Crisis económico-financiera y salud en España. Evidencia y perspectivas. Informe SESPAS 2014

The objectives of the SESPAS 2014 Report are as follows: a) to analyze the impact of the economic crisis on health and health-related behaviors, on health inequalities, and on the determinants of health in Spain; b) to describe the changes in the Spanish health system following measures to address the crisis and assess its potential impact on health; c) to review the evidence on the health impact of economic crises in other countries, as well as policy responses; and d) to suggest policy interventions alternative to those carried out to date with a population health perspective and scientific evidence in order to help mitigate the impact of the economic downturn on health and health inequalities. The report is organized in five sections: 1) the economic, financial and health crisis: causes, consequences, and contexts; 2) the impact on structural determinants of health and health inequalities; 3) the impact on health and health-related behaviors, and indicators for monitoring; 4) the impact on health systems; and 5) the impact on specific populations: children, seniors, and immigrants. There is some evidence on the relationship between the crisis and the health of the Spanish population, health inequalities, some changes in lifestyle, and variations in access to health services. The crisis has impacted many structural determinants of health, particularly among the most vulnerable population groups. Generally, policy responses on how to manage the crisis have not taken the evidence into account. The crisis may contribute to making public policy vulnerable to corporate action, thus jeopardizing the implementation of healthy policies.     

Crisis económica y salud mental. Informe SESPAS 2014

Studies published before the financial crisis of 2008 suggest that economic difficulties contribute to poorer mental health. The IMPACT study conducted in primary health care centers in Spain found a significant increase in common mental disorders. Between 2006 and 2010, mood disorders increased by 19%, anxiety disorders by 8% and alcohol abuse disorders by 5%. There were also gender differences, with increased alcohol dependence in women during the crisis period. The most important risk factor for this increase was unemployment. In parallel, antidepressant consumption has increased in recent years, although there has not been a significant inrease in the number of suicides. Finally, the study offers some proposals to reduce the impact of the crisis on mental health: increased community services, employment activation measures, and active policies to reduce alcohol consumption and prevent suicidal behavior, particularly among young people.     

Crisis económica y patología infecciosa. Informe SESPAS 2014

Past economic crises have increased the impact of communicable diseases especially on groups particularly vulnerable to the social and health consequences of the recession. However, it has been shown that the impact of these crises largely depends on the response of governments and the inhabitants of affected countries. We describe the consequences of the current crisis in the causal chain of infectious disease, including the response of the health system, and explore whether there is evidence of its impact in Spain. It is assumed that the possible effect of the crisis on living and working conditions is due to individual and social debt coupled with high unemployment as defining features of the crisis. We highlight the potential negative consequences of healthcare cuts on vulnerable populations, which have been partly excluded with the recent reform of health coverage. We compare mortality and morbidity data between two periods: before and after 2008, integrating, where possible, observed trends and institutional reports. Overall, no effect on infectious disease has been detected so far, although some signs of worsening, which could be compatible with the effects of the crisis, have been observed and need to be monitored and confirmed. We review the limitations of data sources that may not be sufficiently sensitive or up-to-date to detect changes that may require a latency period to become manifest. Instead of cutting resources, surveillance of these diseases should be improved, and an equitable social health response, which targets the population most affected by the crisis, should be guaranteed.     

La crisis económica española y sus consecuencias sobre el gasto social. Informe SESPAS 2014

This article offers a brief summary of the factors that the author believes should be considered when analyzing the multiple interrelations between the economic crisis and its effects on public finances, social spending, and the health and welfare of Spaniards. For the sake of brevity, a linear argument is followed, with the basic contents of the message, leaving some of the more controversial issues whose interpretation may be heavily influenced by ideology to the discussion. The core of the argument is that, despite the double dip of the Spanish recession, healthcare has survived the consequences of the crisis fairly well. This is particularly the case when the situation is analyzed in terms of the share of public expenditure to GDP and in per capita terms, given the evolution of these ratios, although the final effect is unknown in terms of the actual and potential beneficiaries. This relatively low incidence so far on the health of Spaniards is basically due to family networks, pooling their incomes, and to the acceptance by Spanish health professionals of budget cuts, which have allowed services and their apparent quality to be maintained, contrasting with private employment and public finances. Obviously, this is not a guarantee of sustainability unless economic growth recovers. Even if the Spanish economy and public finances improve, the composition of health care delivery needs to be reevaluated to achieve a new allocation between public and private responsibilities for healthcare in accordance with the social development of the 21th century.     

