In recent years, child poverty has increased in Catalonia as a result of the economic crisis. According to the 2016 figures from the Idescat, the latest figures available, and from 2009, children are the group most at risk of poverty, more than the adult population and also more than the 65-year-old or older population group.
“Child health and poverty. What can we learn from the data?” was the title of the conference held within the framework of the Celebration of the 2018 World Health Day.
Data from the latest report related to children and the effects of the crisis on the health of the population were highlighted at the conference, published by the Observatory of the Health System of Catalonia: children with a lower socio-economic level present up to 5 times more morbidity, consume more pharmaceutical drugs (three times more psychotropic drugs) than the remainder of the child population, visit mental health centres more frequently (5.9% of girls and 11.4% of boys as opposed to 1.3% and 2.2% in girls and boys with a higher socio-economic level) and are admitted more to hospitals (45 girls and 58 boys for every 1000 as opposed to 13 and 26, respectively) especially for psychiatric reasons.
A child’s health largely depends on the economy of their parents and those that belong to families with a lower socio-economic level have more health problems, a fact that can have disastrous consequences in other areas such as education and social life and which condition their future. This fact is exacerbated in the case of children with special needs or chronic diseases where their health suffers even more from the effects of poverty because in some cases their care requires specific products which families cannot afford.
This is one of the problems that we are facing right now. There is growing scientific evidence, both in biology and in social sciences, of the importance of the early years in life (including exposure in the womb) in the development of the capacities that stimulate personal well-being throughout the life cycle. Childhood is also a structural transmitter of inequalities, both from a health and socio-economic point of view. If nothing is done, boys and girls who belong to families with few resources run the risk of growing up into adults with worse health and a lower educational and socio-economic level than others.
What can we do? We can of course strengthen the social welfare state, with structural and institutional reforms which are more than ever necessary. Educational policy is fundamental, especially by reinforcing primary education, guaranteeing equal opportunities and putting the spotlight on those children in a disadvantaged situation. Once they are adult, active labour policies are also needed. And from health policies, despite their eminently palliative nature, primary and community care is particularly important as is guaranteeing care to all children.
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.
The real novelty about this year’s report is that it is the first time that the socioeconomic inequalities in the state of health and the use of public health services have been analysed according to the socioeconomic level of the population using information of individuals of the entire population of Catalonia. To this end, a classification has been designed which takes both the employment situation and income of the person into consideration, based on the information of the social security benefits provided by the Social Security system and the information of the level of co-payment of medicines of people.
What reflections can we make?
The economic crisis of recent years has had a considerable impact on the social determinants of health, limiting the available income of citizens and affecting their conditions of life, work and housing. However, understanding the mechanisms of how social inequalities impact on the health of the population, so as to know how to combat and neutralise them in the most effective way, in every place and moment in time, is still an unresolved issue of our social policies.
Merely acknowledging the effects of the crisis on inequalities in income on the one hand, and on health on the other, gives no clear clues as to how elements arise and interact. Who could possibly think that the main cause of inequalities in health is a consequence of the effects of cuts in health expenditure in order to balance the drop in tax revenue? Or that the increase inequality would be eliminated by simply restoring financial levels to those of before the crisis?
It is true that some European health systems resisted better than others to the crisis and among the factors that could explain this better response is, according to some authors, public policies in health expenditure. Nevertheless, are we talking about the resilience in levels of expenditure or of systems that have been able to respond better to the crisis by refocusing available resources in each case, having accepted that a higher expenditure in health is not always better and that now, more than ever, it has been necessary to prioritise?
Are we then saying that it is inertia, or the incapacity of adapting to changing economic circumstances which is the decisive element? Is it perhaps not more likely that spending “a fixed amount” when facing a reduction in healthcare resources not only worsens the health of the population but makes it less equal? Are factors of demand decisive if higher unemployment rates, lower expectations of consumption, unpaid commitments made senselessly in the past and anxiety and the loss of self-esteem the important vectors?
To prevent more inequality, and not only a greater loss of health, we need to take on board some hypotheses about the behaviour of demand, resulting from of the elasticities between price and income to be able to identify an increase in inequalities in health as a result of the economic crisis.
This might not occur, however, if the system lost universality, were more selective and better prioritised the new and greater relative needs of certain social groups. Or if in the case where elasticity of income existed, groups with medium/high incomes abandoned the complementary insurances which would in turn affect their health.
We can see that these cannot be unusual assumptions for some, because they would follow the same logic as that of many analysts that link health results to healthcare use (but not to appropriately standardised needs), attributing higher levels of health to the users of the services that combine access to both public and private healthcare services.
Other forms of social protection, such as those that would ensure adequate levels of public health expenditure, avoiding loopholes in health coverage, both legal and of cost of opportunity of access to free services, should be considered in a much more specific way. This can affect freelance and self-employed workers, illegal immigrants and regular employees who avoid absenteeism for fear of losing their jobs, and also those citizens that have lower levels of direct payment to cover the costs of alternative private healthcare services
In fact, in general, a change in inequality of income due to an additional increase in unemployment (in the case of Spain) is not the same reaction mechanism as that of an increase in the incomes of the richest with respect to the poorest (as in the case of Nordic countries), or in contexts in which the loss of employment reduces stress and facilitates “jogging” as some American literature points out.
Admittedly, all this must be put within the context of each situation, given the lifestyles, and not assessing income but wealth (the composition of assets here is important considering the huge drop in the prices of assets, with greater effects in large estates), be it by individual, salary earner or head of family.
