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Health and social inequities in Yugoslavia
Sm. Sci.Med. Vol.31,No. 3.pp.405412. 1990 Printed m Great Britain. All rights reserved
HEALTH
0277-9536190 53.00f0.00 Copyright ,c 1990 Pergamon Pressplc
AND SOCIAL INEQUITIES
IN YUGOSLAVIA
MIROSLAV MASTILICA
Department of Medical Sociology, Andrija Stampar School of Public Health, Medical School, University of Zagreb, 41000 Zagreb, Yugoslavia Abstract-In Yugoslavia the problem of social inequities comes on the political agenda every time when society is in a crisis. This paper describes the pattern of social inequities in health. Data are mostly used from statistics. The features of health inequalities are shown. The marked inequalities exist regionally, among republics and provinces, in spite of the reallocation of resources. Health inequalities exist also among social classes however they are measured. Individually based measurement shows inequalities in health between all individuals of the population. As Yugoslav society is passing through severe economic crisis when social structure polarizes and becomes rigid-inequalities in health tend to increase. Key words-inequities,
health, Yugoslavia
INTRODUCTION
The problem of social inequity has remained one of the open social problems of socialist societies [I]. In Yugoslavia, the problem of social inequities has been pointed out as an important political problem every time the society has found itself in some kind of crisis. It was only at the beginning of the seventies that the problem of social inequities in Yugoslav society became the subject of more serious sociological studies [2-4]. In spite of realization that health status and health care can be a sensitive area of social differentiation and stratification, social inequities in health and health care have not been given the same importance as some other forms of expressing social inequities [5]. There is almost no significant sociological research of social inequities coming out in health and health care. This paper is one of the first attempts of describing the basic pattern of social inequities in health in Yugoslavia. Yugoslavia is well known as a country with large geographical, cultural and ethnical differences as well as a country with marked inequalities in socio-economic development, so that it was easy to make the starting assumption that there are inequalities in health which correspond to the numerous social inequalities. Explanations of health inequalities presented here are mostly based on the data from statistics. That is where certain difficulties in interpretation come from. They come from shortcomings in Yugoslav official statistics, i.e. from the lack of socio-economic variables in health statistics. Most of the data of health statistics are published so that most of the indicators presented here are being calculated. Other problems to be further discussed are validity of indicators and how much found inequalities are an artifact of the indicators themselves. Data on social inequities relate to the period of the beginning of serious socio-econonmic crisis in Yugoslavia, which nowadays has a considerable impact on the increase of social inequities, particularly in the field of health. 405
The discussion is divided in three parts. Inequities in health are analyzed in relation to the regional, social class and individual inequalities. REGIONAL INEQUALITIES
Regional disparities are an important indicator of the existence of health inequalities in Yugoslavia. Namely, there are well-recognized disparities in socio-economic development among regions (socialist republics and autonomous provincestifrom highly developed Slovenia, Croatia, Serbia and Vojvodina, to less developed Bosnia & Herzegovina and Montenegro, and to the least developed Macedonia and Kosovo. It is possible to assume that regional inequalities reflect underlying regional disparities in socio-economic conditions, rural-urban distribution, and industrialization, as well as regional differences in culture, differences in life-styles and levels of living, etc. The second reason for using regional indicators in explanation of health inequalities is the availability of data, which are mostly collected and published on regional basis. In the following analysis of inequalities data are not analyzed for Yugoslavia as a whole but by republic and provinces. Comparison over time is also shown. Data for the Socialist Republic of Serbia are presented for its proper part, i.e. Serbia without provinces. Infant mortality In Yugoslavia infant mortality has declined very sharply-from 164.5 per 1000 live births in 1931 to 27.1 in 1986, but it is still one of the highest in Europe. However, regional comparisons show that there are significant differences in infant mortality among different areas. It occurs that regional inequalities in infant mortality correspond to the degree of socio-economic development (Table 1). Regional disparities in illiteracy rates, as a general indicator of social and cultural development, in correlation to the infant mortality rate show that
406
MIROSLAV
Tlrble
I.
InPdant mortality republics
rates and
and
GNP
provinces
Infant
per
c;lpita
index
by
MASTILICA
Table
2.
Infant
(1981)
mortalitv
mortaltry
provmces
rate
GNP
index
rates
1950-54
Yugoslavia. 1986. per
republics
and
1000
1961
1971
I981
Slovenia
13.3
196
Sloven3
69.6
29.4
25.5
13.1
13.3
Croatia
18.9
126
Croatia
I IO.8
62.9
29.5
IX.9
15.3
Serbia
23.8
Proper
Bosnia
98
17.1
Vojvodina
II8
30. I
& Hercegovina
67
1950-54
in to
Serbia
Proper
1986
96.4
66.3
37.3
23.8
24. I
Vojvodina
119.6
71.6
34.5
17.1
II.1
Bosnia
135.5
98.7
54.7
30.1
17.9
27.8
22.8
24.x 47.9
& Hercegovina
Montenegro
22.8
79
Montenegro
s9.0
61.4
Macedonia
51.1
66
Macedonia
139.2
112.1
s2.2
51.1
KOSOVO
62.9
29
KOSOVO
155.6
125.9
69.6
62.9
55.x
Yugoslavia
30.8
100
Yugoslavia
116.2
82.0
49.5
30.8
27. I
Source:
Ref.
Source:
[6].
inequalities in infant mortality reflect not only economical but also cultural status of the population (Fig. 1). Infant mortality rates are low in the developed regions (13.3 in Slovenia, I I.1 in Vojvodina, 15.3 in Croatia) and high in comparatively poor regions in the south (55.8 in Kosovo, 47.9 in Macedonia). The ratio of the highest (Kosovo) to the lowest (Vojvodina) in 1986 was 5.0 (Table 2). Comparison over time shows that general decline has not been uniform in the country as a whole. Infant mortality rates have fallen in all regions, but not to the same extent-the fall was greater in developed Slovenia, Croatia and Vojvodina than in undeveloped Macedonia and Kosovo. The degree of disparity (based on the ratio of the highest to the lowest infant mortality rate) was lower in 1950-54 (2.2) than in 1986 (5.0). It suggests that inequalities in infant mortalities among regions has increased during this period (Fig. 2). The significant regional disparities exist also in reproductive mortality (Table 3). In the perinatal mortality rates disparities are lower (ratio 2.0) than in the post-neonatal mortality (ratio 9.5) which is quite understandable because the post-neonatal mortality rates reflect socio-environmental differences to a greater extent than the perinatal rates. Regional inequalities in infant mortality can be explained by comparison of the relative importance of causes of death (Table 4). This shows that infant mortality disparities are influenced mostly by disparities in death due to the two causes of death-infections and respiratory conditions and diseases-both associated mostly with poor socio-economic environment. One of the disadvantages of the proceeding analysis of regional disparities is that several republics KOSOVO . 60 J 0,
50
.
t
MACEDONIA
L I
BOSNIA 6 HERZEGOVINA .
