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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' (worstcase 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.

Background Population health measurements are recognised as appropriate tools to support public health monitoring. Yet, there is still a lack of tools that offer a basis for policy appraisal and for foreseeing impacts on health equity. In the context of persistent regional inequalities, it is critical to ascertain which regions are performing best, which factors might shape future health outcomes and where there is room for improvement. Methods Under the EURO-HEALTHY project, tools combining the technical elements of multi-criteria value models and the social elements of participatory processes were developed to measure health in multiple dimensions and to inform policies. The flagship tool is the Population Health Index (PHI), a multidimensional measure that evaluates health from the lens of equity in health determinants and health outcomes, further divided into sub-indices. Foresight tools for policy analysis were also developed, namely: (1) scenarios of future patterns of population health in Europe in 2030, combining group elicitation with the Extreme-World method and (2) a multi-criteria evaluation framework informing policy appraisal (case study of Lisbon). Finally, a WebGIS was built to map and communicate the results to wider audiences. Results The Population Health Index was applied to all European Union (EU) regions, indicating which regions are lagging behind and where investments are most needed to close the health gap. Three scenarios for 2030 were produced - (1) the 'Failing Europe' scenario (worst case/increasing inequalities), (2) the 'Sustainable Prosperity' scenario (best case/decreasing inequalities) and (3) the 'Being Stuck' scenario (the EU and Member States maintain the status quo). Finally, the policy appraisal exercise conducted in Lisbon illustrates which policies have higher potential to improve health and how their feasibility can change according to different scenarios. Conclusions The article makes a theoretical and practical contribution to the field of population health. Theoretically, it contributes to the conceptualisation of health in a broader sense by advancing a model able to integrate multiple aspects of health, including health outcomes and multisectoral determinants. Empirically, the model and tools are closely tied to what is measurable when using the EU context but offering opportunities to be upscaled to other settings. ; The EURO-HEALTHY project (Shaping EUROpean policies to promote HEALTHequity) has received funding from the European Union's Horizon 2020 re-search and innovation programme under Grant Agreement No. 643398. Add-itionally, this study was supported by the Centre of Studies in Geographyand Spatial Planning (CEGOT), funded by national funds through the Founda-tion for Science and Technology (FCT) under the reference UID/GEO/04084/2019. The authors Angela Freitas and Cláudia Costa are recipients of Individ-ual Doctoral Fellowships funded by national funds through the Foundationfor Science and Technology (FCT), under the references SFRH/BD/123091/2016 and SFRH/BD/132218/2017, respectively.