria
|
95
|
Male
|
.59
|
.06
|
.03
|
.02
|
.03
|
.02
|
.02
|
.10
|
Austria
|
95
|
Female
|
.49
|
.03
|
.04
|
.02
|
.01
|
.01
|
.01
|
.03
|
Belarus
|
93
|
Male
|
1.47
|
.03
|
.
|
.
|
.
|
.04
|
.04
|
.12
|
Belarus
|
93
|
Female
|
1.07
|
.02
|
.
|
.
|
.
|
.03
|
.03
|
.05
|
Belgium
|
91
|
Male
|
.94
|
.05
|
.04
|
.03
|
.03
|
.02
|
.02
|
.09
|
Belgium
|
91
|
Female
|
.74
|
.05
|
.02
|
.03
|
.02
|
.01
|
.02
|
.04
|
Bulgaria
|
94
|
Male
|
1.71
|
.16
|
.11
|
.11
|
.08
|
.05
|
.04
|
.10
|
Bulgaria
|
94
|
Female
|
1.48
|
.15
|
.06
|
.08
|
.06
|
.03
|
.03
|
.05
|
Czech Republic
|
93
|
Male
|
.97
|
.02
|
.
|
.
|
.
|
.03
|
.03
|
.09
|
Czech Republic
|
93
|
Female
|
.73
|
.01
|
.
|
.
|
.
|
.02
|
.02
|
.03
|
Czechoslovakia (former)
|
91
|
Male
|
1.27
|
.09
|
.05
|
.04
|
.04
|
.03
|
.03
|
.08
|
Czechoslovakia (former)
|
91
|
Female
|
1.04
|
.07
|
.03
|
.03
|
.03
|
.02
|
.02
|
.04
|
Croatia
|
94
|
Male
|
1.12
|
.01
|
.
|
.
|
.
|
.03
|
.03
|
.09
|
Croatia
|
94
|
Female
|
.75
|
.01
|
.
|
.
|
.
|
.01
|
.02
|
.03
|
Eire
|
92
|
Male
|
.74
|
.05
|
.04
|
.03
|
.01
|
.02
|
.02
|
.08
|
Eire
|
92
|
Female
|
.56
|
.04
|
.03
|
.03
|
.02
|
.01
|
.01
|
.03
|
Estonia
|
94
|
Male
|
1.57
|
.11
|
.08
|
.05
|
.02
|
.04
|
.06
|
.16
|
Estonia
|
94
|
Female
|
1.27
|
.08
|
.02
|
.07
|
.04
|
.03
|
.03
|
.08
|
Finland
|
94
|
Male
|
.50
|
.03
|
.03
|
.01
|
.02
|
.01
|
.02
|
.09
|
Finland
|
94
|
Female
|
.42
|
.02
|
.02
|
.01
|
.02
|
.01
|
.01
|
.03
|
France
|
94
|
Male
|
.68
|
.01
|
.
|
.
|
.
|
.02
|
.02
|
.07
|
France
|
94
|
Female
|
.51
|
.01
|
.
|
.
|
.
|
.01
|
.02
|
.03
|
Germany
|
94
|
Male
|
.60
|
.04
|
.
|
.
|
.
|
.02
|
.02
|
.08
|
Germany
|
94
|
Female
|
.48
|
.03
|
.
|
.
|
.
