Health Inequalities

Definition and explanations of socioeconomic inequalities in health

Socioeconomic inequalities in health (higher morbidity and mortality among people with a low level of education, occupation or income) have been reported for many countries and are an important challenge for public health in Europe.

Socioeconomic inequalities in health may be reduced by aiming policies and interventions at:

• inequalities in education, income, occupation
• the negative effects of health problems on the educational level, occupational level and income of people
• exposure to unhealthy living and working conditions and to an unhealthy life style in the lower socioeconomic groups
• access to health care facilities and quality of health care for people with a low socioeconomic status.

Eurothine project important data source

In this EUphocus we mainly present findings of the Eurothine project, the most recent (1990s and early 2000s) European project on the magnitude of socioeconomic inequalities in health in a large number of countries of both Western and Eastern Europe (Mackenbach et al., 2007a). The sections on ‘inequalities in mortality and morbidity’, 'inequalities in cancer mortality', ‘inequalities in diabetes mellitus’ and ‘inequalities in lifestyle’ are mainly based on results from this project.

Inequalities in mortality and morbidity and in cancer mortality

The most important findings are that in all countries included in the study:

• all cause mortality is higher in the lower as compared to higher educated men and women
• self-assessed health is worse in lower as compared to higher educated men and women
• alcohol related mortality is higher among the lower educated men and women
• avoidable mortality is higher among lower educated men and women; this was found for all cause avoidable mortality and for mortality from infectious diseases, cardio-respiratory conditions and all avoidable acute conditions, but to a much lesser extent for mortality from all avoidable malignant conditions.
• both total cancer mortality rates and lung cancer mortality are higher among lower educated men than among higher educated men, while among women, the gradient is much smaller or even absent in some countries
• inequalities in morbidity and mortality vary substantially between countries for each of the studied causes

Inequalities in diabetes mellitus

Low educated people have a higher prevalence of diabetes than the higher educated. Inequalities in the prevalence of diabetes are larger among women than among men. Among men, the majority of countries show weak associations between educational level and diabetes prevalence, while in women these associations are clearer.

Inequalities in life style

The association between socioeconomic status and a number of lifestyle factors is presented in this EUphocus, as lifestyle factors are important determinants of socioeconomic inequalities in health.

Inequalities in obesity

The prevalence of obesity is higher among lower socioeconomic groups almost anywhere in Europe. Exceptions are men in all Baltic and most Eastern European countries, where obesity was (slightly) more common among higher educated men. Among women, the inequalities were largest in Southern Europe. In countries with a high general welfare level obesity is more common among lower educated men than among higher educated men. This association between general welfare level and inequalities in obesity was not found among women.

Inequalities in physical activity

The prevalence of a sedentary lifestyle was lowest in the highest educational group in most countries. Northern countries (Finland, Norway, Denmark) have a distinct profile. Although the overall prevalence of a sedentary lifestyle is relatively low, relatively small differences between the highest and lowest educated groups can be observed. In Southern countries a stronger association between educational level and a sedentary life style is found than in Central European countries.

Inequalities in smoking

In Europe as a whole, smoking is more common in lower educational groups, with inequalities in smoking being larger among men. In the North, West and Continental regions large inequalities in smoking can be identified. Small inequalities, even ‘reverse’ inequalities, among women in smoking are observed in the southern regions. In the East and Baltic regions the pattern is inconsistent. Inequalities in the quitting smoking are also observed. Among both men and women, higher educated ever-smokers are more likely to have quitted than lower educated ever-smokers.

Inequalities in health service access

Access to good quality health services is an important determinant of socioeconomic inequalities in health. The most commonly used definition of ‘equitable access to health services’ is described as equal access to treatment for those in equal medical need, irrespective of other characteristics, such as income.

EU Member States have identified the need to ensure equal access for all as a priority. Accessible healthcare is included in the common objectives of the ‘Open method of coordination’ on social protection and social inclusion.

