Strategic mapping of public perceptions of health equity

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Strategic mapping of public perceptions of health equity

What the public think is important to live a healthy prosperous life

public opinion

housing living wage

social protection

combat crime

income security

job creation local infrastructure

health services

fair work learning and education

equal opportunities

combat stigma

income equality

solidarity

safe place to live combat corruption

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Mapping exercise conducted to inform the implementation of the Health Equity Status Report initiative (HESRi) of the WHO Regional Office for Europe

Strategic mapping of public

perceptions of health equity

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Abstract

Public perceptions of equity in health policy, as well as other policy areas that are of relevance to the distribution of health inequities in society, vary across the 53 countries of the WHO European Region. Health is considered a high political and policy priority in numerous countries and areas; in addition, many respondents consider that income inequalities in their countries/areas are too great. Nonetheless, widespread dissatisfaction with regards to the high levels of perceived corruption and unemployment, or with the management of economic and migration policies, may undermine efforts to pursue health equity policies in countries and areas. This report scans and analyses a series of public opinion surveys conducted across the Region to explore perceptions on health equity-related issues and identify factors that may potentially enable, support or hinder the scale-up and implementation of the Health Equity Status Report initiative of the WHO Regional Office for Europe.

Acknowledging the political significance of public opinion data in democratic contexts, the results from this rapid analysis are proposed to be used as an advocacy tool to encourage political action for health equity across policy areas.

Keywords:

HEALTH EQUITY

SOCIAL DETERMINANTS OF HEALTH HEALTH POLICY

PUBLIC OPINION PUBLIC PERCEPTION

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Abbreviations

EC European Commission

EU European Union

EU28 28 Member States of the EU from 1 July 2013 HESR Health Equity Status Report

ISO International Organization for Standardization RCC Regional Cooperation Council

SEE south-eastern European

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Acknowledgements

The authors of this paper are Sara Barragán Montes, WHO consultant, and Chris Brown, Head of the WHO European Office for Investment for Health and Development (WHO Venice Office).

This publication is one of the products developed under the WHO European Health Equity Status Report initiative (HESRi). The work is led by the WHO European Office for Investment for Health and Development of the WHO Regional Office for Europe based in Venice, Italy and aims to bring forward innovations in the methods, solutions and partnerships to accelerate progress for healthy prosperous lives for all in the WHO European Region.

Chris Brown, Head of the WHO Venice Office, is responsible for the strategic development and coordination of the HESRi. Development of the initial framework was guided by the external Scientific Expert Advisory Group to the WHO European HESRi.

Support for this report was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.

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Executive summary

In 2012, the endorsement by Member States of the European health policy framework, Health 2020, set two strategic priorities that would lead the work of the WHO Regional Office for Europe in the years to come: the reduction of health inequities and the improvement of governance for health. Political commitment to reducing inequalities was also placed at the heart of the 2030 Agenda for Sustainable Development, adopted in 2015.

Guided by these normative frameworks and as part of its efforts to promote action on health equity across the European Region, the WHO Regional Office for Europe launched in 2018 the Health Equity Status Report (HESR) initiative. Its objectives are twofold: to improve the evidence available by establishing a baseline for monitoring health equity outcomes within countries and areas; and to set up an agenda to scale up action on health equity across the Region within countries and areas.

This strategic mapping exercise contributes to the second objective of the HESR initiative. Its overarching aim is to provide insight into the current political context in the WHO European Region, highlighting factors that may potentially enable, support or hinder the scale-up and implementation of the HESR. In order to do so, a series of public opinion surveys conducted across the Region have been selected and scanned to explore perceptions on health equity- related issues.

The mapping takes a political economy approach, which intends to bridge the gap between the available scientific knowledge on how to reduce health inequities and the extent of political action taken to do so, by tapping into the politically driven interests of politicians and policy- makers in democratic contexts. It supports the advocacy work of WHO and partners with politicians and policy-makers across the European Region by providing them with intelligence that connects the health equity agenda with the expressed interests of populations.

Results from this rapid analysis show that health is considered a high political and policy priority by populations across the WHO European Region. For example, health and social security rank as the second most important issue at national level in the European Union (EU), and occupy the first position in 10 EU countries. Health is also positioned among the three most relevant development priorities in Kazakhstan and Turkmenistan, and considered an important factor to achieve shared prosperity in Tajikistan. Additionally, most respondents in all EU and south- eastern European countries and areas, as well as several countries in the Caucasus and of central Asia, share the view that income differences in their country/area are too great. Education, housing, and violence against women are identified as policy areas in which governmental action to reduce inequities benefits from wide public support in multiple countries and areas across the Region. Nevertheless, the analysis also reveals potential challenges that may undermine efforts to achieve health equity, such as high levels of dissatisfaction with the management of migration and economic policy across the Region, and high levels of perceived corruption and unemployment.

This strategic mapping is not conceived as a one-time static document, but rather as a dynamic exercise that seeks to promote the regular monitoring of public perceptions in order to inform both regional and country-level advocacy strategies for health equity.

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Introduction

Both health and non-health sectors play a central role in the attainment of health equity goals, as emphasized in the social determinants of health and Health in All Policies agendas, as well as in the European health policy framework Health 2020 and the 2030 Agenda for Sustainable Development. In addition, globalization contributes to the blurring of boundaries across levels of governance, thus increasing the interdependence and potential impact on health equity of policies and interventions undertaken at global, regional, national and subnational levels. For these reasons, this analysis includes public opinion trends on a wide variety of policy issues across sectors and levels, which may accelerate or hamper progress on health equity.

