Philipa Mladovsky

Financial crisis, austerity, and health in Europe

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

Migration and health in an increasingly diverse Europe.

The share of migrants in European populations is substantial and growing, despite a slowdown in immigration after the global economic crisis. This paper describes key aspects of migration and health in Europe, including the scale of international migration, available data for migrant health, barriers to accessing health services, ways of improving health service provision to migrants, and migrant health policies that have been adopted across Europe. Improvement of migrant health and provision of access for migrants to appropriate health services is not without challenges, but knowledge about what steps need to be taken to achieve these aims is increasing.

A framework for analysing migrant health policies in Europe

Evidence suggests migrants experience inequalities in health and access to health care. However, to date there has been little analysis of the policies employed to address these inequalities. This article develops a framework to compare migrant health policies, focusing on England, Italy, the Netherlands and Sweden. The first issue addressed in the framework is data collection. All four countries collect migrant health data, but many methodological limitations remain. The second issue is targeting of population groups. Countries typically focus either on first generation immigrants or on ethnic minorities, but not both, despite the often divergent needs of the two groups. Another issue is whether specific diseases should take priority in migrant health policy. While communicable diseases, sexual and reproductive health and mental health have been targeted, there may be a lack of attention paid to lifestyle related risk factors and preventive care. Fourthly, decisions about the mix of demand and supply-side interventions need to be made and evaluated. Finally, the challenge of implementation is discussed. Although migrant health policy has been elaborated in the four countries, implementation has not necessarily reflected this on the ground. These experiences signal important policy issues and options in the development of migrant health policies in Europe.

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.

Informal payments for maternity health services in public hospitals in Greece.

BACKGROUND Private health expenditure for consuming maternity health services has been identified as an issue within public hospitals. AIM To estimate level of private health expenditure, in the form of informal payments, for maternal services in public hospitals in Greece. METHODS The study population consisted of 160 women who had recently given birth in three provincial general hospitals and one general hospital in Athens. A three-part questionnaire was developed in order to collect financial information regarding the use of public obstetrics services in Greece. RESULTS The mean age of respondents was 29.5 (±5.6) years. There was a high rate of informal payments with 74.4% of women involved in informal transactions. Mean total private payments were €1549 (±992), representing 7.9% of the mean annual per capita income in Greece. Mean informal payment was €848 (±714). For 56.3% of the respondents, it was at the obstetricians request, on top of formal payment of €701 (±1351). Total informal payments were higher for women who gave birth in Athens (p<0.001), for Greek women compared to non Greek (p<0.001) and for deliveries that were conducted by womens personal obstetrician (p=0.001). CONCLUSION There is a large black economy in the field of obstetric services, as 74.4% of women who used public maternity services had to pay under-the-table payments corresponding approximately to the net salary of an intern physician. There is a need for the state to adopt innovative strategies and mechanisms in order to reduce informal payments for obstetric services in the public sector.

Is there a statistical relationship between economic crises and changes in government health expenditure growth? an analysis of twenty-four European countries.

OBJECTIVE To identify whether, by what means, and the extent to which historically, government health care expenditure growth in Europe has changed following economic crises. DATA SOURCES Organization for Economic Cooperation and Development Health Data 2011. STUDY DESIGN Cross-country fixed effects multiple regression analysis is used to determine whether statutory health care expenditure growth in the year after economic crises differs from that which would otherwise be predicted by general economic trends. Better understanding of the mechanisms involved is achieved by distinguishing between policy responses which lead to cost-shifting and all others. FINDINGS In the year after an economic downturn, public health care expenditure grows more slowly than would have been expected given the longer term economic climate. Cost-shifting and other policy responses are both associated with these slowdowns. However, while changes in tax-derived expenditure are associated with both cost-shifting and other policy responses following a crisis, changes in expenditure derived from social insurance have been associated only with changes in cost-shifting. CONCLUSIONS Disproportionate cuts to the health sector, as well as reliance on cost-shifting to slow growth in health care expenditure, serve as a warning in terms of potentially negative effects on equity, efficiency, and quality of health services and, potentially, health outcomes following economic crises.

