Inequalities in health 5

means that more af uent individuals along with those with higher social participation
and position in a society infuence access to health production inputs. Income and eco-
nomic af uence infuence individuals budget restrictions; moreover, sources of income
determine access to enabling inputs such as education, which, in turn, afect health.
Most of this association is dynamic, infuenced by unobserved factors; often we
barely observe changes over time. The Marmot Review (Marmot, 2009, p. 3) established
that inequalities in health result from a combination of material goods, social status
and participation, as well as education and housing, as follows: Inequalities in social
determinants closely relate to health inequalities the more unequal income distribution,
educational outcomes, and housing quality are, for instance, the more unequal health is.
The review refers to the so- called absolute hypothesis, where absolute income and
material condition are argued to afect health. Parallel to this, Wilkinson (1996, 1997)
developed an alternative explanation for health inequalities based on the efect that
inequalities in income exert on the health status of individuals.
Longitudinal studies seem to point towards evidence for the absolute- income hypoth-
esis (Gerdtham and Johannesson, 2004); the explanations are not mutually exclusive and
suggest that to reduce inequalities in health, it may be important to design interventions
that address both psychosocial and purely material health production determinants.
None the less, not all inequalities in health are determined by socioeconomic position
(Le Grand, 1987), which implies that inequalities should be clearly distinguished from
inequities. Even when they are, not all of the causes of social inequalities in health can
be avoided by (usually short- term) public policy interventions in individual health pro-
duction processes. Some inequalities are not under individual or public authority control
for instance inequalities resulting from the depreciation of health capital over time;
the same would apply to biologically driven gender diferences in health (Wagstaf et al.,
1991), or environmental or generic features.
The health economic and policy literature has documented that inequalities favouring
the better- of exist in all European countries, both with respect to the use of health care
and with respect to the distribution of health itself, and that the degree of inequality is
particularly associated with education, income and job status (Hernndez- Quevedo et
al., 2006, 2008). Although health deteriorates with age and is a function of the socioeco-
nomic status of the individual, the exact nature of this union is complex and controver-
sial. An important source of debate is the association between health and socioeconomic
status, in particular health and education (see Grossman, 2000; Smith, 2004); and health
and income or wealth (see, e.g., Smith, 1999, 2004). A positive relationship between
health and socioeconomic status is widely documented across many societies and periods
(see, e.g., Smith, 1999; Deaton, 2003). But the causal mechanisms underlying this rela-
tionship are complex and controversial. Socioeconomic status can infuence health
through the direct infuence of material deprivation on the health production function
and on the access to health care, or of education on the take- up and compliance with
medical treatments; health may infuence socioeconomic status through the impact of
health shocks on labour market outcomes, such as unemployment, early retirement
(Bound, 1991; Disney et al., 2006) and earnings (Contoyannis and Rice, 2001). In addi-
tion, it has been argued that this association between health and socioeconomic status
could be due to third factors, such as time preference rates, that do not imply any causal
relationship (Hernndez- Quevedo et al., 2008).
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