Health and Crisis
! ! ! ! ! ! REACH Towards a right to health without borders Izmir 8 to 18 July 2014
What is health ? ! !
Situation today
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“A girl born in Sweden will live 43 years longer than a girl born in Sierra Leone� ! ! ! WHO Commission on Social Determinants of Health
Îœortality 1 - 4 year olds
Territory size shows the proportion of all deaths of children aged over 1 year and under 5 years old, that occurred there in 2002.
www.worldmapper.org
GDP wealth
Territory size shows the proportion of worldwide wealth, that is Gross Domestic Product based on exchange rates with the US$, that is found there.
www.worldmapper.org
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“in Glasgow an unskilled working class person will have a lifespan 28 years shorter than a businessman in the top income bracket� ! Commission on Social Determinants of Health
•
Causes of the causes ! −
Social determination of health !
Neoliberal globalisation â—?
Main characteristics
â—?
Impacts
Neoliberal globalisation State withdraw Labor derregulation Unlimited mobility of capital, goods, services !
impacts of neoliberal globalisation
•
increasing social inequalities
•
increasing health inequalities
•
ecological disasters
•
wars & oppression
•
marginalisation
•
Causes of the causes −
●
Social determination of health
health services !
•
Causes of the causes −
●
Social determination of health
Health Services ●
availability
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•
Causes of the causes −
● • •
Social determination of health
Health Services Availability Accessibility − economic barriers
The inverse care law •
consumerism of health services addressed to young, healthy and rich people and rising expenditures !
•economic barriers leading to inadequate and spare health services for elderly, unemployed, immigrants and poor and rising unmet needs of the population
The Greek economic crisis
Hellenic Statistical Authority. National Accounts (accessed December 2013), own calculations
The Greek Economic Adjustment Programmes - EAPs •
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May 2010 (1st EAP)
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Loan: €110 billion Installments: the assistance to Greece was provided in quarterly installments Main Fiscal Target of the Program: reduction of government deficit from 14% of GDP in 2009 to below 3% GDP in 2014 through the implementation of fiscal consolidation measures worth of 11.3% GDP (approximately €25 billion) within a five year period Structural Reform Targets: reforms of the pension system; public administration; labour market; state enterprises; reforms for the improvement in the business environment; privatization of public assets and enterprises (target €50 billion), government guaranteed bank bonds to the Greek private banks (€55 billion)
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March 2012 (2nd EAP) Loan: €130 billion Duration of the Program: the program was extended until 2016 Main Fiscal Targets of the Program: reduction of government’s overall deficit to 2% GDP in 2016 through the implementation of consolidation measures cumulatively worth of 30.6% GDP (approximately €65 billion) between 2010-6 Structural Reform Targets: completion of the reforms of the 1st program, recapitalization of private Greek banks (€50 billion)
Directorate-General for Economic and Financial Affairs (own calculations)
The Greek EAPs and healthcare reform “Health care reform is a crucial component of Greece’s fiscal consolidation efforts”
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(EC Occasional paper 87, October 2011)
The Memoranda of Understanding (MoUs) that the Greek government signed with the Troika from May 2010 to May 2013 included 170 conditionalities related to healthcare: – Fiscal consolidation conditionalities related to healthcare (40 austerity measures)
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Structural healthcare reform conditionalities (60 measures)
– Pharmaceutical policy conditionalities (70 measures)
Kondilis E et al (forthcoming)
Greek EAPs and austerity Public health expenditure savings (realized and projected) under the Greek EAPs 7000 Government Health Expenditure savings 6000
Social Security Health Expenditure savings Total Public Health Expenditure savings 4977