Some barriers to access health services may have relatively more impact on disadvantaged groups than others. Examples of such barriers are costs and distance on the supply-side, as well as demand-side factors such as communication skills and health beliefs. These barriers should be translated into clear policy measures when aiming to tackle inequalities in access.

Access to health services is mostly measured by the proxy measure ‘service utilisation’ or by indicators of access hurdles such as user charges of waiting times. Need for services is often measured by levels of (self-reported) ill-health, which is generally worse among the lower socioeconomic groups. Within EU-related frameworks, indicators of access barriers and indicators of service utilisation are used.

In all current EU member states inequalities in access to health services exist. In general, people with a higher socioeconomic status have better access to the medical specialist and dentist, while they use less emergency services than those with a lower socioeconomic status. The access to GP services seems fairly equally distributed across socioeconomic groups. However, once people go to see their GP the people with lower incomes are more likely to consult them more often.

Costs of health services seem to be the most important barrier in health service access, compared to organisational distance and availability of transport, in the vast majority of Member States. The extent and characteristics of financial hurdles are shaped by national health system characteristics and vary from country to country. Private health insurance and especially costs sharing seem to impact equity of access most negatively.

Policies to reduce health inequalities

Both the World Health Organisation (WHO) and the European Union (EU) provide policy frameworks which supports individual countries in emphasizing the need to tackle inequalities in health.

WHO policy

The WHO set a health equity target for its European region in 1998 (WHO, 1998a): ‘By the year 2020, the health gap between socioeconomic groups should be reduced by at least one fourth in all member states, by substantially improving the level of health of disadvantaged groups’. Furthermore WHO has undertaken two important initiatives which help to prioritise health inequalities: the WHO-Europe Programme 'Socioeconomic Determinants of Health’ and ‘the Commission on Social Determinants of Health’.

EU policy

EU policy in the area of inequalities in health involves:

• the inclusion of a specific health equity objective within both its new Health Strategy (‘the reduction of inequities in health, both between and within member states’) and its Public Health Programme (‘greater equality in health’). Both programmes cover the period 2008 to 2013.
• supporting the reduction of inequalities by promoting the integration of health equity considerations into non-health policies and legislation (‘cross-sectoral policies’.
• promoting social inclusion within its member states (via the ‘Community Action Programme to Combat Social Exclusion’ and the ‘PROGRESS programme’);
• funding a number of initiatives through its Public Health Programmes that promote the sharing of good practice and knowledge on health inequalities and policy advice (these include: ‘Closing the Gap’, ‘Eurothine’ and ‘DETERMINE’). [link all three: see document on policies)

National policies and strategies

Socioeconomic inequalities in health are the result of a broad range of determinants and therefore a comprehensive national policy approach is needed to tackle these inequalities. Country specific analyses of the contribution of these determinants to inequalities in health should guide a national policy and this policy should be supported by specific, measurable, achievable, realistic and time-based equity targets. These targets enable the progress towards greater health equity to be monitored at a national level and the effectiveness of the chosen policy approach to be evaluated on a regular basis.

Currently, EU member states are at different stages in establishing policies and strategies to reduce these inequalities. Some countries have adopted a cross-government strategy to tackle health inequalities, such as Norway, Sweden and England. The policy approach in England serves as an example for other countries: the cross-government strategy is backed by all government departments, is based on strong local, regional and national partnerships and is supported by clear targets which are being monitored.

Definition of ‘socioeconomic inequalities in health’

Socioeconomic inequalities in health can be defined as systematic differences in the prevalence or incidence of health problems between people of higher and lower socioeconomic status (distinguished by level of education, occupational class, or income) (Kunst & Mackenbach, 1994). For most health problems, a higher prevalence or incidence is observed in the lower socioeconomic groups.