|
.01
|
.01
|
.03
|
Greece
|
94
|
Male
|
.83
|
.03
|
.02
|
.03
|
.02
|
.02
|
.02
|
.08
|
Greece
|
94
|
Female
|
.78
|
.03
|
.03
|
.02
|
.03
|
.01
|
.01
|
.03
|
Hungary
|
95
|
Male
|
1.19
|
.06
|
.05
|
.04
|
.03
|
.03
|
.03
|
.07
|
Hungary
|
95
|
Female
|
.92
|
.07
|
.03
|
.03
|
.03
|
.02
|
.02
|
.03
|
Italy
|
92
|
Male
|
.90
|
.05
|
.03
|
.03
|
.02
|
.02
|
.03
|
.08
|
Italy
|
92
|
Female
|
.70
|
.05
|
.03
|
.02
|
.01
|
.01
|
.02
|
.03
|
Latvia
|
94
|
Male
|
1.66
|
.16
|
.07
|
.09
|
.11
|
.06
|
.06
|
.19
|
Latvia
|
94
|
Female
|
1.38
|
.09
|
.10
|
.05
|
.06
|
.03
|
.04
|
.05
|
Lithuania
|
94
|
Male
|
1.50
|
.15
|
.13
|
.08
|
.06
|
.06
|
.04
|
.16
|
Lithuania
|
94
|
Female
|
1.24
|
.08
|
.07
|
.06
|
.03
|
.03
|
.03
|
.05
|
Netherlands
|
94
|
Male
|
.64
|
.14
|
.00
|
.00
|
.00
|
.02
|
.02
|
.05
|
Netherlands
|
94
|
Female
|
.49
|
.11
|
.00
|
.00
|
.00
|
.01
|
.02
|
.03
|
Norway
|
93
|
Male
|
.58
|
.04
|
.04
|
.03
|
.02
|
.02
|
.02
|
.07
|
Norway
|
93
|
Female
|
.43
|
.05
|
.04
|
.03
|
.02
|
.01
|
.01
|
.03
|
Poland
|
95
|
Male
|
1.42
|
.08
|
.05
|
.03
|
.03
|
.03
|
.03
|
.09
|
Poland
|
95
|
Female
|
1.20
|
.07
|
.04
|
.03
|
.02
|
.02
|
.02
|
.03
|
Portugal
|
94
|
Male
|
.84
|
.09
|
.06
|
.05
|
.04
|
.04
|
.04
|
.12
|
Portugal
|
94
|
Female
|
.75
|
.09
|
.04
|
.04
|
.03
|
.04
|
.03
|
.04
|
Romania
|
93
|
Male
|
2.63
|
.24
|
.17
|
.12
|
.15
|
.07
|
.06
|
.09
|
Romania
|
93
|
Female
|
2.08
|
.21
|
.13
|
.10
|
.09
|
.04
|
.03
|
.04
|
Russian Federation
|
94
|
Male
|
2.13
|
.19
|
.11
|
.09
|
.08
|
.06
|
.06
|
.21
|
Russian Federation
|
94
|
Female
|
1.57
|
.16
|
.09
|
.07
|
.06
|
.04
|
.03
|
.08
|
Slovenia
|
95
|
Male
|
.60
|
.06
|
.04
|
.05
|
.03
|
.02
|
.03
|
.09
|
Slovenia
|
95
|
Female
|
.51
|
.02
|
.02
|
.00
|
.00
|
.03
|
.01
|
.04
|
Spain
|
93
|
Male
|
.73
|
.06
|
.04
|
.04
|
.03
|
.02
|
.03
|
.07
|
Spain
|
93
|
Female
|
.59
|
.06
|
.04
|
.03
|
.02
|
.02
|
.01
|
.03
|
Sweden
|
93
|
Male
|
.53
|
.03
|
.03
|
.03
|
.03
|
.02
|
.02
|
.05
|
Sweden
|
93
|
Female
|
.41
|
.03
|
.02
|
.02
|
.01
|
.01
|
.01
|
.03
|
Ukraine
|
92
|
Male
|
1.58
|
.20
|
.10
|
.08
|
.08
|
.06
|
.05
|
.13
|
Ukraine
|
92
|
Female
|
1.17
|
.15
|
.08
|
.07
|
.05
|
.04
|
.03
|
.06
|
United Kingdom
|
94
|
Male
|
.68
|
.05
|
.03
|
.02
|
.02
|
.02
|
.02
|
.06
|
United Kingdom
|
94
|
Female
|
.54
|
.05
|
.03
|
.02
|
.01
|
.01
|
.01
