ABSTRACT It is a fundamental requirement of governments that they allocate resources to public services among institutions or populations that are potential competitors for funding. In Brazil, a ...country with clear social inequalities, equitable allocation of resources in the Unified Health System (SUS) poses a particular challenge. The present study proposes an individual-level matrix model for allocating health resources in the SUS based on data from the National Health Survey (PNS) 2013. This model is founded on a matrix of the following variables: age, sex, education, employment and income and the relationships between them. A morbidity score is used to estimate weights for each category. This model provides an opportunity for managers to use objective methods to provide a clear guide for decision-making in accordance with principles laid down in Brazilian law and in a manner based on health needs and epidemiological and demographic factors, in addition to the capacity to offer services.
RESUMO É um requisito fundamental dos governos alocar recursos para serviços públicos entre instituições ou populações que são concorrentes potenciais para financiamento. No Brasil, país com desigualdades sociais claras, alocar recursos no Sistema Único de Saúde (SUS) se torna particularmente desafiador e equitativo. O estudo tem por objetivo apresentar um modelo matricial de nível individual para alocação de recursos em saúde no SUS com base em dados da Pesquisa Nacional de Saúde (PNS) 2013. Este modelo é baseado na matriz de variáveis idade, sexo, educação, emprego e renda e seus relacionamentos. Um escore de morbidade é usado para estimar pesos para cada categoria. Este modelo oferece uma oportunidade para que os gestores utilizem métodos objetivos que auxiliem a tomada de decisão de forma clara e baseada nas leis brasileiras, considerando as necessidades de saúde, aspectos epidemiológicos, demográficos, bem como a capacidade de oferecer serviços.
Denmark and Sweden are considered to be countries of rather similar socio-political type, but public health policies and smoking habits differ considerably between the two neighbours. A study ...comparing mechanisms behind socioeconomic inequalities in tobacco smoking, could yield information regarding the impact of health policy and -promotion in the two countries.
Cross-sectional comparisons of socioeconomic and gender differences in smoking behaviour among 6 995 Danish and 13 604 Swedish persons aged 18-80 years.
The prevalence of smoking was higher in Denmark compared to Sweden. The total attributable fraction (TAF) of low education regarding daily smoking was 36% for Danish men and 35% for Danish women, and 32% and 46%, respectively, for Swedish men and women. TAF of low education regarding continued smoking were 16.2% and 15.8% for Danish men and women, and 11.0% and 18.8% for Swedish men and women, respectively. The main finding of the study was that the socioeconomic patterning of smoking, based on level of education and expressed as the relative contribution to the total burden of smoking exposure, was rather different in Sweden and Denmark. Moreover, these differences were modified by gender and age. As a general pattern, socioeconomic differences in Sweden tended to contribute more to the total burden of this habit among women, especially in the younger age groups. In men, the patterns were much more similar between the two countries. Regarding continued smoking/unsuccessful quitting, the patterns were similar for women, but somewhat different for men. Here we found that socioeconomic differences contributed more to overall continued smoking in Danish men, especially in the middle-age and older age strata.
The results imply that Swedish anti-smoking policy and/or implemented measures have been less effective in a health equity perspective among the younger generation of women, but more effective among men, compared to Danish policy implementation. The results also raises the more general issue regarding the possible need for a trade-off principle between overall population efficacy versus equity efficacy of anti-tobacco, as well as general public health policies and intervention strategies.
A clear distinction can then be made between the determinants of health and how their distribution is driven by commercial and political interests. The Dahlgren–Whitehead ‘rainbow’ model illustrates ...the different levels of health determinants.2 We do not suggest to include commercial interests as just another determinant, but to include them in the framework as a force driving the development and social patterning of determinants. Our Diderichsen framework can be used to illuminate this more explicitly. We will use an adaptation of that shown in figure 1, to illustrate the point of disagreement.
Aims: Local governments in the Scandinavian countries are increasingly committed to reduce health inequity through ‘health equity in all policies’ (HEiAP) governance. There exists, however, only very ...sporadic implementation evidence concerning municipal HEiAP governance, which is the focus of this study. Methods: Data are based on qualitative thematic network analysis of 20 interviews conducted from 2014 to 2015 with Scandinavian political and administrative practitioners. Results: We identify 24 factors located within three categories; political processes, where insufficient political commitment to health equity goals outside of the health sector and inadequate economic prioritization budget curbs implementation. Concerning evidence, there is a lack of epidemiological data, detailed evidence of health equity interventions as well as indicators relevant for monitoring implementation. Concerted administrative action relates to a lack of vertical support and alignment from the national and the regional level to the local level. Horizontally within the municipality, insufficient coordination across policy sectors inhibits effective health equity governance.
