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The Lasting Effects of a “Relentless Crisis”: The Great Recession and Health Inequalities in Spain

Os efeitos permanentes de uma “crise infindável”: a Grande Recessão e as desigualdades na saúde em Espanha
Juan Antonio Córdoba-Doña e Antonio Escolar-Pujolar

Resumos

A Espanha é geralmente vista como um dos países europeus mais afetados pela Grande Recessão e as subsequentes políticas restritivas. Neste artigo, tentamos, em primeiro lugar, compreender os impactos da crise no Estado-Providência, que levaram a desigualdades na área da saúde, centrando-nos sobretudo na história do Sistema de Saúde Nacional espanhol desde meados do século passado. Também analisamos as reações dos cidadãos às medidas de austeridade no sistema de saúde, salientando o papel do movimento das “marés brancas”. Num segundo momento, apresentamos uma análise seletiva dos principais dados sobre os efeitos da Grande Recessão no país, centrando-nos em especial nos resultados sobre a saúde mental e nas desigualdades na saúde e na utilização do sistema de saúde. Concluímos que as principais políticas têm de ser direcionadas para “as causas das causas” da desigualdade na saúde, o que é um desafio complicado na fase atual do capitalismo.

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Notas da redacção

Edited by Ricardo Cabrita

Received on 08.01.2019
Accepted for publication on 23.06.2019

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1Evidence on how the previous and current crises have affected the well-being of the population is still fragmented and uncertain, particularly with respect to health inequalities. Alongside this, in recent years the focus has been more on studying the impacts of post-crisis cutbacks on health, especially in Europe (Toffolutti and Suhrcke, 2019). Several mechanisms have been suggested to explain the effects of the global financial crisis and associated structural reforms on health outcomes. Kentikelenis proposed three pathways by which austerity measures could affect health: (i) policies directly target health systems; (ii) policies have an indirect effect on health systems; (iii) policies affect the social determinants of health (Kentikelenis, 2017). More specifically, it has been claimed that the most obvious effects of the austerity-driven welfare reforms (that have taken place) since 2008 have been channeled through social welfare cuts and labor market policies (Ruckert and Labonté, 2017).

2Spain is generally regarded as one of the European countries most affected by the Great Recession that followed the global financial crisis of 2008 (Ministerio de Sanidad, Consumo y Bienestar Social, 2018a). According to the foregoing considerations, it is worth highlighting the important role played not only by the cyclical change in unemployment rates but also by the high structural unemployment in Spain that has persisted for several decades. These aspects have been thoroughly evaluated in multiple studies in recent literature. However, much less attention has been paid to date to the role of the policies implemented that affect the performance of the health system. Besides this, any attempt to gain a better understanding of the consequences of the crisis and subsequent restrictive policies for the welfare state, especially the health sector, should include the history of the Spanish National Health System (SNHS) from the middle of the last century onwards. To date, analyses of the impacts of the Great Recession on health have been mostly based on very recent historical frameworks, with scant evaluation of the relations between political power and health policies. A description, even in a very summarized form, of the historical roots of our national health system, makes the changes that have taken place during our short democratic history more understandable as do those that have developed subsequently during the Great Recession, under the auspices of the adjustment policies imposed by the European Union (EU) together with Spanish governments (budgetary cuts, personnel reductions and privatizations, among others).

3This study aims to contribute to this area of research by evaluating the impacts of the economic recession starting in 2008 on health and health inequalities, with emphasis on the historical process and previous economic and political context, and does not limit its analysis to the consequences of the steep fall in GDP and the sharp increase in unemployment and precariousness rates.

4We first present a historical overview, ranging from the period of the Franco dictatorship, through the democratic era, to the period of the Great Recession, where we focus especially on citizens’ responses to austerity measures within the health system – highlighting the “white tides” movement – which, according to our hypothesis, may have been a buffer against the negative consequences of austerity policies. In the second part of this study, we provide a selective review of the main scientific findings on the effects of the Great Recession in Spain, covering most of the original papers published in international health-related journals in English and Spanish up to November 2018, as well as selected documents drawn from the reference lists of relevant articles. Our review focuses particularly on the effects of the Great Recession on mental health outcomes and on inequalities in health and healthcare utilization.

