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.

Saving lives, reducing vehicles in cities

23 Jun
Cristina Ribas

Air pollution is a major public health concern, perhaps one of the most serious problems facing large developed cities. The evidence of the negative effects on health are growing day by day, with contributions from internationally renowned scientific groups such as the Centre for Research in Environmental Epidemiology (CREAL) which estimates that there are 3,500 premature deaths each year in the Barcelona area resulting from air pollution. Pollution not only affects patients suffering from respiratory diseases, but is also a cause of cancer and cardiovascular conditions when nitrogen oxides and smaller particles are capable of passing through the bronchi and enter the bloodstream. Recently, CREAL also discovered cognitive development impairment in children in schools in close proximity to highly contaminated streets.

Many European cities have done their homework focusing on one of the major causes of pollution: vehicle traffic, above all diesel engines which are the primary agent responsible for nitrogen oxide emissions reaching unacceptable levels, as revealed by the Volkswagen scandal. One of the most effective initiatives in this area is the delimitation of Low Emissions Zone (LEZ) in city centres, which restricts the access of the most pollutant vehicles to entering these areas in conjunction with improvements in public transport and promotion of sustainable mobility. These policies enjoy greater scientific consensus and have been implemented by more than 200 cities in 12 European countries, including Berlin and London.

None of the cities which have implemented measures restricting traffic wish to backtrack on these improvements, much in the same way as what we have experienced with the ban on smoking in public places. In fact, the story has a lot in common with the smoking ban if we consider for example that in Barcelona, only 15% of inner-city displacements use private vehicles. This means that most of the city’s inhabitants are passive smokers subject to emissions produced by others. Experts in mobility explain that traffic tends to adapt its behaviour. The greater the limitations in circulation, the less traffic there is and, inversely, when circulation is made easier and more channels are made available, the heavier traffic becomes to the point of collapsing entirely. Another advantage of reducing cars in cities, apart from the positive effects on health, is the greater occupation of public space by pedestrians and cyclists with the added benefit of an improvement in quality of life.

For all these reasons, courageous decisions are needed from governments, as they were when it came to the application of the smoking ban legislation. In order to promote these initiatives and help raising awareness about the problem of pollution, last year the Platform for Air Quality in Catalonia was set up, which includes neighbourhood associations, environmentalists, public transport activists and advocates for the use of bicycles, as well as citizen groups and professionals from the areas of health, the environment and mobility. One of these groups is the Catalan Association for Science Communication, which understands that scientific journalism should serve the community if it is to be responsible and play a leading role in a society where everyone is potentially a means of communication.

It is also vital for the authorities to understand that they must collaborate with the public and experts in disseminating and using information. Applications to measure contamination levels should not be limited only to warning us when European legal standards have been exceeded, but must in addition take into account the limits recommended by the WHO, the only secure parameters in terms of safeguarding health. This, together with the different data and models utilised, result in the fact that the services and applications which provide information on pollution in the Catalan region do not agree 100% in their forecasts:, Caliope, Plumbe, Real Time Air Quality Index… The most serious feature is that despite all these resources, people do not quite understand when, where and why it is dangerous to walk, play sports or simply breathe.

Thus, the platform calls for free and open access to all the data: pollution measurements and positioning, traffic, weather, models… so that one can create one’s own applications, extract the know-how and create services that the public feel are useful. With the data available, journalists can also provide reports of public interest such as this interactive map of the UK drawn up by The Guardian that shows the boroughs with the most deaths from particulate air pollution.


Post written by Cristina Ribas (@cristinaribas), Catalan Association for Science Communication and Platform for Air Quality.