This mapping exercise is a formative contextual analysis. As such, it is not intended to paint a picture of the current state of health equity in the WHO European Region. Its goal is rather to focus on contextual political factors that may inform the identification of potential entry points for and challenges to the scale-up and implementation of the HESR initiative. Given the wide scope of the exercise, the mapping does not offer an in-depth analysis of any particular country/area, but rather outlines the situation across the Region, accounting for its broad diversity to the extent possible.

The mapping exercise has been prepared by the consultant Sara Barragán Montes with the strategic input of Chris Brown, Head of the WHO European Office for Investment for Health and Development, and coordinator of the HESR initiative. It also includes feedback received after the presentation of its results at the meeting of the Scientific Advisory Expert Group of the HESR initiative, held on 6–8 November 2018 in Copenhagen, Denmark.

Objectives

The main objectives of the mapping exercise are to:

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provide a rapid analysis of public perceptions across the WHO European Region with regards to health equity-related issues, in order to inform the implementation of the HESR initiative;

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identify potential entry points for the scale-up of action on health equity, as well as challenges for the implementation of the HESR initiative across the Region;

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inform consultations and discussions with key stakeholders throughout the development of the HESR initiative, including high-level meetings with government representatives (such as the High-level Conference on Health Equity planned for 11–13 June 2019 in Ljubljana, Slovenia, which will bring together Member States, international organizations and civil society representatives).

Structure

To conduct this exercise, a series of public opinion surveys conducted across the WHO European Region have been selected for review. These are published by the European Commission (EC), the Regional Cooperation Council (RCC) and the World Bank. The surveys reveal the perceptions

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of populations with regards to topics relevant to the health equity agenda. The results from the mapping have been organized into three main sections:

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perceived policy priorities

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perceptions about fairness, inequalities, inclusiveness or integration

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perceptions on other policy issues of relevance to health equity.

Potential entry points and challenges for the scale-up of action and implementation of the HESR initiative have been identified from the results of the analysis of the selected public opinion surveys. These have been summarized and organized according to the five policy areas of the HESR initiative: health services; living conditions/environments; personal and community capabilities (social and human capital); employment and working conditions; and income and social protection.

Limitations

In addition to the individual limitations of each survey, a major constraint of this mapping is the lack of availability of a single public opinion survey that assesses consistently the perceptions of populations across all 53 Member States of the WHO European Region on health equity-related issues. To cover this large spectrum and account for its diversity, several surveys produced by the EC, the RCC and the World Bank have been selected. These surveys include data for 46 European countries and areas. The following seven countries are not included in any of the surveys and, therefore, public opinion data from their citizens are not considered in this rapid analysis: Azerbaijan, Iceland, Israel, Monaco, Norway, San Marino and Switzerland.

The use of multiple surveys conducted by different institutions poses a series of limitations in the analysis that must be acknowledged. First, the general focus across surveys varies slightly:

while the EC surveys cover a wide range of policy issues, those conducted by the RCC and the World Bank have a specific focus on economic growth. The World Bank’s scope broadened after 2015, when the institution aligned its objectives to the Sustainable Development Goals, focusing more prominently on poverty reduction, shared prosperity, income inequalities and climate change.

Second, even when the focus between surveys is similar, the format of their questions can vary considerably. In addition, the answers provided depend to a considerable extent on those that are given as possible options. These differences have been accounted for in the analysis that follows, and the main questions and results used are included in their original form in Annex I.

Third, while the EC and the RCC disaggregate most of their results by socioeconomic group, the World Bank does not; therefore, it has not been possible to account for the socioeconomic impact of differences in perceptions in those countries for which data are only made available by the World Bank.

Fourth, the target audience across surveys differs slightly: while the EC and the RCC aim at the general population, the World Bank targets a mixed audience composed of individuals from selected political, policy-making, economic, civil society and academic groups, as well as

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beneficiaries from its programmes. The results from the World Bank surveys may therefore not be as representative of the views of the general population as others.

Finally, using public opinion surveys available only in English limits the scope of the analysis.

Expanding the search to other languages, such as Russian, may increase the amount of information available, particularly for eastern European and central Asian countries. However, the use of multiple languages may also pose additional challenges, given the many connotations implied in the translation of complex concepts such as equity, equality, fairness or inclusiveness.

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Mapping of public perceptions

Methodology

The following surveys conducted by the EC, the RCC and the World Bank have been used for this rapid analysis and the results cover 46 European countries and areas.

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Standard Eurobarometer 89 was conducted by the EC in March 2018 across all Member States belonging to the EU from 1 July 2013 (EU28) (1). This survey explored the main issues of concern at both European and national levels, prioritized by citizens across the EU. While the results provide a ranking of policy areas according to their public support, they do not explicitly consider equity implications.

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Special Eurobarometer 471 on fairness, inequality and intergenerational mobility was prepared by the EC in December 2017 across all of the EU28 (2). This special analysis was used as a background paper to inform the discussions among European leaders at the Social Summit for Fair Jobs and Growth in Sweden in 2017, where the new European Pillar on Social Rights was signed. It provides an insight into public perceptions of fair and equal societies and of social mobility, as well as the main factors influencing those perceptions.

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Special Eurobarometer 469 on the integration of migrants in the EU was conducted by the EC across the EU28 in October 2017 to better understand public opinion in the aftermath of the increase of arrivals (3). The survey provides an overview of the perceptions of citizens across countries and by socioeconomic groups.

