Cristina Hernández-Quevedo

Spanish health care cuts: Penny wise and pound foolish?

The purpose of this paper is to convey the specific health care actions and policies undertaken by the Spanish government, as well as by regional governments, as a result of the economic crisis. Throughout the last two years we have witnessed a number of actions in areas such as human capital, activity and processes, outsourcing and investment that, poorly coordinated, have shaped the nature of financial cuts on public services. This paper discloses the size and magnitude of these actions, the main actors involved and the major consequences for the health sector, citizens and patients. We further argue that there are a number of factors which have been neglected in the discourse and in the actions undertaken. First, the crisis situation is not being used as an opportunity for major reforms in the health care system. Further, the lay public and professionals have remained as observers in the process, with little to no participation at any point. Moreover, there is a general perception that the solution to the Spanish situation is either the proposed health care cuts or an increase in cost sharing for services which neglects alternative and/or complementary measures. Finally, there is a complete absence of any scientific component in the discourse and in the policies proposed.

The socio-economic determinants of the health status of Roma in comparison with non-Roma in Bulgaria, Hungary and Romania

BACKGROUNDS Roma people from Central and Eastern Europe suffer some of the worst health conditions in the industrialized world. This article aims at identifying the determinants of health status among Roma in comparison with non-Roma in Bulgaria, Romania and Hungary. METHODS Non-linear models were estimated for three different health indicators: self-reported health compared with the previous year, probability of reporting chronic conditions and feeling threatened by illness because of sanitary and hygienic circumstances. Ethnic origin differentiated by Roma, national population and other ethnic minorities is self-reported. The data used are from a unique data set provided by the United Nations Development Programme household survey on Roma and populations living in their close proximity for 2004. Sample sizes are 2536 for Bulgaria, 2640 for Hungary and 3292 for Romania. RESULTS After controlling for demographic variables the Roma were significantly more likely to report worse health in any indicator than the non-Roma everywhere. However, after including socio-economic variables, Roma had a significantly higher probability of reporting chronic conditions only in Romania. For the probability of feeling threatened by illness because of unhygienic circumstances, being Roma was a main determinant in Hungary and Romania, but not in Bulgaria. The results for self-reported health were inconclusive. CONCLUSIONS While these results in part support the development of health policies targeting Roma, the finding that poorly educated and less wealthy people, as well as other ethnic minorities also experience health inequalities suggests that broader multisectoral policies are needed in the countries studied.

Inequalities in the use of health services between immigrants and the native population in Spain: what is driving the differences?

In Spain, a growing body of literature has drawn attention to analysing the differences in health and health resource utilisation of immigrants relative to the autochthonous population. The results of these studies generally find substantial variations in health-related patterns between both population groups. In this study, we use the Oaxaca-Blinder decomposition technique to explore to what extent disparities in the probability of using medical care use can be attributed to differences in the determinants of use due to, e.g. a different demographic structure of the immigrant collective, rather than to a different effect of health care use determinants by nationality, holding all other factors equal. Our findings show that unexplained factors associated to immigrant status determine to a great extent disparities in the probability of using hospital, specialist and emergency services of immigrants relative to Spaniards, while individual characteristics, in particular self-reported health and chronic conditions, are much more important in explaining the differences in the probability of using general practitioner services between immigrants and Spaniards.

Measuring inequalities in health: What do we know? What do we need to know?

We argue that policy analysis aiming at curving inequalities in health calls for a better understanding of what we know about its measurement pathways. Assuming that health is a good that individuals trade off against other goods, unavoidable health inequalities result when after controlling for unavoidable factors (e.g., age and gender), differences in socioeconomic status of an individual systemically engender differences in health outcomes. However, the measurement of such inequality and underpinning reasons behind are not suggestive of a clear picture. In reviewing the literature, we conclude that it is unclear what the evidence suggests about the reasons for health inequalities as well as the best possible instruments to measure both inequality and socioeconomic health gradients. We provide an evaluation of the different sources of health inequity and we draw upon measurement issues and their policy significance.

Income inequalities in unhealthy life styles in England and Spain.