Explanations of socioeconomic inequalities in health

Several explanations of socioeconomic inequalities in health are entry-points for policies and interventions to reduce these inequalities. A reduction of socioeconomic inequalities in health may be achieved by (a combination of) the following entry-points:

• a reduction of inequalities in education, income, occupation
• to diminish the negative effects of health problems on the educational level, occupational level and income of people
• to diminish the negative health effects of exposure to unhealthy living and working conditions and of an unhealthy life style; the prevalence of these unhealthy factors is often higher in the lower socioeconomic groups (see: Inequalities in smoking and lung cancer)
• to improve access to health care facilities and the quality of health care for people with a low socioeconomic status.

Inequalities in health are strongly connected to inequalities in other areas of society, such as inequalities in socioeconomic status and living and working conditions. It is a problem with many causes, that cannot be tackled by the health care sector alone. An integrated approach based on integrated policy is needed (Wilkinson & Marmot, 2003; De Hollander et al., 2006).

Introduction

Socioeconomic inequalities in health are an important challenge for public health in Europe. Such inequalities are substantial in all countries for which data exist and they concern inequalities in mortality, life expectancy and morbidity.

In the 1980s, socioeconomic inequalities in mortality and morbidity were found in many Western European countries. In countries in Northern Europe, such as Norway, Sweden and Finland, health inequalities were not smaller than in other Western European countries, despite long-term political commitment to reduce socioeconomic inequalities in these Northern countries (Mackenbach et al., 1997).

Here we present the findings of the Eurothine project, the most recent (1990s and early 2000s) European project on the magnitude of socioeconomic inequalities in mortality and morbidity in a large number of countries of both Western and Eastern Europe (Mackenbach et al., 2007a).

Inequalities in all cause mortality

In 16 European countries, all cause mortality was higher in the lower as compared to the higher socioeconomic groups. See Relative inequalities in total mortality by level of education. However, the magnitude of inequalities in total mortality by educational level varies substantially between countries. For both men and women, inequalities are smallest in the Basque Country and the largest in the Czech Republic (for men) and Lithuania (for women). In the Southern European populations, educational inequalities in mortality were smaller than average, while most countries in the East and Baltic regions have larger-than-average educational inequalities in mortality (Mackenbach et al., 2007b).

Inequalities in morbidity

Throughout the European continent, the same pattern is observed: worse self-assessed health is lower as compared to higher socioeconomic groups. In Italy and Spain, educational inequalities in self-assessed health are smaller than the European average. In the Baltic region, educational inequalities in self-assessed health are larger than average (see Relative inequalities in self-assessed health by level of education).

The association between alcohol consumption and mortality is complex: there are potential benefical effects of moderate alcohol consumption, while excessive use may cause substantial health problems and mortality.

Alcohol related mortality includes deaths from a great number of underlying causes, which can be divided into two large groups:

• mortality from alcohol related disease (natural causes);
• mortality from alcohol related injuries or adverse effects (external causes).

It is important to note that only part of the specific causes of death related to alcohol, such as alcoholic cirrhosis, can be wholly attributed to alcohol. For many other diseases, alcohol is only one of the potential causes.

A few earlier studies reported on higher alcohol-related mortality among lower socioeconomic groups within some European populations (Harrison & Gardiner, 1999; Mäkelä et al., 1997; Mäkelä et al., 2003). From the Eurothine study it appears that alcohol related mortality is higher among lower educated men and women in all countries. Educational differences in alcohol related mortality are especially large in some countries; for example in Hungary and the Czech Republic for men and in the East and Baltic region for women (Van Oyen et al., 2007).

See Relative indices of inequality for all cause mortality and alcohol related mortality in men in selected countries by age, and Relative indices of inequality for all cause mortality and alcohol related mortality in women in selected countries by age.

See also EUphact details Alcohol use.

Socioeconomic inequalities in health may partly be caused by inequalities in access to and quality of health services. Avoidable mortality stands for mortality from conditions amenable to medical interventions.

