Has austerity brought Europe to the brink of a health disaster?
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3773 (Published 18 June 2013) Cite this as: BMJ 2013;346:f3773
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Cyprus, the latest Eurozone country to enter a memorandum of understanding (MOU) with Troika, is a country with diverse healthcare delivery which has so far never taken up any opportunity for a major healthcare reform mainly because of political indecisiveness(1). To date, Cypriots pay the highest out-of-pocket payment for Healthcare in EU, more than 50 % of their healthcare cost (2).
There are serious consequences from maintaining the current ineffective healthcare ‘’system’’in a time of financial crisis. For example, this resource-starved country is plagued by the misuse of existing resources. Indicatively, there is a lack of evidence-based clinical guidelines, clinical governance and especially medical audit, multidisciplinary team approach, unified healthcare records in order to avoid duplication of visits and tests, lack of gatekeeping system ie GPs, resource-planning, etc.
One area which is beginning to show signs of strain with the current financial downturn is the specialty of radiology. Despite the fact that Cyprus has the highest patient-to-MRI ratio in Europe, the public sector only possesses one MRI unit. With the current turn of patients towards the public healthcare sector, such resources are stretched to the limit with exponential increase in waiting times and an inappropriate use of resources hindering patient safety. For example, CT is used preferentially to MRI in the imaging of the lumbar spine, a test which has a heavy radiation load without much diagnostic information.
Another area of looming concern is oncology, a costly service offered for free; yet early diagnosis of cancer is simply neither a priority nor feasible in the current financial climate and healthcare structure.
Moreover, the private sector is also under enormous strain, and with people not being able to afford it, it is now underused, with private state-of-the-art imaging and other infrastructure sitting idle.
We urge the government and Troika to take the necessary steps, as soon as possible, to slow down this downward spiral that is endangering people’s health and lives. In our opinion, the only solution for Cyprus to come out of its own healthcare maze is to put forward the meticulously prepared National Health Insurance Scheme (3)
1. Samoutis G, Paschalides C. When will the sun shine on Cyprus National Health Service? The Lancet 2011;377(9759): 29
2. Health at a Glance: Europe 2012
3. Restructuring health systems for an era of prolonged austerity: an essay by Richard B Saltman and Zachary Cahn. BMJ 2013;346:f3972
email:samoutis.g@unic.ac.cy
web: www.nicosia.sgul.ac.cy
Competing interests: No competing interests
Thank for a very good article.
I am a doctor who was practising before the massive crisis in Finland in 1990. I have worked for some time in UK as well.
It is right that there has not a been a jump in suicide rate during the time of this massive crisis in Finland. There was a decrease in money for health care during that time, which was justified. Later the problem has been that the policy has been continuing. All the time less and less money for clinical work with explanation of continuous economic crisis.
Finland does have at the moment the lowest number of healthy years in EU, at the same level as Romania. (Eurostat http://epp.eurostat.ec.europa.eu/tgm/printMap.do?tab=map&plugin=0&langua... ).
The health inequalities are the worst in EU at the same level with USA and Mexico. People do retire very early due to health problems. There is a significant difference to Sweden. Now there is real fear of not having enough money for paying pensions and cost of sicknesses.
I have not seen a very good study of what has really happened here, but my personal opinion is that there has been a slow and steady decrease of health status of population due to the continuing effects of massive economic crisis -90. Now we are in a situation when there is not enough workforce due to early retirement for ill health.
It would be very good to have a good analysis. This is not the way economic crisis should be handled. There should not be negative effects for several decades on health causing even early retirement due to ill health.
Competing interests: No competing interests
Thank you for this and the other articles in this issue of the BMJ which address these matters. Most particularly thank you for the review of Stuckler and Basu. Surely people and their elected representatives will see now that giving priority to caring for people has benefits for our humanity and for economic recovery. As I understand it, the financial constraints of war and rationing led to improved health of the nation and determination to continue caring for each other. Are we too blinkered by ingrained beliefs and prejudice to learn from these lessons and to take appropriate corrective actions?