million â‚Ź, current prices
5000
4910
4489 3729
4000 3000 1970
2000 1000 0 2010
2011
2012
Kondilis E et al (forthcoming)
2013
2014
Greek EAPs and austerity MoUs’ user fees conditionalities €3-5 co-payment for outpatient services in public hospitals
€30 million
Extension of “all day” functioning of public hospitals
€40 million
Fee on prescription €115 million Increased co-payments for public inpatient care Restriction of EOPYY’s health benefit package
€180 million
Total
€365 million
Note: co-payments for pharmaceuticals and increased co-payments to private, contracted to SSFs providers are not included in the above table since Troika didn’t quantify the subsequent projected savings resulting from these measures
Kondilis E et al (forthcoming)
45%
45%
40%
40%
35%
35%
30%
30%
25%
25%
20%
20%
15%
15%
10%
10%
5%
5%
0%
0% 2004
2005
2006
2007
2008
2009
2010
2011
2012
Unemployed, % labour force (left scale) Long-term unmeployed, % labour force (left scale) Unemployed aged 15-29 years, % labour force aged <30 years (left scale) People severely materially deprived, % population (right scale) People at risk of poverty (adjusted 2005 risk-of-poverty threshold), % population (right scale) People at risk of poverty and/or social exclusion, % population (right scale)
Kondilis E, Bodini C, De Vos P, Stefanini A, Benos A. 2013
% population
% labour force
The Greek social crisis
The Greek healthcare crisis Utilization of public hospital services, Greece 2000-2012 2.500
600
2.000
Visits Private Outpatient Departments Public Hospitals (right scale)
550 500
1.500 450 1.000 400 500
350
0
300 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Hellenic Statistical Authority and Greek Ministry of Health â&#x20AC;&#x201C; ESYnet (accessed May 2013), own calculations
number of patients in thousands
number of patients in thousands
Patients Discharged Public Hospitals (left scale)
The Greek healthcare crisis Self-reported unmet healthcare needs, Greece 2004-2011
% population
10% 8% 6% 4% 2% 0% 2004
2005
2006
2007
2008
2009
2010
2011
2012
People with self-reported unmet healthcare needs, % population People of the lowest income quintile with self-reported unmet healthcare needs, % specific population group
Hellenic Statistical Authority, Living conditions in Greece (accessed April 2013), own calculations
The Greek health crisis Infant mortality rate, Greece 1990 - 2011
10
Deaths per 1,000 live births
9 8 7 6 5 4 3 2 1990
1993
1996
1999
2002
2005
Kondilis E, Bodini C, De Vos P, Stefanini A, Benos A. 2013
2008
2011
The Greek health crisis
Deaths, per 100,000 population
Suicide mortality by sex and age group, Greece 1998-2010
12 11 10 9 8 7 6 5 4 3 2 1 0 2000
2001
Total all ages
2002
2003
2004
Females all ages
2005
2006
2007
Males aged 30-34 years
2008
2009
2010
Males aged 50-54 years
Kondilis E, Bodini C, De Vos P, Stefanini A, Benos A. 2013 Kondilis E, Ierodiakonou I, Gavana M, Giannakopoulos S, Benos A. 2013
Economic crisis and health in Greeceâ&#x20AC;¨
One-month prevalence of Major Depression Episode, Greece 2008-9 18%
% survey's sample
16% 14%
15,3%
2008 2009
11,2%
12% 10%
6,8%
8%
5,4%
6%
4,4%
4%
3,3%
2% 0% I (high)
II
III
Socioeconomic status
IV (low) Employed
2008: n=2.197, 2009: n=2.192, *2009-2008 difference: p<0.0001 Madianos M, Economou M, Alexiou T, Stefanis C. 2011
Unemployed
Total*
Economic crisis and health: â&#x20AC;¨ Greece 2008-2013 Depression and attempted suicides
Attempted suicides one month before the survey, Greece 2008-2011
8,0% 1,6% 7,0% 1,4%
8,2%
6,0% 1,2% 5,0% % survey's sample
% survey's sample
9,0%
4,0% 3,0% 2,0%
6,8%
1,0%
1,1%
0,8%
3,3%
0,6%
1,0% 0,4% 0,0% 0,2% 0,0%
1,5%
0,6%
0,6%
1,1%
1,5%
2008 2009 2011 2009 of Major Depression Episode 2011 Attempted2008 suicides One month prevalence 2008: n=2.197, 2009: n=2.192, 2011: n=2256 Madianos M, Economou M, Alexiou T, Stefanis C. 2011 Economou M, Madianos M, Theleritis C, Peppou L, Stefanis C. 2011
Economic crisis and health in Greece Suicide, homicide and infectious diseases mortality rates and trends (men < 65y), Greece 1998-2009
Kondilis E, Giannakopoulos S, Gavana M, Ierodiakonou I, Waitzkin H, Benos A. 2013
Economic crisis and health in Greece
Deaths, per 100,000 population
Suicide mortality by sex and age group, Greece 1998-2010
12 11 10 9 8 7 6 5 4 3 2 1 0 2000
2001
Total all ages
2002
2003
2004
2005
Females all ages
2006
2007
Males aged 30-34 years
!