|
.02
|
Yugoslavia (former)
|
90
|
Male
|
2.09
|
.13
|
.07
|
.05
|
.03
|
.04
|
.03
|
.07
|
Yugoslavia (former)
|
90
|
Female
|
1.82
|
.13
|
.05
|
.03
|
.03
|
.03
|
.02
|
.03
|
Table 2: Death Rates: Ages 20-49 in bands
(latest figures available for each country, source WHO on-line mortality database)
Country
|
Year
|
Sex
|
20-24
|
25-29
|
30-34
|
35-39
|
40-44
|
45-49
|
Albania
|
93
|
Male
|
.22
|
.21
|
.17
|
.17
|
.22
|
.23
|
Albania
|
93
|
Female
|
.06
|
.06
|
.08
|
.08
|
.12
|
.15
|
Austria
|
95
|
Male
|
.13
|
.11
|
.13
|
.17
|
.28
|
.43
|
Austria
|
95
|
Female
|
.03
|
.04
|
.05
|
.08
|
.14
|
.23
|
Belarus
|
93
|
Male
|
.25
|
.32
|
.42
|
.57
|
.84
|
1.24
|
Belarus
|
93
|
Female
|
.06
|
.08
|
.10
|
.14
|
.25
|
.40
|
Belgium
|
91
|
Male
|
.13
|
.13
|
.14
|
.18
|
.25
|
.41
|
Belgium
|
91
|
Female
|
.04
|
.04
|
.07
|
.09
|
.16
|
.24
|
Bulgaria
|
94
|
Male
|
.15
|
.17
|
.23
|
.35
|
.54
|
.91
|
Bulgaria
|
94
|
Female
|
.05
|
.06
|
.08
|
.14
|
.19
|
.31
|
Croatia
|
94
|
Male
|
.15
|
.15
|
.20
|
.25
|
.42
|
.70
|
Croatia
|
94
|
Female
|
.05
|
.04
|
.06
|
.10
|
.16
|
.29
|
Czech Republic
|
93
|
Male
|
.12
|
.12
|
.16
|
.23
|
.37
|
.65
|
Czech Republic
|
93
|
Female
|
.04
|
.05
|
.06
|
.11
|
.16
|
.28
|
Czechoslovakia (former)
|
91
|
Male
|
.12
|
.14
|
.18
|
.28
|
.47
|
.81
|
Czechoslovakia (former)
|
91
|
Female
|
.04
|
.04
|
.07
|
.11
|
.19
|
.31
|
Eire
|
92
|
Male
|
.12
|
.12
|
.12
|
.14
|
.18
|
.36
|
Eire
|
92
|
Female
|
.03
|
.04
|
.05
|
.08
|
.14
|
.25
|
Estonia
|
94
|
Male
|
.34
|
.39
|
.57
|
.85
|
1.28
|
1.57
|
Estonia
|
94
|
Female
|
.13
|
.13
|
.14
|
.25
|
.32
|
.49
|
Finland
|
94
|
Male
|
.12
|
.13
|
.14
|
.24
|
.37
|
.50
|
Finland
|
94
|
Female
|
.04
|
.05
|
.05
|
.09
|
.13
|
.20
|
France
|
94
|
Male
|
.13
|
.15
|
.20
|
.25
|
.34
|
.48
|
France
|
94
|
Female
|
.04
|
.05
|
.07
|
.10
|
.13
|
.20
|
Germany
|
94
|
Male
|
.10
|
.10
|
.14
|
.20
|
.30
|
.44
|
Germany
|
94
|
Female
|
.03
|
.04
|
.06
|
.09
|
.15
|
.23
|
Greece
|
94
|
Male
|
.12
|
.13
|
.13
|
.15
|
.21
|
.35
|
Greece
|
94
|
Female
|
.04
|
.03
|
.05
|
.06
|
.10
|
.16
|
Hungary
|
95
|
Male
|
.10
|
.15
|
.30
|
.54
|
.86
|
1.28
|
Hungary
|
95
|
Female
|
.04
|
.05
|
.11
|
.20
|
.32
|
.47
|
Italy
|
92
|
Male
|
.12
|
.14
|
.17
|
.16
|
.21
|
.35
|
Italy
|
92
|
Female
|
.03
|
.05
|
.06
|
.08
|
.10
|
.18
|
Latvia
|
94
|
Male
|
.36
|
.48
