Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context

Abstract

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.     

中国医疗卫生:挑战与出路

疾病风险可以引发经济风险、社会风险甚至政治风险。国内外都对疾病风险的防范给予高度重视,很多国家通过制度为百姓提供医疗保障,化解由疾病风险引发的其他风险。通过对中国疾病风险严重程度的分析,指出“看病难、看病贵”问题的核心原因是政府公共服务职能的缺失,这种缺失表现为社会保障制度的缺失和医疗公共筹资制度的弱化。为此,在发展战略选择上,主张选择以健康为核心的发展战略,以改革推动事业发展。在改革路径选择方面,提出以筹资模式的转变为突破口,促进医疗卫生服务管理模式、服务模式以及就医模式的转变。从而,全面实现推动以健康为核心的发展模式。     

The impact of economic crisis on the Greek hospitals' productivity

During the recent economic crisis, Greece implemented a comprehensive reform in the health care system. The 2010 health reform occurred under the constraints imposed by the memorandum of understanding that the Greek Government signed with its EU/International Monetary Fund creditors to control its deficit. The objective of the study is to examine the impact of the reform on the efficiency and productivity of public hospitals in Greece. We use the Malmquist productivity index to comparatively examine the potential changes before and after the reform years. We compare productivity, efficiency, and technological changes using panel data of 111 public acute hospitals operating in Greece throughout the recession period of 2009 to 2012. Bootstrapping methods are applied to allow for uncertainty owing to sampling error and for statistical inference for the Malmquist productivity index and its decompositions. The analysis indicates that the productivity has been increased following the policy changes. It appears that the expected benefits from the reform in general have been achieved, at least in the short‐term. This result is examined in the light of management and operations activities, which are related with the reform process. Therefore, at a second stage, the Malmquist index is regressed on variables that may potentially be statistically associated with productivity growth.     

Economic barriers to better mental health practice and policy

Mental health systems in many countries are seriously under-developed, yet mental health problems not only have huge consequences for quality of life, but--particularly in low- and middle-income countries--contribute to continued economic burden and reinforce poverty. This paper discusses economic barriers to improving the availability, accessibility, efficiency and equity of mental health care in low- and middle-income countries. Six sets of barriers are identified: an information barrier, resource insufficiency, resource distribution, resource inappropriateness, resource inflexibility and resource timing. Overcoming these barriers will be a major task, although there is no shortage of suggestions for action. The paper discusses broadening the evidence base, improving mental health literacy, tackling stigma, improving financing mechanisms, prioritizing and protecting mental health care budgets, emphasizing mental health promotion through the development of resilience, exploring routes to improved equity, experimenting with new arrangements for purchasing and delivering services, improving coordination between agencies and professionals at both macro- and micro-levels, building alliances between public and private sectors, and training and mobilizing primary care services to improve identification and treatment of mental health problems.     

Percepciones de médicas y médicos de atención primaria de Madrid sobre las medidas de ajuste en el sistema público de salud

ObjectiveTo address the current economic crisis, governments have promoted austerity measures that have affected the taxpayer-funded health system. We report the findings of a study exploring the perceptions of primary care physicians in Madrid (Spain) on measures implemented in the Spanish health system.MethodsWe carried out a qualitative study in two primary health care centres located in two neighbourhoods with unemployment and migrant population rates above the average of those in Madrid. Interviews were conducted with 12 primary health care physicians. Interview data were analysed by using thematic analysis and by adopting some elements of the grounded theory approach.ResultsTwo categories were identified: evaluation of austerity measures and evaluation of decision-making in this process. Respondents believed there was a need to promote measures to improve the taxpayer-funded health system, but expressed their disagreement with the measures implemented. They considered that the measures were not evidence-based and responded to the need to decrease public health care expenditure in the short term. Respondents believed that they had not been properly informed about the measures and that there was adequate professional participation in the prioritization, selection and implementation of measures. They considered physician participation to be essential in the decision-making process because physicians have a more patient-centred view and have first-hand knowledge of areas requiring improvement in the system.ConclusionsIt is essential that public authorities actively involve health care professionals in decision-making processes to ensure the implementation of evidence-based measures with strong professional support, thus maintaining the quality of care.     