Crisis económica al inicio del siglo xxi y mortalidad en España. Tendencia e impacto sobre las desigualdades sociales. Informe SESPAS 2014

This study aimed to assess the impact of the current economic crisis on mortality trends in Spain and its effect on social inequalities in mortality in Andalusia. We used data from vital statistics and the Population Register for 1999 to 2011, as provided by the Spanish Institute of Statistics, to estimate general and sex- and age-specific mortality rates. The Longitudinal Database of the Andalusian Population (2001 census cohort) was used to estimate general mortality rates and ratios by educational level. The annual percentages of change and trends were calculated using Joinpoint regressions. No significant change in the mortality trend was observed in Spain from 2008 onward. A downward trend after 1999 was confirmed for all causes and both sexes, with the exception of nervous system-related diseases. The reduction in mortality due to traffic accidents accelerated after 2003, while the negative trend in suicide was unchanged throughout the period studied.In Andalusia, social inequalities in mortality have increased among men since the beginning of the crisis, mainly due to a more intense reduction in mortality among persons with a higher educational level. Among women, no changes were observed in the pattern of inequality.     

Funcionamiento del ascensor social en España y posibles mejoras. Informe SESPAS 2014

In this article, we analyze the extent to which an individual's socioeconomic status is inherited and how equality of opportunity could be increased to improve social mobility. Poverty and deprivation can stop being dynastic-like if the social elevator works. In Spain, income inequality, measured by the Gini coefficient, rose from 0.31 in 2006 to 0.35 in 2012 (moving away from Scandinavia and Central Europe and more closely resembling income inequality in the UK or the United States), while the degree of intergenerational mobility is half-way between that in Italy and the United States. To change this situation and make the social elevator work, primary education should be improved and the health system should be steered toward primary healthcare. This will not be feasible without an improvement in politics and the institutional framework that determine these factors.     

Evolución de los riesgos ambientales en el contexto de la crisis económica. Informe SESPAS 2014

This article aims to analyze the impact of the economic and financial crisis on environmental determinants of health. The World Health Organization estimates that between 13% and 27% of the disease burden in countries could be prevented by improving the environment. These effects are larger in vulnerable populations, especially among the poorest. In the last decade, outdoor air pollution (the most significant environmental health risk in most European countries) has declined, mostly due to the European policy of reducing emissions and to the decrease in activity following the economic crisis. During the last few years, this improvement in air quality has occurred simultaneously with a reduction in investment in environmental protection and could therefore be offset in the medium-term. The economic crisis has not reduced the trend for higher temperatures in Spain and Europe because climate change is a global phenomenon that is not directly related to local emissions. To reduce the risk of an increase in the health impact of environmental factors, certain key aspects should be considered, such as the need to maintain or develop adequate monitoring and control systems and the opportunity to implement policies that help improve the quality of the environment and reduce the vulnerability of different population groups in a cross-disciplinary framework of transparency and citizen participation.     

