Alvarenga et al. International Journal for Equity in Health (2019) 18:100 https://doi.org/10.1186/s12939-019-1000-8 RESEARCH Open Access Scenarios for population health inequalities in 2030 in Europe: the EURO-HEALTHY project experience António Alvarenga1,2,3,4,5, Carlos A. Bana e Costa2, Carme Borrell6,7, Pedro Lopes Ferreira8, Ângela Freitas9, Liliana Freitas2, Mónica D. Oliveira2, Teresa C. Rodrigues2, Paula Santana9, Maria Lopes Santos1 and Ana C. L. Vieira2* Abstract Background: Health inequalities have been consistently reported across and within European countries and continue to pose major challenges to policy-making. The development of scenarios regarding what could affect population health (PH) inequalities across Europe in the future is considered critical. Scenarios can help policy-makers prepare and better cope with fast evolving challenges. Objective: This paper describes the three 2030 time-horizon scenarios developed under the EURO-HEALTHY project, depicting the key factors that may affect the evolution of PH inequalities across European regions. Methods: A three-stage socio-technical approach was applied: i) identification of drivers (key factors expected to affect the evolution of PH inequalities across European regions until 2030) – this stage engaged in a Web-Delphi process a multidisciplinary panel of 51 experts and other stakeholders representing the different perspectives regarding PH inequalities; ii) generation of scenario structures – different drivers’ configurations (i.e. their hypotheses for evolution) were organized into coherent scenario structures using the Extreme-World Method; and iii) validation of scenario structures and generation of scenario narratives. Stages ii) and iii) were conducted in two workshops with a strategic group of 13 experts with a wide view about PH inequalities. The scenario narratives were elaborated with the participants’ insights from both the Web-Delphi process and the two workshops, together with the use of evidence (both current and future-oriented) on the different areas within the PH domain. Results: Three scenarios were developed for the evolution of PH inequalities in Europe until 2030: ‘Failing Europe’ (worst- case but plausible picture of the future), ‘Sustainable Prosperity’ (best-case but plausible picture of the future), and an interim scenario ‘Being Stuck’ depicting a ‘to the best of our knowledge’ evolution. These scenarios show the extent to which a combination of Political, Economic, Social, Technological, Legal and Environmental drivers shape future health inequalities, providing information for European policy-makers to reflect upon whether and how to design robust policy solutions to tackle PH inequalities. Conclusions: The EURO-HEALTHY scenarios were designed to inform both policy design and appraisal. They broaden the scope, create awareness and generate insights regarding the evolution of PH inequalities across European regions. Keywords: Health inequalities, Population Health, Participatory approach, Delphi method, Foresight, Policies, Socio- technical approach, Scenarios, Stakeholders * Correspondence: ana.lopes.vieira@tecnico.ulisboa.pt 2 CEG-IST, Centre for Management Studies of Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisbon, Portugal Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 2 of 18 Background population, the patterns of determinants that influence such Recognising the importance of health inequalities as a grow- outcomes, and the policies that influence the optimal bal- ing policy issue for the European Union (EU), the European ance of determinants” ([12], p. 382). Accordingly, the PHI Commission [1] issued some key recommendations to the has two components, one regarding health determinants Member States: “• lead on clear and comprehensive strat- and another regarding health outcomes [13]. Departing from egies to redress the current patterns and magnitude of this approach and assuming that scenarios may provide new health inequalities; • ensure the coherence and effectiveness evidence on possible future developments, the EURO- of action to reduce health inequalities at all levels of govern- HEALTHY project took the construction of PH scenarios as ment and across all sectors and stakeholders; • ensure that a key challenge to inform the evaluation of policies in the the capacities exist for coherent and effective implementa- context of health inequalities evolution. tion of action on health inequalities; • ensure progressive A key challenge regarding the scenarios built under the improvement in the availability and use of data needed to EURO-HEALTHY project was that they needed to be de- identify priorities, plan action, monitor trends and evaluate signed in a transparent and replicable way that considered what actions are most effective” ([1], p. x). There are how- not only the evidence (both current and future-oriented ever several challenges in the design and implementation of evidence) on the different areas of concern within the do- policies for reducing health inequalities, not only on how to main of PH, but also the diversity of perspectives and assist policy-makers to holistically evaluate policies’ benefits values of the full panoply of stakeholders across Europe and to reflect upon their doability and power issues, but [14]. This is aligned with literature suggesting that for sce- particularly on how to anticipate the extent to which future narios to be relevant, consistent and useful, the scenario events may affect those policies [2, 3]. building process should involve “people whose futures are The field of foresight and scenario planning offers suitable being discussed are part of the scenario development tools to provide support and advice to policy-makers [4, 5] process” ([8], p. 346). Also, health research has recognised because the key to choose resilient (policy) actions is to de- the importance of participatory processes in recent years fine what they should be resilient to [6]. Looking at different [15], with a growing understanding that participation of plausible scenarios, decision-makers can anticipate possible both researchers and stakeholders potentiates dialogue to- or potential strategies [7] and use their knowledge to prepare wards health improvements and ways of addressing health for what may lie ahead, taking a proactive position instead of inequalities [16–18]. just accepting the events [8]. Applications of foresight Specifically, this paper describes the EURO-HEALTHY methods to the health context has shown many advantages PH scenarios whose focal issue was the future of PH in- and offer insights to “be better equipped to improve health equalities across European regions in 2030. The proposed systems and interventions, and prepare for future public scenarios aim to support European policy-makers, and the health incidents” ([9], p. 54). Vollmar and colleagues [10] scientific community, to reflect upon what can affect reviewed 41 papers on the use of scenarios in the health field health and health inequalities across European regions in and concluded that, despite the great potential of scenarios the future, so as to assist policy design and appraisal. as a strategic decision-making and healthcare planning tool, scenario building methods are not widely used when com- pared to other methods (e.g. consensus methods, simulation Methods modelling). These authors also found that most published Overview of the socio-technical approach for scenario studies do not describe the scenario building process on a building transparent and comprehensive way. The reported literature The goal of our study was to develop PH scenarios able to explored issues mainly related with diseases, public health facilitate European policy-makers’ reflection upon what on an organizational level, the healthcare labour market, could affect PH inequalities across Europe. Given the wide technology, the pharmaceutical field and aging [10], but up range of plausible variations in health determinants’ to our knowledge no study has focused on population health inequalities (and on their causal factors) across European (PH) inequalities across European regions. regions, an array of possible futures (i.e. scenarios) should The EURO-HEALTHY H2020 research project (with be envisaged in order to explicitly consider contextual un- EURO-HEALTHY standing for ‘Shaping EUROpean policies certainty during policy design and appraisal. There are sev- to promote HEALTH equitY’) (2015-2017) [11] proposes a eral methodological approaches for building scenarios [19]. multicriteria Population Health