|
.67
|
1.01
|
1.40
|
2.10
|
Latvia
|
94
|
Female
|
.08
|
.12
|
.14
|
.24
|
.41
|
.61
|
Lithuania
|
94
|
Male
|
.28
|
.38
|
.51
|
.75
|
1.10
|
1.53
|
Lithuania
|
94
|
Female
|
.07
|
.08
|
.12
|
.19
|
.31
|
.51
|
Netherlands
|
94
|
Male
|
.07
|
.07
|
.09
|
.12
|
.19
|
.30
|
Netherlands
|
94
|
Female
|
.03
|
.04
|
.05
|
.09
|
.14
|
.21
|
Norway
|
93
|
Male
|
.08
|
.09
|
.12
|
.15
|
.22
|
.34
|
Norway
|
93
|
Female
|
.03
|
.03
|
.05
|
.07
|
.13
|
.18
|
Poland
|
95
|
Male
|
.13
|
.16
|
.23
|
.37
|
.58
|
.87
|
Poland
|
95
|
Female
|
.04
|
.04
|
.07
|
.12
|
.20
|
.32
|
Portugal
|
94
|
Male
|
.17
|
.20
|
.24
|
.27
|
.34
|
.47
|
Portugal
|
94
|
Female
|
.04
|
.06
|
.08
|
.12
|
.16
|
.22
|
Romania
|
93
|
Male
|
.13
|
.17
|
.27
|
.40
|
.65
|
.94
|
Romania
|
93
|
Female
|
.05
|
.06
|
.11
|
.17
|
.25
|
.37
|
Russian Federation
|
94
|
Male
|
.40
|
.54
|
.76
|
1.06
|
1.51
|
2.07
|
Russian Federation
|
94
|
Female
|
.10
|
.13
|
.18
|
.26
|
.41
|
.61
|
Slovenia
|
95
|
Male
|
.14
|
.13
|
.17
|
.22
|
.40
|
.54
|
Slovenia
|
95
|
Female
|
.04
|
.04
|
.06
|
.10
|
.16
|
.26
|
Spain
|
93
|
Male
|
.12
|
.18
|
.23
|
.22
|
.27
|
.42
|
Spain
|
93
|
Female
|
.04
|
.06
|
.07
|
.08
|
.12
|
.16
|
Sweden
|
93
|
Male
|
.07
|
.08
|
.10
|
.14
|
.20
|
.29
|
Sweden
|
93
|
Female
|
.03
|
.03
|
.05
|
.07
|
.11
|
.19
|
Ukraine
|
92
|
Male
|
.25
|
.32
|
.42
|
.59
|
.85
|
1.20
|
Ukraine
|
92
|
Female
|
.07
|
.08
|
.11
|
.16
|
.25
|
.40
|
United Kingdom
|
94
|
Male
|
.09
|
.09
|
.11
|
.13
|
.21
|
.31
|
United Kingdom
|
94
|
Female
|
.03
|
.04
|
.05
|
.08
|
.14
|
.21
|
Yugoslavia (former)
|
90
|
Male
|
.11
|
.13
|
.16
|
.24
|
.35
|
.60
|
Yugoslavia (former)
|
90
|
Female
|
.04
|
.05
|
.07
|
.11
|
.17
|
.28
|
Table 3: Death Rates: Ages above 49 in bands
(latest figures available for each country, source WHO on-line mortality database)
Country
|
Year
|
Sex
|
50-54
|
55-59
|
60-64
|
65-69
|
70-74
|
75-79
|
80-84
|
85+
|
Albania
|
93
|
Male
|
.52
|
.91
|
1.66
|
2.07
|
4.95
|
6.93
|
13.82
|
21.21
|
Albania
|
93
|
Female
|
.29
|
.36
|
.66
|
1.03
|
2.17
|
3.80
|
8.09
|
16.79
|
Austria
|
95
|
Male
|
.70
|
1.01
|
1.77
|
2.64
|
4.11
|
6.41
|
10.75
|
20.73
|
Austria
|
95
|
Female
|
.35
|
.44
|
.75
|
1.24
|
2.19
|
3.81
|
7.60
|
17.37
|
Belarus
|
93
|
Male
|
2.06
|
2.51
|
3.61
|
4.51
|
6.42
|
10.09
|
14.91
|
24.94
|
Belarus
|
93
|
Female
|
.65