Indicadores para monitorizar la evolución de la crisis económica y sus efectos en la salud y en las desigualdades en salud. Informe SESPAS 2014

The economic crisis has adverse effects on determinants of health and health inequalities. The aim of this article was to present a set of indicators of health and its determinants to monitor the effects of the crisis in Spain. On the basis of the conceptual framework proposed by the Commission for the Reduction of Social Health Inequalities in Spain, we searched for indicators of social, economic, and political (structural and intermediate) determinants of health, as well as for health indicators, bearing in mind the axes of social inequality (gender, age, socioeconomic status, and country of origin). The indicators were mainly obtained from official data sources published on the internet. The selected indicators are periodically updated and are comparable over time and among territories (among autonomous communities and in some cases among European Union countries), and are available for age groups, gender, socio-economic status, and country of origin. However, many of these indicators are not sufficiently reactive to rapid change, which occurs in the economic crisis, and consequently require monitoring over time. Another limitation is the lack of availability of indicators for the various axes of social inequality. In conclusion, the proposed indicators allow for progress in monitoring the effects of the economic crisis on health and health inequalities in Spain.     

Protocolo del estudio sobre el efecto de la crisis económica en la mortalidad,la salud reproductiva y las desigualdades en salud en España

The aim is to present the protocol of the two sub-studies on the effect of the economic crisis on mortality and reproductive health and health inequalities in Spain. Substudy 1: describe the evolution of mortality and reproductive health between 1990 and 2013 through a longitudinal ecological study in the Autonomous Communities. This study will identify changes caused by the economic crisis in trends or reproductive health and mortality indicators using panel data (17 Autonomous Communities per study year) and adjusting Poisson models with random effects variance. Substudy 2: analyse inequalities by socioeconomic deprivation in mortality and reproductive health in several areas of Spain. An ecological study analysing trends in the pre-crisis (1999–2003 and 2004–2008) and crisis (2009–2013) periods will be performed. Random effects models Besag York and Mollié will be adjusted to estimate mortality indicators softened in reproductive health and census tracts.     

Impacto de la crisis en el derecho a una alimentación sana y saludable. Informe SESPAS 2014

The present article analyzes the impact of the economic crisis on food consumption in Spain, the most affected social profiles, and the consequences of changing patterns of food consumption on health. This article is based on official reports and previous empirical studies. The crisis has affected diet and food consumption. Families are attempting to spend less money on food. Food insecurity is rising and the most affected groups are those spending a higher proportion of their income on food. Cuts in food spending run parallel with unhealthy eating habits that encourage obesity. Consequently, the crisis contributes to undermining the right to a healthy diet, recognized by the International Covenant on Economic, Social and Cultural Rights of the United Nations.     

Crisis económica,pobreza e infancia. ¿Qué podemos esperar en el corto y largo plazo para los “niños y niñas de la crisis”? Informe SESPAS 2014

The way a person will develop over the lifespan is largely determined by the first few years of life. A substantial share of the inequalities in health and socioeconomic status observed in adult life originate during childhood (and even while in utero). In this paper, we first review the literature on the impact of childhood conditions throughout the life cycle. We next discuss some of the social and biological mechanisms behind the transmission of the effects of poverty during the prenatal period, childhood, and adulthood. We then analyze several international experiences aimed at reducing intergenerational transmission of poverty. The article ends with some critical thoughts and policy recommendations to avoid the possible long-term effects of the current crisis on the health and socioeconomic status of the “children of the crisis” in Spain.     

Tendencia de la mortalidad por edad y sexo en España (1981-2016). Cambios asociados a la crisis económica

ObjectiveTo analyze trends in age-sex-specific mortality in Spain, and to identify if there have been changes following the onset of economic crisis.MethodA study of trends in mortality rates by sex and quinquennial groups of age was carried out, from 1981 to 2016. Time trends were established by joint-point regression models. The results of the last two periods identified in the regressions are presented in detail, identifying changes after the onset of the economic crisis. When slowdown or stagnation of the mortality trends were identified in several successive age groups, an analysis of trends by causes was carried out.ResultsMortality was significantly reduced between 1981 and 2016. After the beginning of the economic crisis, the trend in total age-standardized mortality did not change for men, but it stagnated for women from 2013 to 2016. In the analysis by quinquennial age groups, the downward trend in mortality suffered a stagnation in men in all the groups between 15 and 39 years, which started between 2011 and 2014, and lasted until 2016. In both women and men, in the four groups between 60 and 79 years, the previous decline in mortality suffered a slowdown or stagnation, which began between 2009 and 2014, and continued until 2016. Negative changes in mortality trends were mainly influenced by external causes (in 15-39 years men) and diseases of the circulatory and respiratory systems (in 60-79 years men and women).ConclusionsThe downward trend of mortality suffered stagnation or deceleration after the onset of the economic crisis in young men and 60-79 years old men and women.     