A policy of introducing a new contract and funding system of general practice in Estonia

The socialist bloc of post-war Europe was obliged to follow the Soviet example with a hierarchical, centrally controlled health care system based on polyclinics and other facilities providing extensive specialist services at the first level of contact. All the countries of Central and Eastern Europe have now expressed their wish to totally change their health care systems. Changes in these countries include: the introduction of market economy mechanisms in health care, an increased focus on population health needs in guiding health care systems, and the possibility of introducing a more general type of care at primary level. Patient expectations of access, choice and convenience are factors in shaping new models of health care delivery. Appropriate timing is the key determinant of the success of reforms. In Estonia the beginning of the 1990s was the time when several interest groups in society supported changes in the health care system. The first step after regaining independence was the reintroduction of a Bismarck-type insurance system. In the late 1990s the primary care reforms have changed the initial plans and elements of a National Health Service were introduced, especially general practitioners' lists, capitation payment and gate-keeping principles. The family medicine reform in Estonia has two main objectives: introduction of general practice as a specialty into Estonian health care and changing the remuneration system of primary care doctors. The specific tasks are: to provide practising primary care doctors with opportunities for retraining to gain the specialty status of a general practitioner, to create a list system for the population to register with a primary care doctor, to introduce a partial gate-keeping system and to give the status of the independent contractor to primary care doctors.     

COVID‐19: The Time for Collaboration Between Long‐Term Services and Supports,Health Care Systems,and Public Health Is Now

Policy Points

• To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
• Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
• Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.

ContextThe heavy toll of COVID‐19 brings the failings of the long‐term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID‐19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long‐term disinvestment and neglect of state‐ and local‐level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.MethodsWe analyze several impacts of the COVID‐19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states’ fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.FindingsWe propose seven near‐term actions that US policymakers could take: implementing a uniform public reporting of COVID‐19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionsCOVID‐19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.     

The differential impact of the financial crisis on health in Ireland and Greece: a quasi-experimental approach

ObjectivesGreece and Ireland suffered an economic recession of similar magnitude, but whether their health has deteriorated as a result has not yet been well established.Study designBased on five waves (2006–2010) of the European Union Statistics of Income and Living Conditions (EU-SILC) survey a (DID) approach was implemented that compared trends in self-rated health in Greece and Ireland before and after the crisis with trends in a ‘control’ population (Poland) that did not experience a recession and had health trends comparable to both countries before the crisis.MethodsLogistic regression using a (DID) approach.ResultsA simple examination of trends suggests that there was no significant change in health in Greece or Ireland following the onset of the financial crisis. However, DID estimates that incorporated a control population suggest an increase in the prevalence of poor self-rated health in Greece (OR = 1.216; CI = 1.11–1.32). Effects were most pronounced for older individuals and those living in high-density areas, but effects in Greece were overwhelmingly consistent in different population sub-groups. In contrast, DID estimates revealed no effect of the financial crisis on the prevalence of poor self-rated health in Ireland (OR = 0.97; CI = 0.81–1.16).ConclusionsDID estimates suggest that the financial crisis led to higher prevalence of reporting poor health in Greece but not in Ireland. Although the research design does not allow the authors to directly assess the role of specific policies, contextual factors including policy responses may have contributed to the different effect of the crisis on the health of the two countries.     

Comparison of primary health care services between urban and rural settings after the introduction of the first urban health centre in Vyronas,Greece

Background  

Discrepancies in primary health care (PHC) services between urban and rural settings have already been studied in many countries; however, limited information exists regarding countries, such as Greece, where public Health Centres dedicated to primary care have not been in existence in major cities. The objective of this study was to evaluate points of divergence or convergence between an urban and a rural health centre, in an attempt to underline challenges faced by the introduction of urban health centres in Greece.     

Measuring recession severity and its impact on healthcare expenditure

The financial crisis that manifested itself in late 2007 resulted in a Europe-wide economic crisis by 2009. As the economic climate worsened, Governments and households were put under increased strain and more focus was placed on prioritising expenditures. Across European countries and their heterogeneous health care systems, this paper examines the initial responsiveness of health expenditures to the crisis and whether recession severity can be considered a predictor of health expenditure growth. In measuring severity we move away from solely gross domestic product (GDP) as a metric and construct a recession severity index predicated on a number of key macroeconomic indicators. We then regress this index on measures of total, public and private health expenditure to identify potential relationships. Analysis suggests that for 2009, the Baltic States, along with Ireland, Italy and Greece, experienced comparatively severe recessions. We find, overall, an initial counter-cyclical response in health spending (both public and private) across countries. However, our analysis finds evidence of a negative relationship between recession severity and changes in certain health expenditures. As a predictor of health expenditure growth in 2009, the derived index is an improvement over GDP change alone.     

