Auszug aus einer Studie der medizinischen Fachzeitschrift "The Lancet" zu den Auswirkungen der Finanzkrise auf den Gesundheitszustand der Europäer, 27.3.2013 (engl. Originalfassung)
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.
This is the seventh in a Series of seven papers about health in Europe.
The economic crisis that has engulfed Europe since 2008 has raised concerns about the health of ordinary people. Despite more than 100 years of research about the effects of economic turbulence on health, the relation between the two is not yet fully understood. We briefly review the origins of the financial crisis and examine what European countries have done in terms of health policy to respond, with a focus on changes to health systems. In the absence of comprehensive data for health during this crisis, we postulate what might be expected to occur on the basis of previous experiences, and review what has actually happened (as far as can be ascertained). We conclude with recommendations for the development of epidemiology of resilience1—ie, understanding how people, households, communities, and entire societies cope with difficult economic circumstances and shocks, and how public health policy can improve health outcomes in this context.
The public health effects of the economic crisis are already visible, particularly in the countries most affected by recession; however, Iceland has so far avoided negative health effects
Strong social protection mechanisms (both formal and informal) can mitigate some negative effects of recession on health, such as increasing suicides
Austerity measures can exacerbate the short-term public health effect of economic crises—eg, through cost-cutting or increased cost-sharing in health care, which reduce access and shift the financial burden to households
Policy responses to a similar set of economic shocks varied between countries and have led to differing health outcomes, creating potential for future research about how economic changes affect health, policy responses that can mitigate risks, and why some societies are more resilient than others
Economic crises and their countermeasures have pronounced and unintended effects on public health, yet public health experts have remained largely silent during this crisis
Effects on health systems
Much work has been done to establish how health outcomes might be affected by economic crises, but little previous research has assessed what might happen to health systems.12 Thus, theory-based testable hypotheses should be developed for comparison with empirical data. When confronted by a fiscal crisis, policy makers might face pressure to maintain, decrease, or increase public expenditure on health (and could also reallocate funds within the health system).13 Changes to public expenditure on health can implicate several policy instruments (or combinations thereof) aimed at affecting the provision of publicly financed care.
In a study13 of responses of health systems to the global financial crisis (as of March or April, 2011), a questionnaire was sent to health policy experts (most of whom were based in universities, WHO country offices, and other non-governmental organisations) in all WHO member states in the European region to gather information about policy responses—ie, those introduced directly, partially, or possibly in response to the crisis. These data were analysed and verified, and showed that countries in Europe had responded to the financial crisis in various ways. Within the EU, some countries (eg, the Czech Republic, Estonia, Italy, Lithuania, Slovakia) were better prepared than others because of fiscal measures adopted before the crisis. These countries were able to draw on countercyclical policies, such as holding of financial reserves earmarked for health or linking of government contributions for economically inactive groups to earnings in previous years.14 In other countries, health budgets were protected (Belgium, Denmark) or frozen (the UK, although actual expenditure did decrease, contrary to government assertions), whereas other sectors experienced cuts.13
Some countries used the crisis to cut costs, particularly in the hospital and pharmaceutical sectors. For example, the governments of Austria, Latvia, Poland, and Slovenia strengthened their position in price negotiations with pharmaceutical companies, and those of Denmark, Greece, Latvia, Portugal, and Slovenia sped up the restructuring of their hospital sectors.13 Some countries reduced (eg, Cyprus, Greece, Ireland, Lithuania, Portugal, Romania) or froze (eg, England, Slovenia) the salaries of health professionals, or reduced the rate of salary increase (eg, Denmark).13 These policies could exacerbate wage imbalances between (depending on the relative change in wages in net immigration countries compared with that in net emigration countries) or within (if health-sector wages fall at a different rate from private-sector wages) countries, which could increase health-worker brain drain.
Initially no major changes were made to the scope (ie, statutory benefits package and services provided to the population that are covered by the state) or the breadth (ie, the population covered by the state) of health coverage, although some reductions were made (usually minor). Thus, in a few countries, some services were removed from the benefits package (eg, in-vitro fertilisation and physiotherapy in the Netherlands).13 In some countries, benefits for low-income groups were expanded (eg, Moldova).13 However, some countries—specifically, the Czech Republic, Denmark, Estonia, Finland, France, Greece, Ireland, Italy, Latvia, the Netherlands, Portugal, Romania, and Slovenia—decreased the extent of coverage by instituting or increasing user charges for some health services in response to the crisis. In most countries, the scarcity of data and potential lagged effects mean that assessment of the effects of these reforms on access to care and health outcomes is not yet possible. However, evidence from the wider medical literature suggests probable consequences. Rises in user charges are a particular cause of concern, because they increase the financial burden on households15 and probably reduce the use of high-value and low-value care equally, especially by people with low incomes and high users of health care, even when user charges are low.16, 17 Introduction or increases of user charges in primary or ambulatory specialist care might worsen health outcomes and lead to increased use of free but resource-intensive services—eg emergency care. Thus, cost savings and enhanced efficiency are scarce.
Some countries have increased taxes on alcohol or tobacco, or both. A combination of motives—such as raising of revenue and promotion of health—is often behind such measures. For example, in 2012, alcohol taxes increased in both Finland and the UK, where alcohol-related mortality has risen in the 2000s.18, 19 Cigarettes and alcohol have price elasticities of less than one; tax rises both generate additional revenue and decrease consumption and thus offer dual benefits for governments facing falling revenues and increasing alcohol-related problems because of the financial crisis.20 Some countries (eg, Finland, France, Hungary) have introduced taxes on soft drinks, but these taxes are small, and, in France, the tax is explicitly a revenue-raising rather than health-promoting measure (it applies equally to drinks with artificial sweeteners).
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14 WHO Regional Office for Europe. Interim report on implementation of the Tallin Charter. Copenhagen: World Health Organization, 2011.
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19 Davies SC. On the state of the public's health 2011. London: Department of Health, 2012.