Gasto sanitario en atención primaria en España: insuficiente para ofrecer servicios atrayentes para pacientes y profesionales. Informe SESPAS 2012

The relatively low health expenditure on primary care in Spain is a result of the status quo in the health system, in which hospital/specialized care is much more widespread and better financed than primary care. Another cause consists of the health policies developed in the last 30 years, which have prioritized the development of the private ambulatory health sector over primary care.     

Lecciones desde fuera. Otros países en ésta y otras crisis anteriores. Informe SESPAS 2014

The evidence available on the impact of previous crises on health reveals different patterns attributable to study designs, the characteristics of each crisis, and other factors related to the socioeconomic and political context. There is greater consensus on the mediating role of government policy responses to financial crises. These responses may magnify or mitigate the adverse effects of crises on population health. Some studies have shown a significant deterioration in some health indicators in the context of the current crisis, mainly in relation to mental health and communicable diseases. Alcohol and tobacco use have also declined in some European countries. In addition, this crisis is being used by some governments to push reforms aimed at privatizing health services, thereby restricting the right to health and healthcare. Specifically, action is being taken on the three axes that determine health system financing: the population covered, the scope of services, and the share of the costs covered. These measures are often arbitrarily implemented based on ideological decisions rather than on the available evidence and therefore adverse consequences are to be expected in terms of financial protection, efficiency, and equity.     

Promoción de la salud y prevención en tiempos de crisis: el rol del sector sanitario. Informe SESPAS 2014

This article reviews trends in lifestyle factors and identifies priorities in the fields of prevention and health promotion in the current economic recession. Several information sources were used, including a survey of 30 public health and primary care experts. Between 2006 and 2012, no significant changes in lifestyle factors were detected except for a decrease in habitual alcohol drinking. There was a slight decrease in the use of illegal drugs and a significant increase in the use of psychoactive drugs. Most experts believe that decision-making about new mass screening programs and changes in vaccination schedules needs to be improved by including opportunity cost analysis and increasing the transparency and independence of the professionals involved. Preventive health services are contributing to medicalization, but experts’ opinions are divided on the need for some preventive activities.Priorities in preventive services are mental health and HIV infection in vulnerable populations. Most experts trust in the potential of health promotion to mitigate the health effects of the economic crisis. Priority groups are children, unemployed people and other vulnerable groups. Priority interventions are community health activities (working in partnership with local governments and other sectors), advocacy, and mental health promotion. Effective tools for health promotion that are currently underused are legislation and mass media. There is a need to clarify the role of the healthcare sector in intersectorial activities, as well as to acknowledge that social determinants of health depend on other sectors. Experts also warn of the consequences of austerity and of policies that negatively impact on living conditions.     

Crisis económica y condiciones de empleo: diferencias de género y respuesta de las políticas sociales de empleo. Informe SESPAS 2014

The economic crisis has had an impact across the European Union (EU), but has had a devastating impact on the labor market in Spain, which has become the country within the EU-15 with the worst employment indicators. The situation is worse in younger people, half of whom were unemployed in 2012, with a slightly higher rate in men (54.4%) than in women (51.8%). This high unemployment rate will be even more difficult to redress because of the decrease in public spending on active employment per percentage point of unemployment in 2012 compared with 2007. Furthermore, the decrease in spending on passive employment policies will worsen the health of the unemployed population.