2008
2009
2010
Males aged 50-54 years
Kondilis E, Ierodiakonou I, Gavana M, Giannakopoulos S, Benos A. 2013
Οικονοµική κρίση και ψυχική υγεία στην Ελλάδα
Έναρξη ύφεσης
5,0 Αυτοκτονίες
4,0 3,0 2,0 Ανθρωποκτονίες
1,0 0,0 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
θάνατοι ανά 100,000 πληθυσµού
6,0
Θνησιµότητα από αυτοκτονίες, ανθρωποκτονίες (άρρενες, 0-64 ετών), Ελλάδα 1970-2011
WHO. European health for all database (accessed March 2014), ίδιοι υπολογισµοί
Economic crisis and health: â&#x20AC;¨ Greece 2008-2013
Greek Documentation and Monitoring Centre for Drugs. Annual reports on the state of drugs in Greece 2008-2011.
The health impact of economic crisis and fiscal consolidation. Greece
number of newly diagnosed cases
Newly diagnosed cases of HIV-1 infection reported in Greece, Jan 2000 – Oct 2012
Total HIV IDUs
1200 1000
954
800 600 492
565 406
400 200
397
434
573
442
653
606
517
1049
607 487 241
18
15
17
11
11
19
16
9
9
14
15
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 October 2012*
IDUs: Injecting Drug Users, * 1 JAN – 31 OCTOBER 2012 Paraskevis D, Nikolopoulos G, Tsiara C, Paraskeva D, Antoniadou A, Lazanas M, et al 2011, KEELPNO. Epidemiological data on HIV infection in Greece (until 31/10/2012) www.keelpno.gr
The Greek health crisis
Malliori M, Terzidou M, Paraskevis D, Hatzakis A. 2011
Greek EAPs and austerity Movement of health personnel in public hospitals, Greece Feb-Dec 2012
200 100
number of employees
0 -100 -200 -300 -400 -500 -600 -700 Exits Recruitments Transfers
-800 -900 -1.000 Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Kondilis E et al (forthcoming)
Oct
Nov
Dec
Conclusions the conventional wisdom that health, is a commodity has devastating effects on the health status of the world population
•Global health
•2. solutions – proposals – alternatives !
•2.1. social determinants !
•2.2. health services
Conclusions !
Health is NOT a commodity !
Health is a social right
â&#x20AC;˘
The goal is NOT to develop health policies that favour the poor
! â&#x20AC;˘
But to impose policies targeting the social determinants of inequalities
â&#x20AC;˘The socio-economic determinants of health could be changed if new policies are implemented targeting a democratic, socially just and sustainable development
The challengeâ&#x20AC;Ś The elaboration of new policies promoting health sustaining environments !
Health as a social goal of the development instead of being its product
WHO Conference â&#x20AC;¨ Alma Ata - 1978 Right to health & health care Universal access Integrated health and health services strategy Government responsibility Multi sectorial approach Participation Comprehensive approach to health
Public Health Care Services providing equal access and utilisation for equal need high quality of services democratic and accountable structure and based on the PHC approach could be a reality
Social Solidarity Clinic of Thessaloniki
50
IAHP www.healthp.org People’s Health Movement www.phmovement.org
â&#x20AC;˘
The socio-economic determinants of health could be changed if new policies are implemented targeting a democratic, socially just and sustainable development
â&#x20AC;˘
The goal is NOT to develop health policies that favour the poor
! â&#x20AC;˘
But to impose policies targeting the social determinants of inequalities
!
Health is NOT a commodity !
Health is a social right