Part 1. Historical Background

The Legacy of Francoism (1939‑1975)

5From the end of the Civil War in 1939 until the first democratic elections in 1977 the Franco dictatorship’s approach to public health was based on a division between health care services, which were under the control of Falangist ministers in the Ministry of Labor, and public health services, which were the responsibility of the Ministry of the Interior, under the supervision of Catholic military officials (Rodríguez-Ocaña and Martínez-Navarro, 2008). As early as 1967, in a report on the organization of the health services in Spain, Dr. Fraser Brockington, a World Health Organization (WHO) consultant, criticized the Franco administration for failing to establish a Ministry of Health and retaining a system in which the various aspects of health services were dispersed across different ministries (Brockington, 2018 [1967]).

  • 1 All the translations were made by the authors.

6To a large extent, Franco’s government limited its efforts to maintaining the health system designed in the Second Republic (Rodríguez-Ocaña, 2008). In the middle of the civil war, the Republican government tried to establish something resembling a national health service, as specified in a document of the Popular Front “[...] the State will take care that each man or woman of the people remains healthy and is duly treated if he or she falls ill” (Huertas, 2000: 41).1

7For almost 40 years the Franco regime maintained a very centralized, paternalistic health system that was extremely fragmented (Pons-Pons and Vilar-Rodríguez, 2011; Aguilar, 2010). Brockington’s (2018 [1967]: 10) report stated that “the health of the community constitutes a unitary domain that suffers if it is broken down into different and independent sectors; the diversity of efforts and the lack of integration of services are harmful”. It also stressed that “the principles of social and preventive medicine are conspicuous by their absence” (ibidem: 3), a problem that remains, at least to some extent, to this day. It was not until the introduction of democracy that health care was recognized constitutionally as a right of citizenship.

Changes During the First Period of Democracy (1977‑1986) and Consolidation of the National Health System (1987‑1992)

8When democracy was introduced, Spain’s first democratic government inherited a health system that had serious deficiencies in outpatient health care and out-of-date public health services and had ignored the country’s changing epidemiological profile, which had come to be dominated by non-communicable diseases. There were also serious deficiencies in health information systems and in the training of medical and public health professionals.

9Internationally the 1970s were marked by a major global economic crisis, and rising health care costs meant that the need to reform Western health systems entered the scientific and institutional agendas (Lorraine and Götze, 2011). The Laframboise-Lalonde Report had shown that biomedical interventions were only one of the influences on health, which was more strongly associated with social, environmental and lifestyle factors (Lalonde, 1974). It followed that existing health policies should be replaced by policies that prioritized prevention and health promotion and built people’s capacity to manage their own health and well-being. In 1978, the Alma-Ata Conference endorsed moves to challenge the then dominant hospital-centric model of health care and reaffirmed the centrality of universal health care to improve the health of the population, emphasizing that the main focus should be on primary care (WHO, 1978).

10The creation of Spain’s first Ministry of Health in 1977, two years after the death of the dictator Franco, did not lead to a substantial modification in the programs or territorial organization of the previous health system. It was not until the Spanish Socialist Workers Party (PSOE) entered government in 1982 that enough momentum was generated to set in motion a whole series of legislative initiatives aimed at establishing a welfare state that would put Spain on the same level as other European countries. The enactment of the General Health Law (Ley General de Sanidad, LGS) in 1986 stood out amongst these initiatives (Magro, 2016). The LGS was underpinned by three basic aims: to reorganize primary health care, to encourage community participation and to implement inter-sector policies. Amongst the greatest achievements of these reforms were the universalization of health coverage (98.5% in 1995), the introduction of the specialization in Family and Community Medicine, greater administrative integration of the healthcare network and an improvement in the quality of care (Benach, 2018).

11The devolution of health competencies to the 17 Autonomous Communities started before the enactment of the LGS. This process enabled the first modernization of the structure and services provided by health care units (hospitals and outpatient services) and was not completed until 2002. At present – in very general terms – the Health Departments of each region set their own annual budgets and purchase health care services from Regional Health Services (SRSs), which are in charge of the management of hospitals, clinics and primary care centers. Health Departments may also contract services out to private providers, who generally play a minor role in overall provision, although this varies greatly between regions. The provision of care services is free at the point of care, with the exception of drugs and some ancillary products (prostheses), for which co-payment up to a maximum is expected (VV. AA., 2018a).