YUGOSLAVIA
1 2
3
4
II 5 6
I
I
7
6
I
I
9 10
Illiteracy Fig.
I.
Table
3. Perinzttal.
neonatal
I
I 12
I
I 14
I
I 16
I
I 16
rote
Illiteracy rate and infant mortality (1981). Source: Ref. (61.
and post-neonatal per
Proper
death
rates by region.
1000 (1981)
Perinatal
Serbia
SLOVENIA I
The crude mortality rate declined from 14.2 in I95 I to 9.0 in 1981 which is a basic indicator of improvement of health status concurrent with socio-economic development. Regional comparisons show the same trend, but regional differences in mortality rates can still be noticed. Data on average age-at-death show regional variations (Table 5). The highest average age-at-death is in socio-economic developed regions and the low average age-at-death is characteristic for less developed and rural areas. Comparisons over time show that inequalities in age-at-death between regions have decreased. The ratio of the highest average-at-death (for males) to the lowest fell from 2.3 in 1950 to 1.6 in 1981. Life expectancy at birth increased from 56.9 years for males and 59.3 for females in 1952-54 to 67.7 and 73.2 respectively in 1979-80. Again, regional inequalities decreased, but there are still great disparities among all regions which may be associated with the socio-economic disparities. Inequalities exist also in premature death, measured by proportion of deaths occurring before the age of 65. Changes over time show that proportion of deaths before 65 generally decreased (from 72.0 for males and 68.6 for females in 1950 to 41.8 and 28.1 respectively in 1981). Regionally, in 1983 premature
Croatia VOJVODINA
I
Mortality
Slovenia
.
I
(Croatia, Serbia and Bosnia & Herzegovina) have a large and heterogeneous population. However, comparisons among the communes within the same republic or province show substantial inequalities in health indicators. For example, in 1981 the range of infant mortality rates for communes in Slovenja was from 4.0 (Kamnik) to 33.7 (Cerknica), in Croatia from 5.2 (Novi Marof) to 60.0 (Vis), in Macedonia from 13.3 (Valandovo) to 87.9 (Tetovo). in Kosovo from 30.5 (LeposaviC) to 117.8 (KaCanik). etc. (61. This again proves that marked inequalities in health exist in all regions in Yugoslavia.
P.fOPER .
CROATIA.
I
[IO].
SERBIA
l
MONTENEGRO
.
Ref.
Neonatal
Post-neonatal
6.7
8.4
10.8
13.4
4.7 5.5
13.4
15.6
8.2
Vojvodina
10.3
12.1
5.4
Bosnia
13.4
16.9
13.1
& Hercegovina
Montenegro
II.1
13.6
9.2
Macedonia
13.5
21.1
30.0
Kosovo
12.6
18.1
44.7
Yugoslavia
12.0
15.5
15.3
Source:
Ref.
[IO].
Health
and social inequities
in Yugoslavia
407
‘Table 4. Infant mortality by cause of death and region for selected causes, per loo0 live births (1982)
Slovenia Croatia Serbia Proper Vojvodina Bosnia & Hercegovina Montenegro Macedonia Kosovo Yueoslavia
Infections
Respiratory disease and respiratory conditions
Various causes of perinatal mortality
Congenital abnormality
Injuries
0.3 0.9 0.2 0.3 0.7 2.7 8.1 12.4 3.0
2.8 3.2 5.6 4.4 6.0 3.7 12.7 17.5 7.3
5.1 8.1 I I.2 7.7 9.1 7.8 13.0 12.0 10.0
3.1 3.2 3.3 3.6 2.8 3.3 3.2 1.6 2.9
0.5 0.3 0.1 0.5 0.2 0. I 0.2
Source: Ref. [7].
death rate was lower in socio-economic developed regions and higher in less developed regions (Table 6). SOCIAL
CLASS
INEQUALITIEs
Sociological studies on the social stratification in Yugoslavia has shown that Yugoslav society is class stratified rather than egalitarian [12]. Unfortunately, the official statistics do not collect valid data on social stratification which could be productively correlated to health data. Here presented data are collected partly from the field studies or from statistics. SMRs calculated from available data (Table 7) give rather doubtful impression on health inequalities among social classes. The genera1 problem arises from the use of occupation as an indicator of inequalities, as explained by Illsley and LeGrand [14]. Here analyzed occupations are heterogeneous groups, different in size, and also regional different. However, data on SMRs indicate occupational differences in mortality-mortality rates are higher for farmers and industrial workers, and low for non-manual occupations. The lowest mortality rate is that of managers and politicians, but this data is based on a small number of deaths. The other questionable finding is that of professionals. High mortality rates for professionals can be explained by the fact that this group contains large and heterogeneous occupational subgroups. These results can be interpreted according to the recent findings from sociological studies on social stratification of Yugoslav society [15-171. The results of these surveys confirmed the hypothesis that there is a hierarchy in quality of life which corresponds to a hierarchy of social groups. At the top of the social structure is a political and managerial elite, at the bottom are workers and peasants. In the middle of Table 5. Regional variations in averaae age-at-death tl950--1981) Females
Males
Slovenia Croatia Serbia Proper Vojvodina Bosnia & Hercegovina Montenegro Macedonia Kosovo Yugoslavia Source: Ref. [IO].
1950
1981
1950
1981
48.7 42.0 37.7 39.8 23.9 34.2 24.9 21.5 35.6
63.7 64.3 65.3 65. I 56.7 63.6 56.2 42.0 61.7
55.0 45.9 42. I 43.4 24.9 37.0 26.2 23.0 38.9
71.7 71.7 70.3 71.7 63. I 66.3 59.0 39.9 67.3
the social structure with the medium quality of life is a very heterogeneous layer (‘service class’) composed of professionals, clerks, teachers, service workers, artisans, etc. The results from the survey of the morbidity by occupation (Table 8) show inequalities in morbidity between lower and higher occupations. According to the average number of diagnoses per person (data not shown), the biggest number of diagnoses among males was found among farmers (7.5) then unskilled workers (6.8). The smallest number of diagnoses were found among intellectuals (5.9). Among females, the biggest number of diagnoses were again among farmers (8.8) and housewives (7.2). Again, the smallest number of diagnoses were among intellectuals (5.6). There is also evidence for social class inequalities in health if educational level is used as a social indicator (Tables 9 and 10). The lowest levels of education are associated with higher death rates. The significant (negative) correlation between personal income and infant mortality was found in the recent analysis of the impact of economic instability on infant mortality [19]. The results from Table 11 suggest that income status may be also associated with the self-reported health status.
