Europe’s health systems are facing a convergence of challenges like never before. Populations are ageing, chronic diseases are increasing, health inequalities remain deeply entrenched, and public services are under growing pressure. At the same time, scientific advances, digital technologies and new approaches to care are creating unprecedented opportunities to improve lives.
Yet, despite decades of innovation and investment, one fundamental question remains: why do so many health inequalities persist? For Alison Maassen, Programme Manager at EuroHealthNet, the answer lies in a common misconception about where health is actually created.
EuroHealthNet is the European Partnership for Health Equity and Wellbeing, bringing together more than 80 public health agencies, ministries, research organisations, universities and civil society groups from across Europe. Working at the intersection of policy, practice and research, its mission is to reduce health inequalities by addressing the factors that shape health long before people enter a healthcare setting.
For EuroHealthNet, health is shaped not only by healthcare services, but by the economic, environmental, social and political conditions that influence people’s lives. Housing, employment, education, financial security, community connections and the environments in which people live all play a role in determining health outcomes.
“Our work focuses on health inequalities,” explains Maassen. “How can we reduce health inequalities within and between European states? And the way that’s done isn’t by necessarily just tweaking the health system. It’s looking at all the determinants of health, those great big levers and drivers that are underpinning how well we’re doing.”
It is this broader, systemic understanding of health that underpins the partnership’s work and explains why improving health outcomes requires action far beyond hospitals and clinics.
“We really consider ourselves a catalyst and convener,” Maassen explains. “What we do try to do is bring people together and in doing so we look to act as a catalyst – to make a spark.”
Looking beyond healthcare
Central to EuroHealthNet’s thinking is the belief that health is created far beyond the healthcare system itself. The conditions in which people live, work and age often have a greater influence on health outcomes than the medical care they eventually receive.
The evidence increasingly supports this view. In a recent analysis of ten years of European Social Survey data, EuroHealthNet examined how health inequalities have evolved across the continent and whether progress is being made in narrowing the gap between different groups. The findings were sobering. “What we found was basically that we’re stagnating,” Maassen explains. “And in many cases, we’re actually even declining.”
Perhaps most concerning was that reductions in health inequalities were not always the result of healthier populations. “What happened is that people who had been better off actually reported worse health outcomes than they did before, whereas people who were the worst off continued to report not great health outcomes.
So you had reduced the inequalities between the best off and the least well off. But nobody benefited from that reduction.”
When EuroHealthNet examined the factors driving poor health outcomes, the results pointed well beyond traditional healthcare. “The number one driver that people indicated was financial insecurity. The second was a lack of feeling of control over their lives. And then the third and the fourth were unhealthy diets and housing.”
These findings reinforce a growing body of evidence showing that health is closely linked to education, employment, income, housing quality, environmental conditions and social participation. For EuroHealthNet, improving health therefore requires a much broader societal response. “It’s really working through more of a health promotion approach,” says Maassen. “And that’s why we are working across health and social.”
This thinking also underpins EuroHealthNet’s growing focus on the concept of a wellbeing economy, an approach that asks whether economies should serve people and the planet, rather than the other way around. “Why is it that people are working in service of the economy and the economy is not working in service of the people and the planet?” she asks. “How can we actually flip this around?”
Prevention
If there is one area where rhetoric and reality continue to diverge, it is prevention.
Few policymakers would argue against the value of preventing disease rather than treating it. Yet investment patterns tell a different story. “Health promotion and disease prevention have a lot of rhetorical prominence,” says Maassen. “Everybody loves to talk about them, and they say they are important, but you don’t see that reflected in budgets.
“For 20 years now, we’ve seen health promotion and disease prevention at around 3% of total health expenditure across OECD countries. It jumped in 2021 to 5%, but that was because of COVID-19 vaccine purchases.”
For Maassen, the challenge is structural. “It’s almost a design flaw in the way that the public sector works, that it is by its nature reactive. To be health-promoting, you have to be forward-looking. You have to be proactive.”
The issue becomes even more pressing as Europe’s population ages. By 2050, the number of Europeans aged 65 and over is expected to increase by more than 40%, while the number aged over 80 could almost double. Yet, as EuroHealthNet’s recent policy work highlights, the real challenge is not ageing itself but ageing in poor health. “There is a huge economic argument to be made for investing more in health promotion and disease prevention,” says Maassen. “If we age in poor health, then the system faces so many more demands.”