Competing interests: No competing interests
In a recent article published in the BMJ, Arie asks: “Has austerity brought Europe to the brink of a health disaster?” The author also writes about the plight of suicides due to the crisis and budget cuts in Italy making specific references to the suicide of a couple of Italian pensioners hit by austerity measures and struggling with financial difficulties. [1] In a recent short report we showed a statistically significant association of the economic crisis with suicides and suicide attempts due to economic reasons in Italy. [2] So far, however, no study investigated the impact of austerity on suicides. Here we present novel data on the role of social protection in moderating the association between unemployment and suicides across Italian regions.
In order to address this question, I first retrieved annual data on suicides per 100,000 and unemployment for all Italian regions from the Italian Institute of National Statistics (ISTAT). [3] Data on unemployment and suicides were available for all regions from 2000 to 2010. Linear regression models were used to assess the association between change in unemployment and change in suicides stratified by regions. Models corrected for fixed effects, [4] [5] including social conditions and differences in surveillance systems and data quality, that may predispose some regions to higher or lower unemployment and suicide rates. I also employed robust standard errors clustered by region to adjust for the lack of independence of the sample. [6] All models were analyzed using STATA version 12.0.
Figure 1 shows that, similarly to previous analyses conducted in Europe, [7] unemployment and suicides were falling in Italy before the economic crisis, but reversed upon the onset of the financial downturn in 2007. Across Italian regions, levels of unemployment correlated strongly with levels of suicides per 100,000 in the period studied (r =0.7359; p=0.01).
[Figure 1 about here]
There was a statistically significant association between within-region change in unemployment and change in suicide. Every 1% increase in unemployment between 2000 and 2010 was associated with an increase of 0.1 suicides per 100,000 (95% CI; 0.0001 to 0.2, p=0.05). When using a 1-year or 2-year lagged measure of unemployment as independent variable there was no significant difference. However, there was substantial heterogeneity in terms of change in unemployment and suicide rates across Italian regions. The strongest positive correlation between unemployment and suicides was in Sicily (r=0.759). In regions such as Trentino Alto-Adige, however, the association was negative (r=-0.44).
I thus investigated the role of social protection identified by previous authors as potential effect modifier for the association between unemployment and health outcomes. [8] Data on social protection (per capita expenditure in Euro for social services and benefits delivered by single and associated municipalities in 2008) and social cohesion (percentage of population aged 14 or older who participated to free-of-charge activity for volunteer groups or associations in 2010) came from the SocialCohesion.Stat database, a warehouse of statistics produced by the National Social Security Institute (INPS), the Ministry of Labor and Social Policy and ISTAT. [9] As shown in figure 2, the association between unemployment and suicides from 2000 to 2010 was negatively correlated to levels of social protection (r=-0.49; p=0.02) across Italian regions. I then added a time-invariant interaction term between unemployment and social protection and one for unemployment and social cohesion (separately) in the basic model between unemployment and suicides. In regions investing more than 135 Euro per capita on social services and benefits, each 1% rise in unemployment was associated with a reduction of 0.41 suicides per 100,000 (95% CI; -0.07 to -0.76, p=0.02).
[Figure 2 about here]
Results have important implications for research and policy. Although various Italian media outlets and even ISTAT claim that suicides have not increased in Italy, our study is in line with international evidence on the adverse effects of the Great Recession on suicides in Europe. [7] Findings are also consistent with previous research indicating that strong social protection can mitigate the consequences of economic crises on health outcomes. [8] The case of Trentino Alto-Adige, which has the second highest per capita expenditure on social services and benefits and the highest volunteerism rate in Italy, is in line with evidence from Sweden, [7] which showed that investment in social protection can decouple unemployment from suicides. As Italy is still struggling with the sixth consecutive year of economic contraction, new policies (alternative to austerity) buffering the victims of the financial crisis from the adverse effects of unemployment, foreclosure and bankruptcy are more urgent than ever.
References:
1. Arie S. Has austerity brought Europe to the brink of a health disaster? BMJ 2013;346.
2. De Vogli R, Marmot M, Stuckler D. Excess suicides and attempted suicides in Italy attributable to the great recession. J Epidemiol Community Health. 2013; 67(4): 378-9.
