1. Status and trends in health equity and well-being in the
1.2 Child health differences: status and trends
Gaps in children reporting poor or fair health are not changing
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Data for the 38 countries in Fig. 1.3 show that out of every 100 girls, there are on average seven more girls in the least affluent families reporting only poor or fair health, compared to the most affluent families.•
For boys, there are on average six more reporting only poor or fair health in every 100 boys in the least affluent families, compared to the most affluent families.•
In most countries, these gaps in the percentages of children reporting poor or fair health did not change noticeably between 2002 and 2014 (Fig. 1.3). In countries in which the gap narrowed, this mainly occurred among girls.Health and well-being differences in early years last into adulthood
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Despite almost all countries in the WHO European Region offering universal and accessible primary-level education, inequities still occur at an early age.This suggests universal programmes are powerful, but to tackle inequities successfully, accelerated programmes are needed, including support during pregnancy and the early years of life (24).
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For long-term, inclusive economic growth, it is vital that every child has good health and well-being, as well as equal opportunities to succeed.Children’s early development lays the foundation for their later lives
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Children who report good health have better health and well-being as adults, better results at school, and attain better paid employment (24).•
Addressing the underlying causes of inequities, and influencing the many ways in which children develop involves implementing wide-ranging approaches alongside accelerated strategies for those most likely to be left behind (24).Children from more affluent households have better well-being across the Region
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In countries across the WHO European Region, children from the least affluent households are more likely than children from the most affluent households to report poor well-being, as measured by life satisfaction (Fig. 1.4). They are also more likely to report poor health (Fig. 1.3), and to be less physically active (Fig. 1.5).•
Analysis of data for 39 countries, grouped by clusters of countries with similar policy and political landscapes in Fig. 1.4,3 shows that out of every 100 girls, between eight and 17 more in the least affluentquintile report poor life satisfaction, compared to girls in the most affluent quintile. For boys, between nine and 18 out of every 100 in the least affluent quintile report poor life satisfaction, compared to those in the most affluent quintile.
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In country clusters such as the Nordic countries, south-eastern Europe/western Balkans and western Europe, these differences in the percentage of children reporting poor well-being did not change noticeably between 2002 and 2015 (Fig. 1.4).3 Details of the clustering of countries used in the report are provided in Annex 3.
Fig. 1.3. The percentage difference in children reporting poor or fair health per 100 children in the least affluent families compared to the most affluent families, 2014 (and trends since 2002)
● Republic of Moldova Portugal
Decreased ●No noticeable change Increased
Trend Trend
Notes. F = females. M = males. Affluence established according to the FAS.4
Sources: authors’ own compilation based on data from the 2014 HBSC survey, among other country-level data.5
4 The Health Behaviour in School-aged Children (HBSC) study developed the Family Affluence Scale (FAS) to measure material affluence, a proxy for socioeconomic status (more frequently measured by parental occupation or years of parental education). The FAS includes items such as ownership of a vehicle, dishwasher and computer, having one’s own bedroom, the number of bathrooms in a dwelling, and various travel factors. These elements reflect a family’s patterns of consumption and purchasing power.
5 Much of the data used are derived from surveys and administrative systems within Member States, and these data can fluctuate from year to year. Trends are based on a statistical test, establishing that there is less than 10% chance that the trend was due to random fluctuations in the data. As such, if a trend is labelled “increased”, this indicates likelihood of a real increasing trend in the country, rather than random fluctuations between years.
15
1. Status and trends in health equity and well-being in the WHO European Region
Fig. 1.4. The percentage difference in children in the least affluent families reporting poor life satisfaction compared to the most affluent families, per 100 children, 2014 (or latest available year; and trends since
2002), by country cluster
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F M
0 10 20 30 0 10 20 30
Western Europe Southern Europe South-eastern Europe/western Balkans Russian Federation Nordic countries Central Europe Caucasus
% difference
Decreased ●No noticeable change
Trend Trend
Notes. F = females. M = males.