12Over the course of a decade (1982‑1992), an intensive program of reform was implemented, albeit unevenly across regions; this was accompanied by major investments in infrastructure and human resources, especially in relation to the incorporation of family and community medicine specialists and nursing professionals into the new primary care centers (Rodríguez-Ocaña et al., 2008). In spite of these efforts, the health system continued to be focused primarily on assistance, prioritizing existing illness over the promotion of health; the biomedical continued to dominate and there was a certain disregard for the social determinants of health and community action in health (Benach, 2018). Although initially the objectives of the new primary care centers (Health Centers) were formulated in accordance with the principles of Alma-Ata and the Ottawa Charter, the rise of the neoliberal tide led to their progressive replacement by objectives couched in terms of the management of care processes and based on a vision of an internal market and the implementation of programs aimed at modifying individual lifestyles.

The Rising of the Neoliberal Tide: Counter-reforms of the Health System (1990‑2018)

13In 1990, only four years after the enactment of the LGS and with the European Community pressing Spain to reduce its public deficit, the PSOE government set up a commission of experts known as the “Abril Commission”. Its final report noted that there was a need to introduce private management of public health services, to extend private sector participation in publicly-funded care, to separate funding and provision of services and to extend the co-payment scheme for medication to pensioners (Gobierno de España, 1991). Opposition to the Abril Report meant that the drive for privatization was delayed for a few years, but it received further support after the approval of Law 15/1997, which is still in force. This law enabled new forms of management of the SNHS (BOE, 1997). It made it legal for provision and management of health and social-health services to be carried out by means of agreements or contracts with public or private persons or entities. Policies, based on this law, that were promulgated during the period 1996‑2004 by governments led by the Popular Party (PP), fueled an increase in private management of publicly-funded services (FADSP, 2017). In the regions where PP governments predominated, privatization initiatives took the form of public-private partnerships for the construction and management of hospitals, outsourcing of healthcare activities (mainly surgery), diagnostic procedures and complementary services (FADSP, 2017; Ponte-Mittelbrun, 2005). Although regions with PSOE governments opted for policies that reflected a greater commitment to a public health system, they passed laws incorporating some of the recommendations of the Abril Report.

14However, the most serious attack on the public health model defined in the LGS occurred in 2012, in the midst of the Great Recession, thanks to the enactment by the PP government of Royal Decree-Law 16/2012 (BOE, 2012). This decree was part of the neoliberal austerity policies promoted by the EU, which were designed to reduce public spending and prioritize debt repayment. The decree linked the right to health care to the condition of being insured, breaking the principle, which had until then prevailed in the SNHS, that the right to health care was conditional only on citizenship (Sánchez-Bayle, 2012). One of the consequences was the exclusion of illegal immigrants from health care, with 873,000 health cards being withdrawn from foreign residents (Médicos del Mundo, 2013). The replacement rate for public sector retirements was limited to 10%. Although not all the cuts that were implemented have been reversed, RD 16/2012 was partially revoked recently, through Royal Decree 07/2018, which states among its general provisions “[...] access to the National Health System under conditions of equity and universality is a fundamental right of every person” (BOE, 2018).

15Neoliberalism’s penetration of healthcare field and the neoliberal recipe for austerity in public spending have reached all areas of healthcare in Spain, affecting specialist services the most and influencing the ideas of politicians and managers of public health care services (Navarro, 2012). This penetration stalled in 2011 when citizens mobilized strongly in defense of public health services. This mobilization was underpinned by the strongly favorable opinion that the Spanish population has of the SNHS, despite the impact of neoliberal austerity policies (Sánchez-Bayle and Fernández-Ruiz, 2018).

The Great Recession and Its Collateral Effects on the Social Health System. Social Inequality Spikes (2008‑2018)

16The first manifestation of the Great Recession in Spain was the bursting of the real estate bubble, generated over the decade prior to the 2008 crisis by a very lax credit policy and, by extension, the breakdown of the speculative instruments created and used by US investment banks and their insurance companies (Weissman, 2009). The incompetence of the regulatory bodies, mainly the Bank of Spain, allowed an unsustainable expansion of credit to families and companies in the real estate sector (Navarro, 2012; Ekaizer, 2018). The Spanish banks, especially the savings banks, which transferred speculative capital from Central European banks, were particularly affected. Eventually, the government decided to offer the banks a publicly-financed bailout which, although officially estimated at 122 billion euros by the Court of Auditors, would rise to some 300 billion euros if other types of indirect aid were taken into account (Ekaizer, 2018). Spain’s public debt which, at 35.5%, had been amongst the lowest in the EU in 2007 rose to 99.0% of GDP in 2016 (Delgado et al., 2018). The priority given to payment of this private debt, which had been converted into public debt, became a constitutional norm when the two big parties, PSOE and PP, agreed in September 2011 on a rapid reform to the Constitution (BOE, 2011), making controlling the deficit an absolute priority that took precedence over other economic measures that might mitigate the negative impact of the Great Recession.