Some studies revealed higher levels of avoidable mortality among people with a low socioeconomic status or among people from disadvantaged ethnic groups (Tobias & Jackson, 2001; Poikolainen & Eskola, 1995; Wood et al., 1999; Stirbu et al., 2006; Westerling et al., 1996; Schwarz, 2007.

In the Eurothine study, avoidable mortality refers to mortality from conditions that are amenable to treatment, including those subject to early detection programs (Stirbu et al., 2007).

Inequalities in all avoidable mortality

Inequalities in all avoidable mortality are present in all included European populations. Smaller inequalities in all avoidable mortality are observed in Southern European populations and larger inequalities are found in Central-Eastern European countries and Baltic countries (Stirbu et al., 2007).

See Relative index of inequality (RII) for all avoidable mortality in selected countries.

Inequalities in mortality from infectious diseases

Large inequalities are observed in the group infectious diseases. For all infectious diseases combined, inequalities are larger in CEE and Baltic countries, while among western European countries large inequalities are found in Denmark and the Basque region (Stirbu et al., 2007).

See Relative index of inequality (RII) for diseases of infectious origin in selected countries.

Inequalities in mortality from all avoidable malignant conditions

Small or no inequalities are found in mortality from all avoidable malignant conditions in Northern and Western European countries. In CEE and Baltic countries, inequalities in mortality from these causes are clearly larger, in favour of the higher educated (Stirbu et al., 2007).

See Relative index of inequality (RII) for avoidable mortility of all malignant diseases in selected countries.

Inequalities in mortality from cardio-respiratory conditions

For all countries, inequalities by education are observed for mortality from all cardio-respiratory conditions, favouring the higher educated. Inequalities are especially large in CEE and Baltic countries (Stirbu et al., 2007).

See Relative index of inequality (RII) for all cardio-respiratory conditions in selected countries.

Inequalities in mortality from all avoidable acute conditions

Relatively large inequalities, with higher mortality in the lower educated, are found in all European countries for all avoidable acute conditions. The level of inequalities varies substantially between countries however (Stirbu et al., 2007).

See Relative index of inequality (RII) for all avoidable acute conditions in selected countries.

Inequalities in total cancer mortality

Total cancer mortality rates are higher among lower educated men than among higher educated men (Faggiano et al., 1997; Borrell et al., 2003; Mackenbach et al., 1999; Doornbos & Kromhout, 1990; Faggiano et al., 1995; Menvielle et al., 2005; Davey Smith et al., 1991; Menvielle et al., 2007).

Among women, the educational gradient in cancer mortality is much smaller than among men and even absent in Spanish regions and Slovenia.

See Relative indices of inequality related to education and mortality rates for total cancer mortality.

Most earlier studies were conduced in Southern Europe and did not find any variation in total cancer mortality by socioeconomic status among women (Faggiano et al., 1997; Borrell et al., 2003; Menvielle et al., 2005; Michelozzi, 1999).

Inequalities in lung cancer mortality

Lung cancer is the most common death from cancer (almost 20% from total cancer mortality) (Ferlay et al., 2007).

Socioeconomic differences in lung cancer mortality are present in many countries. Although there is quite some variation in the size of inequalities in lung cancer mortality, lung cancer mortality is higher among men with a lower socioeconomic status in all countries (Mackenbach et al., 2004; van der Van der Heyden et al., 2007). See Relative indices of inequality for lung cancer mortality in men in selected countries by age.

Among women, more variation in the pattern of lung cancer mortality by education is observed than among men. In the Northern European and Continental populations, lung cancer mortality is higher among women with a low education. In Southern European populations and Slovenia, a low socioeconomic status is associated with a lower lung cancer mortality. See Relative indices of inequality for lung cancer mortality in women in selected countries by age.

Inequalities in smoking and lung cancer

Patterns of educational differences in lung cancer mortality differ according to population and gender. The differences in lung cancer mortality found between populations reflect differences in the smoking epidemic between countries.

