Who are the vulnerable people you refer to?

Xenia Scheil-Adlung: These groups are mainly the people living in poverty, particularly rural women, Roma and Sinti people, and the elderly. Policies have not paid enough attention to the needs of these groups, who face significant gaps in access to health care because of deficits in social health protection.

You write that gaps in legal health coverage are among the factors contributing to the inequities. Could you explain?

Xenia Scheil-Adlung: Eligibility criteria for social health protection including maternity coverage often include employment contracts based on full-time work or residency. Women, Roma and migrant populations, who often face difficulties in accessing the labour market, are particularly disadvantaged. In Bulgaria, for example, 46 per cent of Roma do not have health insurance because they do not meet the criteria. In Britain an estimated 47 per cent of all migrants are not covered by standard employment-based social health protection.

You also mention gaps in financial protection? What are they?

Xenia Scheil-Adlung: The lack of financial protection against out-of-pocket payments can substantially limit the ability to access care for vulnerable groups. In Georgia for example, out-of-pocket payments account for as much as 74.7 per cent of total health expenditure. Such inequities in financial protection can lead to catastrophic health expenditure – out-of-pocket expenditure that exceeds 40 per cent of the household income. In the European region, such effects are particularly relevant for female-headed households, in case of complicated deliveries and for the elderly.

There are presumably also vast differences from one country to another?

Xenia Scheil-Adlung: Yes, and in many cases there are also geographical inequalities within a given country. Within the region, the availability of practicing physicians ranges from 459 per 100,000 population in Austria to 216 in Poland. Annual expenditure for maternity protection per baby varies from US$ 31,109 in Norway and US$ 24 in Armenia. There is also a strong urban-rural divide. In France, for example, there are 458 physicians per 100,000 people in urban areas, and only 122 per 100,000 people in rural areas.

So inequities in access to health care are found across the region, including the wealthier countries?

Xenia Scheil-Adlung: Indeed. Even in countries like Germany there are inequities. Some rural areas suffer from a critical shortage of doctors, while there are many in cities like Munich or Frankfurt. Gaps in access to health care may also result from a limited scope of benefits. In Belgium, Denmark, Greece, Iceland, and Portugal, for example, dental care is often excluded from benefit packages. The exclusion of such benefits results in high out-of-pocket payments and hinders effective access to care.

What needs to be done to resolve these issues?

Xenia Scheil-Adlung: First one needs to understand that these inequalities originate from Issues related to gaps in social health protection that need to be closed, as well as the broader contextual environment in which these vulnerable groups live, including poverty, lack of access to employment and deficits in social protection coverage e.g. in case of old age, unemployment, and low or no income. So, addressing the issues requires a comprehensive approach focused on extending coverage and effective access to health care, as well as on addressing socio-economic inequalities through at least a basic set of social rights for all — the social protection floor approach.

Addressing inequities in access to health care for vulnerable groups in countries of the European region, by Xenia Scheil-Adlung and Catharina Kuhl, International Labour Office, Geneva, 2011