Healthy ageing is not simply about extending life expectancy but extending healthy life expectancy. The challenge facing Europe is not that people are living longer, but that too many people spend later life in poor health, placing greater pressure on healthcare, long-term care and support services.
Healthy ageing, she argues, should not be viewed as a cost but as an investment that helps people maintain independence, wellbeing and quality of life for longer.
A changing Europe
As EuroHealthNet develops its strategy for the coming years, the organisation has adopted a powerful metaphor to describe the forces shaping Europe’s future. “We see that there are currents,” Maassen explains. “The big immovable trends. You can’t turn this boat.”
These currents include climate change, digitalisation, demographic change and growing inequalities. “The climate transition is one of them. The digital transition is one of them. The demographic transition is one of them. And then we would also say that this increase in health and social inequalities is one of them.”
Above these currents sit what Maassen describes as “waves” – the challenges emerging from these deeper shifts. Mental ill health, growing corporate influence over health-related behaviours, misinformation and social fragmentation are among these pressures now confronting policymakers.
One area of particular concern is the growing influence of commercial determinants of health. “It’s very common that people will say obesity is an individual choice,” says Maassen. “But if 50% of your population is obese, that’s not an individual choice anymore. So much of the choices we think are individual choices are obviously influenced by our environments.”
The implication is clear. Improving health outcomes requires more than encouraging individual responsibility. It requires addressing the systems and environments that shape behaviour in the first place.
Digital innovation
Few developments have generated as much excitement in healthcare as digital innovation. Artificial intelligence, remote monitoring, telemedicine and personalised care technologies are increasingly seen as solutions to many of healthcare’s biggest challenges, and Maassen acknowledges their potential.
“Digital can be a huge asset,” she says. “Telemedicine, for example, could play a transformative role in addressing rural health inequalities by connecting patients with healthcare professionals regardless of location.
“What is one of the most promising tools that we have to help address rural health inequalities and access? Telemedicine. It’s a fantastic tool.”
She also points to initiatives that allow people with chronic conditions to monitor their health from home, reducing hospital visits and improving quality of life. Yet she is equally clear that technology alone cannot solve systemic problems.
“The challenge we have right now is that it has to be embedded in a governance structure and in a societal structure that are supportive of it being used in the most equitable and best possible way.”
Without appropriate safeguards, digital technologies risk reinforcing existing inequalities. “It has very, very great potential to increase inequalities and not reduce inequalities.”
Issues such as digital literacy, access to technology, algorithmic bias, misinformation and data governance all require careful attention. “If we don’t put the systems in place, then they’ll widen inequalities.”
For EuroHealthNet, the answer is not to slow innovation, but to ensure innovation serves public wellbeing rather than undermining it. “Digital can be a tremendous force for good in so many ways, but it has to be harnessed in the right way. It has to be directed in the right way.”
Practical action
Despite the scale of the challenges, Maassen remains focused on the need for practical action. Asked whether she is optimistic about Europe’s future, she pauses. “I think I’m more of a pragmatist.”
“I think people will realise that there’s not really any other way, unless we want to go down the route of a truly dystopian future, where we are just experiencing even greater disparities and inequalities between the haves and the have-nots.”
For her, the path forward involves investing seriously in prevention, confronting harmful commercial influences, rebuilding trust in institutions and empowering communities to participate in shaping healthier societies. It also requires organisations like EuroHealthNet to continue connecting people, sectors and ideas across Europe. “My dad had an expression that I loved,” she says. “‘Never underestimate the value of being competent.'”
It is a deceptively simple philosophy for tackling some of society’s most complex challenges. Whether connecting policymakers with researchers, helping countries learn from one another, or ensuring that health is considered alongside education, housing and employment, EuroHealthNet’s work is ultimately about making countless small connections that collectively create meaningful change.
The long-term vision, however, remains ambitious: “An economy and a society that works in the service of people, equitably in the service of people and in the service of our planet,” says Maassen. “That we all have the best possible opportunity for a good quality of life and a life that we can live in dignity.”
For EuroHealthNet, achieving that vision is not simply a matter of improving healthcare but of reshaping the conditions that allow health, wellbeing and opportunity to flourish in the first place. Because, as Maassen concludes, “there’s not really any other way.”