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Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Delegación Territorial de la Consejería de Salud de la Junta de Andalucía, Cádiz, Spain.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7234-3510
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2018 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 3, article id e0195293Article in journal (Refereed) Published
Abstract [en]

Scant research is available on the impact of the current economic crisis and austerity policies on inequality in health services utilisation in Europe. This study aimed to describe the trends in horizontal inequity in the use of health services in Andalusia, Spain, during the early years of the Great Recession, and the contribution of demographic, economic and social factors. Consultation with a general practitioner (GP) and specialist, hospitalisation and emergency care were studied through the Andalusian Health Survey 2007 (pre-crisis) and 2011-2012 (crisis), using a composite income index as socioeconomic status (SES) indicator. Horizontal inequity indices (HII) were calculated to take differential healthcare needs into account, and a decomposition analysis of change in inequality between periods was performed. Results showed that before the crisis, the HII was positive (greater access for people with higher SES) for specialist visits but negative (greater access for people with lower SES) in the other three utilisation models. During the crisis no change was observed in inequalities in GP visits, but a pro-poor development was seen for the other types of utilisation, with hospital and emergency care showing significant inequality in favour of low income groups. Overall, the main contributors to pro-poor changes in utilisation were socioeconomic variables and poor mental health, due to changes in their elasticities. Our findings show that inequalities in healthcare utilisation largely remained in favour of the less well-off, despite the cuts in welfare benefits and health services provision during the early years of the recession in Andalusia. Further research is needed to monitor the potential impact of such measures in subsequent years.

Place, publisher, year, edition, pages
2018. Vol. 13, no 3, article id e0195293
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-130574DOI: 10.1371/journal.pone.0195293ISI: 000428845900026PubMedID: 29601609Scopus ID: 2-s2.0-85044858050OAI: oai:DiVA.org:umu-130574DiVA, id: diva2:1068089
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2006-1512; 2014-0451
Note

Originally included in thesis in manuscript form with title: Withstanding austerity: equity in access to health services in the first stage of the economic recession in southern Spain

Available from: 2017-01-24 Created: 2017-01-24 Last updated: 2018-06-25Bibliographically approved
In thesis
1. Withstanding austerity: economic crisis and health inequalities in Spain
Open this publication in new window or tab >>Withstanding austerity: economic crisis and health inequalities in Spain
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Along with the austerity measures introduced in many countries, the economic crisis affecting Europe since 2008 seems to have impacted many aspects of the health of the Spanish population and has had a negative effect on the provision health services. An increasing body of knowledge has shown a clear impact of the current crisis on suicidal behaviour and mental health, and a less consistent effect on physical health and access to healthcare. However, little is known about the impact of the crisis on social inequalities in health and healthcare access, an area on which the present study seeks to shed light in the context of Spain, and specifically Andalusia, a region hit very hard by the crisis.

Objective: To study the impact of the economic crisis starting in 2008 on health, health inequalities and health service utilisation in Spain and Andalusia and the roles of socio-demographic factors in these associations.

Methods: Death rates were analysed to study the annual percent change in overall and cause-specific mortality in Spain between 1999 and 2011, and the Longitudinal Database of the Andalusian Population was used to study educational inequalities in overall mortality from 2002 to 2010 (study 1). To calculate suicide attempt rates, information from 2003 to 2012 on 11,494 men and 12,886 women provided by the Health Emergencies Public Enterprise Information System in Andalusia was utilised. The association between unemployment and suicide attempts was studied through linear regression models (study 2). Two waves of the Andalusian Health Survey (2007 and 2011–12) provided data for the third and fourth studies of this thesis. Educational and employment status inequalities in poor mental health in relation with the crisis were analysed through Poisson regression models (study 3). The change in inequalities (pre-crisis–crisis) in health care utilisation outcomes (general practitioner, specialist, hospitalisation and emergency attendance) was measured by the change in horizontal inequality indices. A decomposition analysis of change in inequality between periods was performed using the Oaxaca approach (study 4).

Results: Study 1: Overall mortality in Spain decreased steadily during the period, with annual percent changes of -2.44% in men and -2.20% in women. An increase in educational inequality in mortality was observed in men in Andalusia. In women, the inequalities instead remained stable. Suicide mortality showed a downward trend in both sexes in Spain. Study 2: A sharp increase in suicide attempts in Andalusia was detected after the onset of the crisis in both sexes, with adults aged 35 to 54 years being the most affected. Suicide attempts were associated with unemployment rates only in men. Study 3: Poor mental health increased in working individuals with secondary and primary studies during the crisis compared to the pre-crisis period, while it decreased in the university study group. However, in unemployed individuals poor mental health increased only in the secondary studies group. Financial strain could partly explain the crisis effect on mental health among the unemployed. Study 4: Horizontal inequality in utilisation changed to a greater equality or a more pro-poor inequality in both sexes. In the decomposition analysis, socioeconomic position and health status showed greater contributions to the changes in inequalities.

Conclusion: This thesis illustrates the complexity of the influences of the current economic crisis on health inequalities in a Southern European region. Specifically, no noticeable effects of the crisis on overall and suicide mortality were detected; instead, increasing educational inequalities in mortality in men and a large increase in suicide attempts in middle aged men and women were observed. The deterioration in poor mental health was mainly detected in those of intermediate educational level. Economic conditions such as unemployment and financial strain proved to be relevant. Finally, in the light of no increased inequalities in healthcare utilisation, the universal coverage health system seems to buffer the deleterious effect of the crisis and austerity policies in this context.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2017. p. 83
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1875
Keywords
Economic crisis, mental health, socioeconomic inequalities, health determinants, health care utilisation, Spain, Andalusia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-130950 (URN)978-91-7601-645-9 (ISBN)
Public defence
2017-02-24, Sal 135, By 9A, Allmänmedicin, ingång X5, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2017-02-03 Created: 2017-02-01 Last updated: 2018-06-09Bibliographically approved

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Córdoba-Doña, Juan AntonioSan Sebastián, MiguelGustafsson, Per E.

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