An economic perspective on childhood obesity: recent findings on cost of illness and cost effectiveness of interventions

ObjectiveThis review aims to put an economic perspective on childhood and adolescent obesity by providing an overview on the latest literature on obesity-related costs and the cost effectiveness of interventions to prevent or manage the problem.MethodsThe review is based on a comprehensive PubMed/Medline search performed in October 2011.ResultsFindings on the economic burden of childhood obesity are inconclusive. Considering the different cost components and age groups, most but not all studies found excess health care costs for obese compared with normal-weight peers. The main limitations relate to short study periods and the strong focus on health care costs, neglecting other components of the economic burden of childhood obesity. The results of the economic evaluations of childhood and adolescent obesity programs support the expectation that preventive and management interventions with acceptable cost effectiveness do exist. Some interventions may even be cost saving. However, owing to the differences in various methodologic aspects, it is difficult to compare preventive and treatment approaches in their cost effectiveness or to determine the most cost-effective timing of preventive interventions during infancy and adolescence.ConclusionTo design effective public policies against the obesity epidemic, a better understanding and a more precise assessment of the health care costs and the broader economic burden are necessary but, critically, depend on the collection of additional longitudinal data. The economic evaluation of childhood obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision making.     

Reforms in the Portuguese health care sector: Challenges and proposals

Portugal has one of the most complete public systems worldwide. Since 1979, the Portuguese National Health Service (NHS) was developed based on the integration and complementarity between different levels of care (primary, secondary, continued, and palliative care). However, in 2009, the absence of economic growth and the increased foreign debt led the country to a severe economic slowdown, reducing the public funding and weakening the decentralized model of health care administration. During the austerity period, political attention has focused primarily on reducing health care costs and consolidating the efficiency and sustainability with no structural reform. After the postcrisis period (since 2016), the recovery of the public health system begun. Since then, some proposals have required a reform of the health sector's governance structure based on the promotion of access, quality, and efficiency. This study presents several key issues involved in the current postcrisis reform of the Portuguese NHS response structure to citizens' needs. The article also discusses the implications of this Portuguese experience based on current reforms with impact on the future of citizens' health.     

Health reform in Greece: planning and implementation of a national health system

The health system in Greece has for many years been in a state of continuous crisis. The basic aspects of this crisis involve: a fragmented administrative framework; low level of public expenditure; a significant private sector; inadequate hospitals; skewed manpower; and, a low level of primary care. In 1983, the National Health System (ESY) was established, as an effort to improve the above situation. This article presents the context of the ESY and the situation of the health system prior to and after the establishment of the ESY. The conclusion drawn is that many of the goals of the ESY have not been achieved or only partly achieved, and that a number of the above serious problems still persist.     

Health,economic crisis,and austerity: A comparison of Greece,Finland and Iceland

Reports have attributed a public health tragedy in Greece to the Great Recession and the subsequent application of austerity programs. It is also claimed that the comparison of Greece with Iceland and Finland—where austerity policies were not applied—reveals the harmful effect of austerity on health and that by protecting spending in health and social budgets, governments can offset the harmful effects of economic crises on health. We use data on life expectancy, mortality rates, incidence of infectious diseases, rates of vaccination, self-reported health and other measures to examine the evolution of population health and health services performance in Greece, Finland and Iceland since 1990–2011 or 2012—the most recent years for which data are available. We find that in the three countries most indicators of population health continued improving after the Great Recession started. In terms of population health and performance of the health care system, in the period after 2007 for which data are available, Greece did as good as Iceland and Finland. The evidence does not support the claim that there is a health crisis in Greece. On the basis of the extant evidence, claims of a public health tragedy in Greece seem overly exaggerated.     

The economic burden of excessive sugar consumption in Canada: should the scope of preventive action be broadened?

ObjectiveExcessive sugar consumption is an established risk factor for various chronic diseases (CDs). No earlier study has quantified its economic burden in terms of health care costs for treatment and management of CDs, and costs associated with lost productivity and premature mortality. This information, however, is essential to public health decision-makers when planning and prioritizing interventions. The present study aimed to estimate the economic burden of excessive free sugar consumption in Canada.MethodsFree sugars refer to all monosaccharides and disaccharides added to foods plus sugars naturally present in honey, syrups, and fruit juice. Based on free sugar consumption reported in the 2015 Canadian Community Health Survey–Nutrition and established risk estimates for 16 main CDs, we calculated the avoidable direct health care costs and indirect costs.ResultsIf Canadians were to comply with the free sugar recommendation (consumption below 10% of total energy intake (TEI)), an estimated $2.5 billion (95% CI: 1.5, 3.6) in direct health care and indirect costs could have been avoided in 2019. For the stricter recommendation (consumption below 5% of TEI), this was $5.0 billion (95% CI: 3.1, 6.9).ConclusionExcessive free sugar in our diet has an enormous economic burden that is larger than that of any food group and 3 to 6 times that of sugar-sweetened beverages (SSBs). Public health interventions to reduce sugar consumption should therefore consider going beyond taxation of SSBs to target a broader set of products, in order to more effectively reduce the public health and economic burden of CDs.     