Sources: authors’ own compilation based on data from the 2014 HBSC survey, except Lithuania, North Macedonia and Turkey, for which the source is 2015 data from the OECD’s Programme for International Student Assessment (PISA).6
The social gradient in children who are physically active
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Both girls and boys in more affluent households, as measured by the PISA ESCS index,6 are more likely to be physically active (Fig. 1.5).•
In 65% of countries (20/31) girls in the least affluent households (demarcated by the red dots in Fig. 1.5) are least likely to exercise, compared to girls in more affluent households.•
In 77% of countries (24/31) boys in the least affluent households are least likely to exercise, compared to boys in more affluent households.•
In all but two of the 31 countries in Fig. 1.5, fewer girls are physically active in the least affluent households than in the most affluent ones (up to 17 fewer girls in every 100).•
For boys, across these 31 countries, between 2 and 19 fewer boys out of every 100 in the least affluent households are physically active, compared to the most affluent households.•
Across the WHO European Region, boys tend to be more physically active than girls on average.Average percentages of physically active girls within countries range from 9.1% to 36.8%, while this range is from 16.3% to 39.6% for boys.
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Inequities in obesity are also discussed with regard to the social gradient, at the end of this section.6 The OECD PISA index of Economic, Social and Cultural Status (ESCS) was created on the basis of the following variables:
the International Socio-Economic Index of Occupational Status (ISEI); the highest level of education of the student’s parents, converted into years of schooling; the PISA index of family wealth; the PISA index of home educational resources; and the PISA index of possessions related to classical culture in the family home.
Fig. 1.5. Percentage of children aged 15 years who are physically active according to the PISA ESCS index
F M
10 20 30 40 10 20 30 40
United Kingdom Turkey Switzerland Sweden Spain Slovenia Slovakia Russian Federation Portugal Poland Norway Netherlands Montenegro Luxembourg Lithuania Latvia Israel Ireland Iceland Hungary Greece Germany France Finland Estonia Denmark Czechia Croatia Bulgaria Belgium Austria
%
Q1(poorest) Q2 Q3 Q4 Q5 (richest)
Notes. F = females. M = males. Q = quintile.
Source: authors’ own compilation based on data from the 2015 PISA ESCS index.
Where a person is born and lives in a country can influence their chance of thriving, even in the first years of life
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The severity of geographical inequities in infant mortality within countries varies widely across the WHO European Region.•
Data from 2016 for the 35 countries in Fig. 1.6 show that for every 1000 babies born, as many as 41 more babies do not survive their first year of life in the most deprived areas, compared to babies born in the most advantaged areas.•
These inequities are comparable in magnitude to the absolute rates of infant mortality across the Region:average infant mortality rates within countries range from 1.9 to 47.8 deaths per 1000 live births.
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There are notable differences in infant mortality between geographical areas when comparing countries with similar economies and cultural traditions. This shows that inequities in infant mortality are avoidable.17
1. Status and trends in health equity and well-being in the WHO European Region
Fig. 1.6. The difference in infant deaths per 1000 live births in the most disadvantaged subnational regions compared to the most advantaged subnational regions, various years (and trends since 2005)
8.2
Difference in infant deaths per 1000 live births Decreased ●No noticeable change Increased
Country mean Trend
Notes. Most recent data year for most countries was 2016, with the following exceptions: Azerbaijan 2006; Belarus 2005;
Georgia 2005; Kyrgyzstan 2014; Kazakhstan 2015; North Macedonia 2005; Russian Federation 2015; Tajikistan 2015;
Ukraine 2012; Uzbekistan 2006.
Sources: authors’ own compilation based on data for the years 2005–2016 extracted from Eurostat, OECD and the GDL.
In many countries, the gaps in infant mortality remain the same as they were 10 years ago
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In 23 out of 35 countries across the Region, these gaps in infant mortality rates between the most disadvantaged and most advantaged subnationalregions stayed the same or widened between 2005 and 2016.
Infant mortality is associated with household wealth
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Fig. 1.7 shows the differences in infant mortality rates between those with the lowest and highest levels of wealth among 10 countries for which wealth-disaggregated data were available.7•
Children born into the least wealthy families are more likely to die in their first year of life than children born into the wealthiest families.7 The wealth index is a composite measure of a household’s cumulative living standard. It is calculated and its quintiles established using easy-to-collect data on a household’s ownership of selected assets, such as televisions and bicycles, materials used for housing construction, and types of access to water and sanitation facilities.