INDIVIDUAL
INEQUALITIES
Individually-based measurement, as shown by Illsley and LeGrand [ 141,can avoid many disadvantages of social class based measures. Individual inequalities analyzed here complete the impression of inequalities in health found on regional and social class level (Figs 3 and 4). A continuous increase in the mean age-at-death over the period 1951-1981 (data for the period 1931-1951 were not available) can be noticed and at the same time a continuous decrease in mean age-at-death dispersion. In other words, there is a continuous decrease in inequality (measured by variance of actual age-at-death) over this period. Data on cause of death for 1954 and 1981 (Fig. 5) show the impressive reduction in mortality due to infectious diseases and marked decrease in mortality due to respiratory, digestive, genito-urinary diseases and maternal causes. Concurrently, there is a significant increase in mortality due to circulatory disease, cancer and accidents. Analysis of inequalities and age-at-death caused by major causes of death (80% of all)-infectious diseases, cancer, circulatory disease, respiratory diseases and accidents-gives interesting results (Fig. 6).
MIROSLAVMASTILICA
408
80
-
70
-
60 50 40
-
30
-
20
-
MONTENEGRO SERBIA BOSNIA B HERZEGOVINA CROATIA
10 -
VOJVODINA
L
I
I
1
1959
1954
I
I 1974
1969
1964
I
I 1979
I 1966
1964
Fig. 2. Infant mortality rate in Yugoslavia by republics and autonomous provinces (1954-1986). Source: Refs [8, IO].
Although reduced in relative frequency, mortality caused by infections is very unequally spread in the population. The inequality indices for respiratory diseases decline (more rapidly for males than for females), that means that inequalities in mortality due to respiratory diseases decrease. Accidents, circulaTable
6.
Proportion of deaths before 65 by region (1953-1983) 1983
1953
Slovenia Croatia Serbia Proper Vojvodina Bosnia & Hercegovina Montenegro Macedonia Kosovo Yugoslavia Source: Refs [IO.
tory disease and cancer show little changes in inequality indices (although they cause 70% of all deaths in 1981), which might mean that these diseases, as a cause of death, are more evenly distributed among individuals. However, these are first findings from individually-based measurements of health inequalities and, in any case, need to be analyzed and discussed more.
Males
Females
Males
Females
52.1 58.7 61.7 57.8 82.5 63.5 73.9 83.0 67.5
40.0 50.0 57. I 48.8 81.1 56.4 72.2 83.6 61.8
41.3 43.1 38.4 41.6 53. I 42.8 45.3 62.5 44.0
22.6 23.5 26.2 25.5 36.8 29.5 38.6 62.5 29.0
I I. 221.
Table
7.
Standard occupational
mortality ratios (25-64) group and xx (1981)
Occupational group Farmers Industrial workers Service workers Clerks Professionals Managers and politicians
Males
Females
118 110 70 61 93 23
90 105 90 81 94 38
Calculated from Refs [IO, 131.
Table 8. Distribution of selected diagnosis, per 100 in survey (1972) Occupation M&S Farmers Unskilled workers Skilled workers Clerks Intellectuals FfWl&S Farmers
Unskilled workers Housewives Skilled workers Clerks Intellectuals Source: Ref. [la].
Diabetes mellitus
Neuroses
2.4 7.2 9.9 10.7 3.0
14.1 22.1 21.5 14.5 16.5
39.4 26.9 IS.1 4.9
2.6 2.0 2.5 1.0 2.2 -
37.3 27.1 28.2 28.4 27.4 18.4
13.0 2.4 5.0 1.0 0.7 -
Alcoholism
44.8
Heart disease
Varicose veins
Hemorrhoids
17.7 22.6 22.1 26.4 23.9
7.4 7.2 4.3 5.0 3.4
28.2 17.3 16.4 14.5 9.0
7.4 15.4 14.4 25.2 15.7
21.2 22.7 29.7 29.5 22.9 12.6
14.5 4.0 6.4 I .o 4.4 3.4
50.3 32.4 30.7 29.5 20.0 17.2
5.2 10.9 12.8 21.0 15.6 17.2
Hypertension
by
Health and social inequities in Yugoslavia Table
9.
Infant
mortality
rates
education
by
level
of
University/high Primary
per
school
Il.6
school
Source:
21.4
Ref.
and
illiterate
48.4
[IO].
CONCLUSION
In spite of insufficiency of official statistical data, the features of health inequities in Yugoslavia are shown. The marked inequalities exist regionally, among republics and provinces. These regional inequalities in health reflect inequalities in the regional socio-economic and cultural development. Over the last 40 years the health status of the population has improved, but health inequalities have increased regionally. This is happening in spite of the redistributive social and health policy measures which guarantee the proclaimed basic right to health care services for all citizens. It may suggest limited or rather low impact of the health care system on reduction of health inequalities. The presented data show that health inequalities exist also among social classes in whichever way measured. It is possible to assume that these inequalities are derived from unequal positions in the distribution of political and professional power. Health inequalities tend to increase as Yugoslav society is passing through a severe economic crisis when social structure polarizes and becomes rigid. Individually-based measurements show inequalities in health between all individuals of the population. Although inequalities in length of life decreased in the period 1951-1981, at the beginning of the eighties, due to the socio-economic crisis, new inequalities appeared in causes of death. However, more research is needed to prove these hypotheses. Until then, this will remain the first veil to have been taken down from the face of health inequities in Yugoslavia. From the analyzed data on inequalities in health it was not possible to identify specific vulnerable groups whose health was particularly handicapped for their unprivileged socio-economic status. This is due to the fact that it is very difficult to separate data on these subgroups and their health problems from available statistical data. However, socially disadvantaged groups are recognized, although not all explained, in the ad-hoc studies and theoretical analyses in this field [23]. In the sociological and social policy Iiterature on social inequities, the following vulnerable groups are mentioned: socially handicapped, i.e. Table
IO.
Death
rates
unstandardized.
males
by educational and
females,
level. from
per
1000.
I5 and
older
(1981) Educational
level
University/high Secondary Primary
Males
school
school school
Incomplete
Illiterate Refs 17. IO].
primary
school
status
by income
group
Subjective
health
1000
14.3
primary
health
mortality
rate
school
Incomplete
I I. Self-reported
( 1984)
level
Secondary
Table
(1981) Infant
Educational
mothers
409
Income
group
Lowest
income
group
Highest
income
wow
Source:
Ref.