17The consequences of the reduction in social spending have been, and continue to be, dramatic. Unemployment increased from 8.6% in 2007 to 25.7% in 2012, when the youth unemployment rate was above 50%, representing the destruction of almost 4 million jobs between 2007 and 2014. There has also been a deterioration in the quality of employment, with an increase in part-time hiring of 16-29 years old from 26% in 2007 to 44% in 2016. Only 48% of the population affiliated to the social security system in 2017 had full-time permanent contracts while the majority (52%) held temporary and/or part-time contracts. The poverty rate grew from 23.6% in 2008 to 26.6% in 2017, with families with dependent children and single-parent families (mostly headed by women) having the highest relative poverty rates, at 24.1% and 40.6% respectively. The Great Recession has made 4 million people extremely vulnerable and there has been a 40% rise in the number of people classed as severely excluded compared with 10 years ago (Cumbre Social Estatal, 2018). The Gini index rose from 31.9 in 2007 to 34.1 in 2017 (Eurostat, 2017), making Spain one of the most economically unequal countries in the EU.

18Neoliberal austerity measures led to a fall in public health expenditure as a percentage of total health expenditure, from 73.6% in 2009 to 70.8% in 2017 (OECD, 2018). In absolute terms, this represents a cut of 15‑21 billion euros and is reflected in the loss of 9,600 jobs in public hospitals between 2010 and 2014. The cuts to primary care services, 15.5% between 2009 and 2014, were five times as severe as the cuts to specialist services (Médico Crítico, 2016; Simó, 2016). As a consequence of the deterioration of public health services, private spending on health increased from 26.4% in 2008 to 29.2% in 2017.

19As the historian Josep Fontana pointed out,

What Spanish citizens pay for today through cuts, unemployment and sacrifices are the gigantic debts of financial institutions that committed their resources to high-risk investments in order to be in a position to distribute profits and commissions to their executives and to political associates who first let them do it and then accepted that the state bail out the banks and savings banks, but not those of thousands of families who have been evicted. (2013: 61)

Resistance to Austerity Policies in the Health Sector. The Social Phenomenon of the White Tides

20Throughout the different stages of democratic government in Spain, there have been civil movements arguing in favor of the right to health as a common good that should not be subject to the law of markets. One of the most notable groups campaigning in support of the SNHS in the past 35 years is the Federation of Associations for the Defense of Public Health (FADSP) (Palomo, 2011). During the last two decades, FADSP was the core group in the formation of multiple Platforms in Defense of the Public Health System throughout the country (FADSP, 2018a).

21The emergence of the 15-M phenomenon in Madrid and other Spanish cities in 2011, as an outburst of indignation against neoliberal austerity policies, was the most remarkable episode of social mobilization in defense of the welfare state in Spain since the introduction of democracy. The enormous discontent that followed repeated cases of corruption in the largest parties (PSOE and PP) contributed to the birth of movements of outraged citizens, collectively known as mareas blancas (white tides). Organized regionally, the movement mobilizes citizens in defense of the SNHS, against cuts and privatization plans, and also provides a channel by which citizens can express their will, in the absence of effective citizen representation on the governing bodies of the regional health systems (Matos and Serapioni, 2017).

22The first white tide was organized in Madrid in response to the regional PP government’s decision to privatize hospitals and primary care centers. Health professionals played a critical role in the formation and activity of the white tide, their legal and media work being particularly powerful; they were able to document the conflicts of interest of politicians promoting privatization initiatives and the private companies that were likely to benefit from them (Sánchez-Bayle and Fernández-Ruiz, 2018). Ultimately, the social mobilizations, together with a series of judicial rulings, brought a halt to the most visible privatization initiatives (6 hospitals and 26 primary care centers) in 2014 and led to the resignation of the PP politicians involved. This victory was an enormous incentive and led to the formation of several white tides in other regions, provinces and municipalities. These tides are still active in many parts of Spain.