|
.89
|
1.38
|
2.17
|
3.65
|
6.58
|
10.57
|
20.46
|
Belgium
|
91
|
Male
|
.61
|
1.05
|
1.72
|
2.83
|
4.44
|
7.55
|
12.02
|
21.64
|
Belgium
|
91
|
Female
|
.32
|
.50
|
.80
|
1.28
|
2.25
|
4.12
|
7.59
|
16.27
|
Bulgaria
|
94
|
Male
|
1.31
|
1.91
|
2.71
|
3.94
|
6.01
|
9.05
|
13.72
|
24.30
|
Bulgaria
|
94
|
Female
|
.45
|
.72
|
1.20
|
2.09
|
3.70
|
7.16
|
11.39
|
22.67
|
Croatia
|
94
|
Male
|
.96
|
1.51
|
2.67
|
4.12
|
7.77
|
5.69
|
13.03
|
24.25
|
Croatia
|
94
|
Female
|
.40
|
.56
|
1.12
|
1.76
|
4.53
|
3.89
|
10.10
|
20.58
|
Czech Republic
|
93
|
Male
|
1.03
|
1.74
|
2.65
|
4.03
|
6.25
|
9.60
|
14.54
|
23.55
|
Czech Republic
|
93
|
Female
|
.41
|
.69
|
1.18
|
2.01
|
3.41
|
6.48
|
10.57
|
20.53
|
Czechoslovakia (former)
|
91
|
Male
|
1.22
|
1.95
|
3.03
|
4.52
|
6.37
|
10.25
|
15.31
|
24.88
|
Czechoslovakia (former)
|
91
|
Female
|
.48
|
.78
|
1.24
|
2.15
|
3.57
|
6.43
|
11.08
|
20.96
|
Eire
|
92
|
Male
|
.59
|
1.02
|
1.83
|
3.18
|
5.42
|
8.60
|
13.31
|
22.39
|
Eire
|
92
|
Female
|
.36
|
.64
|
1.04
|
1.75
|
2.96
|
5.17
|
8.76
|
18.08
|
Estonia
|
94
|
Male
|
2.19
|
3.06
|
4.10
|
5.16
|
7.00
|
10.06
|
14.20
|
23.12
|
Estonia
|
94
|
Female
|
.71
|
1.05
|
1.54
|
2.28
|
3.71
|
5.93
|
10.65
|
20.52
|
Finland
|
94
|
Male
|
.69
|
1.06
|
1.81
|
2.76
|
4.64
|
7.19
|
11.68
|
19.54
|
Finland
|
94
|
Female
|
.32
|
.40
|
.71
|
1.18
|
2.24
|
4.14
|
7.79
|
17.01
|
France
|
94
|
Male
|
.69
|
1.03
|
1.56
|
2.29
|
3.40
|
5.30
|
8.80
|
17.26
|
France
|
94
|
Female
|
.29
|
.41
|
.59
|
.92
|
1.51
|
2.72
|
5.21
|
13.56
|
Germany
|
94
|
Male
|
.71
|
1.11
|
1.84
|
2.82
|
4.53
|
7.07
|
11.58
|
20.56
|
Germany
|
94
|
Female
|
.34
|
.50
|
.83
|
1.36
|
2.42
|
4.27
|
7.75
|
16.93
|
Greece
|
94
|
Male
|
.49
|
.86
|
1.37
|
2.26
|
3.55
|
6.13
|
9.90
|
16.94
|
Greece
|
94
|
Female
|
.24
|
.38
|
.62
|
1.11
|
2.15
|
4.42
|
8.48
|
17.60
|
Hungary
|
95
|
Male
|
1.84
|
2.56
|
3.39
|
4.77
|
6.62
|
9.14
|
14.66
|
24.06
|
Hungary
|
95
|
Female
|
.64
|
.98
|
1.48
|
2.21
|
3.63
|
5.78
|
10.91
|
20.44
|
Italy
|
92
|
Male
|
.56
|
.95
|
1.63
|
2.60
|
3.91
|
6.41
|
10.22
|
18.62
|
Italy
|
92
|
Female
|
.27
|
.43
|
.69
|
1.17
|
1.98
|
3.82
|
6.96
|
15.85
|
Latvia
|
94
|
Male
|
2.74
|
3.45
|
4.61
|
5.56
|
7.69
|
10.31
|
14.93
|
24.59
|
Latvia
|
94
|
Female
|
.87
|
1.17
|
1.70
|
2.38
|
3.86
|
6.38
|
10.43
|
21.19
|
Lithuania
|
94
|
Male
|