Index (PHI) as a tool to help Our methodological choice was aligned with the Extreme- reflecting upon the future of PH inequalities and to assist World Method [20], having in view the advantage of pro- policy evaluation. The development of the PHI was based viding a practical and transparent way of establishing plaus- on the definition of PH by Kindig and Stoddart [12], which ible boundaries within which the future of PH inequalities acknowledges that accurate measurement of PH must con- in Europe can unfold. These boundaries are defined by two sider the “health outcomes and their distribution within a extreme, yet still plausible, contrasted scenarios, covering Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 3 of 18 both the more optimistic (best-case) and the more pessim- Stage iii) ‘Validation of scenario structures and generation istic (worst-case) perspectives. of scenario narratives’ kept the workshop format and aimed Specifically, the Extreme-World Method [20] was em- to adjust and validate the two contrasted scenario structures, bedded into a three-stage scenario building socio- as well as to build an interim scenario structure depicting technical approach (see Fig. 1). Stage i) ‘Identification of the ‘to the best of our knowledge’ evolution, in view of giving potential drivers’ aimed to determine the key factors that rise to a reference scenario. The three scenario structures were expected to affect the evolution of PH inequalities were validated and provided the backbones for the develop- across European regions until 2030 (these key factors are ment of scenario narratives to enable a better understanding called drivers in the scenario terminology). The potential and communication of the scenarios, which were later drivers were collected through a Web-Delphi process [21] enriched with future-oriented evidence that was collected. implemented in the WELPHI Decision Support System Details from the implementation of each stage of the [22] that was designed to drive a large multidisciplinary adopted socio-technical approach are described in the panel of experts and stakeholders, representing a wide following sub-sections. range of perspectives regarding PH inequalities, into the process of identifying drivers relevant to the evolution of Stage i) Identification of potential drivers PH inequalities. The potential drivers were generated con- A total of 51 experts and other stakeholders were invited to sidering criteria adapted from the Group Elicitation take part of a Web-Delphi process to determine which key Method (GEM) [23]. In its original application, GEM is a factors were expected to affect the evolution of PH inequal- combination of the brain writing technique with a deci- ities across European regions until 2030 (the drivers). The sion support system that allows to depart from an array of participants included people from all over Europe, linked to viewpoints and reformulate them in a list of concepts by the public and private sectors and the society at large. Their applying different criteria – simplicity, interest, robustness fields of expertise covered a large spectrum, such as public and corroboration [23]. In our adaptation of GEM, the health, urban and regional planning, social inequalities, analysts set of number of criteria (see stage i) to then indi- environment, and groups at-risk [14]. The Web-Delphi vidually perform an individual analysis of the results of the included two rounds: round 1 with open-ended questions first round of the Web-Delphi process. for idea-generation regarding the reasons for possible Stage ii) ‘Validation of drivers and generation of scenario evolutions in PH determinants in Europe; and round 2 for structures’ was designed to create two contrasting scenario the participants to state their agreement regarding the structures following the Extreme-World Method. For that potential drivers obtained in round 1. purpose, a strategic group of 13 members – representing a In round 1, participants were faced with sets of health de- wide range of perspectives regarding PH inequalities – par- terminants’ indicators (i.e. integrating the health determi- ticipated in a workshop and validated the drivers collected nants component of the PHI), organized per PH area of in stage i) (along with the corresponding hypothesis for concern (list of indicators within each area of concern evolution, called drivers’ configurations) and further orga- provided in Table 2 in Appendix 1), together with their nized them into two scenario structures: one with all the respective performance ranges across regions (reference worst-case (increasing PH inequalities) hypotheses of evolu- year 2014; info with reference to the European NUTS 2 tion, and the other with all the best-case (decreasing PH regions). For each area of concern, the participants were inequalities) hypotheses. asked the ‘trigger-question’: Given the set of current gaps Fig. 1 Three-stage socio-technical approach for scenario building Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 4 of 18 across European regions on the [area of concern] indicators, Stage iii) Validation of scenario structures and generation shown on the left side of your screen, please indicate which of scenario narratives of the following three statements do you consider to be The strategic group gathered in a second workshop to ad- plausible (you can select more than one). The options pre- just and validate the two contrasted scenario structures, sented (in text boxes) were the following: Until 2030, there and to build an interim scenario structure depicting the ‘to will be [an increase, a decrease and/or no change] in [area the best of our knowledge’ evolution, to give rise to a refer- of concern] inequalities across European regions for the fol- ence scenario. The group discussed the three scenario lowing main reasons. Participants were then invited to opt structures, along with key characteristics for scenarios, such for a statement of increase, decrease and/or no change on as compatibility, meaningfulness, representativeness and PH inequalities, and then to provide one or two main rea- plausibility [19]. To improve the description of each driver sons for each of those selections. An illustrative example configurations – i.e. worst-case (increasing PH inequalities) for the area of concern Economic conditions, social protec- and best-case (decreasing PH inequalities) – future- tion and security is provided in Figure 4 in Appendix 1. oriented evidence was collected (the search protocol is The participants’ answers provided a list of potential drivers listed in Table 5 in Appendix 2) and a file with all the infor- generated taking into account the following criteria adapted mation was systematized for each driver. This file can be from GEM [23]: (i) address a specific issue, (ii) be non- made available from authors upon request. The final task of redundant, (iii) be simple, and (iv) be understandable. this stage was the generation of scenario narratives and the In round 2, participants were presented with the list of development of factsheets describing each one of the three potential drivers, organized into six PESTLE categories EURO-HEALTHY PH scenarios. The scenario structures (Political, Economic, Social, Technological, Legal and Envir- previously validated in the second workshop provided the onmental). The PESTLE framework is recognised in the lit- backbones for these narratives, with the future-oriented erature as an useful tool to identify key drivers of change in evidence being also used to enrich each storyline. scenario building exercises [24]. For each potential driver, participants had to express their level of agreement regard- ing its relevance, reacting to the following statement: By it- Results self, this driver can originate a change in population health Analysing the results from the Web-Delphi round 1, five inequalities until 2030. The answers were given in a five- types of answers were identified: answers containing rea- level Likert scale (‘Strongly Disagree (SD)’, ‘Disagree (D)’, sons for an increase in PH inequalities, for a decrease, and ‘Neither Agree nor Disagree (NAD)’, ‘Agree (A)’, ‘Strongly for no change; justifications for the ‘Don’t know/Don’t Agree (SA)’). Group agreement, which was meant to deter- want to answer’ option; and additional comments left by mine either approval or rejection of any given driver, was participants during the process. These resulted in 362 an- analysed by applying specific rules for dealing with differ- swers collected, with 240 of these enabling the extraction ences