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Special Eurobarometer 467 on the future of Europe was prepared by the EC in September–

October 2017 across the EU28 (4). Part of a series dating back to 2006, the survey assesses changing perceptions on key social issues. It was released after the proclamation of the European Pillar of Social Rights.

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The Balkan Barometer was conducted by the RCC to assess public opinion on a variety of policy areas in south-eastern European (SEE) countries and areas. These include Albania, Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia and Serbia, as well as Kosovo¹ (5). The 2017 edition also contained a focus section on Turkey. The Balkan Barometer has been conducted since 2015 as part of the monitoring and reporting mechanism for the SEE 2020 Strategy and it has a particular focus on economic growth. In line with the EU 2020 Strategy, it assesses perceptions about integrated, smart, sustainable, inclusive growth, as well as those on governance for growth.

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World Bank country opinion surveys, conducted with the primary objective of assessing the opinions of political, policy-making and civil society groups, as well as of recipients of programmes, on the work of the World Bank (6–16). These surveys also include a section on general issues, which contain information on public perceptions of development priorities, poverty reduction, income inequalities and climate change. This information has been used to gather data on those countries and areas not covered by the EC and RCC surveys, including Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan.

1 For the purposes of this publication, all references, including in the bibliography, to “Kosovo” should be understood/read as “Kosovo (in accordance with Security Council resolution 1244 (1999))”.

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Summary of results

Findings from the rapid analysis of public opinions from the above-mentioned surveys conducted across the WHO European Region that are relevant to the implementation of the HESR initiative are summarized below in relation to the following three main areas:

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perceived policy priorities

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perceptions of equality, fairness, inclusion and integration

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perceptions of other policy matters of relevance to health equity.

Within each area, results are reported for the different geographical subsections covered in the surveys, including: EU countries; SEE countries and areas, and Turkey; and other countries belonging to the eastern and central Asian part of the WHO European Region.

Perceived policy priorities

There is relative agreement among respondents across the EU regarding the most important issues at European level (1). As reflected in Annex I, Fig. 1, EU citizens rate highest immigration, followed by terrorism and the economic situation.

Immigration occupies the top position among all European issues in 21 EU countries; a considerable increase compared to 14 countries in 2017. In all remaining EU countries, immigration ranks as the second most important European issue, except for in Portugal, where it ranks in fifth place. The highest scores were recorded in Estonia, Czechia and Hungary (1).² Terrorism is considered the second most important European issue by EU citizens overall. It occupies the first position in seven EU countries, with highest scores recorded in Lithuania, Cyprus and Ireland; and the second position in 15 other EU countries (1).

The economic situation is considered the third most relevant European issue for EU citizens.

Its highest scores are recorded in Greece, Cyprus and Spain. Compared to the 2017 results, perceptions about the state of the European economy have improved in 21 EU countries, with the greatest improvements recorded in Denmark, Croatia and Romania; and they have worsened most significantly in Malta (1).

Results vary substantially when EU citizens are asked to consider the same issues at national level. As shown in Annex I, Fig. 2, there is much wider diversity among the responses. Overall, unemployment, health and social security, and immigration rank in the top three positions.

Both the economic situation and terrorism accumulate much less support among national priorities, suggesting they are widely considered by EU citizens as matters to be addressed at supranational level (1).

On average, unemployment is the most important national issue for EU citizens. Its overall score has recorded a steady decrease since 2013, but it remains stable since 2017. It ranks highest

2 Countries and areas throughout the report are not listed according to an alphabetical order. The order of countries and areas (with the exception of Kosovo*) mentioned in each case responds to their ranking as per the scores obtained in the specific poll question being analysed.

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in Greece, Spain and Croatia (1).

Health and social security ranks as the second most important national issue for EU citizens overall, although it has been in a decreasing trend since 2015. It ranks first in 10 EU countries (Netherlands, Sweden, Finland, Denmark, United Kingdom, Slovakia, Slovenia, Poland, Hungary and Latvia); and second in an additional six EU countries (Romania, Portugal, Austria, Ireland, Estonia and Germany) (1).

Immigration occupies the third position among national issues overall across the EU, although it has also been decreasing since it reached its peak in 2015. Nevertheless, it still stands as the most important national issue in Malta, Germany, Austria, Belgium and Denmark (1).

There are relevant variations when comparing data between EU countries (1).

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The economic situation is considered the most important matter in Cyprus, and the second most important in Greece. Significant differences of opinion exist between EU countries:

93% of respondents in the Netherlands and Luxembourg consider the state of their national economy to be “good”, while only 2% share this opinion in Greece, 11% in Croatia, 16% in Spain, and 18% in both Italy and Bulgaria. There are also wide differences between countries if comparing the latest results with those of 2017: the largest improvements are recorded in Portugal (+10), Ireland (+7), Finland (+6) and Lithuania (+6); whereas they have decreased the most in Malta (-7), Spain (-4) and Sweden (-4).

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For most respondents in Lithuania, Estonia, Bulgaria, Czechia and Romania, their primary concerns are rising prices, inflation and the cost of living.

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Housing ranks as the most important issue in Luxembourg and Ireland, and as the second most important in the United Kingdom.

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Pensions occupy the position of the second most important issue in Spain, Czechia and Belgium.

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The education system is the second most important national matter in Sweden.

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The environment, climate and energy issues rank highest in the Netherlands and high in Denmark, where respondents consider it the second most important issue at national level;

followed by Malta, where the issue is ranked in third position.

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Terrorism is the second most important national issue in France, and the fourth most important in the United Kingdom.