1.99
|
2.68
|
3.44
|
4.62
|
6.60
|
8.13
|
12.38
|
20.26
|
Lithuania
|
94
|
Female
|
.63
|
.87
|
1.25
|
1.94
|
3.41
|
5.17
|
9.15
|
18.73
|
Netherlands
|
94
|
Male
|
.49
|
.88
|
1.59
|
2.64
|
4.37
|
7.23
|
11.51
|
21.17
|
Netherlands
|
94
|
Female
|
.33
|
.50
|
.81
|
1.25
|
2.11
|
3.80
|
6.86
|
16.35
|
Norway
|
93
|
Male
|
.52
|
.86
|
1.64
|
2.59
|
4.43
|
7.11
|
11.48
|
22.58
|
Norway
|
93
|
Female
|
.29
|
.48
|
.80
|
1.31
|
2.09
|
3.99
|
7.39
|
17.47
|
Poland
|
95
|
Male
|
1.33
|
1.96
|
2.86
|
4.06
|
5.90
|
8.69
|
13.56
|
21.90
|
Poland
|
95
|
Female
|
.47
|
.69
|
1.13
|
1.88
|
3.17
|
5.52
|
9.88
|
20.00
|
Portugal
|
94
|
Male
|
.72
|
1.10
|
1.75
|
2.70
|
4.39
|
7.49
|
12.31
|
24.70
|
Portugal
|
94
|
Female
|
.33
|
.47
|
.76
|
1.25
|
2.30
|
4.55
|
8.67
|
20.63
|
Romania
|
93
|
Male
|
1.49
|
2.00
|
2.77
|
3.93
|
5.79
|
9.48
|
14.23
|
23.88
|
Romania
|
93
|
Female
|
.60
|
.84
|
1.35
|
2.21
|
3.83
|
7.28
|
12.20
|
22.41
|
Russian Federation
|
94
|
Male
|
2.89
|
3.60
|
4.95
|
6.23
|
8.02
|
11.47
|
16.01
|
23.66
|
Russian Federation
|
94
|
Female
|
.89
|
1.22
|
1.82
|
2.69
|
4.25
|
7.17
|
11.76
|
21.52
|
Slovenia
|
95
|
Male
|
.95
|
1.45
|
2.39
|
3.47
|
5.08
|
7.54
|
13.18
|
21.44
|
Slovenia
|
95
|
Female
|
.43
|
.53
|
.98
|
1.56
|
2.62
|
4.34
|
9.12
|
17.99
|
Spain
|
93
|
Male
|
.59
|
.96
|
1.49
|
2.36
|
3.73
|
6.05
|
10.10
|
18.78
|
Spain
|
93
|
Female
|
.24
|
.38
|
.60
|
.99
|
1.79
|
3.46
|
6.85
|
16.32
|
Sweden
|
93
|
Male
|
.48
|
.81
|
1.33
|
2.26
|
3.71
|
6.46
|
10.78
|
21.06
|
Sweden
|
93
|
Female
|
.28
|
.46
|
.73
|
1.20
|
2.00
|
3.67
|
6.98
|
16.46
|
Ukraine
|
92
|
Male
|
1.80
|
2.33
|
3.44
|
4.64
|
6.55
|
9.96
|
14.67
|
23.96
|
Ukraine
|
92
|
Female
|
.59
|
.89
|
1.42
|
2.26
|
3.85
|
6.73
|
11.15
|
21.22
|
United Kingdom
|
94
|
Male
|
.55
|
.94
|
1.65
|
2.85
|
4.61
|
7.39
|
11.40
|
19.05
|
United Kingdom
|
94
|
Female
|
.35
|
.56
|
.97
|
1.65
|
2.69
|
4.40
|
7.34
|
14.84
|
Yugoslavia (former)
|
90
|
Male
|
.98
|
1.61
|
2.41
|
3.53
|
5.25
|
8.58
|
13.19
|
19.01
|
Yugoslavia (former)
|
90
|
Female
|
.44
|
.69
|
1.17
|
1.99
|
3.43
|
6.14
|
10.82
|
17.92
|
Table 4: Infant mortality: deaths during first year per 1000 live births
(source: Council of Europe 1997b)
Country
|
1970
|
1975
|
1980
|
1985
|
1990
|
1992
|
1993
|
1994
|
1995
|
1996
|
Albania
|
97,9
|
70,4
|
50,3
|
30,1
|
28,3
|
...
