12 Chapter 1 same period (Norway and Hungary, 1970 to 2010) [55]. International differences in the equity of health care financing and delivery also has been attracting policy attention since the early 1990s [56]. By then, studies showed that higher-income individuals used specialist doctor appointments substantially more than low-income groups, accounting for these groups differences in need for such services. The inequities were observed in most European countries regardless of their different health care systems. In contrast, the likelihood of using primary care (seeing a GP) was more equitably distributed according to need [57]. Some countries even had a pro-poor distribution on the number of GP appointments, conditional on having at least one visit [56]. Despite some country commitment to reducing health care inequities findings from more than a decade later concluded that the inequity persisted through time, except for a few exceptions [58]. Progress has been equally slow towards reducing health inequalities, even though the ambition to do so has been shared by countries throughout the last decades. One of the ambitions set internationally was “Closing the gap in a generation”, an initiative led by the World Health Organization (WHO) and anchored in the work of the Commission on Social Determinants of Health [59]. The initiative included several countries and partners aiming to shape policy and programs on social determinants of health to improve health equity. Unfortunately, the progress towards closing the gap in a generation has been minimal. Several reasons can be discussed as being behind this lack of progress. First, the widening of inequalities in social determinants of health, particularly those linked to socioeconomic conditions such as income and occupation [54]. A set of crises has recently fuelled the increase in income inequality. Among these crises is the COVID-19 pandemic, which has threatened to reverse part of the last years´ achievements in reducing disparities [60]. Second, how progress has been measured and whether the focus should be on relative (e.g., rate ratios of mortality) or absolute (e.g. rate differences in mortality) changes in inequalities [61]. Progress is admittedly more difficult to achieve when measured relatively in the presence of downward trends, as was the case of mortality and morbidity in Europe pre-pandemic [54]. While such an argument favours looking at absolute inequalities, methodological concerns exist for this approach: particularly in the case of steadily decreasing outcomes, an “arithmetic maturation process” could automatically lead to a decrease in absolute inequalities that does not represent actual progress [61]. Third, and perhaps most important, deliberate efforts towards closing the health gap have been too few and of too small magnitude to deal with the challenge [54]. Most countries have never implemented a strategy primarily aimed at reducing health inequalities. In those that did – like the almost unique case of England - the population-level effects were limited [54]. International comparisons suggest that country differences in mortality inequalities seem to be greatly driven by inequalities in lifestyle behaviours (smoking and excessive alcohol consumption) and poverty. Country-level contextual factors such as
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