The information available on the priorities expressed by populations in SEE countries and areas differs in scope to that of EU citizens, since the surveys conducted by the RCC have a specific focus on economic growth. It is important to note, therefore, that the expressed priorities in these countries and areas reflect the opinions of populations on specifically the most important problems facing their economies (5).

As reflected in Annex I, Fig. 3, the top problems identified on average by all populations across SEE countries and areas were unemployment, followed by the economic situation, and corruption. In comparison with results from 2015, concerns about unemployment have remained unchanged, while those relating to the economic situation have decreased, and concerns about corruption, crime, and brain drain/emigration have increased (5).

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Significant variations are also observed between SEE countries and areas (5).

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While unemployment ranks as the first concern in all countries and areas, it scores highest in Bosnia and Herzegovina (73%), and lowest in North Macedonia (50%).

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The overall economic situation ranks as the second problem in all SEE countries and areas. In Kosovo,³ the economic situation ranks as the third most significant problem.

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Corruption is identified as the third most significant problem for economies in all SEE countries and areas, except for North Macedonia, where political disputes rank in the third position and score highest in the region (26%). In Kosovo,³ corruption comes in second place and scores highest in the region (62%).

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Results in North Macedonia show the highest concerns in the region for the economic impact of brain drain and emigration (23%); while the highest concerns for crime are recorded in Bosnia and Herzegovina (27%) and in Montenegro (25%).

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Compared with the results obtained in 2015, the highest increases in concerns about crime are recorded in Albania, Bosnia and Herzegovina, and Montenegro; and for corruption, in Bosnia and Herzegovina. In Kosovo,³ too, there was a significant increase since 2015 in concerns about corruption.

Results also vary across SEE countries and areas when respondents were asked to prioritize policy areas for public investment. The first priority identified in Bosnia and Herzegovina, North Macedonia and Serbia was industrial development; in Croatia and Montenegro, agriculture; and in Albania it was social infrastructure, such as schools and hospitals (5). In Kosovo,³ the first priority identified was social infrastructure.

In its focus on Turkey, the 2017 edition of the RCC survey asked Turkish respondents about the two most important issues facing their society. It is important to note that, unlike in the case of SEE countries and areas, the question does not focus particularly on the economy. As shown in Annex I, Fig. 4, Turkish citizens are mostly concerned about security and terrorism, followed by unemployment, and the economic situation. Social infrastructure is the first priority for public investment in Turkey, followed by the energy sector, and small and medium enterprise development (5).

Annex I, Fig. 5 shows the three first development priorities identified by respondents in the World Bank country surveys. Public sector governance and reform ranks in the first position in Belarus, the Republic of Moldova and the Russian Federation (6, 9, 12), while in Kyrgyzstan, public administration and service delivery occupy the first place (11). Respondents in Turkmenistan, Kazakhstan and Tajikistan identified private sector development as their first priority (13, 15, 16). In Armenia, both economic growth and employment receive the same support as priority issues, sharing the first and second positions (8). Education was mentioned by the majority of respondents in Georgia and Uzbekistan (10, 14), while most respondents identified anti- corruption as their first priority in Ukraine (7).

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Perceptions of fairness, equality, inclusiveness and integration Fairness and equality

A large majority of EU respondents think that income differences in their countries are too great (84%). Over 90% of respondents agreed with this statement in Portugal, Germany, Lithuania, Spain, Slovakia and Bulgaria (Annex I, Fig. 6). In addition, 81% of respondents across the EU agreed that their governments should do something to reduce these differences in income level.

Highest support for governmental action was recorded in Portugal, Spain, Lithuania, Cyprus and Latvia, where over 90% of respondents shared this view. The lowest scores were obtained in Denmark, where only 51% of respondents agreed, followed by the Netherlands (65%) and Sweden (68%) (Annex I, Fig. 7) (1).

Public opinion across the EU about whether opportunities to succeed in life are equal for everyone is split: 51% overall expressed that they share this view, while 46% thought the opposite.

There was wider agreement on this statement among citizens in Malta, Ireland, Luxembourg, Austria and Finland, and less agreement in Spain, Portugal, Bulgaria, Greece and Slovenia (Annex I, Fig. 8) (4). When asked to compare the situation with that of 30 years ago, 46% agreed that opportunities for getting ahead in life have become more equal in their country, while 29%

disagreed: the highest percentage of agreement was recorded in Ireland, Finland and Malta; and the lowest in Greece, France and Croatia (2).

A total of 83% of EU respondents agreed that a free-market economy should go hand in hand with a high level of social protection; only 8% disagreed with this statement. The highest scores were recorded in Greece, Cyprus, Germany, Latvia and Lithuania; and the lowest in Finland, United Kingdom, Italy, Czechia and Spain. However, the lowest score, in Finland, was still at 74%. Taking into account disaggregation by socioeconomic groups and gender, male respondents, those who have completed more education, and those who have experienced less financial hardship, as well as those who place themselves higher up the social scale, were more likely to agree with this statement (4).

Asked about what issues should be emphasized to enable facing major global challenges, the first topic identified by EU respondents was social equality and solidarity (45% overall; scoring highest in Portugal, Germany, Spain and France, and lowest in Italy, Romania, Poland and Hungary), followed by protection of the environment (35% overall; with the highest scores recorded in Malta and Denmark) (Annex I, Fig. 9) (4).