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In these 10 countries, the data show that for every 1000 babies born, between four and 23 more babies do not survive the first year of life in the least wealthy households, compared to babies born in the wealthiest households.•
This is in comparison to an average across the WHO European Region of 27 babies in every 1000 who do not survive the first year of life.Fig. 1.7. Number of deaths per 1000 live births in children aged under 12 months, by wealth quintile, various years
Uzbekistan Ukraine Turkmenistan Turkey Tajikistan Republic of Moldova Kyrgyzstan Kazakhstan Azerbaijan Armenia Albania
20 40 60
Deaths per 1000 live births
Wealth quintiles Q1 (poorest) Q2 Q3 Q4 Q5 (richest)
Notes. Most recent data available varied by country: Albania 2009, Armenia 2016, Azerbaijan 2006, Kazakhstan 2011, Kyrgyzstan 2014, Republic of Moldova 2005, Tajikistan 2012, Turkmenistan 2016, Ukraine 2007, Uzbekistan 2006.
Source: authors’ own compilation based on data for the years 2006–2016 from the World Bank.
SDGs and infant mortality
Target 3.1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births.
Target 3.2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births.
The socioeconomic health gradient is seen in other indicators of health in the early years
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Fig. 1.8 shows that there are differences in uptake for the measles vaccine. In 11 out of 16 countries for which wealth-disaggregated data were available, children from households in one of the lowest two wealth quintiles are least likely to have had the measles vaccine.•
Across these countries, out of every 100 children on average nine fewer children have receivedthe measles vaccine in the least wealthy quintile, compared to the wealthiest quintile. Average rates of vaccination uptake range from 71 to 98 children in every 100.
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The data presented are the most up-to-date disaggregated data available. More recent data on vaccine uptake are available but have not been disaggregated by wealth quintiles.19
1. Status and trends in health equity and well-being in the WHO European Region
Guidance is provided to reduce inequities in immunization
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The European Vaccine Action Plan aims for a“European Region free of vaccine-preventable diseases, where all countries provide equitable access to high-quality, safe, affordable vaccines and immunization services throughout the life-course”
(25).
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Vaccine hesitancy is the delay in acceptance or the refusal of vaccines despite availability of vaccination services and it includes health inequities as a reason for hesitancy (26). It was identified by WHO as one of the 10 threats to global health in 2019 (27).•
In some countries in the WHO European Region, children of parents with a higher number of years in education have lower rates of immunization uptake.This relationship is not consistent, and low uptake in these groups is often associated with specific vaccines (e.g. the human papillomavirus (HPV) vaccine; see for example Feiring et al., 2015 (28)).
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Tailoring immunization programmes (TIP) provides guidance on accelerating actions to reduce gaps in immunization uptake. The TIP approach recommends Member States identify, diagnose and design bespoke interventions to increase uptake for certain vaccines (26).Fig. 1.8. Percentage of children aged 12–59 months who have received at least one dose of a measles-containing vaccine, by wealth quintile, various years
Uzbekistan Ukraine Turkey Tajikistan Serbia Republic of Moldova North Macedonia Montenegro Kyrgyzstan Kazakhstan Georgia Bosnia and Herzegovina Belarus Azerbaijan Armenia Albania
60 70 80 90 100
%
Wealth quintiles Q1 (poorest) Q2 Q3 Q4 Q5 (richest)
Notes. Most recent data available varied by country: Albania 2008, Armenia 2010, Azerbaijan 2006, Bosnia and Herzegovina 2011, Belarus 2005, Georgia 2005, Kazakhstan 2010, Kyrgyzstan 2012, Republic of Moldova 2012, North Macedonia 2011, Serbia 2005, Tajikistan 2006, Turkey 2003, Ukraine 2012, Uzbekistan 2006.
Source: authors’ own compilation based on data for the years 2003–2012 from the WHO Global Health Observatory (GHO).
SDGs and vaccinations
Target 3.8. Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.