“etY good
Bad
Good
(Oh)
19.6
66.3
14.1
(%)
16.5
67.3
16.3
(201
groups living on social support; groups living at guaranteed minimum income level, the retired and elderly people in general (isolated and in rural areas particularly); the unskilled manual workers; the migrant workers from poorer, rural regions working in more developed, urban areas; the unemployed; the physically and mentally handicapped; some ethnic minorities; the population living in remote rural areas (in small villages); etc. However, to explain more precisely the health status of these socially vulnerable groups the synthesis of pieces of information from various sources and systematic research are needed. Causal processes by which inequalities in socioeconomic status are translated into health inequalities can also only be theoretically explained. One of the reasons is a dispersion of evidence in literature which need to be collected and productively analyzed. Other difficulties emerge from the fact that it is a question 60 0
70
Females
r
60
1961
1971
1981
Fig. 3. Mean age-at-death(l931-1981). Source: Refs[lO. 211. Females 1100
-
1000
-
900
-
800
-
700
-
600
-
500
-
Females
4.9
2.1
6.1
2.6
5.8
4.3
16.0 43.9
9.6 25.2
. l1951
1961
1971
1981
Fig. 4. Inequality in age-at-death (1951-1981). Source: Refs [IO, 221.
MIROSLAVMASTILICA
410
of a large number of different factors which influence health inequalities but which do not stay with them in a one-way causative-consecutive relation, but in a more ‘vicious circle’ type of combination of various social and health factors. There are many different reasons and processes leading to inequalities in health, but, in spite of the Hales
1954
fact that many factors are involved. it seems that it is not possible to explain inequalities in health separately from social inequalities-inequities. Most of the health inequalities are of social origin: directly, for example through poverty, poor nutrition, harmful (working and living) environment, or indirectly, when health inequalities are caused, for example by Female.3
loo Accidents
and violence
90 a0
70 60
1981
r
J
Accidents
and violence
80
a0 70 60
60
m
Neoplasms
a
Circulatory dlseose
m
Maternal causes
I
Others and unknown
UUJ.LI disease
0 Fig. 5. Mortality by cause, age and sex (1954, 1981). Source: Refs [IO, 221.
Health and social inequities in Yugoslavia education, attitude toward health and disease or by access to health care services, distribution of wealth and income, etc. All changes in the social structure of the Yugoslav society caused by quick processes of industrialization, de-agrarization, urbanization, expansion in education. etc. are reflected in producing inequalities in health. After all, as a starting point for understanding health inequalities, those from the general social position of people should be taken into account, namely those “systematic and structural inequalities which by their overall long-term and short-term effects, either directly or indirectly, reflect on general life situation and average life chances and perspectives . . . , i.e. on the quality of life and destiny of large social groups” [I, p. 1801. Most relevant information available comes from statistics. Detailed data on general socio-economic, vital and health indicators are published annually, but these statistical sources have many defects: data are at least 2 years late, indicators are methodologically out-of-date, data on social and economic structure do not include health and health care variables and vice versa, etc. An approach to the original data could be more productive. Also, a way should be found of including socioeconomic indicators in health and health care statistics. Social and health policy interventions in reducing undesirable inequalities in health are largely determined and limited by the actual situation in Yugoslavia. The economic crisis, which began in 1979, has had severe impact upon a standard of living and health status of the population. In the situation of decreasing real income, increasing prices and, as a consequence of economic policy, decreasing spending for health and social services, it is easy to assume that social and particularly health inequalities are increasing. On the other hand, the principles of reciprocity and solidarity, as basic principles of social and health policy in Yugoslavia, would be mitigating for social and health inequalities. As it was described [19], the reallocation of resources from Federal or Republic
411
funds, which are established on the principle of solidarity, can have some mitigating effect on regional health inequalities. The system of health care and health insurance, however, can have an effect upon the emergency of inequalities in health. The right to health care, granted by Federal and Republic/Provincial Constitutions, presupposes the equity of users. In the situation where there exists a growing disproportion between possibilities of health care system and users’ needs, the problem of inequities of users appears [24]; it is one of the basic problems in fulfilling the right to health care in Yugoslavia. In the new law on health care and health insurance (in Socialist Republic Croatia 1980) the right of standard level of health care has been established as a temporary solution which guarantees (optimum and minimum) health standard [25]. Unique health insurance rate for all people doesn’t make such an important redistribution of resources from the rich to the poor so that it might be taken as a sufficient measure for preventing social inequities in health [5]. The health care system is not equally open to all. In the system the rich-upper socio-economic groups-are favored. and the poorlower socio-economic groups-are discriminated. It is not only because of often unequal availability of care, but also because of the disproportionate share of health care resources. As the preliminary studies on health care utilization show [20]. there are significant social inequities in the use of health care in Yugoslavia. In public opinion, among social and health experts and policy makers, there is not enough awareness of existing inequities in health. The health inequities are rarely perceived as one of the basic manifestations of social inequities existence. Also, social inequities in health are not taken into consideration enough when formulating more adequate social and health policies. WHO Program on Social Inequities in Health is a chance that, also in Yugoslavia, awareness would be intensified on health consequences of social inequities and also necessary actions taken.
Females /----
Males _/
Y
\
Res,/
\
/
\
-+
/J
\
\
\ Act 1
././w"'............. Iflf
300
CO
_._.;------____
200
co -------______________ -.-._ Cir
.C.-._
-.-
100 1961
I
I
I
I
1954
1961
1971
1961
Fig. 6. Inequality in age-at-death, selected causes (19561981), variance. Source: Refs [IO, 221.
MIROSLAVMAST~LICA
412 REFERENCES
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3. SkrbiC M. Pojavni oblici i uzroci jafanja socijalnih razlika (The pattern and causes of the social inequities rowth). NaSe tense 1, 4-47, 1973. 4. $ upanov J. Smanjivanje socijalnih razlika-kampanja ih politika? (Social inequities reduction-campaign or policy?). NaSe teme 3. 590-601, 1973. i Zdravlje (Population and 5. Skrbic M. Stanocniitvo Health). JUMENA. Zagreb. 1976. Yearbook ;;/ Yugoslavia 1984. Federal 6. Bar&al Statistical Office, Belgrade, 1984. Yearbook of Yugoslavia 1986. Federal 7. Statistical Statistical Office, Belgrade, 1986. Yearbook of Yugoslavia 198% Federal 8. Statistical Statistical Office, Belgrade, 1987. 9. Demography Statistics 1961. Federal Statistical Office, Belgrade, 1964. IO. Demography Sfarisrics 1981. Federal Statistical Office, Belgrade, 1986. II. Statistical Yearbook of People’s Health and Health Care in SFR Yugoslavia 1985. Federal Institute of Health Care, Belgrade, 1986. 12. Sekulic D. 0 pristupima proufavanju stratifikacione strukture Jugoslavenskog drustva. Sociologija 1, I-21, 1983. 13. Narional Census 1981. Federal Statistical Office, Belgrade, 1987. 14. Illsley R. and LeGrand J. Measurement of Inequalities in Health. STICERD, London, 1987.