3. ISTAT. Suicidi e Tentativi di Suicidio in Italia (Tavole 2000-2010). Istituto Nazionale di Statistica; 2000-2010.
4. Wooldridge J. Advanced Panel Data Methods. In: Wooldridge J, editor. Introductory Econometrics: A Modern Approach. Canada: South-Western Cengage Learning; 2009. p. 489.
5. Greene W. Econometric Analysis - 5th Edition. Upper Saddle River, NJ: Prentice Hall; 2012.
6. Baum C. An Introduction to Modern Econometrics Using STATA. College Station, TX: Stata Press; 2006.
7. Stuckler D, Sanjay Basu, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. The Lancet. 2011; 378: 124-5.
8. Stuckler D, et al. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009; 374(9686): 315–23.
9. INPS. SocialCohesion.Stat database. National Social Security Institute (INPS), Ministry of Labor and Social Policy and National Institute of Statistics; 2013. http://dati.coesione-sociale.it/?lang=en
10. De Vogli R, Marmot M, Stuckler D. Strong evidence that the economic crisis caused a rise in suicides in Europe: the need for social protection. J Epidemiol Community Health. 2013; 67(4): 298.
Competing interests: No competing interests
The author makes a plea for measured and evidenced responses by health services to austerity measures and better governance to maintain standards in a climate of contracting health service budgets1. The National Health Service in the United Kingdom (UK) is no exception to budgetary constraints. A number of provider organizations in the UK have coped with these measures through redesigning and integrating services. However, often these changes are implemented without relevance to wider public service changes or an assessment of their impact on patient care and workforce productivity. Emphasis needs to be on enabling organisations and the workforce during change to maintain quality of patient care, which should be the primary objective of any health service commissioner, provider and governor.
The authors emphasise that during such times, the effects on mental health of the population are compounded. Numerous studies have linked unemployment and other socio - economic circumstances with poor mental health (2) and suicide rates (3,4). In addition, mental health services often become a soft target for financial cuts, thereby impacting on access to these services. This, in turn, can have an adverse effect on social recovery.
Happiness and labour economists believe that better access and delivery of mental health care could have an impact on overall workforce productivity (5) and therefore aid in the economic recovery. Therefore, changes to such a vital service should be made with extra care with a focus on maintaining outcomes for patients and wider society. In summary, any proposed measures must consider the whole system.
References:
1. Arie S. Has austerity brought Europe to the brink of a health disaster? BMJ,
2013; 346:f3773.
2. Dorling D. Unemployment and health. BMJ, 2009; 338, b829.
3. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis, austerity, and health in Europe. Lancet, 2013; 381:1323-31.
4. Legido-Quigley H, Otero-Garcia L, la Parra D, Alvarez-Dardet C, Martin-Moreno JM, McKee M. Will austerity cuts dismantle the Spanish healthcare system? BMJ2013; 346:f2363.
5. The Centre for Economic Performance’s Mental Health Policy Group: The Depression Report. A new deal for depression and anxiety disorders". London School of Economics; 2006.
Competing interests: No competing interests
The quoted analogy of austerity as 'a drug that would fail its trial' is somewhat misleading. Authorities know that austerity measures have their side effects and non-compliant nations. But economists know that Keynesian spending in the face of recession - specifically chasing lower unemployment rates as eluded to in Arie's article - is not the answer.
Stuckler would do well to extend his analogy to include the placebo effect of such a drug; much evidence shows that faith in austerity goes a long way (1, 2, 3)
1. Corsetti, G., A. Acconcia and S. Simonelli, 2011, “Mafia and Public Spending: Evidence on the Fiscal Multiplier from a Quasi-experiment ”.
