Health inequity, that is socially determined, and preventable disparities in health, hinders the advancement of life expectancy. In Russia, which has witnessed the collapse of a social system rooted in the principles of social equality in a remarkably brief historical period, both the topic itself and the search for methods to investigate it are of utmost importance. The purpose of the study is to evaluate the manifestations of health inequity through the lens of their social dependence and preventability in terms of avoidable mortality.

Material and methods. The calculation of avoidable mortality is based on the cause classification in ages under 65, proposed by Walter W. Holland in 1993. The analysis was conducted using data for the period between 2000 and 2019.The subsequent period is marked by turbulence. The study used official data provided by Rosstat as its information base. Standardized mortality rates for preventable death causes were calculated using the direct method (European standard population).

Results. The disparity in life expectancy between urban and rural populations, as well as its regional variations, is largely attributable to avoidable mortality. The example of a substantial reduction in the rural-urban gap in avoidable mortality over the first two decades of the 21st century, including a convergence in treatable deaths, suggests that significant progress has been made in addressing health disparities between urban and rural populations within a remarkably short timeframe.

In terms of regional disparities, progress is minimal. The economically prosperous regions of the country have much greater potential for improving the life expectancy of their populations by reducing preventable deaths, compared to poorer regions. In both cases, priority should be given to prevention interventions aimed at lifestyle modification, as the social component of avoidable mortality dominates, and interventions aimed at reducing it are the most cost-effective strategy.

health inequality, health inequity, avoidable mortality, preventable death causes, death causes as markers of health care availability and quality

Health inequality refers to any measurable aspects of health that vary among different people, i.e. there are no moral judgments in this term about whether the observed differences are fair (Kawachi et al. 2002).

The disparities between age groups are not unfair when older people die more often than younger (Arcaya et al. 2015). Furthermore, most disparities in health of different people are attributed to random factors (Smith 2011). That is, some level of inequality in health is objective.

If disparities in the health status of population groups living within the same area or country are systematic, persist over a long period of time and become more pronounced, then they are amenable to change and must be eliminated (Krieger 2012). That is, inequality in health is useful to analyze not in a general sense but only to identify unjust differences where the problem of social injustice arises. In English, a different term is used for health inequality in this sense – “health inequity” (McCartney et al. 2019). It is precisely health inequity, which can be addressed and eliminated, that should be a priority for public health promotion programs in addressing the challenge of increasing overall life expectancy. Accordingly, we will continue to analyze health disparities using the English-language term “health inequity”, even though it is often translated as “health inequality” in Russian.

A literature review conducted by O.A. Kislitsyna identified three main hypotheses explaining socio-economic inequality in health. The first hypothesis, based on social selection theory, suggests that health determines a person’s social and economic status. The second hypothesis, known as the social causation hypothesis, argues that social and economic status affects health through intermediate factors such as material, psychosocial, and behavioral factors. The third hypothesis, called the life journey hypothesis, suggests that differences in adult health can be partially explained by social and economic factors experienced during early development (Kislitsyna 2017).

The assessment of social inequality in terms of the life cycle is based on the understanding that different types of factors contribute to social inequality at different stages of life. These factors can include those that affect the intrauterine period, such as fetal growth retardation, premature birth, and congenital malformations. These conditions are more likely to occur in children born to mothers with low education levels and social and economic status (Mortensen et al. 2009). Neglect in childhood can lead to low self-esteem, increased risk of behavioral problems, depression, and decreased stress tolerance later in life. Children from families with limited resources are more likely to experience problems during early development (Yanos et al. 2010).

Economic research has demonstrated that investments in children’s intellectual and social development in their early years have a far greater influence on their health and economic prospects than those made later in life (Conti and Heckman 2010). It is evident that a prosperous childhood, including intrauterine development of a child, serves as the foundation for their health, extending into adulthood.

The next stage of a child’s development has a significant impact on their education, and subsequently on their chances in the job market. These chances are lower for individuals with health issues and those who lack sufficient education. According to the first hypothesis, social factors play a role in this process, as poor health can hinder the pursuit of a high-quality education or lucrative employment. There is a strong relationship between the parental social status and the academic success of their children, especially in terms of their educational attainment. The education of the mother has a significant influence on the child’s future prospects (Davis-Kean et al. 2021). Habits that are formed at an early age can have a significant impact on a person’s future health choices (Fasang and Mayer 2020). During the school years and adolescence, health disparities formed in early childhood become more pronounced.

Depending on the social status of adults in society, they may be exposed to different levels of risk factors due to their work, living conditions, and physical environment. Poor health, especially psychological problems, can increase the risk of unemployment (Bartley et al. 2006).