23Amongst the achievements of the white tides, it is worth highlighting the fact that the privatization and dismantling of the health system are now on the agenda of political organizations and state institutions. The white tides have shown that when citizen mobilization is unified, massive and sustained, it can paralyze privatization processes (Beiras and Sánchez-Bayle, 2015). The huge deterioration in the working conditions of health workers, especially in primary care, has led to a reaction that is taking shape as we write this text – in late 2018 – but includes strikes and demonstrations by health professionals in several Autonomous Communities (FADSP, 2018b).

24The activities of white tides have not been limited to defending the SNHS and attempting to reverse budget cuts: “[...] we have started to talk about and act on health and not only on disease but on its determinants and on health inequalities” (Martí, 2018). They also claim to have “introduced the need to stop the progressive medicalization of the SNHS, promoted by the health insurance industry and the big pharma-techno-industrial complex” (Burlage et al., 2018: 70).

25During the dismantling of the social state, the white tides have helped to open up a public space where conflicts can be discussed, solidarity can be generated or a common will to cope with the uncertainty and suffering generated by the neoliberal individualizing of stress can be articulated (Solé Blanch, 2018). In the face of contemporary capitalism, with its hostility to life, the defense of justice and equity remains the objective for the white tides and similar citizens’ movements.

Part 2. Impact of the Crisis on Health and Health Inequalities in Spain

26Before addressing the special features of the Spanish case, we need to consider some context-specific factors and methodological considerations that have been raised in relation to the apparent inconsistencies in the associations between crises and subsequent health outcomes (Suhrcke and Stuckler, 2012). First, there have been national differences in the impact of economic crises that appear to be related to the generosity of state welfare protection (Norström and Gronqvist, 2015). Second, a wide range of mortality and morbidity indicators has been employed to measure impact, limiting the comparability of studies. Third, the direction of associations found may depend on whether they are based on individual or aggregated data (Martikainen and Valkonen, 1996). Fourth, the health consequences of the ‘normal’, less dramatic variations in the trade cycle may differ substantially from those occurring under exceptional circumstances, such as the recession we are currently experiencing (Ruhm, 2016). Fifth, the short- and long-term health effects of crises, especially on longevity or mortality, may diverge. Finally, one of the main methodological considerations is the difference between average effects in the population and specific group effects (Marmot and Bell, 2009). When considering this aspect, caution should be applied to the socio-economic variable used in the analysis of health inequalities. For instance, one of the characteristics of the recession in Spain is that young adults have been more deeply affected by unemployment and income reductions than other adults. Hence there has been an increase in the numbers of healthier young people in lower income brackets, combined with an increase in older adults – who have benefited from stable pensions but have more health problems – in higher income brackets, yielding a reduction in income-related health inequalities, as shown in a recent study assessing income inequalities in self-rated health (Coveney et al., 2016). In the following subsections, we present a summary of the main effects of the crisis and austerity measures on inequality in key health outcomes.

Mental Health Outcomes

27The impact of the Great Recession on mental health in Spain has been thoroughly investigated since its onset. With some exceptions, researchers have used repeated cross-sectional studies, extracting data from population-based surveys, such as the National Health Survey. The vast majority of studies report an unambiguous negative association between the recession, subsequent neoliberal measures and mental health.

28A longitudinal study based on primary data from GP consultations between 2006 and 2010 (Gili et al., 2013) represented a milestone in research into the impact of the recession on mental health. Gili et al. reported that mood disorders increased by 19% and anxiety disorders by 8% and that both were particularly frequent in families experiencing unemployment and mortgage payment difficulties. Multi-country research based on the European Social Survey (2006-2014) revealed that the negative consequences of the recession for mental health (measured by depressive feelings) were evident in Spain and recommended that particular attention should be paid to the economically inactive and precariously employed (Reibling et al., 2017). Another publication based on the same data source found that Spaniards showed low social optimism and high levels of depressive symptoms, and attributed the deterioration in mental health over the period 2008-2013 to the financial crisis (Chaves et al., 2018).