in opinion. Two rules for approval were established of drivers – Fig. 2 presents the distribution of the 240 to select drivers (see Table 3 in Appendix 1) and at least answers by area of concern and by type of answer. one driver from each PESTLE category was included. The scrutiny of the 240 answers led to 178 drivers (see Table 4 in Appendix 1) that were included in the Web- Stage ii) Validation of drivers and generation of scenario Delphi round 2. The application of the selection rules de- structures fined (see Table 3 in Appendix 1) resulted in 49 drivers (see A strategic group of 13 experts and stakeholders partici- Table 4 in Appendix 1, drivers highlighted in bold). Then, pated in a first (face-to-face) workshop that targeted the the generation of scenario structures and the analysis of validation of drivers and the development of contrasted, consistency during the workshops led to 36 drivers, which extreme scenario structures. The 13 participants were di- were plausible and coherent in the framework of the three vided in two groups that worked separately with a coher- scenario structures (stages ii) and iii) described above). ent sub-set of PESTLE categories and the respective Table 1 presents the 36 drivers and corresponding config- drivers obtained by the end of Stage i). Each group started urations for each scenario structure, organised by PESTLE by discussing the drivers and their configurations – i.e. the category: Political (seven drivers), Economic (10 drivers), worst-case (increasing PH inequalities) and best-case (de- Social (10 drivers), Technological (one driver), Environmen- creasing PH inequalities) hypotheses of evolution. The dis- tal (seven drivers) and Legal (one driver). The worst-case cussion resulted in two preliminary scenario structures: scenario structure gathers the configurations that, once one for the worst-case and one for the best-case. The sce- combined, describe a (plausible) increase in PH inequalities. nario structures’ internal consistency was subsequently On the opposite, the best-case scenario structure, gathers analysed, and redundancies were eliminated. This work- combinations leading to a (plausible) decrease in PH shop ended with the members of the strategic group inequalities. The interim structure, defined as ‘to the best of discussing the results obtained by each sub-group. our knowledge’ structure, contains the hypothesis that Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 5 of 18 Fig. 2 Number of answers used for extraction of drivers by PH area of concern and answer type participants expect to happen given the current trends and that the reader of this paper positions her/himself in the the available information to this day. future, as in the style of scenario literature. Furthermore, it Out of these driver’s configurations, three scenarios is important that the reader bears in mind that the scenarios were constructed and supported by a narrative and narratives were built departing from the scenario structures storyline. A short symbolic description containing a set developed (the scenario backbones), together with the in- of key ideas and the structure for the worst-case sce- sights coming from both the Delphi participants (informed nario ‘Failing Europe’ (Fig. 3a) and the best-case scenario by current evidence on PH inequalities) and the strategic ‘Sustainable Prosperity’ (Fig. 3b) were also developed as group discussions in the two workshops (informed by both a result of the process. current and future-oriented evidence). Our expectation is that both the scenario narratives content and the exercise of Discussion reading the scenarios while being in the future offer insights The EURO-HEALTHY scenario narratives on key drivers of PH inequalities which are relevant to in- This paper presents the scenarios for the future of PH form European health stakeholders and policymakers. inequalities across European regions, for the 2030 time-hori- The text that follows describes what will be the future of zon, developed under the EURO-HEALTHY project. Up to PH inequalities across European regions, for the our knowledge these are the first PH scenarios that focus on 2030 time-horizon, considering each one of the three PH inequalities across European regions, hence it is not pos- EURO-HEALTHY scenarios and all the evidence gathered sible to compare them with other scenario building exer- along the scenario building process. cises. However, it should be noted that (a) previous research has recognized there is a large number of determinants of inequalities in health [25], which is aligned with the EURO- ‘Failing Europe’ Scenario HEALTHY scenarios’ complexity; and (b) some of the In 2030, Europe plunged into a new, deeper, and long- EURO-HEALTHY scenario drivers were also captured in lasting economic crisis. The already difficult situation is four other large public health scenario studies [3, 26–28]. being amplified by the refugees’ situation, which it is not Two highly contrasted scenarios (‘Failing Europe’ and ‘Sus- only far from being solved: it has deteriorated over recent tainable Prosperity’) and one reference scenario (‘Being years. The impacts on people’s lives are very negative with Stuck’) are now outlined and discussed in the light of health the increase of inequalities and limited access to basic inequalities in Europe in 2030. The ‘Failing Europe’ scenario services such as healthcare. With the social and economic – the worst-case scenario – assumes an increase in inequal- challenges rising every day, other urgent issues such as ities, whereas ‘Sustainable Prosperity’ corresponds to the tackling climate change, have been given second priority, best-case scenario structure, which includes all the configu- exacerbating the already very serious impacts of the rations that lead to a decrease in PH inequalities. The refer- fragmented and ineffective laws and agreements that have ence scenario ‘Being Stuck’, corresponds to a narrative been introduced over the last decade. Europe is no longer reflecting the “to best of our knowledge”. To comprehen- the solid, strong old continent that we were used to: sively capture the discussion being conducted it is necessary connection and cohesion gave way to fragmentation. Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 6 of 18 Table 1 Overview of the three scenario structures, composed by drivers and drivers’ configurations PESTLE category Drivers Worst-case To the best of Best-case (increase in our knowledge (decrease in inequalities) inequalities) Political Cohesion funds (or other funds) for less-favoured Reduction Maintaining Maintaining regions Political commitment and public support towards Weak Weak Strong universal access to healthcare Public expenditure in the healthcare system Reductions Priority with often Increases insufficient funding Social protection policies for the elderly Significantly weaker Significantly weaker Significantly stronger Investments in national social security systems Significantly lower Without significant Significantly higher change Extent of compulsory education Limited and Extension with weak Throughout the EU and non-harmonized harmonization increasingly harmonized Quality of Public Education Decrease A priority with often Increase insufficient funding Economic Healthcare efficiency Significant decrease Without significant Significant increase change Financial, Economic and Social crises Deeper and long lasting Occasional and regular Mitigated cyclical global crises People's material deprivation Increase Small decrease Significant decrease Economic inequalities Increase Increase Decrease Social Insurance Schemes Weakening Without significant change Strengthening Unemployment rate in Europe Significantly higher Without significant change Significantly lower Long-term structural unemployment Significant growth Without significant Significant decrease change Unemployment among 55+ Significant increase Significant increase Decrease Employment precariousness Significant increase Small increase Decrease Employment with low income Significant increase Small increase Decrease Social Concentration of people at of poverty and social Higher Higher Lower exclusion Medical quality and effectiveness of healthcare Deterioration Improvements with Significantly higher services many dissimilarities Access to healthcare More limited More limited Widening Quality and accessibility of the primary healthcare Significant reduction Maintaining Steady growth services Access and Quality of Emergency Medical Services Significantly lower Without significant Significantly