Health inequalities in Europe
While considerable progress has been made when it comes to improving overall population health in the European region, inequalities in health have generally widened. Health inequalities in Europe have generally widened over the past decades. These inequalities were even witnessed by more affluent countries and have been exacerbated by the economic crisis from 2008 onward. Death rates and poorer self-assessments of health were higher in groups with lower socioeconomic status (SES). Less affluent and less educated people in the European Union have worse average levels of health than those with a higher income and education. These inequalities were larger in some countries than in others: for example, they were very substantial in most countries in the eastern and Baltic regions and small in some southern European countries.
In 2005, the World Health Organization (WHO) established the Commission on the Social Determinants of Health, led by Sir Michael Marmot. The aim of this Committee was to support countries and international actors in addressing the social factors leading to health inequalities. According to its 2008 report, an important contributor to health inequalities are the conditions in which we are ‘born, grow, live, work and age’: the ‘social determinants of health’. Important social determinants include one’s education, family income, housing, and employment status. Where such conditions and not biological variations or free choice are at the root of inequalities, we call them ‘socioeconomic health inequalities’. Socioeconomic health inequalities are seen as inequalities that societies can address, inter alia by improving socioeconomic living conditions.
Health inequalities: from social justice to human rights
Given that socioeconomic health inequalities are generally considered to be unnecessary and avoidable, it is widely claimed that they lead to health inequities (i.e., avoidable inequalities in health). Addressing health inequities is considered to be an ‘ethical imperative’ and a ‘matter of social justice’. This leads us automatically to the role of human rights. Human rights standards provide a moral and legal framework for assessing matters of social justice, including socioeconomic health inequalities. According to Marmot et al., “Human rights approaches support giving priority to improving health and reducing inequities.” Human rights law makes clear and compelling appeals to governmental authorities at all levels to take action when injustices in health and other social fields occur.
A human rights approach to health inequalities
Assuming that health inequalities born out of social determinants are unjust, we need to identify how human rights standards and specific laws can be best employed to improve social conditions. Without doubt, the prime right in this field is the ‘right to health’ as recognized in a wide range of human rights treaties, both at international and regional levels. To cite Hunt, former UN Special Rapporteur on the Right to Health, about the relation between the right to health and the social determinants: “there can be no doubt that the right to the highest attainable standard of health encompasses social determinants.…Addressing harmful social determinants is also a legal imperative. Reinforced by law, human rights are equity and ethics with teeth.” Both the right to health under the UN International Covenant on Economic, Social and Cultural Rights (ICESCR) and the right to protection of health under the (Revised) European Social Charter (ESC) reflect a broad approach to health, including not only access to healthcare but also the ‘underlying’ or social determinants. This approach to the right of health is important for the recognition and protection of social determinants.
As suggested above, health inequalities arise from the conditions in which people are born, grow, live, and work. If we translate this understanding to human rights law, this suggests that human rights should guarantee not only an entitlement to healthcare but also an adequate physical environment and social conditions. As such, it is important to connect the right to health to other human rights that relate to and reflect the determinants of health, including the right to life, the rights to information and participation, and the rights to an adequate standard of living, social security, food, housing, property, education, and employment. These rights imply legal obligations to ensure access to housing, a safe and clean living environment, education, and social protection. As such, they carry the potential to address the health consequences of poor housing conditions, lack of access to proper education, and occupational health hazards. Taking a human rights approach thus requires looking at the right to health in an interaction with other human rights, including rights to housing and social security, as well as labor rights.
In Europe, social rights are a strong potential driver for addressing socioeconomic health inequalities. EU policies in this field should be explicitly grounded in social rights, as defined by the human rights framework of the Council of Europe and the EU’s Fundamental Charter. The European Committee of Social Rights, Council of Europe’s treaty body for the European Social Charter, addresses the social determinants to some extent under the umbrella of the social rights in the Charter. In this context the substantive social rights, including the right to health, housing, social security, and education, are used to address social conditions directly.
Rights in action
From an accountability perspective, it is important for courts and other accountability mechanisms (complaint bodies, inspectorates, parliamentary bodies) to have an understanding of health inequalities and social determinants and of how human rights come into play in this context. So far, there is little experience with this matter.
- Paul Hunt, ‘Missed opportunities: human rights and the Commission on Social Determinants of Health’, UN Special Rapporteur on the right to the highest attainable standard of health (2002-8), 2009 Global Health Promotion 1757-9759; Supp (1): 36-41, 38.
- Johan P. Mackenbach et al, ‘Trends in health inequalities in 27 European countries’, Proceedings of the National Academy of Sciences, Jun 2018, 115 (25) 6440-6445; DOI:10.1073/pnas.1800028115.
- M. Marmot, J. Allen, R. Bell, E. Bloomer and P. Goldblat (for the Consortium for the European Review of Social Determinants of Health and the Health Divide), ‘WHO European Review of social determinants of health and the health divide’, Lancet 380 (2012) 1011-1029.
- WHO, Commission on the Social Determinants of Health, Closing the gap in a generation: health equity through action on the social determinants of health, 2008.
- WHO, Social determinants of health. Available at http://www.who.int/social_determinants/sdh_definition/en/
Professor of health law in a global context (Groningen University)