Health inequalities in developed societies are persistent. Arguably, the rising inequalities in unhealthy lifestyles might underpin these inequality patterns, yet supportive empirical evidence is scarce. We examine the patterns of inequality in unhealthy lifestyles in England and Spain, two countries that exhibit rising obesity levels with a high prevalence of smoking and alcohol use. This study is unique in that it draws from health survey data spanning over a period in which major contextual and policy changes have taken place. We document persistent income-related inequalities in obesity and smoking; both unhealthy lifestyles appear to be disproportionately concentrated among the relatively poor in recent decades. In contrast, alcohol use appears to be concentrated among richer individuals in both periods and countries examined.

Integrated care: a Danish perspective

Despite three decades of reform Denmark’s health sector is still struggling to provide coordinated care for an ageing population with a high burden of chronic disease. Andreas Rudkjøbing and colleagues describe recent initiatives to improve continuity of care

Inequity in long-term care use and unmet need: Two sides of the same coin

We investigate the determinants of several LTC services and unmet need using data from a representative sample of the non-institutionalised disabled population in Spain in 2008. We measure the level of horizontal inequity and compare results using self-reported versus a more objective indicator of unmet needs. Evidence suggests that after controlling for a wide set of need variables, there is not an equitable distribution of use and unmet need of LTC services in Spain; formal services are concentrated among the better-off, while intensive informal care is concentrated among the worst-off. The distribution of unmet needs for LTC services depends on the service considered and on whether we focus on subjective or objective measures. In 2008, only individuals with the highest dependency level had universal coverage. Our results show that inequities in most LTC services and unmet needs among this group either remain or even increase for formal services.

Persistence despite action? Measuring the patterns of health inequality in England (1997–2007)

The persistence of socioeconomic inequalities in health is a major policy concern in England, which was addressed by the new labour government in 1997 which prioritised curtailing health inequalities as a policy goal. This paper addresses two related questions: first, it empirically examines the dynamic patterns of socioeconomic inequalities in health in England from 1997 to 2007 by estimating concentration indices over three measures of health, namely self-reported health, long standing illness and health limitations, calculated across different years of the Health Survey for England. Second, using regression based decomposition analysis, we explore whether specifically prioritised areas (spearhead local authority areas in the bottom fifth nationally on health indicators) exhibit a different pattern of inequality in the years following a (2005) targeted intervention. Results suggest that patterns of health inequalities in England exhibit no significant variation from 1997 to 2007, although importantly, some reduction on inequalities in health, measured through self-assessed health, is found. Patterns of socioeconomic inequalities in health in spearhead areas are not found to be significantly different than health inequalities in non-spearhead areas.

Explaining the demand for pharmaceuticals in Spain: are there differences in drug consumption between foreigners and the Spanish population?

OBJECTIVE The aim of this study is to examine the factors driving the demand for drugs in Spain, focusing on the existence of disparities in pharmaceutical consumption between the Spanish and the foreign population. METHODS Our analysis is based on a multilevel multinomial probit model that compares three consumption options (no consumption, prescribed consumption and self-medicated consumption) on the five most consumed drugs in Spain. Data is taken from the adult sample of the 2006 Spanish National Health Survey, including 29,478 individuals over 15 years old. RESULTS Overall, the findings show a lower consumption of medicines by some immigrants categories relative to Spaniards. In addition, the results indicate that the consumption of medicines is mainly related to variables associated to the specific cost sharing structure in Spain, such as health limitations and retirement status. Other variables found to explain the demand for drugs were: private health insurance, age, sex, alcohol and cigarette consumption and drug class. CONCLUSION Further understanding of the reasons for the observed differences in drug consumption on the basis of country of birth would allow the health system to design more effective health policies aimed at ensuring equality of access to health resources to all population groups.

Integrated care: The Basque perspective

Abstract Introduction The increasing healthcare expenditure, the rising prevalence of chronic diseases and the ageing of population pose some challenges to Basque Health System, like to other health systems in Europe. Hence, a Strategy for Tackling the Challenge of Chronicity in the Basque Country was published in 2010 to address chronicity and to contribute to sustainability. Objective To analyze and describe the transformation of the Basque health system carried out in the last years, as well as, the different initiatives implemented in order to improve coordination and continuity of care. Conclusion The effects of the ongoing reform of the Basque health system have started to be evaluated. So far, results are only available regarding the impact of specific pilots. However, to date, the results obtained from the different projects carried out are very promising and preliminary evaluations suggest that the Basque health system is on the right track. Value of the paper This paper represents the most updated version of the progress made to date in integrated care in the Basque Country. In addition, it highlights the explicit use of assessment schemes which is one of the cornerstones underlying the Basque healthcare transformation process.