higher (EMS) in remote and/or rural areas changes Smoking restriction policies Softer Stricter Stricter Diet and nutrition Significantly less healthy Limited improvement Significantly more healthy Sedentary lifestyles Increase Limited reduction Reduction Non-communicable diseases like diabetes and Increase Increase Decrease hypertension Food security Compromised Without significant change Improved Technological Medical innovation (improved and affordable Stagnation Slow growth Rapid growth medicines, medical research and technologies) Environmental Quality of the built environment Decrease Without significant Significant change improvement Quality of the natural environment Decline Without significant change Improvement Quality of the outdoor air Decline Sustain the current Improvement levels Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 7 of 18 Table 1 Overview of the three scenario structures, composed by drivers and drivers’ configurations (Continued) PESTLE category Drivers Worst-case To the best of Best-case (increase in our knowledge (decrease in inequalities) inequalities) Climate change adaptation Maladaptation Limited adaptation Improved resilient adaptation Climate change mitigation Disengagement Limited action Engagement Priorities in terms of economic model: Fossil fuel-based Slow transition Green-based green-based vs. fossil fuel-based Development and penetration of renewable Slowdown Increase Significant and rapid energy production (water, wind, sun) increase Legal EU environmental policies and regulations Ineffective Limited improvements Effective (air, water, soil, waste, noise, chemicals) in effectiveness Europe’s rough ride is very much linked to social and pol- financial and social barriers limits the access to basic ser- itical decisions made over the past 15 years. The weak polit- vices like healthcare services, which raises serious questions ical commitment and consequent reduction of the funds regarding, for instance, the increasing number of cases of available to support and help level the European economies non-communicable diseases. People are focused on making are consider holding a significant part of the responsibility ends meet and, as some say, ‘cannot waste time and money’ for bringing us to this unprecedented crisis. The expression on keeping healthy lifestyles. public investment was wiped off the Europe leaders’ vo- The deeper consequences of an apparently silent enemy, cabulary. No one knows the exact moment people stopped climate change, are also unfolding at a faster pace. The being the priority, but the consequences are being felt. government’s inaction towards climate changes, together People’s material deprivation and social exclusion have with the ineffective EU environmental policies and regula- augmented considerably. And the increasing number of tions have caused, among others, a decrease in food Fig. 3 Factsheet for the ‘Failing Europe’ (a) and ‘Sustainable Prosperity’ (b) scenarios Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 8 of 18 security and availability, translating into an increase of public services did not block Europe’s determination to basic food prices. The international disengagement to- widen the access to healthcare nor the objective, fully ac- wards climate change mitigation had other consequences, complished, to significantly improve the medical quality mainly related to the prevalence of a fossil fuel-based eco- and effectiveness of healthcare services. The goal to de- nomic model: the green, alternative technologies needed velop better public institutions involved a strong political today to try to overturn the effects of the maladaptation to commitment and implied the reinforcement of invest- climate changes do not exist because the necessary invest- ments. The increase of public expenditure in the health ments were not made at the right time. A new model system, for instance, was not only responsible for the de- needs to be settled as soon as possible in order to ensure crease in non-communicable diseases, like diabetes and minimal levels of quality of life for the citizens. This para- hypertension, but also contributed for significantly lower digm shift requires workforce to be fulfil. But, throughout unemployment rates throughout Europe since the systems Europe, the unemployment rates are significantly higher needed to be reinforced with qualified workforce. The de- than 15 years ago, which means that the problem is not the cline of the unemployment rate was also influenced by the quantity of available workforce. This is an emerging key di- commitment to technology development, another goal set lemma of our times: the expertise needed to achieve the in the Europe’s bold view of the future. With that vision goal does not exist and the technology required to leverage on one hand and the climate change challenges on the and sustain the change in the economic paradigm does not other, European countries made a joint effort towards the exist or it is not sufficiently developed. Who is to blame? development of cutting-edge technologies, capable of en- The lack of efforts made to improve and develop the quality abling a successful transition from a fossil fuel-based para- of the public education and to harmonize and extent the digm to a Europe powered by renewable energies. public compulsory education and the slowdown of the de- The results exceed the initial expectations: the new velopment and penetration of renewable energy technolo- green economy, together with effective EU environmental gies might be part of the explanation. Europe stands with its policies and regulations helped mitigating climate change hands tied behind its back. Is it too late now to say sorry? and supported the improvement of the quality of the nat- ural environment, with direct consequences on the food se- ‘Sustainable Prosperity’ Scenario curity and on the population’s health and lifestyles in It is no understatement to claim that Europe “is at its’ best”. general. Europe has been sending a strong and clear mes- Europe was able to mitigate the cyclical global crises, allow- sage to the world: “old continent” is an outdated nickname. ing a reduction of social inequalities in 2030. These import- A statement included in the Schuman Declaration of 1950 ant achievements were sustained by the maintenance of [30], and recalled in the 2017 White Paper on the Future of funds to help less-favoured regions and through invest- Europe [29], can sum up Europe’s last decade very well: ments in crucial areas such as healthcare and innovation. “Europe will not be made all at once, or according to a sin- After the conclusions presented in the White Paper on the gle plan. It will be built through concrete achievements Future of Europe [29], in 2017, the European leaders gath- which first create solidarity.” ered and decided that Europe needed to make partnerships with other economies and companies worldwide and adopt ‘Being stuck’ Scenario a forward-looking approach, with all the effort that would Europe finds itself in a crossroad. In 2030, the envisioned take: focusing on technological development and people’s development and the transformation attempts continue to quality of life allowed to establish a green-based economy be held by political and economic conditions. The Euro- and to decrease the unemployment rates. The technology pean countries failed to achieve their goals of speeding up progresses along with the implementation of effective EU the economic growth and create more and better jobs. environmental policies lead Europe to improve its adapta- Few things have changed in the last 15 years. People’s eco- tion towards climate change, “making peace” with both the nomic deprivation experienced a small decrease in gen- planet Earth and the European citizens. eral, but economic inequalities increased. People’s quality The European integration process is alive and delivering. of life did not experience an improvement and old prob- As mentioned, the cyclical global crises were mitigated, lems are still present problems. It was “now or never” for and the economic inequalities decreased. The most re- the European leaders to shape the future of Europe. Did markable and evident consequence of this economic pros- Europe just miss its golden opportunity? perity is the significant decrease in people’s material Europe’s current situation is the result of a sequence of deprivation and in people at risk of poverty, as well as the failed or wasted intentions. After the 2008 economic crisis general improvement in the quality of life. Europe effect- and