‘Smoking epidemic’ is a concept used to describe the diffusion of the smoking habit in a population. The general pattern is that first, higher smoking rates are observed among people with a high socioeconomic position, but later smoking rates are higher among people with a low socioeconomic position.

• in Slovenia and Spain, smoking occurs more often among highly educated women (but among men the reverse pattern is observed).
• in Nordic countries, Belgium and Switzerland, smoking is more common among women with a low education.
• France and Northern Italy (Turin) show an intermediate situation.

Also see Inequalities in life style, and the EUphacts on Smoking, and Lung cancer.

Inequalities in the prevalence of diabetes

In earlier studies on the association between socioeconomic position and diabetes prevalence, a disadvantaged socioeconomic position was related to a higher prevalence of diabetes (Dalstra et al., 2005; Larranaga et al., 2005; Abu et al., 1997; Connolly et al., 2000; Brown et al., 2004; Kumari et al., 2004; Wray et al., 2006).

This association was confirmed in a more recent study on socioeconomic inequalities in the prevalence of diabetes in different areas of Europe (Espelt et al., 2007). In the majority of the studied countries, people with a higher socioeconomic position have a prevalence of diabetes of around 3%. People with a lower socioeconomic position have a higher prevalence of diabetes, which is around 5%. Inequalities in the prevalence of diabetes are larger in women than in men. In men, the majority of countries show weak associations between socioeconomic position and diabetes, while in women these associations are clearer. These differences are more accentuated in Western countries, both in women as in men.

See Age-standardised prevalence ratio of diabetes by educational level in men and women, 30-64 years of age in selected countries.

Obesity and diabetes

Diabetes and obesity are strongly linked but the prevalence of both diabetes and obesity varies throughout populations. In Western countries, the risk of developing diabetes and/or risk factors associated with diabetes is linked to a low socioeconomic position (Connolly & Kesson, 1996; Connolly et al., 2000; Evans et al., 2000; Hjelm et al., 1996).

In most countries, a lower educational level was associated with a relatively high prevalence of diabetes. Among people with a lower education diabetes was 1.5 and 2.7 times more common for men and women, respectively. Obesity was 1.6 and 1.9 times more common for men and women with lower education. Inequalities in both diabetes and obesity were generally larger among women, especially among those from southern European countries. Combating inequalities in obesity prevalence is very likely to also impact inequalities in diabetes (Roskam & Kunst, 2007).

Also see EUphacts Overweight and Diabetes..

Obesity is, just like smoking, strongly socially patterned in many countries, and therefore potentially relevant for explaining international variations in health inequalities. Over the past decades, obesity has become more prevalent in the lower socioeconomic groups in many countries, sometimes with transitions from ‘reverse’ inequalities (higher rates of obesity in higher socioeconomic groups) to ‘regular’ inequalities (higher rates of obesity in lower socioeconomic groups) (Van Oort et al., 2005; Lopez et al., 1994; Huisman et al., 2005a; Ezzati et al., 2005; Sobal & Stunkard, 1989).

It is found that in Europe obesity is more common in lower educational groups, with larger inequalities among women than among men. Large inequalities in obesity are observed in the Southern region of Europe, particularly among women. In the East and Baltic regions inequalities in obesity tend to be smaller than the European average (Mackenbach et al., 2007).

Also see EUphact Overweight.

Among men, the overall prevalence of obesity was 11%, and ranged from 6.0% in France to 21.6% in England. Considerable variations in inequalities in obesity in men could be observed between different countries. Sweden, Czech Republic and the Netherlands showed the largest ‘negative’ educational inequalities in obesity and Ireland, Latvia and Lithuania the smallest. Among women, the overall prevalence of obesity was also 11%, and ranged from 5.0% in Italy to 23.3% in England. The educational inequalities in obesity were smallest in Latvia, Finland and Norway and largest in Portugal.