The relationship between income and mortality reflects the cumulative effect of a long causal chain in which social background and early development affect both income and health through their effects on health, employment and work environment, on the development of health problems and their solution, but the disease and its consequences for employment affect income (Galobardes et al. 2006). According to experts, addressing the root causes of health inequity requires breaking the cycle of poverty that leads to diseases leading to poverty – “a 21st century health poverty trap” (Bor et al. 2017).

In the Russian scientific literature, the topic of inequity in health is not very popular. In the Soviet period – for ideological reasons, because of setting the goal of achieving social homogeneity of society and “erasing differences” in terms of social, professional, educational, ethnic, residence-dependent and other features. In the post-Soviet period, against the background of significant social and economic polarization of society and an obvious increase in disparities in health and mortality, research on this topic for a long time was practically suppressed as a result of the adoption of the Federal Law “On civil status acts” No 143-03 dated November 15, 1997. According to this law, all social and economic characteristics of the deceased were excluded from the primary accounting and reporting documents.

However, a number of studies based on population censuses, found significant differences in adult mortality during the Soviet period by level of education and type of employment (Andreev and Dobrovolskaya 1993; Inequality and mortality in Russia 2000; Andreev et al. 2005a). In the post-Soviet period, the topic was further developed. For example, studies conducted over a period of available data have shown that during the first half of the 1990s – an unprecedented rise in peace-time mortality – the increase among well-educated men over 30 was twice as low as the general population of this age, while there was no increase in mortality among their educated female peers (Andreev et al. 2005b). The educational mortality factor has been confirmed to be important in explaining the variation in the level and causes of death, not only among the adult population (Ivanova et al. 2014), but also in infant mortality (Andreev and Kvasha 2005).

However, the majority of studies focus on the analysis of regional differences in mortality, which can be explained by the vast territory of Russia, diversity of natural, socio-economic, cultural and ethnic conditions. In the Soviet era, it was found that there is a “northeastern gradient of mortality” in Russia (Andreev 1979; Shkolnikov 1987). This phenomenon has remained stable for almost six decades and is still relevant today (Starodubov et al. 2003; Demographic development of Russia in the 21st century 2009; Demographic present and future of Russia 2012; Razvitie chelovecheskogo potentsiala v Rossii skvoz’ prizmu zdorov’ya naseleniya 2012; Rybakovsky and Kozhevnikova 2015; Timonin et al. 2017; Danilova 2018; Rodionova and Kopnova 2020). As a general rule, the northeastern mortality gradient is explained by the level of “favorable living conditions”. This refers primarily to the overall level of development of the area and favorable natural and climatic conditions.

Inequities in health are manifested through different levels of morbidity and mortality within one country, region or city. Many diseases can act as markers of a social gradient of health. The toolkit proposed as part of the concept of avoidable mortality seems to be effective. This approach identifies a group of causes that can be prevented in the context of modern advancements in medicine, healthcare, and social sector and, therefore, are excessive. There are two categories of causes: treatable and preventable. The prevention of deaths that are caused by treatable causes depends on timely and accurate diagnosis, as well as quality treatment. Deaths due to preventable causes can be prevented through public health interventions that address broader determinants of health, such as behaviors, lifestyles, socio-economic factors (such as living conditions and standard of living), and environmental factors (Nolte and McKee 2004).

The purpose of the study is to evaluate the manifestations of health inequity through the lens of their social dependence and preventability in terms of avoidable mortality.

Mortality is not the only indicator of health. Simultaneously, with a relatively low life expectancy (with clear success in reducing mortality after 2004, this is precisely the case in Russia), mortality rates can accurately reflect the health of the population. The issue of finding additional health indicators beyond mortality is becoming more acute in developed countries, with a significant increase in the number of older people and the length of their lives. So far, the main source of life expectancy growth in Russia has been a reduction in premature mortality at working age with a very little increase in the lifespan of the elderly population.

The disparities in avoidable mortality are examined in relation to the place of residence, urban or rural area. This approach is informed by the well-documented disparities in mortality between rural and urban areas, as well as between different regions of Russia. These disparities are not limited to our country; they are global, albeit with varying degrees of magnitude and focus.

The age under 65 is considered a reasonable period for prevention in Russia, given the current level of development. However, for developed countries with life expectancy above 80 years, it rises to 75 years. The age range up to 65 is most relevant as it encompasses the period of childhood and working age, i.e. the interval within which determinants of inequities in health are formed and implemented.