An overwhelming majority of respondents across SEE countries and areas think that the gap between the rich and poor is increasing in their economies, with the highest rates of agreement recorded in Croatia (94%), Bosnia and Herzegovina (91%) and Serbia (89%). In Kosovo,⁴ only 66%

of respondents think that the rich–poor divide is increasing. Responses vary widely depending on the socioeconomic status of the respondents: overall, only 16% of those who positioned themselves above the social average perceived the gap, as opposed to 94% of those below the social average. In comparison with SEE countries and areas, fewer people in Turkey think that the gap between the rich and the poor is increasing in their economy; however, they represent a large majority (80%) (Annex I, Fig. 10) (5).

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In order to reduce inequalities that affect women and men, respondents in SEE countries and areas identified violence against women as the first priority which governments should tackle. Highest support for action in this area was recorded in Serbia, followed by Albania. Kosovo⁵ also registered as highly supportive of action to reduce violence against women. Violence against women was also identified as the first priority in Turkey, by 84% of respondents (Annex I, Fig. 11) (5).

Among all countries surveyed by the World Bank, respondents in the Republic of Moldova, Georgia, Kyrgyzstan and Kazakhstan showed the highest agreement that the gap between rich and poor people in their countries is a problem (Annex I, Fig. 12). Data on this issue are not available for Turkmenistan, Tajikistan, Ukraine or the Russian Federation (10–12, 15).

Annex I, Fig. 13 shows the three main factors contributing to poverty reduction identified by respondents to the World Bank country surveys. Economic growth ranks in the top position in Belarus and Georgia; public administration and service delivery are first in Uzbekistan, Kazakhstan and Tajikistan; anti-corruption is at the top in the Republic of Moldova; rural development, in Kyrgyzstan; private sector development, in the Russian Federation; and social protection, in Ukraine. No data are available on this question in Armenia or Turkmenistan (6, 7, 9–12, 14–16).

Asked about the top three factors contributing to shared prosperity in their countries, respondents in Belarus, Georgia, Kyrgyzstan and the Republic of Moldova identified consistent economic growth as the first priority. Education and training that better ensure job opportunities ranks first in Uzbekistan; better entrepreneurial opportunities, in Kazakhstan and the Russian Federation;

quality of education and training, in Tajikistan; and a growing middle class, in Ukraine (Annex I, Fig. 14). No data are available on this issue for Armenia or Turkmenistan (6, 7, 9–12, 14–16).

Inclusiveness and integration

As already mentioned, immigration has been identified as the most important issue for EU citizens overall at European level, and the third most important at national level (1). Political sensitivity associated with the reception and integration of refugees and migrants into EU countries has increased since the number of arrivals has risen, from 2014. Forcibly displaced migrants are often subject to inequities in health care access, coverage and outcomes. According to the special survey on the integration of non-EU migrants conducted in 2017 (Special Eurobarometer 469), all EU citizens overestimated the number of non-EU immigrants living in their countries, except for those in Croatia, Estonia and Sweden (in the latter, the level of overestimation is minimal). In 19 EU countries, the overestimation is at least twice the size of the actual proportion. Highest scores were recorded in Slovakia, Poland, Bulgaria and Romania (Annex I, Fig. 15) (3).

Citizens across the EU are divided regarding their opinion on the impact of migration:

42% consider it to be positive, 30% negative, and 23% neutral. Most respondents in Sweden, Luxembourg and the United Kingdom described the impact as positive, while the majority in Bulgaria, Greece, Hungary and Czechia, and half of the respondents in Slovakia, thought the opposite (Annex I, Fig. 16) (3). Data disaggregated by socioeconomic status show that the younger the respondent, the longer they have remained in education, the fewer the financial difficulties they have experienced, and the more urbanized their environment, the more likely they are to agree that immigration is a good thing (2).

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Slightly over half of the respondents across the EU (51%) think that their governments are doing enough to support the integration of immigrants; this view was most widely shared in Austria, Portugal, Luxembourg, Ireland and Czechia, and least supported in Sweden, United Kingdom, Latvia, Denmark and Poland (Annex I, Fig. 17) (3).

In all EU countries, except for Hungary, over half of the respondents agreed that giving immigrants the same rights as citizens in their countries, in terms of access to education, health care and social protection, could increase their prospects of a successful integration process. The greatest support for this statement was recorded in Portugal, Netherlands, Ireland, Denmark and Luxembourg; and the lowest level of agreement was found in Hungary, Bulgaria, Slovakia and Czechia (Annex I, Fig. 18) (3).

Support for action by governments and public authorities to promote opportunities for equal access for vulnerable groups across all SEE countries and areas, as well as in Turkey, was found to be higher for measures targeting people with disabilities than it was for Roma, displaced people or refugees and other ethnic minorities (5).

Public opinion about the economic impact of immigration is split in SEE countries and areas:

44% of respondents are neutral, 27% think it is positive, while 24% think it is negative. The largest opposition towards immigration was recorded in Montenegro (where 32% opposed it), and the least in Albania (where 37% supported it) (Annex I, Fig. 19). In Kosovo⁶ 52% of respondents supported immigration. Socioeconomic patterns are similar to those registered for EU citizens:

on average, the younger and more educated, and the higher the social status of respondents, the more likely they are to have positive attitudes towards migration. Greater opposition towards immigration was recorded in Turkey in comparison to SEE countries and areas; 40% of Turkish respondents considered the impact of immigration to be bad; 17% thought it was good; and 39%

were indifferent (Annex I, Fig. 20) (5).