It can be concluded that the phenomenon of inverse gradients of obesity (prevalence is higher among lower socioeconomic groups) is present almost anywhere in Europe. Exceptions were men in all Baltic and most Eastern European countries, where obesity was (slightly) more common among men with a higher education. The inequalities were largest among women of Southern Europe. When general welfare levels increased obesity became increasingly more common among men of lower education, while the opposite was true for men of higher education. Women did not show a clear effect of general welfare level on inequalities in obesity.

See Relative inequalities by level of education in obesity in men and women in selected countries.

Evidence for socioeconomic inequalities in physical activity is scarce and inconclusive. Earlier studies show that, for total physical activity among males, the higher socioeconomic groups have lower levels of physical activity, while females display fewer differences between the socioeconomic groups (DoH, 2004; NCSR, 2003, 2004). When the focus is on sports activities, the relation shows the opposite; higher socioeconomic groups have higher levels of participation in sports (NCSR, 2003, 2004). Furthermore it was found that participants with primary level education were more sedentary than those with higher levels of education, with greater differences among females (Varo et al., 2003).

Also see EUphact Physical activity

A more recent study shows that the levels of physical activity during leisure time are low in general throughout Europe (Demarest et al., 2007). Overall, 36% of males and 42% of females in the age group 16 to 64 years describe their leisure time activity as predominantly of a sedentary nature. The prevalence of a sedentary lifestyle was lowest in the highest educational group. Northern countries (Finland, Norway, Denmark) have a distinct profile. Although the overall prevalence of a sedentary lifestyle is relatively low, relatively small differences between the highest and lowest educated groups can be observed. In both Southern and Eastern European countries, large parts of the population do indicate not to perform any leisure time activity. In Southern countries, this phenomenon is more explicitly socioeconomical determined than in Central European countries.

See Percentage age-adjusted prevalence of a sedentary lifestyle by educational level in men and women in selected countries.

Socio-economic inequalities in smoking have widened and persisted in the last decades (Giskes et al., 2005). Due to higher initiation rates and lower cessation rates, smoking prevalence is higher among lower socioeconomic groups compared to higher socioeconomic groups in most European countries. On average, lower socioeconomic groups smoke more cigarettes per day and are more susceptible to nicotine addiction compared to higher socioeconomic groups. The inequalities in smoking are somewhat more pronounced in northern Europe than in southern Europe. This is a consequence of a more advanced evolvement of the smoking epidemic in northern European countries (Schaap et al., 2007a; Huisman et al., 2005b; Cavelaars et al., 2000).

Countries in the South region are in an earlier stage of the smoking epidemic than countries in the North, West and Continental regions (Van Oort et al., 2005; Lopez et al., 1994). For women a reverse association between educational level and smoking was found (higher educated women smoke more often than lower educated women), while inequalities in smoking were small among men (Mackenbach et al., 2007b).

The history of the smoking epidemic is not extensively documented for the East and Baltic regions, contrary to other European regions. For decades smoking has been highly prevalent among men, and although smoking rates have traditionally been low among women, they have increased strongly in the 1990s (Kubik et al., 1995; Pudule et al., 1999). Although proper historical data on the social pattern in smoking is lacking in these countries, it can be assumed that smoking rates are higher in the lower socioeconomic groups. This is consistent with the larger inequalities in mortality from smoking related conditions (Mackenbach et al., 2007b).

In Europe as a whole, smoking is more common in lower educational groups, with inequalities in smoking being larger among men. In the North, West and Continental regions large inequalities in smoking can be identified. Small inequalities, even ‘reverse’ inequalities, among women in smoking are observed in the southern regions. In the East and Baltic regions the pattern is inconsistent (Mackenbach et al., 2007b).

See Relative inequalities by level of education in current smoking in men and women in selected countries

Inequalities in smoking quit ratios

Among both men and women, higher educated ever-smokers are more likely to have quitted than lower educated ever-smokers. Absolute differences in quit ratios between high and low educated are generally larger in the age group 25-39 years than in the age group 40-59 years. Quit ratios are especially high in Sweden, England, The Netherlands, Belgium and France, and relatively low in Lithuania and Latvia (Schaap et al., 2007b).

