**3. Educational inequality in mortality**

insurance, and their access to health care is limited [25]. Despite the recent slowdown, US healthcare expenditures exceed those of other high‐income countries in Europe [26]. The high cost of US healthcare may to some extent explain the higher levels of mortality compared to the high income population of Europe. In July 2014, The Lancet journal published a series of contributions on the health of Americans [27]. According to the authors, a fragmented healthcare delivery system, social environments (differences in health outcomes according to race, education, region), and individual risk factors (health-related behavior: obesity, smoking, physical inactivity, alcohol use, diets low in fruits, and vegetables) play

The Czech Republic manifests four dissimilar stages of mortality development (**Figure 1a** and **b**): before World War II; between World War II and mid‐1960s; from the mid‐1960s to the mid‐ 1980s; and from the mid‐1980s until now [28]. During the interwar period up to the mid‐1960s, male and female survival in the Czech Republic was close to the levels observed in France [29]. However, age‐specific mortality rates at that time were different in both countries. Before WWII, a high infant mortality rate in the Czech population was counterbalanced by a lower mortality at adult ages. Between World War II and the mid‐1960s, the situation reversed and the upward trend of life expectancy at birth accelerated mainly because of the decrease in infant mortality rate, while adult and old age mortality had not changed too much. In the Czech Republic from 1950, all health services were nationalized, provided free of charge, and were accessible to anybody according to the new law. Particular attention was paid to child and mother. The comprehensive network of services was established for children and preventive vaccination and medical check‐ups became compulsory. The "health‐extensive approach"—a large number of medical staff with limited expenditures for equipment, drugs, and maintenance—was successful in reducing and controlling communicable and infectious diseases. Later on, the emergence of new degenerative diseases required a "health intensive approach" involving specialized training, sophisticated equipment, and expensive procedures and drugs. Despite growing awareness among the medical profession, health systems were not able to adjust to the changing health needs of the population. Therefore, the trend of increased mortality started in the mid‐1960s and affected most of the population of Central and Eastern Europe including the Czech Republic. The deterioration was particularly marked for the elderly and middle-aged adults and primarily for men. A substantial part of the mortality increase was attributable to an "epidemic" of heart diseases. To a lesser degree, an increase in cerebrovascular diseases, lung cancer, and cirrhosis of the liver was noticed [29]. For instance, by the mid‐1980s, the mortality rate from cardiovascular and cerebrovascular diseases was twice as high in the Czech Republic than in France [29]. It appears that the negative mortality development in the Czech Republic since the mid‐1960s can be interpreted as an accumulation of previous problems (relatively high mortality of the elderly) and of inapt solutions for new ones (rising intensity of degenerative diseases). From that time, the gap in life expectancy between the Czech Republic and France or USA began to widen rapidly. Since the mid‐1980s a new favorable trend in mortality has appeared in the Czech Republic, a new mortality decline has been initiated [28]. From the medical perspective, the use of cardiovascular drugs and the number of operations such as invasive heart surgery increased considerably. In addition, the structure of treatment shifted from traditional medicines to

an important role for length of life.

142 Senescence - Physiology or Pathology

Educational attainment plays a central role throughout a life course. In early life, harsh conditions (due to parental socioeconomic status) might impact a later-life mortality risk. However, infant and child mortality fell faster during the twentieth century and also childhood health dramatically improved. Thus, the association between early-life conditions and adult mortality has diminished across cohorts at the aggregate level [12]. Consequently, personal behaviors (diet, smoking, alcoholism, exercise) and the knowledge and the use of health technologies affect adult mortality risk more than early life factors [12].

Everywhere, highly educated adults have lower mortality rates than less educated people. Educational differences in mortality are frequently wider among younger adults compared with their older counterparts. The convergence of differentials by education at later age seems to be more complex, and the explanations vary. The study of Beckett [32] confirms the convergence gradient with age and shows that the protective effect of higher education declines with age because higher educated groups only postpone morbidity toward older age. On the other hand, Masters et al. [12] demonstrate the use of age-period-cohort modeling that educational gap in mortality grows across birth cohorts but not across time periods. Disparities in mortality by education are wider among men than among women. However, recent studies have shown that since the mid‐1980s the growing gradient for US all‐cause female mortality reflected increasing mortality among low educated women and faster-declining mortality among college-educated women [9].

Increases in all‐cause life expectancy at adult ages mask a lot of disparities, including diverging trends, among population groups. Well-educated people live longer and thus represent the potential for reducing future mortality developments. Information on stratification by education of population as well as on mortality differentials can help in promoting and targeting health and social policies.

**Figure 2a** and **b** presents life expectancy at age 30 by gender in European countries where data on education are available. Educational attainment is classified into three categories (ISCED ‐ The International Standard Classification of Education defined by Eurostat): basic = pre-primary, primary, and lower secondary education (ISCED levels 0–2); secondary = upper secondary and post‐secondary non‐tertiary education (ISCED levels 3 and 4); and tertiary = first and

**Figure 2.** a) Life expectancy at age of 30 according to education level in 2010, males. b) Life expectancy at age of 30 according to education level in 2010, females.

second stage of tertiary education (ISCED levels 5 and 6). In all countries, under the study, highly educated adults experience longer survival (the mean number of remaining years of life beyond age 30 or mean survival duration at age 30 under the mortality conditions of the year in question) than less educated people. The results show variation in survival by educational attainment everywhere. However, former socialist countries show not only shorter life expectancies but also a wide variation in survival by educational attainment for both men and women. The Czech Republic displays a short life expectancy at age 30 for males and females with the lowest education even when compared with countries of higher mortality (Estonia, Hungary, Bulgaria). The difference between life expectancy at 30 of people with the highest and the lowest educational attainment reaches 16.9 years among Czech men compared to 2.9 years in Portugal or 3.9 in Sweden. The gap in Czech female mortality between the highest and the lowest education level is the second high (7.5), after the Bulgarian one (8.5). This phenomenon happens in spite of low social differentiation and universal access to health services. The explanation can be related to the fact that university graduates experienced better health situation because of better working conditions than people with only basic education working in factories with low-tech equipment and therefore in the more detrimental environment. In addition, the lack of knowledge and awareness of less educated may impair the ability to use available health care services. Also, differences in the lifestyle contributed in widening the gap in health and mortality between educational groups. After the political change (started in 1989) accompanied by transformation toward market economy, better‐educated people have been less likely to be unemployed and were better able to face economic hardship. They also have had higher income and more fulfilling and rewarding jobs than less educated individuals. All these facts imply that educational attainment (besides other factors) has played an important role for survival in any society, regardless of living under former socialism, capitalism, or new market economy. Increasing the amount of schooling can lower total level of mortality by two ways: (a) increasing share of highly educated people (with lower mortality) will impact total mortality level as structural effect and (b) faster decrease of death rates among higher educated adults will act as intensity effect. Therefore, in the next part, we model such situations in order to estimate the effects of changing population structure and mortality rates by education toward higher degrees.