In both the SEE countries and areas, and Turkey, negative perceptions about the impact of immigration increased when respondents were asked about refugees, specifically. There are, however, some differences across countries and areas: North Macedonia is the only country where the majority of the population considered the impact of refugees coming to live and work in their country to be negative (57%), followed by Serbia and Turkey (47%). Most positive attitudes towards refugees were recorded in Albania, where 27% of the population considered their impact to be positive. In Kosovo,⁶ attitudes towards refugees were similarly favourable, with 27% of respondents considering their impact as positive (Annex I, Fig. 21 and Fig. 22) (5).

The country surveys conducted by the World Bank do not account for public opinion on inclusiveness and integration; therefore, data are not available from other countries of the WHO European Region, beyond those listed above.

Perceptions of other policy matters of relevance to health equity Health services

Having good health is the first perceived factor for getting ahead in life by EU citizens overall;

it is considered as essential by 48% of respondents (Annex I, Fig. 23). The highest support was 6 For the purposes of this publication, all references, including in the bibliography, to “Kosovo” should be understood/read as “Kosovo (in accordance with Security Council resolution 1244 (1999))”.

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recorded in Bulgaria, Cyprus, Greece, Austria and Germany (2). A total of 60% of EU citizens supported more European-level decision-making, with regards to health and social security issues, while 32% thought the opposite. However, when respondents were asked to prioritize policy areas where European-level decision-making is needed most, health and social security ranked last after other policy priorities, such as fighting terrorism, promoting democracy and peace, protecting the environment, dealing with migration, promoting equal treatment of men and women, securing energy supply, and stimulating investment and job creation (4).

Populations of SEE countries and areas reported varying levels of satisfaction with the health services available in their countries/areas. Croatia has the highest levels of satisfaction in the subregion, while Albania records the lowest levels of satisfaction, followed by Bosnia and Herzegovina (Annex I, Fig. 24) (5).

High perceptions of corruption across SEE countries and areas corroborate the fact that the rule of law remains a challenge. When asked to which institutions respondents or their relatives had paid bribes in the past 12 months, health care came first in all SEE countries and areas (Annex I, Fig. 25). A total of 12% of respondents on average claimed having paid bribes to health care providers. The highest level was recorded in Albania (54%). In comparison with SEE countries and areas, Turkish citizens are more satisfied with medical and health services, and consider them to be less corrupt (only 1.7% reported having paid bribes for medical and health services) (5).

As shown in Annex 1, Fig. 26, responses in the World Bank surveys vary across countries with regards to the perceived relevance of health as a development priority. The highest support was recorded in Turkmenistan and Kazakhstan, where 24% and 19% of respondents, respectively, considered it a priority, thus occupying the fourth and sixth positions among all development priorities (6–16).

Health is not identified as a top priority for poverty reduction in any country, according to the surveys conducted by the World Bank. The largest support for this was recorded in Ukraine and the Russian Federation, where it was mentioned by 7% of respondents (6, 7, 9–12, 14–16). With regards to factors contributing to shared prosperity, health did not receive enough support to rank in the top three positions in any country. However, it ranked as the fourth most important factor for achieving shared prosperity in Tajikistan, mentioned by 16% of respondents (6, 7, 9–12, 14–16).

Living conditions/environments

In terms of climate change, EU citizens considered it the sixth issue of concern at European level overall. As mentioned previously, the highest levels of concern for climate change were recorded in the Netherlands and Denmark, where respondents considered it the second most important issue at national level; followed by Malta, where it ranked third (1).

Overall in SEE countries and areas, 73% of respondents think that climate change is a problem, with 36% of them describing it as a very serious problem. Similar results were recorded in Turkey, where 74% see climate change as a problem, including 51% who described it as very serious (5).

The majority of interviewees in all countries surveyed by the World Bank think that climate change is a problem, with lowest scores recorded in the Republic of Moldova (52%) and the highest found in Georgia and Turkmenistan (91%), followed by Kyrgyzstan and Uzbekistan (86%) (8–15). No data are available on this issue for Tajikistan, Ukraine or the Russian Federation.

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Personal and community capabilities (social and human capital)

Education is considered an essential factor for getting ahead in life by 33% of EU citizens overall, ranking as the second most important aspect (Annex I, Fig. 23), with the highest scores recorded in Germany, Cyprus, Austria, Latvia and Malta (2).

The three most important factors for getting ahead in life for populations across SEE countries and areas are: knowing the right people, working hard and having a good education. In Kosovo⁷ 58% of respondents considered having a good education as the most important aspect. Turkey also stands out, with 44% of respondents sharing the same view (5).

Overview of entry points and challenges to the scale-up and implementation of the HESR initiative

The analysis of public opinion on key policy areas, as well as of general perceptions of equity, fairness, inclusion and integration, may reveal potential advocacy messages and entry points for action to reduce health inequities across countries and areas in the WHO European Region, which benefit from a large public support.

Table 1 outlines the main potential entry points and challenges identified in the rapid analysis. It does not represent a finite and exhaustive list, but rather highlights the most relevant outcomes from this exercise. Issues are categorized as an entry point or a challenge in particular countries and areas, depending on whether they rank highly as a priority and/or a concern, as well as based on the overall public support they receive.

These entry points and challenges have been classified in relation to the five main policy areas identified through the HESR initiative, and according to the definitions of each area provided in the report. These areas include: health services; living conditions/environments; personal and community capabilities (social and human capital); employment and working conditions; and income and social protection.