15. Lay V. Kvalitet svakidajnjeg iivota druStvenih grupa (Quality of everyday life of social groups). Rev. =a sot. 14, 19-29, 1986. 16. MrkSiC D. Podela rada i stratifikacija jugoslavenskog druStva (Division of labour and stratification of Yugoslav society). Rev. :a sot. 1-4, 3-17. 1986. 17. Bogdanovic M. DruStvene nejednakosti sa stanovista primenjenog klasifikacijskog okvira analize (Social inequalities perception from the standpoint of applied classification framework of analysis). Rev. ra sot. l-4, 1986. 18. Mimica M., SariC M., Malinar M. and Madjaric M. Zanimanje stanovnigtva i pojava Eestih kronifnih bolesti (Occupation and chronic diseases). Arhiv hig. rada 28, 243-253,
1977.
19. Kunitz S. J., Simic S. and Odorff C. L. Infant mortality and economic instability in Yugoslavia. Sot. Sci. Med. 11, 953-960,
1987.
20. Mastilica M. Socijalne nejednakosti u koriStenju zdravstene zaStite (Social inequities in health care utilization). Pogledi 1, 51-63, 1986. Yeurbook 193f. State General Statistics, 21. Stafistical Belgrade, 1935. 22. Viral Staristics 1954. Federal Statistical Office, Belgrade, 1956. 23. SocQalna ZaStita in the Socialist
u SR Hrvarskoj (Social Werfare Republic of Croatia) (Edited by SkrbiC M., Letica S.. Popovic B. et al.). JUMENA,
Zagreb, 1984. 24. Zakon o Zdravstvenoj Zasliti i Zdravsrcenom Osiguranju s Obja.Gsjenjima. CIP, Zagreb, 1980. 25. Health System in Yugoslavia (Edited by Letica S. and Skupnjak B.). Institute for Organization and Economics of Health, Zagreb, 1985.
HEALTH
0277-9536190 53.00f0.00 Copyright ,c 1990 Pergamon Pressplc
AND SOCIAL INEQUITIES
IN YUGOSLAVIA
MIROSLAV MASTILICA
Department of Medical Sociology, Andrija Stampar School of Public Health, Medical School, University of Zagreb, 41000 Zagreb, Yugoslavia Abstract-In Yugoslavia the problem of social inequities comes on the political agenda every time when society is in a crisis. This paper describes the pattern of social inequities in health. Data are mostly used from statistics. The features of health inequalities are shown. The marked inequalities exist regionally, among republics and provinces, in spite of the reallocation of resources. Health inequalities exist also among social classes however they are measured. Individually based measurement shows inequalities in health between all individuals of the population. As Yugoslav society is passing through severe economic crisis when social structure polarizes and becomes rigid-inequalities in health tend to increase. Key words-inequities,
health, Yugoslavia
INTRODUCTION
The problem of social inequity has remained one of the open social problems of socialist societies [I]. In Yugoslavia, the problem of social inequities has been pointed out as an important political problem every time the society has found itself in some kind of crisis. It was only at the beginning of the seventies that the problem of social inequities in Yugoslav society became the subject of more serious sociological studies [2-4]. In spite of realization that health status and health care can be a sensitive area of social differentiation and stratification, social inequities in health and health care have not been given the same importance as some other forms of expressing social inequities [5]. There is almost no significant sociological research of social inequities coming out in health and health care. This paper is one of the first attempts of describing the basic pattern of social inequities in health in Yugoslavia. Yugoslavia is well known as a country with large geographical, cultural and ethnical differences as well as a country with marked inequalities in socio-economic development, so that it was easy to make the starting assumption that there are inequalities in health which correspond to the numerous social inequalities. Explanations of health inequalities presented here are mostly based on the data from statistics. That is where certain difficulties in interpretation come from. They come from shortcomings in Yugoslav official statistics, i.e. from the lack of socio-economic variables in health statistics. Most of the data of health statistics are published so that most of the indicators presented here are being calculated. Other problems to be further discussed are validity of indicators and how much found inequalities are an artifact of the indicators themselves. Data on social inequities relate to the period of the beginning of serious socio-econonmic crisis in Yugoslavia, which nowadays has a considerable impact on the increase of social inequities, particularly in the field of health. 405
The discussion is divided in three parts. Inequities in health are analyzed in relation to the regional, social class and individual inequalities. REGIONAL INEQUALITIES
Regional disparities are an important indicator of the existence of health inequalities in Yugoslavia. Namely, there are well-recognized disparities in socio-economic development among regions (socialist republics and autonomous provincestifrom highly developed Slovenia, Croatia, Serbia and Vojvodina, to less developed Bosnia & Herzegovina and Montenegro, and to the least developed Macedonia and Kosovo. It is possible to assume that regional inequalities reflect underlying regional disparities in socio-economic conditions, rural-urban distribution, and industrialization, as well as regional differences in culture, differences in life-styles and levels of living, etc. The second reason for using regional indicators in explanation of health inequalities is the availability of data, which are mostly collected and published on regional basis. In the following analysis of inequalities data are not analyzed for Yugoslavia as a whole but by republic and provinces. Comparison over time is also shown. Data for the Socialist Republic of Serbia are presented for its proper part, i.e. Serbia without provinces. Infant mortality In Yugoslavia infant mortality has declined very sharply-from 164.5 per 1000 live births in 1931 to 27.1 in 1986, but it is still one of the highest in Europe. However, regional comparisons show that there are significant differences in infant mortality among different areas. It occurs that regional inequalities in infant mortality correspond to the degree of socio-economic development (Table 1). Regional disparities in illiteracy rates, as a general indicator of social and cultural development, in correlation to the infant mortality rate show that
406
MIROSLAV
Tlrble
I.
InPdant mortality republics
rates and
and
GNP
provinces
Infant
per
c;lpita
index
by
MASTILICA
Table
2.
Infant
(1981)
mortalitv
mortaltry
provmces
rate
GNP
index
rates
1950-54
Yugoslavia. 1986. per
republics
and
1000
1961
1971
I981
Slovenia
13.3
196
Sloven3
69.6
29.4
25.5
13.1
13.3
Croatia
18.9
126
Croatia
I IO.8
62.9
29.5
IX.9
15.3
Serbia
23.8
Proper
Bosnia
98
17.1
Vojvodina
II8
30. I
& Hercegovina
67
1950-54
in to
Serbia
Proper
1986
96.4
66.3
37.3
23.8
24. I
Vojvodina
119.6
71.6
34.5
17.1
II.1
Bosnia
135.5
98.7
54.7
30.1
17.9
27.8
22.8
24.x 47.9
& Hercegovina
Montenegro
22.8
79
Montenegro
s9.0
61.4
Macedonia
51.1
66
Macedonia
139.2
112.1
s2.2
51.1
KOSOVO
62.9
29
KOSOVO
155.6
125.9
69.6
62.9
55.x
Yugoslavia
30.8
100
Yugoslavia
116.2
82.0
49.5
30.8
27. I
Source:
Ref.