29Several studies have found an increase in the prevalence of poor mental health during the crisis period compared with the pre-crisis period. This increase has been attributed to individual-level changes in unemployment (Bartoll et al., 2014), income (Tamayo-Fonseca et al., 2018) or both (Moncho et al., 2018) and to contextual-level changes in the prevalence of precarious employment and lower health spending per capita (Ruiz-Pérez et al., 2017a). Research into sex differences found that the recession has had a greater impact on men’s mental health (Bacigalupe et al., 2016; Moncho et al., 2018).

30A study using four waves of data from the Basque Health Survey (1997‑2013) did not observe any association between employment status or social class and the increase in poor mental health (Bacigalupe et al., 2016). This lack of association was corroborated by another study in Andalusia which, instead, found that the negative impact of the recession on mental health was concentrated amongst those with secondary education, whether employed or unemployed (Córdoba-Doña et al., 2016)

31The impact of the financial crisis on mental health appears to have differed between age groups. Specifically, the risk of suffering from mental health problems for children with unemployed parents was higher in 2011 compared to 2006 (Arroyo-Borrell et al., 2017). However, the apparent effects of the crisis on the mental health of the young population vary according to the data source (Aguilar-Palacio et al., 2015; Medel-Herrero and Gómez-Beneyto, 2017). Finally, education- and income-related inequalities amongst the over-50s in Catalonia were found to have increased from 2006 to 2015 (Spijker and Zueras, 2018).

Suicide and Suicidal Behavior

32Spain has for decades had low suicide rates relative to the European average. Although in the wake of the recession several countries have seen an increase in suicides or a change to the previous downward trend (De Vogli et al., 2013), it is not entirely clear what the situation in Spain is. López-Bernal et al. (2013) reported an 8% increase in suicides based on an interrupted time series analysis with several methodological drawbacks, including the limited time span 2010‑2015. Ruiz-Pérez et al. (2017b) found that the financial crisis was associated with suicides at two different times – the double-dip recession – and not with a sustained trend after its onset. In contrast Álvarez-Gálvez et al. (2017), who measured monthly rates, observed an increase in the period 2011‑2014 but not before then, suggesting that the impact of economic problems on suicide may have been delayed by policies designed to mitigate their effects. These results are consistent with an earlier study by Ruiz-Ramos et al. (2014), who reported that suicide rates in Spain had decreased between 1999 and 2011, in both men and women.

33The lack of an overall increase in the suicide rate was also observed in Catalonia from 2010, although there were increases in several subgroups (Saurina et al., 2015). A study performed in the Basque Country and the city of Barcelona showed that educational inequalities in male suicide have remained broadly stable between 2001 and 2012 (Borrell et al., 2017). A study covering the period 1999 to 2013 showed that before the crisis there was a correlation between unemployment and suicide that has weakened during the recent financial crisis (VV. AA., 2017). Interestingly, in contrast with the variability in suicide mortality, there has been a consistent increase in attempted suicide since the Great Recession, especially in the working age population (Córdoba-Doña et al., 2014; Celada et al., 2017).

Mortality

34According to the majority of authors, overall mortality in Spain has not changed since the Great Recession, although there is some controversy about the rate of decline relative to the pre-Recession trend (Regidor et al., 2014; Ruiz-Ramos et al., 2014; Tapia-Granados, 2014) and in relation to specific causes of mortality and age groups. For instance, it has recently been reported that cancer mortality has been decreasing more slowly since the onset of the crisis (VV. AA., 2018b), while amenable mortality decreased more significantly than overall mortality between periods, though unevenly distributed among causes of death (Nolasco et al., 2018). Moreover, an earlier study reported that in persons aged 60 years or older mortality appears to be decreasing more slowly than would have been expected had the recession not occurred (Benmarhnia et al., 2014).

35At European level, crisis-related economic conditions were not associated with widening health inequalities in mortality until 2014 (VV. AA., 2018c). However, this conclusion is not supported by the results of several studies based on local and regional data. In Andalusia, social inequalities in male mortality have increased since the early years of the crisis and this is linked to a deeper reduction in mortality rates amongst more educated men (Ruiz-Ramos et al., 2014). A study which took an ecological approach to mortality found that between 2008 and 2011 it increased more relative to the pre-crisis period in deprived neighborhoods of Barcelona than in affluent neighborhoods (Maynou Pujolras et al., 2016). However, it remains to be determined whether deaths from specific causes may have been disproportionately affected by the recession in specific vulnerable subgroups (Alonso et al., 2017).