Conclusions
: A shift away from ‘health in all policies’ based on a narrow health concept towards ‘health equity for all policies’ based on a broader concept such as ‘sustainability’ can improve ownership of health equity policy goals across municipal sectors.
The persistence of health inequalities means that many public health professionals face an ongoing task to develop and update policies to tackle them. However, although the inequalities might be ...unchanged, the political priorities in the many policy areas involved are changing and the ambition to reduce the health divide is constantly facing strong forces pushing in the opposite direction. Recent proposals to re-think health inequalities need to be treated with caution because they are disconnected from what is needed for policy-making in this area. From our experience of 35 years in developing strategies to tackle health inequalities, we still see many entry points with space for local and national improvements, but it is crucial to ask the right questions. The aim of this Commentary is to present a new framework of eight questions that might provide a helpful structure for the necessary dialogue between researchers and policy-makers. Even if answers are not yet available for all of them, we believe that discussing them for a specific population in a specific political context will be fruitful to inform policy on the ground.
Social investment policy has become a central response to the demographic and economic challenges facing European welfare states. This focus on investment in human capabilities and their efficient ...use is, however, challenged by health inequalities where education, health and employment are increasingly linked. This paper outlines the main principles of social investment policies (learning, activation and protection) and links them to a conceptual model of health inequalities and the policy entry-points tackling them by addressing the processes of social stratification, differential exposure and vulnerability as well as differential consequences of illness. It illustrates, with reference to selected empirical studies from the Nordic countries, how the balance between the elements of social investment policies might be adjusted, resources allocated differently and policies supplemented by more direct investments in health so as to enable social investments to tackle the health divide.
Aims: In this paper, we examine income- and education-related inequality in small-for-gestational age (SGA) and preterm birth in Denmark and Finland from 1987 to 2003 using concentration indexes ...(CIXs). Methods: From the national medical birth registries we gathered information on all births from 1987 to 2003. Information on highest completed maternal education and household income in the year preceding birth of the offspring was obtained for 1,012,400 births in Denmark and 499,390 in Finland. We then calculated CIXs for income- and education-related inequality in SGA and preterm birth. Results: The mean household income-related inequality in SGA was —0.04 (95% confidence interval: —0.05, —0.04) in Denmark and —0.03 (—0.04, —0.02) in Finland. The maternal education-related inequality in SGA was —0.08 (—0.10, —0.06) in Denmark and —0.07 (—0.08, —0.06) in Finland. The income-related inequality in preterm birth was —0.03 (—0.03, —0.02) in Denmark and —0.03 (—0.04, —0.02) in Finland. The education-related inequality in preterm birth was —0.05 (—0.07, —0.04) in Denmark and —0.04 (—0.05, —0.03) in Finland. In Denmark, the income-related and education-related inequity in SGA increased over time. In Finland, the income-related inequality in SGA birth increased slightly, while education-related inequalities remained stable. Inequalities in preterm birth decreased over time in both countries. Conclusions: Denmark and Finland are examples of nations with free prenatal care and publicly financed obstetric care of high quality. During the period of study there were macroeconomic shocks affecting both countries. However, only small income- and education-related inequalities in SGA and preterm births during the period were observed.
We sought to analyse how much of the total burden of disease in Sweden, measured in disability-adjusted life years (DALYs), is a result of inequalities in health between socioeconomic groups. We also ...sought to determine how this unequal burden is distributed across different disease groups and socioeconomic groups.
Our analysis used data from the Swedish Burden of Disease Study. We studied all Swedish men and women in three age groups (15-44, 45-64, 65-84) and five major socioeconomic groups. The 18 disease and injury groups that contributed to 65% of the total burden of disease were analysed using attributable fractions and the slope index of inequality and the relative index of inequality.
About 30% of the burden of disease among women and 37% of the burden among men is a differential burden resulting from socioeconomic inequalities in health. A large part of this unequally distributed burden falls on unskilled manual workers. The largest contributors to inequalities in health for women are ischaemic heart disease, depression and neurosis, and stroke. For men, the largest contributors are ischaemic heart disease, alcohol addiction and self-inflicted injuries.
This is the first study to use socioeconomic differences, measured by socioeconomic position, to assess the burden of disease using DALYs. We found that in Sweden one-third of the burden of the diseases we studied is unequally distributed. Studies of socioeconomic inequalities in the burden of disease that take both mortality and morbidity into account can help policy-makers understand the magnitude of inequalities in health for different disease groups.
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