What is more, even if the mechanisms that interact in health inequalities of socioeconomic origin can be identified, caution obliges one to limit conclusion to a specific country, time and place, with doubts about whether what is known of the past can inform the corrections needed in the future with guarantees.
Reviewing the literature on the impact of the economic crises on the health of populations, prior to the 2008 crisis, and considering all the previous clarifications and nuances, it all points towards an increase in the death rate as a result of all the causes associated with unemployment, of an increase in suicides, albeit with certain nuances, and of an increase in mental health problems. The people most affected by the effects of the crisis are those belonging to the most vulnerable groups (in particular, people of long term unemployment) and children.
In Spain, some global indicators such as life expectancy or the general death rate do not seem to have been affected by the recent economic crisis although there is evidence of the effects of the crisis on health determinants, changes in some lifestyles and in some cases of access to healthcare services.
Beyond the limitations that the data impose, ceteris paribus, in the future it will be very important to monitor the different waves of analysis that the Observatory might offer, so as to understand what vectors provoke variations in the inequalities observed, and inasmuch as these are relevant in the political approach (as the pioneering work of John Roemer reminds us, not all inequalities are in fact precisely that), and how to approach them based on the understanding of how their fundamental mechanisms work.
This emphasises the importance of how an analysis should generate more efforts from scholars and less of a supposed preoccupation of some groups who make political use of the subject of socioeconomic inequalities and health to set their own objectives which do not always correspond to general interests.
Post written by Anna García-Altés (@annagaal) and Guillem López Casasnovas.
– Your post code is more important than your genetic code when it comes to children’s health (Anonymous).
– It takes the whole tribe to raise the children (African proverb).
Currently, there is a wealth of accumulated information to show that life experience and living conditions during prenatal and early life are extremely influential factors when it comes to the health and social participation of the future adult. The World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) has proposed eliminating the health gap within a generation noting that inequalities during the early growth and development of children are one of the main contributing factors in creating and perpetuating inequalities in health in adulthood. According to the CSDH, the academic level of a family, education in the school-going years and academic performance all play a crucial role, in addition to exposure to a situation of family economic vulnerability.
The UNICEF Innocenti Report Card 13 shows that among developed countries, Spain rates very poorly in relation to the state’s capacity to reduce the socioeconomic inequality gap since the beginning of the Great Recession.
Children are the most vulnerable population risk group and the worst affected by the current economic crisis: in Catalonia it is estimated that one in three children live at risk of poverty, according to data from the Statistical Institute of Catalonia (IEC) for 2015. The IEC data reflects the serious impact of unemployment, household employment insecurity and the impact of the historical public investment deficit in child protection policies (or lack thereof) on the lives of children. In Spain, the number of families who turn to non-governmental organizations in search for assistance to cover their basic needs has tripled since 2007.
The short-term effects of the economic crisis on children’s health depends on the degree of exposure to material deprivation, family living conditions and access to basic minimum services as well as the family’s economic capacity to meet the children’s needs. As a result of the crisis, the already existing social gradients in health have increased. Thus, the inequality in life expectancy at birth of a child between the more and less prosperous districts of Barcelona has grown to 8 years’ difference (thereby reinforcing the claim that post code is more important in children’s health that genetic code). The evidence shows generally poorer health and worse mental health in children of at-risk families who require assistance to maintain their homes or have been evicted, according to a study carried out by the SOPHIE project and Caritas of people at-risk of eviction or who have been evicted. Evidence also shows an increase in obesity and overweight children in the general population of Catalonia but this increase cannot be attributed solely to the economic crisis as it had been detected before the onset of the recession. However, obesity is linked to important social gradients and these have increased in recent years. The perception of quality of life related to health has deteriorated for children of families with primary level studies in comparison with those with third-level education between 2006 and 2012. Studies have also detected an impact on perinatal health with decreased fertility and increased maternity age, above all for the first child, an increase in abortions among women aged 15-24, and an increase in low birthweight among young women in Spain.
The policies implemented to deal with the situation however have not resolved the problem, but instead they are helping to increase the gap. Investment in public policies targeting children in Spain is the lowest in the European Union. Local scientific societies such as the Catalan Paediatric Society (SCP), state bodies such as Spanish Society of Public Health and Administration (SESPAS) and international organisations like the International Society of Social Paediatrics (ISSOP), NGOs such as UNICEF and other organizations are calling on governments to ensure that vulnerable children are not subject to further disadvantages due to cutback policies. These bodies propose the following measures: suspend evictions of families with children / ensure basic measures against energy poverty and housing for all families; promote quality employment for young people and parents; maintain and finance school canteens throughout the year; ensure a guaranteed minimum income for families with fewer resources; and reduce regional disparities prioritizing disadvantaged districts and municipalities.
Early enrolment has shown a positive impact on cognitive development, academic level and future possibilities for social insertion of the general population and which has a particularly positive effect on the members of society who are not as well educated and have fewer resources. The proposals regarding education are summarized in ensuring children’s access to education; universal access to educational material and activities and early detection and intervention in cases of children with disadvantages.
As far as health policy is concerned, the objectives include fostering healthy nutrition and eating habits, promoting breastfeeding, extending programs and policies that have shown greater effectiveness, ensuring the rights of children with and without disabilities and complying with The United Nations Convention on the Rights of the Child, and guaranteeing universal access to effective health services for the entire population and the repeal of Royal Decree Law 16/2012 regarding exclusion from healthcare.
It is essential that all professionals responsible for the care of children and families become aware of and take an active role in reducing social inequalities in health and education if the goal is to ensure future generations of adults with equal opportunities to healthcare.
What 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),