Some entry points and challenges may affect more than one policy area, given the close interrelationship between them. In addition, the entry points and challenges are not incompatible. Certain challenges, such as climate change, may also present opportunities to reduce inequities, for example through preparedness actions that address particularly the needs of groups in situations that leave them exposed to vulnerability. Policies related to security and the global economy are included in the category of living environments, given their high impact on shaping the broader conditions in which people live; while policies related to immigration are included in the category of personal and community capabilities (social and human capital).

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Table 1. Potential entry points for and challenges to scaling up action on health equity, by policy area

Policy area Entry points Challenges

Health

services Having good health is considered the first factor for getting ahead in life across the EU, especially in Bulgaria, Cyprus, Greece, Austria and Germany.

Health is considered a high development priority in Turkmenistan and Kazakhstan, as well as a key factor to achieve shared prosperity in Tajikistan.

Levels of satisfaction with health services are particularly low in Albania, and Bosnia and Herzegovina.

High levels of corruption are found in the health sector across SEE countries and areas, and particularly in Albania.

Living

environments Housing is perceived as a national priority in Luxembourg, Ireland and the United Kingdom.

Environment, climate and energy issues are national priorities in the Netherlands, Denmark and Malta.

Social infrastructure is perceived as a priority in Albania and Turkey. This is also the case in Kosovo.^*

The energy sector is a national priority for citizens in Turkey.

Public sector governance and reform are perceived as priorities in Belarus, the Republic of Moldova and the Russian Federation.

Public administration and service delivery are prioritized in Kyrgyzstan, Uzbekistan, Kazakhstan and Tajikistan.

Anti-corruption is considered a priority to achieve poverty reduction in the Republic of Moldova.

Rural development is considered the first priority to reduce poverty in Kyrgyzstan.

Terrorism is a major concern overall in the EU, and especially in Lithuania, Cyprus, Ireland, France and the United Kingdom, as well as in Turkey.

Corruption is considered a main concern in SEE countries and areas overall, and especially in Bosnia and Herzegovina, and in Ukraine, as well as in Kosovo.^*

Political disputes rank particularly high as a concern in North Macedonia, along with brain drain and emigration.

Crime is highlighted as a concern for citizens in Bosnia and Herzegovina, Montenegro and Albania.

Climate change is widely considered to be a problem across SEE countries and areas and Turkey, as well as in Georgia, Turkmenistan, Kyrgyzstan and Uzbekistan.

Personal and community capabilities (social and human capital)

Education is a national priority in Sweden, Georgia, Uzbekistan and Tajikistan. It is also considered a key factor for getting ahead in life across the EU, and especially in Germany, Cyprus, Austria, Latvia and Malta. In Turkey, as well as in Kosovo,^* education is also

believed to be essential to getting ahead in life.

Social equity and solidarity are considered the first priorities in the EU in the context of globalization; this is particularly the case in Portugal, Germany, Spain and France.

Violence against women is perceived as the first priority to reduce inequalities between men and women across SEE countries and areas, and especially in Albania, Serbia and Turkey, as well as in Kosovo.^*

Immigration is widely seen as a positive factor in Sweden, Luxembourg and the United Kingdom. Most positive attitudes towards immigration (and refugees particularly) in SEE countries and areas are found in Albania. The results from Kosovo^* also revealed positive attitudes towards immigration and refugees.

Immigration is a major concern overall in the EU, with the most negative attitudes towards it recorded in Estonia, Czechia, Hungary, Germany, Austria, Belgium, Malta, Denmark, Bulgaria, Greece and Slovakia.

Widespread opposition to immigration (and refugees particularly) is also found in Turkey, Montenegro, North Macedonia and Serbia.

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Policy area Entry points Challenges Employment

and working conditions

Industrial development is perceived as a priority in Bosnia and Herzegovina, North Macedonia and Serbia.

Small and medium enterprise development is a priority in Turkey.

Agriculture is prioritized by citizens in Croatia and Montenegro.

Private sector development is highlighted as a priority in the context of poverty reduction in Turkmenistan, Kazakhstan and Tajikistan, as well as in the Russian Federation.

Employment is a key priority for citizens in Armenia.

Obtaining better entrepreneurial opportunities is considered particularly important in Kazakhstan and the Russian Federation.

Creating a growing middle class is prioritized in Ukraine.

Unemployment is a major concern overall in the EU and in SEE countries and areas, especially in Greece, Spain, Croatia, Bosnia and Herzegovina, and Turkey.

Income and social protection

Health and social security are main priorities at national level across the EU, and especially in the Netherlands, Sweden, Finland,

Denmark, United Kingdom, Slovakia, Slovenia, Hungary, Poland, Latvia, Romania, Portugal, Austria, Ireland, Estonia and Germany.

Economic growth is considered a priority in Armenia; it is considered essential to reduce poverty and achieve shared prosperity in Belarus and Georgia; and in Kyrgyzstan and the Republic of Moldova it is also widely seen as a priority to attain shared prosperity.

Reduction of income inequalities is a priority requiring national government-led action across the EU, especially in Portugal, Germany, Lithuania, Spain, Slovakia, Bulgaria, Cyprus and Latvia, as well as in Croatia, Bosnia and Herzegovina, Serbia, the Republic of Moldova, Georgia, Kyrgyzstan and Kazakhstan.

Unequal access to opportunities to succeed in life for everyone is widely acknowledged as being problematic in Portugal, Spain, Bulgaria, Greece and Slovenia.

Social protection is widely considered indispensable across the EU as a condition for advancing free-market economies, and especially in Greece, Cyprus, Germany, Latvia and Lithuania, as well as in Ukraine, where it is also considered as the first priority to reduce poverty.