Source:
[6].
inequalities in infant mortality reflect not only economical but also cultural status of the population (Fig. 1). Infant mortality rates are low in the developed regions (13.3 in Slovenia, I I.1 in Vojvodina, 15.3 in Croatia) and high in comparatively poor regions in the south (55.8 in Kosovo, 47.9 in Macedonia). The ratio of the highest (Kosovo) to the lowest (Vojvodina) in 1986 was 5.0 (Table 2). Comparison over time shows that general decline has not been uniform in the country as a whole. Infant mortality rates have fallen in all regions, but not to the same extent-the fall was greater in developed Slovenia, Croatia and Vojvodina than in undeveloped Macedonia and Kosovo. The degree of disparity (based on the ratio of the highest to the lowest infant mortality rate) was lower in 1950-54 (2.2) than in 1986 (5.0). It suggests that inequalities in infant mortalities among regions has increased during this period (Fig. 2). The significant regional disparities exist also in reproductive mortality (Table 3). In the perinatal mortality rates disparities are lower (ratio 2.0) than in the post-neonatal mortality (ratio 9.5) which is quite understandable because the post-neonatal mortality rates reflect socio-environmental differences to a greater extent than the perinatal rates. Regional inequalities in infant mortality can be explained by comparison of the relative importance of causes of death (Table 4). This shows that infant mortality disparities are influenced mostly by disparities in death due to the two causes of death-infections and respiratory conditions and diseases-both associated mostly with poor socio-economic environment. One of the disadvantages of the proceeding analysis of regional disparities is that several republics KOSOVO . 60 J 0,
50
.
t
MACEDONIA
L I
BOSNIA 6 HERZEGOVINA .
YUGOSLAVIA
1 2
3
4
II 5 6
I
I
7
6
I
I
9 10
Illiteracy Fig.
I.
Table
3. Perinzttal.
neonatal
I
I 12
I
I 14
I
I 16
I
I 16
rote
Illiteracy rate and infant mortality (1981). Source: Ref. (61.
and post-neonatal per
Proper
death
rates by region.
1000 (1981)
Perinatal
Serbia
SLOVENIA I
The crude mortality rate declined from 14.2 in I95 I to 9.0 in 1981 which is a basic indicator of improvement of health status concurrent with socio-economic development. Regional comparisons show the same trend, but regional differences in mortality rates can still be noticed. Data on average age-at-death show regional variations (Table 5). The highest average age-at-death is in socio-economic developed regions and the low average age-at-death is characteristic for less developed and rural areas. Comparisons over time show that inequalities in age-at-death between regions have decreased. The ratio of the highest average-at-death (for males) to the lowest fell from 2.3 in 1950 to 1.6 in 1981. Life expectancy at birth increased from 56.9 years for males and 59.3 for females in 1952-54 to 67.7 and 73.2 respectively in 1979-80. Again, regional inequalities decreased, but there are still great disparities among all regions which may be associated with the socio-economic disparities. Inequalities exist also in premature death, measured by proportion of deaths occurring before the age of 65. Changes over time show that proportion of deaths before 65 generally decreased (from 72.0 for males and 68.6 for females in 1950 to 41.8 and 28.1 respectively in 1981). Regionally, in 1983 premature
Croatia VOJVODINA
I
Mortality
Slovenia
.
I
(Croatia, Serbia and Bosnia & Herzegovina) have a large and heterogeneous population. However, comparisons among the communes within the same republic or province show substantial inequalities in health indicators. For example, in 1981 the range of infant mortality rates for communes in Slovenja was from 4.0 (Kamnik) to 33.7 (Cerknica), in Croatia from 5.2 (Novi Marof) to 60.0 (Vis), in Macedonia from 13.3 (Valandovo) to 87.9 (Tetovo). in Kosovo from 30.5 (LeposaviC) to 117.8 (KaCanik). etc. (61. This again proves that marked inequalities in health exist in all regions in Yugoslavia.
P.fOPER .
CROATIA.
I
[IO].
SERBIA
l
MONTENEGRO
.
Ref.
Neonatal
Post-neonatal
6.7
8.4
10.8
13.4
4.7 5.5
13.4
15.6
8.2
Vojvodina
10.3
12.1
5.4
Bosnia
13.4
16.9
13.1
& Hercegovina
Montenegro
II.1
13.6
9.2
Macedonia
13.5
21.1
30.0
Kosovo
12.6
18.1
44.7
Yugoslavia
12.0
15.5
15.3
Source:
Ref.
[IO].
Health
and social inequities
in Yugoslavia
407
‘Table 4. Infant mortality by cause of death and region for selected causes, per loo0 live births (1982)
Slovenia Croatia Serbia Proper Vojvodina Bosnia & Hercegovina Montenegro Macedonia Kosovo Yueoslavia
Infections
Respiratory disease and respiratory conditions
Various causes of perinatal mortality
Congenital abnormality
Injuries
0.3 0.9 0.2 0.3 0.7 2.7 8.1 12.4 3.0
2.8 3.2 5.6 4.4 6.0 3.7 12.7 17.5 7.3
5.1 8.1 I I.2 7.7 9.1 7.8 13.0 12.0 10.0
3.1 3.2 3.3 3.6 2.8 3.3 3.2 1.6 2.9
0.5 0.3 0.1 0.5 0.2 0. I 0.2
Source: Ref. [7].
death rate was lower in socio-economic developed regions and higher in less developed regions (Table 6). SOCIAL
CLASS
INEQUALITIEs
Sociological studies on the social stratification in Yugoslavia has shown that Yugoslav society is class stratified rather than egalitarian [12]. Unfortunately, the official statistics do not collect valid data on social stratification which could be productively correlated to health data. Here presented data are collected partly from the field studies or from statistics. SMRs calculated from available data (Table 7) give rather doubtful impression on health inequalities among social classes. The genera1 problem arises from the use of occupation as an indicator of inequalities, as explained by Illsley and LeGrand [14]. Here analyzed occupations are heterogeneous groups, different in size, and also regional different. However, data on SMRs indicate occupational differences in mortality-mortality rates are higher for farmers and industrial workers, and low for non-manual occupations. The lowest mortality rate is that of managers and politicians, but this data is based on a small number of deaths. The other questionable finding is that of professionals. High mortality rates for professionals can be explained by the fact that this group contains large and heterogeneous occupational subgroups. These results can be interpreted according to the recent findings from sociological studies on social stratification of Yugoslav society [15-171. The results of these surveys confirmed the hypothesis that there is a hierarchy in quality of life which corresponds to a hierarchy of social groups. At the top of the social structure is a political and managerial elite, at the bottom are workers and peasants. In the middle of Table 5. Regional variations in averaae age-at-death tl950--1981) Females
Males
Slovenia Croatia Serbia Proper Vojvodina Bosnia & Hercegovina Montenegro Macedonia Kosovo Yugoslavia Source: Ref. [IO].