Men

For men in the age of 25-39 years, the largest inequalities in quit ratios are found in the Czech Republic and Latvia. Inequalities in quit ratios are smallest in Ireland and Sweden. For men in the age of 40-59 years, largest inequalities in quit ratios are found in Latvia, Lithuania and Estonia. In Portugal and Germany the inequalities in quit ratios are smallest in this subgroup (Schaap et al., 2007b).

See National levels and educational inequalities in quit ratios in men in selected countries

Women

For women in the age of 25-39 years, the largest inequalities in quit ratios are found in Latvia and Hungary, while Portugal had small inequalities in this subgroup. For women in the age of 40-59 years, the largest inequalities in quit ratios are observed in Denmark and Slovakia, while small inequalities are observed in Latvia and Portugal (Schaap et al., 2007b).

See National levels and educational inequalities in quit ratios in women in selected countries

Also see EUphacts Smoking and Smoking policies.

Equitable access to health care may alleviate health inequalities

Access to good quality health services is an important health determinant. Over the years, improved access to health care services for the lower socio-economic groups helped reduce inequities in health, notably differences in mortality (Dahlgren & Whitehead, 2006). Health systems are still widely recognized as an important means to improve population health and improving health systems can play a role in tackling health inequalities (WHO, 2000c; Mackenbach, 2005). Socio-economic differences in health services access across may exacerbate existing health inequalities. Thus, understanding the extent of inequalities in access is essential in understanding the broader goal of health equity (Allin et al., 2005).

Principles of universal and equitable access widely acknowledged

Equitable distribution of health care is a principle subscribed to in many EU countries, as are universal rights to health care access. This is reflected in the Charter of Fundamental Rights of the European Union: article 35 states that “Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices” (Official Journal of the European Communities, 2000).

The EU Council endorsed universality, access to good quality care, equity, and solidarity as common values and principles underpinning the health systems in the EU Member States. It also confirmed that health systems should aim to reduce the gap in health inequalities (CEU, 2006).

EU Member States have identified the need to ensure equal access for all as a priority. At EU-level, work on safeguarding equity of access to good-quality care is predominantly channeled via the Open Method of Coordination (OMC) on social protection and social inclusion. Accessible healthcare is included in the common objectives of in this process.

Defining equity of access not clear-cut

There is no one clear-cut definition of equitable access to health services (Allin et al., 2007). Most commonly, it is described as equal access to treatment for those in equal medical need, irrespective of other characteristics, such as income. This principle is also known as ‘horizontal equity’ of health care delivery (Wagstaff & Van Doorslaer, 2000). In contrast, the concept of ‘vertical equity’ refers to the extent to which individuals on unequal incomes are treated unequally to achieve equity (‘fairness’) in health care finance (Tamsma & Berman, 2004). WHO defines accessibility as ‘a measure of the proportion of the population that reaches appropriate health services’ (WHO, 1998b).

Potential of universal access may be hindered by access barriers

Even where universal access to health services is formally in place, individuals can face a range of barriers hindering the actual utilisation of that service. If persisting inequities in access are to be addressed it is necessary to look beyond the assumption of universal coverage (Busse et al., 2006).

Barriers to access may stem from factors within the health system itself (i.e. at the supply side) or be due to patient-related (demand side) aspects. Supply-side barriers may be due to:

• gaps in population coverage of health insurance;
• scope of the public health benefit package (‘health basket’);
• financial factors such as cost-sharing;
• geographical factors such as distance;
• organisational factors, including waiting lists and opening hours;
• lack/appropriateness of information

Inequality of access at the demand side is related to the characteristics of the potential service users, such as income, age, gender, cultural background, health literacy, or health beliefs.

Some access hurdles have relatively more impact on disadvantaged groups than others (