The economic situation is a major concern overall in the EU and in SEE countries and areas, but especially in Greece, Cyprus, Spain, Malta, Croatia, Italy and Bulgaria, as well as in Turkey.

Rising prices, inflation and the cost of living are highlighted as key concerns in Lithuania, Estonia, Bulgaria, Czechia and Romania.

The state of pensions ranks as a high priority in Spain, Czechia and Belgium.

Support for national-level government- led action to reduce income inequalities is lowest in Denmark, the Netherlands and Sweden in comparison with the EU average. Such support is also low in Kosovo,* compared to the average for the SEE countries and areas.

The belief that opportunities to succeed in life are equal for everybody is widely shared by citizens of Malta, Ireland, Austria, Luxembourg and Finland.

* For the purposes of this publication, all references, including in the bibliography, to “Kosovo” should be understood/read as “Kosovo (in accordance with Security Council resolution 1244 (1999))”.

Table 1 contd

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Conclusions

Health and well-being are shaped by a variety of factors of genetic, biological, chemical, physical, social, economic, environmental and political nature. As a consequence, health outcomes are determined by the conditions in which people are born, grow, live, work and age, as well as the wider social, economic and political forces that shape such conditions (17). Action in any policy area that affects people’s lives – from health care to transport, employment or foreign policy – may potentially have a positive or negative impact on health outcomes, as well as on the distribution of health inequities within and between countries and areas.

In a context of limited resources, the understanding that action across all policy sectors may have a potential impact on the enjoyment of good health and the distribution of health inequities poses a fundamental question: where should efforts to advocate for health equity in public policy-making be prioritized?

Furthermore, critics of the limited progress on addressing the social determinants of health have pointed to an additional challenge that hinders the translation of scientific evidence into action in this area: the lack of political will. In recent years, taking action to reduce health inequities has been widely recognized as an explicit political process (17).

Acknowledging the inherently political nature of the health equity agenda, this mapping exercise has used information on public opinion, attitudes and perceptions expressed by populations across the WHO European Region to identify key messages, entry points for and challenges to its implementation. It must be acknowledged that public opinion surveys may not reflect accurately public political support, particularly with regards to ethically charged issues (such as equity) that may lead respondents to publicly defend one position but to act differently in reality.

Nevertheless, surveys remain one of the main tools to gauge public opinion. Acknowledging the political significance of public opinion data in democratic contexts, the results from this rapid analysis may be used as an advocacy tool to encourage political action for health equity across policy areas.

The broad scope of this mapping exercise, covering all policy areas across the 53 countries of the WHO European Region, has posed necessary limitations on the depth of the study. Nevertheless, the methodology used may be applied in subsequent exercises, conducted in more restrained contexts. For example, a similar mapping exercise within a given country or area may be used to identify key policy areas for which there is wide public support for governmental action to reduce inequities, thus informing and supporting advocacy strategies to promote multisectoral action for health equity.

Additionally, this analysis may be used to inform further research on the relationship between the self-reported data on health status and life satisfaction (used in the forthcoming Health Equity Atlas, hosted on the WHO Regional Office for Europe’s European Health Information Gateway) and public perceptions on health equity-related issues from public opinion surveys. Finally, the use of opinion polls to inform advocacy for health equity may prompt new institutional collaborations to adapt the scope of population surveys for this purpose.

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References

1. Standard Eurobarometer 89. Public opinion in the European Union. First results. Brussels:

European Commission; 2018.

2. Special Eurobarometer 471. Fairness, inequality and intergenerational mobility. Brussels:

3. Special Eurobarometer 469. Integration of immigrants in the European Union. Brussels:

4. Special Eurobarometer 467. Future of Europe – social issues. Brussels: European Commission; 2017.

5. Public opinion survey. Balkan barometer 2017. Sarajevo: Regional Cooperation Council;

2017.

6. Russia. The World Bank Group country survey FY 2014. Report of findings. Washington (DC): The World Bank Group; 2014.

7. Ukraine. The World Bank Group country survey FY 2014. Report of findings. Washington (DC): The World Bank Group; 2014.

8. FY16 Armenia country opinion survey report. Washington (DC): The World Bank Group;

2016.

9. FY16 Belarus country opinion survey report. Washington (DC): The World Bank Group;

2016.

10. FY16 Georgia country opinion survey report. Washington (DC): The World Bank Group;

2016.

11. FY16 the Kyrgyz Republic country opinion survey report. Washington (DC): The World Bank Group; 2016.

12. FY16 Moldova country opinion survey report. Washington (DC): The World Bank Group;

2016.

13. FY16 Turkmenistan country opinion survey report. Washington (DC): The World Bank Group; 2016.

14. FY16 Uzbekistan country opinion survey report. Washington (DC): The World Bank Group; 2016.

15. FY 2017 Kazakhstan country opinion survey report. Washington (DC): The World Bank Group; 2017.

16. FY 2017 Tajikistan country opinion survey report. Washington (DC): The World Bank Group; 2017.

17. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health.

Geneva: World Health Organization; 2008.

Strategic mapping of public perceptions of health equity

Strategic mapping of public perceptions of health equity

What the public think is important to live a healthy prosperous life

public opinion

health services

Strategic mapping of public

perceptions of health equity

Contents

Abbreviations

Acknowledgements

Executive summary

Introduction

Objectives

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Structure

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Limitations

Mapping of public perceptions

Methodology

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Summary of results

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Overview of entry points and challenges to the scale-up and implementation of the HESR initiative

Conclusions

References