the Brexit, Europe seemed to have learned a valuable ively solved the refugees’ crisis, something that seemed lesson and the conditions were met to the start of a new impossible 15 years ago. The concerns around the long- era. But the reality turned out to be much more rough and term sustainability of the healthcare systems and other harder to change than expected. One of Europe’s main Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 9 of 18 challenges was to recover from the economic crisis and re- [31]). The importance of having a reference scenario gain the citizens’ and the world confidence. But the eco- (the ‘to the best of our knowledge’ scenario) was also ac- nomic growth was slow, and the unemployment rates had knowledged given that in some policy contexts it may no significant changes. The creation of thousands of new help people reflect on what is politically and economic- jobs seemed feasible: the economic model needed to ally realistic and most likely to occur, therefore boosting change and that was the perfect timing to invest and open their critical reflection around the more extreme-case space for all the unemployed workforce. But the green- scenarios. As noted by Wack [32], a ‘business as usual’ model economy expansion was slow. Impacts were felt not scenario “build on the implicit views of the future shared only in the employment rates but also in the climate change by most managers, making it possible for them to adaptation process: it was limited and far from the objec- recognize their outlook in the scenario package.” (p. 71). tives set after the Paris Agreement. Despite the govern- Our reference ‘to the best of our knowledge’ scenario, al- ments’ engagement, leaders responded too slowly. EU though different from a classic ‘business as usual’ sce- environmental policies were ambitious and experienced a nario – because it acknowledges expected change (i.e. it generic improvement in its effectiveness. But those improve- does not imply a simple continuation of past trends and ments were limited by different interests and financial con- structural stability) – shares with the ‘business as usual’ straints. The development of renewable energies continued conception the self-recognition quality highlighted by but always pressured by high completion from non- Wack. Of course, this can only happen when the refer- renewable sources and controlled by budget limitations. In- ence scenario is framed, in the scenario building process, vestment was also a problem in other key areas. Insufficient by other contrasted plausible scenarios, as it is the case investments in healthcare and social security prevailed, in both our project and in the classic Shell case, avoiding which limited the improvement of the efficiency of these sys- the dangers of a single future consideration, as also re- tems; public expenditure in the healthcare system was a pri- ported by Wack [33]. ority but the funding was insufficient to tackle all the needs. There are limitations in the process of developing sce- Overall, we cannot clearly say that Europe is worse, or narios that should be considered and that go beyond the better, then 15 years ago. But postponing the resolution of time-consuming and work-intensity issues. In addition so many major issues puts the old continent in a difficult to a subjective assessment and evaluation of complex position. Europe, nowadays (in 2030), is the embodiment facts, the type of scenarios depends greatly on the infor- of the well-known adage: ‘The road to hell is paved with mation basis provided and the imagination and back- good intentions’. ground of the experts and other parties involved [34]. Strengths and Limitations The three-stage socio-technical approach adopted to de- Conclusions velop the EURO-HEALTHY scenarios proved to be a The EURO-HEALTHY scenarios provide information on transparent and meaningful approach, enabling a multi- the most likely future development of health inequalities disciplinary and multidimensional understanding on in Europe in light of the identified drivers. These follow how the future of PH in Europe may unfold. The com- the model structure designed within the PHI framework, bination of both the Web-Delphi process and the work- defined a priori in 2015. New realities posing challenges shops allowed answering the technical challenges of to European cohesion, such as the growing mistrust on identifying a list of drivers together with their hypoth- EU institutions, the cultural conflict over the refugee cri- eses for evolution. The views and perspectives of a sis and migrant influx, the rise of populist movements diverse and geographically dispersed group of experts, and terrorism, were not explicitly identified as key stakeholders and policy-makers are crucial in the drivers affecting the future of health inequalities. Never- process of scenarios building. In fact, this not only con- theless, greater attention should be paid to these aspects, tributes for their validity but particularly meets the chal- linked to the present social and political context, as they lenge of enhancing participation in scenario building. potentially affect the drivers selected in this study. Furthermore, the scenarios proved to be plausible, rele- The scenario building process proved to be a transpar- vant and showed a new and original perspective on PH ent and replicable approach to produce substantively inequalities. As an example, the two contrasted scenarios meaningful scenarios, with the participants in the (best-case and worst-case) were applied to the EURO- process recognising its value and validating the scenarios HEALTHY Lisbon case-study, in which a panel of local developed. Hence, the scenarios obtained can be consid- stakeholders engaged in a participatory process of policy ered as a tool for European policy makers to have a bet- appraisal and prioritization of policies with potential to ter understanding about plausible future developments promote PH and decrease inequalities at the city level in of PH, preparing them to counteract increases in light of the PH scenarios (more details can be found in inequalities. Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 10 of 18 Appendix 1 Identification of drivers Table 2 Indicators used in Web-Delphi round 1, by area of concern of the EURO-HEALTHY Population Health Index Area of concern Indicator Economic conditions, social protection and Unemployment rate (%) security Long-term unemployment rate – 12 months and more (%) Disposable income of private households per capita (Euro per inhabitant) People at risk of poverty or social exclusion (%) Disposable income ratio – S80/S20 (ratio) Expenditure on care for elderly (% of GDP) Crimes recorded by the police per 100 000 inhabitants Education Population aged 25-64 with upper secondary or tertiary education attainment (%) Early leavers from education and training (%) Demographic change At risk of poverty rate of older people – aged 65 years or over (%) Ageing index (ratio) Lifestyle and Health behaviours Adults who are obese (%) Daily smokers – aged 15 and over (%) Pure alcohol consumption – aged 15 and over (Liters per capita) Live births by mothers under age of 20 (%) Physical environment Annual mean of the daily PM2.5 concentrations (μg/m3) Annual mean of the daily PM10 concentrations (μg/m3) Greenhouse Gas (GHG), total tonnes of CO2 eq. emissions per annum per capita Population exposed to traffic noise – Lden 55-59db, during day (%) Population affected by flooding, per 1 000 000 inhabitants Built environment Average number of rooms per person Households without indoor flushing toilet (%) Households without central heating (%) Population density (inhabitants/km2) Population connected to public water supply (%) Population connected to wastewater treatment plants (%) Recycling rate of municipal waste (%) Road safety Victims in road accidents – injured and killed, per 100 000 inhabitants Fatality rate due to road traffic accidents, per 1000 victims Healthcare resources and expenditure Medical doctors, per 100 000 inhabitants Health personnel (nurses and midwives, dentists, pharmacists and physiotherapists), per 100 000 inhabitants Total health expenditure (THE), PPP$ per capita, World Health Organization (WHO) estimates Private households’ out-of-pocket on health as percentage of total health expenditure (THE) Public expenditure on health, PPP$ per capita, WHO estimates Healthcare performance Hospital discharges due to diabetes, hypertension and asthma, per 100 000 inhabitants Amenable deaths to health care – standardised death rate, per 100 000 inhabitants Source: Santana P, Costa C, Freitas A, Stefanik I et al. (2017) Atlas of population health in European Union regions (Imprensa da Universidade de Coimbra: Coimbra). Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 11 of 18 Fig. 4 Print-screen showing the Web-Delphi round 1 questionnaire. Areas of concern of the EURO-HEALTHY PHI are on the top and the respect- ive indicators are on the left. A text box opened when participants selected an option to answer Table 3 Selection rules applied to the answers of the Web-Delphi round 2 considering the five-level Likert scale: ‘Strongly Disagree (SD)’, ‘Disagree (D)’, ‘Neither Agree nor Disagree (NAD)’, ‘Agree (A)’, ‘Strongly Agree (SA)’ Selection rules Selection rule First rule – applied to all drivers from all PESTLE categories (SA + A) ≥ 23 and SA ≥ 13 and (SD + D) < 10% Second rule – applied to drivers within the PESTLE categories in which [(SA + A) ≥ 34 or SA ≥ 14)] and (SD + D) < 10% the first rule did not select any driver Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 12 of 18 Table 4 List of 178 potential drivers included in round 2 of the Web-Delphi, and distribution of the answers in that round PESTLE category Driver SD D NAD A SA DK/ DWtA Political Strength of liberal political orientations 7% 7% 10% 33% 38% 5% Political Capacity to produce EU agreements 7% 40% 48% 5% Political EU integration process 2% 26% 55% 17% Political Confidence in EU policies 2% 2% 43% 48% 5% Political Cohesion funds (or other funds) for less-favoured regions 2% 7% 43% 48% Political Political commitment and ideological support towards 2% 5% 10% 29% 55% universal access to healthcare Political State involvement in public health 2% 2% 12% 33% 50% Political Commitment to appropriateness of the healthcare systems in 5% 31% 36% 26% 2% the EU Political Market oriented reforms in healthcare (including privatization 7% 10% 14% 31% 38% of healthcare) Political Priority for investment in innovation in health 5% 7% 14% 45% 29% Political Social protection policies for the elderly 7% 5% 40% 48% Political Investments in national social security systems 2% 10% 48% 40% Political Global political evolution (e.g. the aftermath of the United States 2% 12% 26% 29% 31% elections; Syria war, etc.) Political Power of populistic, protectionist and nationalist radical political 5% 7% 19% 29% 38% 2% projects in the EU Political Political stability in the EU and its Member-States (e.g. Brexit) 2% 7% 21% 50% 17% 2% Political Municipalisation [i.e. power to the municipalities] 5% 10% 33% 33% 17% 2% Political Application of road regulations/rules 10% 31% 48% 2% 10% Political Degree of penalization associated with traffic policies to reduce 2% 12% 31% 38% 7% 10% traffic accidents Political Policies for reducing traffic accidents in Eastern countries 29% 48% 19% 5% Political Levels of investment in road safety 5% 26% 48% 19% 2% Political Austerity policies 7% 5% 10% 31% 43% 5% Political Growth of compulsory education 5% 7% 40% 45% 2% Political Privatization of education 10% 17% 19% 31% 21% 2% Political Investment in the modernization of the built environment 5% 21% 40% 33% Economic Financing of the healthcare sector (in proportion of the Gross 2% 2% 10% 55% 29% 2% Domestic Product) in more economically vulnerable countries Economic Social insurance schemes 2% 7% 10% 40% 40% Economic Financial pressure on healthcare systems 5% 7% 10% 50% 29% Economic Public expenditure in the healthcare system 2% 7% 50% 40% Economic Healthcare costs 2% 5% 17% 36% 40% Economic Constraints on fiscal policies 2% 33% 43% 14% 7% Economic Economic evolution in EU countries with a younger population 2% 24% 55% 12% 7% compared to the economic evolution in EU countries with an older population Economic Economic growth of some EU countries, namely of the ones 2% 24% 64% 10% from the former Eastern block Economic Evolution of socioeconomic conditions and wealth in less 2% 7% 57% 31% 2% developed countries/areas in Europe Economic Economic evolution (e.g. Gross Domestic Product, productivity) 5% 24% 43% 26% 2% Economic Economic evolution in some countries of the Southern Europe 2% 17% 52% 26% 2% (compared to the other EU countries) Economic Economic and social crises 5% 43% 52% Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 13 of 18 Table 4 List of 178 potential drivers included in round 2 of the Web-Delphi, and distribution of the answers in that round (Continued) PESTLE category Driver SD D NAD A SA DK/ DWtA Economic Financial crisis 2% 10% 38% 50% Economic Concentration of capital accumulation 2% 5% 24% 36% 33% Economic People's economic stress 2% 14% 38% 45% Economic Economic inequalities 2% 2% 21% 74% Economic Early retirement in some countries of the Southern Europe 12% 52% 26% 7% 2% (compared to the other EU countries) Economic Pension levels and differences in working after retirement 2% 19% 57% 21% Economic Proportion of economically dependent population 2% 21% 45% 31% Economic Evolution of financial burden share between generations 5% 26% 45% 24% within families Economic Financial pressures leading to cuts in social expenditures 2% 7% 40% 50% (e.g. pensions) Economic Differences in pension regimes within the EU (e.g. differences 2% 29% 45% 21% 2% in national net pension replacement rates) Economic Poverty levels 7% 21% 71% Economic Social benefits 12% 43% 45% Economic Global economic integration and interrelations 7% 21% 45% 21% 5% Economic Inclusion of the refugees on the labour market 2% 10% 21% 40% 26% Economic Unemployment rate in Europe 2% 2% 48% 48% Economic Long-term structural unemployment 2% 33% 64% Economic Unemployment in late ages 7% 43% 50% Economic Employment precariousness 2% 52% 43% 2% Economic Employment with low income/limited social benefits 7% 43% 50% Economic Unemployment in countries of the Southern Europe (compared 7% 21% 43% 24% 5% to the other EU countries) Economic Employment opportunities for people with low qualifications 2% 17% 64% 17% Economic Employment opportunities for medical/health personnel 2% 14% 29% 45% 10% Economic Disparities in industry production 14% 50% 24% 7% 5% Economic Investment in formal education 2% 24% 45% 29% Economic Demand for qualified workers 10% 33% 48% 7% 2% Social Refugees and migrants’ fluxes 7% 17% 60% 14% 2% Social Migrations to the most economically developed North-West 7% 26% 57% 7% 2% European countries Social Emigration from EU countries already affected by population 12% 26% 48% 12% 2% ageing and decrease in natality Social Urbanisation (attractiveness of urban areas) 7% 31% 50% 12% Social Concentration of people in suburban areas 7% 33% 45% 14% Social Concentration of people at risk (e.g. poverty) in problematic 2% 7% 48% 43% neighbourhoods Social Differential in regions’ ability (political and/or economic) to attract 5% 21% 55% 17% 2% young people, including migrants and refugees Social Population ageing 14% 19% 31% 36% Social Quantitative evolution of the young population 14% 36% 36% 10% 5% Social Birth rates across EU countries 14% 43% 33% 10% Social Birth rates in some countries of the Southern Europe (compared 14% 45% 33% 7% to the other EU countries) Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 14 of 18 Table 4 List of 178 potential drivers included in round 2 of the Web-Delphi, and distribution of the answers in that round (Continued) PESTLE category Driver SD D NAD A SA DK/ DWtA Social Ageing pace in Central and Eastern Europe compared to 12% 43% 40% 5% other EU countries Social Regional differences in ageing patterns at a European level 12% 40% 40% 7% Social Life expectancy 12% 19% 43% 21% 5% Social Healthy life expectancy 10% 17% 29% 38% 7% Social Differential in regions’ health expectancy 7% 19% 50% 17% 7% Social Voting power of the elderly population 2% 12% 60% 21% 5% Social Population growth in relation to the “housing capacity” 7% 55% 29% 5% 5% Social Awareness of the road safety problematic 17% 45% 31% 5% 2% Social Road safety campaigns and education 2% 10% 38% 40% 7% 2% Social Social pressure for “bridging the gap” in terms of built environment 5% 29% 62% 5% Social Overall quality of road infrastructure 2% 2% 31% 55% 7% 2% Social Quality of the roads in Southern and Eastern Europe 2% 7% 29% 52% 7% 2% Social Vehicles quality and safety 2% 36% 50% 10% 2% Social Metropolization 2% 45% 45% 5% 2% Social Traffic density 5% 38% 38% 19% Social Disparities in medical standards 2% 17% 43% 36% 2% Social Medical quality 5% 17% 38% 40% Social Medical effectiveness of healthcare services 2% 12% 45% 40% Social Access to healthcare 5% 33% 62% Social Access to hospital emergency room 5% 10% 52% 33% Social