Immigrants’ Health and Healthcare

36One of the first assessments of the impact on the Great Recession on immigrant healthcare access in Spain (covering 2006‑2012) did not find any deterioration, possibly because the SNHS performed fairly well until 2012 (García-Subirats, 2014). Using the same databases, Gotsens et al. (2015) found that immigrants who arrived in Spain before 2006 had worse health status than natives and posited that the recession was responsible for the loss of the so-called healthy immigrant effect.

37Cimas et al. (2016) evaluated the implementation of the above-mentioned Royal Decree-Law 16/2012 of the Spanish government, which limited immigrants’ previously comprehensive access to public health services. They found that implementation varied geopolitically, reflecting the complexity of nation-wide regulation in a highly decentralized system (ibidem). A more recent review also showed that regional legislation protecting the rights of undocumented migrants may have limited the deleterious health effects of the recession and subsequent austerity measures on this group (Peralta-Gallego et al., 2018). One of the few publications to compare native and migrant populations found that immigrant women and men were more likely to use GP and emergency services than their native counterparts (Rodríguez-Álvarez et al., 2018).

38There are limits to how effectively one can assess immigrants’ access to healthcare services using quantitative data extracted from population-based surveys. A qualitative study designed to address the drawbacks of quantitative research found an exacerbation of pre-existing barriers to the use of healthcare services and the appearance of new obstacles to entering the healthcare system in the wake of the crisis (Porthé et al., 2016), as well as a decline in the perceived quality of the technical and interpersonal resources of the health services during the economic crisis (ibidem, 2018).

Children’s Health

39A comparative study of the Catalonian Health Surveys for 2006 to 2010, and 2012, found that although some health-related behaviors improved during the study period, childhood obesity increased and inequalities in health-related quality of life increased in children under 15 years of age (Rajmil et al., 2013).

40Interestingly, two publications from 2018 focused on perinatal outcomes in Spain, covering 2002 to 2013 (VV. AA., 2018d) and 2007 to 2015 (Terán et al., 2018), and observed that the prevalence of small-for-gestational-age births has increased during the crisis, interrupting the previous downward trend. In addition, the pre-crisis inequalities in perinatal health have persisted, although low birth weight proved to be more strongly associated with maternal educational level after the onset of the crisis than in the previous period (ibidem). These findings are consistent with a broadly-based study using data for 2005‑2015 from 16 European countries. This study concluded that countries that implemented more severe austerity measures have experienced an increase in the prevalence of low birth weight together with an increase in material deprivation in families with no more than primary education (Rajmil et al., 2018).

Use of Healthcare Services

41López-Valcárcel and Urbanos-Garrido have studied a wide variety of health service performance indicators during the crisis and related them to diverse socioeconomic variables. Their research, together with contributions from other scholars, is included in a very recent comprehensive review, edited by the Spanish Ministry of Health, of the impact of the current economic recession on health and use of healthcare services (Ministerio de Sanidad, Consumo y Bienestar Social, 2018a).

42The overall use of health care services was unchanged during the early years of the crisis, although a study by Urbanos-Garrido and Puig-Junoy (2014) described how waiting times and waiting lists for surgery increased, in parallel with the increase in dissatisfaction with the SNHS that has been detected in health surveys. More specifically, the average waiting time for surgery rose from 63 to 76 days between 2009 and 2012 (López-Valcárcel and Barber, 2017) and increased further to 93 days in June 2018 (Ministerio de Sanidad, Consumo y Bienestar Social, 2018b).

43No significant socioeconomic differences in the frequency of use of physician consultations and hospitalizations in Spain were observed in 2007 or 2011 (Lostao et al., 2017). Using the same data (from the Spanish Health Survey) Abásolo et al. (2017) found that, in relative terms, the recession has had a greater detrimental effect – a decrease in utilization – on low-income groups with respect to specialist appointments and hospitalizations, whereas it has worked to their advantage with respect to emergency services and GP consultations (ibidem).