Since these are circumstances of a fundamental nature, the analysis is based on the 2019 data. The situation in the subsequent period is turbulent due to the crisis associated with the COVID-19 pandemic in 2020-2021 and the geopolitical risks the country has been facing since 2022. The analysis of regional differences for one year does not affect the sustainability of results. The period up to 2020 was characterized by sustained positive trends, against the background of which regional differences in mortality began to decrease slightly. The traditional geographic patterns of prosperity – disadvantage remained unchanged.

The calculation of avoidable mortality is based on the cause classification in aged under 65, proposed by Walter W. Holland in 1993 (Holland 1993). Although there are more current versions of the list of preventable causes, it was considered advisable to use an earlier version given the mortality rates in Russia and significant reserves of reducing mortality precisely from preventable causes.

Mortality classified as preventable includes 38 causes, groups and classes of causes, divided into three main groups according to the three levels of prevention (Table 1).

The first group includes causes of death that can be prevented through primary prevention. This group includes causes largely determined by lifestyle, mainly what are commonly called bad habits, the most important of which is alcohol and tobacco consumption (vascular disorders of the brain, malignant neoplasms of the upper digestive and respiratory tracts, lungs, bladder, and liver) and other conditions associated with alcohol consumption (chronic diseases of the liver). In addition, some of malignant neoplasms in this group may also be defined by occupational risk factors (lungs, bladder, liver). The first group also includes injury and poisoning which, in addition to behavioral factors, are significantly influenced by law enforcement, socio-economic and social factors such as road safety (speed limits, use of safety belts, etc.) and crime control.

The second group refers to causes eligible for secondary prevention, i.e. timely detection and early diagnosis. This group includes, primarily, breast and cervix uterine malignant neoplasms, as well as melanoma. Other malignant neoplasms of the uterus are also included in this group, because inaccurate coding and poor diagnosis make it difficult to separate these causes from malignant neoplasms of the uterus.

The third group includes causes associated with improvements in quality of treatment and care. Vaccination and treatment are largely related to deaths from infectious diseases, although factors such as clean water and healthy diet should not be underestimated. Changes in mortality from other causes in this group requiring medical and surgical intervention (hypertension, ulcers, complications of pregnancy, appendicitis, hernia, cholelithiasis) are related to the set of measures and coordination of different health services, such as emergency services, adequate medical care and surgery, etc.

For ease of analysis, the second and third groups of causes are combined into a group caused by medical or health factors. The first group is attributed to social factors.

The information basis for the study was the official statistics provided by Rosstat, on death distribution by place of residence, gender, age, and cause of death as well as data on the average annual population of urban and rural areas by gender and age, for both Russia as a whole for the years 2000 to 2019 and for each constituent entity of the Russian Federation in 2019. Furthermore, data on life expectancy for urban and rural populations was obtained from the EMISS Rosstat system.

To calculate the standardized mortality rates for preventable causes of death, the direct method was employed, using the European Standard Population¹.

When discussing the issues of health equality and equity in Russia, the issue of equality and inequality is quantitative and rather declarative. The problem of equity is much more complex: at first glance, it may seem fair to address the noted lag in some of the most important indicators in the country. However, this approach is unlikely to be feasible, so the purpose of this study is to determine whether this inequity is objectively substantiated and therefore fair in the current context.

Discussing the disparities in health between urban and rural populations, it is important to acknowledge that these disparities are common throughout the modern world, yet they are not universally applicable. In this context, the narrowing gap in life expectancy between rural and urban populations in Russia, observed in the 2000s, is a positive development. Furthermore, it is crucial to consider that the convergence in life expectancy between urban and rural populations is primarily driven by trends in avoidable mortality, which are more favorable among rural population. This has resulted in a substantial reduction in the disparity in mortality from preventable causes, and in almost eliminated disparity in mortality from treatable causes.

It can thus be stated that, despite the continuing gap in life expectancy between rural and urban populations, there is a gradual minimization of this inequity, determined by both preventable causes and treatable causes of avoidable mortality.

What are the drivers of such dramatic changes in health inequity between urban and rural populations?

Probably, two groups of factors can be distinguished. The first and, in our view, most important is investment in agriculture to ensure food security of the country. This not only created jobs with decent pay, but in general led to the development of rural areas, renovation and creation of new infrastructure. Not all regions in the country are affected by these processes, but overall at the national level the positive dynamics cannot be denied. The second group of factors is related to the implementation of the program of modernization of the primary health care, which has primarily benefited the rural health care by building and equipping feldsher-midwife stations, medical outpatient clinics, developing the system of mobile diagnostics, etc.

The disparities in health across regions are less encouraging. In 2019, the disparity in life expectancy between males and females added up to 14.8 years and 9.4 years, respectively. Despite positive trends in life expectancy in the country, these disparities remained almost unchanged. The geographic vector of mortality distribution remains consistent.