Quality and accessibility of the primary health care services 5% 38% 57% Social Access to healthcare services in rural areas 10% 40% 48% 2% Social Quality of Emergency Medical Services (EMS) in remote and/or 2% 10% 50% 36% 2% rural areas Social Emergency Medical Services efficiency 5% 19% 45% 31% Social European medical network 7% 36% 45% 12% Social European citizens’ health literacy and collaboration capacity as patients 29% 43% 29% Social Educational and public health campaigns 10% 21% 43% 26% Social Education and training of health professionals 10% 24% 43% 24% Social Mobility of health professionals between countries and regions 10% 36% 40% 12% 2% Social Concentration of equipment and clusters of medical activities 5% 43% 36% 17% Social Availability of health infrastructures 2% 19% 48% 31% Social Coverage of National Health Service 5% 52% 40% 2% Social Response capacity of the health sector (quality of emergency/first 12% 55% 31% 2% respondents and hospital care) in less developed countries Social Quality of healthcare organization and management 5% 10% 48% 38% Social Knowledge sharing 2% 33% 36% 26% 2% Social Availability of information on better lifestyles 5% 36% 36% 24% Social Quality of the education in the EU 17% 52% 31% Social Academisation of the society 7% 40% 40% 10% 2% Social Low qualifications in the EU 29% 64% 7% Social Impacts on the quality of jobs and enthusiasm for Tertiary 38% 52% 5% 5% Education Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 15 of 18 Table 4 List of 178 potential drivers included in round 2 of the Web-Delphi, and distribution of the answers in that round (Continued) PESTLE category Driver SD D NAD A SA DK/ DWtA Social Monitoring of education results 7% 55% 36% 2% Social Capacity of Eastern European countries to cope with the 10% 45% 38% 5% 2% collapse of the soviet society [i.e. with the loss of some of its key features, for instance in education] Social Educational attainment as an aspiration of EU countries 10% 29% 50% 7% 5% Social Objectives in education in the EU 5% 43% 36% 14% 2% Social Levels of education and literacy 2% 2% 69% 24% 2% Social Flexibility of academic curricula in the EU 2% 12% 48% 31% 2% 5% Social University fees 7% 40% 36% 12% 5% Social Academisation of job profiles 14% 50% 29% 2% 5% Social Existence of vocational training 10% 36% 43% 7% 5% Social Differences in cultural traditions 19% 31% 36% 10% 5% Social Globalization of style life 17% 31% 43% 5% 5% Social Awareness regarding the impact of lifestyles on quality of life 14% 17% 50% 14% 5% Social Stress 7% 17% 33% 40% 2% Social Awareness campaigns tackling alcohol consumption 12% 12% 52% 24% Social Awareness regarding the impact of smoking 10% 14% 48% 29% Social Smoking restriction policies 2% 2% 48% 48% Social Smoking among women 12% 40% 48% Social Smoking among manual workers 14% 52% 31% 2% Social Taxation and control of unhealthy food consumption 2% 10% 57% 31% Social Diet 5% 17% 38% 40% Social Disparities in health behaviours 7% 10% 52% 31% Social Sedentary lifestyles 17% 43% 40% Social Evolution of Non-communicable diseases like diabetes 2% 10% 43% 43% 2% and hypertension Social Social mobility (change in hierarchies in socio-economic positions) 7% 14% 52% 26% Social Motorization in Eastern countries 7% 45% 38% 5% 5% Technological Medical innovation (new medicines and technologies) 5% 17% 45% 31% 2% Technological Technology and medical devices at home 10% 19% 45% 24% 2% Technological Technology and innovation costs in healthcare systems 7% 17% 50% 26% Technological Evolution of vehicles batteries’ autonomy 19% 40% 31% 10% Technological Knowledge and innovation in technology and materials for road 10% 33% 45% 7% 5% safety Technological Innovation in technology and materials for the built environment 10% 33% 40% 14% 2% Technological Innovation in housing (new forms of housing) 14% 33% 33% 14% 5% Technological Price of technology and materials for road safety and for the built 7% 38% 38% 14% 2% environment Technological Acceleration in industry development in less developed countries 14% 33% 38% 12% 2% Technological Pace of change in manufacturing in Europe (industry 4.0) 14% 43% 26% 12% 5% Technological Automation of industrial production 7% 40% 33% 14% 5% Technological Internet access 2% 5% 33% 48% 12% Environmental Quality of the living environment 2% 2% 50% 45% Environmental Quality of the outdoor air 2% 38% 60% Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 16 of 18 Table 4 List of 178 potential drivers included in round 2 of the Web-Delphi, and distribution of the answers in that round (Continued) PESTLE category Driver SD D NAD A SA DK/ DWtA Environmental Climate change 2% 14% 43% 38% 2% Environmental Climate change actions and policies 5% 17% 43% 33% 2% Environmental Concerns related to natural resources efficiency (e.g. energy 7% 26% 43% 24% efficiency) Environmental Energy efficiency efforts 10% 19% 52% 19% Environmental Recycling: taxation and quotas 12% 29% 45% 14% Environmental Social and political awareness/preoccupation with the physical 7% 14% 55% 24% environment, namely air and noise conditions Environmental Gap in “environmental awareness” between more developed 2% 24% 48% 26% and less developed countries Environmental Priorities in terms of economic model: green-based vs 5% 10% 45% 36% 5% oil-based (e.g. evolution of the number of environmental friendly vehicles) Environmental Development of sustainable energy production (water, 21% 38% 40% wind, sun) Environmental Industrial development sustainability 2% 7% 29% 38% 24% Environmental Regional differences of the building construction boom 14% 29% 52% 5% Environmental Coordination of environmental-focused political measures 7% 21% 57% 14% Environmental Environmental protection policies focused on industrial manufacturing 7% 17% 57% 17% 2% Environmental Environmental protection policies focused on vehicles circulation 5% 14% 60% 19% 2% Environmental International and worldwide environmental agreements 7% 14% 45% 31% 2% Environmental United States of America commitment towards the Paris Agreement on 10% 14% 48% 26% 2% climate change global action Legal EU Legislation/ Directives and its transposition into the legislation of each 10% 33% 43% 10% 5% country Legal Adaptability of EU regulations (especially inside the Eurozone) to 7% 45% 33% 12% 2% Member-states specificities Legal Commitment to follow EU directives and World Health Organization 5% 19% 52% 21% 2% guidelines Legal EU legislation / directives on built environment 7% 21% 57% 10% 5% Legal National building construction rules and legislation 12% 31% 40% 10% 7% Legal Differences in road safety national legislation 2% 7% 29% 55% 2% 5% Legal EU environmental policies and regulations 5% 17% 64% 12% 2% Legal Requirements of compliance to environmental regulations for market 2% 24% 55% 17% 2% purposes (e.g. quality of fuel) Legal Evolution of intellectual property rights in health 2% 12% 43% 24% 14% 5% Legal Impact of the TTIP (Transatlantic Trade and Investment Partnership) project 5% 5% 45% 26% 17% 2% in the access to the latest advances in medicines, diagnostic tools, and other life-saving medical technologies Legal Integration of EU labour markets 10% 38% 38% 10% 5% SD Strongly Disagree, D Disagree, NAD Neither Agree nor Disagree, A Agree, SA Strongly Agree, DK/DWtA Don’t Know/Don’t Want to Answer Note: the 49 drivers selected after round 2, by applying the selection rules, are highlighted in bold; among these, in italic, are the drivers that resulted from the application of the second selection rule. Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 17 of 18 Appendix 2 Search protocol to collect future-oriented evidence Table 5 Search protocol used to collect future-oriented evidence to inform the scenario building process (March of 2017) Sources European Union (EU) publications, through the EU Bookshop | https://bookshop.europa.eu/en/home FRESHER project | https://www.foresight-fresher.eu/fresher-project-results/ Keywords Search words combined with drivers’ keywords (combinations followed this order): future; forecast; scenario; foresight; prospective [If the search did not deliver meaningful results, the protocol was extended to searches with Google’s Search Engine, using the driver’s keywords (or equivalent) + the expression European Union. Search results obtained beyond the Search Protocol were pointed out in the drivers’ cards] Timespan 2012-2017 Language English Abbreviations Av. Rovisco Pais, 1049-001 Lisbon, Portugal. 3IHC, Institute of Contemporary EU: European Union; EURO-HEALTHY: Shaping EUROpean policies to History, Universidade NOVA de Lisboa, Lisbon, Portugal. 