Public Financing of IVF: A Review of Policy Rationales

There is great diversity in in vitro fertilization (IVF) funding and reimbursement policies and practice throughout Europe and the rest of the world. While many existing reimbursement and regulatory frameworks address safety and legal concerns, economic factors also assume a central role. However, there are several problems with the evidence that is available on the economics of IVF. This suggests there is a need for more robust cost-effectiveness studies. It also indicates the need for alternative rationales to justify the reimbursement of IVF, which might more fully account for the social, political, ethical, and philosophical considerations embedded in notions of infertility and technology-driven reproductive treatments. The merits and limitations of five alternative rationales are discussed. The review suggests that while no existing single rationale provides a complete framework with which to support funding decisions, taken together they provide guideposts which signal important issues for consideration and highlight where further research, action, and debate are needed.

Social capital and the social formation of health-related preferences and behaviours

Social capital appears to be an important determinant of health production and health utilization and demand. However, there is limited evidence on the mechanisms underlying this relationship. In this article we draw on the evidence and insights reported in this special issue along with findings from the economic and other social science literature to develop a discussion on the explanations of the likely (behavioural) mechanisms that underpin the connection between social capital and health. An important and under-explored influence mediating the relationship between social capital and health (behaviour) lies in the individuals face in determining their life-styles and in using health care. In particular, we point to the interdependence in how individuals in the first place perceive and also respond to common health risks and the role of cultural transmission and social identity as conveyors of this process. We argue that an emerging body of evidence suggesting that interdependent preferences influence health calls for further re-formulation of traditional demand for and production of health models. Additionally, methodological problems are highlighted and possible ways forward suggested.

How do economic crises affect migrants' risk of infectious disease? A systematic-narrative review

Background: It is not well understood how economic crises affect infectious disease incidence and prevalence, particularly among vulnerable groups. Using a susceptible-infected-recovered framework, we systematically reviewed literature on the impact of the economic crises on infectious disease risks in migrants in Europe, focusing principally on HIV, TB, hepatitis and other STIs. Methods: We conducted two searches in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar, websites of key organizations and grey literature to identify how economic changes affect migrant populations and infectious disease. We perform a narrative synthesis in order to map critical pathways and identify hypotheses for subsequent research. Results: The systematic review on links between economic crises and migrant health identified 653 studies through database searching; only seven met the inclusion criteria. Fourteen items were identified through further searches. The systematic review on links between economic crises and infectious disease identified 480 studies through database searching; 19 met the inclusion criteria. Eight items were identified through further searches. The reviews show that migrant populations in Europe appear disproportionately at risk of specific infectious diseases, and that economic crises and subsequent responses have tended to exacerbate such risks. Recessions lead to unemployment, impoverishment and other risk factors that can be linked to the transmissibility of disease among migrants. Austerity measures that lead to cuts in prevention and treatment programmes further exacerbate infectious disease risks among migrants. Non-governmental health service providers occasionally stepped in to cater to specific populations that include migrants. Conclusions: There is evidence that migrants are especially vulnerable to infectious disease during economic crises. Ring-fenced funding of prevention programs, including screening and treatment, is important for addressing this vulnerability.

Tuberculosis among migrant populations in the European Union and the European Economic Area

Background: Although tuberculosis (TB) incidence has been decreasing in the European Union/European Economic Area (EU/EEA) in the last decades, specific subgroups of the population, such as migrants, remain at high risk of TB. This study is based on the report ‘Key Infectious Diseases in Migrant Populations in the EU/EEA’ commissioned by The European Centre for Disease Prevention and Control. Methods: We collected, critically appraised and summarized the available evidence on the TB burden in migrants in the EU/EEA. Data were collected through: (i) a comprehensive literature review; (ii) analysis of data from The European Surveillance System (TESSy) and (iii) evidence provided by TB experts during an infectious disease workshop in 2012. Results: In 2010, of the 73 996 TB cases notified in the EU/EEA, 25% were of foreign origin. The overall decrease of TB cases observed in recent years has not been reflected in migrant populations. Foreign-born people with TB exhibit different socioeconomic and clinical characteristics than native sufferers. Conclusion: This is one of the first studies to use multiple data sources, including the largest available European database on infectious disease notifications, to assess the burden and provide a comprehensive description and analysis of specific TB features in migrants in the EU/EEA. Strengthened information about health determinants and factors for migrants’ vulnerability is needed to plan, implement and evaluate targeted TB care and control interventions for migrants in the EU/EEA.