|
...
|
30,7
|
...
|
...
|
Andorra
|
...
|
...
|
...
|
...
|
3,2
|
11,0
|
6,9
|
2,8
|
2,8
|
2,9
|
Austria
|
25,9
|
20,5
|
14,3
|
11,2
|
7,8
|
7,5
|
6,5
|
6,3
|
5,4
|
5,1
|
Belgium
|
21,1
|
16,1
|
12,1
|
9,8
|
7,9
|
8,2
|
8,0 P
|
7,6 P
|
6,1 P
|
5,6 P
|
Bulgaria
|
27,3
|
23,1
|
20,2
|
15,4
|
14,8
|
15,9
|
15,5
|
16,3
|
14,8
|
15,6
|
Croatia
|
34,2
|
23,0
|
20,6
|
16,6
|
10,7
|
11,6
|
9,9
|
10,2
|
8,9
|
8,0
|
Cyprus
|
26,0
|
15,0
|
12,0
|
12,0
|
11,0
|
9,7
|
8,6
|
8,6
|
8,5
|
8,3
|
Czech Republic
|
20,2
|
19,4
|
16,9
|
12,5
|
10,8
|
9,9
|
8,5
|
7,9
|
7,7
|
6,0
|
Denmark
|
14,2
|
10,4
|
8,4
|
7,9
|
7,5
|
6,6
|
5,4
|
6,7
|
5,3
|
...
|
Estonia
|
17,7
|
18,2
|
17,1
|
14,1
|
12,4
|
15,8
|
15,8
|
14,5
|
14,8
|
10,4
|
Finland
|
13,2
|
10,0
|
7,6
|
6,3
|
5,6
|
5,2
|
4,4
|
4,7
|
3,9
|
3,5
|
France
|
18,2
|
13,8
|
10,0
|
8,3
|
7,3
|
6,8
|
6,5
|
5,9
|
4,6 P
|
...
|
Germany
|
|
|
|
|
|
6,2
|
5,8
|
5,6
|
5,3
|
5,0
|
FRG bef.unif.
|
23,6
|
19,8
|
12,6
|
8,9
|
7,0
|
6,0
|
5,8
|
5,5
|
5,3
|
4,9
|
Former DGR
|
18,5
|
15,9
|
12,1
|
9,6
|
7,3
|
7,3
|
6,4
|
6,2
|
5,4
|
5,3
|
Greece
|
29,6
|
24,0
|
17,9
|
14,1
|
9,7
|
8,4
|
8,5
|
7,9
|
8,1
|
7,2
|
Hungary
|
35,9
|
32,8
|
23,2
|
20,4
|
14,8
|
14,1
|
12,5
|
11,5
|
10,7
|
10,9
|
Iceland
|
13,2
|
12,5
|
7,7
|
5,7
|
5,9
|
3,9
|
4,8
|
3,4
|
6,1
|
3,7
|
Ireland
|
19,5
|
17,5
|
11,1
|
8,8
|
8,2
|
6,6
|
6,1
|
6,0 P
|
6,4 P
|
5,5 P
|
Italy
|
29,6
|
21,2
|
14,6
|
10,5
|
8,2
|
7,9
|
7,1
|
6,6
|
6,2 P
|
6,0 P
|
Latvia
|
17,9
|
20,3
|
15,4
|
13,0
|
13,7
|
17,4
|
15,9
|
15,7
|
18,8
|
15,9
|
Liechtenstein
|
...
