Crisis, inequalities and policies: proposed intinerary

7 Sep

Unfortunately, inequalities in health are still an issue today including in our country. The crisis of recent years has once again put the spotlight on this subject.

 This is why we propose an itinerary taking us through the different texts which we have published on the subject in this blog and, in particular, we invite you to read the original texts which are mentioned here in more depth, a large proportion of which have been elaborated at the AQuAS.

In September of last year, Luis Rajmil reflected on social inequalities in child health and the economic crisis in this post placing the concepts of equality, equity and reality  on the agenda for discussion.

 “At present, there is enough accumulated information that shows that life’s course and the conditions of prenatal life as well as life during the first few years are very influential factors in the health and social participation of an adult to come.”

At a later date, the Observatory of the effects of the crisis on the health of the population published its third report but prior to that, a post was published with a collection of individual thoughts and reflections on this subject by Xavier Trabado, Angelina González and Andreu Segura focussing on, respectively, the effects of the crisis on the mental health of people, the coordination of different mechanisms in primary and specialised care, the urgency for community health actions and the need to engage in intersectoral actions.

 “It is urgent to put community health processes into action; processes in which the community is the protagonist, which constitute the shift from treating an illness to a bio-psycho-social approach which gives an impulse to intersectoral work in a network with local agents, with who there is the shared aim of improving the community’s well-being. Based on the needs detected and prioritised in a participatory way and with the local assets identified, these processes activate interventions based on evidence which are assessed”

In this other post, Cristina Colls presented an interesting case of the application of scientific evidence to political action which occurred with the revision of the socio-economic dimension of the formula for allocating resources to primary care.

 “Social inequality leads to an unbalanced distribution of the population in a territory, concentrating the most serious social problems in certain municipalities or neighbourhoods having higher needs for social and health services than other territories. In this context, more needs to be done where needs are greater if the aim is to guarantee equality in the allocation of resources”

Finally, the most recent post was written by Anna García-Altés and Guillem López-Casanovas. It is a text that provides food for thought based on the latest report published from the Observatory of the Health System of Catalonia on the effects of the crisis on the health of the population.

 “Understanding the mechanisms  by which social inequalities have an impact on the health of the population, so as to know how best to counter or neutralise them, in any place and at any time, is an issue that must still be addressed by our social policies”

We hope that you this very short itinerary through these texts, initiatives and analyses that aim to be useful in tackling inequalities has been of interest.

Post written by Marta Millaret (@MartaMillaret)

An indicator for a more fairly funded primary care

7 Apr
Cristina Colls

The Catalan government has recently expressed its willingness to increase the importance ascribed to the socio-economic level of regions when calculating the budget for each primary care team.

This fact invites us to ask ourselves a question: why is it important to bear in mind the economic inequality in the funding of primary care teams?

The influence of socio-economic inequalities on the health of the population is a fact that has been widely studied since the 60s of last century and of which there is evidence both in the international and national context.

We know that people with a lower socio-economic status have more probability of dying before the age of 65 and that they show more physical and mental health problems during their lives. It is logical, therefore, to conclude that they need to make a more intensive use of health resources.

We also know that social inequality is a recipe for an unbalanced distribution of the population in a territory leading to an accumulation of the most serious social problems in specific municipalities or neighbourhoods that have a greater need for social and healthcare than other regions.

It is in this context that more needs to be done where there is greater necessity if equity in the allocation of resources is to be guaranteed. But where should more resources be provided?

The professionals of primary care teams are those closest to the citizen and therefore, have a comprehensive view of the health needs of the population in their territory.

In addition, the primary environment is the reference in prevention activities, in controlling chronic diseases and from which a large part of community activity is coordinated. For all these reasons, the provision for primary care teams must bear in mind the socio-economic conditions of the population they serve.

How can we find out what the socio-economic situation is of territories in which a primary care primary care team works? Many variables exist which give us indirect information (income, occupation, education, housing conditions, among others) but if we are looking for only one classification we need a unique index that synthesises all these aspects; it is what we call a deprivation index.

Deprivation indexes have been widely used as a tool in social policies because they allow an objective prioritisation to be established in small regions, ranging from a low to high socio-economic status. The concept of “deprivation” refers to unmet needs as a result of a lack of resources, not exclusively economic.

All indexes of deprivation are built by adding up the results of different socio-economic status indicators. The weight given to each indicator could be theoretical, that is, based on what a particular indicator is thought to contribute to the phenomenon of deprivation; or otherwise, the result of a multivariate statistical model.