Legacies of primary health care in an age of health sector reform: Vietnam's commune clinics in transition

Developing countries that were early, enthusiastic adopters of primary health care often developed an extensive - but eventually dilapidated and under utilized - network of public clinics at the grassroots. As paradigms and investment patterns of health sector reform have shifted, the question of what role these public clinics can meaningfully play, and how best to revitalize them, has become important in a number of countries. This paper evaluates the strategy taken by, and outcomes of, a major attempt in Vietnam to revitalize the grassroots infrastructure of primary health care against the backdrop of the country's economic transition. The project's substantial supply-side investments in infrastructure led to marginal increases in utilization and the quality of preventive health services provided by the centers. But because the project failed to take adequate stock of broader, public sector-wide trends and reforms over the transition, the investments had little impact on the incentives, accountability patterns and capacities of clinic staff and the local authorities. Such institutional factors are heavily implicated, in Vietnam as elsewhere, in the substantial and often increasing disparities in service access and quality that continue to afflict transitional health sectors.     

Economic Crisis,Restrictive Policies,and the Population’s Health and Health Care: The Greek Case

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population’s well-being.Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health’s total expenditures fell by 23.7% between 2009 and 2011.In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece’s population health to further risks.THE CURRENT GLOBAL ECOnomic crisis, manifested in 2007 with the collapse of the subprime mortgage market and the bankruptcy of several financial institutions in the United States, affected the Greek economy—viewed by some as the Eurozone’s weakened economic link—with unprecedented severity.Many commentators in the past and present have debated whether the ongoing international economic turmoil, the worst since the Great Depression, threatens the health of the population both in the United States and throughout the developed and less-developed world.1–5 The World Health Organization has added one more concern to this dialogue: whether spending restrictions in times of economic downturn (especially in countries that have required emergency assistance from the International Monetary Fund [IMF]) could impose further risks on the population’s health.6,7We present empirical evidence from Greece’s experience that clarifies the impact of restrictive policies during economic crisis and illustrates the implications for public health in other countries.     

Combined social and private health insurance versus catastrophic out of pocket payments for private hospital care in Greece

The high level of out of pocket (OOP) payments constitutes a major concern for Greece and several other European and OECD countries as a result of the significant down turning of their public health finances due to the 2008 financial crisis. The basic objective of this study is to provide empirical evidence on the effect of combining social health insurance (SHI) and private health insurance (PHI) on OOP payments. Further, this study examines the catastrophic impact of OOP payments on insured’s welfare using the incidence and intensity methodological approach of measuring catastrophic health care expenditures. Conducting a cross-sectional survey in Greece in 2013, we find that the combination of SHI–PHI has a strong negative influence on insured OOP payments for inpatient health care in private hospitals. Furthermore, our results indicate that SHI coverage is not sufficient by itself to manage with this issue. Moreover, we find that poor people present a greater tendency to incur catastrophic OOP expenditures for hospital health care in private providers. Drawing evidence from Greece, a country with huge fiscal problems that has suffered the consequences of the economic crisis more than any other, could be a starting point for policymakers to consider the perspective of SHI–PHI co-operation against OOP payments more seriously.     

福建省基层医疗卫生综合评价

目的：了解福建省基层医疗卫生综合情况。方法：利用福建省医改中期评估调查表中＂医疗卫生综合情况调查表＂的基础资料和该表涉及的7项核心指标,运用RSR法、功效系数法和Z分评价法,对全省的基层医疗卫生综合情况进行分析。结果：通过九个设区市排名,县级市、市辖区和县级间的排名及不同经济发展水平县（市）的排名,发现区域医疗卫生综合情况与经济发展水平相关,且在机构、人力、公共卫生服务等方面存在差异。结论与建议：福建省主要存在基层医疗卫生机构区域发展不平衡、公共卫生服务发展不均等和基层医疗卫生人才队伍整体水平较低等问题。建议自主发展和财政投入相结合,促进基层医疗卫生机构区域平衡发展;专项经费保障和标准化体系建设相结合,促进公共卫生服务均等化发展;人事和经费保障制度相结合,加强卫生人才队伍建设。     

Gestión de los recursos humanos y estrategias de vacunación en atención primaria en Europa en la pandemia COVID-19

This article describes the management of human resource and the vaccination strategies in primary care in twelve European countries in relation to the COVID-19 pandemic. All the countries have found solutions to increase their workforce in primary care. Other healthcare professionals were incorporated to support family doctors assuming their tasks, under their supervision and coordination. The European Commission had a crucial role in the production, purchase and distribution of the vaccines. The engagement of primary care in the vaccination campaign has had an unequal participation in the different countries, although the greatest burden has been managed from the government's public health departments.