1950
1981
1950
1981
48.7 42.0 37.7 39.8 23.9 34.2 24.9 21.5 35.6
63.7 64.3 65.3 65. I 56.7 63.6 56.2 42.0 61.7
55.0 45.9 42. I 43.4 24.9 37.0 26.2 23.0 38.9
71.7 71.7 70.3 71.7 63. I 66.3 59.0 39.9 67.3
the social structure with the medium quality of life is a very heterogeneous layer (‘service class’) composed of professionals, clerks, teachers, service workers, artisans, etc. The results from the survey of the morbidity by occupation (Table 8) show inequalities in morbidity between lower and higher occupations. According to the average number of diagnoses per person (data not shown), the biggest number of diagnoses among males was found among farmers (7.5) then unskilled workers (6.8). The smallest number of diagnoses were found among intellectuals (5.9). Among females, the biggest number of diagnoses were again among farmers (8.8) and housewives (7.2). Again, the smallest number of diagnoses were among intellectuals (5.6). There is also evidence for social class inequalities in health if educational level is used as a social indicator (Tables 9 and 10). The lowest levels of education are associated with higher death rates. The significant (negative) correlation between personal income and infant mortality was found in the recent analysis of the impact of economic instability on infant mortality [19]. The results from Table 11 suggest that income status may be also associated with the self-reported health status.
INDIVIDUAL
INEQUALITIES
Individually-based measurement, as shown by Illsley and LeGrand [ 141,can avoid many disadvantages of social class based measures. Individual inequalities analyzed here complete the impression of inequalities in health found on regional and social class level (Figs 3 and 4). A continuous increase in the mean age-at-death over the period 1951-1981 (data for the period 1931-1951 were not available) can be noticed and at the same time a continuous decrease in mean age-at-death dispersion. In other words, there is a continuous decrease in inequality (measured by variance of actual age-at-death) over this period. Data on cause of death for 1954 and 1981 (Fig. 5) show the impressive reduction in mortality due to infectious diseases and marked decrease in mortality due to respiratory, digestive, genito-urinary diseases and maternal causes. Concurrently, there is a significant increase in mortality due to circulatory disease, cancer and accidents. Analysis of inequalities and age-at-death caused by major causes of death (80% of all)-infectious diseases, cancer, circulatory disease, respiratory diseases and accidents-gives interesting results (Fig. 6).
MIROSLAVMASTILICA
408
80
-
70
-
60 50 40
-
30
-
20
-
MONTENEGRO SERBIA BOSNIA B HERZEGOVINA CROATIA
10 -
VOJVODINA
L
I
I
1
1959
1954
I
I 1974
1969
1964
I
I 1979
I 1966
1964
Fig. 2. Infant mortality rate in Yugoslavia by republics and autonomous provinces (1954-1986). Source: Refs [8, IO].
Although reduced in relative frequency, mortality caused by infections is very unequally spread in the population. The inequality indices for respiratory diseases decline (more rapidly for males than for females), that means that inequalities in mortality due to respiratory diseases decrease. Accidents, circulaTable
6.
Proportion of deaths before 65 by region (1953-1983) 1983
1953
Slovenia Croatia Serbia Proper Vojvodina Bosnia & Hercegovina Montenegro Macedonia Kosovo Yugoslavia Source: Refs [IO.
tory disease and cancer show little changes in inequality indices (although they cause 70% of all deaths in 1981), which might mean that these diseases, as a cause of death, are more evenly distributed among individuals. However, these are first findings from individually-based measurements of health inequalities and, in any case, need to be analyzed and discussed more.
Males
Females
Males
Females
52.1 58.7 61.7 57.8 82.5 63.5 73.9 83.0 67.5
40.0 50.0 57. I 48.8 81.1 56.4 72.2 83.6 61.8
41.3 43.1 38.4 41.6 53. I 42.8 45.3 62.5 44.0
22.6 23.5 26.2 25.5 36.8 29.5 38.6 62.5 29.0
I I. 221.
Table
7.
Standard occupational
mortality ratios (25-64) group and xx (1981)
Occupational group Farmers Industrial workers Service workers Clerks Professionals Managers and politicians
Males
Females
118 110 70 61 93 23
90 105 90 81 94 38
Calculated from Refs [IO, 131.
Table 8. Distribution of selected diagnosis, per 100 in survey (1972) Occupation M&S Farmers Unskilled workers Skilled workers Clerks Intellectuals FfWl&S Farmers
Unskilled workers Housewives Skilled workers Clerks Intellectuals Source: Ref. [la].
Diabetes mellitus
Neuroses
2.4 7.2 9.9 10.7 3.0
14.1 22.1 21.5 14.5 16.5
39.4 26.9 IS.1 4.9
2.6 2.0 2.5 1.0 2.2 -
37.3 27.1 28.2 28.4 27.4 18.4
13.0 2.4 5.0 1.0 0.7 -
Alcoholism
44.8
Heart disease
Varicose veins
Hemorrhoids
17.7 22.6 22.1 26.4 23.9
7.4 7.2 4.3 5.0 3.4
28.2 17.3 16.4 14.5 9.0
7.4 15.4 14.4 25.2 15.7
21.2 22.7 29.7 29.5 22.9 12.6
14.5 4.0 6.4 I .o 4.4 3.4
50.3 32.4 30.7 29.5 20.0 17.2
5.2 10.9 12.8 21.0 15.6 17.2
Hypertension
by
Health and social inequities in Yugoslavia Table
9.
Infant
mortality
rates
education
by
level
of
University/high Primary
per
school
Il.6
school
Source:
21.4
Ref.
and
illiterate
48.4
[IO].
CONCLUSION
In spite of insufficiency of official statistical data, the features of health inequities in Yugoslavia are shown. The marked inequalities exist regionally, among republics and provinces. These regional inequalities in health reflect inequalities in the regional socio-economic and cultural development. Over the last 40 years the health status of the population has improved, but health inequalities have increased regionally. This is happening in spite of the redistributive social and health policy measures which guarantee the proclaimed basic right to health care services for all citizens. It may suggest limited or rather low impact of the health care system on reduction of health inequalities. The presented data show that health inequalities exist also among social classes in whichever way measured. It is possible to assume that these inequalities are derived from unequal positions in the distribution of political and professional power. Health inequalities tend to increase as Yugoslav society is passing through a severe economic crisis when social structure polarizes and becomes rigid. Individually-based measurements show inequalities in health between all individuals of the population. Although inequalities in length of life decreased in the period 1951-1981, at the beginning of the eighties, due to the socio-economic crisis, new inequalities appeared in causes of death. However, more research is needed to prove these hypotheses. Until then, this will remain the first veil to have been taken down from the face of health inequities in Yugoslavia. From the analyzed data on inequalities in health it was not possible to identify specific vulnerable groups whose health was particularly handicapped for their unprivileged socio-economic status. This is due to the fact that it is very difficult to separate data on these subgroups and their health problems from available statistical data. However, socially disadvantaged groups are recognized, although not all explained, in the ad-hoc studies and theoretical analyses in this field [23]. In the sociological and social policy Iiterature on social inequities, the following vulnerable groups are mentioned: socially handicapped, i.e. Table
IO.