To be able to classify the basic areas of health (reference territories of a primary care team) according to their socio-economic level, AQuAS has built an index called a composite socio-economic status indicator which synthesises seven indicators: population exempt from drug co-payment, population with incomes lower than 18,000€, population with incomes higher than 100,000€, population with manual jobs, population with insufficient educational attainment, premature deaths or potentially avoidable hospitalisations.

The statistical methodology used for calculating this indicator has been that of principal component analysis. The application of this methodology has allowed us to obtain a socio-economic status map of Catalonia.

The application of the composite socio-economic status indicator has been done within the framework of the redefinition of the model of allocation of resources for primary care and has enabled the identification of those primary care teams which will increase their budgets in coming years.

This new model of allocating resources for primary care is an experience in applying scientific evidence to political action.

Post written by Cristina Colls.

Public policy in times of crisis

28 Jan

SalutPoblacióWhat has happened in periods of economic crisis has also occurred at other moments in time and in other contexts. It is also a well-known fact that this can lead to an increase in mortality rates among the population (both due to general causes, as well as for certain specific causes, such as suicide), an increase in mental health problems and a worsening of lifestyles. We also know that inequalities in healthcare can increase, particularly as the crisis affects the most vulnerable members of society first.

The second report from the Observatory on the effects of the crisis on public health, publicly presented just before the Christmas holidays, closely monitors the principal socio-economic and health indicators at a territorial level (by regions) and analyses their evolution. It also analyses the relationship between socioeconomic and health indicators and provides information to define, or redefine, strategies aimed at tackling the effects of the crisis based on the needs identified through the report.

In this period of crisis in Catalonia, long-term unemployment, above all, has increased, and production (the gross value added in the economy) has declined. Household income has fallen, the percentage of people living below the poverty line has increased, especially those under 16 years of age, and the percentage of families receiving assistance from the social protection system has increased.

The fall in public revenue triggered a decrease in the budget, including the budget of the Department of Health, which was especially significant between 2011 and 2013. The health sector was forced to adjust, doing the same work but with less resources, improving efficiency while making every effort to do so without hindering the quantity and quality of healthcare service provision. However, in the period 2007-2013, life expectancy increased by 1.8 years (1.5 in women and 2.6 in men), as has been the case for life expectancy in good health.

Nevertheless, the impact of the economic situation on people’s health is evident: the unemployed have worse self-perceived health, especially those who have been out of work for over a year and present a higher risk prevalence of poor mental health. Similarly, tobacco sales, which is on the decline population-wide, increased among the unemployed, especially among men. Excessive alcohol consumption levels are also higher among the unemployed.

Focusing the analysis on the most vulnerable social groups, the report compares the population group aged 15 to 64 years, in other words, those who are exempt from the pharmacy copayment rates (basically unemployed people who have lost the right to unemployment benefits, receiving social insertion benefits, or have non-contributory pensions), with those who are subject to copayment. In Catalonia, in 2014 there were 187,775 people aged between 15 and 64, exempt from copayment rates (2.3% of the population). Those who were exempt are statistically twice as likely to consume psychoactive drugs that people subject to co-payment and have 1.5 times greater likelihood of being admitted to hospital. This group made 1.4 times the number of visits to primary care, and were treated in mental health centres 3.5 times more than the other group.

There is no question that public, social and economic policy has an impact on a population’s level of health and that they modulate the influence of socioeconomic, gender and immigration factors on health inequalities. Social protection policies seem to be effective in cushioning the influence of macroeconomic fluctuations on mortality rates. Policies aimed at equality contribute to improving health inequalities. The consequences of the crisis in Russia in the early 90s had little in comparison with those suffered by Finland during the same period. The main reason for this being the policies implemented by both governments.

Given the complexity and the multiple impacts produced by economic crises, the public policy-centred method to mitigate its effects must be approached from different sectors. Tools like the Interdepartmental Public Health Plan (PINSAP), as per the Catalan acronym, are key to ensuring this cross-sectoral approach, targeting factors which impact health to reduce or eliminate health inequalities. Another fundamental step is to maintain social protection (unemployment benefits, retirement benefits, family assistance, etc.) to mitigate the decline in family income and its consequences. However, this must go hand-in-hand with policy aimed at generating employment and promoting the rapid reintegration into the workplace. Education policy is the other mainstay, given the relationship between education, income and health, and the fact that it acts as a “social ladder” between generations. Policies aimed at the most vulnerable groups, such as lower income families and children, also deserve special attention.

Finally, it is essential that the implementation of these public policies are evaluated in the medium and long-term in order to continually validate their utility and impact, and to enable policymakers to adapt these programs to meet an ever-changing environment.

Post written by Veva Barba, Dolores Ruiz-Muñoz and Anna García-Altés (@annagaal),