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The Population Health Index


Professor Paula Santana outlines the EURO-HEALTHY Population Health Index, a robust tool to monitor population health across European regions.

EURO-HEALTHY is a three-year Horizon 2020 research project launched in January 2015. The project has brought together 15 esteemed academic institutions from 12 European countries to create a highly collaborative partnership that enhances the capacity of more than 50 researchers involved in conducting transdisciplinary and interdisciplinary research on health and wellbeing.

The objective of EURO-HEALTHY was to advance knowledge of policies that have the highest potential to enhance health and health equity across European regions, with particular focus on metropolitan areas. Within the EU Horizon 2020 research and innovation programme, the ‘Foresight for health policy development and regulation’ call underpinned the need for more meaningful information, particularly with respect to the regional health inequalities within the EU. Consequently, EURO-HEALTHY developed a comprehensive, structured and participatory framework of analysis, integrating and quantifying key factors which affect population health and health inequalities, taking the EU’s diversity into account and foreseeing the impact of policies.

EURO-HEALTHY Population Health Index

To answer to this challenge, the EURO-HEALTHY Consortium constructed a Population Health Index (PHI) – a multidimensional and multilevel robust measure – to evaluate and monitor overall health across all regions of the 28 EU member states.

Presenting a bottom-up hierarchical structure, the PHI takes two main components of population health into consideration: health outcomes and health determinants, both disaggregated to areas of concern, dimensions and indicators. The indicators are presented for the following 17 health dimensions: employment, income and living conditions, social protection, security, education, demographic change, lifestyle and health behaviours, pollution, housing conditions, water and sanitation, waste management, road safety, healthcare resources, healthcare expenditure, healthcare performance, mortality, and morbidity.

The index was built through a MACBETH1 socio-technical approach: i) on the social side, integrating evidence with the views and opinions of stakeholders (including policymakers and experts) collected through participatory approaches; and ii) on the technical side, building a multidimensional model, informed by multicriteria decision analysis methods and sensitivity analysis techniques.

The PHI was the starting point to develop population health scenarios for 2030. Three scenarios were produced – two extreme (‘Sustainable Prosperity’ and ‘Failing Europe’) scenarios and an interim (‘Being Stuck’) scenario – also using a socio-technical approach combining the views of stakeholders and experts through Web-Delphi and workshops with the extreme world method. Scenario structures involve drivers organised under the PESTEL categories and having a twofold role in understanding factors that are key to influence population health in the future and in influencing the design and evaluation of policies.


From the beginning, a high priority for the EURO-HEALTHY Consortium was to progressively involve a large number of relevant stakeholders from distinct European countries. Their expertise was utilised in developing and applying methods and tools to evaluate population health at the European level and to assess policies with the potential to improve health and health equity across European regions and for two case studies (Lisbon and Turin). Departing from the PHI, both case studies have highly involved local stakeholders in the process of selecting and evaluating policies.

In total, 96 relevant stakeholders (inter alia: national, regional and local authorities; advisors and technicians; international bodies; political parties; healthcare professionals; urban planners) were actively engaged in a set of participatory processes over the three years of the project. These processes were performed with a range of participatory approaches, including web-based Delphi panels, workshops, and decision conferences.

Capacity of the PHI

The EURO-HEALTHY PHI was designed to produce transparent and comprehensive evidence that will serve numerous objectives:

  • To understand the degree of variations in Health Determinants and Health Outcomes and their geographical distribution in a useful cartographical visualisation;
  • To emphasise the inequalities that still persist in Europe, both amongst and within EU countries;
  • To highlight the importance of monitoring health determinants and health outcomes to promote population health and reduce health inequalities; and
  • To provide evidence to foresee and discuss the impact of multilevel policies and combinations of the policies to improve the determinants of population health and to reduce population health inequalities across Europe.

Analysing inequalities

Recently, the project published the EURO-HEALTHY Atlas of Population Health in European Union2 – a comprehensive guide illustrating what is known – that is i) which EU regions are the most and least healthy; ii) which determinants are currently shaping the future health outcomes of those regions; iii) the extent to which the opportunity for good health differs among those regions; and iv) how health can be improved.

The EURO-HEALTHY PHI findings in the atlas demonstrate a high degree of variation in the geographical distribution of health determinants and health outcomes, emphasising that inequalities still persist across Europe.

The evidence shows that economic conditions and social protection remain the most important domains for reducing the EU regional health inequalities. The ‘Income and living conditions’ dimension presents the largest inequalities (S80/S20): regions within the highest quintile (S80) have an income 11 times higher than that of regions in the lowest quintile (S20) (Fig. 1). Almost 100 million people live in the latter.

Regarding environmental health, there are 157 million Europeans who live in regions of particular concern for physical environment indicators (pollution: greenhouse gases and particulate matter) and are evaluated with the lowest population health value-scores mainly concentrated in East-Central Europe (Fig. 2).

Regarding health outcomes, deaths from causes considered to be ‘avoidable’ remain excessive, particularly in the Baltic States and Eastern European countries.


To facilitate visualisation of the evidence produced by the PHI, the project has developed a web-based geographic information system (Web GIS) that allows for the space-time analysis, and comparison of population health (current and future) at NUTS 2 European regions, and for ten selected metropolitan areas (Athens, Barcelona, Berlin, Brussels, Lisbon, London, Paris, Prague, Stockholm and Turin).

The portal is accessible at: (to be made available to the public without cost by December 2017).


1          Bana e Costa C, De Corte J-M, Vansnick J-C. MACBETH Measuring Attractiveness by a Categorical Based Evaluation Technique. Int J Inf Technol Decis Mak. 2012; 11(2):359-387. doi:10.1142/S0219622012400068

2          Santana P, Costa C, Freitas Â, Stefanik I, et al. Atlas of Population Health in European Union Regions. Coimbra, Portugal: Imprensa da Universidade de Coimbra; 2017. doi:10.14195/978-989-26-1463-2





The EURO-HEALTHY project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 643398.

The sole responsibility for the content of this report lies with the authors. It does not necessarily reflect the opinion of the European Union. The European Commission is not responsible for any use that may be made of the information contained therein 



Professor Paula Santana

University of Coimbra

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This article will appear in Pan European Networks: Science & Technology issue 25, which will be published in December, 2017 

Pan European Networks Ltd