In this context, there is a possibility of a “geographical curse”, which would imply the existence of an objective disparity in life expectancy. Furthermore, efforts to identify a relationship between the level of economic development and life expectancy in Russia, as determined by international comparisons, have failed. While in the 1990s, the lack of this relationship could be attributed to the social and economic transformations in the country, after nearly three decades, a more plausible explanation is required.

If we exclude the regions where, probably because of unreliable data, there is a reverse relationship between the living standards and life expectancy, it can be said that a significant number of economically prosperous regions have much greater untapped life expectancy reserves compared to poor regions. It is not a question of geography, but rather of targeting economic potential for social development. Such antipodes are, for example, the Khanty-Mansi autonomous district and the Yamalo-Nenets autonomous district on the one hand, and the Krasnoyarsk Territory, the Sakhalin region and especially the Magadan region and the Chukotka autonomous district on the other hand. At the same time, in the group of regions with low economic potential, there are regions with high life expectancy. Again, one cannot ignore the geographical factor. Among the mentioned regions, there is not a single one located in harsh climatic and geographical conditions, by contrast, it is mostly the south of Central Russia and the Volga region.

The goal of developing a comprehensive mortality reduction strategy is closely linked to the issue of reducing inequity.

In regions with high avoidable mortality, regardless of their level of economic development, both the social and medical components (preventable causes of death and treatable causes of death) are problematic. However, in most cases, the priority is given to prevention interventions, both due to greater significance of the social component and higher cost-effectiveness of such measures.

With avoidable mortality rates close to the national average, priorities often depend on the economic potential of a region. In regions with higher economic opportunities, prevention interventions are also a priority, given a relatively favorable situation with treatable causes of avoidable mortality. However, in regions with lower economic potential, there is more variability, and priorities are determined by social policies in the region, such as a focus on prestigious facilities at the expense of social infrastructure or the prevention of marginalization.

At low levels of avoidable mortality, both components are usually balanced as a result of the motivation of people towards self-preservation behavior and effective healthcare.

Avoidable mortality prevented by lifestyle interventions and effective health care contributes significantly to the dispraises in life expectancy between urban and rural populations, as well as its interregional variation. This makes it possible to mark such disparities as preventable and, therefore, unequitable.

Considering a substantial reduction in rural-urban disparities in avoidable mortality over the first two decades of the 21st century, including a convergence of mortality rates from treatable causes, it is evident that substantial progress has been achieved in eliminating health inequity between urban and rural populations within a remarkably short timeframe.

Russia is characterized by a significant disparity in health across different regions, as evidenced by a difference in life expectancy of 14.8 years in males and 9.4 years in females. This disparity remains largely unchanged despite positive trends at the national level. The absence of a relationship between the economic potential of a region, measured by GRP per capita, and the level of avoidable mortality highlights the inequity of these disparities.

Economically prosperous regions of the country have a more substantial unrealized potential for enhancing life expectancy by curbing avoidable mortality, compared to poor regions. In both cases, the imperative to refine public health policies is pressing, yet for poor regions, economic expansion is paramount, primarily to advance in reducing avoidable mortality. Conversely, for prosperous regions, the realization of economic growth is essential for social advancement. Priority in both cases is given to prevention interventions aimed at lifestyle modification, as the social component in avoidable mortality prevails, and efforts to reduce mortality from preventable causes are the most cost-effective strategy, as demonstrated by nations that have achieved high levels of life expectancy.

The Demographic Yearbook of Russia (2023) Section 6 Methodical notes. URL: https://rosstat.gov.ru/storage/mediabank/Dem_ejegod_2023.htm

Alla E. Ivanova – Dr. Sci. (Economy), Professor, Head, Department of Health and Health-Preserving Behaviour, Institute for Demographic Research, Branch of the Federal Center of Theoretical and Applied Sociology of the Russian Academy of Sciences. Moscow, 119333, Russia. E-mail: ivanova-home@yandex.ru

Viktoria G. Semyonova – Dr. Sci. (Economy), Chief Researcher, Department of Health and Health-Preserving Behaviour, Institute for Demographic Research, Branch of the Federal Center of Theoretical and Applied Sociology of the Russian Academy of Sciences. Moscow, 119333, Russia. E-mail: vika-home@yandex.ru

Tamara P. Sabgaida – Dr. Sci. (Medicine), Professor, Chief Researcher, Department of Health and Health-Preserving Behaviour, Institute for Demographic Research, Branch of the Federal Center of Theoretical and Applied Sociology of the Russian Academy of Sciences. Moscow, 119333, Russia. E-mail: tsabgaida@mail.ru