|
6,5
|
7,6
|
10,7
|
0,0
|
10,7
|
0,0
|
5,6
|
0,0
|
7,4
|
Lithuania
|
19,3
|
19,6
|
14,5
|
14,2
|
10,2
|
16,5
|
16,0
|
14,1
|
12,5
|
10,1
|
Luxembourg
|
24,9
|
14,8
|
11,5
|
9,0
|
7,3
|
8,5
|
6,0
|
5,3
|
5,5
|
4,9
|
Malta
|
...
|
18,3
|
15,2
|
13,6
|
9,1
|
10,0
|
8,2
|
9,1
|
8,7
|
7,7
|
Moldova
|
24,1
|
43,2
|
35,0
|
30,8
|
19,0
|
18,4
|
21,5
|
22,9
|
21,5
|
20,5
|
Netherlands
|
12,7
|
10,6
|
8,6
|
8,0
|
7,1
|
6,3
|
6,3
|
5,6
|
5,5
|
5,7
|
Norway
|
12,7
|
11,1
|
8,1
|
8,5
|
6,9
|
5,8
|
5,0
|
5,2
|
4,0
|
4,0
|
Poland
|
33,2
|
24,9
|
21,3
|
18,5
|
16,0
|
14,5
|
13,4
|
15,1
|
13,6
|
12,2
|
Portugal
|
55,5
|
38,9
|
24,3
|
17,8
|
10,9
|
9,2
|
8,6
|
7,9
|
7,4
|
6,8
|
Romania
|
49,4
|
34,7
|
29,3
|
25,6
|
26,9
|
23,3
|
23,3
|
23,9
|
21,2
|
22,3
|
Russian Federation
|
22,9
|
23,6
|
22,0
|
20,8
|
17,6
|
18,4
|
20,3
|
18,6
|
18,2
|
...
|
San Marino
|
13,9
|
17,9
|
20,9
|
14,5
|
3,8
|
8,4
|
0,0
|
7,5
|
12,3
|
10,6
|
Slovak Republic
|
25,7
|
23,7
|
20,9
|
16,3
|
12,0
|
12,6
|
10,6
|
11,2
|
11,0
|
10,2
|
Slovenia
|
24,5
|
17,3
|
15,3
|
13,0
|
8,4
|
8,9
|
6,8
|
6,5
|
5,5
|
4,7
|
Spain
|
28,1
|
18,9
|
12,3
|
8,9
|
7,6
|
7,1
|
6,7
|
6,0
|
5,6 P
|
...
|
Sweden
|
11,0
|
8,6
|
6,9
|
6,8
|
6,0
|
5,4
|
4,8
|
4,4
|
4,1
|
2,1
|
Switzerland
|
15,1
|
10,7
|
9,1
|
6,9
|
6,8
|
6,6
|
5,6
|
5,1
|
5,0
|
4,7
|
"The former Yugoslav Republic of Macedonia"
|
88,0
|
65,1
|
54,2
|
43,4
|
31,6
|
30,6
|
24,1
|
22,5
|
22,7
|
16,4
|
Turkey
|
150,9
|
128,6
|
95,4
|
88,9
|
58,0
|
51,9
|
49,3
|
46,8
|
44,4
|
42,2
|
Ukraine
|
17,0
|
19,7
|
16,6
|
15,9
|
13,0
|
14,1
|
15,1
|
14,7
|
...
|
...
|
United Kingdom
|
18,5
|
16,1
|
12,1
|
9,3
|
7,9
|
6,6
|
6,3
|
6,2
|
6,2
|
6,0
|
