Boosting access to healthcare in times of crisis
The economic crisis has had a profound effect on people's lives, not least in the area of health. Public spending on healthcare has been frozen or cut; in some respects, citizens' health has deteriorated; and accessing healthcare has become more difficult. In response to this, many public authorities and service providers are attempting to ease the impact of the crisis by maintaining access for all to quality healthcare.
Impacts of the crisis
On 19 January 2016, Eurofound research officer Hans Dubois presented some of the key findings of the Agency's research into access to healthcare at a lecture series on Human Rights and Inclusive Global Health, organised by the Centre for Global Health in Trinity College, Dublin.
Changes in public spending on health: In the context of the crisis, the longstanding general trend of increases in public health spending has come to a halt. Moreover, since 2007, in 18 Member States, public spending on health has undergone cuts. In addition, those countries have made cuts are more likely to be countries in which public spending on health was already lower. This makes concern for decreasing access to, and quality of, healthcare in the EU all the more valid.
Deterioration in mental health: At a personal level, people’s mental health has suffered during the crisis. In the EU28, the proportion of people at risk of poor mental health rose from 24% in 2007 to 25% in 2011; while this may look small, it represents an increase of over 3 million people. Much of this increase can be attributed to a rise in unemployment; another contributing factor is a a greater feeling of insecurity in terms of housing and job tenure.
Impact of crisis greater on low earners: The impact of the crisis upon citizens has not been equal: over the course of the crisis, a greater proportion of people at the bottom of the income scale have experienced bad health. This is in contrast to those with higher incomes, whose health has remained stable or even improved, as Figure 1 demonstrates.
Figure 1: Poor reported health status by income, EU28, 2007 and 2011
Source: Impacts of the crisis on access to healthcare services in the EU (Eurofound, 2013)
Problems with access
As well as stalled or falling government expenditures, and worsening health outcomes for some, access to health care services has become more problematic for many. Most commonly, this is because citizens cannot afford the services: difficulties accessing services because of their cost have increased more than any for any other reason in crisis-hit countries. Several more key problems with access have come to light:
- Circumstances may mean that coverage has been reduced: unemployment, for some, has meant the loss of work-provided health insurance.
- Increased demand for services, and reduced supply, have led to longer waiting times.
- Cuts in spending on services such as transport can make services harder to reach: in Bulgaria, fewer resources are available to clear roads of snow, for example.
- Information services that, previously, helped citizens navigate the health system, may have been cut
- Lack of awareness can also pose a problem, particularly for vulnerable groups. In Portugal, migrant workers are entitled to access, but many people, including doctors, are not aware of this.
Measures to maintain access
Over the course of the crisis, service providers have sought to maintain access to services. Some approaches identified in the research include the following.
Resorting to less expensive forms of care: In some cases, this has included continuing the ongoing trend of deinstitutionalisation: shortening the length of hospital stays, keeping older people in the community, and developing an alternative care infrastructure.
Working more effectively with personnel: To make better use of limited resources service providers have reorganised work processes, brought in measures to motivate and retain staff, and used less costly workers (such as trainees) – which brings its own challenges, such as possible loss of quality of service.
Seeking new sources of funding: Funding has been sought from local stakeholders, such as businesses. Extra paid-for features have been added for wealthier patients (such as VIP rooms in a Bulgarian hospital). And Denmark and Hungary have implemented a tax on less healthy foods.
Incentivising access: In some cases, governments have incentivised healthcare providers to improve access, granting them subsidies if they reach certain defined targets. In Portugal, for instance, primary care providers and the Ministry of Health agreed a target for 2012 that 85% of pregnant women would receive a consultation with a general practitioner within the first three months of their pregnancy. (While such initiatives have potential, there is also scope for introducing unintended consequences.)
Economising on cost: Faced with reductions in budgets, service providers have sought to economise in various ways – on utility bills; on food for patients. They have scrapped services not required by minimum national standards – psychiatric and physiotherapy services in a Latvian nursing home. And, in Portugal, service providers actively reduced costs for patients by reusing already used, yet functional, equipment.
Placing emphasis on primary care: A service provider in Sweden has encouraged people to go to a primary care centre (rather than using emergency care) by extending primary care opening hours, and locating the primary care unit close to the emergency unit to boost patient confidence.
Moving towards ICT-based services: In Latvia, a family doctor advisory telephone service has been developed. And in Portugal and Romania, web portals and email systems have facilitated emote diagnosis of conditions in remote areas, allowing primary care providers to send digital images of the patient’s condition to specialists in hospitals. Elsewhere, however, ICT services have been cut, in some cases introducing the risk of greater costs being incurred in the long term.
Greater flexibility: For instance, service providers may be more lenient in enforcing copayments for people in need.
In the context of the crisis, measures were taken in response to immediate, pressing constraints on public budgets. In early 2016, those constraints have been reduced somewhat in most countries, so it is timely to review measures that have been implemented. It should be noted that many measures were put in place only recently, so it may be more difficult to gauge their impact upon outcomes.
Later this year, Eurofound will be conducting fieldwork for its Fourth European Quality of Life Survey. This wave of the pan-European survey will include a special module on healthcare systems.
Healthcare policy at EU level
Health care policy is mainly a national matter, but increasingly, it reaches the EU level. For instance, the importance of healthcare is cited in the Europe 2020 strategy (150 KB PDF) in the context of social inclusion: ‘A major effort will be needed to combat poverty and social exclusion and reduce health inequalities to ensure that everybody can benefit from growth. Equally important will be our ability to meet the challenge of promoting a healthy and active ageing population to allow for social cohesion and higher productivity.’
The EU Charter of Fundamental Rights, from 2000, in Article 35 states that access to quality healthcare is a fundamental right for citizens (770 KB PDF). While the Council conclusions on health inequality state that poor health outcomes may result from uneven access to health services, and stress the importance of ‘interventions that facilitate real access for all’ (120 KB PDF). And the Social Investment Package states that better healthcare can increase productivity and longer-term savings for EU Member States.
While the EU-level approach has, to date, been only indirect in its impact, that is changing with the advent of the European Semester, particularly in the form of the country-specific recommendations (CSRs). For instance, the CSRs for Romania’s urge the country to seek to improve access to health care for people in remote regions.
Data for the research
A key source of the data is the Eurofound project on Access to healthcare in times of crisis. In this study, in-depth studies focused on nine countries: Greece, Hungary, Ireland, Latvia, Luxembourg, Portugal, Romania, Slovenia and Sweden. It drew on a wide range of sources, including national literature, surveys and interviews with stakeholders.
In addition, over 30 case studies illustrate how in practice budget-balancing measures have affected specific public healthcare services and access to them, for providers and service users, and how service providers have sought to maintain access. Most of the 31 case studies are publicly funded healthcare providers.