44A study in Andalusia, comparing 2007 to 2012, found that horizontal inequity in the use of GPs and specialists had reduced, but argued that the increase in lower income groups’ use of hospitalizations and emergency services could indicate that their access to appropriate primary care services had been curtailed (Córdoba-Doña et al., 2018). Increases in the use of emergency services associated with poor mental health and limitations on daily activities in lower income groups have also been reported (Pereira et al., 2016). Non-attendance to dental visits by lower social classes has increased, leading to a steeper social gradient in the use of dental services (Calzón-Fernández et al., 2015). Finally, the Health Barometer data from 2014 to 2016 showed that unemployed people were four times more likely to discontinue medication because they could not afford it than qualified workers and professionals, which raises important questions about equity of access to treatment (Ministerio de Sanidad, Consumo y Bienestar Social, 2018a).

Conclusions

45This extended historical contextualization and review of the literature add to the growing body of research that indicates that the Great Recession and neoliberal austerity measures have so far had a deleterious impact on mental health and suicidal behavior, especially in the middle-aged Spanish population. We highlight the importance of these findings, often disregarded in favor of research that focuses too much on the weak or unclear effects of the recession on general mortality and self-rated health.

46Although it is not yet possible to observe all the health consequences of the Great Recession, it seems very plausible that the aggravation of social inequalities during these years, and the detrimental effect on other structural and proximal determinants, will be translated into medium- and long-term negative effects on health, with the latency depending on the nature of the health outcome in question. For example, it is only very recently, several years into the recession in Spain, that increases in poor perinatal outcomes have been reported. The observed effects of the recession appear to be mediated by unemployment, loss of access to housing and economic hardship, all of which disproportionately affect vulnerable populations. The effects on health inequalities will also depend on the indicators of socio-economic position employed. In Spain, the young population – which is relatively highly educated – has suffered most from increased unemployment, precarious jobs and cut wages and this is why we see paradoxical results such as the reduction in income inequality, alongside an increase in educational inequality in some health outcomes.

47In general, the results relating to equity in the use of health services indicate that the SNHS showed considerable resistance to the effects of recession during the early years, primarily as a result of professionals absorbing the extra burden at the cost of overstraining themselves. Some indicators – such as the growing dissatisfaction of the population – suggest that by 2013 the system’s buffer capacity was exhausted. Although inequalities in access to medication and timely admission to services are being detected, with the information currently available it is not possible to assess the impact on health outcomes that is due to deterioration in the quality of services directly. The deleterious effects on immigrants’ access to healthcare are clear from qualitative research carried out in recent years, although the high regional variability in the implementation of restrictive measures prevents us from reaching an overall conclusion.

48Finally, if we put the Great Recession and the consequences that have flowed from it into a broad temporal perspective, it does not seem appropriate to consider the crisis or recession as a specific event or a temporary variation/fluctuation occurring in a certain country. We propose that the world has entered a new, qualitatively different era, as these changes are taking place in the context of a global crisis (climatic, cultural and social) that affects the majority of the structural determinants of health and health inequalities in multiple ways. We would strongly suggest/claim that the oxymoron “relentless crisis” can be applied to the situation in the countries of Southern Europe – and to the global South – and argue that the only way out is policies directed towards “the causes of the causes” of inequalities in health. This implies that the welfare of people must be central, and that achieving this is a complicated challenge in the current phase of capitalism.

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Notas

1 All the translations were made by the authors.

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Referência eletrónica

Juan Antonio Córdoba-Doña e Antonio Escolar-Pujolar, « The Lasting Effects of a “Relentless Crisis”: The Great Recession and Health Inequalities in Spain », e-cadernos CES [Online], 31 | 2019, posto online no dia 15 junho 2019, consultado o 16 fevereiro 2020. URL : http://journals.openedition.org/eces/4223 ; DOI : https://doi.org/10.4000/eces.4223

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Autores

Juan Antonio Córdoba-Doña

Unidad de Medicina Preventiva y Salud Pública, Hospital Universitario de Jerez, Área de Gestión Sanitaria de Jerez, Costa Noroeste y Sierra de Cádiz | Instituto de Investigación Biomédica e Innovación de Cádiz, INIBICA
Ronda de Circunvalación, s/n., Jerez de la Frontera, 11407 España
jantonio.cordoba.sspa@juntadeandalucia.es

Antonio Escolar-Pujolar

Consejería de Salud de la Junta de Andalucía, Delegación Territorial en Cádiz (retired)
Cádiz, España
antonio.escolar@uca.es

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Licença Creative Commons CC BY 4.0

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