4Nova School of promote HEALTH equitY; PESTLE: Political, Economic, Social, Technological, Business and Economics, Universidade NOVA de Lisboa, Campus de Legal and Environmental; PH: Population Health; PHI: Population Health Carcavelos, Rua da Holanda 1, 2775-405 Carcavelos, Portugal. 5ISEG, Lisbon Index; WHO: World Health Organization School of Economics & Management, Universidade de Lisboa, Lisbon, Portugal. 6Agència de Salut Pública de Barcelona, Barcelona, Spain. 7CIBER of Acknowledgements Epidemiology and Public Health (CIBERESP), Madrid, Spain. 8Center for Health We would like to thank all the experts and stakeholders that participated in Studies and Research (CEISUC), University of Coimbra, Coimbra, Portugal. 9 the scenario building process for bringing in their time and knowledge. Centre of Studies in Geography and Spatial Planning (CEGOT), University of Coimbra, Coimbra, Portugal. Authors’ contributions MO, CBC and PS outlined scenario development within the EURO-HEALTHY Received: 15 March 2019 Accepted: 7 June 2019 project, which general coordinator was PS. AA, CBC and MO conceptualised this paper research aims and methods and participated in the design of the study; they also supervised AV, LF and MLS in the implementation of the References methods; AA, AV and LF conducted data collection and analysis; CB, PLF and 1. European Commission. Health inequalities in the EU — Final report of a TR contributed to decisions regarding the study execution; AA, AV, LF, MLS, consortium. Consortium lead: Sir Michael Marmot: European Commission MO, AF and PS prepared the manuscript. All authors contributed to, read Directorate-General for Health and Consumers; 2013. https://doi.org/10. and approved the final manuscript. Authors are presented by alphabetical 2772/34426. order. 2. Volkery A, Ribeiro T. Scenario planning in public policy: Understanding use, impacts and the role of institutional context factors. Technol Forecast Soc Funding Chang. 2009;76(9):1198–207. This work is part of the EURO-HEALTHY project (Shaping EUROpean policies 3. Wepner B, Giesecke S. Drivers, trends and scenarios for the future of health in to promote HEALTH equitY) and it was supported by the European Union’s Europe. Impressions from the FRESHER project. Eur J Futur Res. 2018;6(1):38–48. Horizon 2020 research and innovation programme [Grant Agreement No 4. Meyer R. Comparison of scenarios on futures of European food chains. 643398; 2015-2017]. Trends Food Sci Technol. 2007;18(11):540–5. 5. Misuraca G, Broster D, Centeno C. Digital Europe 2030: Designing scenarios for Availability of data and materials ICT in future governance and policy making. Gov Inf Q. 2012;29:S121–S31. All data generated and/or analysed during this study are included in this 6. Mikko D, Raija K, Leena I-S, Seija J. Anticipating Alternative Futures for the published article and its additional files. The datasets used and/or analysed Platform Economy. Technol Innov Manag Rev. 2017;7(9):6–16. during the current study are available from the corresponding author on 7. Gambelli D, Vairo D, Zanoli R. Exploiting Qualitative Information for Decision reasonable request. Anonymised fields will be used to ensure that individual Support in Scenario Analysis. J Decis Syst. 2010;19(4):407–22. participants are not identified. 8. Reed MS, Kenter J, Bonn A, Broad K, Burt TP, Fazey IR, et al. Participatory scenario development for environmental management: A methodological Ethics approval and consent to participate framework illustrated with experience from the UK uplands. J Environ The study was approved by Centre for Social Studies Ethics Commission (CE- Manag. 2013;128(Supplement C):345–62. CES) of the University of Coimbra. All participants were invited and informed 9. Masum H, Ranck J, Singer PA. Five promising methods for health foresight. about the objective, scope and research design of the Web-Delphi and Foresight. 2010;12(1):54–66. about the uses of Delphi data within the scope of the EURO-HEALTHY pro- 10. Vollmar HC, Ostermann T, Redaelli M. Using the scenario method in the ject, and have provided, via email, written consent to participate before be- context of health and health care - a scoping review. BMC Med Res ing enrolled in the Delphi process. Methodol. 2015;15:10. 11. Santana P, editor. Promoting population health and equity in Europe: from Consent for publication evidence to policy. Coimbra: Imprensa da Universidade de Coimbra; 2017. Not applicable. The manuscript does not include details related to any 12. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003; individual person. 93(3):380–3. 13. Santana P, Costa C, Freitas Â, Stefanik I, Quintal C, Bana e Costa C, et al. Competing interests Atlas of population health in European Union regions. Coimbra: Imprensa The authors declare that they have no competing interests, whether actual da Universidade de Coimbra; 2017. or potential, including any financial, personal or other relationships with 14. Stefanik I, Freitas Â, Doetsch J, Santana P. Involving key stakeholders in the other people or organizations. EURO-HEALTHY. In: Santana P, editor. Promoting population health and equity in Europe: from evidence to policy. Coimbra: Coimbra University Author details Press; 2017. p. 60–3. 1 ALVA Research and Consulting, Lisbon, Portugal. 2CEG-IST, Centre for 15. Orlowski SK, Lawn S, Venning A, Winsall M, Jones GM, Wyld K, et al. Management Studies of Instituto Superior Técnico, Universidade de Lisboa, Participatory Research as One Piece of the Puzzle: A Systematic Review of Alvarenga et al. International Journal for Equity in Health (2019) 18:100 Page 18 of 18 Consumer Involvement in Design of Technology-Based Youth Mental Health and Well-Being Interventions. JMIR Hum Factors. 2015;2(2):e12. 16. Scott V, Stern R, Sanders D, Reagon G, Mathews V. Research to action to address inequities: the experience of the Cape Town Equity Gauge. Int J Equity Health. 2008;7(1):6. 17. Cargo M, Mercer SL. The value and challenges of participatory research: strengthening its practice. Annu Rev Public Health. 2008;29:325–50. 18. Pauly B, Martin W, Perkin K, van Roode T, Kwan A, Patterson T, et al. Critical considerations for the practical utility of health equity tools: a concept mapping study. Int J Equity Health. 2018;17:48. 19. Amer M, Daim TU, Jetter A. A review of scenario planning. Futures. 2013;46:23–40. 20. Goodwin P, Wright G. Scenario planning: an alternative way of dealing with uncertainty. In: Wiley J, Sons L, editors. Decision Analysis for Management Judgment. 3rd ed; 2004. 21. Linstone HA, Turoff M. Introduction. In: Turoff HALM, editor. The Delphi Method: Techniques and applications. London: Addison-Wesley Publishing Company; 1975. p. 3–12. 22. Welphi. Welphi 2017 [14 Mar 2018]. Available from: https://www.welphi.com/. 23. Boy GA. The group elicitation method for participatory design and usability testing. Interactions. 1997;4(2):27–33. 24. Johnson G, Scholes K, Whittington R. Fundamentals of strategy: Pearson Education; 2009. 25. Sundmacher L, Scheller-Kreinsen D, Busse R. The wider determinants of inequalities in health: a decomposition analysis. Int J Equity Health. 2011;10(1):30. 26. Futures IA. Public Health 2030: A Scenario Exploration. Alexandria: Institute for Alternative Futures; 2014. 27. Forum WE, editor. Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios. Geneva: World Economic Forum; 2013. 28. Hoeymans N, Van Loon A, Van den Berg M, Harbers M, Hilderink H, Van Oers J, et al. A healthier Netherlands: Key findings from the dutch 2014 public health status and foresight report. Bilthoven: National Institute for Public Health and the Environment (RIVM); 2014. 29. European Commission S-G. White Paper on the Future of Europe - Reflections and scenarios for the EU27 by 2025. Brussels: Belgium European Commission; 2017. 30. Schuman R. The Schuman Declaration; 1950. 31. Bana e Costa C, Freitas L, Oliveira M, Rodrigues T, Vieira A. Devising and testing a novel methodology for the evaluation of policies under European population health scenarios. In: Santana P, editor. Promoting population health and equity in Europe: from evidence to policy. Coimbra: Coimbra University Press; 2017. p. 85–7. 32. Wack P. Uncharted waters ahead. Business Harvard Review. 1985;63(5):73–89. 33. Wack P. Shooting the rapids. Harvard Business Review. 1985;63(6):139–50. 34. Kosow H, Gaßner R. Methods of future and scenario analysis: overview, assessment, and selection criteria: German Development Institute; 2008. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.