2. Congressional Budget Office, 2012, “Estimated Impact of the American Recovery and Reinvestment Act on Employment and Economic Output from January 2012 Through March 2012”, http://www.cbo.gov/publication/43274
3. Perotti R, 2011, “The "Austerity Myth",Gain Without Pain? ”, NBER Working Paper Series, w1757.
Competing interests: No competing interests
Dear Editors,
Extreme fund mismanagement and widespread corruption are the leading causes of the ongoing humanitarian crisis in Greece. [1][2][3][4][5][6][7][9]
Austerity programs merely managed to cut some of the embezzlement costs. [8][10][11][12][13]
ENI-EOPYY organization and iatropedia.gr reporters have been presenting, for months, all official expenditures of the Greek NHS: only 82 million euros per year for all GPs and Specialist Consultants in the Country, but 500 million euros per year for various bureaucratic Headquarters costs!
References
[1] http://www.bmj.com/content/342/bmj.d2408?tab=responses
[2] http://www.bmj.com/content/343/bmj.d4803?tab=responses
[3] http://www.bmj.com/content/342/bmj.d200?tab=responses
[4] http://www.bmj.com/content/346/bmj.f2360/rr/647326
[5] http://www.bmj.com/content/346/bmj.f2874/rr/645024
[6] http://www.bmj.com/content/341/bmj.c5496/rr/609720
[7] http://www.bmj.com/content/345/bmj.e5633/rr/609182
[8] http://www.bmj.com/content/343/bmj.d7326/rr/608272
[9] http://www.bmj.com/content/344/bmj.e2935/rr/603727
[10] http://www.bmj.com/content/345/bmj.e4607/rr/600855
[11] http://www.bmj.com/content/343/bmj.d7372/rr/592258
[12] http://www.bmj.com/content/344/bmj.e3589/rr/587805
[13] http://www.bmj.com/content/343/bmj.d7234/rr/568545
Competing interests: Dr Stavros Saripanidis is a diligent taxpayer who has been financing Greek health Authorities for years. He is outraged to see such extreme and humiliating shortages. Public managers must answer where all those billions of State funds went.
Re: Has austerity brought Europe to the brink of a health disaster?
While the tremendous toll of the crisis on the health of the Greek population has received considerable attention,1 a largely overlooked victim has been the births and marriages that take place in Greece. Recently, Neels et al in a study that encompassed 14 European countries showed that recession induced postponement and recuperation of fertility over the course of 35 years.2 Furthermore, the positive correlation between births and marriages is well established in the Greek society.3
Herein, we present the last 4-year trends (2009 to 2012) of births and marriages in Greece (Table). The purpose was to evaluate the potential associations between the financial crisis period and the number of births and marriages. Over the 4 years assessed, unemployment rate increased from 9.5% to a staggering 24.2%, whereas the Gross Domestic Product decreased by 17.3% (Table). During the same period, the number of births decreased from 117,933 in 2009 to 100,371 in 2012 (relative decrease of 14.9%). This decrease was due to the decrease of births in wedlock (from 110,184 to 92,731; relative decrease of 15.8%). Births out of wedlock did not change over the course of the 4 years. Similarly, marriages decreased from 59,212 in 2009 to 49,710 in 2012 (relative decrease of 16.0%). On the contrary, registered partnerships that were first allowed in 2009 increased from 161 in 2009 to 314 in 2012 (relative increase of 95%).
In a conservative Greek society, where most of the births take place in wedlock, plagued by unemployment it seems as an unavoidable side-effect that less births will take place. Given the fact that the total fertility rate in Greece in 2011 was 1.40 and the replacement fertility rate is roughly 2.10 births per woman for most industrialized countries one can understand how serious the Greek demographic problem is. It is imperative that preventive policies will give access to labor markets for younger generations.
References
1. Kondilis E, Giannakopoulos S, Gavana M, Ierodiakonou I, Waitzkin H, Benos A. Economic crisis, restrictive policies, and the population's health and health care: the Greek case. Am J Public Health 2013;103(6):973-9.
2. Neels K, Theunynck Z, Wood J. Economic recession and first births in Europe: recession-induced postponement and recuperation of fertility in 14 European countries between 1970 and 2005. Int J Public Health 2013;58(1):43-55.
3. Demoliates YD, Katsouyiannopoulos VC. Seasonality of births: changing pattern correlated with the seasonality of marriage. J Epidemiol Community Health 1995;49(1):110-1.
Competing interests: No competing interests