Death
rates
unstandardized.
males
by educational and
females,
level. from
per
1000.
I5 and
older
(1981) Educational
level
University/high Secondary Primary
Males
school
school school
Incomplete
Illiterate Refs 17. IO].
primary
school
status
by income
group
Subjective
health
1000
14.3
primary
health
mortality
rate
school
Incomplete
I I. Self-reported
( 1984)
level
Secondary
Table
(1981) Infant
Educational
mothers
409
Income
group
Lowest
income
group
Highest
income
wow
Source:
Ref.
“etY good
Bad
Good
(Oh)
19.6
66.3
14.1
(%)
16.5
67.3
16.3
(201
groups living on social support; groups living at guaranteed minimum income level, the retired and elderly people in general (isolated and in rural areas particularly); the unskilled manual workers; the migrant workers from poorer, rural regions working in more developed, urban areas; the unemployed; the physically and mentally handicapped; some ethnic minorities; the population living in remote rural areas (in small villages); etc. However, to explain more precisely the health status of these socially vulnerable groups the synthesis of pieces of information from various sources and systematic research are needed. Causal processes by which inequalities in socioeconomic status are translated into health inequalities can also only be theoretically explained. One of the reasons is a dispersion of evidence in literature which need to be collected and productively analyzed. Other difficulties emerge from the fact that it is a question 60 0
70
Females
r
60
1961
1971
1981
Fig. 3. Mean age-at-death(l931-1981). Source: Refs[lO. 211. Females 1100
-
1000
-
900
-
800
-
700
-
600
-
500
-
Females
4.9
2.1
6.1
2.6
5.8
4.3
16.0 43.9
9.6 25.2
. l1951
1961
1971
1981
Fig. 4. Inequality in age-at-death (1951-1981). Source: Refs [IO, 221.
MIROSLAVMASTILICA
410
of a large number of different factors which influence health inequalities but which do not stay with them in a one-way causative-consecutive relation, but in a more ‘vicious circle’ type of combination of various social and health factors. There are many different reasons and processes leading to inequalities in health, but, in spite of the Hales
1954
fact that many factors are involved. it seems that it is not possible to explain inequalities in health separately from social inequalities-inequities. Most of the health inequalities are of social origin: directly, for example through poverty, poor nutrition, harmful (working and living) environment, or indirectly, when health inequalities are caused, for example by Female.3
loo Accidents
and violence
90 a0
70 60
1981
r
J
Accidents
and violence
80
a0 70 60
60
m
Neoplasms
a
Circulatory dlseose
m
Maternal causes
I
Others and unknown
UUJ.LI disease
0 Fig. 5. Mortality by cause, age and sex (1954, 1981). Source: Refs [IO, 221.
Health and social inequities in Yugoslavia education, attitude toward health and disease or by access to health care services, distribution of wealth and income, etc. All changes in the social structure of the Yugoslav society caused by quick processes of industrialization, de-agrarization, urbanization, expansion in education. etc. are reflected in producing inequalities in health. After all, as a starting point for understanding health inequalities, those from the general social position of people should be taken into account, namely those “systematic and structural inequalities which by their overall long-term and short-term effects, either directly or indirectly, reflect on general life situation and average life chances and perspectives . . . , i.e. on the quality of life and destiny of large social groups” [I, p. 1801. Most relevant information available comes from statistics. Detailed data on general socio-economic, vital and health indicators are published annually, but these statistical sources have many defects: data are at least 2 years late, indicators are methodologically out-of-date, data on social and economic structure do not include health and health care variables and vice versa, etc. An approach to the original data could be more productive. Also, a way should be found of including socioeconomic indicators in health and health care statistics. Social and health policy interventions in reducing undesirable inequalities in health are largely determined and limited by the actual situation in Yugoslavia. The economic crisis, which began in 1979, has had severe impact upon a standard of living and health status of the population. In the situation of decreasing real income, increasing prices and, as a consequence of economic policy, decreasing spending for health and social services, it is easy to assume that social and particularly health inequalities are increasing. On the other hand, the principles of reciprocity and solidarity, as basic principles of social and health policy in Yugoslavia, would be mitigating for social and health inequalities. As it was described [19], the reallocation of resources from Federal or Republic
411
funds, which are established on the principle of solidarity, can have some mitigating effect on regional health inequalities. The system of health care and health insurance, however, can have an effect upon the emergency of inequalities in health. The right to health care, granted by Federal and Republic/Provincial Constitutions, presupposes the equity of users. In the situation where there exists a growing disproportion between possibilities of health care system and users’ needs, the problem of inequities of users appears [24]; it is one of the basic problems in fulfilling the right to health care in Yugoslavia. In the new law on health care and health insurance (in Socialist Republic Croatia 1980) the right of standard level of health care has been established as a temporary solution which guarantees (optimum and minimum) health standard [25]. Unique health insurance rate for all people doesn’t make such an important redistribution of resources from the rich to the poor so that it might be taken as a sufficient measure for preventing social inequities in health [5]. The health care system is not equally open to all. In the system the rich-upper socio-economic groups-are favored. and the poorlower socio-economic groups-are discriminated. It is not only because of often unequal availability of care, but also because of the disproportionate share of health care resources. As the preliminary studies on health care utilization show [20]. there are significant social inequities in the use of health care in Yugoslavia. In public opinion, among social and health experts and policy makers, there is not enough awareness of existing inequities in health. The health inequities are rarely perceived as one of the basic manifestations of social inequities existence. Also, social inequities in health are not taken into consideration enough when formulating more adequate social and health policies. WHO Program on Social Inequities in Health is a chance that, also in Yugoslavia, awareness would be intensified on health consequences of social inequities and also necessary actions taken.
Females /----
Males _/
Y
\
Res,/
\
/
\
-+
/J
\
\
\ Act 1
././w"'............. Iflf
300
CO
_._.;------____
200
co -------______________ -.-._ Cir
.C.-._
-.-
100 1961
I
I
I
I
1954
1961
1971
1961
Fig. 6. Inequality in age-at-death, selected causes (19561981), variance. Source: Refs [IO, 221.
MIROSLAVMAST~LICA
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